BLD20170904-APPROVED PERMIT.pdfCITY OF EDMONDS
121 5TH AVENUE NORTH - EDMONDS, WA 98020
PHONE: (425) 771-0220 -FAX: (425) 771-0221
STATUS: ISSUED
CINDY M CRAIG
REYNALDO PULIDU
KhYNALUU rULIVU
24227 78TH PL W
24227 78TH PL W
24227 78TH PL W
EDMONDS, WA 98026-9112
EDMONDS, WA 98026
EDMONDS, WA 98026
(425) 750-7119
(425) 750-7119
LICENSE #: EXP:
Repair and replace roof.
VALUATION: ,$0.00
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
TtII,R ° 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,
THISU" TI IN. IS NOT A PERMIT UNTIL SIGNED BY THE BUILDING(TTICIAL OR I1118NER DEPUTY AND ALL FEES ARE PAID.
7
tlghatt#e RInt Name Date FWeesecl By V Mate
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 M OTBER
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:
❑ 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 he/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 18.27.090(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 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 DAMEDIATELY REVOKED AND ALL FEES PAID FORFEITED.
DATED this � f d day of _ R 20_J7
PROPERTY F,R/AU 1"H;ORIZED WITNESS.
PERSON
Signature Signature
Print Name
Print Name
L:\TEMP\BUILDING\HANDOUTS REVISED IN 2009\PREVIOUS HANDOUTS\FORMS\CONTRACTOR EXEMPTION FORM
D.DOCREVISED 7/07