HomeMy WebLinkAboutPermit B92-0320 - WHANG RESIDENCE - DEMOLITIONO
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,.
TO: Kim Hart, Finance
FROM: Shellie Bates, Permit Center _cgs
DATE: October 19, 1992
SUBJECT: Release of Bond
Please release the $2,000 bond to Ik Duk Whang. His demo permit
was approved to final on October 14, 1992. The original
transaction was September 16, 1992, Receipt #3432 for $2,060.
Please mail the check to the applicant at the following address:
Ik Duk Whang
16244 10th Avenue S.W.
Seattle, WA. 98166
Thank You!
1 ' • • .• . '
City of Tukwila
Department of Community Development
John W. Rants, Mayor
Rick Beeler, Director
6300 Soirthcnter Boulevard, Suite #100 Tukwila, Washington 98188 (206) 431-3670 • Fax. (206) 431-3665
• •
•
. • • ` • , „
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701) A. old r..c.cs I a? ; rtmv Kai So RECEIVED_
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— 0 _„ CITY OF TUKWILA
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City o Tlcakwid
Community Development / Public Works • 6300 Southcenter Boulevard, Suite 100 • Tukwila, Washington 98188
Permit No: B92 -0320
Type: B -DEMO
Category: RES
Address: 13508 MILITARY RD S
Location:
Parcel #: 734660 -0030
Wetlands:
Water Dist: N/A
Units: 001
Contractor License No:IDHOMB *216BW
TENANT WHANG IK DUK Phone: (206)244 -5954
16244 10TH AVENUE _ S.W;: ";'; SEATTLE ..
OWNER WHANG IK DUK ,:, (206)244 -5954
16244 10TH,, AVENE S.W. SEATTLE WA 98166;
CONTRACTOR I D HOME: BUILDER.: .Phone: 206 244 -5954
16244,10TH AVENUE S.W.,SEATTLE, WA
***************'** * * * * * *. * * ** * * * * * * * * * ** * * * * * * * **
Permit Descriplikbn Valuation: 500 00
ESIDE
Demoliti op' `,Fee
Cash';Aond:
2,000'.00
Bond Number: CHECK #1222y
**********;****.,0***********,******. * * * * **..# * * * * * * * * * * * * *.km * * * ** k * * * * * * * * **
DEMOLITION PERMIT
30::00
Slopes:
Sewer Dist: N/A
Buildings: 001
/investigation Fee:
.- .,Total Permit Fee.:
faado 4 ,
Permit Center
Date
examined the
t
or not.
(206) 431 -3670
Status: ISSUED
Issued: 09/16/1992
Expires: 03/15/1993
.00
;030.00
same to Ub'e, tr=ue � correct. /All /A-ll provisions of law and ordinances
governi - th- is� will 1 'be' ` co'mplied with whether• specif_;ied herein
The granting f ,;thi .m
s . permit does not presume to° author ,to violate
or cancel' the ,,pro,visions of any other; state +:loca;l laws 'regula4ng
construct1on' the performance of work. L'am 'authori'zed to sign:.;:for an
obtain this permit.
Signature -amt
Print Name:
Date
Title: f
This permit shall bed() ' nul and void,if th'e work; is .:n'ot commenced within
180 days from the date of 1 or if the work pis suspended or
abandoned for a period of 180 days ?wfrom tithe ;lastw''inspection.
PERMIT NO.
CONTACTED
yy�
DATE READY
DATE NOTIFIED
t.
(init.) ,-.2LE3
BY:
(init.)
PERMIT EXPIRES
2nd NOTIFICATION
AMOUNT OWING
3° •
3RD NOTIFICATION
BY:
(init.)
PLAN CHECK
NUMBER
S c la -
PROJECT NAME
SITE ADDRESS
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)
PLCOR
OCC.
LOAD
SQUARE
FEET
OCC.
LOAD
SQUARE
FEET
SQUARE
FEET
000.
LOAD
SQUARE
FEET
OCC.
LOAD
TOTAL
...................
...................
SQUARE
OCC.
L• D
TOTAL
*UA E
DEPARTMENTAL REVIEW
"X" in box indicates which departments need to review the project.
