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Permit B92-0206 - ROGERS RESIDENCE - MANUFACTURED HOME
/ CY.3egs , arigg.L.Rs fr 4p60s City of TizkwilL Community Development / Public Works • 6300 Southcenter Boulevard, Suite 100 • Tukwila, Washington 98188 Permit No: Type: Category: Address: Location: Parcel #: Zoning: Type Const: Gas /Elec: TENANT OWNER CONTRACTOR Signature._ 892 -0206 8 -BUILD NSFR 5218 S 144 ST 725520 -0200 R1.72 V -N Units: 001 Buildings: 001, Fire Protection: N/A UBC Edition: 1988 BUILDING PERMIT Wetlands: Slopes: X Water: N/A Sewer: N/A Contractor License No.: DUTCHMH254KA ROGERS CHARLES & DORIS 5218 SOUTH 144TH - .STREET, TUKWILA, WA 98168 ROGERS FAMILY TRUST 14261 53RD AVE S, TUKWILA;WA 98168 DUTCH'S MOBILE HOME SERVICE 20302.;S.E. 284TH, KENT, WA 98031 * * * * * * * * * * * **tk*** * ** ** *fir * ** * ** * * *** * *** ** Mfr * *k***** * *si* *** *** ***** *fir * * ** ** * Permit Description: REMOVE EXISTING SINGLE WIDE MOBILE HOME AND REPLACE WITH DOUBLE WIDE MANUFACTURED HOME. SETBACKS Back: Right: Name: k Type of Occupancy: DWELLING Permit Center AUthorized Signature ,,Dat4Y Valuation: 7,665:00 Total Permit Fee: 167.85 ********************************** x********** * * * * * * * * * * * * * * * * * * * * * * ** * * * ** I hereby certify that I have read and examined this permit and know the same to be true ; and correct. All provisions,,of ..law and ordinances governing this will be complied ;with, whether ::specified herein or not. The granting of thi's does not presume t o give authority violate or cancel the , provisions of`'any other state or local laws regulating construction or.• ; the performance 'of:, work. _, ,; I.. a • authorized to`�si gn for and obtain this building permit Date: • i.t l � .ew (206) 431-3670 Status: ISSUED Issued: 08/03/1992 Expires: 01/30/1993 This permit shall become null and void if the work is not commenced within 180 days from the date of issuance, or if the work is suspended or abandoned for a period of 180 days from the last inspection. Phone: 206 243 -2023 Phone,:, 206 631 -0653 PERMIT NO. CONTACTED 11 0 ; ._.. DATE READY DATE NOTIFIED % 3— nQ 'r( Bit ) ....s?5, BY: (init.) PERMIT EXPIRES 2nd NOTIFICATION AMOUNT OWING ft-i / 3RD NOTIFICATION BY: (init.) PLAN CHECK NUMBER INSTRUCTIONS TO STAFF • Contacts with applicants or requests for information should be summarized in writing by staff so that any time the status of the project may be ascertained. • Plan corrections shall be completed and approved prior to sending on to the next department. • Any conditions or requirements for the permit shall be noted on the plans or summarized concisely in the form of a formal letter or memo, which will be attached to the permit. • Please fill out your section of the tracking chart completely. Where information requested is not applicable, so note by using "N /A ". BUILDING SQUARE FOOTAGE/OCCUPANCY INFORMATION (to be filled out by Plan Checker) Flt SQUARE FEET :T. ................ ................... OCC. LOAD SQUARE FEET OCC. LOAD SQUARE FEET OCC. LOAD SQUARE FEET CCC. LOAD SQUARE FEET OCC. LOAD TOTAL SQUARE FEET DEPARTMENTAL REVIEW "X" in box indicates which departments need to review the project.. <i`DE : RTM E N T . BUILDING - initial review • FIRE PLANNING 2 PUBLIC WORKS 0 OTHER BUILDING - final review PROJECT NAME SITE ADDRESS REVIEW COMPLETED - BUILDING `., ERMIT APPLICATION TRACKING (/ t )/ (ROUTED INIT/ INIT: 144 / / � pa ' INIT: INIT: Ro�.�yS > C_hby k :Dor ► SUITE NO. AJIEME .............................................................. ............................... CONSULTANT: Date Sent - Date Approved - TYPE OF CONSTRUCTION: VN — �o�oeu.ellemE) Yes Detectors FIRE PROTECTION: FIRE DEPT. TIER DATED:) INSPECTOR: /3 "? % `7 'i1✓I C:�? (' ✓ 1 ZONING: R I - 2� IBAR/LAND USE CONDITIONS? (g)Yes rrtro REFERENCE FILE NOS.: / 5'.' i .0 r e, i f MINIMUM SETBACKS: N- - W- UTILITY PERMITS REQUIRED? PUBLIC WORKS LETTER DATED: V ±0 Pt /JD LD- UBC EDITION (year): /A TOTAL OCC LOAD 08/17/80 SITE ADDRESS SUITE # /,' 2 r., 4/1 . �' J i l VALUE OF CONSTRUCTION - $ r up Gz `�' e ,5 ( J . PROJECT NAM ENANT 42&5 t ers 6 E 2 ASSESSOR ACCOUNT # 7 ,1-(;.5 0 —pJ 00 ---v I TYPE OF fg, New Building Li Addition Li Tenant Improvement (commercial) U Demolition (building) WORK: 0 Rack Storage 0 Reroof 0 Remodel (residential) Other: 0Po( &)2E- MrR!L' / -/06 -! DESCRIBE WORK TO BE DONE: rdirm rci. Srr./.-ri IAoDz: /1.4c71'.rr..e /64 4 XIA/L' Repl <: IN/7 H DotieLE IA)/ DE 114,o Air,. / Al (-7 C/O. ,;, / /c -iffi i BUILDING USE (office, warehouse, etc.) NATURE OF BUSINESS: WILL THERE BE A CHANGE IN USE? 2. No 0 Yes If Yes, new building requirements may need to be met. Please explain: SQUARE FOOTAGE - Building: /73(0 Tenant Space: Area of Construction: WILL THERE BE STORAGE OR USE OF FLAMMABLE, COMBUSTIBLE OR HAZARDOUS MATERIALS IN THE BUILDING? No 0 Yes IF YES, EXPLAIN: PROPERTY OWNER i r" / /aRiE: S ; r)02I s L. roc) 6.F PHONE 2q3 PHONE 3 - 2oz3 ZIP /� 1 � -- o!e, ZIP Cifsc n ADDRESS �l� // /. 4, / - L -... iIV D Iii . •� / f/ e., A S 7 (. CONTRACTOR bti, /'S '406//f /lprq:.: -5 tI t ;''6_ ADDRESS 2, S.E, 2 gtnti K21"* ) i WA. ST. CONTRACTOR'S LICENSE # Di/70.(40/ 7 cei ! EXP. DATE ARCHITECT PHONE • ADDRESS ZIP CITY OF TUKWILA Department of Community Development - Building Division 6300 Southcenter Boulevard, Tukwila WA 98188 (206) 431-3670 DESCRIPTION PLAN CHECK NUMBER 139Q BULDIN PERMIT APPLICATION BUILDING PERMIT.FEE PLAN CHECK BUILDING SURCHARGE OTHER: ::: 'TOTAL_ - :1: HEREBY: CERTiF :Y;:THAT I: HAVER EAD:<AND:: XAMINEE):; T HIS APP.LICATIOIV.A ID N BE TRUE AND;CORRECT; AND >I A `8: AUTHORIZED ::TO ARPLY. .';:FOR: >THIS`.P.ERMiT BUILDING OWNER SIGNATURE J PRINT NAME ADDRESS /c /l / _ Y A V , OR AUTHORIZED AGENT CONTACT PERSON DATE APPLICATION ACCEPTED DATE APPLICATION EXPIRES AMOUNT RCPT. ,# DATE DATE. PHONE 9.43 CITY/ZIP lk ///.9 '/ 14cg r k PHONE L APPLICATION SUBMITTAL In order to ensure that your application is accepted for plan review, please make sure to fill out the application completely and follow the plan submittal checklist on the reverse side of this form. Handouts are available at the Building counter which provide more detailed information on application and plan submittal requirements. Application and plans must be complete in order to be accepted for plan review. VALUATION OF CONSTRUCTION Valuation for new construction and additions are calculated by the Department of Community Development prior to application submittal. Contact the Permit Coordinator at 431 -3670 prior to submitting application. In all cases, a valuation amount should be entered by the applicant. This figure will be reviewed and is subject to possible revision by the Building Division to comply with current fee schedules. BUILDING OWNER / AUTHORIZED AGENT If the applicant is other than the owner, registered architect/engineer, or contractor licensed by the State of Washington, a notarized letter from the property owner authorizing the agent to submit this permit application and obtain the permit will be required as part of this submittal. EXPIRATION OF PLAN REVIEW Applications for which no permit is issued within 180 days following the date of application shall expire by limitations., The building official may extend the time for action by the applicant for a period not exceeding 180 days upon written request by the applicant as defined in Section 304(d) of the Uniform Building Code (current edition). No application shall be extended more than once. If you have any questions about our process or plan submittal requirements, please contact the Department of Community Development Building Division at 431 -3670. 