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For Inspections, call: Town of Coupeville PO Box 725 360-678-4461 BUILDING DEPARTMENT 4 NE 7 th Street 24 Hours Notice Requested PERMIT APPLICATION Coupeville WA 98239 OWNER Name or Name of Business APPLICANT: Complete this form within shaded area for the work to be done under this permit. Mailing Address PLUMBING City/State/Zip Telephone # No. Type of Fixture or Item Fee, $ Water Closet (Toilet) ARCHITECT Name Bathtub w/shower head Lavatory (Wash Basin) Address Shower (stall) Kitchen Sink & Disposal City/State/Zip Telephone # Dishwasher Laundry Tray CONTRACTOR Name Clothes Washer Water Heater Address Urinal Drinking Fountain City/State/Zip Telephone # Floor – Sink or Drain Slop Sink State License Number Yard Sprinkler System Residential Demolish Plumbing Commercial Fence Mechanical Non-commercial Swimming Pool Addition Permit New Remodel Repairs Total Plumbing Fee Assessor’s Tax Parcel Number MECHANICAL Natural Gas Oil LPG Electric Nature of Work to be done No Type of Equipment Fee, $ Residential Heating System Ventilation Fan Range Hood Gas Piping Proposed use: NOTICE: This permit becomes null & void if work or construction authorized is not commenced within 180 days, or if construction or work is suspended or abandoned for a period of 180 days at any time after work is commenced. I hereby certify that I have Permit read and examined this application & know the same to be true and correct. I will comply Total Mechanical Fee with all provisions of the laws & ordinances governing this type of work whether or not Building Fee Calculation Valuation, $ Fee, $ PERMIT NO. ADDRESS: specified herein. Approval of this permit does not presume to give authority to violate or Building (001.322.10) cancel the provisions of any other state or local law regarding construction or Plumbing (001.322.10) performance of construction. Mechanical (001.322.10) Plan Check (001.345.83) X State Fee ($4.50) (001.389.01) Signature of Owner or Authorized Agent Date Other______________ Building Fees Due NOTE: Permit Limit One year (Except DEMOLITIONS, which shall be completed in sixty days; moving permits in thirty days.) Public Works Permits Account Fee, $ Side Setback Street Setback Rear Setback Right of Way 001.322.90.01 Lt. Rt. Stormwater 001.322.10.03 Zoning Lot Area Vacant Site Clearing & Grading 001.322.10.03 Yes No Water Hookup Right 410.900.000.343.40 Type of Construction Occupancy Group No. of Dwelling Units Sewer Hookup Right 420.900.000.343.50 Park Impact Fee 109.345.85.00.01 --------- Size of Building (total) Sq. Ft. Basement No. Stories Max. Occupancy Load Water Inspection Fee 410.343.40.00.14 Sewer Inspection Fee 420.343.50.00.14 Fire Zone Fire Sprinklers Required? Other __________ Yes No TOTAL FEES DUE Deck Fireplace/Stove Culvert Date paid Date application received: Plans checked by: Approved for Issuance by: Amount paid Receipt Number WHEN SIGNED & DATED BELOW, THIS IS YOUR PERMIT AND RECEIPT. Permission is hereby given to do the above described work, according to the conditions herein, and according to the approved plans and specifications pertaining thereto, subject to compliance with the ordinances of the Town of Coupeville. Permit Issued , 20 By , Building Official Original: Applicant copy to: Building File, A/R bldg permit application, final 072109.doc, rev 05/11/04
19

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Page 1: PLUMBING - · PDF file11/05/2004 · New Remodel Repairs Total Plumbing Fee ... is less than the label or design thickness of the insulation, the compressed R-value of the insulation

For Inspections, call: Town of Coupeville PO Box 725 360-678-4461 BUILDING DEPARTMENT 4 NE 7th Street 24 Hours Notice Requested PERMIT APPLICATION Coupeville WA 98239

O

WN

ER

Name or Name of Business

APPLICANT: Complete this form within shaded area for the work to be done under this permit.

Mailing Address PLUMBING City/State/Zip Telephone # No. Type of Fixture or Item Fee, $

Water Closet (Toilet)

AR

CH

ITE

CT

Name

Bathtub w/shower head Lavatory (Wash Basin)

Address

Shower (stall) Kitchen Sink & Disposal

City/State/Zip

Telephone # Dishwasher

Laundry Tray

CO

NT

RA

CT

OR

Name Clothes Washer Water Heater

Address

Urinal Drinking Fountain

City/State/Zip

Telephone # Floor – Sink or Drain Slop Sink

State License Number

Yard Sprinkler System

Residential Demolish Plumbing

Commercial Fence Mechanical Non-commercial Swimming Pool Addition Permit New Remodel Repairs Total Plumbing Fee

Assessor’s Tax Parcel Number MECHANICAL Natural Gas Oil LPG Electric

Nature of Work to be done No Type of Equipment Fee, $ Residential Heating System Ventilation Fan

Range Hood Gas Piping

Proposed use:

NOTICE: This permit becomes null & void if work or construction authorized is not commenced within 180 days, or if construction or work is suspended or abandoned for a period of 180 days at any time after work is commenced. I hereby certify that I have Permit read and examined this application & know the same to be true and correct. I will comply Total Mechanical Fee with all provisions of the laws & ordinances governing this type of work whether or not Building Fee Calculation Valuation, $ Fee, $ P

ER

MIT

NO

. A

DD

RE

SS

:

specified herein. Approval of this permit does not presume to give authority to violate or Building (001.322.10) cancel the provisions of any other state or local law regarding construction or Plumbing (001.322.10) performance of construction. Mechanical (001.322.10) Plan Check (001.345.83) X State Fee ($4.50) (001.389.01) Signature of Owner or Authorized Agent Date Other______________ Building Fees Due NOTE: Permit Limit One year (Except DEMOLITIONS, which shall be completed in sixty days; moving permits in thirty days.)