O PLANNING
(k1 PUBLIC
WORKS
O OTHER
�• ' ► 'Trsii:
BUILDING -
Initial review
BUILDING -
final review
INIT:
CONSULTANT: Date Sent -
VIR All E S : IS�Nd 5 f �T . .
FIRE PROTECTION: ■ S. rinklers
FIRE DEPT. LETTER DATED:
Date A
Detectors
INSPECTOR:
BAR/LAND USE CONDITIONS?
UBC EDITION (year):
.................. .
•
REVIEW COMPLETED
t3 000 91c ry
( BUILDING' ?ERMIT
APPLICATION TRACKING
L1icrrc , k
3 0�� X111rtur Rd, 5
ZONING:
REFERENCE FILE NOS.:
MINIMUM SETBACKS: N-
UTILITY PERMITS REQUIRED? ) Yes No
PUBLIC WORKS LETTER DATED:
TYPE OF CONSTRUCTION:
SUITE NO.
roved -
S- E- W-
TOTAL
OCC LO D
SITE ADDRESS
l3So ? m;ii1ely
SUITE #
D 56
-- .1<
g U Addition U Tenant Improvement
❑ Reroof ❑ Remodel (residential)
VALUE OF CONSTRUCTION - $
law ,Z
ASSESSOR ACCOUNT #
2 3 V.660 -- 00,50 -- o 9
(commercial) (X.1 Demolition (building)
❑ Other
PROJECT NAME/TENANT
W h U•Ytc
TYPE OF ❑ New Buiidf
WORK: ❑ Rack Storage
DESCRIBE WORK TO BE DONE:
(7110 / ; - a
BUILDING USE (office, warehouse, etc.)
144 (f h-Q--
NATURE OF BUSINESS: - 37e 1^ d IL7 ; I
WILL THERE BE A CHANGE IN USE? ❑ No 4 Yes I Yes, new building requirements may need to be met. Please explain:
f
I-U114 r R. Af•. thaSt A K ahI-4 + 111/17■E i 41oUs -e_
SQUARE FOOTAGE -
Building: v d 4 f Tenant Space: Area of Construction:
OR USE OF FLAMMABLE, COMBUSTIBLE OR HAZARDOUS MATERIALS IN THE BUILDING?
EXPLAIN:
WiLL THERE BE STORAGE
Z No ❑ Yes IF YES,
PROPERTY OWNER k 000S utf h "
PHONF�
_ T195 , 1 4
ZIP V/64
ADDRESS 1 b2 4 q, to -t /, 41/4j € £;
•tf' (,t/
_,_(,
CONTRACTOR i 17 140-14,.‘‹ 4 L, ! , -t. r
PHONE
ADDRESS �' -i��. ( Cf- h A -e c �,t,J_
5j•�'l� 1t�q
ZIP �e' /d
WA. ST. CONTRACTOR'S LICENSE # .- ,p N C M ►s
.211, Y3 LJ
EXP. DATE 3 _ _ /
ARCHITECT
PHONE
ADDRESS
ZIP
CITY OF TUKWILA
Department of Community Development - Building
.6300 Southcenter Boulevard, Tukwila WA 98188
(206) 431 -3670
PLAN CHECK
NUMBER
BUILDING OWNER
OR
AUTHORIZED
AGENT
t HEREB.
BE TRUE:AND .CORRECT, AND I
SIGNATURE
H,
VEi
PRINT NAME )‹.
ADDRESS
DATE APPLICATION ACCEPTED
OTHER:
READ AND::EXAMiNE
..................... ...............................
A D TO A
CONTACT PERSON k ;A) vk W \an
BUILDINva PERMIT
APPLICATION
Division
DESCRIPTION:
BUILDING: PERMIT FEE....
PLAN :CHECK FEE
o i K ° ul i-1- /N•
BUILDING SURCHARGE:
AMOUNT: .
DATE APPLICATION EXPIRES
CITY/ZIP
PHONE
RCPT < #
DATE
DATE
PHONE $ ,S /
APPLICATION SUBMITTAL In order to ensure that your application i 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 authrrizing 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.