1� - 9 - 9a 1a- 9 -9ca,r m RETAKE Of PREVIOUS DOCUMENT SITE ADDRESS SUITE # dpi VALUE OF CONSTRUCTION - $ r UP F2.a PROJECT NAM ENANT &de-ZS t ers � 6E2-s ASSESSOR ACCOUNT # 7,.?x.5'0 -o ---0 J D0 �v I (commercial) U Demolition (building) t,? Other: Lin 44f) F f LE Ala AIL- TYPE OF N, New Building U Addition — 0 Tenant Improvement WORK: 0 Rack Storage 0 Reroof 0 Remodel (residential) DESCRIBE WORK TO BE DONE: REmrvE r /"i, /i iA /1DF Poi rT/e_p 111 1 ,etnfD An: Pl►7rc= WiT "/ Dou/3CE tAi /DE . (1 it ii /",/ ) C 1 i • ,') / /f"A"if• BUILDING USE (office, warehouse, etc.) NATURE OF BUSINESS: WILL THERE BE A CHANGE IN USE? 1 No 0 Yes If Yes, new building requirements may need to be met. Please explain: SQUARE FOOTAGE - Building: !? 3c , Tenant Space: Area of Construction: WILL THERE BE STORAGE OR USE OF FLAMMABLE, COMBUSTIBLE OR HAZARDOUS MATERIALS IN THE BUILDING? Vil No 0 Yes iF YES, EXPLAIN: PROPERTY OWNER ( " a k. e b o„ f S L, 0.) e F/2 PHONE2y3_202 3 ADDRESS �� J /•/ / • : (JC • � fs 1U /� ,A / C.!'► �I1,�il ., 1, r , PHONE b 3/., ZIPy��' G7le� . ► ZIP vl �� I CONTRACTOR b +t`t'r�/'s 4,16,6://e.- /./pt-76.: ,�' i `4 ?td I tra ADDRESS ,- 03 0 Z. S,E, 27t, -# K -calf I w-A WA. ST. CONTRACTOR'S LICENSE # A//707 / 7 " y' I n EXP. DATE ARCHITECT PHONE - ADDRESS ZIP PLAN CHECK NUMBER CONTACT PERSON (0—q —cieQ BULDII' PERMIT APPLICATION CITY OF TUKWILA Department of Community Development - Building Division 6300 Southcenter Boulevard, Tukwila WA 98188 DESCRIPTION (206) 431 -3670 BUILDING PERMIT FEE PLAN CHECK FEE BUILDING SURCHARGE OTHER: TOTAL. ••AMOUNT Tip --('0 I :HEREBY CERTIFY THAT I HAVE:11E,AD AND .EXAMiNE©.:THIS : KN BE 'TRUE AND; CORRECT, AND I A ai :AUTHORIZE : TO: APPL Y: FOR: THIS PERM BUILDING OWNER SIGNATURE4 ; i OR AUTHORIZED PRINT NAME ea 4 R CN , T\ RO e =gs AGENT ADDRESS / /,, /- .53 I F-PA Vt.:',' . S , RCPT # PHONE 2 . . q 3 - 2 . 0Z3 CITY/ZIP i7kr, /ri19 S 2 1 DATE / g ) / 2- APPLICATION SUBMITTAL In order to ensure that your application is accepted for plan review, please make sure to fill out the application completely and follow the plan submittal checklist on the reverse side of this form. Handouts are available at the Building counter which provide more detailed information on application and plan submittal requirements. Application and pians must be complete in order to be accepted for plan review. VALUATION OF CONSTRUCTION Valuation for new construction and additions are calculated by the Department of Community Development prior to application submittal. Contact the Permit Coordinator at 431 -3670 prior to submitting application. In all cases, a valuation amount should be entered by the applicant. This figure will be reviewed and is subject to possible revision by the Building Division to comply with current fee schedules. BUILDING OWNER / AUTHORIZED AGENT If the applicant is other than the owner, registered architect/engineer, or contractor licensed by the State of Washington, a notarized letter from the property owner authorizing the agent to submit this permit application and obtain the permit will be required as part of this submittal. EXPIRATION OF PLAN REVIEW Applications for which no permit is issued within 180 days following the date of application shall expire by limitations.. The building official may extend the time for action by the applicant for a period not exceeding 180 days upon written request by the applicant as defined in Section 304(d) of the Uniform Building Code (current edition). No application shall be extended more than once. if you have any questions about our process or plan submittal requirements, please contact the Department of Community Development Building Division at 431 -3670. DATE APPLICATION ACCEPTED DATE APPLICATION EXPIRES DATE COMMERCIAL NEW COMMERCIAL BUILDINGS/ADDITIONS „ • • : . • „ • . J Completed building permit application (one for each structure) [1 Assessor Account Number , • • • ...Two sets (2) of the following ri Structural calculations stairivetf by• a Wablngton : State Iicoed engineer • • [Sella report stamped by a Washington liCensed engineer • • • El Energy Calc;ulations stamped by a Washington State licensed ' engineer or architect., . • .:.••• 7 . . . : • Legal description . . . . . • " .• • :• „ Working drinvingSjstamPedbY a Washington State licensed Architectural drnwlngs • Structural drawings •• Mechanical •draWings'.•: Elevations .„. • • • • - ,,,, • - Civil drawings plan Completed utility pennit:application Six (6) sets of civil dra ings NOTE • • Seit"utilitkPefinit application and checklist for spccifi utility tta . requiremnt 7 , ,, • •••••:,-....••• • • • ,, " . " . :. - :.: ::'...: :".• - :.. ... :.....:::...:-...:•::::••::„.::::::: ::::::„' •::::::::::,:.:::::. : .::: :''. .:::: : .:•":::: ..•:....:.. RACK.. S .....: .., permit 'application - ..'''''''''.::'''::.''''"''.;"'1,1':....:•..,,,.:., 6OMOletadblinding :pa — Ass?6'c'''1..."...*::::'...':.:''';'•:::-. dude:. • '''''..:'.'.'•::::::-::...:"...::::::::::::: ::, „:.....:.::.:::'...:::::'''''''':''f.iaiirl.0140..", 9.w:17:::::'''''''''..:•!:': ....'ff'lited ''....'. , , ::' ..::'::: — :.".' ' '''' f:plane,::whiCh,... .,,;,... .., ... ...,.. "...::::6'.(). ' e . : !. ' :,.., ;:: : : •:..:'-. , ::::.;:::::::::::':.-:':•'''''''' , .'•;:.:i:•":";". ••••::::::"....::::''';::::::::::.:::::::::::::::::::":::::::::::;:':'..":".•:::::::::::•::::::1::".::::::::::::::',..':::::::::::::„,,. cke:injill, be o . ‘ . .. ... . . "...Dimension's.. all ':' ,.„ 1 ... rsisles .,: and TenantSPaCelloor. plan showing raCli storage layout aisles ......,,... NOTE Include racks And long th),."aisleS.::::•:::::: ::•and exit .ways on plan.. :• :7::•:::.:::::::::::%... •,. ::• • :::::•..:::::":-::.::::::::::.... • .... : : 7 • 7 RESIDENTIAL '..........,;:,.... . ....„..-::::::.. , .. . : OVV Li.1 NG s i App■Tis.:oN 5 ,.....:::::::;.':'! v'COMpleteri building permit application (one f structur — , '' •;....:'..." •••:: ' , ::::' •-:. ::•.•• •'... ,-.,., ::':••• • ' ' • :::::.:.....:::•:•:. ,... , .., ,, :: :.........:.::::::. ,,,,, :......:,..,...: :.; ...,... .:•:::;:••.• • :.:,... • : : .....:::,...:::: :::...,.::::. ..: i..::.',..:: ,•:::::•••:::,,.....• •:••:.:..:,•. • :: .: ' ::::: :••••:•:::•!'• '•::',..::::::•:.:*:::';.::::::-.::.... • • ,:. • ..:,.: : :: Legal description :: :::::.:: ::.,::: ::-:. :: .'... :•.• .., : : "::.• ...-' , . : .:•.,........:::::...:•.,..'::::•:.::::,,:.....:,..... .• ., i working drawings • ,v (arkin )"-..i..-.:.::::•••"•:c- draWinbS .„.,..."..:.:::::•:..:::::.......::::::.:"::::':,:::::: , ', , i , :.:"'•:::::::‘,...."..,,,'::: , •:•"::::::, • .:.•::;.:::••••"7:,;:.:::::.......:..::::::.... Fou ndation - :::::•::.:""•:..::::::"'•''':''''•:::::•""•:1'.':.::::...;'::'...::::,''' ''',';,:. (On imarV?ipii:qosi closest - • showing Floor FlOor:Plan w idth • ••"7:''." Site: plan .,, , , .., .::::.::::',.:::::::::.■,::::",:::: .............. ..."'"'::::::::::::•::::..,.. .:01an•:::....• .:: 1 .!....... , .... k arid leng I to bu ildi ng 7 7777777 , . 7,77.: ,... 7,::i.., ' ..:„ • •• .:. ...'•'.Btillding''ele'vetieris — • • :: , ...:•:.... .::::::......P.O.q0. Pro P ::::"...:"'::.':'::.. ''..::• Structural framing plana::•.::::::::"::::•"•:::':""::::.::::":", ...■■•••••■■•• •, Structural calmilatloriatamPed by .a Washington State Itcensod engineer (rack storage' and oyer); • Washington State Energy Code data ••••:': IVt 01) Ole ied.utility:perniit:a0PliCatiOn::::::::.?„„ • . . . .. Six ;! (p) sets of site plans showing utilities NOTE4;7BUilding site plan and ublity site plan:M4 combiied See • utility permit application and ditecidiit'fb(Sii■eCificiubinittairequiiementS.:: AdcUtid nal topogrOiticai:and soils informntien may biite goo!! uni site conditions : • • • ••:. • •■•■•••■• SUBMITTAL CHECKLIST INN. COMMERCIAL 'TENANT . ... . . : .... . • ........ . . . . Completed building permit appliCation„(Oni f . each . .. . .;.• • Assessor Account Number ............................................................................................................................................ Two (2) Sets of const plans which include • . . . . .. . .... . . . ..... ..... ..... . . .....:, .....,........' Lo6r) Von ' of tenant space :::-•:::••::.....„,.:::'':"......."':.":::::::., C.:76a dg::nOni:annps:::: (6o:..°".'"