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'. �► ELECTRICAL 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.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS:f2 4)-c, 3C c-A BUILDING AREA: )-c-ii: sq ft <br /> PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION rZTENANT IMPROVMENT 0 REMODEL <br /> BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: ,OMMERCIAL <br /> ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK <br /> CONTRACT PRICE OF WORK:$ a)Li?'TOO ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: AXr\c;v‘c, 6-.r�,� \-C "tQ LC(,)-0,-A. CS NG u <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? 0 NO cl4S-Select Scope: 0 Service 0 Feeder 2 C rcuits-#:el 0 Complete Re-wire <br /> LOW VOLTAGE WORK? SO 0 YES-#of Devices: <br /> SELECT SCOPE(REQUIRED): 0 Data 0 Intercom 0 Thermostat 0 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: gNO 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:, IJO DYES-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. <br /> CONTACT INFORMATION ' _ . . <br /> OWNER NAME: \ c;oL-'\ L c -k') 5 TENANT BUSINESS NAME(If Commercial): t-:: v\ (jj' C-�+e � <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: s' 1 ("A" riCC-•# i C- <br /> CONTRACTOR ADDRESS: STREET LA41V e•-\ ?C.C.',(-4-C_ Au <br /> CITY '-.1.C-0'1r&ck ` STATE LA)I ZIP p 1 p,�r,R <br /> CON, ,TRACTOR PHONE: X)4'-`1O5-el D)/ CONTRACTOR EMAIL: t c kt c-A fkec-4 ,i-. - <br /> CONTRACTOR LIC.#(REQUIRED):. �REel3,4.LC> CITY OF EVERETT BUSINESS LIC.#(REQUIRED): i(—) 33 <br /> \I <br /> ‘ s , <br /> PRIMARY CONTACT:" ❑OWNER�.. .. ._... �a �.._� <br /> . CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACTg� NAME: (� '- CONTACT PHONE: ( -53- 4 y5 .eicS1 ' <br /> Vk "`y Re:A c.\ -. CONTACT EMAIL: etki,srrity24apt <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 work for which application is made and I <br /> comply with the State Contractors Law 18. 'CW and 296.200 WAC. City of Everett Official Use Only <br /> PERMIT#: <br /> , EII6L\— \12 (a <br /> Tr Autho "ed Age 't Si. - ure Date (Revised 1/11/2019) Page 1-Application <br />