COMMERCIAL
Specification
Structural calculations stamped 6y aWashington State licenser
engineer
Soils report stamped by a .Washington State licensed engineer
Topographical survey
Energy calcufations;stamped by a Washington
engineer or architect
Legal description
• Entire space where racks
• Exit doors
Dimensions of all :aisles
Workin drawings stamped by a Washington: State1icensed
a which include.
Site plan
Architectural drawings
Structural : drawings
Mechanical drawings
Elevations
Oiyil drawings
Landscape; plan
- Completed utility permit application;(ono for entire project)
- Six'(6) sets of ciwi drawings
NOTB ;See utrliry permit application and checklist for specific utili
submittal. requirements . : :... ; .
storage layout;;
:structure
Assessor Account Number
Two sets (2) of working drawings, which include
Site plan .o��� (pn plan show closest hydrant locatlort
Foundation plan Tnciudeacxoss tohutlding showlg
Floor': plan width and langrh of access ;
•, Roof "plan
• Building elevations (all views)
Building cross section::
•Struc framing pla
Washington State Energy Code data;
Completed utility permit application •
REROOF
r Completed building perrnit appiication
Assessor Account Number
Narrative describing existing
aterial ;being installed:::
NOTE .4 ceiirficatroriaetter is required onor to'fnar inspe arid,%
011 of the permit
ANTENNA/SATELI.ITE DISHES
n
C ompleted building permi(applicati on
Assessor Account Number
Two (2) sets of plans, which include,
n Site Plan (showing building and location of antenna/satellite
antonna/satetlite dish and method of attachme .:
00 fng0f) State liter
Completed building permit application
Assessor Account Number
Two (2) sets of working drawings, whichinciu
material; being
structure
for each structure
rovtde utihry permit epplicatig;
NEW COMMERCIAL
Completed building permit application (one tor each structure;
Assessor :Accourft Num
Tenant Space limit. :plan showing: rack,
NOTE::. Include dimensions of racks lharght, width and length);
and exit ways on plan
Structural caiculatlons stamped by a Washington State license
engineor(rack storage 8 an over):;
RESIDENTIAL
NEW SINGLE FAMILY DWELL INGS /ADDITIONS
Completed building permit application
sots;of site plans showing
NOtE Building site plan' and utility site planmay contb1rred '.S....
utility perrrilt application and checklist for specific submlital requirements
Additional topographlcal and sods rnformahon may be required it unique
;site:condltions
SUBMITTAL CHECKLIST
• Location of tenant, space
• Existing cf and propo sed parkin
Landscape plan (if applicable, i e ,,change of use)
Overall building plan
• Tenant location'
Use adjacent (common wall) tenant
• Overall dimensions of buliding or square footage
Floor plan of proposed tenant space
• Tenant space plan with use of each roo labelled:'.:`;
Exit doors, egress patterns:
New walls, existing wall; and walls to be donioUShed;
Construction details
B ros s sections showing wall constructlor and method o1
attaohment for floor and ceiling
l :Structural calculations stamped by a Wangton State license
engineer may be required if structural wor is to be done (2 sal
TE 1 eriy uLhty work Is to be done, submit separate utility p errji,
•
epplicahon end plans:
RESIDENTIAL REMODEL
COMMERCIAL TENANT:IMPROVEME
Completed building permit application
tenant)
Assessor Account:
wo (2) sets of construction plans „which
Site pia
... plan
Foundation pia
l pla
• o of Flan .
uiiding,elovations (all wows
adding ,cross section
iructural framing plans
NOTE 11 any.utility work is to
and; plans'rrrust:be :stibrrilttei
:Completed building permit application:
ssessor AccOtinC:Ni m
,native describing existing roof, material barn
aterlat :being installed
NOTl: A ca rtl ficatrop letter Is roqulrod prior to final inspection ark
oil dl the permit : ;. ,
L i Cnat Pro
gn intr: - (rn ae: 7 0 ( - W 1 A7
rn ae 2. w i . hq 6 Ades L, I Od :2... ,-.- L- C
7/ Q" / hn: 2- 51.
ae Apiain Acpe: 9 _ %- Cc aeApiain Eprs % - '3
PROJECT , ..• Site Address: /" 1 9 c `d 6 v y n.
