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E» '71 <br />9H <br />aHm <br />HEM <br />H Rl <br />f!z H <br />H <br />x <br />o tv <br />Hog <br />z y <br />gy <br />H OCA <br />(please check one) <br />❑ New Building <br />Jurisdiction: <br />Building Record <br />❑ Addition over 500 sq. ft. <br />ease check dnB' ❑ CItY ❑ CounN <br />A. Site Information <br />Address - -- -- __-- _ <br />City, _ Zip - <br />Assessor's Property Tax # (mattech lapel desarphnm <br />Servicing.Electric UlllitY <br />CLASSIFICATION <br />WSEO Contract # <br />Attachment B <br />(please check one) <br />❑ Single Family ❑.Duplex <br />❑ Multilamily ❑ Zero Lot Line Home <br />❑ Planned Unit Development -- <br />Permit # -- <br />File. ID # (If different Iron Permll AJ <br />CONSTRUCTION <br />��. C. If Single Family, Zero Lot Line or <br />Planned Unit Development <br />Total Conditioned Floor Area sq. ft. <br />Second Duplex Unit sq. ft. <br />A. Primary Space Heat Type <br />(check one) <br />_ � El Electric Baseboard <br />' ❑ Electric Furnace <br />❑ Electric Heat Pump <br />j t ' ❑ Other (spealy below) <br />COMPUANCE <br />WSEC Compliance Method <br />❑ Prescriptive Path <br />❑ Component Performance <br />171 Cvernm Analvsis <br />B. owner Information <br />Owner (owner et pine of cvrsmtcdorr leceivee wiry peyrtrertU <br />Company__ _ <br />Address <br />City State <br />Phone <br />Federal ID# or SSN _ <br />D. I1 Multifamily (R-1) <br />Total # of Buildings <br />Total # of Units <br />Total sq, ft. (optional) <br />HEATSOURCE <br />B. Back -Up Space Heat Trp0 <br />(optional, check all lhnl npp y <br />❑ None <br />❑ Wood <br />❑ Electric Baseboard <br />❑ Other (specify bsbw) <br />Zip <br />C. Water Heal Type <br />(optional, check one) <br />❑ Electric <br />❑ Gas <br />❑ Other (spedh bebw) <br />INSPECTION/ENFORCEMENT <br />Date of Permit Application <br />Date Building Permit Issued <br />Date of Insulation Inspection <br />Date of Final Inspection- <br />1 hereby certify that this building or addition has been inspected for the measures required <br />by the 1991 Washington State Energy Code (WSEC), that It Is In substantial compliance <br />with the WSEC, and that the WSEC checklist for this building Is on file. <br />azure of Building Vidal or Aulhorizod Representative <br />Dalo <br />Return while copy to: Kathleen Skaar, Washington State F.riorgy Office. 809 Legion Way SE, FA-11. jurisdiction A Copy 141 <br />1 <br />WSEO White Copy utility,Dwner CanaryCopy <br />