..o',..',•:,,s'...e'.,•::n,.....l.tPoa"..ri,...•••rerl).:,'.....:"..,•:...,,caa....,i'..'..,:,•'„''..:.:.........!::::.,::.:....,......':':..:....6...,..,........'i..:,..:.........,....:........,..::,....,..,.:..,........:....:,,,....;„...,......::.::;,....,.,..:,.... ••''''.. location ‘rn buildintf•or:sqUaref1 ..;. ':•:::•".Land•.icape" p (if lit chaii0.cit:.66 ... tenant space Tenant• :".'.:.:::•:::::::•.: . e plan .W .... ... 71:-.4.....':1!xit iri.:•':::1'. rtb.liSeeachoiir..fi 10,..,:!!!..f.,...,.'A-.!..::::,2.,:i,,,..., • : :::: ."::::::':•';',..'".:.' • Exit doors ef:f re 1:3 • atte r . 9.7 . • .'':''''''''•••••••"''''..•'' '•• • r'.:Fi conSir .:::::::••••••:.,::.: .,...„,,, ,..... • . • „ • 4 9 j , ...ifctiOn 7 . , - .7:,..',. : :: : . ; 11.'•,. . . • ,. • • .,......,„..:.•.:•..........:,,":::::.::::,:::::::.:::.,.....:•:,-:::::.•:::..;.....,.,!.......„:„;•;.......,:,....;• app l i cation ,y. NOTE u tility wor is biiiit:'411iii16..1.1 i 77 •: : ::: „ :::: : : . ::::: . •:::: • ' - 77....• . :: A S n r g6icnt14 al 1. ii1 .9. 4)i l ' ' s .:. . ...: .:. • ::,..r.......::‘;'':°•.-.Fk...:.:...!,..,.:::''`;.":11.''...d..i.ii°17‘'•.,..:6..•-•i.,..i'ii....0!i);:,j..!!':,1:.,.....,..:.!.:(, T.E .. any , . . ... :-.,.--.....,-.,...:.....••.,......:.:..?,.:,::::.- ........... ...... li.:.c..:.:..,'''...! 1,n.:....:.':''.. r i : i pl s....' ari : s gt .: f i7 :: . . n :,. .. ,, .... : .. , : , 'e:6: -. :sit - %Aiihiiiii W ii:iO ........................ ... ..,, .. :.... ....,..:-.. .. ........H.... - • - 8t.a.TP:tri,CiU: showing wall construction Onci01 ... ... .,;.:::::•..,.:.. • • ,.'.....: attachment for;floor.end.Ciilf19.i.:,...:.....::::„........,:.::,..,-,....,:.;„::::.:....::„.......„,....,,.... • . „ . REROOc Asse.SerAcicoun; . 7 . 7 • El d • letter • terial :being NOTE A certific inspection NarratiVe'ilesc .. .. o f' the p .. • • . „ .. . ANTENNA/SATELLITE Completed building permit application .." ,AsSessor.Accciunt*Number::::::: Two (2) sets of plans which include .... Site Plan (showing building and location of antenna/satellite dish " ... Details antenna/satenite,dish.and rn ..:StruCtUrel:calaikitionS"'stairip:11*.kWastilatortStatkiiCenae erjOlpeo'f. may be required : ..:. ... .:.:....... ..: , 7 , ... .......„..,.,...„...,•..,.„ ,, .......: ::::, ,. ,.. , ,..:........ , :„.:,,,....7:....,., j1 . : 7:... ' •, .,. .. ,‘,.:.? ,......... :::. , ;.:::.,.. A. ,. . i...,0::.,:d.: ,.....R ,.., : . , ... ,,.. ' .., A .:.. . ' :,..‘....,,... ,; ., ... : . ..e .. .. :: s .. : :: .. :.. . s.;,. .. : o :: .......r :::;... . :. .... ,: : .i . 1: ::....:.; Cc building .....,.::i ril : ....... it ,.: .: ...: : ._::. .:.. ii,..1ju ,Two..(?)APts.9 i;,v .,:.,....... .....,.:. ...2..,::.-..,-,..z..............:.:,........ ...:..... 0- .. . ......... .. .......... .. ;;:i ' Foundation . • • ,1■6itif'.'iiIiiii . :.... . : t31:166aildt ,.-: ............::!:■'.:.Building .................................................................................................................................................. ............''''' Stiucturirifiairiiiig:Plan::::::::..??,,,'.:.:.: NOTL:i:if any ../c!!..ti://Y:PIT app lication and.plani.'aiiiPt be OYPq?!..tteF ... ...:::::i::::::::::. :•,...,•:...,,,, •: / -This Mobile i1011 ; i, (jvr -► MA l: { ieai-P ef'. No Real or PersonRi Lf�] � TATE OF W SNINGTON -�' L✓ /, / . �AIIMfar 0 , Property Tax is due 4; - a3 t`�C> IICEfSIIIG MANUFACTURED HOME APPLICAT ON 1 2 3 5 COUNTY X INC UNINC NUMBER OF I I REGISTERED OWNERS TITLE OPTIONS H Original Transfer Duplicate Reissue YEAR MAKE ':fLcc I N7 ✓ .WIDTH/LENOTH:`:::: <':< VEHICLE IDENTIFICATION NUMBER (VINI /US 81101 24 / d t I I J I rLA131 8 / i 5 5 ' R4 LAND • Attach a copy of the legal description of your land. It can be obtained from your Cou-1ty Assessor's office. • Land to which the manufactured home is being :® AFFIXED n REMOVED PROPERTY TAX PARCEL NUMBER TITLE COMPANY CERTI I certify that the legal description of the land and ownership are NAME •. .TITLE NOTE: Application must be finalized with a Licensing Agent within 10 calendar BUILDING PERMIT OFFICE CERTIFICATION I certify that the manufactured home has been affixed to the real property as described, or the BLDG PERMIT following building permit has been iss for this put •ose an will be in:: acted upon completion. 392 - o 20 SIGNATUR 1 '1::;;i; , s i::<; ::Ya i •: , . ; >a;: ' ; I .BLDG PERMIT OFHCE/PHONE NUMBER DATE OWNER / FORMATION 'FEES Anyone who knowingly makes a false statement of a material fact Is guilty of a felony, and upon conviction may be punished by a fine of up to $5,000 and /or 10 years Imprisonment (RCW 46.12.210). I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY LAW THAT UWF. ARE THE REGISTERED OWNERS OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: R•gI•tsr•d Owner Slpnalura(sl: (Tula) X X I NAME OF FIRST REGISTERED OWNER /WOE E s R• Po 46R NAME OF SECOND REGISTERED OWNER 3.0 C., Ro 6cEe5 ADDRESS OF FIRST REGISTERED OWNER CITY NAME OF FIRST LEGAL OWNER' MAILING ADDRESS OF FIRST LEGAL OWNER CITY ELIMINATION OF TITLE: X NAME RECORDING 2 TD•420.729 MANUF HOME APPLIR/7 /S3IOR Paps 1 of 2 TITLE ELIMINATION (Complete all but section 3, below) TRANSFER IN LOCATION (Complete ALL sections below) REMOVAL FROM REAL PROPERTY (Complete all but section 4, I slow) NUMBER OF LEGAL OWNERS X / STATE ZIPCODE wA `(8141 STATE ZIPCODE 'SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR IDATE X NOTARY OR UCENSE AGENT a NUMBER Subscribed aM Sworn to Before Me This X Day of 19 MANUFACTURED HOME Please provide the Department of Licensing (DOL) Client "NUMBER" for each owner: Rssiding In 'CATION true and correct. x days of the date signed by the Title Company Representative. Rio IGIEii:ICIRI ?isl ?iRi Rio 1G I n 1L 17 (7 i L la This "NUMBER" may be found on your Washington Drivers License/ I.D. Card --OR-- If the owner Is a business, provide the Unified business identifler(UBI) number. 1[ 1( 1 I( 1 1 1 1 More than two registered or one legal owner? . Please use attachment forms (TD•420 -732) DEALER'S REPORT OF SALE I certify that this Information Is correct. Tha vehicle is clear of encumbrances except as shown. >DEALEffNAME' 1: .......... DEALERS AUTHORIZED:SIGNATURE X Count RECORDING OFFICE This form has been recorded in the county records. RECORDED AT REQUEST OF: RECORDER'S CLOCK COLOR /1 COLOR l2 TOP OR � / BOTTOM OR 141.4 /Tc- FRONT: I REAR COLOR: 725526 - 0200 - FILING FEE APPLICATION MOBILE HOME FEES ELIMINATION USE TAX SUB•AGENT FEES TOTAL FEES & TAX PURCHASE PRICE TAX JURISDICTION/TAX RATE DATE OF SALE El USE TAX EXEMPT sal. to Indian on the Reservation (attach notarised statement of deliver/1 COUNTY AUDITOR /AGENT LICENSING OFFICE APPROVAL: (Not for use by Sub - Agents) I certify that the above application appears to have been completed correctly, and the applicant has sufficient documentation to proceed with the recording of this form. :'<:i::i i::: : >::; :::>:i:::::: ':.::. OFFICE/VFS OPERATOR NUMBER COUNTY': > ..:':: 'VOLUME/PAGE DATE DATE DATE FILE COPY I understand that the Plan Check approvals are subject to errors and omissions and approval of plans does not authorize The violation of any adopted code or ordinance. Receipt of contractor's copy sJ f2wrav_ecLplans.acknowledged. feA44 041•01011• • Date... ......... ........ ..,.) Permit No Da 0 4'44( 1S) CS- C) . .orx)14DATtON Pit•lektolar› IZE.Qiitaa4) IzeFEtz. #64c4.c.t4 eV• 1>erAtt. APPROVED AU 3 199 APPROVED, PER PUBLIC WORKS 1% TTF:1: 0A if3 (i •1 A L. 6 rks CITY OF TIl • BUILPIG DIVISION RECEIVED CITY OF TUKWILA JUN 9 1992 PERMIT CENTER i rr - /' .y 4,:$4.1.4. W- A\ w Z 7?d 7LO � GT -, 1 4 ;,.1o -A' � y 0LY 21 W . r1 • z.3rt1.. i\ `Sa391 14 igrii on.b9N11 3WV rnvw ��►}t1D Z3Q v 3-I +0.113 93 'o /La t -NM 2 vf G , I r r/ ai I .ra Th% ‘; 1 N i LXC DN l Lt 66 C NV • f le • .d7 Wei 1sior �IOCT► • • _ I 7,lt+• lh 3 crRyFf. 