3726 BROADWAY US HEALTHWORKS 2017-04-19

ELECTRICAL PERMIT APPLICATION 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: BUILDING AREA(if residential,new construction, remodel,or addition) SF BUILDING TYPE: ❑ SFR-DETACHED ❑SFR-ATTACHED ❑ DUPLEX ❑ MULTI-FAMILY-#OF UNITS: i•COMMERCIAL USE OF BUILDING: ELECTRICAL APPLICATION INFORMATION CONTRACT PRICE OF WORK: $ NUMBER OF DEVICES (if low voltage): FIRE ALARM? ❑YES —�W NO ASSOCIATED BUILDING PERMIT# if applicable) DESCRIPTION OF WORK: OO �()C UVW2127 CONTACT INFORMATION i OWNER NAME: QS4EWEN.k-AATENANT NAME(If Commercial): i OWNER MAILING ADDRESS: STREET CITY Aam STATE ZIP OWNER PHONE: % OWNER EMAIL: CONTRACTOR NAME: 0) 1 CONTRACTOR ADDRESS: STREET CITY STATE zIP 1 CONTRACTOR PHONE: 1 a _ A (%Cu CONTRACTOR EMAIL: , CONTRACTOR LIC.#(REQUIRED): ,` ��1�� J CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: ❑OWNER CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: © � CONTACT PHONE: t — CONTACT EMAIL: AGREEMENT.T hereby certify that I 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/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 FEE PERMIT# CO2- OwnerlAuthorized Agent Signature Date (Revised 10/12/2015)