Public Works Permits Account Fee, $

Side Setback Street Setback Rear Setback Right of Way 001.322.90.01 Lt. Rt. Stormwater 001.322.10.03 Zoning Lot Area Vacant Site Clearing & Grading 001.322.10.03 Yes No Water Hookup Right 410.900.000.343.40 Type of Construction Occupancy Group No. of Dwelling Units Sewer Hookup Right 420.900.000.343.50 Park Impact Fee 109.345.85.00.01 --------- Size of Building (total) Sq. Ft. Basement No. Stories Max. Occupancy Load Water Inspection Fee 410.343.40.00.14 Sewer Inspection Fee 420.343.50.00.14 Fire Zone Fire Sprinklers Required? Other __________ Yes No TOTAL FEES DUE Deck Fireplace/Stove Culvert Date paid Date application received: Plans checked by: Approved for Issuance by: Amount paid

Receipt Number

WHEN SIGNED & DATED BELOW, THIS IS YOUR PERMIT AND RECEIPT. Permission is hereby given to do the above described work, according to the conditions herein, and according to the approved plans and specifications pertaining thereto, subject to compliance with the ordinances of the Town of Coupeville. Permit Issued , 20 By , Building Official

Original: Applicant copy to: Building File, A/R bldg permit application, final 072109.doc, rev 05/11/04

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PLUMBING / MECHANICAL 1. Has this building been previously heated? ____________

2. Is this for a mobile home? _____ If yes, approval of an alteration permit from the Department of Labor and Industries is required for interior fixtures.

3. Please attach a floor plan indicating location of proposed fixtures. ____________

4. Propane tank (s) proposed? _____ If yes, How many? ____ # of gallons? _______ ASME tank/DOT tank Above ground/Underground (circle as appropriate). Provide site plan showing proposed location(s) of tank(s) including setbacks from property lines and structures.

PLUMBING: Type of fixtures@ $10.00 per fixture MECHANICAL: Toilet/Bidet Ventilation Fans @ $ 7.00 Each Bathtub/Shower Combo/Shower Stall Appliance Vents @ $ 7.00 Each Bathroom Sink Range Hood @ $11.00 Each Kitchen Sink/Disposal Wall Heaters @ $15.00 Dishwasher F.A. Furnace @ $20.00 Hot Water Heater Baseboard @ $15.00 Laundry Washer Fireplace or Woodstove @ $20.00 Each Laundry Sink Pellet Stove @ $15.00 Each Wet Bar Sink Propane Tank @ $11.00 Each Spa/Jacuzzi Tub Gas/Propane Piping System @ $ 5.00 Floor Sink or Drain Repairs and Additions @ $14.00 Waste Interceptor Heat Pump @ $15.00 Each TOTAL FIXTURES Ductless Unit @ $10.00 Each Building Sewer @ $10.00 Air Handler @ $15.00 Each

Grease Trap @ $10.00 Ea. Other ____________________ @ $

Lawn Sprinkler @ $10.00 + $1.00/sprinkler Backflow Device @ $10.00 Ea. Total Fixture Fee $ Other ____________________ + Base Permit Fee $ 30.00

= $ Total Fixtures x $10.00

+ $ 30.00 Base Permit Fee TOTAL MECHANICAL = $

= $ TOTAL PLUMBING FEE

I affirm that I am the owner or owner’s authorized representative and all information on this form is complete and accurate. Applicant signature________________________________ Printed name______________________________________

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1

Permit #: Project Address:

This set of forms has been developed to assist permit applicants documenting compliance with the Washington

State Energy Code, (2015 edition).

This set is for structures built under the IRC and located in Climatic Zone Marine 4. This form in not a substitute

for the energy code itself. To obtain a copy of the energy code, go to the following web address.

http://www.energy.wsu.edu/code.

The following forms provide much of the required documentation for plan review. The details noted here must

also be shown on the drawings (WSEC 103.2).

TABLE R402.1.1

INSULATION AND FENESTRATION REQUIREMENTS BY COMPONENT (a)

CLIMATE ZONE 5 AND MARINE 4

FENESTRATION U-FACTOR (b) 0.30

SKYLIGHT(b) U-FACTOR 0.50

GLAZED FENESTRATION SHGC(b, e) NR

CEILING R-VALUE(k) 49

WOOD FRAME WALL(g, m, n) R-VALUE 21 int

Mass Wall R-Value(i) 21/21

FLOOR R-VALUE 30

BELOW-GRADE(c,m) WALL R-VALUE 10/15/21 int + TB

SLAB(d) R-VALUE & DEPTH 10, 2 ft

For SI: 1 foot = 304.8 mm, ci = continuous insulation, int = intermediate framing.

(a) R-values are minimums. U-factors and SHGC are maximums. When insulation is installed in a cavity which

is less than the label or design thickness of the insulation, the compressed R-value of the insulation from

Appendix Table A101.4 shall not be less than the R-value specified in the table.

(b) The fenestration U-factor column excludes skylights. The SHGC column applies to all glazed fenestration.

(c) "10/15/21 +TB" means R-10 continuous insulation on the exterior of the wall, or R-15 continuous insulation

on the interior of the wall, or R-21 cavity insulation plus a thermal break between the slab and the

basement wall at the interior of the basement wall. "10/15/21 +TB" shall be permitted to be met with

R-13 cavity insulation on the interior of the basement wall plus R-5 continuous insulation on the interior

or exterior of the wall. "TB" means thermal break between floor slab and basement wall.

(d) R-10 continuous insulation is required under heated slab on grade floors. See R402.2.9.1.

(e) There are no SHGC requirements in the Marine Zone.

(f) Reserved.

(g) Reserved.

(h) Reserved.

(i) The second R-value applies when more than half the insulation is on the interior of the mass wall.(

(j) Reserved.

(k) For single rafter- or joist-vaulted ceilings, the insulation may be reduced to R-38.

(l) Reserved.

(m) Int. (intermediate framing) denotes standard framing 16 inches on center with headers insulated with a

minimum of R-10 insulation.

(n) Log and solid timber walls with a minimum average thickness of 3.5 inches are exempt from this insulation requirement.

