1717 13TH ST FLOOR 2 MEDICAL CENTER 2021-09-08

li OTten. ELECTRICAL PERMIT APPLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT,WA 98201 (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION' PROJECT ADDRESS: 1 f- 1. tc..1 5-,-- El vi:-if-( )ti101 BUILDING AREA: sq ft PROJECT TYPE: 0 NEW CONSTRUCTION 0 ADDITION TENANT IMPROVMENT 0 REMODEL BUILDING USE: 0 SFR 0 TOWNHOUSE 0 DUPLEX 0 ADU 0 MULTI-FAMILY-#OF UNITS: MCOMMERCIAL ELECTRICAL APPLICATION=INFORMATION-&;DESCRIPTION OF WORK . CONTRACT PRICE OF WORK:$ S-00 "- ASSOCIATED BUILDING PERMIT#(if applicable): DESCRIBE SCOPE OF WORK: ✓G( 2 Cut-.;'( 3 ow-1-(SFS q 'I>re)a: crs 6•M+Ce__ THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LINE VOLTAGE WORK? 0 NO (ES-Select Scope: 0 Service 0 Feeder 0 Circuits-#: 0 Complete Re-wire LOW VOLTAGE WORK? NO r//❑YES-#of Devices: gco, SELECT SCOPE(REQUIRED): Data 0 Intercom ❑Thermostat 0 Audio 0 Secure Access 0 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): CODE COMPLIANCE _ - IS THIS P MIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: 0 NOYES--See Below&Pg.2 By checking this box, I am stating that I have read and understand all of WAC 296-46B-900,selecte the pecific 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 age 2 require Plan Review. ARE YOU AN OWNER PERFORMING WORK AS THE CONTRACTOR WITHOUT ELECTRICAL LICENSURE: ONO OYES-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: s�t"oUi�(ff O_�ivtCI Y� IA I cL TENANT BUSINESS NAME(If Commercial): nn!'��a�1�I C' C OWNER MAILING ADDRESS: STREET j$C 1 Lt pct Ac S 1,j 4-70 I CITY d* yl STATE 6'34- !ZIP 465- 3 OWNER PHONE: OWNER EMAIL: t CONTRACTOR NAME: V4'L.A `(CCfc' L. ,( CONTRACTOR ADDRESS: STREET 76) (14 Xv r 5 CITY 5e6..14 k STATE /j(,4 ZIP 72)!L' p) CONTRACTOR PHONE: -1t)4 "J ZOC) CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): V 4} JL 3-442- M Ld CITY OF EVERETT BUSINESS LIC.#(REQUIRED) r -111 i!S- PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR AOTHER(Please Specify) (d Lt.vrG.`ct( f=.:)!'G.vie sr7 CONTACT NAME: n CONTACT PHONE: i ,j --)t),'�, " 2 ,— �A G�►OL%IW�,r C CONTACT EMAIL: 5 `. , v,s4:�..4./C( !; - o�''-'r 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 wCity f Everettk for wichOfficial ti application is made Use Only and I comply with the State Contractors Law 18.27 RCW and 296.200 WAC. - PERMIT#: 41/r 6//.7 0 r/Authoriz A en 'gnature Date (Revised 1/11/2019) Page 1-Application gLl I