2. REQUEST FOR BUILDING PERMIT SIGN-OFF
   Please use this form when requesting a final occupancy inspection for new construction, remodel, or tenant improvement * indicates required information
4. Name of builder or property owner*
6. Site address including any applicable building or suite numbers*
8. City
9. State
10. Zip Code
12. Building permit number*
13. Type of building permit*
    -- Select One --Single-family residence, new constructionSingle-family residence, remodelMulti-family Commercial, new constructionCommercial, tenant improvementSwimming pool/SpaOther
15. Side sewer permit number*
    (If there is no sewer connection, enter "n/a")
16. Water meter application number*
    (If there is no water connection, enter "n/a")
20. BACKFLOW PREVENTION ASSEMBLIES

    A backflow test report must be submitted for devices listed below with backflow prevention assemblies. **Test reports must be uploaded to this form submission before an inspection and sign-off will be completed.**

22. Does the property have any of the following devices?
24. Fire Sprinkler System*

    1. Yes
    2. Check here if a flow-through meter for fire flow

    1. No
26. Irrigation/Sprinkler System*

    1. Yes
    2. No
27. Boiler*

    1. Yes
    2. No
28. Swimming Pool/Spa*

    1. Yes
    2. No
30. Please list any other devices with a backflow prevention assembly
32. Please upload completed backflow test report for Fire Sprinkler System*
34. Please upload completed backflow test report for Irrigation/Sprinkler System*
36. Please upload completed backflow test report for Boiler*
38. Please upload completed backflow test report for Swimming Pool/Spa*
42. COVID-19 JOB SITE SAFETY REQUIREMENTS
    IMPORTANT: Samammish Plateau Water will only complete building permit sign-offs for sites that comply with Governor Jay Inslee’s "Phase 2 Construction COVID-19 Job Site Requirements". Please answer the following:
44. Is your site classified as "low risk" with the ability to maintain physical distancing of at least 6 feet of separation between all personnel?*

    1. Yes

    1. No
46. Do you have a COVID-19 exposure control, mitigation and recovery plan?*

    1. Yes

    1. No
48. What is the name and phone number of the COVID-SPECIFIC site supervisor/contact person?*
52. Building permit sign-off inspections take place within two (2) business days of the District receiving a completed request form. Forms submitted after 3:00pm will be considered received on the next business day, which will then start the 2-business-day turnaround period. To request a future date, please enter that date here.
53. Requested date
55. **Verifying Statement**

    By electronically signing and submitting this request, I verify the following: (1) that all building permit sign-off requirements have been met, (2) the site complies with Governor Jay Inslee’s "Phase 2 Construction COVID-19 Job Site Requirements", and (3) all backflow prevention devices have been tested and test results have been uploaded to this form submission.

57. Name of person requesting inspection*
58. My contact phone number is*
60. Reply e-mail address*
62. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
64. Electronic Signature*
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field