HomeMy WebLinkAbout1122 D St - BuildingApplication Number
Application pin number
Property Address
ASSESSOR PARCEL NUMBER
Tenant nbr name
Application type description
Subdivision Name
Property Use
Property Zoning
Application valuation
Owner Contractor
ZINK DALE A
1122 S D ST
PORT ANGELES
WA )83637050
Permit ELE2TRICAL ALTER RESIDENTIAL
Additional desc EL SVC 2 CIRCUITS.
Permit pin number 106P89
Sub Contractor ELE2TRIC SERVICE
Permit Fee 46 00 Plan,Check Fee 00
Issue Date 7/30,/0,7 Valuation 0
Expiration Date 1/26/08
Qty Unit,•Charge: Fer
1 00 4'6, 00WEC'd Et R OR km 1 4 ALT CIRCUITS
Fee summary Charced Paid Credited Due
Permit Fee Total 46 00 46 00 00 00
Plan Check Total 00 00 00 '00
Grand Total 46 00 46 00 00 00
COMMI_NT /ACTION NEE )ED
CITY OF PORT ANGELES
PUBLIC WORKS ELECTRICAL DIVISION
321 EAST 5TH STREET PORT ANGELES. WA 98362
07 00000778 Date 7/30/07
347360
1122 D ST
06 30 00 0 3 5490 0000
DALE DIANE ZINK
PLUMBING REPAIR
RS7 RESDNTL SINGLE FAMILY
12300
ALPHA BUILDER CORPORATION
1028 W 13TH STREET
PORT ANGELES WA 98363
(360) 775 0759
Extension
46 00
CALL 417 -4735 FOR ELECTRICAL INSPECTIONS. PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. IT IS UNLAWFUL TO COVER,
INSULATE OR CONCEAL ANY WORK BEFORE IT IS INSPECTED AND ACCEPTED.
KEEP PERMIT CARD AND APPROVED PLANS AT JOB SITE
INSPECTION TYPE
DITCH 1 I ROUGH -IN COVER N 7 !o o 1
SERVICE I I
FINAL l 8/a/07 I,, I
i
GENERAL COMMENTS:
ELECTRICAL PERMIT INSPECTION RECORD
DATE
ACCEPTED
YES I NO
COMMENTS
Pw- 1102.13 [4'961
Job wired by
Electrical contractor nam
C_
Purchaser s mailing ad
Premises It vner'vamc
q G7..
LP t
Address ofitespeetion
0 22 S'
p4
City
Phone number to schedule inspection.
1:1 LOAD CHANGES
O Baseboard KW
O Furnace KW
Heat Pump Ton LAR
O Fan•Wall KW
Inspection
Date
JUL 12 201)7
UcHTDEP't
Tit d
Approve
FINA�
Dot I Appruvcu By
TT.I t7LT17 01
ecial Contractor 0 Owner
vet 2 Tzu-i T•r f 1320.1
oxa, g
State ZIP 1
r et 5y 6
License number Date Expires
Telephone number 'AX number
t t
1 /Installation description
O Commercial 11
O Overhead Service
O Temp Service
Underground Service
Area, Building or Equipment Inspected
ELECTRICAL WORK PERMIT APPLICATION
�•V
New
Owner as defined by RCW 19.28 26I (1) Owner will occupy the structure for two
years after this electrical permit is finalized. (2) Owner is required to hire an electrical
contractor if above said property is for sale. rent or lease.
After reading the above statement, I hereby certify that 1 ant the owncr of thc above
named property or a licensed electrical contractor. am making the electrical instal-
lation or alteration in compliance with the electrical laws, N.E.0 RCW Chapter
19.28, WAC Chapter 296-46B, The City of Port Angeles Municipal Code, and Card
Utility Specifications.
owner
actor or electrical adminlstr tor
Expiration Date
of card
Electrtpattria Additions and or subtractions
SAME DAY 1NSPECT1Or CALL BEFORE 7.00 AM 360- 417 -4735
ROUGH! IN THERMOSTAT
N. Date Approved By
DUTCH
Date Approved By
Cash Check
172b92S17 33If1d3S
Dote
Date
Altered /Addition
O Credit Card vJ�stercard Discover
IfY
Voltage
Phase 10 3
Service Size:
Feeder Size:
SERVICE
Inspection fee
$S
Service Information
Approved By
FEEDER
Action Taken
Appnuvcd By
Electrical
Inspector
9nI10313 WOdd d60 SO t'002- 2 -1flf
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Application Number
Application pin number
Property Address
ASSESSOR PARCEL NUMBER:
Tenant nbr, name
Application type description
Subdivision Name
Property Use
Property Zoning . . .
