Form D- Contractor exemption - signedEXEMPTION 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 properly 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 1827.090(11).
® 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 PER1VIIrT WILL BE D/Rv EDIA.TELY REVOKED AND ALL FEES PAID FORFEITED.
DATED this 18 day of May , 20 21 .
PROPERTY OWNER/AUTHORIZED
PERSON,
Christopher S mons (May 18, 202119:25 PDT)
Signature
Christopher Simmons
Print Name
WITNESS
Signature
Print Name
LATEMP\BUILDINGUHANDOUTS REVISED IN 2009\PREVIOUS HANDOUTS\FORMSICONTRACTOR EXEMPTION FORM
D.DOCREVISED 7/07
Form D- Contractor exemption
Final Audit Report 2021-05-19
Created: 2021-05-19
By: Heidi Helgeson (heidi@h2darchitects.com)
Status: Signed
Transaction ID: CBJCHBCAABAAm4A2yLyMuEt2n7-glcOrDmIT4V_8y6u1
"Form D- Contractor exemption" History
Document created by Heidi Helgeson (heidi@h2darchitects.com)
2021-05-19 - 2:08:58 AM GMT- IP address: 123.193.152.181
Document emailed to Christopher Simmons (chris@consolidatedservices.org) for signature
2021-05-19 - 2:13:16 AM GMT
Email viewed by Christopher Simmons (chris@consolidatedservices.org)
2021-05-19 - 2:25:12 AM GMT- IP address: 73.254.89.201
Document e-signed by Christopher Simmons (chris@consolidatedservices.org)
Signature Date: 2021-05-19 - 2:25:49 AM GMT - Time Source: server- IP address: 73.254.89.201
Agreement completed.
2021-05-19 - 2:25:49 AM GMT
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