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DocuSign Envelope ID:2302FE1A-EE47-4F72-B 53E53949CB4E Costco Loc. No. 114/BCE#6226 <br /> 44-17- ELECTRICAL PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 FAX 425-257-8857 1 (E) everetteps@everettwa.gov l www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 10200 19th Ave SE Everett, WA 98208 <br /> BUILDING AREA(if residential, new construction, remodel, or addition) N/A SF <br /> BUILDING TYPE: 0 SFR-DETACHED 0 SFR-ATTACHED ❑ DUPLEX 0 MULTI-FAMILY-#OF UNITS: COMMERCIAL <br /> USE OF BUILDING: Costco Fueling Facility (Loc. No. 114) <br /> `IC 1 KATION INFORMATION <br /> CONTRACT PRICE OF WORK: 19,000.00 <br /> NUMBER OF DEVICES (if low voltage): N/A <br /> FIRE ALARM? 0 YES FZI O <br /> ASSOCIATED BUILDING PERMIT#(if applicable): <br /> DESCRIPTION OF WORK: Remove existing dispensers. Install new dispensers. Install new new hoses, nozzels and breakaway valves. <br /> Perform any and all purging, regulatory testing, and calibration on the newly-installed dispensers. Extend the existing dedicated power. <br /> Disconnect and reconnect the power, data, CRIND, and controls. <br /> CONTACT INFORMATION <br /> OWNER NAME: Costco Wholesale (Loc.No. 114) TENANT NAME(If Commercial): Costco Gasoline (Loc. No. 114) <br /> OWNER MAILING ADDRESS: STREET P.O. Box 35005 <br /> CITY Seattle STATE WA Zlp 98124-3405 <br /> OWNER PHONE: (425) 313-8100 OWNER EMAIL: Dlarson@costco.com <br /> CONTRACTOR NAME: Cowlitz Clean Sweep <br /> CONTRACTOR ADDRESS: STREET 55 International Way <br /> CITY Longview STATE WA Zip 98623 <br /> CONTRACTOR PHONE: (360)423-6316La.C�' <br /> La� ONTRACTOR EMAIL: <br /> CONTRACTOR LIC.#(REQUIRED):-501217845- ILC) CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 052186 <br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR fII OTHER(Please Specify) Barghausen Consulting Engineers <br /> CONTACT NAME: CONTACT PHONE: (425)251-6222 <br /> Alexia Inigues CONTACT EMAIL:Ainigues@barghausen.com <br /> AGREEMENT.I 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 <br /> 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 <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 Law 18.27 RCW and 296.200 WA C. <br /> City of Everett Official Use Only <br /> 000usigned by' PERMIT# <br /> 'M GU, 7/31/2017 E _ 002 <br /> i4tfif426811Pd Agent Signature Date <br /> (Revised 9/23/2016) <br />