Application valuation
07-00000778 Date
347360
1122 D ST
06-30-00-0-3-5490-0000-
DALE & DIANE ZINK
PLUMBING REPAIR
7/02/07
o
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~
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o<J
CITY OF PORT ANGELES
DEPARTMENT OF COMMUNITY DEVELOPMENT - BUILDING DIVISION
321 EAST 5TH STREET, PORT ANGELES, W A 98362
RS7 RESDNTL SINGLE FAMILY
12300
Owner
Contractor
ZINK DALE A
1122 S D ST
PORT ANGELES
WA 983637050
ALPHA BUILDER CORPORATION
1028 W 13TH STREET
PORT ANGELES WA 98363
(360) 775-0759
Permit . . . . .
Additional desc .
Permit pin number
Permit Fee
Issue Date
Expiration Date
MECHANICAL PERMIT
106039
57.25 Plan Check Fee
7/02/07 Valuation
12/29/07
.00
o
Qty Unit Charge Per
Extension
50.00
7.25
-
BASE FEE
1.00 7.2500 ECH ME-VENT FAN
106021
93.00
7/02/07
12/29/07
~
Permit . . . . .
Additional desc .
Permit pin number
Permit Fee
Issue Date
Expiration Date
PLUMBING PERMIT
Plan Check Fee
Valuation
.00
o
Qty
Unit Charge Per
2.00
1. 00
1.00
1. 00
7.0000 ECH
7.0000 ECH
15.0000 ECH
7.0000 ECH
BASE FEE
PL- EA. FIXTURE ON ONE TRAP
PL- EA. INSTALL WATER PIPE
PL- EA. BLDG SEWER
PL- EA. WATER HEATER
Extension
50.00
14.00
7.00
15.00
7.00
Fee summary Charged Paid Credited Due
----------------- ---------- ---------- ---------- ----------
Permit Fee Total 150.25 150.25 .00 .00
Plan Check Total .00 .00 .00 .00
Grand Total 150.25 150.25 .00 .00
t7
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+
.
Separate Permits are required for electrical work, SEPA, Shoreline, ESA, utilities, private and public improvements. This permit becomes
null and void if work or construction authorized is not commenced within 180 days, if construction orwork is suspended or abandoned
for a period of 180 days after the work as commenced, or if required inspections have not been requested within 180 days from the last
inspection. 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 of work will be complied with whether specified herein or not. The granting of a permit does not
presume to give authority to violate or cancel the provisions of any state or I aw regulating construction or the performance of
construction.
\)
"
..........
3
'"
Signature of Contractor or Authorized Agent
Date
T:\Policies\II02_15 building penn it inspection rccord05.wpd [1/4/2005]
BUll.,DING PERMIT INSPECTION RECOlill
G'
CALL 417-4815 FOR BUILDING INSPECTIONS. CALL 417-4735 FOR ELECTRICAL INSPECTIONS. ..J
CALL 417-4807 FOR PUBLIC WORKS UTILITIES \
PLEASE PROVIDE A MINIMUM 24 HOUR NOTICE. IT IS UNLA WFUL TO COVER, INSULATE OR CONCEAL AN}' WOFJ( BEFORE -l
INSPECTED A.ND ACCEPTED. POST PERMIT II\' A CONSPJCVOVS LOCA TlON. ,.j
KEEP PERMIT CARD AND APPROVED PLANS AT .lOB SITE. o<:l
INSPECTION TYPE IJATE ACCEPTEIJ COMMENTS
YES NO
FOUNIJA TlON:
FOOTINGS
SHEAR WALLS / WALLS
FOLlNDA TION DRArNAGE / DOWN SPOUTS
PIERS I i
POST HOLES (POLE BLDGS.)
PLUMllING
UNDER FLOOR/ SLAB
ROUGH-IN (ff/12. J 0{ -r~L.
WATER LINE (METER TO BLDG) FINAL 3/J..7!07 DATE TLL
GAS LINE ACCEPTED BY:
.
