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xyxn" <br />[* tt" <br />ay <br />Q �a H <br />g\ vOSHINGTJf <br />9TATE Y <br />CODE <br />(please chock one) <br />❑ New Building <br />Jurisdiction: <br />Building Record <br />❑ Addition over 500 sq. R. <br />please chectr one: 0 City ❑ County__ --- <br />CLASSIFICATION <br />Attachment B <br />WSEO Contract # —_ <br />(please check one) <br />❑ Single Family ❑ Duplex <br />Multifamily ❑ Zero Lot Line Home <br />❑ Planned UnIt—Development <br />Permit #— <br />File ID 1I (If different from Permit o) <br />CONSTRUCTION <br />A. Site Information B. Owner Information <br />Address ' _ . Owner (ow+rer ar ome of mnsrnr#on ecekes uokHaayme^U <br />city _ — ---- Zip -- <br />Assessor's Property Tax It (or attach legal description) t <br />Servicing Electric Utility <br />C. It Single Family, Zero Lot Line or <br />Planned Unit Development <br />Total Condilioned Floor Area <br />Second Duplex Unit <br />A. <br />Primary Space Heat Type <br />(check one) <br />Electric Baseboard <br />❑ <br />Electric Furnace <br />❑ <br />Electric Heat Pump <br />❑ <br />Other (specify bolow) <br />— <br />Addre_ss-- <br />Cllty__ ____— - State Zip <br />FederalID#orSSN <br />D. If Multifamily (R-1) <br />Total # of Buildings <br />Total # of Units <br />Total sq. it. (optional) <br />HEAT -SOURCE <br />B. <br />Back -Up Space HeatTpe <br />(options , check all that apply <br />❑ <br />None <br />❑ <br />Wood <br />❑ <br />Electric Baseboard <br />❑ <br />Other (specify betow) <br />COMPUANCE _ <br />1 WSEC Compliance Method <br />l *•• ❑ Prescriptive Path <br />❑ Component Performance <br />❑ System Analysis <br />C. Water Heat Type <br />(options), check one) <br />❑ Electric <br />❑ Gas <br />❑ Other (speedy helowl <br />INSPECTIONIENFORCEMENT <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 (10i that It Is In substantial compliance <br />with the WSEC, and that the WSEC checklist for this building Is on file. <br />Signature of Buiding Official or Authorized Representative Dal" <br />Return white copy to: Kathleen Skaar, Washington State Energy Office, 809 Legion Way SE, FA 11. Olympia, WA 98504-1211 <br />WSEO - White Copy Utility/Owner - Canary Copy Jurisdiction • Pink Copy 6.91 <br />