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Date <br />�- � • efCOHV MI'lkp>s S.e <br />Application/Permit / ......Owner.. <br />Dt�NNeA- 4,Q�`� \' IO WxIeE of alb ENT IAI, <br />L� l l I 11 <br />H She Address xK �or-y__7yN✓_�SG_yLU <br />H Asses_sor's Property —Tax Account No. <br />C H 'PUD {'{ AN FtEvir.W NO. <br />r eye •�.•; <br />a xH Va • (J <br />SheAddress ................ ...... lf!....:A�.,w�.............................................................. ... .............. ............................ ....................... <br />zKOwner's Address.r.rr.................................r...r................................. City.................................... Zip .................... Phone ................................... H� <br />oy TOH ilder.Oco.4APOh0 <br />yBu..........................1-0-4E 0...................Address...-2� .......C <br />................................................. <br />• 'moo...................._...........Zip.........`1....y.........Pnone........e;..:53....w.C....................... <br />• City.............1.............................r............. <br />MIS <br />O H t7 <br />Hag <br />ca. cg <br />z H • PRE CT DESCRIPTION: <br />• O61 <br />H • ry O Aidition TW$ingle Family / of Stories .............r........ <br />H H O Remodel Or. Conditioned Sa Ft..I a.Y. a O Multi -Family / of Units............... ......... <br />. <br />> FUEL SOURCE: HE4TING SYSTEM TYPE: <br />C to O Electric O Baseboard O Heat pump HSPF ........................... <br />• O Oil 'Wall heater O Other ................................................ <br />r•3 to , O Gas O Furnace AFUE... ........... . __ O Total installed watts or BTU's .......... <br />H O N <br />rI COMPONENT <br />I ENERGY Flat Ceiling <br />Check one of the Cammlamx Down Boxes below. Insert the values into box number 4 Before cor heling dus Vaulted Ceiling R..%.�...1..... <br />C seclion refer to the insfrucaom on back of form. Wall R.A.4.o-0 <br />Below Grade Wall: <br />Electric - Northwest Energy Code, Other Fuel Sources - interior R............ <br />Chapter 6 Washington State Energy Code <br />exterior R............ <br />O Well Insulated Floor O Syysetema Analysis, O Prescriptive Approach, <br />Option Chapier4 Chapter Floor R..S- <br />O Well Insulated Wall )aEomponent Performance, O Component Performance Slab on Grade R.s�..... <br />Option Chapter 5 Approach, Chapter 4 Doors d Frame U.......'... <br />O Passive Solar Option O Component Paint System, O Systems Analysis, Glaring U.l.7...... <br />�A Chapter? Chapters SolarAlg 1,?......!6 <br />O Heat Pump Option SolarAllavranco S6 ........... <br />Air Leakage ri TO OADV <br />AIM <br />FOR DEPARTMENT USE ONLY: <br />Amount of Payment $...r......................_......... <br />Date Permit Issued ......................................... <br />Date Permit Finated................................rye....... <br />I hereby certify that this dwelling was built In <br />compliance with the NWEC. <br />gu <br />.. ild--....Otic..._iar..l..or..A <br />........dred.... ...................... <br />iding ryeu..No..Agent <br />............................. <br />.......... <br />....._ _ ._...._....._. <br />Daa <br />I hereby unify out the slmctural panels wil meet the NWEC Formaldehyde requirements • either the <br />HUD standards a rnarked'extennf or -ex posure 1' / <br />OWnsr or Authnrued Agent: <br />Prml Name SignaWr� <br />The local Wdsdebonlelectrk utility will make a Gpaymart to airier the builder at owner for n+w electrically <br />healed residences. Permit must be issued by I7131A1 and construction 6naod by 6130192 in order to <br />quality for payment. To facilitate payment, the following information must be WI gut emnLrely_ <br />Mailehecklo:(pleaselinnl) (:1UDI'I'I0NS/IiF1I0I)LI,S N0'1 ELIGI.:.::) <br />Name ,.. .r:.:; L. rl/ x:'....... Fed. Tax ID or SS/....:'.1.:........:. '..:...:....:.?............. <br />Address....... _:.:.....,...'_...:...........:..'.L.'.:........`....:........................ ..... ... ......................... <br />city .... .:.L.i..!:.L.'(....r...:....:::.........................................I..... Zip- ... :::...t.:..:............... .......... <br />NOTE: An IRS Form 1099 wa be fend at the end or ism year <br />