1 yJ 11.1 . ) ' `~ A"i`c=J ''!:� , 27'JOIG÷re i 77'0,1 &°i t �N11sI ` - -' 9Y b}4ILCI ° - Tv/v1 -17xz %47 • • /L ?'d f-1-- NV - 1, JI l I L 073- << Yi osz -209 -d),Z: 701 414- ♦ h ©uSINESS_ ( A ' PLEDGED TO AROITRATE ti 9pF COMO\ t' im A d d re.ss _ •f _...�..r.._� ..._ FMaka 1 L REQUESTED SERVICE Year 20302 So. E. 284th St. Authorizing and Approval Signature DUTCH'S Mobile Home Service Size When Properly Signed and Approved property lines, setbacks and positioning of homes. Licensed & Bonded DUTCHMH254KA Model Phone 631.0653 Kent, Washington 98031 pate Serial No. JUN 9 1992 PERMIT CENTER `- 3 0 Park Phone —. Date Work to Colnmencu Charges Water Meter Lines Pehk Test .3.701 Septic Tank Installation w/1 Drain Field �5 - , - - 677---&t ` oc.'' ,i as , /00 Flo! - AciditioaaL9rain -Field / � .7 E a � . 2G ....44,-644 Foundation Expense • Electrical Hookup and Meter Base ;:- Puget Power Hook Up A c,-)..c.., Lot Clearing - ��^; ^' Culverts fnr Driveway 21' x 12" Backfill Skirting l‘,5 d OO , Ditching & Backfill Dozer Excavate 3. " 0 1, 6 Tiedown Ys 'a - Dozer to Spot House �?.2z Aid Side Sewers _-- -.6. Landings ... 0, // Crushed Rock ?geld. - Gutters & Downspouts ` ,44j/.t4&. ,314 00 cV,e- t / 700 0 O In the event of work performed ustomer Customer the property owner does not pay within 15 days after completion a lien will be placed upon the property. responsibity for determining RECEIVED assumes full res p g CITY 0 TUKWILA TOTAL / ?fM`a Y.'�ir ,1^' SALES TAX C t.''~ ?/y a TOTAL AMOUNT f'4 �J- ' 06 . o ♦ h ©uSINESS_ ( A ' PLEDGED TO AROITRATE ti 9pF COMO\ t' im A d d re.ss _ •f _...�..r.._� ..._ FMaka 1 L REQUESTED SERVICE Year 20302 So. E. 284th St. Authorizing and Approval Signature DUTCH'S Mobile Home Service Size When Properly Signed and Approved property lines, setbacks and positioning of homes. Licensed & Bonded DUTCHMH254KA Model Phone 631.0653 Kent, Washington 98031 pate Serial No. JUN 9 1992 PERMIT CENTER `- 3 0 Park Phone —. Date Work to Colnmencu Charges ci of 7lct kwil� Community Development / Public Works • 6300 Southcenter Boulevard, Suite 100 • Tukwila, Washington 98188 Permit No: PW92 -0226 Status: ISSUED Project: ROGERS MOBILE Site Address: 5218 S 144 ST Parcel No: 725520 -0200 Wetlands: Water: N/A Type of Install: PSFR Number of Units: 001 New SQ FT: 1736 Contractor License No: TENANT CHARLES & DORIS ROGERS' 5218 s 144, TUKWILA, WA 98168 OWNER ROGERS FAMILY:TRUST 14261 53RD AVE S,TUKWILA WA 98168 Description: SANITARY SIDE SEWER RECONNECT * * * * * * ** * * * * * * * * * * * * * * * * ** * ****************** * * * * * * * * ** * * * * * * * * *** * * * **,r * * * * ** Inspection Fee: 20.00 Acct No 402/342.400 Hook. UP Fee: .00 Acct No: 402/388:102 Special Assessment: .00 Acct No 402/388.101 TOTAL FEE: 20.00 ************************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * ** THE APPLICANT HEREBY ACCEPTS THIS PERMIT AND AGREES TO ABIDE BY ALL APPLICABLE SECTIONS OF THE CITY OF TUKWILA CODE AND APPROVED PLANS. WE ALSO AGREE THAT THE CITY OF TUKWILA SHALL BE HELD HARMLESS FROM ALL OR ANY CLAIMS ARISING RESULT OF THIS PROJECT PERMITS WHICH HAVE LAPSED BEYOND THE PERMIT EXPIRATION DATE SHALL REQUIRE REAPPLICATION AND RE-ISSUANCE OF THE PERMIT THROUGH THE CITY OF TUKWILA AT AN ADDITIONAL FEE. APPLICANT, MUST NOTIFY THE CITY INSPECTOR OF COMMENCEMENT & COMPLETION OF WORK AT LEAST 24. HOURS IN ADVA E. FOR AN INSPECTION CALL 433 - 0 S i gna .. G+ _ =' - -- =L Date 1 � � L Company: �LV Title ************* * * * * * * * * * * * ** * * ** *** * * * * * * * * ** APPROVED FOR ISSUANCE JAP Issued By: * SL O % a� -! Q Q ,: Authorized Permit Center.. - Signatu,re ' Date ******************** * * * * *. * *: * *. * * * * * * * * * * * * * * * * ** • I hereby certify that 'thee permit hol whose namean;d appears on this record has satisfactorily =me ,.the standards;,':and� conditions for side sewer construction. Final Inspection Approved: Inspector Signature SANITARY SIDE SEWER Watercourse: 14 -1 Slopes: X Sewer: N/A Exist SQ FT: Date Issued: 08/03/1992 Approval Letter: 07/31/1992 Expires: 01/30/1993 Add SQ FT: (206) 431 -3670 City o 71kwilL Permit No: PW92 -0225 Status: ISSUED Project: ROGERS MOBILE Site Address: 5218 S 144 ST Parcel No: 725520 -0200 Wetlands: Water: N/A Type of Install: TSFR Number of Units: 001 New SQ FT: 1736 Contractor License No: Final Inspection Approved: Inspector Signature SANITARY SIDE SEWER Exist SQ FT: TENANT CHARLES & DORIS ,,ROGERS 5218 s 144, TUKWILA,' WA 98168 OWNER ROGERS FAMILY TRUST 14261 53RD AVE S, TUKWILA WA 98168 Date Community Development / Public Works • 6300 Southcenter Boulevard, Suite 100 • Tukwila, Washington 98188 Watercourse: 14 -1 Slopes: X Sewer: N/A Issued: 08/03/1992 Approval Letter: 07/31/1992 Expires: 01/30/1993 Description: SANITARY SIDE SEWER TEMPORARY DISCONNECT ************************************************* * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** Inspection Fee: 20.00 `. Acct No: 402/342.400 Hook UP Fee: .00 Acct No: 402/388.102 Special Assessment: 00 Acct No 402/388.101 TOTAL . FEE: . 20.00 ************************************************ * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** THE APPLICANT HEREBY ACCEPTS THIS PERMIT AND AGREES TO ABIDE BY ALL APPLICABLE SECTIONS OF THE CITY; OF TUKWILA MUNICIPAL CODE AND APPROVED PLANS. WE ALSO AGREE THAT THE CITY OF TUKWILA SHALL BE HELD HARMLESS FROM ALL''OR ANY CLAIMS ARISING AS A RESULT OF THIS PROJECTPERMITS WHICH HAVE LAPSED BEYOND THE PERMIT EXPIRATION DATE SHALL REQUIRE REAPPLICATION AND RE- ISSUANCE'; OF THE PERMIT THROUGH THE CITY OF TUKWILA AT AN ADDITIONAL FEE. APPLICANT,MUST NOTIFY THE CITY INSPECTOR OF, COMMENCEMENT & COMPLETION: OF WORK AT LEAST 24. HOURS IN ADVANCE. FOR AN INSPECTION CALL 433 -0179. Add SQ FT: S i gnaturr:�i.� 1�,(n� ;Date: Company: N ) Title: ********************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ** APPROVED FOR I S.SUANCE BY : JAP Issued By: (206) 431 -3670 Authorized Permit Center Signature Date *********************'************** * * * * * * * ** *';t * * * * * * * * * * * * * * * * ** I hereby certify that the . permit holder' whose name,a'nd appears on this record has satisfactorily met.,the standard a n:d 'conditions for side • sewer construction. " X " Permits Date Routed to PWD Date Plans Approved G - t ( A L I l ' u ?e2lrilil Permit Number Approved Plan /Letter Date Issued )Sth-e l l ) 1) - M Channelization / Striping / Signing Suite No. Curb Cut / Access / Sidewalk Fire Loop / Hydrant Flood Zone Control Hauling Land Altering Landscape Irrigation PWca 0 6-C N S tT'/ - c 9 , Moving an Oversized Load I,_ or t • 1J -srie. q -Odgq 0 ` - --1_3 1-0 . :.--3 - (1 Sanitary Side Sewer 1- -a( iMMOr nt e...4 -- 1 — pe co�t��c - pw a n ° A °Ar 5 , 1.3 (.0_3-3�r� Sewer Main Extension (private) Sewer Main Extension (public) Storm Drainage Water Main Extension (private) Water Main Extension (public) Water Meter (exempt) Size No. 0 Deduct O Water only Water Meter (permanent) Size No. Water Meter (temporary) Size No. Other: Other: Data Plans Received T e of Review Date Routed to PWD Date Plans Approved G - t ( A L I l ' u ?e2lrilil Date Resub. Requested u e. Comments . 1 -Zq Z )Sth-e l l ) 1) - M I -Za -C -- Suite No. Plan Check No. f ,i �`D_CZ L Project Name I , t� Site Address r1 g Suite No. ROUTING PERMITS REQUIRED City of TukC i Public Works Department 6300 Southcenter Boulevard, Suite #100 Tukwila, Washington 98188 Phone: (206) 433 -0179 UTILITY PROJECT TRACKING CHECKLIST CONDITIONS OF PERMIT ISSUANCE OR FINAL SIGN -OFF OF PROJECT TO: CITY OF T."WILA 6200 Southcenter Boulevard, Tukwila, Washington 98188 (206) 433 -1800 PE-, ,47 /7- FROM: . /.9/1/ ,.9 P /.� DATE' r,.//902 SUBJECT: /QG .RAP$ / '4' MEMORANDUM # 4- 7/G 7 - Y r ' y 7 4 . ' y ' S /MX, a 7Vle 7 z ,aL�rP/Yir . - 7w? / scprt/4 7 t HEHEE3Y CERTIFY ..THA L:HAVE TH/S APPLICATION ANQ KNO. E s.e. lei BE TRUE AND.CORRECT Applicant /Authorized / , A.: i•n. ur:: _i.