20170131162448.pdf4C,
� ITY � �� EDN S
1215THAVENUENORTH- EDMONDS, WA 98020
�.:11)r1 PHONE: (425) 771-0220 - FAX: (425) 771-0221
STATUS: ISSUED 01/31/2017 � a
Expiration Date• 07/31/2017 �r,
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Parcel No: 27032500219000
111111011ERTY0WNER APPLICANT CONTRACTOR
GAIL L SAILER GAIL L SAILER OWNER EXEMPTION
714 7TH AVE S 714 7TH AVE S C/O GAIL L SAILER`
EDMONDS, WA 98020-4012 EDMONDS, WA 98020-4012 714 7TH AVE S
EDMONDS WA 98020-4012
(206) 854-8899 (206)854-8899 (206)854-8899
LICENSE #: EXP•
EXTEND GA S LINE FROM UTILITY BOX ON NORTH SIDE OF HOUSE TO SOUTH SIDE FOR KITCHEN COOKTOP. ONE NEW GA S
FIREPLACE INSERT PLUS ONE ADD'L T FOR FUTURE GA S FIREPLACE.
VALUATION: ,$0.00
PERMIT TYPE: Residential PERMIT GROUP: 47 - Plumbing
GRADING: N CYDS:`0 TYPE OF CONSTRUCTION:
RETAINING WALL ROCKERY: OCCUPANT GROUP:
OCCUPANT LOAD:
FENCE: 0 X 0 FT.) CODE: 2015
OTHER: ------- OTHER DESC: ZONE:
NUMBER OF STORIES: 0 VESTED'DATE
NUMBER OF DWELLING UNITS:0 LOT #„
BASEMENT: 0 1 ST FLOOR: 0 2ND FLOOR: 0 BASEMENT: 0 1 ST FLOOR: 0 2ND FLOOR: 0
3RD FLOOR: 0 GARAGE: 0 DECK: 0 OTHER: 0 3RD FLOOR: 0 GARAGE: 0 DECK: 0 OTHER: 0
BEDROOMS:0 BATHROOMS:0 BEDROOM&0 BATHROOMS:0
REQUIRED:- PROPOSED: REQUIRED: PROPOSED: JREQUIRED: PROPOSED:
HEIGHT ALLOWEDO PROPOSED:O ' REQUIRED: PROPOSED:'
SETBACK NOTES:
I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUCTION AND IN DOING THE WORK AUTHORIZED
THEREBY, NO PERSON WILL BE EMPLOYED IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURANCE AND RCW 18:27.
THISAIRLICATION ISNOT A PERMIT UNTIL SIGNED BY THE BUILDING OFFICIAL OR klISVERDEPUTY AND ALL FEES ARE .PAID.
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Signature DAte ! I1 aced By Date
ATTENTION
ITIS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFICATE OF
OCCUPANCY HAS BEEN GRANTED UBC109/ IBC110/ IRC110.
ONLINE APPLICANT ASSESSOR OTBm ,
EXEMPTION 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:
0 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. 11-ds 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).
66 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(11).
04 Work pel'formed 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
pe:rfon,n any activity of a contractor on his/her property for the purpose of selling,
demolishing, or leasing the property. RCW 18,27.090(12).
o Use of own employees. Property owner using hire/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).
0 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 1.8.72.090(14).
0 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 WELL BE DAMEDIATELY REVOKED AND ALL FEES PAID FORFEITED.
DATED this 31 day of 20_Q
PROPERTY OWNER/AUTHORIZED
PER N
L
Si iature
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Print Name
WITNESS.
k6l, S
Signature
Print Name
Pr
LATEMP\BUILDrNG\HANDOUTS REVISED IN 2009\PREVIOUS HANDOUTSWORMS\CONTRACTOR EXEMPTION FORM
D.DOCREVISED 7/07
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` DEVELOPMENT SERVICES
PLUMBING, MECHANICAL, TANK, & DEMOLITION
PERMIT APPLICATION
121 5`h Avenue N, Edmonds, WA 98020
Est i ` Phone 425.771.0220 !k 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: Phone: Fax:
Cesar . Sit 54-V399
Address (Strect, cityState aip): E-Mail Address:
,1
PROPERTY OWNER: Phone: Fax:
�Oy I L_- Sa-1e� :1
Address (Street, City, State, Zip):' L E-Mail Address:
$ AYY% Gts CL,U uvc-
LENDING AGENCY: Phone: 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 City Business License #/Exp. Date:
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PLUMBING MECHANICAL TANK DEMOLITION
� DETAIL THE SCOPE OF WORK ��..�.�.. '��.._...._� � .r1.e-..r_��"��.� !� �. �.!�_...._ ..�."�('".. on ylcr+hCeu\.... ....
�.........._ ....: �..._.. ... --_ . �..._. ....M�IeL�-rr� I v.....w ............_.
. A, \ T �
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:..._.. r��� Owner /AgcnMther ❑ (specify) ...w........ _...�
0►. r`-�.-- F Date:
Signature:
FORM C LABuilding New Folder 2010\DONE & x-ferred to L-Building-New drive\Form C 2014.docx Updated: 1/17/2014