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x L0 lv <br />p7 rzf <br />C H <br />9 H N <br />O 50 <br />V H '+] <br />HyC <br />O C�rJ <br />O H C7 <br />g <br />ayI <br />rHH <br />rn <br />H <br />O t7 In <br />H Ho co <br />STATE <br />ou E <br />PROGRAM <br />Building Record <br />(please check one) <br />New Build!ng ❑ Addition over 500 sq. ft. <br />Jurisdiction: dy 4`y e t c t <br />r <br />please check one: ❑�Clty ❑ County <br />CLASSIFICATION <br />WSEO Conbxt # <br />Attachmerd B <br />(please check one) <br />El Single Family ❑ Duplex <br />❑ Multifamily ❑ Zero Lot Line Home <br />❑ Planned Unit Development _ <br />Permit # <br />File ID If (if different from Permit Jtj <br />CONSTRUCTION — — —_-- — <br />A. Site Information B. Owner Information <br />Address Q -7 LA% 1i1111'I ^ Owner(owneratOmeofcommxdonxa�vsuohrvPayment) <br />City L_ V c 1 C Zip_ - ) _ Com an <br />Assessor's Pro art Tax # (or ahach legal des_crrplionj : Address <br />)_ I City fT State i ZIP <br />Servicing Electric UtilityI I1 it : i.` I': I ( 1). Phone ( ) <br />Federal ID# or SSN <br />C. If Single Family, Zero Lot Line or <br />Planned Unit Development <br />Total Conditioned Floor Area sq. &_ <br />Second Duplex Unit sq. ft. <br />A. Primary Space Heal Type <br />(check one) <br />❑ <br />Electric Baseboard <br />❑ <br />Electric Furnace <br />❑ <br />Electric Heat Pump <br />❑ <br />Other (spealybelow) <br />COMPLIANCE <br />WSEC Compliance Method <br />I.. ❑ Prescriptive Path <br />Component Performance <br />❑ System Analysis <br />D. If Multifamily (R-1) <br />Total # of Buildings <br />Total # of Units _ <br />Total sq. ft. (optional) <br />HEAT SOURCE <br />B. Back -Up Space HeatTVpe <br />(optional, check all that apply) <br />❑ None <br />❑ Wood <br />❑ Electric Baseboard <br />❑ Other (specify below) <br />C. Water Heat Type <br />(optional, check one) <br />❑ <br />Electric <br />❑ <br />Gas <br />❑ <br />Other (specify below) <br />INSPECTIONIENFORCEIIMENT <br />_Date of Permit Application <br />Date Building Permit Issued <br />Date of Insulation Inspection <br />Date of Final Ins eectton <br />I hereby certify that this building or addition has been inspected for the measures required <br />by the 1991 Washington State knergy Code (WSEC), that it is in substantial compliance <br />With the WSEC, and that the WSEC checklist for this building is on file. <br />Signature of Building Official or Authorized Representative <br />D;uo <br />Return white copy to: Kathleen Skaar, Washington State Energy Office_809 Legion Way SE, FA-I1, Olympia, WA 98604-12t 1 <br />-- WSEO-White Copy ufility/O W_Canary Copy Jurisdiction - Pink Copy g.gl <br />