BACI~ FLOW I WATER
AIR SEAL O'1-I{<,/o1' :11 ~L
WALLS
CEILING
FRAMING
JOISTS / GIRDERS
SHEAR W ALlJHOLD DOWNS
WALLS / ROOF / CEILING
DRYWALL (fNTERJOR BRA.CED PANEL ONLY)
T-BAR
INSULATION CH II,] 01- :TLL
SLAB
WALL / FLOOR / CEILING
MECHANICAL
ROUGH-IN 01'11 ~ I (}t jU
HEAT PUMP I FURNACE / DUCTS 0'3'(2-7 J01ATE
GAS LINE FINAL ILL ACCEPTED BY:
WOOD STOVE / PELLET / CHIMNEY
MANUFACTURED HOMES
FOOTING / SLAB
BLOCYJNG & HOLD DOWNS
SKIRTING
PLANNING DEPT. SEPARATE PERMIT #'s SEPA:
PARKING/LIGHTING ESA:
LANDSCAPING SHORELINE:
FINAL INSPECTIONS REQUIRED PRIOR TO OCCUPANCY/USE
RESIDENTIAL DATE YES NO COMMERCIAL DATE ACCEPTED
YES NO
ELECTRJCAL - LIGHT DEPT. 417-4735 ELECTRJCAL
LIGHT DEPT
CONSTRUCTION R. W. / PW / CONSTRUCTION - R.W.
ENGINEERING 417-4807 PW / ENGINEERING
FIRE 417-4653 . FIRE DEPT.
PLANNING DEPT. 417-4750 PLANNING DEPT.
BUlLDING 417-4815 BUlLDING
---
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BUILDING PERMIT - APPLICATION
FOR OFFICIAL USE ONLY:
Date Rec.: Oc - 0'L-07
Pennit#: 1)1- 7 ,g
Date Approved: C>{ .... rr2.-
Date Issued: ~ \
Fill out COMPLETELY and in INK. Your application and site plan MUST BE
COMPLETE to be accepted for review. If you have any questions, call
PERMITS (360) 417-4815 FAX(360)417-4711
Applicant or Agent: C)CL\f'~ ~~ \)\r:~n-e, 7~ In ~. Phone: ~- '+~( 'b~ ~?
Owner: :s(~ ~ ("I c:; (0.-\':")'"\\ ~ Phone: 5r~ ~ D.s: l.Lbo \.Ie'
Address: \ \ ';}..'d- -=s . \') S\-n?.e..--t-- City~X--\ Arqe1p51 \_~ , Zip:C{X':3l~ .:S
Architect/Engineer: Phone:
Cootracto,-p \ pro, 'i3; Ji '()fr, in <' State license #:~ U:>\-\-l\RC - EXP:5:3l::D&- Phone: ltSd- 315Lj
Address: ID.~ S. LiN\O\1\ sr. City:P~.)~~~ Zip:q~3b~
PROJECT ADDRESS: \ \ ~~ ~ i \) <;:..J,\r>~t/-f 'A-. ZONING:
LEGAL DESCRIPTION: Lot: Block: Subdivision:
CLALLAM COUNTI PARCEL NUMJ3ER:
\-\
pex- 3,(Y\ L.'- A p\umbi'oj A rneGkW\\co..,l ~m,t ca..n
TYPE OF WORK: SIZENALUATION: b~ Ic;C;UeA tOVer- ~e
Ilt'Residential 0 New Constr. 0 Re-roof 0 Stove SF. @$ /SF. = $ COU V\{e.K
D Multi-family D Addition 0 MoveD Garage SF. @ $ /SF. = $
o Commercial ~ Remodel 0 Demolition 0 Deck SF. @ $ /SF. = $
D Repair D Sign . D Other TOTAL VALUATION $ /:,). ~~
~R1EF DESCRIPTION OF THE PROJECT: ~e -:: rrf~ \ (\ h/1l' 'P (~flrtl" P. . . J ('flolJ:ecl
q",-\- 10Cl..W ( ~'\ K \-0 (Q +i 1,_ 1 rr _~ L6h"f: r tr1uyvtbaA.), , t'i Y Ci 'Rrl ~m -b skids}
L . . .' II" uJ~
COMMER IALlRESIDENTIAL: Occupancy Group: Occupant Looo: Constructiou Type: ~
No. of Stories: l Lot Size: Existing Sq. Ft. & Proposed Sq. Ft. = TOTAL Sq. Ft.
