City of Bainbridge Island Planning and Community Development
280 Madison Ave. N.
Bainbridge Island, WA 98110
pcd@bainbridgewa.gov
Phone: (206) 780-3750
Fax: (206) 780-0955
Revision Date:02/20/20
Page 2 of 2
Section 4 – Applicant/Property Owner Information
Name: ____________________________________ Address: ___________________________________
Contact Phone #: __________________________ Email Address: ______________________________
Applicant: Note: For projects with multiple owners, attach a separate sheet with each owner(s) information and
signatures.
Applicant (other than owner)
Authorized Agent/Representative*
Name: ____________________________________ Address: ___________________________________
Contact Phone #: __________________________ Email Address: ______________________________
Contractor Washington State allows homeowners to be their own general contractor. However, when choosing a contractor or
subcontractor to perform work they are required to be registered with the Washington State Department of Labor and Industries.
For more information about choosing and hiring a contractor visit http://www.lni.wa.gov/tradeslicensing/.
Check if this is the Authorized Agent/Representative* for this project.
Name: ____________________________________ Title: _____________________________________
License Number: ____________________________ Liability Certificate: __________________________
Address: _____________________________________________________________________________
Contact Phone #: __________________________ Email Address: ______________________________
*I authorize the listed contractor to perform those inspections the City has identified in the self-certification
program. (Residential projects only)
_________________________________ _________________
Owner Signature Date
*The authorized agent/representative is the primary contact for all project-related questions and correspondence. The City will email
requests and information about the application to the authorized agent/representative and will ‘copy’ (Cc) the owner noted below. The
authorized agent/representative is responsible for communicating information to all parties involved with the application. It is the
responsibility of the authorized agent/representative and owner to ensure their mailbox accepts City email (i.e., City email is not
blocked or sent to “junk mail”). There may be instances where regular USPS or courier mail is used.
I affirm, under penalty of perjury, that all answers, statements, and information submitted with this application
are correct and accurate to the best of my knowledge. I also affirm that I am the owner of the subject site.
Further, as owner, I grant permission to any and all employees and representative of the City of Bainbridge
Island and other governmental agencies to enter upon and inspect said property as reasonably necessary to
process this application.
____________________________ _________________ ______ ___________
Print Name (Owner) Signature (Owner) Date
____________________________ ____________________________ ____________
Print Name (Owner) Signature (Owner) Date
click to sign
signature
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