�. ,•, .; rr,�. Print Name: /.J,//,''?L S . Ppect02 Contact Person .ri tname): �'/,/9re .e. ,a4..e,e 5 Address: /'.Z4 / - .3:3 V /- , £ Date: -9 Phone: 2/3 -217 Z 40c4 / ,Q.9_7f ' Phone Z�/� -Z IQ _ , (3 q `1 Date Application Accepted: ( Q _ q_, -� sr�n �lly ��rrrr �_ Date Application Expires: PROJEC INFORMATI Property Owner: Street Address: Engineer: Street Address: Contractor: i c h'S r-w QY u i c 2. Phone No.: WTI -- O (03 Street Address: 3 c ry +� , City /State/Zip: toh qso) King Cty Assessor Acct #: � Contractor's License # :L� �.0 r 04/1 ,),5 �5 - .40 - A Exp. Date: i� % rr�rr � PERMF REQUEST >`WATER;METER'. REFUNDlBILLI MON.THLY;> BILLINGS`:TO: ❑ Water Name: ❑ Multiple - Family Dwelling No. of Units: ❑ CommerciaVindustrial ,, .SC INFORMATIO . < Site Address: S Q I. c 5 LI LI JN ` Name of Project: e14-412/- 5 v Y2r s 141 S32? City of f Tu ✓ila Central Permit System - Engineering Division 6300 Southcenter Blvd., Suite #100, Tukwila, WA 98188 ❑ Channelization /Striping /Signing ❑ Curb Cut/Access /Sidewalk ❑ Fire Loop /Hydr. (main to vault) - No.: Sizes: ❑ Flood Zone Control ❑ Hauling ❑ Land Altering cubic yards ❑ Landscape irrigation ❑ Moving an Oversized Load Est. start/end times: Date: ❑ Sanitary Side Sewer- No.: Street Address: Name: Street Address: ❑ Sewer ❑ Metro ❑ Hotel ❑ Motel ❑ Office ❑ Retail UTILITY PERMIT APPLICATION ❑ Standby ❑ Duplex ❑ Triplex ❑ Warehouse ❑ Manufacturing New Building tnobi■z- ❑ Remodel/ Square R Addition Footage: 1710 (a King County Assessor's valuation of existing structures: $ ❑ Apartments ❑ Condominiums ❑ Church Applit ,n # pc a JO O (D l Phone: (206) 433 -0179 Phone No.: Loc.- Z. 43 - 2-02.3 City /State/Zip: 1t.�,v.. ►4,�A. 981 (08 Phone No.: City/State/Zip: IgJ Sewer Main Extension ❑Private Rj Public ❑ Storm Drainage ❑ Street Use iZs )S( Water Main Extension IZPrivate i-` L • ❑ Water Meter / Exempt: - No.: — Sizes' Deduct ❑ Water Only ❑ ❑ Water Meter / Permanent - No • — Sizes ❑ Water Meter/ Temporary:- No.: —_ Sizes• Estimated quantity: Schedule' ❑ Other: Phone No.: City /State /Zip: Phone No.: City /State /Zip: ❑ Other: ❑ School /College /University ❑ Hospital ❑ Other: Square footage of original building space: Square footage of additional building space: Valuation of work to be done: $ • VA •r • I.• U.. •_1 DESCRIPTION : OF. PROJE CT!'<; Single - Family Residential 04/22/92 SUBMITTAL CHE (LIST All site plans shall be provided in one submittal for review by the Public Works Department. Six (6) sets of plans stamped by a licensed engineer are required along with this application completed and signed by the applicant's representative. The following information is necessary for Public Works Department evaluation and approval of site plans: • All utility construction is to meet the City of Tukwila Standards • Indicate scale of drawing and show north arrow • Identify location by address or distance to nearest intersection • Identify public right -of -way and any easements • Use standard 24" x 36" sheets for all site plans CURB CUT /ACCESS /SIDEWALK / CHANNELIZATION /STRIPING /SIGNING O Dimensions O Type of surfacing - asphalt, crushed rock, etc.(and thickness) O Percent of slope and runoff direction O Size of curb cuts / locations O Vehicular and pedestrian traffic facilities, including signing and striping, wheel chair ramps, curb cuts O 20' of paving on all gravel driveways connecting to paved roads FIRE LOOP /HYDRANT O Type of pipe / hydrant O Size of pipe /location O Location and type of all valves O Type of bedding and backfill material / percent compaction O Distance from structures, storm and sewer facilities O Location and size of thrust blocking FLOOD ZONE CONTROL (Requirements are under Flood Ord. No. 1462 and can be obtained from the Public Works Dept.) O Lowest finished floor elevation O Contours and elevations per National Geodetic Vertical Datum LAND ALTERING (CLEARING, CUT AND FILL) O Contour map (2' intervals) showing existing and proposed contours O Estimate of yardage, both cut and fill O Erosion control plan with temporary and permanent measures HAULING O Quantities of materials to be hauled to and/or from site O Copy of Certificate of insurance coverage (minimum $1,000,000) O $2,000 bond made out to the City of Tukwila for property damages caused by activities O Route map LANDSCAPE IRRIGATION O Location of DSHS approved double check valve • O Type of pipe - copper, high density molecular plastic, ductile O Size and depth of pipe O Size of meter and meter box O Location and elevation of meter box (water meter - permanent and exempt). Clearly show whether tap is on main or domestic service O Location and type of tap O Type of bedding and backtill material / percent compaction MOVING AN OVERSIZED LOAD O Copy of Certificate of insurance coverage (minimum $1,000,000) O $5,000 bond made out to the City of Tukwila for property damages caused by activities O Business License with City of Tukwila O Route map O Dimensions (L X W X H) of overall load SANITARY SIlL.SEWER O Type of pipe - concrete, PVC, etc. O Size of pipe/location O Percent of slope on pipe/length of run O Connection point(s) to existing system O Location of cleanout(s) and test Tec(s) O Type of bedding and backfill material /percent compaction O Invert elevations at structures and Junctions SEWER MAIN EXTENSION O Type of pipe - concrete, PVC, etc. O Size of pipe/location O Percent of slope on pipe/length of run O Connection point(s) to existing system O Location of cleanouts and manholes O Type of bedding and backfill material /percent compaction STORM DRAINAGE (include existing topography and proposed grading and surfacing) O Type of pipe — concrete, ADS, etc. O Size of pipe / location O Percent of slope on pipe / length of run O Location of ali structures O Square footage of area to be drained, including roof area O Type of bedding and backfill material / percent compaction O Invert or flow line elevations STREET USE O Complete description of proposed activity O Map with address and outline of limits of activity relative to public right -of -way and easements O Proposed traffic control/detour (per Manual of Uniform Traffic Control Devices) O Proposed schedule (times and dates) WATER MAIN EXTENSION O Type of pipe — copper, PVC, etc. O Size of pipe / location O Hydrant types and locations O Valve types and locations O Connection point(s) to existing system O Type of connection - live tap, tee, etc. O Location and size of thrust blocking O Size and location of mains, including elevations (profile) WATER METER - EXEMPT O Diagram of domestic system/tie in of exempt meter O Number /account for existing domestic meter O Size and type of material of meter, service and meter box O Site address WATER METER - PERMANENT O Type of pipe - copper, high density molecular plastic, ductile O Size and depth of pips O Size of meter and meter box O Location and elevation of meter box (water meter - permanent and exempt) O Location and type of tap O Type of bedding and backfill materials /percent compaction WATER METER - TEMPORARY O Address and hydrant location O Size of meter O Estimate of quantity and schedule A er t e `u. rc F'or s ' apartment as compete. t err review an. e . ans are approve, t e app want WI ► : nob re by letter concerning the necessary permits and requirements; an approved set of plans will accompany the letter. If the plans are not approved, the applicant will be notified by letter of necessary resubmittal requirements. PROJE ; INFORMATI C Property Owner: Street Address: Engineer: Street Address: �,/ Contractor. < rc+� S OC.(..Cl.