INFORMATION Name of Project: /4±1-/r4(7 (S /)Er7,?)
Pro ert Owner: "7-7:- )(.." D 0 iVJ Phone No.: 2.
Street Address:
Engineer:
Street Address:
Contractor:
Street Address:
King Cty Assessor Acct #:
PERMITS 0
REQUESTED
4/€2
VA TS
0
0
0
DESCRIPTION OF PROJECT
City of Tukwila
Central Permit S. n Engineering Division
6300 Southcenter Blvd., Suite #100, Tukwila„ WA 98188
0 Multiple-Family Dwelling El Hotel
No. of Units: D Mot&
LI CommerciaUlndustrial
MISCELLANEOUS
INFORMATION
0 Office
0 Retail
0 New Building
Square
Footage:
UTILITY PERMIT APPLICATION
0714 A-0 .42 !:;.t 4.cyi
trvh-e i,H
.(
Q. ue .
O Duplex
O Triplex'
O Warehouse
O Manufacturing
2C
Contractors License #:
Channelization/Striping/Signing
Curb Cut/Access/Sidewalk
Fire Loop/Hydr. (main to vautt) - 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.:
Single-Family Residential
Application 4
O Apartments
O Condominiums
pc)Q- (Di I
Phone: (206) 433-0179
5
Cs
•/ City/State/Zip: q /
Phone No.:
City/State/Zip:
Phone No.:
City/State/Zip: C
Exp. Date:
O Sewer Main Extension 0 Private
O Storm Drainage
o Street Use
O Water Main Extension OPrivate
O Water Meter/ Exempt: - No.:
Deduct 0 Water Only 0
O Water Meter / Permanent - No •
O Water Meter/ Temporary:- No •
Estimated quantity:
Schedule:
o Other:
• Public
O Public
Sizes*
Sizes**
Stzes:_
WATER M •"!:::: Name: *-G i; Q tit p, tk, 14144\1 (7
DEP.os.i
:.REFUND/BLLING : Street Address: brt ix ,2 ; ui City/State/Zip:
:::rs.i1Q.N.Ii4:JV:f::::' :;.:
SERVICE Name: ... g w \b-4p4 ( Phone No.: 2,14 .._g.f75
-;:;:oii: v .. ;;
: :: Street Address: 1 , .,2,„(.3.q , . r (y1+ P.,.U. C7.0/ , City/State/Zip:
ES,water ewer 0 Metro 0 Standby
Phone No.:
0 Other:
0 Church 0 School/College/University
0 Hospital 0 Other:
paemodel/ Square footage of original building space:
Addition
7.1 Square footage of additional building space:
Applicant/Authorized
04/22/92
r************ A.#4s.******* * ** /14 *k * **k * *** *** ** * **44* * * * ***** * ** ** * ._ ...
;ITV 'OP': TUKWILAI WA TRANSMIT.
t * * ****.k* .ka' * **4(* * * ** k:*: * *,.* *.**** k***** k **** * *k *; *k *, *k **. *4, ** *k: * * * *
TRANSMZr: Number: .: 92000992'''Amount: 030.00 03/.16/92 08,:5
Permit NO: . : ' 092•0320. Type: '13 DEMO 'DEMOLITION PERMIT
Patt^oe1. No: 7346b0- x.0.030 , :.