Town of Coupeville 4 NE Seventh PO Box 725 Coupeville, WA 98239

360 678 4461 360 678 3299 Fax www.townofcoupeville.org

.

. . .

.

. . .

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2

WA STATE ENERGY CODE SECTION R406

ADDITIONAL ENERGY EFFICIENCY REQUIREMENTS

Choose sufficient options from Table R406.2 so as to achieve the following minimum number of credits:

1. Small Dwelling Unit: .......1.5 credits Dwelling units less than 1500 square feet in conditioned floor area

with less than 300 square feet of fenestration area. Additions to

existing building greater than 500 square feet of heated floor area

but less than 1500.

2. Medium Dwelling Unit: ...3.5 credits All dwelling units that are not included in #1 or #3.

3. Large Dwelling Unit: .......4.5 credits Dwelling units exceeding 5000 sq ft of conditioned floor area.

4. Additions ………………...0.5 credit Additions less than 500 square feet.

The drawings included with the building permit application shall identify which options have been selected and

the point value of each option, regardless of whether separate mechanical, plumbing, electrical, or other permits

are utilized for the project. Please circle the OPTION(s) below

TABLE 406.2 OPTION DESCRIPTION CREDIT

1a EFFICIENT BUILDING ENVELOPE 1a:

Prescriptive compliance is based on Table R402.1.1 with the following modifications:

Vertical fenestration U = 0.28; Floor R-38; Slab on grade R-10 perimeter and under entire slab; Below grade slab R-10

perimeter and under entire slab

or Compliance based on Section R402.1.4: Reduce the Total UA by 5%.

0.5

1b EFFICIENT BUILDING ENVELOPE 1b:

Prescriptive compliance is based on Table R402.1.1 with the following modifications:

Vertical fenestration U = 0.25; Wall R-21 plus R-4; Floor R-38; Basement wall R-21 int plus R-5 ci; Slab on grade R-10

perimeter and under entire slab; Below grade slab R-10 perimeter and under entire slab

or Compliance based on Section R402.1.4: Reduce the Total UA by 15%.

1.0

1c EFFICIENT BUILDING ENVELOPE 1c:

Prescriptive compliance is based on Table R402.1.1 with the following modifications:

Vertical fenestration U = 0.22; Ceiling and single-rafter or joist-vaulted R-49 advanced; Wood frame wall R-21 int plus

R-12 ci; Floor R-38; Basement wall R-21 int plus R-12 ci; Slab on grade R-10 perimeter and under entire slab

Below grade slab R-10 perimeter and under entire slab

or Compliance based on Section R402.1.4: Reduce the Total UA by 30%.

2.0

1d

(a)

EFFICIENT BUILDING ENVELOPE 1d:

Prescriptive compliance is based on Table R402.1.1 with the following modifications: Vertical fenestration U = 0.24

0.5

2a AIR LEAKAGE CONTROL AND EFFICIENT VENTILATION 2a:

Compliance based on R402.4.1.2: Reduce the tested air leakage to 3.0 air changes per hour maximum

and All whole house ventilation requirements as determined by Section M1507.3 of the International Residential Code shall be

met with a high efficiency fan (maximum 0.35 watts/cfm), not interlocked with the furnace fan. Ventilation systems using a

furnace including an ECM motor are allowed, provided that they are controlled to operate at low speed in ventilation only

mode.

To qualify to claim this credit, the building permit drawings shall specify the option being selected and shall specify the

maximum tested building air leakage and shall show the qualifying ventilation system.

0.5

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3

2b AIR LEAKAGE CONTROL AND EFFICIENT VENTILATION 2b:

Compliance based on Section R402.4.1.2: Reduce the tested air leakage to 2.0 air

changes per hour maximum

and All whole house ventilation requirements as determined by Section M1507.3 of the International Residential Code shall be

met with a heat recovery ventilation system with minimum sensible heat recovery efficiency of 0.70.

To qualify to claim this credit, the building permit drawings shall specify the option being selected and shall specify the

maximum tested building air leakage and shall show the heat recovery ventilation system.

1.0

2c AIR LEAKAGE CONTROL AND EFFICIENT VENTILATION 2c:

Compliance based on Section R402.4.1.2: Reduce the tested air leakage to 1.5 air changes per hour maximum

and All whole house ventilation requirements as determined by Section M1507.3 of the International Residential Code shall be

met with a heat recovery ventilation system with minimum sensible heat recovery efficiency of 0.85.

To qualify to claim this credit, the building permit drawings shall specify the option being selected and shall specify the

maximum tested building air leakage and shall show the heat recovery ventilation system.

1.5

3a

(b)

HIGH EFFICIENCY HVAC EQUIPMENT 3a:

Gas, propane or oil-fired furnace with minimum AFUE of 94%,

or Gas, propane or oiled-fired boiler with minimum AFUE of 92%.

To qualify to claim this credit, the building permit drawings shall specify the option being selected and shall specify the

heating equipment type and the minimum equipment efficiency.

1.0

3b

(b)

HIGH EFFICIENCY HVAC EQUIPMENT 3b:

Air-source heat pump with minimum HSPF of 9.0

To qualify to claim this credit, the building permit drawings shall specify the option being selected and shall specify the

heating equipment type and the minimum equipment efficiency.

1.0

3c

(b)

HIGH EFFICIENCY HVAC EQUIPMENT 3c:

Closed-loop ground source heat pump; with a minimum COP of 3.3

or Open loop water source heat pump with a maximum pumping hydraulic head of 150 feet and minimum COP of 3.6

To qualify to claim this credit, the building permit drawings shall specify the option being selected and shall specify the

heating equipment type and the minimum equipment efficiency.

1.5

3d

(b)

HIGH EFFICIENCY HVAC EQUIPMENT 3d:

Ductless Split System Heat Pumps, Zonal Control: In homes where the primary space heating system is zonal electric

heating, a ductless heat pump system shall be installed and provide heating to the largest zone of the housing unit.

To qualify to claim this credit, the building permit drawings shall specify the option being selected and shall specify the

heating equipment type and the minimum equipment efficiency.