(! Fy l /S _L__ C - Street Address: ; 0/ ' e! (? c I4cle. cf» . &lex - King Cty Assessor Acct #: ::PERMITS::: REQUESTI :::WATER:;;. ET REFUND /BILLI City of TuIC Lila Central Permit System - Engineering Division 6300 Southcenter Blvd., Suite #100, Tukwila, WA 98188 P iJ Site Address: 52(Y / 414 7 ' Name of Project: ® rt5 evy er,S • ❑ Channelization /Striping /Signing ❑ Curb Cut/Access /Sidewalk ❑ Fire Loop /Hydr. (main to vault) – No.: — Sizes: ❑ Flood Zone Control ❑ Hauling 6 F ❑ Land Altering cubicy as 0 ❑ Landscape Irrigation f f Moving an Oversized Load Est. start/end times: / / - Date: J! o v ' l 9� ❑ Sanitary Side Sewer – Nod MONTH SERVICE :::;:;:;; BILLIN Cl Water El Single- Family Residential SCRIPTION;OF P.ROJE El Multiple - Family Dwelling No. of Units: ❑ Commercial/Industrial ISCELLANEC . Nir.oRMAT,ION Square footage of original building space: Square footage of additional building space: King County Assessor's valuation of existing structures: $ Valuation of work to be done: $ 1. HEREB.Y Applicant /Authorized Agent Signature: Print Name: / Name: Street Address: Name: Street Address: ❑ Sewer ❑ Metro 02- Qad( Phone: (206) 433 -0179 UTILITY PERMIT APPLICATION El Hotel ❑ Motel El Office El Retail Contractor's Lice se #: ❑ Standby El Duplex El Triplex El Warehouse ❑ Manufacturing ED New Building ❑ Remodel/ Square Addition Footage: CI Condominiums ❑ Church ❑ Hospital 4 Ap ` n # I (cc_ c,< Y(cL e, Phone No.: Cit /State/Zi•: Phone No.: City /State/Zip: Phone No.: Exp. Date: ❑ Sewer Main Extension ❑ Private El Public O Storm Drainage O Street Use ❑ Water Main Extension ❑Private El Public O Water Meter / Exempt: – No.: Sizes' Deduct ❑ Water Only ❑ ❑ Water Meter / Permanent – No • — Sizes• ❑ Water Meter / Temporary:– No.: — Sizes' Estimated quantity: Schedule: ❑ Other: El Apartments ❑ Other: Phone No.: City /State /Zip: Phone No.: City /State /Zip: ❑ School /College /University ❑ Other: T[m . 44071:73.0.0 AND Kl U Contact Person (print name): Address: :S. ,v> Phone: Date Application Accepted 7 . Date Application Expires: ,� ��11 `tom OfiR 04/22/92 SUBMITTAL CHEU(LIST All site plans shall be provided in one submittal for review by the Public Works Department. Six (6) sets of plans stamped by a licensed engineer are required along with this application completed and signed by the applicant's representative. The following information is necessary for Public Works Department evaluation and approval of site plans: • All utility construction is to meet the City of Tukwila Standards • Indicate scale of drawing and show north arrow • Identify location by address or distance to nearest intersection • Identity public right -of -way and any easements • Use standard 24" x 36" sheets for all site plans CURB CUT /ACCESS /SIDEWALK / CHANNELIZATION /STRIPING/SIGNING O Dimensions O Type of surfacing - asphalt, crushed rock, etc.(and thickness) O Percent of slope and runoff direction O Size of curb cuts / locations O Vehicular and pedestrian traffic facilities, including signing and striping, wheel chair ramps, curb cuts O 20' of paving on all gravel driveways connecting to paved roads FIRE LOOP /HYDRANT O Type of pipe / hydrant O Size of pipe /location O Location and type of all valves O Type of bedding and backfill material / percent compaction O Distance from structures, storm and sewer facilities O Location and size of thrust blocking FLOOD ZONE CONTROL (Requirements are under Flood Ord. No. 1462 and can be obtained from the Public Works Dept.) O Lowest finished floor elevation O Contours and elevations per National Geodetic Vertical Datum LAND ALTERING (CLEARING, CUT AND FILL) O Contour map (2' intervals) showing existing and proposed contours O Estimate of yardage, both cut and fill O Erosion control plan with temporary and permanent measures HAULING O Quantities of materials to be hauled to and/or from site O Copy of Certificate of insurance coverage (minimum $1,000,000) O $2,000 bond made out to the City of Tukwila for property damages caused by activities O Route map LANDSCAPE IRRIGATION O Location of DSHS approved double check valve O Type of pipe - copper, high density molecular plastic, ductile O Size and depth of pipe O Size of meter and meter box • 0 Location and elevation of meter box (water meter - permanent and exempt). Clearly show whether tap is on main or domestic service O Location and type of tap O Type of bedding and backfill material / percent compaction MOVING AN OVERSIZED LOAD O Copy of Certificate of insurance coverage (minimum $1,000,000) O $5,000 bond made out to the City of Tukwila for property damages caused by activities O Business License with City of Tukwila O Route map O Dimensions (L X W X H) of overall load SANITARY SILL SEWER O Type of pipe - concrete, PVC, etc. O Size of pipe/location O Percent of slope on pipe/length of run O Connection point(s) to existing system O Location of cleanout(s) and test Tec(s) O Type of bedding and backfill material /percent compaction O Invert elevations at structures and junctions SEWER MAIN EXTENSION O Type of pipe - concrete, PVC, etc. O Size of pipe/location O Percent of slope on pipe /length of run O Connection point(s) to existing system O Location of cleanouts and manholes O Type of bedding and backfill material /percent compaction STORM DRAINAGE (include existing topography and proposed grading and surfacing) Type of pipe — concrete, ADS, etc. Size of pipe / location Percent of slope on pipe / length of run Location of all structures Square footage of area to be drained, including roof area Type of bedding and backfill material / percent compaction Invert or flow line elevations STREET USE O Complete description of proposed activity O Map with address and outline of limits of activity relative to public right -of -way and easements O Proposed traffic control /detour (per Manual of Uniform Traffic Control Devices) O Proposed schedule (times and dates) WATER MAIN EXTENSION O Type of pipe — copper, PVC, etc. O Size of pipe / location O Hydrant types and locations O Valve types and locations O Connection point(s) to existing system O Type of connection - live tap, tee, etc. O Location and size of thrust blocking O Size and location of mains, including elevations (profile) WATER METER - EXEMPT O Diagram of domestic system/tie in of exempt meter O Number /account for existing domestic meter O Size and type of material of meter, service and meter box O Site address WATER METER - PERMANENT O Type of pipe - copper, high density molecular plastic, ductile O Size and depth of pipe O Size of meter and meter box O Location and elevation of meter box (water meter - permanent and exempt) O Location and type of tap O Type of bedding and backfill materials /percent compaction WATER METER - TEMPORARY O Address and hydrant location O Size of meter O Estimate of quantity and schedule er t e •u• rc or s ►apartment as comp ete• t err review an e • ans are approve •, t e app ►cant wi •: nob re by letter concerning the necessary permits and requirements; an approved set of plans will accompany the letter. If the plans are not approved, the applicant will be notified by letter of necessary resubmittal requirements. Account Code 000/322.100 000/345.830 000/386.304 h **** **k *******Jr ** ** k*** • k*k********* * ***h* * * ** *A * * *Jr**** CITY OF TUKWILA, WA TRANSMIT *** h**** k* hJ**** J************ ****k****J * * * * * * ** * * ***h* * *h **k TRANSMIT Number: 92000800 Amount; 167.85 08/03/92 15:07 Permit No: 892 -0206 Type: B-BUILD BUILDING PERMIT Parcel No: 725520 -•0200 S i t e Address: 0218 5 1 4 ST Payment Method: CHECK Notation: DORIS ROGERS mite SLB ** ********** k******* k*** h * * * * * *•k * * ** * * ** * * * *A **** **k* ** Total Fees: Total All Payments: Balance: Description )B UILDING - RES PLAN CHECK - RES STATE .BUILDING SURCHARGE Total •(This Payment): 167.85 167,85 .00 Paid 5900 64.35 4.50 167.85 Total Fees: Total All Payments: Balance: 25.00 2500. .Op r*** **.**4<***A** ******* ***A*** ** ** *fir ** hit **• **•h * ****. *AA *****. *. **•k * ** ITY OF TUKWILA, WA TRANSMIT r** k* A* rk********•************•***A ** * ** *A * **A* **** **A * * *•h * ** * * ** 'TRANSMIT Number 92000737 Amount: 25.00 08/03/32 10 :59 Permit No: PW92.0224 . Type: PW-MOL MOVING AN OVERSIZED ..Parcel Nu: 725 -0200 08/Q3/92 Site Address: 3218 S 144 ST Location: MOBILE HOME PARK Payment Me. CHECK Notation :: DETRAY'S QUALITY xnit: SLB k** k*****'*** A*** k** 4!****** ***• * * * �h• ** * * *A * *** **.