1700 13TH ST 9TH FLOOR 2022-01-20

fLECTRICAL PERMIT APPLI -ATION EVERETT 32CITY OF EVERETT PERMIT SERVICES 00 CEDAR STREET, EVERETT, WA 98201 WASHINGTON (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT ADDRESS: 1 324- COIb Ave 1 -7,�'? IBUILDING AREA: 9,000 sq ft PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ ADDITION ✓❑ TENANT IMPROVMENT ❑ REMODEL BUILDING USE: ❑ SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: ✓❑ COMMERCIAL ICONTRACT PRICE OF WORK: $ 26,000.00 (ASSOCIATED BUILDING PERMIT # (if applicable): _j J 01 O 3-DOZ I DESCRIBE SCOPE OF WORK: Installation of (40) dual Cat6A Dlenum data cables to 9th floor Datient rooms THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? ✓❑ NO ❑ YES - Select Scope: ❑ Service ❑ Feeder ❑ Circuits-#: ❑ Complete Re -wire LOW VOLTAGE WORK? ❑ NO ❑✓ YES- # of Devices: 40 SELECT SCOPE (REQUIRED): ✓❑ Data ❑ Intercom ❑ Thermostat ❑ Audio ❑ Secure Access ❑ Security System ❑ Fire Alarm - Installations under this permit only include electrical wiring rough -in of the system. An additional Fire Alarm Permit is required for review of device location and installation approval. ❑ Other (List All): IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: U NO IJ YES --See Below & Pg. 2 By checking this box, I am stating that I have read and understand all of WAG 296-46B-900, selected the specific reason on page 2 of this application (see next page), AND Plan Review is NOT required because I meet all of the following sub sections that do not See Page 2 require Plan Review. ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ✓❑NO DYES -See Below & Pg. 3 Pursuant to RCW 19.28.261, property owners and leaseholders cannot perform electrical work on buildings for rent, sale, or lease without the proper electrical licensing and certification, or exemption. By checking this box, I am stating that I have completed and See Page 3 signed the AFFIDAVIT on page 3 of this application to receive an exemption from this licensing/certification requirement. OWNER NAME: Providence Health & Services TENANT BUSINESS NAME If Commercial): Providence Hospital OWNER MAILING ADDRESS: STREET 1801 Lind Ave SW I CITY Renton STATE WA ... 98057 1 (OWNER PHONE: 425-525-3355 1OWNER EMAIL: CONTRACTOR NAME: Pacific Communications Cabling CONTRACTOR ADDRESS: STREET 10604 E Riverside Dr I CITY Bothell STATE WA ZIP 98011 1 CONTRACTOR PHONE: 425-483-5957 1CONTRACTOR EMAIL: administrator@pacificcc.com CONTRACTOR LIC. #(REQUIRED): PACIFCC9101_5 CITY OF EVERETT BUSINESS LIC. #(REQUIRED): 035656 PRIMARY CONTACT: DOWNER ❑✓ CONTRACTOR ❑OTHER (Please Specify) (CONTACT NAME: Chris B u rg h d CONTACT PHONE: 425-770-3764 uff CONTACT EMAIL: administrator@pacificcc.com certify that I have read and examined this application and know the same 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 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/ comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only FPERM�IIT #: i 8/5/2019 I �� Owner/Authorize gent Signature Date (Revised 1/1112019) Page 1-Application I )3