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AECTRICAL PERMIT APPLICITION <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETT 3200 CEDAR STREET, EVERETT, WA 98201 <br />VVASHfNGTON (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everettepscf-Deverettvia.Qov I www.everettwa.00vinprmils <br />PROJECT SITE INFOrtMATION-- <br />PROJECT ADDRESS: 5209 Evergreen Way <br />BUILDING AREA. 10,000 ft <br />—sq <br />PROJECT TYPE: 0 NEW CONSTRUCTION 11 ADDITION ❑ TENANT IMPROMENT OV REMODEL <br />BUILDING USE: 1JSFR 0TOWNHOUSE ODUPLEX 11ADU 11 MULTI -FAMILY - #OF UNITS: COMMERCIAL <br />ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WONK <br />CONTRACT PRICE OF WORK: $ 900 <br />ASSOCIATED BUILDING PERMIT# (if applicable): <br />DESCRIBE SCOPE OF WORK: <br />Replace meter base due to water damage, PUD disconnected due to significat rust and water intrusion <br />THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) <br />LINE VOLTAGE WORK? 1:1 NO Z YES - Select Scope: 9 Service D Feeder [I Circults-#; ❑ Complete Re -wire <br />LOW VOLTAGE WORK? Z No 0 YES- # of Devices: <br />SELECT SCOPE (REQUIRED): 0 Data D Intercom 7 Thermostat ❑ Audio ❑ secure Access ❑ 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: ✓[!�JNO 11-YES--SeeBelow&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 />F] 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: M-/ NO []YES -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 />F-1 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: TENANT BUSINESS NAME if Commerclal): Grocery Outlet <br />OWNER MAILING ADDRESS: STREET <br />CITY STATE ZIP <br />OWNER PHONE: <br />1OWNER EMAIL: <br />CONTRACTOR NAME: OEG, Inc. dba Pride Electric, Inc. <br />CONTRACTOR ADDRESS: ITREST3200 NW yeon Ave. <br />cay Portland STATE Or zip 97210 <br />CONTRACTOR PHONE: 4254543665 <br />1CONTRACTOR EMAIL:mruSSell@prideelectric.com <br />CONTRACTOR LIC. #(REQUIRED):OEG*11*823NF <br />ICITY OF EVERETT BUSINESS LIC. #(REQUIRED). 60442 <br />PRIMARY CONTACT: 0OWNER RICONTRACTOR E]OTHER (Please Specify) <br />CONTACT NAME: Mark Russell <br />AGREE;Z_NT.- i jj;r_&bv certffv that I have ra.H <br />CONTACT PHONE: 425-681 -5 356 <br />CONTACT EMAJL:mark.russell@prideelectric.com <br />ahu till provisions or laws and ordinances governing this <br />type of work will be completed whether spa dried herein or not. The granting of a permit W''11e.'n"'' o'tp' presume "u <br />umato give authority to violate or cancel the provisions at 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 Low 18. 27 RCW and 296.200 WAC. Cltv of Everett official Use nniv <br />