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EVERETT ELECTRICAL PERMIT AFFIDAVIT wAINIMGTGN Code Exemptions: A property owner,renter or lessee may purchase a permit to do an electrical installation on his/her own or qualified leased property under the conditions as described in RCW 19.28.261. A nonprofit corporation with current tax exempt status or a nonprofit religious organization may purchase an electrical permit as described in RCW 19.28.091(7). 1 am applying for the property owner exemption under the following conditions: You must select the option that applies to your situation: I swear under penalty of perjury that: ❑ I am a registered general contractor who is installing a temporary electrical service owned by me on a project where I am the general contractor OR I swear under penalty of perjury that I am: The owner of real property;or ❑ The renter or lessee of real property.(You must provide a signed letter from the owner of the property granting permission for you as the tenant to perform electrical work on the property);or A nonprofit corporation that holds a current tax exempt status as provided under 26 U.S.C.Sec.501(c)(3)or a nonprofit religious El organization,and the total value of the electrical work does not exceed thirty thousand dollars($30,000.00). AND You must select the option that applies to your situation: ❑ A single family residence THAT IS NOT intended for rent,sale,or lease AND I will be personally doing the electrical work AND I will occupy the residence for at least 24 months after completion of the electrical work; A NEW 2,3,or 4 unit residential property that IS intended for rent,sale,or lease AND myself and/or a regularly scheduled and paid employee(s)will be doing the electrical work AND I will occupy one of the units for at least 24 months after completion of the electrical work. rncor/i/c(,-/-seshc4_W1,4h P VA aAn EXISTING 1,2,3,or 4 unit residential property that IS intended for rent,sale,or lease AND myseff arrd/er a fegafarfy schedvied and vr+erk; A farm AND I,personally, and/or a regularly scheduled and paid employee(s)will be doing the electrical work; An EXISTING place of business AND I,personally,and/or a regularly scheduled and paid employee(s)will be doing the electrical work; ❑ A NEW place of business that is NOT intended for rent,sale,or lease AND I,personally,and/or a regularly scheduled and paid employee(s)will be doing the electrical work;or ❑ Other property that is NOT intended for rent,sale,or lease AND I,personally,and/or a regularly scheduled and paid employee(s)will be doing the electrical work. I am a nonprofit corporation that holds a current tax exempt status as provided under 26 U.S.C.Sec.501(c)(3)or a nonprofit religious ❑ organization and the total market value of the electrical work does not exceed thirty thousand dollars($30,000.00),and the electrical work will be performed by appropriately certified electricians or certified and supervised trainees who are volunteering and not being compensated for electrical work per RCW 19.28.091(7). ❑✓ I AGREE and wish to purchase an electrical permit under the conditions described above. Adam E. Cobb Owner Name(Print) .XA�w � 6 li 1/13/22 Owner Signature Date E 2 301017 PERMIT# Page 3-Affidavit