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ELECTRICAL �TIl CITY OF EVERETT PERMIT SERVICES
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<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 1 FAX 425 257-882507 1(E))everrnette�ppC�sOp@everettwa gov I��,1waw everettwa gov/perTmits
<br /> ! �x 1 Y x.' _ \ "S 3 e 2� .,`� ROYECT�SLT 1NtOLP VIOLA B T �. v 'Ty.'4 ,S:Y �'��Sy. �` „4��.K� �'...`;v21 ti. ti�i h..
<br /> PROJECT ADDRESS:.._.� ,��.,,�,�> 4..�, �-,.a..�-- _�---
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<br /> b 1 5 epAN.1 6 Pro e BUILDING AREA: sq ft
<br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION 0 TENANT IMPROVMENT 0 REMODEL
<br /> BUILDING USE: 0 SFR 0 TOWNHOUSE DUPLEX 0 ADU MULTI FAMILY #OF UNITS: 0 COMMERCIAL
<br /> n EL`EC'TR �A4 A!PiL1 T{ON„NM,NFORMAT` ON& DES UP .a. > $W r . , .., .....,.
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<br /> CONTRACT PRICE OF WORK:$ 3 T\ 4506 •"° 'ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> DESCRIBE SCOPE OF WORK: �t.t n\ t y j - ��` c e, J J o
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<br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY)
<br /> LINE VOLTAGE WORK? 0 NO YES-Select Scope:pService 0 Feeder 0 Circuits-#: 0 Complete Re wire
<br /> LOW VOLTAGE WORK? 0 NO YES-#of Devices:
<br /> SELECT SCOPE(REQUIRED):
<br /> 0 Data 0 Intercom Thermostat 0 Audio Secure Access 0 Security System
<br /> ❑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 /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: U NO O 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.
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<br /> OWNER NAME: cl\c��i 4yve- 4-e `w�h TENANT BUSINESS NAME(If Commercial):
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<br /> OWNER MAILING ADDRESS: STREET tt 5 1 V E ,J I I r 1 ' elg-j 3
<br /> CITY Pt Y` ` 4 'O V t` STATE iJ 4- ZIP 1 23
<br /> OWNER PHONE / — - OWNER EMAIL: ^ (/vt � —
<br /> CONTRACTOR NAME Psa-U C K e Ay l'(-- TIA E , �, /l
<br /> CONTRACTOR ADDRESS: sTREEr ��
<br /> . eSi'ek�''. STATE t t .ZIP
<br /> CITY ((�� t (�
<br /> CONTRACTOR PHONE: 'CONTRACTOR EMAIL: S``W,..PZ(,.J' 1 =Q �� a Ni�
<br /> CITY OF EVERETT BUSINESS LIC.#(REQUIRED)
<br /> CONTRACTOR LIC.#(REQUIRED): � I '! � tires dikok
<br /> PRIMARY CONTACT: 0 OWNER I CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 1-4-D6-^19 0 3c _-
<br /> 1 ! CONTACT EMAIL: j.r 1 av�..v (<-K Q) C/Ovrk C'-54 . r e
<br /> AGREEMENT::I hereby certify 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 wor rk for
<br /> Ewhictt Official on Use made and I
<br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. CitPERMIT#:
<br /> �. ^ - �.� o2 �-\ 05
<br /> Own ":uthonaed Agent Signature
<br /> Dat- (Revised 1/11/2019) Page 1-Application
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