** * * ** Account 'Code]. Description Paid 000 /345.030 PLAN CHECK - UTILITY 10.00 000/342.400 INSP FEE UTILITY 13.00 Total (This Payment): 25.00 GENERA GENERA TOTAL CHECK 10.00 15.00 2 25.00 25.00 CHANGE 0.00 2063A000 14 :18 Y '******* *** *********** ***************** ** ***k****:**************** CI1'Y .;OF " TUKWILA, . WA TRANSMIT kkalrkk *k k" hk kkh* ***************** *k ******k****. **.****** ** TRANSMIT Number. 92000.795 Amount: 20.00 08/03/52 15:06 Permit' Noa PW92 -022b Type. PW -°858 SANITARY SIDE $$CWI R P4rcel.No: 725520 -0200' •Site Ad.dre.04: 3218 8 144 8T. : PaymeMt Methods CHECK Notations 00RIS ROGERS, Ini *** k***** ***** *******k************k* **** ** **** ***k **. **kk' V"' ** Account Code Description Paid 000/342.400 INS!' FEE - UTILITY, • 20.00 Total (This Payment): 20.00 Total Feesg• Total All Payments; Balance: 20..00 20.00 .00 GENERA 99.00 GENERA 64.3E GENERA 4..50 GENERA 20.00 GENERA 20.00 TOTAL 207.85 CHECK 207.85 CHANGE 0.00 2062A000 1I :17 ** k* k*** k***'**•***** Iv* *********** * **k*****k* *** *****k ** *A/e***kk ITV OF TUKWILA, WA TRANSMIT ****k**** A*****************- 4****** * * ****** *•k** ***** *k•* * *** ***k* TRANSMIT Number: 92000798 Amount: 20.00 08/03/92 15:05 Permit No: PW92 -0225 Type: PW-SSS SANITARY SIDE SEWER Parcel • No 7 -0200 Site Address: 5215.5 144 ST Payment Method: CHECK Notation: DORIS.ROGERS Init: SL13. r* * * * * * * *k *** 4****** * * *k* * * **A * * *k ** * * * * * * * * * * * * *** *7th *A• * * *** * **•. Account Code Description Paid 000/342.400 INSP FEE - UTILITY 20.00 Total (This Payment): 20.00 Total Fees: 20.00 Total All Payments; 20.00 Balance: .00 icsfi 41\co' e)' �fy.\! Y .. '��.t' ' 1.,• •} . (' ..' 4`�AMd1t'.!:{11T1t�rTt!T tt�7Cr�ny,Nr ,.. C- � **** k* * A **- k * 4 k*********.****** * * * * * ** **k *** * *.4 * *k4* * *** *** CI1 Y 'OF TUKWILH, WA TRANSMIT * r4ikk.** � Irrkk., k*#** ks4hhk ;kk * *k�k *.k * ** Pik* �4k *ylr * *rkrk�F, * * *�4h. * * r k k.k.ki4 TRANSMIT Numbers. 42 000909.Amaunt. 2 . +.�.f�00 0�1/31f92 15.1Q Permit No PW92.0245 Type: PW -MOL, MOVING AN 09619040 Parcel. No: 725520 -0200 5 i rte Addreas.: 521.8 8 144 . Payment Method: CHECK . Natation. ROGERS, DORIS Iriit. DLM *+ 4: k******, k******* d4* ** *** * *** * ** * * **** * * *.k *. *k; *fink* ***** * * * * * * ** * Accaurii; Code '000/345.1330 000/342:400' Total Fees': Total All Paymer►ts. Bel artre•. Description PLAN CHECK - UTILITY IN5P FEE - UTILITY :Total (This Payment): 25.00 25,00 .00 Paid 10.0() • 15,00 23,00' .GENERA GENERA TOTAL. CHECK. CHANGE. 2988A000 10.00 15.00 25,00 25.00 0.00 10:38 P ect: 1 A IV I e C Db 6 S re ocpx5. ype ofin pedionr— ''''K t - , R c.na-IL I i - - Date Cat ea: Specie Instructions: Date Wanted: - / 0-- 9 aCr ,P 11 2 Requester: r, c_40-401. h A Phone No.: 3 k 4 :-. 1 (2- * • I SPE • 0. CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd., #100, Tukwila, WA 98188 I Inspector: or. . . INSPECTION RECORD L. Retain a copy with permit Approved per applicable codes. %L 4..• • • • , ,,,, - I; z- o z exp PERIAFT7 (206) 431-3670 0 Corrections required prior to approval. O $30.00 REINSPECTI. N FEE REQUIRED. Prior to reinspection, fee must be paid at 6300 Southcenter Blvd„ Suite 100. Call to schedule relnspection. I Recept No.: Date: • . pozAt5 t)oet.S �1X�1,, ype ° nsped, .e ..) Apt; e c • /41i , I J Date Called: p ai - ,- Sp: • = Instructions: Date Wanted: /6 ° gR— q -41•.. Requester: Pt neNo.: D COMMENTS: Inspector: o. CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd., #100, Tukwila, WA 98188 ree r INSPECTION RECORD Retain a copy with permit ❑ Approved per applicable codes. Corrections required prior to approval. N 36 te )(lc L,er,. s Dale : 1 a- ZR ❑ $30.00 REINSPECTION FEE REQUIRED. Prior to reinspection, fee must be paid at 6300 Southcenter Blvd., Suite 100. Call to schedule reinspection. pawn ' t ord F N y � t n P t • :1 � /I / bGP ivang • 3 ,■ ' - to aI _ 8,_ i Specie Instructions: ; < Date Wa d: • -- -` - a p.m. Requeste . Phone No.. �► - — i 0 r. 0 INSPECTION RECORD CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd., #100, Tukwila, WA 98188 4 Approved per applicable codes. Retain a copy with permi I 89Z —oZ(X PERMIT NO. 206) 431 -3670 ❑ Corrections required prior to approval. — e: 31 ❑ $30.00 REINSPECTION FEE REQUIRED. Prior to reinspection, fee must be paid at 6300 Southcenter Blvd., Suite 100. Call to schedule reinspection. I Receipt No.: Dale: r ct; � � �e��1 I . � tYr�e1 S ype o Ins an: c �►aZ`t3 , d st /44 JJ Date Called: _• I r (�2-- Special InstNctions: _ Date Wanted: p - jams P,m Requester: E..0 P h a 'INSPE6TI®N.sittOtAR'D' 1a 2D(c Retain a copy with permit INSPE't♦TION NO. , PERMIT NO. CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd., #100, Tukwila, WA 98188 x . (206) 431 -3670 Approved per applicable codes. ❑ Corrections required prior to approval. COMMENTS: Date: 6 ;,_, /7ycf 2 1 ❑ $30.00 REINSPECTION FEE REQUIRED. Prior to reinspection, fee must be paid at 6300 Southcenter Blvd., Suite 100. Call to schedule reinspection. f Recept No,: Date: Address: 521E S 144 ST Tenant: ROGERS CHARLES & DORIS Type: B -BUILD Parcel #: 725520 -0200 CITY" OF TUKWILA Permit No: B92 -0206 Status: ISSUED Applied: 06/09/1992 Issued: 08/03/1992 *• k*******'***************************•k*********** ** ** ** * * * *'k ** *** *** * ** ***•k* Permit Conditions: 1.. PILOT CAR IS TO BE USED.. NO PARKING SIGNS, IF NEEDED, TO BE PLACED A MINIMUM OF 48 HRS. IN ADVANCE OF MOVE. NEW MOBILE HOME IS TO BE LOwED.....SO,K,THAT ADEQUATE SETBACKS ARE PROVIDED FOR AFTER",DEDgAT,ION ,`:OF,; °ADDIT:I,ONAL 5' OF R/W ALONG 53RD AVENUE SOUT ..R / W EDICATT'O(V TO .y: r BE =;C OMPLETED PRIOR TO PUBLIC WORKS : SIGN -OFF; 2. No changes wi l l s f be made, n. s tic #thie � l ans` un i ess approved by the Tukwila Build {ing�'Di.vi�sio < w ,, ��•;.:. s .t � 3. All permits spect records, and approved plans shra.l,l• be maintained avaitilable : ?at the ,rjo s ite 'prtio,r to.et17e star ` oaf any cons;t;i iictiori: ;T 1,t'��i hese'�'documents are to'be, mainta`i'ned ava i t abFl;e;. unt'i l f i'na, nspect� l is �'gran,te : 4. All co.nstruction" to" be don,e conformance withf:app'ro;ved, plansand r�e.quirements of. the Uniform Building Cbde (1` E d i t io 1;) `r M u 5. AS 6• M NIMUM, THE MOBILE HOME. INSTALLER SHALL INSTAL • DIAGONA LON L': TIES FOR EACH`' ° °'I- BEAM� ;FOR OTHER MAIN FRAME ''` #it Ga� �TUDNA L` MMBER a...r.,, / r y 6. Va 1 : ;, ;.•' .'i p of P , . . o . ,.. t y ermit., H The.� irasf an;ce,, o.f" f �J + f er,M'4 or approval 'bf j�u p1 , spec lf 1' °c t.i..ans' "an computation ' shall not be conk. str ed :to "a .errn.i c ` , , +r' tl, ; ( � p .z t_ f �,� ,� a��, 5 a n a�P P t o�v a j any v i a�� a t i'�a ri of F a : ny of •; t°he: prtrvisions�' code` -or O'f >.`any other; or dt'ance j of t'he risi iict' ianN6 i.:.p"'resuming .t`o g vn a u t '�"' 1 i. „�, � f . �+ d r y 4 S ' p ,�i�, .1'd.