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OLTELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa.gov i www.everettwa.govlpermits <br /> MtfffiefigiVtjRggi44smvzi,i;,:.:_.-- PROJECT SITE 1 . . <br /> PROJECT ADDRESS: 2..7z--7 y Jt BUILDING AREA: sq ft <br /> PROJECT TYPE: gNEW CONSTRUCTION ❑ADDITION ❑TENANT IMPROVMENT ❑ REMODEL <br /> BUILDING USE: ❑SFR El TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI FAMILY #OF UNITS: COMMERCIAL <br /> of EPECTR1! AL APR4OCATION INFOM A 1• fDESC tIPTI: F.WO... ''' . i of <br /> CONTRACT PRICE OF WORK:$ 200.00 ASSOCIATED BUILDING PERMIT#(if applicable): 51 9 0 2 - (0{o <br /> DESCRIBE SCOPE OF WORK: <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? El NO El YES -Select Scope:❑Service ❑ Feeder Li Circuits-#: El Complete Re-wire <br /> LOW VOLTAGE WORK? ❑✓ NO El YES-#of Devices:_ <br /> SELECT SCOPE(REQUIRED): CI Data fl .niarcorr El-i nE:rmostat El Audio El Seciu,:Access ❑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 A!I)_SIGN LIGHTING <br /> 1 _,TentC;O__ C( PLiAtNCE-,--!- ..., _ ' . -- .: .1,.' -_.•f..' . .• ,' • :.'',74Alista <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACtILITIES: ✓ NO ❑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 I`iOT required because I meet all of_re 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 LK:ENSURE° LINO EYES-See Below&Pg.3 <br /> Pursuant to RCW 19.28.261,property owners and leaseholders cannot perform electrical workor; 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 rer:eive an exemption from this iicensir 3/certification requirement. <br /> 0,0 4._ ®t. ON FORMATION .. ` . .. <br /> OWNER NAME: A /, el Ir 4 TENANT BUSINESS NAME(if Commercial): iff/j/PQ//trt J, /< <br /> OWNER MAILING ADDRESS: STREET s a. -V -,fl'Z <br /> CITY � cillif:l ik2 �s..-__, /1- .9CJb 1 5,-R E ZIP _ <br /> OWNER PHONE: IiDWNER EMAIL: <br /> CONTRACTOR NAME: SECURITY SIGNS, INC <br /> CONTRACTOR ADDRESS: STREET2424 SE HOL}ATE E;_VD <br /> . CITY PORTLAND STATE OR ZIP 97202 <br /> CONTRACTOR PHONE:503.'5546/102 {ICON n RACTOR LAIAL:permits@securitysignii.com <br /> (CONTRACTOR LIC.#(REQUIRED):SECURSI005KS �YIC.JY OF EVERETT EIUSINESS LIC #(REQUIRED): 1Q g� <br /> PRIMARY CONTACT: ❑OWNER [✓]CONTRACTOR E01-HER(;'lease Specify) <br /> ;CONTACT NAME: CONTr.CT PHONE F03.546.7102 <br /> CYNDI STOCKS :C_, IT,'.( t-zviAlL:oa mits@secL ritysig ns.r:onn -- <br /> AGREEMENT::I hereby certify that I have read and examined this a,plic=tier au 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 R hermit roes not presume to give atr'hority to via%ate or cancel the provisions of any other state or <br /> local law regulating construction or the performance of construct.on That I am<ruthorized by the owner of this properly is perform the work for which application is made and I <br /> comply with the State Contractors Law 18.27 RCW and 296.200 W4C. C i.v..c.1.2arlt.L.01.0 cial Use Only <br /> PERMIT t: <br /> ,4,-/ L.,ii_=_;7_/7 E: }0, (9- 6 7.--i <br /> Owner! thorized Agent Signature De.e (Revised'7//*1;'2019) Papa'I-Application <br />