Total lot coverage %
~ "Actd o~et ~ SW\-\C.h I Qct~ 1(gU bc'du,1.e t ~(Y\"~h c4 ~.
. , ,
PLANNING USE ONLY:
ESAlWetland(s): 0 Yes 0 No SEPA Checklist required? 0 Yes 0 No Other:
APPROVALS:
PLAN:
BLDG:
DPWU:
FIRE:
OTHER:
VALUATION OF CONSTRUCTION: In all cases, a valuation amount must be entered by the applicant.
This figure will be reviewed and may be revised by the Building Division to comply with current fee schedules. Contact the Permit
Coordinator at 417-4815 for assistance.
PLAN CHECK FEE: IF a plan check fee is due it must be submitted at the time the building permit application and construction plans are
submitted. All other permit fees are due at the time of permit issuance. .
EXPffiATION OF PLAN REVIEW: If no permit is issued within 180 days of the date of application, the application will expire. The
Building Official can extend the time for action by the applicant up to 180 days upon written request by the applicant (see Section
RI05.3.2 of the International Building/Residential Code, 2003). No application can be extended more than once.
I hereby certify that I have read and examined this application and know the same to be true and correct. I am authorized to
apply for this permit and understand that it,is my responsibility to determine what permits are required ,not the City's, and that I
must obtain such permits prior to wo~. !7
T,\FORMSlBldgP.-mm.wpd Applio""t: 1).0' (~ 5 j{) <'-.. Date: '7 - 'd-- 0 7
E EC,
Uj�
r r 4CiRF fF j �1
CITY OF PORT ANGELES PERMIT APPI.ICATI ®1iT OCT 2 2 2-C-1 n
Building Division /Electrical Inspections ] "
321 East Fifth Street — P.O. Box 11501 Port Angeles Washington, 98362 ELECT BIVX
Ph: (360) 417 -4735 Fax: (360) 417 -4711 WPIEUION
Date: /0- 2 t 17 _ 1 & 2 Single Family Dwelling
* Plan Review May Be Required, Please Complete Electrical Plan Review Information Sheet
Job Address: Sy""
Building Square Footage: _
Description of above
C! Azw
Owner Inform Lion
Contractor Information
Name: _ Lf�� 26 ?L_
Name: OED
Mailing Address:
Mailing Address:
City, State: Zip:
City: State: Zip:
Phone: — Fax:
Phone: Fax:
License # I Exp.
License # 1 Exp, L�GiL�F L 8'9 �tpL
Item
Unit Charge
0 Total (Qty Multiplied by Unit Charge)
ServicelFeeder 200 Amp.
$120.00
$
ServicelFeeder 201 -400 Amp.
$146.00
$
ServicelFeeder 401.600 Amp
$ 205.00
$
ServicelFeeder 601 -1000 Amp
$ 262.00
$
ServicelFeeder over 1000 Amp.
$ 373.00
$
Branch Circuit NfI Service Feeder
$ 5,00
$
Branch Circuit WIO Service Feeder
$ 63,00
e_ $ �
Each Additional Branch Circuit
$ 5,00
$
Branch Circuits 1-4
$ 75.00
$
Temp. Service/ Feeder 200 Amp.
$ 93,00
$
Temp. ServicelFeeder 201400 Amp,
$ 110.00
$
Temp. ServicelFeeder 401 -600 Amp.
$ 149.00
$
Temp. ServicelFeeder 601 -1000 Amp .
$ 168.00
$
Portal to Portal Hourly
$ 96.00
$
Signal Circuit/ Limited Energy -1 & 2 Family dwelling
$ 64.00
$
Manufactured Home Connection
$ 120.00
$
Renewable Electrical Energy - 5KVA System or Less
$ 102.00
$
Thermostat
$ 56.00
$
Note: $5.00 for each additional T -Stat
NEW CONSTRUCTION ONLY:
First 1300 Square Ft.
