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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)PermitServices@everettwa.gov I WVAV.everettWa.gov/perm its <br /> ANPOIRMAT jTE <br /> PROJECT ADDRESS: C, <br /> 4t Z IBUILDING AREA: sq ft <br /> PROJECT TYPE: ONEW CONSTRUCTION [ADDITION ;RTENANTIMPROVMENT OREMODEL <br /> BUILDING USE: 11 SFR ❑TOWNHOUSE ❑ DUPLEX ADU ❑ MULTI-FAMILY-#OF UNITS: ❑ COMMERCIAL <br /> A <br /> CONTRACT PRICE OF WORK:$ 1ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: 3��-�� -1,e, �_2 0 <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? 0 NO 0 YES-Select Scope:A'Service 11 Feeder 11 Circuits-#: ❑ Complete Re-wire <br /> LOW VOLTAGE WORK? 11 NO 11 YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): 0 Data 1:1 Intercom 13 Thermostat 1:1 Audio 11 Secure Access El Security System <br /> [3 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 /> 11 Other(List All): <br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: JK No U 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. <br /> ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ONO OYES-See Below&Pg. 3 <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 /> CONTACT17' NFORMATTI <br /> 11X <br /> OWNER NAME: TENANT BUSINESS NAME(if Commercial): <br /> OWNER MAILING ADDRESS: STREET (07_ MUV `60t- flil-, <br /> CITY STATE ZIP <br /> OWNER PHONE: -e� e-"-1 1 C,4"4'—' <br /> OWNER EMAIL: <br /> CONTRACTOR NAME: <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: [CONTRACTOR EMAIL: <br /> CONTRACTOR LIC.#(REQUIRED): ICITY OF EVERETT BUSINESS LIC.#(REQUIRED): <br /> PRIMARY CONTACT: 11 OWNER 11 CONTRACTOR 11 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 6 0 Qj <br /> CONTACT EMAIL: Ce"4C&-k [� <br /> AGREEMENT.•I hereby certifj 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 I <br /> comply with the State Contract Law 18 Wand 296.200 WAC.C PERMIT M I T M City of Everett Official Use Only <br /> / �1 'Z"��2'5 1 0+E Z602_- 0 1 <br /> Owner/Authorized A", gnature Date (Revised 41512022) Page 1-Application <br />