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ELECTRICAL PERMIT APPLICATION
<br />CITY OF EVERETT PERMIT SERVICES
<br />EVERETT 3200 CEDAR STREET, EVERETT, WA 98201
<br />WASHINGTON (P) 425-257-8810 1 (E) Perm!tServices@everettwa.gov I wvnv.everettwa.gov/permits
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<br />PROJECT ADDRESS: " �r 0 j 7- 9 r 1, I E
<br />BUILDING AREA: sq ft
<br />PROJECT TYPE: ❑ EW CONSTRUCTION ❑ ADDITION ❑ TENANT IMPROVMENT UKREMODEL
<br />BUILDING USE: SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: ❑ COMMERCIAL
<br />:TRI,CAL^'APRICrA?ION"INFORMAT.iON $:`D,SCRIPTION'`iOF=WO:R; """ ' ` ',` >•,y'i``T-"
<br />CONTRACT PRICE OF WORK: $ SD3D ✓
<br />ASSOCIATED BUILDING PERMIT # (if applicable): t_ — 5—
<br />DESCRIBE SCOPE OF WORK:
<br />e-1 � i v � � jZ+ NM
<br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br />LINE VOLTAGE WORK? ❑ NO ffyES - Select Scope: ❑ Service ❑ Feeder ❑ Circuits-#: ❑ Complete Re -wire
<br />LOW VOLTAGE WORK? ❑ NO YES- # of Devices:
<br />SELECT SCOPE (REQUIRED): ❑ Data ❑ Intercom Thermostat ❑ Audio ❑ Secure Access ❑ Security System
<br />❑ Fire Alarm - Installations under this permit only include electrical wiring rough -In of the system. An additional
<br />Fire Alarm Permit is required for review of device location and installation approval.
<br />❑ Other (List All):
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<br />IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: NO Ll YES --See Below & Pg. 2
<br />ElBy checking this box, I am stating that I have read and understand all of WAC 296-46B-900, selected the specific reason on page 2
<br />of this application (see next page), AND Plan Review is NOT required because I meet all of the following sub sections that do not
<br />See Page 2 require Plan Review.
<br />ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ONO 17YES -See Below & Pg. 3
<br />1 !� Pursuant to RCW 19.28.261, property owners and leaseholders cannot perform electrical work on buildings for rent, sale, or lease
<br />without the proper electrical licensing and certification, or exemption. By checking this box, I am stating that I have completed and
<br />See Page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement.
<br />Y:. ::r r. -:� .err"?:- :.fve;: �4j:;'e, ',rtiL:S'... .:Dt"�• }.l •' ",df+l:' �ttfri: r�:r.
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<br />�� .�.�. ��.,' T�1G��'INFORIVi'I#Y'IQiil t�.
<br />OWNER NAME: t 'h ( TENANT BUSINESS NAME (If Commercial):
<br />OWNER MAILING ADDRESS: STREET W 1 7
<br />j�
<br />CITY t " LI STATE ZIP"--i
<br />OWNER PHONE: ZS - Z 1!,3
<br />1OWNER EMAIL: L I /J i, 3 5 5, h�
<br />CONTRACTOR NAME:
<br />CONTRACTOR ADDRESS: STREET
<br />CITY STATE ZIP
<br />CONTRACTOR PHONE:
<br />CONTRACTOR EMAIL:
<br />CONTRACTOR LIC. #(REQUI ED):
<br />CITY OF EVERETT BUSINESS LIC, #(REQUIRED):
<br />PRIMARY CONTACT: 031OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify)
<br />CONTACT NAME:
<br />CONTACT PHONE: L- ZS 73 } 2�C-3
<br />CONTACT EMAIL: �,� S'} S 1�� �t L nn
<br />AGREEMENT,/ hereby certify that I have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances governing this
<br />type of work will be completed whether specified herein or not. The granting of a permit does not presume to give authority to violate or cancel the provisions of any other state or
<br />local law regulating construction or the performance of construction. That I am authorized by the owner of this property to perform the work for which application is made and/
<br />comply with the State Contractors Law 18.27 R and 296.200 WAC. Cityof Everett Official Use Only
<br />PERMIT #:
<br />11411 Z, 13► ZL-1 I E 24fl-2N
<br />Owner/Authorized Agent Signature MaFe (Revised 41512022) Page 1-Application
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