Fillable Property Owner Exemption Affidavit Building Services When the (City of Kirkland)

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Property Owner Exemption Affidavit Building Services When the (City of Kirkland)

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BROWSE CITY OF KIRKLAND (WA) FORMS

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DevSvcs-TE-2.0-20200131
Page 1 of 2
Property Owner
Exemption Affidavit
Building Services
When the property owner or owner's agent is performing all the work included in the scope of the building or electrical
permit, this form shall be completed and returned to Kirkland City Hall.
A property owner, renter or lessee may purchase a permit to do construction or electrical work on his/her own or
qualified property under the conditions as described in RCW 19.28.261 and RCW 18.27.090.
I am applying for a property owner exemption under the following conditions:
I, __________________________________________________________, certify under penalty of perjury that:
I am a registered general contractor who is installing a temporary electrical service owned by me on a project
where I am the general contractor.
I am the owner of real property where the electrical work will occur.
I am the owner's agent of real property where the electrical work will occur. (You may be required to provide a
copy of the rental or lease agreement showing you are allowed to perform electrical work or construction on the
property.)
Select the option that applies to your situation regarding electrical work:
A NEW single family residence THAT IS NOT intended for rent, sale or lease AND I will be personally doing the
electrical work AND I will occupy the residence for at least 24 months after completion of the electrical work. RCW
19.28.261(1)
A NEW 2, 3, or 4 unit residential property that IS intended for rent, sale or lease AND I, personally, and/or a
regularly scheduled and paid employee(s) will be doing the electrical work AND I will occupy one of the units for at
least 24 months after completion of the electrical work. RCW 19.28.261(1)
An EXISTING 1, 2, 3 or 4 unit residential property that IS intended for rent, sale or lease AND I, personally, and/or a
regularly scheduled and paid employee(s) will be doing the electrical work. RCW 19.28.261(5a)
A farm AND I, personally, and/or a regularly scheduled and paid employee(s) will be doing the electrical work. RCW
19.28.261(1)
An EXISTING place of business AND I, personally, and/or a regularly scheduled and paid employee(s) will be doing
the electrical work. RCW 19.28.261(5a)
A NEW place of business that is NOT intended for rent, sale or lease AND I, personally, and/or a regularly
scheduled and paid employee(s) will be doing the electrical work. RCW 19.28.261(5a)
Other property that is NOT intended for rent, sale or lease AND I, personally, and/or a regularly scheduled and paid
employee(s) will be doing the electrical work. RCW 19.28.261(1)
Permit Number(s):
An EXISTING single family residence AND I will be personally doing the electrical work. RCW 19.28.261(5a)
(printed name)
Address where work is to occur:
Or
I am the property owner or owner's agent and I am exempt from the requirements of the Contractor Registration
laws, RCW 18.27, (Definitions RCW 18.27.010 and Exemptions RCW 18.27.090) and I will do all my own
construction work.
Property Owner Exemption Affidavit - continued
Page 2 of 2
DevSvcs-TE-2.0-20200131
ACKNOWLEDGMENTS
I agree and wish to purchase an electrical permit or building permit under the conditions described above, for the work
occurring at the address indicated above.
Owner/Agent Printed Name:
Owner/Agent Signature:
Date:
STATE OF WASHINGTON )
) SS.
County of King )
On this _______ day of ___________________, 20______, I certify that I have satisfactory evidence that
___________________ is the person who appeared before me, and said person acknowledged that (he/
she) signed this instrument and acknowledged it to be (his/her) free and voluntary act for the uses and
purposes mentioned in the instrument.
STATE OF WASHINGTON )
) SS.
County of King )
On this _____ day of ____________, 20_____, before me, the undersigned, a Notary
Public in and for the State of Washington, duly commissioned and sworn, personally
appeared ____________________________________________________________and
________________________________________to me known to be the individual(s)
described herein and who executed the Property Owner Exemption Affidavit and
acknowledged that _______ signed the same as ______free and voluntary act and
deed, for the uses and purposes therein mentioned.
WITNESS my hand and official seal hereto affixed the day and year first above written.
________________________________________
Notary's Signature
________________________________________
Print Notary's Name
Notary Public in and for the State of Washington,
Residing at: __________________________________________
My commission expires: ______________________
This section is to be notarized.
I certify that I am the owner of this property or the owner's authorized agent. If acting as an authorized agent, I further
certify that I have full power and authority to file this application and to perform, on behalf of the owner, all acts
required to enable the jurisdiction to process and review such application. I have furnished true and correct
information. I will comply with all provisions of law and ordinance governing this type of application. If the scope of
work requires a licensed contractor to perform the work, the information will be provided prior to permit issuance.
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Property Owner Exemption Affidavit Building Services When the (City of Kirkland)

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Completed 3 August 2020

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