Building Department
21630 11th Avenue South, Suite D
Des Moines, WA 98198
(206)870-7576 fax:(206)870-6544
www.desmoineswa.gov
Over the Counter
Residential Re-roof
Building Permit Application
Project Name:
Project Address:
Complex/Park Name:
Unit/Space Number:
Building Owner
Contractor
Name:
Address: City: State: Zip:
Phone: Fax:
Name:
Address: City: State: Zip:
Phone:
Fax:
Email:
Email:
WA Contractor License #:
Des Moines Business License #:
Applicant:
Owner
Owner's Agent
Contractor
Contractor's Agent
I hereby certify that I have read and examined this application and know the same to be true and correct, and agree to comply with City ordinances and State laws
regulating the performance of construction. I certify that I am either the owner of the property described on this permit application, the Washington State licensed
Contractor responsible for the work, or I represent the owner or contractor as signified above, and am acting with the owner's/contractor's full knowledge or consent.
Print name of Applicant
Applicant's signature
Application expires 180 days from date of application
Permit expires 180 days from date of issuance or last inspection
Date:
For all work done within the City of Des Moines, please use Location Code 1709 in reporting and/or remitting to the State all related sales and use taxes
Valuation:
Application Date:
Scope of
Work:
If you are exempt from contractor registration, per RCW 18.27.090, you must complete and submit with this application an Affidavit in
Lieu of General Contractor form. This document is available online, or can be obtained at the Building Department Front counter when
you turn in this application for processing.
Permit Type
Re-roof