1.0

4 HIGH EFFICIENCY HVAC DISTRIBUTION SYSTEM:

All heating and cooling system components installed inside the conditioned space. This includes all equipment and

distribution system components such as forced air ducts, hydronic piping, hydronic floor heating loop, convectors and

radiators. All combustion equipment shall be direct vent or sealed combustion.

For forced air ducts: A maximum of 10 linear feet of return ducts and 5 linear feet of supply ducts may be located outside the

conditioned space. All metallic ducts located outside the conditioned space must have both transverse and longitudinal joints

sealed with mastic. If flex ducts are used, they cannot contain splices. Flex duct connections must be made with nylon straps

and installed using a plastic strapping tensioning tool. Ducts located outside the conditioned space must be insulated to a

minimum of R-8.

Locating system components in conditioned crawl spaces is not permitted under this option.

Electric resistance heat and ductless heat pumps are not permitted under this option.

Direct combustion heating equipment with AFUE less than 80% is not permitted under this option.

To qualify to claim this credit, the building permit drawings shall specify the option being selected and shall specify the

heating equipment type and shall show the location of the heating and cooling equipment and all the ductwork.

1.0

5a EFFICIENT WATER HEATING 5a:

All showerhead and kitchen sink faucets installed in the house shall be rated at 1.75 GPM or less. All other lavatory faucets

shall be rated at 1.0 GPM or less (c)

To qualify to claim this credit, the building permit drawings shall specify the option being selected and shall specify the

maximum flow rates for all showerheads, kitchen sink faucets, and other lavatory faucets.

0.5

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4

5b EFFICIENT WATER HEATING 5b:

Water heating system shall include one of the following:

Gas, propane or oil water heater with a minimum EF of 0.74

or

Water heater heated by ground source heat pump meeting the requirements of Option 3c.

or For R-2 occupancy, a central heat pump water heater with an EF greater than 2.0 that would supply DHW to all the units

through a central water loop insulated with R-8 minimum pipe insulation.

To qualify to claim this credit, the building permit drawings shall specify the option being selected and shall specify the

water heater equipment type and the minimum equipment efficiency.

1.0

5c EFFICIENT WATER HEATING 5c:

Water heating system shall include one of the following:

Gas, propane or oil water heater with a minimum EF of 0.91

or

Solar water heating supplementing a minimum standard water heater. Solar water heating will provide a rated minimum savings of 85 therms or 2000 kWh based on the Solar Rating and Certification Corporation (SRCC) Annual Performance of

OG-300 Certified Solar Water Heating Systems.

or Electric heat pump water heater with a minimum EF of 2.0 and meeting the standards of NEEA's Northern Climate

Specifications for Heat Pump Water Heaters.

To qualify to claim this credit, the building permit drawings shall specify the option being selected and shall specify the

water heater equipment type and the minimum equipment efficiency and, for solar water heating systems, the calculation of

the minimum energy savings.

1.5

5d EFFICIENT WATER HEATING 5d:

A drain water heat recovery unit(s) shall be installed, which captures waste water heat from all the showers, and has a

minimum efficiency of 40% if installed for equal flow or a minimum efficiency of 52% if installed for unequal flow. Such

units shall be rated in accordance with CSA B55.1 and be so labeled.

To qualify to claim this credit, the building permit drawings shall include a plumbing diagram that specifies the drain water

heat recovery units and the plumbing layout needed to install it and labels or other documentation shall be provided that

demonstrates that the unit complies with the standard.

0.5

6 RENEWABLE ELECTRIC ENERGY:

For each 1200 kWh of electrical generation per housing unit provided annually by on-site wind or solar equipment a 0.5

credit shall be allowed, up to 3 credits. Generation shall be calculated as follows:

For solar electric systems, the design shall be demonstrated to meet this requirement using the National Renewable Energy

Laboratory calculator PVWATTs. Documentation noting solar access shall be included on the plans.

For wind generation projects designs shall document annual power generation based on the following factors:

The wind turbine power curve; average annual wind speed at the site; frequency distribution of the wind speed at the site and

height of the tower.

To qualify to claim this credit, the building permit drawings shall specify the option being selected and shall show the

photovoltaic or wind turbine equipment type, provide documentation of solar and wind access, and include a calculation of

the minimum annual energy power production.

0.5

(a) Projects using this option may not use Option 1a, 1b or 1c.

(b) Projects may only include credit from one space heating option, 3a, 3b, 3c or 3d. When a housing unit has two pieces of

equipment (i.e., two furnaces) both must meet the standard to receive the credit.

(c) Plumbing Fixtures Flow Ratings. Low flow plumbing fixtures (water closets and urinals) and fittings (faucets and

showerheads) shall comply with the following requirements:

1. Residential bathroom lavatory sink faucets: Maximum flow rate - 3.8 L/min (1.0 gal/min) when tested in accordance

with ASME A112.18.1/CSA B125.1.

2. Residential kitchen faucets: Maximum flow rate - 6.6 L/min (1.75 gal/min) when tested in accordance with ASME

A112.18.1/CSA B125.1.

3. Residential showerheads: Maximum flow rate - 6.6 L/min (1.75 gal/min) when tested in accordance with ASME

A112.18.1/CSA B125.1.

Per WSEC Section R402.4 Air leakage (Mandatory), the building or dwelling unit shall be tested and verified as

having an air leakage rate of not exceeding 5 air changes per hour. (See WSEC)

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Town of Coupeville 

Single Family Site Plan Checklist 

Note:  The items below may be shown on one sheet, if legibility is maintained, or on multiple sheets.  If 

more than one sheet is submitted, the scale should be consistent for each.  As applicable, the site plan 

elements below are the minimum requirements.  Other information may be required on a case‐by‐case 

basis to determine compliance with applicable regulations, e.g., base flood location and elevation.   

Existing Site Conditions (include this information on all site plans) 

Applicant 

check 

Staff 

check  

□  □ Scale, north arrow and date.  Scale shall be standard architectural or engineering.  

The scale must allow clear depiction of all required information, typically between 

1”=10’ and 1’=40’. 

