Form D- Contractor exemption - signedEXEMPTION 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 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 day of _
PROPERTY OWNER/AUTHORIZED
PERSON,
01&" �-
Signature v
Caleb Johns
Print Name
09/07/2021
_, 20_
WITNESS
Signature
Blake Fisher
Print Name
ENV35950179-07 ,�NDOUTS REVISED IN 2009\FREVIOUS HANDOUTS\FORMSICONTRACTOR EXEMPTION FORM
09/07/2021 16:56�VISED 7/07
Envelope Data
Subject:
City of Edmonds - GC exemption form
Documents:
Form D- Contractor exemption.pdf
Document Hash:
34457634
Envelope ID:
ENV35950179-0741-ADCE-5815-ACDB
Sender:
Blake Fisher
Sent:
09/07/2021 16:48 PM PDT
Status:
Completed
Status Date:
09/07/2021 16:56 PM PDT
Recipient(s) / Roles
Name / Role Address
Blake Fisher blake@blakefisherarchitecture.com
Caleb Johns calebejohns@gmail.com
Blake blake@blakefisherarchitecture.com
Document Events
Type
Sender
Signer
Signer
Name / Roles MIP
Address
Date
Event
Blake Fisher blakeCblakefisherarchitecture.com
67.160.0.233
09/07/2021 16
Created
:48 PM PDT
Blake blake@blakefisherarchitecture.com
67.160.0.233
09/07/2021 16
Signed
:49 PM PDT
Caleb Johns calebejohnsCgmail.com
50.125.89.2
09/07/2021 16
�:56
Signed
PM PDT
J
09/07/2021 16
Status - Completed
Signer Signatures
Signer Name / Roles
Blake
Signature
6&&-Icfah
Caleb Johns
f