1010 SE EVERETT MALL WAY NORTHWEST KIDNEY CENTER - EVERETT 2022-03-07

EVERETT WASHINGTON 10ECTRICAL PERMIT APPL*ATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 1010 SE Everett Mall Way, Suites 100,102,104 Everett WA 98208 BUILDING AREA: 9200 sq ft PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ ADDITION ❑✓ TENANT IMPROVMENT ❑ REMODEL BUILDING USE: ❑ SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ ADU ❑ MULTI -FAMILY - # OF UNITS: ❑✓ COMMERCIAL ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK CONTRACT PRICE OF WORK: $ 421,939.00 ASSOCIATED BUILDING PERMIT # (if applicable): DESCRIBE SCOPE OF WORK: New TI Build Out for Dialysis clinic includes all new electrical wiring, lighting, receptecles, panels, transfomers, connections to BBraun water treatment equipment. THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? ❑ NO ❑✓ YES - Select Scope: ❑ Service ✓❑ Feeder ❑✓ Circuits-#: 120 ❑✓ Complete Re -wire LOW VOLTAGE WORK? ❑ NO ❑✓ YES- # of Devices: 50 SELECT SCOPE (REQUIRED): ✓❑ Data Z Intercom ❑ Thermostat ❑ Audio ✓❑ Secure Access ❑✓ Security System 0 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): CODE COMPLIANCE IS THIS PERMIT EDUCATION, INSTITUTIONAL, HEALTH AND/OR PERSONAL CARE FACILITIES: D NO ✓ YES -- See Below & Pg. 2 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 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 YES -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. CONTACT INFORMATION OWNER NAME: Northwest Kidney Centers TENANT BUSINESS NAME (If Commercial): Northwest Kidney Centers OWNER MAILING ADDRESS: STREET 700 Broadway c,, Seattle STATEWA zia 98122 OWNER PHONE: 206-605-4484 OWNER EMAIL: randy.thompson@nwkidney.org CONTRACTOR NAME: Northstar Electrical, LLC CONTRACTOR ADDRESS: STREET PO BOX 1909 A ... 98041 CITY Bothell STATEWA CONTRACTOR PHONE: 206-786-2983 CONTRACTOR EMAIL: adamcCa northstar-electrical.com CONTRACTOR LIC. #(REQUIRED): NORTHEL878QF CITY OF EVERETT BUSINESS LIC. #(REQUIRED): 052744 PRIMARY CONTACT: DOWNER ❑✓ CONTRACTOR ❑OTHER (Please Specify) CONTACT NAME: Adam Chudoba CONTACT PHONE: 206-786-2983 CONTACT EMAIL:adamcl@nortshtar-electrical.com AGREEMENT: 1 hereby certify that 1 have read and examined this application and know the same to be true and correct. All provisions of laws and ordinances 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 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 I comply with the State Contractors Law 18.27 RCW and 296.200 WAC. City of Everett Official Use Only r RMIT #: Adam Chudoba �- 02/07/2020� _ Owner/Authorized Agent Signature Date (Revised 1/1112019) age 1-Application