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<br /> LI ELECTRICAL PERMIT APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET.EVERETT,WA 98201
<br /> (P)425-257-8810 j FAX 425-257-8857 I(E)everetteps@everettwa.gov j www.everettwa,goviperrnits
<br /> WASWNGTON
<br /> PROJECT SITE INFORMATION -----. .---:
<br /> PROJECT ADDRESS: 1 5 \,,,, \—\( \),,,,,,jscAt ilt,a_ BUI NG ARE k COG sq ft
<br /> PROJECT TYPE: El NEW CONSTRUCTION El ADDITION El TENANT IMPROVMENT E' MO L
<br /> BUILDING USE: E1SFR EJ TOWNHOUSE Li DUPLEX El ADU 0 MULTI-F MILY-# UNITS: 7 COMMERCIAL
<br /> ELECTRIC , , -- -: - -= . ORMATION & DE RIPTION OF WORK
<br /> ,
<br /> CONTRACT PRICE OF WOR .$ 00 \
<br /> IATED BUILDING PERMIT#(if applicable):
<br /> __-.--
<br /> DESCRIBE SCOPE OF WORK: C. c-k ni, re fyr,:).t. ce,40,, c-V ,41 0 Vt. Qcs ,...I.A rt. ta ler..le Li4 L '
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<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? El NO Er/YES-Select Scope:0 Service 0 Feeder D Circuits-#: EL Complete Re-wire
<br /> LOW VOLTAGE WORK? El NO El YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED). 0 Data El Intercom 71 Thermostat 0 Audio El Secure Access 0 Security System
<br /> El 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 /> El Other(List All):
<br /> CODE COMPLIANCE
<br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: NO in YES—See Below&Pg.2
<br /> By checking this box, I am stating that I have read and understand all of WAC 296-46B-800,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 (31-ES-See Below&Pg. 3
<br /> 7 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 /> ,..,,,,
<br /> OWNER NAME: t-1 t. ki,..,
<br /> r,„:,,,c,,'\.,) \ ,,,4-5 LL(.. TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: srnser 2.0 0 c 4?“-v_A-1„,1-51rAtt., QN-OC" e>
<br /> CITY Ca*dt'lr* 1A3 A- STATE ffet )„xo A LP 9 V Cli
<br /> OWNER PHONE: 154\1 in A 7-S'7....‘ OWNER EMAIL: e , ,,,,,,e,51.° C. (i)•rvIc. ,,,‘ •
<br /> CONTRACTOR NAME:
<br /> CONTRACTOR ADDRESS:
<br /> CITY SIAIE i If
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.kREOUIRE0):
<br /> - - ,
<br /> PRIMARY CONTACT: UtIWNER ECONTRACTOR EOTHER(Please Specify) _
<br /> CONTACT NAME: CONTACT PHONE: 3til 47141 1,.„g-Zi
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<br /> N--r 1.41(...i i CONTACT EMAIL: eale_ Vieveicr \,,,,,,,e,s-)- 34,ne.,,A ,
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<br /> AGREEMEN I hereby codify that I have read and examined this application and know the same to be true an (rect. 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 taw regulating construction or the performance of construction, That I am authorized by the owner of this property to perform the work for which aophcahon is made and I
<br /> comply with the Stale Cont, ris.kaw 18.27 RCW and 296.200 WAC. City of Everett Official Use Only
<br /> ,
<br /> PERMIT#:
<br /> E..,, , ....„,
<br /> darnel/Authorized Agent Signature •Date (Rev/Sett In 1/2019) Page 1-Application
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