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(please check one) <br />❑ New Building MAddition over 500 sq. It. <br />Jurisdiction- i-min1i <br />please check one: ®City ❑ COBntV <br />A. Site Information <br />Address <br />C-tip2 `I 1 b 6 <br />city F✓i,rP:U zip y8z03 <br />Assessors Proprty Tax # (or attach legal description) <br />t�q 5 a na ISi� <br />Servicing Electric Utility ) U NI r P ie 14L- v St, c' <br />C. it Single Family, Zero Lot Line or <br />Planned Unit Development <br />Total Conditioned Floor Area J(]R�4 tt <br />Second Duplex Unit sq. h- <br />A. <br />Primary Space Heat Type <br />(check one) <br />❑ <br />Electric Baseboard <br />�] <br />Electric Wall Haater <br />❑ <br />Electric Furnace <br />❑ <br />Electric Heat Pump <br />❑ <br />Other <br />(please check one) <br />® Single Family ❑ Duplex <br />❑ Multifamily ❑ Zero Lot Line Home <br />❑ Planned Unit Development <br />Permit# C-•i07(c5r <br />File ID # of different from Permit a1 — <br />B. owner Information <br />Owner(owneratfimeofmnsducdonrecehesudrMPayment) <br />Company 11 11d 0 A,C 6 ecto,-.n <br />Address 5Rz9 Elo p a) A✓0 <br />City - N Stater rig/ Zip VUQn <br />Phone ( z tJ (e ) 355 - 222 4 <br />Federal ID# or SSN <br />D. If Multifamily (R-1) <br />Total # of Buildings <br />Total # of Units <br />Total sa ft. (optional) <br />B. <br />Back -Up Space Heat Type <br />(check all that apply) <br />❑ <br />None <br />❑ <br />Wood <br />❑ <br />Electric Baseboard <br />❑ <br />Other (specify below) <br />C. <br />Water Heat Type <br />('beck one) <br />❑ <br />Electric <br />❑ <br />Gas <br />❑ <br />Other (specify below) <br />�C, s3'1... 6'1i €GSk�4FI�J <br />This building meets the <br />Electric <br />❑ Other Fuels <br />requirements of the WSEC. <br />WSEC Compliance Method <br />Prescriptive Path <br />Component Performance <br />❑ System Analysis <br />Date of Permit Application <br />Date Building Permit Issued <br />Date of Insulation Inspection <br />Date of Final Inspection <br />S-Z d'93 <br />1 Z— <br />1 hereby certify that this building or addition has been inspected for the measures required <br />Py the 1991 Washington State Energy Code (WSEC), that it is in substantial compliance <br />Wiftth the WSEC, and tfiat the WSEC checklist for this building is on file. <br />Building Official or Authorized Representative <br />Date <br />Return white copy to: Kathleen Skaar, Washington State Energy Office, 809 Legion Way SE, FA-11,Olypi PAk9Bop 4-1211 <br />WSEO - White Copy U;ility/owner - Canary Copy jurisdiction <br />7-92 <br />