� �t '. ty o v2i o l at`e,�'� , cancel the,.;pr i ons of this code sha l,l Ab x . <e va i d ". .s �• �Y S i 1 M,YyA'�5. • " � •4 <:1 TO: FROM: DATE: SUBJECT: City of Tukwila Department of Public Works M E M O R A N D U M S NOTIFICATION OF UTILITY PERMIT ACTION PERMIT CENTER PUBLIC WORKS ENGINEERING DIVISION July 31, 1992 UTILITY PERMIT AVAILABILITY /REQUIREMENTS Rogers Mobile Home 5218 South 144th Street Project No. P92 -0064 Contact Person: Charles R. Rogers Telephone No.: (206) 243 -2023 John W. Rants, Mayor Ross A. Earnst, P. E., Director THE FOLLOWING PUBLIC WORKS PERMITS ARE AVAILABLE FOR ISSUANCE ACCORDING TO THE SITE PLAN APPROVED ON JULY 31, 1992: Sanitary Side Sewer Disconnect Sanitary Side Sewer Reconnect (These are inspection fees) Permit Fee $20.00 $20.00 The Developer is referred to other City agencies, including the Building and Planning Divisions, for other requirements which may affect this work. The applicant shall fill out the attached Residential Sewer Use Certification Form and return the original to METRO with a copy for our files. , The permit for move on -site cannot be approved at this time since the schedule is not known. A copy of the confirmed Utility Permit Application Form and two (2) sets of site plans will be inserted into the permit file. cf: City Utilities Inspector (w /copy of plans /application) Development File (w /copy of plans /application) amc:14:Rogers 6300 Southcenter Boulevard, Suite #100 • Tukwila, Washington 98188 • Phone: (206) 433.0179 • Fax (206) 4313665 I " Municipality of Metropolitan Seattle Exchange Building • 821 Second Ave. • Seattle, WA 98104 - 1598 1 January 9, 1990 Mr. Ross Earnst Director of Public Works City of Tukwila 6300 Southcenter Boulevard Tukwila, Washington 98188 Metro Capacity Charge for New Sewer Connections Dear Mr. Earnst: I Ul {bViLA PUBLIC WORDS Metro Council Resolution No. 5719 establishes February 1, 1990 as the date after which all new sewer connections in the Metro service area will be subject to a capacity charge for metropolitan sewage facilities. This action follows Metro Council adoption of the final recommendations of the Rate Structure Advisory Committee (RSAC) in June, 1989 and transmittal of appropriate amendments to the agreements for sewage disposal to all participant agencies in September, 1989. As explained in the September 15 transmittal letter, the RSAC recommendations adopted by the Metro Council include the following proposed changes to Metro's charge structure: 1. Impose a charge on new customers and equivalents to help offset the cost of providing treatment capacity for them. This charge will be collected directly from new customers by Metro. 2. Change the residential customer equivalency value used to charge participants for non - residential customers from 900 cubic feet to 750 cubic feet. 3. Establish a level of annual expenditure for infiltration /inflow control for all participants at two cents per inch diameter per foot of local sewers exclusive of combined sewers and force mains. The above recommendations apply to all participants. In addition, the Committee made the following recommendations regarding the City of Seattle: 1. Seattle should pay Metro 50% of the rate relief it realizes because of the connection charge as payment towards the cost of Metro's combined sewer overflow control program. 2. Seattle should pay Metro the incremental costs incurred by Metro to transport and treat stormwater from retention facilities the City constructs to control combined sewer overflows. These recommendations, with the exception of the capacity charge, require amendment of the basic agreement for sewage disposal between Metro and each local agency Metro serves. As already noted, proposed amendments to the agreements for sewage disposal were transmitted to all participant sewer agencies in September. Letter to Mr. Earnst January 9, 1990 Page Two JFS:bha Enclosures John F. Spencer Director of Water Pollution Control Execution of the proposed agreement amendments with all participants may take six months or longer. Substantial growth will take place in the service area during that time. Staff estimates that 7,334 residential customers and equivalents will be added to the Metro system between January 1 and December 31, 1990. This equates to $9,240,462 in connection charges. Resolution 5719 insures that the new customers connected to the system after February 1, 1990 are subject to the charge although collection of the charge will probably not begin until all agreements are amended and the other recommendations can he implemented. In no event would collection begin before April 1, 1990 which is the earliest that Metro can have a billing system established. State law currently limits the Metro capacity charge to $7 per month per residential customer or equivalent for 15 years. It is anticipated that the Metro Council will establish the charge at that level. The charge, when imposed, will be collected directly from the customer by Metro based on information provided by local sewer service agencies. We have enclosed samples of forms to be completed by or on behalf of new sewer customers connected on or after February 1, 1990. Form A is to be used for residential customers including multi - family. Form B is to be used for non- residential customers whose capacity charge will be based upon projected residential customer equivalents determined on the basis of plumbing fixtures. We will provide you with a supply of printed forms prior to February 1. We are requesting that each city and district insure that the forms are completed, collected and transmitted to Metro within thirty days following the end of each calendar quarter. Some agencies may find the most expedient way to have the forms filled out is to make them part of their own sewer connection permit application process. The completed forms should be sent to: Local Agency Affairs Administrator Mailstop 82 Metro 821 Second Avenue Seattle, WA 98104 Metro staff plans to hold a workshop for local agency staff later this month to answer questions about implementation and administration of the capacity charge program. Please contact Robert Hirsch at 684 -1266 if you have any questions in the interim. Very truly yours, ullETRO Municipality of Metropolitan "cattle Exchange 13uilding • 821 Second Ave. • Seattle, WA 0 8I04 - 1598 January 26, 1990 Mr. Ross Earnst Director of Public Works City of Tukwila 6300 Southcenter Boulevard Tukwila, Washington 98188 Metro Capacity Charge Dear Mr. Earnst Enclosed please find an initial supply of forms for collection of information necessary for Metro's imposition of a capacity charge. As explained in John Spencer's letter dated January 9, 1990, all customers connecting to sewer systems served by Metro on or after February 1, 1990 will be subject to the charge. As also explained in the January 9 letter, the completed forms should be sent to: Local Agency Affairs Administrator Metro MS /82 821 Second Avenue Seattle, WA 98104 Please contact me at 684 -1266 if you have any questions. Very truly yours, Robert N. Hirsch. Local Agency Affairs Administrator RNH:ewa Enclosure 4 ‘ METRO Re ; lential Sewer Use Certifi cion (To be completed for all new sewer connections, reconnections, or change of use of existing connections. This form does not apply to repairs or replacements of existing sewer connections.) Pursuant to Metro Council Resolution Nos. 5719 and 5968, all sewer customers who establish a new service which uses metropolitan sewage facilities after February 1, 1990 shall be subject to a capacity charge. The Metro Council has established the amount of the charge at seven dollars ($7.00) per month per residential customer or residential customer equivalent for a period of fifteen years. The purpose of the charge is to recover costs of providing sewage treatment capacity for new sewer customers. All future billings can be prepaid at a discounted amount. (Please print or type) Owner's Name (Last, First, Middle Initial) Property Legal Address: Subdivision Property Street Address City, State, Zip Owner's Mailing Address (If different from above) Owner's Phone Number ( Party to be Billed (if different from owner) Party's Mailing Address (if different from above) City or Sewer District Date of Connection: Side Sewer Permit # Please check appropriate box: ❑ Single- family ❑ Duplex (0.8 RCE per unit) ❑ 3 -Plex (0.8 RCE per unit) ❑ 4 -Plex (0.8 RCE per unit) ❑ 5 or more (0.64 RCE per unit) No. of Units ❑ Mobile home space (1.0 RCE per space) No. of Spaces Plat x 0.64 = x 1.0 = Residential Customer Equivalent (RCE) 1.0 1.6 2.4 3.2 For Metro use :.• Account # • Monthly Rate Six Month Due For condominiums, please fill out Supplemental Form A In addition to this form. I certify that the information given is correct. I understand that the capacity charge levied will be based on this information and any deviation will require resubmission of corrected data for determination of a revised capacity charge. Signature of Owner /Representative Date Print Name of Owner /Representative 1057 (nev. 5191) Whito — Metro Yellow — Local Sower Agency Pink - Sewer Customer