4201 RUCKER AVE COMMUNITY HEALTH CENTER 2022-10-07

I ELECTRICAL PERMIT APPLICATION EVERETT CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET,EVERETT,WA 98201 WASH INGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov l www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 4201 Rucker Ave, Floors 1 & 3 BUILDING AREA: sq ft PROJECT TYPE: ❑ NEW CONSTRUCTION ❑ADDITION LrJ TENANT IMPROVMENT ❑ REMODEL BUILDING USE: ❑ SFR ❑ TOWNHOUSE ❑ DUPLEX ❑ADU ❑ MULTI-FAMILY-#OF UNITS: 9rcOMMERCIAL ELECTRICAL APPLICATION INFORMATION & DESCRIPTION OF WORK CONTRACT PRICE OF WORK:$ 1,200.00 ASSOCIATED BUILDING PERMIT#(if applicable): B21 12-008 DESCRIBE SCOPE OF WORK: Relocate twelve (12) existing thermostats. THIS INSTALLATION INCLUDES THE FOLLOWING SCOPE: (SELECT ALL THAT APPLY) LrJ LINE VOLTAGE WORK? NO ❑ YES-Select Scope: ❑ Service ❑ Feeder ❑ Circuits-#: ❑ Complete Re-wire LOW VOLTAGE WORK? ❑ NO VYES-#of Devices: 12 SELECT SCOPE(REQUIRED): ❑ Data ❑ Intercom 1RThermostat ❑ 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): CODE COMPLIANCE IS THIS PERMIT EDUCATION, INSTITUTIONAL,HEALTH AND/OR PERSONAL CARE FACILITIES: 'NO El 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:VO 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. CONTACT INFORMATION OWNER NAME:Community Health Center of Sno County TENANT BUSINESS NAME(If Commercial): Community Health Center of Snohomish County OWNER MAILING ADDRESS: STREET 8609 Evergreen Way crry Everett STATE WA zP 98208 OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: Evergreen Refrigeration CONTRACTOR ADDRESS: STREET 727 South Kenyon St. crry Seattle STATE WA zw 98108 CONTRACTOR PHONE: 206-763-1744 CONTRACTOR EMAIL: alexb@evergreenhvac.com CONTRACTOR LIC.#(REQUIRED): EVERGRL813MA CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 044350 PRIMARY CONTACT: ❑OWNER CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: Alex Burkhart CONTACT PHONE: 206-763-1744 ext. 247 CONTACT EMAIL: alexb@evergreenhvac.com AGREEMENT:I 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 fhe 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 PERMIT#: �C , �� E `�2 °2- �� Owner/Authorized Agent Signature Date (Revised 1/11/2019) Page 1-Application