.G1.tc ;Addrpss..' MILITARY RD. S
Patymant Method: CHECK . NatHtiarir 1 0 ; HOME 'OUZLDER Xn 'WL
4 : * *. * *vk, * * **** irk * * *4 * * * * **k * * * ,k * * *k*k k* t *k **k * * *.k *k * *i* * * *k* * ***h
gccdur�t.';Code OEs�icr^i ptfiurt.. . Pei d
000/322;:100 OUILOING. -- REa
SU]:LDTNG BOND/DEPOSIT 2,000.00
Total (Thia 'Payment): .2,030.00
GENERA 30.00
GENERA 2000.00
GENERA 30.00
TOTAL 2f0L6f0► 100
CHECK �' .: 2060.00
CHANGE. 0.00
3432A000 :'14 :46
30.00
Permit No: 892 -0320
Status: ISSUED
Applied 09/08/1992
Issued: 09/16/1992
********** •k** * **** ** * ** * ** * ** * * **** k*** *k * *•k * **kk* * ** *** **•k **kkk* *k fr * *k **
Permit Conditions:
1. DEMOLITION ACTIVITY SHALL BE LIMITED TO WITHIN 10' OF THE
BUILDING EXTERIOR. THE SEWER LINE SHALL BE CAPPED OUTSIDE
OF THE 10' DEMO LIMIT.
2 No changes wi 11 be made - to the =`Y p�,1 ns� u l ss by the
Architect and the Tu �wi la` °Buildi Di v 'i °shah .
All permits, inspeot :oh records, and approved»,p l ns shall be
maintained ava1,) tb%ie h °e at, t" e , bb s e priori to th start of
any constr�uct� o1i Tset d oc unents. ar? to ib , mainta;i�vied
ava i l abl e u , 0 flgia; aspect i on, approval �i s ,,,gr ,
C y 4 �'� 11i - Gt' 4p '"� F"•, {..' ov
d `� < ''Mj,
All const cat 10 to a dope 'i'n' `conf'orrmance wi the app ed�
„, ,,, � � ,. e 4 A �, �, gip, b�'�.1• ,
plans an , equ�i re na ts. of the4�� J1rS i orni Bu i ?Mpg ng C,o (1991
Edition o es a�`nnended e by the Via .Mate. Bu,i Code,
. Val i d i .y! of Permit. The �,i A ubnce off" a permit of a p rova l }i
plans, pe ificati�ons and computations shall not be con-
strued/co b r
e a pemit, or an,,,.approval of, any "vio�ia,t�ion \
of i i of 'the prov i s i o "s, of t it "codes or of any other "�� w :� ,, '}
ordl nea ,the jurisdi'ctio ,; No'..pe+mlt presuming to g {' ve
au it or veto1aWar`ju:`ganc l the , 0r, '�vls•10.ns of this code
sha.1 be'vali6'. �, ' " `" , { � 1 .V
Address: 13508 MILITARY RD'S
Tenant: WHANG IK DUK
Type: B -DEMO
Parcel #: 734660 -0030
CITY OF TUKWILA
•
Project: � t..., „ n� ' �� �
ype o nspeclwr�
Date Called: y _ , 13
1
Address: t 3 � rn k n �
C � J ` . �
Special instructions: %....)
Date Wanted: �
LO - I L I' qa
pp.m.
Requester: �-1 Wha n
Phone No.:
INSPECTION RECORD d r
Retain a copy with permit
CITY. OF TUKWILA BUILDING DIVISION
6300 Southcenter Blvd., #100, Tukwila, WA 98188
14 Approved per applicable codes.
COMMENTS:
CI Corrections required prior to approval.
PERMIT N0.
(206) 431 -3670
C7 $30,00 REINSPECTION FEE REQUIRED. Prior to reinspection, fee must be paid at
6300 Southcenter Blvd :, Suite 100. Call to schedule reinspection.
COMMENTS:
a.m. - 5 frc: Is A 64 7x-As10 w(73.1
oz.aps (c..6,,,c. s-i-tia;ces, poit5 , wool') A h-119 A.5.5041
Fr 61/4E/cast itcrrlic &hoe gAmcger Otes
TiLE
j odtm■Fr... Is p t ic p 4 5Th1/4:.-v\ . 51
eg: c.ac4-re 1 2 4 , Plvt- evATc- m er7t- /S Azi
sr
ill L (Ai A t t, a er6 I \i'lrri Ft 07 71) CL/4 NI (A,
THE S re li r4=0 Cm-i- r c A- 1 Ns ?C s 5 v3 . NE
HA-3 A SE 1 4 ti,.. CAP • Docti 141 czrrrr.
- ,
A.
j jk.....3) , A..k. _
i ype 9t pectiol \ik.....)
