20160729145517.pdfDEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
' PERMIT APPLICATION
I5't R1 121 5`h Avenue N, Edmonds, WA 98020
Phone 425.771.0220 It Fax 425.771.0221
City of Edmonds
PLEASE REFER TO THE PLUMBING & MECHANICAL CHECKLIST FOR SUBMITTAL REQUIREMENTS
PROJECT ADDRESS (Street, Suite #, City State, Zip):
Parcel #:
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Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No LYN
APPLICANT:
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Phon : Fax:
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Address (Street, City, State, Zip):
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E-Mail Address:
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PROPERTY OWNER:
Phone:
Fax:
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Address (Street, City, State, Zip): r
E-Mail Address:
LENDING AGENCY:
Phone: Fax:
A e,, (Street, City, State, Zip):
E-Mail Address:
ONTRACTOR:*
Phone. Fax:
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:
PERMIT'APPLICATION FOR:
PLUMBING MECHANICAL TANK
DEM[l:..l't"ION
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DETAIL THE SCOPE OF WORK:u - v .
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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.
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Print Name �� "�� Ownerr Agent/Other ❑ (specify):
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Signature: "ram Date ..1...... ..._.�..1-.....u-
FORM C LABuilding New Folder 2010\DONE & x-fered to L-Building-New drive\Forrn C 2014.docx Updated: 1/17/2014
FORM C: L:\Building New Folder 2010\DONE & x-ferred to L Building -New drive\Form C 2014 doex Updated: 1/17/2014
EXEMPTION FROM CONTRACTOR
REGISTRATION VERIFICATION
FORMI)
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 ti-idertaken 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 1 .27,090(l1).
Work performed personally on own property. Anyone personally working On property
he/she owns, or at which lic/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 M day of 2
x
PROPERTY OWNER/AUTHORIZED WITNESS
PERSON,
Signature
Print Name
Signature
Print Name
LATEMP\BUILDINO\I ANDOUTS REVISED IN 2009\PREVIOUS HANDOUTS\FORMS\CONTRACTOR EXEMPTION FORM
D.DOCREVISED 7/07
TO PERMITTEE AND/OR OWNER
0_1 10 ,
❑ PARTIAL APPROVAL 6R ECTION REQUIRED ;,Ni ORCEME;N]" VIOLATION
Owner
Permit Number
Job Address I ,2-F 23,J P�— Site Contact
Type of Inspection
❑ WORK DESCRIBED BELOW HAS BEEN INSPECTED AND APPROVED.
❑ APPROVED PLANS AND JOB CARD MUST BE AVAILABLE TO INSPECTOR ON SITE.
❑ CORRECTIONS LISTED BELOW MUST BE MADE BEFORE WORK CAN BE APPROVED
AND/OR THE NEXT PHASE OF WORK IS STARTED.
❑ RECALL FOR INSPECTION.
❑ Rf NSPECT] ON FEE MUST BE PAID PRIOR TO NEXT INSPECTION REQUEST.
`-,§ OP WORK -UNTIL AUTHORIZED TO CONTINUE BY CITY INSPECTOR.
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THE ACTIONS OR CORRECTIONS INDICATED ABOVE ARE REQUIRED TO BE CORRECTED BY
(DATE) "7,1 o I OR PENALTIES MAY BE APPLIED. FOR INSPECTION CALL 425-771-0220
0 Building ❑ Plan11 ning ❑ Engineering ❑ Fire ❑ Public
Inspector Date �........._...........
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THIS NOTICE TO REMAIN ON SITE DEVEIOPMENTSERVICESc ,
CITY OF EDMONDS
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