Fillable 565 General Permit Application

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565 General Permit Application

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File type: PDF

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CERTIFICATION OF APPLICANT
I hereby certify under penalty of perjury of the laws of the State of Washington,
that I have read and examined this application and know that the information
contained herein is true and correct. I will comply with all provisions of law and
ordinances governing this type of construction work, whether specified herein or
not. I understand that granting of a permit does not authorize me in any way to
violate or cancel any of the provisions of state or local law regulating the
construction or performance of construction sought under this permit. I further
certify, as applicant, that I am one of the following general categories of
applicants as indicated below.
A. That I am currently registered and properly licensed as a GENERAL
CONTRACTOR OR SPECIALTY CONTRACTOR as defined under
RCW 18.27.010 and 18.27.110 and am legally qualified to perform the work
sought by this permit, or:
B. That I am an AUTHORIZED AGENT of the property owner and all
work will be done by a properly licensed general contractor or specialty
contractor as defined under RCW 18.27.010 and 18.27.110 and is legally
qualified to perform the work sought by this permit, or:
C. That I am EXEMPT from the requirements of the Contractor Registration
laws, RCW 18.27.010 and 18.27.110 and will do all my own work or use all
registered and licensed subcontractors in connection with the work to be
performed under the permit applied herein.
NOTICE TO APPLICANT
1. THIS APPLICATION BECOMES NULL AND VOID 1 YEAR AFTER
DATE OF SUBMITTAL OR MAY BE CANCELED DUE TO INACTIVITY IF
NO RESPONSE IS RECEIVED WITHIN 90 DAYS OF A CORRECTION
LETTER REQUEST.
2. Electrical permits are obtained from the Department of Labor and Industries.
(425) 990-1400.
3. It is understood that any permit will not grant any right or privilege to erect or
use any structure or to use any premises herein described for any purpose or in
any manner in violation of any ordinance, regulation, or rule of the City of
Issaquah.
4. The applicant understands and accepts the Hold Harmless Language on the
reverse side of this form.
5. All information on this application is subject to public disclosure.
Signature of Owner/Contractor or Authorized Agent Date
Printed Name of Owner/Contractor or Authorized Agent
TYPE
PERMIT NUMBER
BLD
SW
PLM
MEC
SGN
FIR
1775 – 12
th
Ave. NW | P.O. Box 1307
Issaquah, WA 98027
425-837-3100
issaquahwa.gov
ROW
PROJECT NAME
PARCEL #
JOB ADDRESS
PROJECT VALUATION
CONTACT NAME MAILING ADDRESS ZIP
EMAIL PHONE
PROPERTY OWNER NAME PHONE MAILING ADDRESS ZIP
CONTRACTOR PHONE MAILING ADDRESS ZIP
CONTRACTOR LICENSE #
EXP. DATE
EXP. DATE
TYPE S.F. RES COMMERCIAL PUBLIC WORKS RIGHT OF WAY USE
MULTI-FAMILY SIGN TEMP SIGN FIRE ALARM/SPRINKLER
CLASS OF
WORK
NEW ADDITION ALTERATION
MOVE DEMO TREE REMOVAL
PRIORITY
PLAN REVIEW
LEED BUILT GREEN
AFFORDABLE HOUSING
DESCRIBE WORK
SPACE IS CURRENTLY FIRE : SPRINKLERED ALARMED NONE
HOLD HARMLESS AGREEMENT
The Permittee shall defend, indemnify and hold the City, its officers, officials, employees and volunteers harmless
from any and all claims, injuries, damages, losses or suits including attorney fees, arising out of, or in connection
with, their performance under this Permit, except for injuries and damages caused by the sole negligence of the
City.
Should a court competent jurisdiction determine that this Permit is subject to RCW4.24.115, then, in the event of
liability for damages arising out of bodily injury to persons or damages to property caused by or resulting from the
concurrent negligence of the Permittee and the City, its officers, officials, employees, and volunteers, the
Permittee’s liability hereunder shall be only to the extent of the Permittee’s negligence. It is further specified and
expressly understood that the indemnification provided herein constitutes the Permittee’s waiver of immunity
under Industrial Insurance, Title 51 RCW, solely for the purpose of this indemnification. The parties have mutually
negotiated this waiver. The provisions of this section shall survive the expiration or termination of this Permit
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565 General Permit Application

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Completed 13 July 2020

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