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<br /> ELECTRICAL RMI FIRE LAR PERMIT APPLICATION
<br /> "SP CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT,WA 98201
<br /> ' .. . - (P)425-257-8810 I FAX 425-257-8857 I (E)everetteps@evereftwa.gov I www.everettwa.gov/permits
<br /> A. `W . Pttait- TSTE IFORMATIONr� , I1 ^
<br /> PROJECT ADDRESS: SPD Citogtc2t 41 . 6.1, 0‘.4
<br /> \IVPROJECT TYPE: 0 NEW CONSTRUCTION ADDITION 0 TENANT IMPROVMENT EMODEL fr,On al)
<br /> BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU pAULTI-FAMILY-#OF UNITS: 0 COMMERCIAL
<br /> BUILDING AREA: sq ft
<br /> NIM , E4:CTRICAL AI'PLICATIO$10:FO1RNI#1N . :. , , . I`.r, s. ..:.:... . ...:,
<br /> CONTRACT PRICE OF WORK:$ ` 000 -- ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> IS THIS LOW VOLTAGE WORK? n -NO 0 YES-#OF DEVICES:
<br /> IS THIS A FIRE ALARM PERMIT? 0 NO 0 YES-Plans required for review(Both Electrical and Fire Department inspections are required)
<br /> 0:, 0:0 PT�OW0 'W-0,0**10 COMPLIANCE 1 ` °a R ' ' '
<br /> , .c.<-, e. a ....s .,. _ -. .ar C�.,.r.,a:v.,:r.. 1, -., a a., � ..,..,w,� .,.�. '..,. a.,. _ .. o,�.,.,.y.xx ,.. ,.`Ctt,v r.h Y-.r, .. .�.a. ; a,.....'
<br /> DESCRIPTION OF WORK: _ . VT 4�I Y1 STct,�, P)(;A—W'�'[r
<br /> ICU $f �'SPc cA‘uoc i r
<br /> mivevw m
<br /> THIS SECTION APPLIES TO ALL EDUCATION,INSITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: ,
<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 /> ATTENTION OWNERS:THIS SECTION IS FOR OWNERS PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE:
<br /> ® Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical work on buildings for rent,sale,or lease without
<br /> the proper electrical licensing and certification,or exemption.By checking this box,I am stating that I have completed and signed the
<br /> See Page 3 AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement.
<br /> 004.1i4OT INFORMATION
<br /> OWNER NAME: 'L O .AA AA" TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREETS oho C/ �D '611614 a!/��� f�
<br /> 2 CITY V 6 /- 1 Coro
<br /> STATE WA ZIP V`lr/.
<br /> OWNER PHONE:f(Q0• '"�Z- OWNER EMAIL ft- L �j W--Mt1 t'
<br /> CONTRACTOR NAME:-#L[ t"OC_ 41 0 M-Ci 614 tt 4-12.I` >
<br /> CONTRACTOR ADDRESS: STREET 592' " ASE
<br /> CIN V 1 STATE w A ZIP',(6Z 0`J
<br /> CONTRACTOR PHONE: -/"))1- DOW CONTRACTOR EMAIL: M)Nei,1 E MA iv tv).e1)IPy)
<br /> CONTRACTOR UC.#(REQUIRED): I ' f) 'LQ 1 K IP CITY OF EVERETT BUSINESS LIC.#(REQUIRED): L.
<br /> PRIMARY CONTACT: ❑OWNER r4 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:t.\' 7„`1-2-U'(�OO
<br /> N t )1 1 1�7 T'A�J 1� _.�f)f r CONTACT EMAIL: ��Y 1'IAA I`aj A nE(/U U 1 bm,i iD IA
<br /> AGREEMENT:l 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
<br /> governing this 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
<br /> provisions of any other state or local law regulating construction or the performance of construction. That I am authorized by the owner of this property to perform the
<br /> work for which application is made and I comply with the State Contractors Law 18.27 RCW and 296.200 WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
<br /> 0,4A),\./ .1(10(PO-12f1
<br /> Owned,uthorized Agent Signature Date (Revised 10/30/2018) Page 1 of 3
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