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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) PemiitSomices@everettwa.gov l www.everettwa.gov/permits <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS: (p� /j � - (JC_ Ra <br />BUILDING AREA: sq It <br />PROJECT TYPE: ❑ <br />NEW CONSTRUCTION <br />❑ADDITION <br />®TENANTIMPROVMENT ❑REMODEL <br />BUILDINGUSE: ❑SFR []TOWNHOUSE ❑DUPLEX ❑ADU []MULTI -FAMILY -#OF UNITS: ❑COMMERCIA <br />ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br />CONTRACT PRICE OF WORK: $ Q <br />ASSOCIATED BUILDING PERMIT # (if applicable): <br />DESCRIBE SCOPE OF WORK: 7'� ?4,4t, 1 V ! , <br />( - c fl <br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? [-]NO <br />©YES <br />-Select Scope: <br />[]Service <br />❑Feeder <br />0 <br />Circuits #: <br />[]Complete <br />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 <br />additional Fire Alarm Permit is required for review of device location and installation approval. <br />❑ Other (List All): <br />CODE COMPLIANCE <br />IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: ONO UYES -See Below & Pg. 2 <br />❑ By checking this box, I am staling that I have read and understand all of WAC 29646B-900, selected the specific reason on page <br />2 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: NO ES -See Below & Pg. <br />❑ 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 />CONTACT INFORMATION <br />OWNER NAME: r6 -, TENANT BUSINESS NAME (If Commercial): <br />p <br />OWNER MAILING ADDRESS: STREET 9/Greets ,cot <br />CITYSTATE ZIP O <br />++�� � 5 <br />OWNER PHONE: V 5 0 L9 OWNER EMAIL: 1 Ill. )CIJc,r C », f?+ l e . C <br />CONTRACTOR NAME: <br />CONTRACTOR ADDRESS: STREET 267121 C AA <br />_ <br />��//A1 <br />CRY STATE IA ZIP <br />CONTRACTOR PHONE: -50 <br />CONTRACTOR EMAIL: (VCt.VN �(� Q 1. <br />CONTRACTOR LIC. #(REQUIRED): 2 <br />CITY OF EVERETT BUSINESS'LI . #(REQUIRED): <br />_ <br />PRIMARY CONTACT: ❑OWNER OCONTRACTOR []OTHER (Please Specify) <br />CONTACT NAME: <br />T—M�W\ Z1 PR ✓� <br />CONTACT PHONE: Q <br />CONTACT EMAIL: (, <br />AGREEMENT.. I hereby certify that I have read anp}Rxammed tms application and Know the same to be true and cenVJCE .va pmwslons onaws ona ommances govea mis <br />type of work will be completed,, 91hersp ed hereln ornot. The granting of a permit does not presume to give authority to violate or cancel the provisions of any otherstate <br />orlocallaw regulating consfmction or th 9 rformanceofconshuction. That I am authorized by the owner of this property to perform the work for which applicatton is made and I <br />comply with the State Contractors Law s.27RCWand296.200 WAC. City of Everen Official Use Onl <br />' PERMIT #: <br />E f3(�-D�� <br />00nerIA(iffiffilzalklAahrit Signature Dale (Revised 41&2022) Page 1-Appllontion <br />iv <br />