Electrical Permit
Property Owner/Renter/ Lessee Affidavit
Page 1 of 2
Updated 11/8/2017
Department of Community Development
801 228th Avenue SE
Sammamish, WA 98075-9509
Phone: 425-295-0500
Fax: 425-295-0600
Web: www.sammamish.us
www.mybuildingpermit.com
SMC 16.05.153
Property Owner/Renter/ Lessee Affidavit
Complete this form, when required, and submit to City Hall or upload to MyBuildingPermit.com.
A property owner, renter or lessee may purchase a permit to do an electrical installation on his/her own
or qualified leased property under the conditions as described in RCW 19.28.261.
This is an application form, not a valid permit. An electrical permit issued by the City of Sammamish is
required to begin electrical work.
Applicant Information
Name of Property owner, renter, or lessee:
Address/location where electrical work is to be done:
As authorized under RCW 19.28.261, the above named is applying for an exemption from Chapter
19.28 RCW by submission of this affidavit and swears under penalty of perjury the following:
Section 1 (must mark one)
I am the owner/lessee of real property as listed
above.
I am the renter of real property as listed
above.
Section 2 (must mark if NEW CONSTRUCTION)
I have not applied for this New Construction exemption within the past two years on a different property.
Section 3 (must be able to mark one in order to obtain a permit)
I am applying for an electrical license exemption for the electrical work for a NEW single family residence that
is not intended for rent, sale, or lease and I will be personally doing the electrical work in accordance with RCW
19.28.261(6) and I will occupy this as my principal residence for at least 24 months after completion of the
electrical work. NOTARIZED SIGNATURE REQUIRED.
I am applying for an electrical license exemption for the electrical work for a NEW 2, 3, or 4-unit residential
property that except one unit is intended for sale, rent, or lease and will be personally doing the electrical work in
accordance with RCW 19.28.261(6) and I will occupy one of the units as my principal residence for at least 24
months after completion of the electrical work. NOTARIZED SIGNATURE REQUIRED.
I am applying for an electrical license exemption for the electrical work for a NEW place of business that is not
intended for rent, sale, or lease and I and/or a regularly scheduled and paid employee will be doing the electrical
work in accordance with RCW 19.28.261 5(a). NOTARIZED SIGNATURE REQUIRED.
I am applying for an electrical license exemption for electrical work in an existing single family residence
(whether for rent or not) and I will be personally doing the electrical work in accordance with RCW 19.28.261(6).
I am applying for an electrical license exemption for electrical work in an existing 2, 3, or 4-unit residential
property that is intended for rent sale or lease and I and/or a regularly scheduled and paid employee(s) will be
doing the electrical work in accordance with RCW 19.28.261 5(a).
I am applying for an electrical license exemption for electrical work in an existing place of business or other
commercial property I own or lease and I and/or a regularly scheduled and paid employee(s) will be doing the
electrical work in accordance with RCW 19.28.261 5(a).
Electrical Permit
Property Owner/Renter/ Lessee Affidavit
Page 2 of 2
Updated 11/8/2017
See Chapter 19.28 RCW and Chapter 296-46B WAC for penalties for false statements or material
misrepresentations. This document will be provided to Washington State Department of Labor and
Industries upon request.
Signature of property owner, renter, or lessee:
Date:
State of Washington )
:
County of ______________________________ )
On this day personally appeared before me
_____________________, to me known to be the
individual(s) described in and who certifies the
above, and acknowledged to me that (s)he/they
signed the same as his/her/their abiding
commitment for the uses and purposes therein
mentioned.
Given under my hand and official seal the ____
day of _________, 20_____.
Notary Public in and for the State of Washington
My commission expires:______________________
Residing in_________________________________