Fillable Affidavit Regarding Contractor Registration (City of Sammamish)

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Affidavit Regarding Contractor Registration (City of Sammamish)

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801 – 228
th
Avenue SE
Sammamish, WA 98075 Phone: 425-295-0500 Fax: 425-295-0600 web: www.sammamish.us
Revised 07/27/15
PERMIT NUMBER
—
Affidavit Regarding Contractor Registration
Date: ______________________ Property Owner: ___________________________________
1. He/She is the owner or authorized agent of the owner of property legally described as:
_______________________________________________________________________________________
_______________________________________________________________________________________
and located at the approximate street address of: _______________________________________________
_______________________________________________________________________________________
2. That he/she is an applicant for a City of Sammamish Building Permit at the above location.
3. That he/she is aware that the State Contractors Registration Act requires all persons doing any work as
contractors to obtain a certificate of registration from the Washington State department of Labor and
Industries.
4. That he/she is aware that it is unlawful to do any work as a contractor without a certificate of registration
and that a violation of this requirement is a criminal misdemeanor.
5. That all construction work done pursuant to the proposed building permit for the property described
above will be done by the owner or owners of the property or by a licensed contractor acting as the
owner’s agent.
6. That, in the case of new construction undertaken by the owner without the use of a licensed contractor,
the proposed construction work is not being done with the intention or for the purpose of selling the
improved property.
Owner’s Signature: Date:
State of: Washington County of: King
On this ______ day of ____________, 20______, before me, ____________________________, the undersigned
Notary Public, _____________________________ , personally appeared and is known to be the
person whose name is subscribed to the within instrument, and acknowledged that he/she executed it.
WITNESS my hand and official seal.
_________________________________
Notary Public
_________________________________
Residing in: ______________, Washington
Term Expires: ____________________
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Affidavit Regarding Contractor Registration (City of Sammamish)

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Completed 24 January 2021

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