20160602113253.pdfEXEMPTION FROM CONTRACTOR
REGISTRATION VERIFICATION
FORM D
The undersigned property owner or authorized person as described below, has applied for a
building permit from the City of Edmonds and claims that he/she/it is exempt from providing
contractor registration in accordance with the provisions of RCW 18.27. The property owner or
authorized person, by their signature below, hereby verifies to the City of Edmonds that:
❑ 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 operation
to be undertaken on the property. This exemption does not apply to a person who advertises
or puts out any sign or card or other device which might indicate to the public that lie/she is
a contractor, or that he/she is qualified to engage in the business of contractor. RCW
18.27.090,(9).
❑ Owner who contracts for a project. A property owner contracting with registered
contractors for the project, and who him/herself is not performing any activity of a
contractor for the purpose of leasing or selling improved property that he/she has owned for
less than twelve months. RCW 18.27.090(l 1).
Work performed personally on own. property. Anyone personally working on property
he/she owns, or at which he/she resides, as long as the property owner, or resident, does not
perform any activity of a contractor on his/her property for the -purpose of selling,
demolishing, or leasing the property. RCW 18.27.090(12).
❑ Use of own employees. Property owner using him/herself or his/her own employees to
perform maintenance, repair, and. alteration work in or upon his/her own property. RCW
18.27.090(13).
❑ Licensed Architect, engineer, electrician or plumber. All work performed under this
permit will be performed by an architect, civil or professional engineer, certified electrician
or certified plumber operating within the scope of his/her certification. RCW 18.72.090(14).
❑ Other. Specify which provision of RCW 18.27.090 applies:
THE UNDERSIGNED PROPERTY OWNER OR AUTHORIZED PERSON 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 day of ' , 20.
PROPERTY OWNER/AUTHORIZED
PERSON,
Signature
Print Name
WITNESS.
SignatIre
C
Print Name
L:\TEMP\BUILDING\HANDOUTS REVISED IN 2009\PREVIOUS HANDOUTS\FORMS\CONTRACTOR EXEMPTION FORM
D.DOCREVISED 7/07
DEVELOPMENT SERVICES
RESIDENTIAL BUILDING PERMIT
APPLICATION
sir V 121 5"' Avenue N, Edmonds, WA 98020
City of Edmonds Phone 425.771.0220 Ik Fax 425.771.0221
PLEASE REFER TO THE RESIDENTIAL BUILDING CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJT"ff ADDRESS a (Stree�ultt , Ci(L§Statc, C ): - Parcel #:
i•,vision/Lot #:.
Address (Street t ]t , State, Zip)°
PIh L'Y OWS'IFR:
Address (Street City", Stat 't;
LENDING AI,MIa"NC'Y:
Address (Street, City, State, Zip);
Project Valuation: $
Phone: Fax:
a
Address (Street, City, State, Zip): E -Mail Address:
WA State License #/Exp. Date.
*Contractor must have a valid City of Edmonds business license prior to
doing work in the City. Contact the City Clerk's Office at 425.775.2525 City Business License #/Exp. Date:
DETAIL THE SCOPE OF WORK:
PROPOSED NEWS DARE FOOTAGE FOR THIS PROJECT:
Basement:
1" Floor:
2'"a Floor:
Bedrooms # _ Full -3/4 Bath #_ mm W
Fire S )rinkleros: Yes LJNo
firadin: Cut _..,,-cu. yds, Fill
t ft. Select Basement T e; Finished Ll Unfinished
��..��t. ft._ +Cttt�elCtt1•art: -.�... ..�. ..._..st'. ft.
Deck/Cvrd Porch/Patio: _ . . ft.
Half -Bath #...�_ Other .._ ..__ ._ ........ _mit . ft.
Retaining Wall: Yes No
cu.vd;s. I Cut/Fill in Critical Area: Yes No
I declare under penalty of perjury laws that the information I have provided on this form/application is true, correct and
complete, and that I am the property owner or duly authorized agent of the property owner to submit a permit application to
the City of Edmonds
Print Mum � Owner Agent/Other Qstae�sly): uu
Si,tt,Ittlre: Date. a��/�...._......_
FORM A L:\Building New Folder 2010\DONE & x -(erred to L -Building -New drive\Form A2014.doex Updated: 1/17/2014
Phone:
Fax:
E -Mail Address:
Phone:
Fax:
E -Mail Address:
Phone:
Fax:
E -Mail Address:
Phone: Fax:
a
Address (Street, City, State, Zip): E -Mail Address:
WA State License #/Exp. Date.
*Contractor must have a valid City of Edmonds business license prior to
doing work in the City. Contact the City Clerk's Office at 425.775.2525 City Business License #/Exp. Date:
DETAIL THE SCOPE OF WORK:
PROPOSED NEWS DARE FOOTAGE FOR THIS PROJECT:
Basement:
1" Floor:
2'"a Floor:
Bedrooms # _ Full -3/4 Bath #_ mm W
Fire S )rinkleros: Yes LJNo
firadin: Cut _..,,-cu. yds, Fill
t ft. Select Basement T e; Finished Ll Unfinished
��..��t. ft._ +Cttt�elCtt1•art: -.�... ..�. ..._..st'. ft.
Deck/Cvrd Porch/Patio: _ . . ft.
Half -Bath #...�_ Other .._ ..__ ._ ........ _mit . ft.
Retaining Wall: Yes No
cu.vd;s. I Cut/Fill in Critical Area: Yes No
I declare under penalty of perjury laws that the information I have provided on this form/application is true, correct and
complete, and that I am the property owner or duly authorized agent of the property owner to submit a permit application to
the City of Edmonds
Print Mum � Owner Agent/Other Qstae�sly): uu
Si,tt,Ittlre: Date. a��/�...._......_
FORM A L:\Building New Folder 2010\DONE & x -(erred to L -Building -New drive\Form A2014.doex Updated: 1/17/2014