20160624160238.pdfEXEMPTION 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 $500.00 and is not part of a larger operation
to be undertaken on the property. This exemption does not apply to a person who advertises
or pelts out any sign or card or other device which might indicate to the public that lie/she is
a contractor, or that he/she is qualified to engage in the business of contractor. RCW
18.27.090,(9).
❑ Owner who contracts for a project. A property owner contracting with registered
contractors for the project, and who him/herself is not performing any activity of a
contractor for the purpose of leasing or selling improved property that he/she has owned for
,,less than twelve months. RCW 1$.27.090(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 properly 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 DAMEDIATELY REVOKED AND ALL FEES PAID FORFEITED.
DATED this day of / , 20 %
PROPERTY OWNER/AUTHORIZED
PERSON,
Print Name
► .ii Nix
Print Name
LATEMP\BUILDING\HANDOUTS REVISED IN 2009\PREVIOUS HANDOUTS\FORMS\CONTRACTOR EXEMPTION FORM
D.DOCREVISED 7/07
DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
sl„ 1 Phone 425.771.0220 ft 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 #:
Associated Permit #:
IS THIS WORK ASSOCIATED WITH ANOTHER PROJECT? Yes ❑ No ❑
APPLICANT: U
L I -Mail Address: 1
Address (Street, Cit , Stag Zip).91 it 0
W
PROPERTY INIAt. l ho nt , Fax:
Z
Address(Street Cit "tata Zip): jV E -Mail Address:
` Mall'14 tI i co l LV 1'-I
LENDING AGE C V: , P lone: Fax:
Address (Street, City, State, Zip): E -Mail Address:
CONTRACTOR:* �, 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 17757 ness License#/Exp. Date:
PLUMBING Lj MECHANICAL TANK DEMOLITION
DETAIL THE SCOPE OF WORK. _._. ! ..... %° ��. .. •. �m �..��.............��� .
..S:..._........_' -- ............_
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 Name: .-.-..... l I.
� Owner Agent/Other (specify)�-..-�....�.....� ,.....� w•.m � ..�........
. f
Signature, ., Date . •_..... .......� .._�_
FORM C L'1i)ur W bK� w Folder 2010vDONE & x-fetred to L -Building -New drivevForm C 2014.doex Updated: 1/17/2014
PLUMBING FIXTURE COUNT
Fixture Type (new and relocated) Total # Fixture Type (new and relocated) Total #
Water Closet (Toilet) Pressure Reduction Valve/Pressure Regulator
Sink (kitchen, laundry, lavatory, bar, eye wash, etc.)Water Service Line
Tub/Shower-�� Drinking Fountain
Dishwasher- ����-_---�- �Clothes Washer
m _ .. ............... .,m..... �..... ..__.--.... W_ . �_ �.
Hose Bib Backflow Prevention Device (e.g. RBPA, DCDA, AVB)
..... _ __..........
Water Heater Tankless? Yes ❑ No ❑ Hydronic Heat in. Floor ❑ Wall
Floor Drain/Floor Sink _ Other:
.............
Refrigerator water supply (for water/ice dispenser) Other:
Equipment Type
MECHANICAL
Appliance/Equipment Information (new and relocated)
Total #
Furnace
Gas #Elec
#Other
:................................... #._........... BTUs: <100k_ >100k_
Air Handler / VAV
Gas #_..........-Elec
#_Other:_.........
#_CFM: <10k_ >10k_
Loct-at"on(s) _.�
(circle selected)
AC / Compressor /
Boiler / Heat Pump /
Gas #Elec
#_Other:
# BTUs: <100k,
100k -500k, 500k-1Mil
Roof Top Unit
HP:
<3, . ............................3-15,
15-30 Location(s)_......... .....
—.........._...............-,
(circle selected)
Hydronic Heating
Gas # .......Elec
#_In
-Floor _Wall Radiant_ Boiler BTUs: ........................
.............. .Location_
Exhaust Fans (single
Bath #
Kitchen
#_Laundry # _.f tlae .............-_._....-�
� m � �� �w� �..._._ ......#�
duct)
..
Fireplace
Gas #Elec
#_Other:
---------- __ _______ #_ Location(s), ,,
Dryer Duct
FORM C LABuilding New Folder 2010\DONE & x-ferred to L -Building -New drive\Form C 2014.docx Updated: 1/17/2014