Date                                            

Property Owner                                                                                                                         

Mailing Address                                                                                                               

Daytime Phone                                     

Contractor                                                                      

Address                                                                                     Phone                             

Contractor License #                                                                   Expiration                       

 Project Address                                                                                                               

Property Legal Description                                                                                                         

Assessor’s Parcel No.                                                                  

 Project Description                                                                                                          

 Washington State Law requires the following information (RCW 19.27.095)

 Lender Information – (Any project valued over $5,000)

I hereby certify that I am the applicant (or authorized representative) for a building permit for construction activity located at:                                                                                         

  A lending institution is NOT administering the interim construction financing for this project.

  The following lending institution IS administering the interim construction financing for this project.

Institution Name                                                                         Phone                             

Institution Address                                                                                                          
 

 A payment bond has NOT been issued and will NOT be issued by any firm on behalf of the prime contractor for this project for the protection of the owner.

 A payment bond IS being issued on behalf of the prime contractor for this project by the firm listed below: 

Name of Firm issuing bond                                                                                                

Address                                                                                                                          

Applicant hereby certifies the information given herein is true and accurate and further agrees to perform work authorized by the permit in accordance with all applicable ordinances and statures.   

                                                                                                                                     
Signature of applicant                                                                 Date  

Required attachments:

Two sets of structural plans no larger than 11” x 17”

Site plan drawn to scale including:

·                  Footprint of existing and proposed structures

·                 Distance from structures to property lines

·                 Square footage of all structure footprints

·                 Floor plan of new/remodeled construction