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E <br /> ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 3200 CEDAR STREET,EVERETT.WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.eyerettwa.goy/permits <br /> PROJECT'SITE;INFORMATION <br /> PROJECT ADDRESS: 10115 Holly Drive Everett, WA 98204 Bldg. T BUILDING AREA: 50 sq ft <br /> PROJECT TYPE: El NEW CONSTRUCTION El ADDITION Ell TENANT IMPROVMENT El REMODEL <br /> BUILDING USE: LI SFR Li TOWNHOUSE El DUPLEX El ADU II MULTI-FAMILY-#OF UNITS:16 71 COMMERCIAL <br /> EIECTRAJ9pPLJYiON-inNiFoRMAronwpgscRkt <br /> CONTRACT PRICE OF WORK:$ 3,234.00 ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIBE SCOPE OF WORK: <br /> Install fire alarm control panel and install AES radio within a NEMA-4 enclosure. <br /> THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br /> LINE VOLTAGE WORK? 0 NO D YES-Select Scope: El Service D Feeder D Circuits-#: El Complete Re-wire <br /> LOW VOLTAGE WORK? El NO El YES-#of Devices: 2 <br /> SELECT SCOPE(REQUIRED): El Data El Intercom D Thermostat Ei Audio D Secure Access El Security System <br /> RI 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 /> Li Other(List All): <br /> cODE COPINIANCE <br /> IS THIS PERMIT EDUCATION,INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: El NO 0 YES--See Below&Pg.2 <br /> By checking this box, I am stating that I have read and understand all of WAC 296-468-900,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: ENO OYES-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 /> 71'''• CONTAZTINFoRmAnoN <br /> OWNER NAME: AMC LLC TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET 10115 Holly Drive <br /> ,,T, Everett STATE WA z„,,98204 <br /> OWNER PHONE: 425- 341- 0146 OWNER EMAIL: olinfieldsmaintenance@gmail.com <br /> CONTRACTOR NAME: Performance Systems Integration, LLC DBA Fire King of Seattle <br /> CONTRACTOR ADDRESS: STREET 240 S. Holden St. <br /> CITY Seattle STATE WA 98108 <br /> CONTRACTOR PIIONE:206- 763-4177 CONTRACTOR EMAIL: tmoore@firekingofseattle.com <br /> CONTRACTOR LIC.#(REOUIRED):PERFOS1831PE CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 04(01(i 3 <br /> PRIMARY CONTACT: DOWNER DCONTRAOTOR DOTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 206- 763-4177 <br /> Tam i Moore 'CONTACT EMAIL: tmoore@firekingorseattle.com <br /> AGREEMENT:I hereby certify that I have read and examined this application and know the same to be true and correct, Al!provisions of taws 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 emulsions of any other state or <br /> local law regulating construction or the performance of construction, That lam authorized by the owner of this property to perform the work for which application is made arid/ <br /> Comply with the State Contractors Law 18.27 RCW and 298.200 WAC. City of Everett Official Use Only <br /> ( <br /> PERMIT#: <br /> E go's-i55' <br /> Owner/Authorized Agent Signature Date (Revised 1/11/2019) Page I-Application <br />