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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 Www.everettwa.gov/permits <br /> 7 7. 7 <br /> F R N <br /> PROJECT ADDRESS: IBUILDING AREA: sqft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION ❑ADDITION MENANT IMPROVMENT 11 REMODEL <br /> BUILDING USE: OSFR 0 TOWNHOUSE 11 DUPLEX 0 ADU 11 MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL <br /> ' 'I ' -PRM WFOIIGAI�VAPK".OATIPWINF C IFIT- 1 N MT 0 '!QF WQRK` ,`� <br /> CONTRACT PRICE OF WORK:$ 1ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: <br /> 'ILI <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? El NO OYES-Select Scope: 0 Service 11 Feeder 1:1 Circuits-#: ❑ Complete Re-wire <br /> LOW VOLTAGE WORK? 0 11 YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): 0 Data 1:1 Intercom 13 Thermostat 0 Audio 11 Secure Access ❑ Security System <br /> 11 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): <br /> �7 7 71: 7,77-7.7. .7 77.7 7 77 <br /> 0 <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: JMO Ll YES See Below&Pg.2 <br /> By 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. ( I <br /> ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE:�kO DYES-See Below&Pg. 3 <br /> 13 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 /> OWNER NAME: C01)C—C TENANT BUSINESP NAME(if Commercial): <br /> OWNER MAILING ADDRESS: STREET ' a 1'7)JAJ kV(f_ I <br /> CITY 1 yv aAL STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: <br /> �� ' C2 <br /> CONTRACTOR ADDRESS: STREET <br /> CITY jk-w STATE ZIP <br /> CONTRACTOR EMAIL: a0areo r �A�CONTRACTOR PHONE: C <br /> 1' -1 ­k' <br /> CONTRACTOR LIC.#(REQUIRED): CITY OF:EVERETT BUSINESS LIC.#(4QUIRED): <br /> PRIMARY CONTACT: 11 OWNER kCONTRACTOR 11 OTHER(Please Specify) <br /> CONTACT NAME; CONTACT PHONE: <br /> CONTACT EMAIL: <br /> AGREEMENT.•I hereby certify that lb.*e read and examined this application and know the same to be true and correct. All provi§17ons o[loris 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 I <br /> comply With the State Contractors Law 18.21 and 296.200 WAC. City of Everett Official Use Only <br /> PERMIT M <br /> —010 <br /> 0; E <br /> e' f.Uth'r"ed n nature Date (Revised 41512022) Page 1-Application <br />