$120,00
$
Each Additional 500 Square Ft. or Portion of
$ 40.00
$
Each Outbuilding or Detached Garage
$ 74.00
$
Each Swimming Pool or Hot Tub
$ 110,00
$
$ Total
Owner as defined by RCW,19.28.261: (1) Owner will occupy the structure for two years after this electrical permit is finalized. (2) Owner is required
to hire an electrical contractor if above said property is for sale, rent or lease, Permit expires after six months of last inspection.
After reading the above statement, I hereby certify
that I am the owner of the above named property or a licensed electrical contractor. I am making
the electrical installation or alteration in compliance with the electrical laws, N E.C., RCW. Chapter 19,28, WAG, Chapter 296 -46B, The City of Port
Angeles Municipal Code, and Utility Specifications
and PAMC 14.05,050 regarding Electrical Permit Applications.
Signature of ow contractor or electrical administrator:
❑ Cash Cheek
s/
❑ Credit Card ft
X Dated: �� ' `'r ''T 0110112012 jf- Z.
v�53-7g
Cash Adjus-tm-e-n-F71
L
Application # 1-31" i Wz
Cashier info
Payment Type
Check #
Receipt #
Fee Type
Amount Paid �U Refund Amount b
Adjustment
Posted Fee New Fee
Signature
/2r,,,jr
5�. Novi
!�_ t J-,
PL4�5 E G4"-p>>T 4` 416
Ora a Dry+ --� z.l
'F4 , rCr,�O OLf—I d �
il7n�Cr 17vG?7�ff �v�
C I-)- t CL
ELECTRICAL PERMIT
CITY OF PORT ANGELES
360417 -4735
Application Number . , , , . 13- 00001225 Date 10/22/13
Application pin number 892150
.Property Addreas 1122 D ST
ASSESSOR PARCEL NUMBER: 06-30-00-0-3- 5190 -000D-
Application type description ELECTRICAL ONLY
Suhdivision Name
Property Use
Property Zoning . , . . . , . R57 RESONTL SINGLE FAMILY
Application valuation . , . . 0
Application desc
Ductless heat pump
Owner Contractor
- ----------------- - - - - -- ------------------------
Z1NK DALE A BLACK DIAMOND ELECTRICAL, CONTR
1122 S D ST 502 BLACK DIAMOND RD
PORT ANGELES WA 983637050 PORT ANGELES WA 98363
(360) 565 --1035
Permit , , , , . , ELECTRICAL ALTER RESIDENTIAL
Additional desc . ,
Permit Fee 63.00 Plan Check Fee .00
Issue Pate 10/22/-13 Valuation , . . , 0
Expiration Date 4/20/14
Qty Unit Charge Per
1100 63,0000 ECH EL -R
Fee summary Charged
Permit Fee Total 63,00
Plan Check Total ,00
Grand Total 63,00
Extension
BRANCH CLR WO/ SER FEED 63.00
Paid Credited Due
63,00 .00 00
,00 ao 00
63,00 .00 .00
REPORT SALES TAX,
on your excise tax form
to the City of Port Angeles
(Location Code 0502)
INSPECTION TYPE
DATE:
RESULTS:
INSPECTOR:
DITCH
SERVICE
ROUGH -IN
FINAL
CO S:
G to L G �4
PERMIT WILT, EXPIRE SIX (6) MONTHS FROM LAST INSPECTION
Signature of owner or Electrical Contractor X Date:
GAEXCIiANGMBUILDING
t.
1�1
ELECTRICAL PERMIT
CITY OF PORT ANGELES
360-417-4735
Application Number . . . . . 17-00001462 Date 10/10/17
Application pin number . . . 900666
Property Address . . . . . . 1122 D ST
ASSESSOR PARCEL NUMBER: 06 -30 -00 -0 -3 -5490 -0000 -
Application type description ELECTRICAL ONLY
Subdivision Name . . . . . .
Property Use . . . . . . . .
Property Zoning . . . . . . . RS7 RESDNTL SINGLE FAMILY
Application valuation . . . . 0
----------------------------------------------------------------------------
Application desc
Ductless heat pumps
----------------------------------------------------------------------------
Owner
DATE: RESULTS:
Contractor
------------------------
ZINK DALE A
------------------------
BLACK DIAMOND ELECTRICAL CONTR
1122 S D ST
FINAL
502 BLACK DIAMOND RD
COMMENTS:
PORT ANGELES
WA 983637050
PORT ANGELES
WA 98363
(360) 565-1035
----------------------------------------------------------------------------
Permit . . . . .
