21-100011-SF Electrical Work Affidavit 0105-202121-100011-SF Electrical Work Affidavit 0105-2021
RECEIVED
Jan 07 2021
41k
CITY OF
Federal Way
CITY OF FEDERAL WAY
COMMUNITY DEVELOPMENT
Property Owner
Electrical Work Permit Affidavit
Applying For Your Electrical Permit
In Washington, only licensed electrical contractors may perform electrical work. Property owners
may apply for an exemption from these requirements by completing and signing the affidavit
below before applying for an electrical permit or beginning electrical work.
As authorized under RCW 19.28.261, I,
Affidavit
(Printed name of property owner, renter, or lessee)
hereby apply for an exemption from the electrical licensing and certification requirements of
RCW 19.28 by submission of this affidavit.
Which statement describes you? (Mark only one. If none apply, you may not take out this permit.)
I own this property.
Your name or your company's name must be shown on the deed to the property. Real estate agents,
property management companies, relatives, etc. cannot purchase permits for the property owner.
❑ I rent or lease thisproperty.
We need a copy of your rental agreement showing you have permission to perform electrical work.
❑ I am an officer for a 501(c)(3) nonprofit corporation, or a nonprofit religious organization.
The total market value of electrical work must be $30,000 or less and all electrical work must be done by
a non -compensated appropriately certified electrician.
Select your property type (Mark only one. If none apply, you may not take out this permit.)
❑ New single family residence that is not intended for rent, sale, or lease, where I will be living for at least
24 months after completing the electrical work. I will be personally doing the electrical work.
❑ New 2, 3, or 4 unit residential building, owned by me, that is intended for rent, sale, or lease. I will be
living in one of the units for at least 24 months after completing electrical work. I, personally, and/or a
regularly employed employee(s), will be doing the electrical work.
❑ New place of business, farm, or other property: Any new structure that is not intended for rent, sale,
or lease. I, personally, and/or a regularly employed employee(s), will be doing the electrical work.
Existing residential property, place of business, or farm. 1, personally, and/or a regularly employed
employee(s), will be doing the electrical work.
DEPARTMENT OF COMMUNITY DEVELOPMENT 133325 8TH AVENUE SOUTH I FEDERAL WAY, WA 98003-6325
253-835-2607 ,N. www.citvoffede_ralway.com & errnitcenter cit offederaiwa .com
Bulletin #170 — July 27, 2018 Page I of 2 k:\Handouts\ Property Owner Electrical Work Affidavit
❑ 501(c)(3) or nonprofit religious organization owned property: The total market value of the
electrical work must be $30,000 or less, and all electrical work will be performed by appropriately
certified electricians, or certified and properly supervised trainees, who are volunteering and not
being compensated for the electrical work per RCW 19.28.091(7).
(our signature is required below:
I believe I should be exempt from the requirements to obtain an electrical license, or use a certified
electrician, as provided under RCW 19.28.261.
By signing below, I certify the information I am providing on this affidavit is true and accurate. I
understand that if I make false statements or misrepresentations, I may be assessed penalties.
1 Z 13 J12o 20
Signature Date
(21 A e0
Printed Name of Property Owner, Renter, or Lessee
Property Owner and Inspection Site Information
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Property Owner's Name and/or Company Name
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Mailing Address Unit/Apt.# City State Zip
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Daytime Phone
20 23 C)
Inspection Site Address
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Electrical Power Company / Serving Utility
Email Address
Unit/Apt.#
Description of work being done (Example: adding outlets in the kitchen, second floor break area, etc.)
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DEPARTMENT OF COMMUNITY DEVELOPMENT / 33325 8TH AVENUE SOUTH / FEDERAL WAY, WA 98003-6325
253-835-2607 za www.ciNoffederalway.com -6permitcenter@cityoffederalway.com
Bulletin #170 — July 27, 2018
Page 2 of 2 k:\Handouts\ Property Owner Electrical Work Affidavit