□  □ 

All lot lines of all lots of record within the site and site boundary dimensions.  

Where the location of a property lines cannot be determined for the purposes of 

confirming compliance with development regulations, a boundary survey may be 

required. 

□  □ Existing easements, if any. 

□  □ 

Regulated critical areas and required buffers, if any.  If present, critical area 

information required in Chapter 16.34 CTC shall be provided in the submittal. 

□  □ 

Location, dimensions, gross floor area and use of existing structures.  Indicate all 

structures to be demolished. 

□  □ Distances between existing structures and property lines. 

New Development 

□  □ 

Dimensioned footprint and eaves of all proposed buildings and structures.  Include 

decks, patios, and fences. 

□  □ Distances between proposed buildings and property lines.  Where the location of a 

property lines cannot be determined for the purposes of confirming compliance 

with development regulations, a boundary survey may be required. 

□  □ 

Topography and slope.  Where required to determine compliance with 

development regulations, topographic contours at five‐foot or two‐foot intervals 

may be required.  Show site grading if more than foundation and drainage facility 

excavation. 

□  □ 

Location, height, top elevation and width of existing and proposed retaining walls 

and rockeries.  Cross sections may be required. 

 

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□  □ 

Proposed stormwater detention and treatment features (rain gardens, dry wells, 

ponds, etc.), conveyance pipes and/or channels, and discharge locations and 

methods.  Size, location and type of facilities shall be shown consistent with 

adopted standards.  Note: the Whidbey Island Conservation District provides 

assistance in designing small‐scale stormwater management solutions. 

□  □ 

Drainage facilities within the adjacent right‐of‐way, if any, including the location 

and dimensions of proposed culverts. 

□  □ 

Location, dimensions, and surface materials for driveways and parking areas.  No 

cement concrete is permitted within public rights‐of‐way. 

□  □ 

Trees greater than six‐inch caliper measured four feet above grade proposed to be 

retained or removed.  Identify the general dripline (canopy extent) of trees to be 

retained.  The site plan shall provide sufficient detail on the location of existing and 

proposed trees to determine compliance with the tree canopy requirements in 

Chapter 16.20 CTC. 

□  □ 

Existing utility stubs or the proposed locations of utility connections, the existing 

or proposed water meter location (if unknown, contact the Public Works 

Supervisor), and proposed alignments of utility lines to the structure.  Note:  

Disturbance of the right‐of‐way requires a right‐of‐way permit and may require a 

bond to ensure acceptable restoration occurs. 

□  □ Location of propane tank, if any. 

Construction period  

□  □ Site disturbance limits, including clearing, grading, and new utilities. 

□  □ 

All proposed temporary erosion and sedimentation control measures, including 

location and description of construction entrance, silt fencing, soil stockpile 

location (must be covered), inlet protection for catch basins, settlement ponds, 

site stabilization (e.g., straw), etc.  Note: If material will be exported, the truck 

route and disposal location must be identified in the submittal. 

□  □ 

A note stating that a pre‐construction meeting will be scheduled with Public Works 

staff prior to any site disturbance. 

 

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I:\Planning\Forms\Utility hookup-connection permit app - indiv.doc1/6/2016

OWNER’S NAME: PHONE:

OWNER’S MAILING ADDRESS:

LOCATION ADDRESS:

TAX PARCEL NUMBER

PROPOSED USE:

The undersigned applicant hereby applies for

Water hookup right only

Water hookup right and connection

Water connection only; I already have a water hookup right, # _____________________.

Sewer hookup right and sewer connection App. Initial

Sewer connection only; I already have a sewer hookup right.

to the above described property at the location shown in the attached plot plan (8 ½” x 11”).

Please indicate if you will have any of the special plumbing or activities indicated below:

Yes No Underground lawn sprinkler system

Yes No Water treatment system (e.g., water softener) Type:________________________

Yes No Solar heating system Type:___________________________________________

Yes No Residential fire sprinkler system

Yes No Private well, including those not connected to your plumbing system

Yes No Grey water system or cistern for irrigation water

Yes No Piping for livestock watering

Yes No Water supply to dock or small boat moorage

Yes No Grinder pump and/or off-site septic field

The applicant is the owner of the described property or the authorized agent of the owner.

By signing this application, the applicant agrees, as a condition of the Town providing and continuing water service to the above described

property, to comply with all provisions of Title 13 of the Coupeville Town Code, or latest revision thereof, and other such rules and regulations now existing or which may be established from time to time governing the Town’s utility system and/or work on Town streets.

APPLICANT’S SIGNATURE DATE:

1. Actual connection of water and sewer service lines to Town’s mains shall be observed by town employee.

2. Contact Public Works Superintendent at 914-1154 a minimum of one week before you want the meter

installed.

Utility Hook-Up Right & Utility

Connection Permit Application

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I:\Planning\Forms\Utility hookup-connection permit app - indiv.doc1/6/2016

FOR TOWN USE SPECIAL CONDITIONS

Domestic meter size Type of Customer

Domestic service size Residential Single Family Residence

Fire line service size Residential, Multifamily

Number of ERU's Commercial, non-restaurant*

Backflow size & type Commercial, restaurant*

Hazard Assessment Governmental

Premise Isolation In- Premise Isolation Non-profit

Out of town WAV on file

Fees:

Water Hookup Right Fee $ 410.900.000.343.40.00.00

Sewer Hookup Right Fee 420.900.000.343.50.00.00

TOTAL $

Payment Info: Account Information:

Date Paid: Utility Account Numbers:

Amount Paid: Domestic:

Check #: Fire Line:

Receipt #: Other:

Routing: Public Works Superintendent (for confirmation of availability and conditions)

Utility Superintendent (for meter size, backflow requirements and conditions)

**Planner (only if new construction) Building Permit #__________________

Utility Clerk (for payment and account creation)

Attach to applicants copy:

_____ Chapter 13 of CTC

_____ Commercial customers: Cross-connection survey report

_____ Backflow Prevention Assembly Test Report (If applicable)

Original to Address File (Include copy of WAV for out of Town customers.)

