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k -m ELECTRIC AL PERMIT IT APPLUCATONI <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT,WA 98201 <br /> ` IJ" <br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> - PROTECT SITE`INFORMATION: _ <br /> pp �`)��� � r BUILDING AREA:,�SC�C� sq ft <br /> PROJECT ADDRESS: ZZ 1 SE Ever -PL- 1/ "`� "y 37-'li-z� <br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION WENANT IMPROVMENT 0 REMODEL <br /> BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX <br /> ADU • MULTI-FAMILY-#OF UNITS: COMMERCIAL <br /> ' ELECTRICAL.APPLICATION.INFORMATION.& DESCRIPTION'OF WORK <br /> CONTRACT PRICE OF WORK:$ Z-A . 00 (ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: f-a-v b�_ -r '�v« 41I Vel c'e- .T 3.40A-0, r "`Ipl`.-`� . <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? Fol NO 0 YES-Select Scope: 0 Service 0 Feeder ® Circuits-#: 0 Complete Re-wire <br /> LOW VOLTAGE WORK? 0 NO YES-#of Devices: 1 0 <br /> SELECT SCOPE(REQUIRED): <br /> Mate ® Intercom 0 Thermostat ill Audio '0 Secure Access 0 Security System <br /> 0 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 /> CODE COMPLIANCE <br /> IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: 'NO 0 YES See Below&Pg.2 <br /> 1:1 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: JO ®YES-See Below&Pg. 3 <br /> El 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: �8_,1.- l.-.)�r.j 5 e-'S TENANT BUSINESS NAME(If Commercial): <br /> 1/ r/ I_J t 61 fir—z <br /> OWNER MAILING ADDRESS: STREET Z Z I Alt- STATE <br /> Ev' i � ' / ) <br /> CITY ,C LiGrTLY�T STATE Li'l/ti- ZIP 9'R z CP? <br /> OWNER PHONE: 'OWNER EMAIL: <br /> CONTRACTOR NAME: 7r..).C,ri-, (.2.,3*-d//,-, -11-7c- - <br /> CONTRACTOR ADDRESS: STREET '/I/ gax7- ✓P • E_ACc CZ [ q4/D© <br /> ` STATE /.J ZIP /cy <br /> e•v <br /> CITY �/.7-i�T� /-� <br /> c,.._ C CQ//5"eczC=c'z"1 " `'4' '' <br /> CONTRACTOR PHONE�YZS/3/7—`>�Z� ICONTRACTOR EMAIL: c. .S y <br /> CONTRACTOR LIC.#(REQUIRED): ‘i-7- ICITY OF EVERETT BUSINESS LIC.#(REQUIRED): <br /> PRIMARY CONTACT: 0 OWNERS`ONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAM4 E: (1-12.3"--) <br /> sz G 7E'Z <br /> :..� S CONTACT PHONE:CONTACT EMAIL: G„f 5 j .�& Cca .0.5 Lc:.c3•.+-, . G,C�--"t 1 <br /> AGREEMENT."t hereby certify thahave 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 <br /> ty for <br /> r which applihrett Opic atil n s made and t <br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. CiPERMIT#: <br /> g <br /> i�/� E "i g 02:OL\(0 <br /> 1/11/2019) Page 1-Application <br /> Owner/Authorized Agent Signature <br /> Date (Revised <br />