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1qmw <br />ri <br />Date ..... 3.1_.+1 fl_`L <br />ApplicatiorVPerrmh /..__________�_____-- ••; <br />!:k <br />Owner <br />Vr_�e-11.]...5+.13t1T--___�___ L e W R 1 S E 11 E <br />Site Address <br />Assessor's Property Tax Account No. <br />She Address . 113 \....... SUM. .`'.... �... �. <br />owner'sAddres.....�Q.N1f��Mll�............l...,..................................Clryc...................................zip....................Phone................................... <br />Builder.........1fii ....STr..G.3......Address............�t1�................................................................................ <br />City <br />PROJECT DESCRIPTION: <br />O New dition <br />O Remodel O Conditioned Sq. Ft .................... <br />Zip.................................... Phone <br />Ingle Family / of Stories.......:........... <br />O Mufti -Family I of Units........... ............. <br />® FUELS URCE: HEATING SYSTEM TYPE: <br />ectric O Baseboard O Heat pump HSPF .............................. <br />OOil (akMSlfileater OOther................................................. <br />Q Gas O Furnace AFUE................... O Total installed wafts or BTU's ............ <br />Check one of the Compliance Option Boxes below. Insert thevatues Into box number e. Before completing this <br />section refer to the instructions on back of form. <br />Electric - Northwest Energy Code, <br />Chapter 6 <br />Gf4ell Insulated Floor O Syetome Analysis, <br />Option Chapter 4 <br />Q Well Insulated Wall <br />Option <br />O Passive Solar Option <br />O Heat Pump Option <br />FOR DEPARTMENT USE ONLY: <br />O Component Performance, <br />Chapter 5 <br />O Component Point System, <br />Chapter 7 <br />Amount of Payment S.......... _............... _......... <br />Date Permit Issued.... .................................. <br />Date Permit Finafed......................................... <br />I hereby certify that this dwelling was built In <br />compliance'wnh the NWEC. <br />.............._............. ................ ............... _........... <br />Building Offiill or Authorized Agent <br />Date <br />Other Fuel Sources - <br />Washington Stets Energy Code <br />O Prescriptive Approach, <br />Chapter 6 <br />O ApprComnent oach, Chapter fiance <br />O Systems Analysis, <br />Chapter 5 <br />COMPONENT <br />�j� <br />Fiat CcIing <br />R.✓.".. <br />Vaulted Ceiling R........... <br />lroc:Y. R1.`If!w <br />Wall aY <br />Below Grade Wall: <br />interior <br />R............ <br />exterior <br />R...... ...... <br />Floor <br />R.I.Q.. <br />Slab on Grade <br />R............ <br />Doors 6 Frame <br />U............ <br />Glazing <br />U.+..`/.Q.. <br />%Glazing <br />.��•S•'� <br />Solar Allowance <br />..........% <br />Air Leakage O STD <br />O ADV <br />I hereby cemNp that the structural panels wiil meet the NWEC Formaldehyde requirements -either the <br />HUD standalds or marked'exlenor or -exposure l.' i• / / <br />Owner or Authorized Agent: <br />f ` <br />tSho.....:............................................ <br />s:......:..t.........../1:.:..:....................... _ neNre <br />Print Name <br />The local (udsdkeon/eiectric utility will make a Vyayment to either the builder or owner for new eleClr,aly <br />heated residences. Permit must be issued by 1GIMA t and construction 6naled b9 &YV92 in ordr.r to <br />quality for payment. To facilitate payment, the following information must be. Nkd oulcompktely_ <br />- — — — — — — — — — — — — — — — — — <br />McIfCheck to: (please pdnng (A DITIONS/REMODELS NOT ELIGIBLE) <br />Name ...:.i :.:......:.1.....%l..a:�.f `. .. Fed. Tax ID or SS/.,, 5.:.' y. Q ..z::...... <br />Address........�....: <br />�'�''............) ............ G'........................................................................ <br />.... <br />:.... . <br />City...............4.":........................... zip.. £:.. 5.................. <br />NOTE: M Ins Form tong wE be sent at the and at sr tar. <br />