Utility Permit Approved by: Date:

Public Works Superintendent

Utility Permit Approved by: Date:

Utility Superintendent

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STORMWATER PERMIT APPLICATION

Owner’s Name: Phone:

Mailing Address:

Contractor’s Name: Phone:

Location Address:

Location Tax Parcel Number:

Description of erosion and sediment control during construction:

If more space is needed for description, please attach a separate sheet.

Description of long term stormwater control:

If more space is needed for description, please attach a separate sheet.

Attach plans for construction erosion control and long term stormwater control.

Total impervious area (all buildings, decks, patios, driveways, etc.)__________________(sq ft)

Total parcel area:_________________________ (sq ft)

The undersigned applicant hereby applies for permission to undertake such land-disturbing activities (e.g., structural

development, building expansion, creation of impervious surfaces, site redevelopment, clearing and grading, etc.)

regulated by Chapter 13.20 of Town Code “Stormwater Management”. The applicant is the owner of the described

property or the authorized agent of the owner. By signing this application, the applicant agrees, as a condition of the

Town approving all other permits required by Town or other applicable regulations, to comply with all provisions of

Town Code, and other such rules and regulations now existing or which may be established from time to time

governing the Town’s Stormwater Management Plan.

Applicant’s Signature Date

(FOR TOWN USE ONLY)

_________Small Parcel Erosion and Sediment Control Plan required (CTC 13.20.070)

_________Large Parcel Erosion and Sediment Control Plan required (CTC 13.20.080)

_________Permanent Stormwater Quality Control (PSQC) Plan required

_________Stormwater Rate Control Plan required

Approved by: Date:

Public Works Superintendent

Permit Fee: Permit Number:

001.000.000.322.10.03.00 Stormwater Permit Application/Revised 2017

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CLEARING & GRADING PERMIT APPLICATION This application is required for all work for clearing and grading within Town limits.

Owner/Applicant Name: Phone:

Mailing Address:

Email:

Contractor: License:

Project site address:

Tax parcel no.:

Attach site plan showing clearing and grading limits, trees to be retained, construction entrance, and

temporary erosion and sediment control measures. If import or export is proposed, indicate truck route.

Description of proposed work:

TREE CREDITS REQUIRED: See CTC 16.20.075

TREE CREDITS PROVIDED: Show on site plan

TOTAL PARCEL AREA: Square feet/acres

TOTAL DISTURBANCE AREA: Square feet

TOTAL QUANTITY OF CUT & FILL: Cubic yards

REGULATED CRITICAL AREAS ON SITE? Yes No If yes, describe and show on site plan

The undersigned applicant hereby certifies under penalty of perjury that he/she is the property owner or is an agent

of the property owner(s) who is duly authorized by the property owner(s) to request this permit on his/her/their

behalf, and that the information provided in this application is true to the best of his/her knowledge. By signing this

application, the applicant agrees, as a condition of the Town approving all other permits required by ordinance or

other applicable regulations, to comply with all provisions of CTC 16.20 of the Development Regulations, or latest

revision thereof, and other such rules and regulations now existing or which may be established from time to time.

APPLICANT’S SIGNATURE: DATE:

PRINTED NAME:

(FOR TOWN USE ONLY)

Permit for clearing only

Permit for grading only

Permit for clearing & grading

Performance bond required, in the amount of $ ________________

Conditions attached

Approved by: DATE

Public Works Superintendent

Permit number: Permit Fee: $ 001.000.000.322.10.03.00 Receipt:

Date:

Clearing & Grading Permit Application/Revised 2017

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I:\Planning\Forms\Right of Way Application.docx 6/6/2017

File No. ______________

Permit Application

APPLICATION TO PERFORM WORK ON TOWN RIGHT-OF-WAY This application is required for all work within a Town right-of-way or easement involving installation,

paving, digging, cutting, excavation, tunneling, breaking up in any manner or depositing any dirt or

excavated material.

NAME OF APPLICANT DATE

MAILING ADDRESS PHONE

LOCATION ADDRESS PARCEL #

CONTACT PERSON (If different) PHONE

CONTRACTORS LICENSE NUMBER

Description of the nature, location and purpose of the proposed construction in Town right-of-way (please attach a

drawing that shows clearly the extent of the proposed work):

Pursuant to franchise (if applicable) Date

Anticipated starting date and duration of construction From To

The undersigned agrees to perform the work described above in strict compliance with the conditions enumerated

below and acknowledges that he/she has read and will adhere to the required inspections and general provisions

applicable to this permit contained on page 2 of this form. Right-of-way permits are valid for one year from the date

of approval.

APPLICANT’S SIGNATURE DATE:

(FOR TOWN USE ONLY)

Conditions Assigned to this Permit:

Approved by:

SIGNED DATE

TITLE JOB NUMBER

Fees/Bonds

Permit Fee: $100

001.322.90.01.00 Residential

$200.00

Commercial

Permit Fee $

Inspection Fee $ 50.00 per inspection Inspection Fees $ 410.343.40.00.14; 420.345.50.00.14

TOTAL $

UTILITY DAMAGE IS COSTLY. CALL 1-800-424-5555 BEFORE YOU DIG

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I:\Planning\Forms\Right of Way Application.docx 6/6/2017

Page 2

INSPECTIONS

*Twenty-fours hours notice for an inspection is required*

Inspections are required at the following stages: Inspected (date and by whom)

Traffic Control

Work on Town-owned utilities (prior to backfill)

Backfill Materials & Compaction

Site Restoration

Site Restoration

The work is not deemed complete until the Public Works Superintendent has accepted it as satisfactory.

GENERAL PROVISIONS The following standards apply to all permits issued in accordance with this chapter. Under certain circumstances,

the public works director may apply more stringent conditions or may waive certain of these requirements.

(A) Site control responsibility. The permit holder is solely responsible for providing adequate work zone and

safety controls for protection of its employees and of public pedestrian and vehicular traffic in and around the work

site. This responsibility extends to the provision of site security during non-construction hours including providing

adequate warning devices and barriers to hazardous conditions. Supplies, debris, unguarded machinery, equipment

or other device having the characteristics of an attractive nuisance, and be hazardous to safety, shall be secured at all

times.