. ELECTRICAL ALTER RESIDENTIAL
Additional desc
.
Permit Fee . . .
. 63.00
Plan Check Fee
.00
Issue Date . . .
. 10/10/17
Valuation
0
Expiration Date .
. 4/08/18
Qty Unit Charge
Per
Extension
1.00 63.0000
ECH EL -R-
BRANCH CIR WO/ SER FEED
63.00
----------------------------------------------------------------------------
Fee summary
Charged
Paid Credited
Due
-----------------
Permit Fee Total
---------- ----------
63.00
---------- ----------
63.00 .00
.00
Plan Check Total
.00
.00 .00
.00
Grand Total
63.00
63.00 .00
.00
INSPECTION TYPE
DATE: RESULTS:
DITCH
ISERVICE
ROUGH -IN
FINAL
r
COMMENTS:
PERMIT WILL EXPIRE SIX (6) MONTHS FROM LAST INSPECTION,
Signature of owner or Electrical Contractor X
REPORT STATE SALES TAX
on your, excise tax form
to the City of Port Angeles
(Location Code 0502)
d
INSPECTOR:
Date:
CITY PAPERNnT APPLICATION
OF ORT l NGELES
Building Division/Electrical Inspections
321 East Fifth Street — Port Angeles Washington, 98362
Ph: (360) 4174735 Fax: (360) 4174711
N =Mw
Date: —/0 — I — L7
X1 & 2 Single Family Dwelling
Plan Review May Be Required, Please Complete Electrical Plan Review Information Sheet
Job Address: /12 IL
Building Square Footage:
Description of above
Owner Inform t*
T
Contract i ion
Name: Iry
Name:!!Vl C—
Mailing Address:
Mailing Address:
City: State: Zip:
City:
State:
Zip:
Phone: 4(;r7 — 6 3? Fax:
Phone:
Fax:
License # / Exp.
License # I Exp.
Item
Unit Charge Qty
Total (Qtv Multiplied by Unit Charcile)
Service/Feeder 200 Amp.
$120.00
$
Service/Feeder 201-400 Amp.
$146.00
$
Service/Feeder 401-600 Amp
$205.00
$
Service/Feeder 601 -1000 Amp.
$262.00
$
Service/Feeder over 1000 Amp.
$373.00
$
Branch Circuit W1 Service Feed
$ 5.00
$
Branch Circuit W/O Service Feeder
$ 63.00
$
Each Additional Branch Circuit
$ 5.00
$
Branch Circuits 1-4 Only
$ 75-00
$
Temp. Service/ Feeder 200 Amp.
$ 93.00
$
Temp. Service/Feeder 201400 Amp.
$110.00
$
Temp. Service/Feeder 401-600 Amp.
$149.00
$
Temp. Service/Feeder 601 -1000 Amp .
$168.00
$
Portal to Portal Hourly
$ 96.00
$
Signal Circuit/ Limited Energy -1 & 2 Family Dwelling
$ 64.00
$
Manufactured Home Connection -
$120.00
$
Renewable Electrical Energy - 5KVA System or Less
$102.00
$
Thermostat
$ 56,00
$
Note: $5.00 for each additional T-Stat
NEW CONSTRUCTION ONLY:
First 1300 Square Ft.
$ 120.00
$
Each Additional 500 Square Ft. or Portion of
$ 40.00
$
Each Outbuilding or Detached Garage
$ 74.00
$
Each Swimming Pool or Hot Tub
$110.00
$
$
Total
Owner as defined by RCW.19.28.261: (1) Owner will
occupy the structure for two years after this electrical permit is finalized.
(2) Owner is required
to hire an electrical contractor if above said property
is for sale, rent or lease. Permit expires after six months
of last inspection.
After reading the above statement, I hereby certify that I am the owner of the above named property or a licensed electrical contractor. I am making
the electrical installation or alteration in compliance with the electrical laws, N.E.C., RCW- Chapter 19.28, WAC. Chapter 296-46B, The City of Port
Angeles Municipal CoqA, d Utility Specifications and PAMC 14,05.050 regarding Electrical Permit Ap lications.
I -A ical contractor or electrical administrator: D C, ck
Signature o;-067Ae, OKI ;Z
Dated: 16-91-17
[I Credit Card #
0210612012