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EXEMPTION FROM CONTRACTOR REGISTRATION
VERIFICATION FORM
The undersigned property owner or contractor has applied for a building permit from the City of
Edmonds and claims that he/she/it are exempt from providing contractor registration in accordance with
the provisions of RCW 18.27. The property owner, by their signature below hereby verifies to the City of
Edmonds that:
0 Value of work under $500.00. The aggregate contract price of labor and materials
and all other items required for the project is less. than $500.00 and is not part of a larger
opertation to be undertaken on the property. The person employed to do this work has not
advertised nor otherwis - e put himself forward to the permittee to be a contractor or
qualified to engage in the business of a contract. RCW 18.27.090(9).
Work performed personally on own property. The undersigned verifies that all work
done under this permit will be done by the permittee personally on his/her own property
and that the improvements constructed on the property are not being undertaken with the
intention and purpose of selling the improved property.
0 Commercial property exemption. The permittee is the owner of commercial property
and the owner's own employees will perform all maintenance, repair and alteration work
on the property. No work will be done by contract under the permit. RCW 18.27.090(13).
0 Licensed architect, engineer, electrician or plumber. All work performed under this
permit will be performed by an architect, civil or professional engineer, licensed electrician
or licensed plumber operating within the scope of his or -her license. RCW 18.27.090(14).
0 General Contractor. The owner is the General Contractor for the project and is required
to hire a minimum of two licensed subcontractors (unrelated building trades or crafts). The
general contractor is responsible to verify all State licenses of subcontractor. RCW
18.27.010
THE UNDERSIGNED PROPERTY OWNER HEREBY VERIFIES THAT ALL
INFORMATION PROVIDED ON THIS FORM IS TRUE AND ACCURATE TO THE BEST OF HIS
OR HER KNOWLEDGE' AND ACKNOWLEDGES THAT IF ANY OF THE INFORMATION
PROVIDED ON THIS FORM IS FALSE, HE OR SHE UNDERSTANDS THAT THE BUILDING
PERMIT WILL BE IMMEDIATELY REVOKED AND ALL FEES PAID FORFEITED.
Dated this I ' of 20 6
day Sej)
PROPERTY OWNER/PERMITTEE
WITNESS:
LATEMMUILDNGTORMmenip contmdor regis verifform.doc03/28/01
RECEIVED
'HOGHT CA.LC5 MAR-..2 0 2001
C
A� 105.40� DEVELOPMENT SERVICES GTR. I OF:' G:9)IK0"T>5
UTY OF EDMONDS LL Co., WN.
tj C) %.40 " L i
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13 1 c, .857,
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-�F 25.000
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RECEIvED
APR 112001
ACCEPTABLE TIGHTLINE
MATERIAL
PERMIT COUNTER
SDR 35,,,,
SCH 40,1
T(3 T h L. N -12
F81 0 HAN6OR A�
TEMPbRARY CONSTRUCTION
ENTRANCE REQUIRED
WATER & SEMA o
WSpECTIONS REQ`D
:.CIALL 425.771-Mo EXT. 1326
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APPROVED BY,ENGINEERING-
Datw.
FILE
City of Edmonds. Permit No:
RIGHT—OF—WAY CONSTRUCTION PERMIT Issue Date:
A. Address or Vicinity of Construction: d�w
B. Type of Work (be specific): 0_e7pg�� 'r��J 0911p4t, (J_n1UT1e;:rW
C. Contractor: /�eg�zz� &16
MailingAddress:
State' tLicense
D. Building Permit # (if applicable):
Co niact:
Phone:
Liability Insurance: Bond:
Side Sewer Permit # (if applicable):
E. F—I Commercial E] Subdivision City Project EUC (PUD, GTE, PSE, CHAMBERS, OVWD)
Multi -Family Single Family Other
INSPECTOR- n
F. PAVEMENT: 0 YES E] NO G. SIZE OF CUT x H. Charge: $
CONCRETE CUT: F-1 YES r-1 NO
APPLICANT TO READ AND SIGN
IDEMNITY. Applicant understands by his/her signature to this application helshe holds the City of Edmonds hdrmlessfrom injuries,
damages or claims of any kind or description whatsoever, foreseen or unforeseen, that may be made against the City of Edmonds or
any of its departments or employees, including but not limited to the -defense of any legal proceedings including defense costs and
attorneyfees by reason ofgrantingthis permit.
THE CONTRACTOR IS RESPONSIBLE FOR WORKMANSHIP AND MATERIALS FOR A PERIOD OF ONE YEAR FOLLOWING THE FINAL
INSPECTION AND A CCEPTANCE OF THE WORK., ESTIMA TED RESTORA TION FEES WILL BE HELD UNTIL THE FINAL STREET PA TCH IS
COMPLETED B Y CITY FORCES, A T WHICH TIME A.DEBIT OR CREDIT WILL BE PROCESSED FOR ISSUANCE TO THE APPLICANT.
* Traffic'contr'ol and public safety shall be in accordance with City regulations as requited by the. City Engineer.
flagger must be trained as required by (WAC) 296-155-305 and*must have certification verifying completiontof the
required training in their possession.
* Restoration is to be in accordance with City codes. All street -cut trench work shall be patched with asphalt or City -
approved material prior to the end of the workday — NO EXCEPTI NS.
* Three sets of construction drawings of proposed work are required with the permit application.
IHAVEREAD THE ABOVE STATEMENTS AND UNDERSTAND THE PERMITREQUIREMENTS AND ACKNOWLEDGE
THATIM T MAKE THE PINK COPY OF THE PERMITA VALLABLE ON SITE A TALL TIMES FOR INSPECTIONS
(J-M4 IV It
(Contractor or Agent)
CALL DJAL-A-DIG (1-800-424-5555), PRIOR TO BEGINNING WORK
FORCITYUSEONLY
Approved by: h4,17 Rig'ht-of-wayfee: IS
Time Authorized: Void After &P*K, Disr,uption,Fee/Fund Ill:
Special Conditions: Alestoration Fee:
—bw W1TW"_4rA Vo" - mor &Ir Total Fee: 41
ReceiptNoll
Issued by: 44g01--,
UPON COMPLETION OF PERMITTED WORK5 AN ENGINEERING FINAL
INSPECTION IS REQUIRED PER CHAPTER 18,00 OF THE EDMONDS
COMMUNITY DEVELOPMENT CODE.
FINAL APPROVAL OF PERMITTED WORK:-
INWMXs'S'IGNA TURE DATE:_J_
For inspection requirements see Engineering Information Handout.
NO WORK SHALL BEGIN PRIOR TO PERNET ISSUANCE
RECEIVED
?R_Dpzn� /,-) I
RECF.IVED
SEP 13 2002
OCIGHT CA-LCS MAR.1 0 2001 BUILDING DEPT.
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