(B) Traffic protection measures. The permit holder shall erect and maintain all necessary warning devices,

signs and barricades at and in the vicinity of the construction site, in accordance with the Manual on Uniform Traffic

Control Devices. These protective measures shall remain in place until such time as the public works director has

inspected and approved the work covered by the permit.

(C) Street closures. Any request to close all or a portion of a public street shall be included in the permit

application. In all cases, street closures shall be kept to a minimum, and every effort shall be made to provide as near

as normal flow of pedestrian and vehicular traffic as possible. At its discretion, the town may require the applicant to

provide public notice to emergency service providers and Island Transit, prepare a pedestrian and/or vehicular traffic

detour plan for approval by the public works director, or maintain qualified flaggers during the street closure.

(D) Protecting public and private property. The permit holder shall be responsible for locates to be performed

prior to excavation work, and is solely responsible for protecting public and private utilities from damage while the

permitted work in underway. All costs associated with damage to public and private utilities, including collateral

damage to private property in the vicinity, are to be borne by the permit holder.

(E) Excavated materials. All material excavated from trenches and piled adjacent to the trench or in town right-

of-way shall be maintained in such manner so as not to endanger those working in the excavation or others using the

public right-of-way. In cases where site constraints make temporary stockpiling of excavated materials unsafe, the

public works director may require that these materials be stored off-site.

(F) Backfilling. In repairing an opened or excavated right-of-way, the permit holder shall fill and properly

compact the subsurface, and shall rebuild the foundation and surface of the street, sidewalk, curb or other structure

to its original condition, all in accordance with town standards. All backfills shall be inspected and approved by the

public works director prior to any overlaying or patching.

(G) Site restoration. The permit holder shall restore the surface of all streets or other construction areas, broken

or damaged as a result of work performed under a right-of-way permit, to the original condition as determined by

the public works director. Following completion of the work, all streets and private properties affected by the

construction shall be cleaned thoroughly of all rubbish, excess earth, rock and other debris resulting from the work.

(H) Documentation. For work performed on town-owned utilities (water, sewer, and stormwater), the permit

holder shall within two weeks submit as-built drawings of all modifications and installations.

UTILITY DAMAGE IS COSTLY. CALL 1-800-424-5555 BEFORE YOU DIG

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Contractor License Requirements  

  

Under State Law, the City is obligated to provide written notification to all homeowners regarding the contractor registration requirements set forth in RCW Chapter 18.27 and to advise homeowners of the risks associated with using an unregistered contractor.

The following are excerpts of noted sections from Title 18 of the RCW. You may go to http://apps.leg.wa.gov/rcw/ to view Title 18 in its entirety.

 18.27.010 Definitions 1) "Contractor" means any person, firm, or corporation who or which, in the pursuit of an independent business undertakes to, or offers to undertake, or submits a bid to, construct, alter, repair, add to, subtract from, improve, move, wreck or demolish, for another, any building, highway, road, railroad, excavation or other structure, project, development, or improvement attached to real estate or to do any part thereof including the installation of carpeting or other floor covering, the erection of scaffolding or other structures or works in connection therewith or who installs or repairs roofing or siding; or, who, to do similar work upon his or her own property, employs members of more than one trade upon a single job or project or under a single building permit except as otherwise provided herein. "Contractor" includes any person, firm, corporation, or other entity covered by this subsection, whether or not registered as required under this chapter.

 18.27.110 Building permits - Verification of registration required - Responsibilities of issuing entity - Penalties (1) No city, town or county shall issue a construction building permit for work which is to be done by any contractor required to be registered under this chapter without verification that such contractor is currently registered as required by law. When such verification is made, nothing contained in this section is intended to be, nor shall be construed to create, or form the basis for any liability under this chapter on the part of any city, town or county, or its officers, employees or agents. However, failure to verify the contractor registration number results in liability to the city, town, or county to a penalty to be imposed according to RCW 18.27.100(7)(a).

(2) At the time of issuing the building permit, all cities, towns, or counties are responsible for: (a) Printing the contractor registration number on the building permit; and (b) Providing a written notice to the building permit applicant informing them of contractor registration laws

and the potential risk and monetary liability to the homeowner for using an unregistered contractor.

(3) If a building permit is obtained by an applicant or contractor who falsifies information to obtain an exemption provided under RCW18.27.090, the building permit shall be forfeited.

 18.27.140 Purpose

 It is the purpose of this chapter to afford protection to the public including all persons, firms, and corporations furnishing labor, materials, or equipment to a contractor from unreliable, fraudulent, financially irresponsible, or incompetent contractors.

 18.27.200 Violation — Infraction

 (1) It is a violation of this chapter and an infraction for any contractor to:

(a) Advertise, offer to do work, submit a bid, or perform any work as a contractor without being registered as required by this chapter;

(b) Advertise, offer to do work, submit a bid, or perform any work as a contractor when the contractor's registration is suspended or revoked;

(c) Transfer a valid registration to an unregistered contractor or allow an unregistered contractor to work under a registration issued to another contractor; or

(d) If the contractor is a contractor as defined in RCW 18.106.010, violate RCW 18.106.320.  

(2) Each day that a contractor works without being registered as required by this chapter, works while the contractor's registration is suspended or revoked, or works under a registration issued to another contractor is a separate infraction. Each worksite at which a contractor works without being registered as required by this chapter, works while the contractor's registration is suspended or revoked, or works under a registration issued to another contractor is a separate infraction.

 There are a number of risks associated with using an unregistered contractor. A property owner that uses an unlicensed contractor will not be protected by the contractor’s bond required by RCW 18.27.040. These bonds are designed to: (1) pay all persons performing labor, including employee benefits; (2) pay all taxes and contributions due to the state of Washington; (3) pay all persons furnishing labor or material or renting or supplying equipment to the contractor; and (4) pay all amounts that may be adjudged against the contractor by reason of breach of contract including negligent or improper work in the conduct of the contracting business. In addition, the property owner’s construction project may be delayed due to enforcement actions of the Department of Labor and Industries and the Town of Coupeville caused by an unregistered contractor. There could be additional risks associated with the use of unregistered contractors. For additional information contact the Department of Labor and Industries at 1.800.647.0982 or www.lni.wa.gov/.

