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' OLT ELECTRICAL PERMIT APPLIGi'ION <br /> CITY OF EVERETT PERMIT SERVICES 24'7 „o <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.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: :JI 9 CpVrj BUILDING AREA: sq ft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION ADDITION 0 TENANT IMPROVMENT 0 REMODEL <br /> BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU VI MULTI-FAMILY-#OF UNITS: pi COMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION &DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$ /55D0 <br /> "t' ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: C✓,4-Tb/Z up e'Li--L AkI4 "5 i 2 - L(6,1473 <br /> •n <br /> �'E6W 0-a-c ,s ,tJ n r /-/I/ eri m-L/t e,a(-f-r/r, f=iq do vivic,.r 0IQ z-/� <br /> 6.1AtreA)V6iii 4 \-5 <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? 0 NO 0 YES-Select Scope: ®Service V9 Feeder ® Circuits-#: EQ 0 Complete Re-wire <br /> LOW VOLTAGE WORK? 0 NO 0 YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): <br /> ❑ Data 0 Intercom 0 Thermostat 0 Audio 0 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 /> CODE COMPLIANCE : <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: TO NO 0 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 /> 0 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: 5flort:4UL J 4t 7141 TENANT� BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET ,Z 1-01-� 6_71.1-;-y /- i/ -"i %Zc- Q ,/ <br /> CITY �G"'�T W <br /> r STATE )4 ZIP r e;266, <br /> 42-76- ZS Z 64ro OWNER EMAIL <br /> OWNER PHONE: <br /> CONTRACTOR NAME: G-241-rU,TG C4,,,EL172-fr..2-- Tt-IC- <br /> CONTRACTOR ADDRESS: STREET Pt, 0 ,.2 <br /> CITY n/g`Gxr STATE 044mew_ <br /> ZIP UVr2 <br /> ,J <br /> CONTRACTOR PHONE: 42- .7 .---,7 44 CONTRACTOR EMAIL: Qyca/1r-fee l�fv''LJ(� <br /> ,�,' mea' , Covi,A <br /> CONTRACTOR LIC.#(REQUIRED): L gni' i�l Z{�,7 CC- CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 2 210 <br /> PRIMARY CONTACT: ❑OWNER ®CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 4 Zy— X0-- /55D <br /> 13, -i- 1--4,730-- 5 CONTACT EMAIL: rgia:l a-re.--<e I trac;.by vici a,_ , 144 <br /> AGREEMENT:1 hereby certify that I have read and examined this application and know the same to be true and correct. All provisions o aws 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 /> r for <br /> r which Opic atl ion is made Use Only <br /> and I <br /> comply with the State Contractors Law 18.27 RCW and 296.200 WAC. <br /> PERMIT#: <br /> • <br /> IV:" 4 ' o E)0 orb_ 10� <br /> Owner/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application <br />