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Certificate of Appropriateness Application        Page 1 of 4 Revised January 2015 

 

Ebey’s Landing National Historical Reserve Certificate of Appropriateness Application

  

REVIEWED TO THE EBEY’S LANDING HISTORICAL RESERVE DESIGN GUIDELINES BY ISLAND COUNTY (Island County Code 17.04A) AND THE TOWN OF COUPEVILLE (Coupeville Town Code Chapter 16.13) IN COOPERATION 

WITH THE TRUST BOARD OF EBEY’S LANDING NATIONAL HISTORICAL RESERVE AND THE HISTORIC PRESERVATION COMMISSION 

  

I, the undersigned, do hereby respectfully make application for your review of my request concerning the property described below:  

1. Applicant(s) (main contact person): Agent for owner must complete the authorization on page 4 

______________________________________________________________________________ 

______________________________________________________________________________ 

Address:  ______________________________________________________________________ 

Phone: _________________________  E‐mail: _______________________________________ 

2. Property Owner(s): 

______________________________________________________________________________ 

______________________________________________________________________________ 

Address:  ______________________________________________________________________ 

Phone: _________________________  E‐mail: _______________________________________ 

3. Address of Subject Property:  

______________________________________________________________________________ 

4. Assessor’s Parcel Number:  

______________________________________________________________________________ 

5. Zone: ______________________________ 

 

Present Use of Property (check all that apply): 

Residential    Agricultural    Other   

Commercial    Institutional       

 

Application # ___________

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Certificate of Appropriateness Application        Page 2 of 4 Revised January 2015 

DESCRIPTION OF PROPOSED WORK: 

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________ 

Note:  Please refer to the checklist on page 3 of this application for required submittal materials  

 Existing & Proposed Materials:    

Doors: (existing)_______________________        (proposed) _______________________________         

Windows: _____________________________                _________________________________ 

Deck/Railing: ___________________________               _________________________________ 

Stairs/Ramp: ___________________________               _________________________________ 

Siding: ________________________________               _________________________________ 

Roofing: _______________________________               _________________________________ 

Fence: ________________________________                _________________________________ 

 

Does the proposed project involve a Historic Building?      Yes     No 

Is the property within 100 feet of a historic building?      Yes      No 

Is there a Conservation Easement on the property?      Yes      No 

If yes, please include easement information with application packet 

 

Applicant’s Acknowledgment 

I am familiar with the Ebey’s Reserve Design Guidelines as they pertain to my project.  I certify by my signature below that the information in this application is accurate and complete. Planning staff has permission to copy materials, including architectural drawings, necessary for the review of my application. 

 

___________________________________________________________ Date _______________ 

Applicant’s Signature  

 

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Certificate of Appropriateness Application        Page 3 of 4 Revised January 2015 

Typically, applications require the following information For projects that are not complex, feel free to ask if the standard submittal requirements are necessary.  

o Clear color photographs of the building, overall site, nearby structures, and any adjacent properties.  

o A complete description of the intended work.  

o A scaled site plan depicting existing and proposed structures and improvements; including significant trees, tree planting, vegetative buffering, and landscaping. Include driveways and nearby roads for context and an “N” (north) arrow.   

o Scaled design elevations of new structures or improvements, alterations, and additions. (Show both existing and proposed).  

o Samples of construction materials (when requested). For historic buildings, submit new material samples for comparison with the existing or the original building materials.   

o Any supplemental information deemed necessary and requested by the County or Town for review of the application (this usually relates to complex or large‐scale projects.)  

o Agent Authorization Form (page 4 if needed)  

o Applicable Planning & Review Fees  

Level A applications; please provide original signed application and 1 copy  Level B applications; please provide original plus 3 copies  Level C applications; please provide original plus color 14 copies 

 

FOR STAFF USE ONLY 

Review Authority ‐ based upon the application description and project location within the Reserve   

Staff:        _______ Level A   

HRC:         _______ Level B 

HPC decision:      _______ Level C 

HPC recommendation:    _______ Level D 

Land Use _______ Construction _______ 

 

ADDITIONAL NOTES: 

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________ 

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Certificate of Appropriateness Application        Page 4 of 4 Revised January 2015 

Agent Authorization Form  

I, ____________________________, the owner(s) of the subject property, understand that by completing this form I hereby authorize ____________________________ to act as my agent.  I understand that said agent will be authorized to submit applications on my behalf.  I also understand that once an application has been submitted that all future correspondence will be directed to said agent.  

 

 

 1)________________________________________ 

Property Owner Name(s) (print) 

________________________________________ Signature(s) 

 2)________________________________________ 

Property Owner Name(s) (print) 

________________________________________ Signature(s) 

 ________________________________________ 

Date 

State of Washington        ) County of _______________ ) 

I certify that I know or have satisfactory evidence that  

_____________________________________________ signed this instrument and acknowledged it to be (his/her) free and voluntary act for the uses and purposes mentioned in this instrument. 

Dated ______________________________ Signature of Notary Public________________________ 

Printed Name ________________________ 

Residing at __________________________ 

My appointment expires _______________  

  1)________________________________________ 

Property Owner Name(s) (print) 

________________________________________ Signature(s) 

 2)________________________________________ 

Property Owner Name(s) (print) 

________________________________________ Signature(s) 

 ________________________________________ 

Date 

State of Washington        ) County of _______________ ) 

I certify that I know or have satisfactory evidence that  

_____________________________________________ signed this instrument and acknowledged it to be (his/her) free and voluntary act for the uses and purposes mentioned in this instrument. 

Dated ______________________________ Signature of Notary Public________________________ 

Printed Name ________________________ 

Residing at __________________________ 

My appointment expires _______________