Date C led:_
9 - <3
R- GL S
at
Special Instructions:
Date Wantedi , 0, Li _13 ?.. ...
kaai p.m,
Requester:
Phone No.:
INSPECTION RECORD,
Retain a copy with permit
'CITY OF TUKWILA BUILDING DIVISION
6300 Southcenter Blvd., #100, Tukwila, WA 98188
(206) 431-3670
0 Approved per applicable codes. Corrections required prior to approval.
o $30.00 REINSPECTION FEE REQUIRED. Prior to reinspection, fee must be paid at
6300 Southcenter Blvd., Suite 100. Call to schedule reinspection.
Recept No,:
Date:
.r lit 5'acrr f 1 °F Ld? z fin/ 8 -ook - ° F Li? / i/c,n7d � i �� ` -cX
l P.V A p 4r9.7 Re arse RE: p Al . v of GlM= or /44-r5
1 foci Rte- F l'r-'17 C,ccr,Ur y
C
Cheek approvals are
Plan s an d approval e
I understand t o errors t hat the o mission o { any
ect to erro and violation of
con -
plans authorize the iol a i
,lens adopted c not ordinance• iedged.
t (acr' code or . roVed plan a cknowle d g ed.
�� actor's copy of app
RECEIVED
CITY OP T1.1KWIJ.A
SEP 0 8 1992
PERMIT CENTER
rt
•
•t/i'L Sa cr rlf k of L. z fir/ 9i c k' z
l Pik 0 4.41 Re o/ ,2 Ver.Gemz ci 4 ,•5
p/4-0Z / R c cn2s OF (7 C-ocpur
y.
T
—
L I
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° F '1 tier *mf S
Dk7"•14L /T /o.N 4qc, ', y
!✓/`1/7 0 y/77iY/N bra'
GQ1J /Z.PM/ . �r'xrE, /eA
S.474YER .4 /NS c W7 r.,DE" T� /s
//7ir
RECEIVED
CITY OF TUKWIIA
SEP 0.81992
PERMI CENTER ; `.
PRIMARY �� •;.,
® k INSURANCE) The INSURAN hange or Company shown on the reverse side as number
( ExcESSCE ) Excess over Primary with Company shown on reverse side as number
(
THIS IS NOT AN INSURANCE POLICY. THIS IS ONLY A VERIFICATION OF INSURANCE. IT DOES NOT IN ANY WAY AMEND, EXTEND OR
ALTER THE COVERAGE PROVIDED BY THE POLICIES LISTED BELOW.
Named , IK DUK WHANG
Insured • D I D HOME BUILDER
Address 16244 — 10TH AVE SW
SEATTLE WA 98168
We certify that .policies for the above Named Insured are in force as follows:
Effective from: 10 -10 -92 to:
certificate becomes ❑ VOID or C continuous until cancelled. (Box "X'd" applies).
COMMERCIAL GENERAL LIABILITY COVERAGE
COVERED NOT COVERED
Ids ❑ PREMISES /OPERATIONS
❑ PRODUCTS - COMPLETED
OPERATIONS
WORKERS' COMPENSATION
COVERED NOT COVERED
❑ QQ STATUTORY
AUTO and /or GARAGE LIABILITY COVERAGE
❑ DEALERS (Plan I) ❑ NON- DEALERS (Plan II)
COVERED NOT COVERED
❑ ® Owned
❑ El Hired
❑ 1 Non -Owned
Single Limit Liability for Coverages checked El above.
COVERED NOT COVERED
❑ al Cargo
Described Description
OWNED ❑ below L...1 waived
AUTOS
IF
COVERED
UMBRELLA LIABILITY
Umbrella Liability
POLICY NUMBER
c E, TINKC;A'I t AS I O tVII[DENCE OF I ►,.'UHANCE
x c
COMBINED PRIMARY & EXCESS LIMITS OF INSURANCE
GENERAL AGGREGATE LIMIT (Other
Than Products - Completed Operations) $
PRODUCTS - COMPLETED OPERATIONS
AGGREGATE LIMIT $
PERSONAL & ADVERTISING INJURY LIMIT$
200,000
200,000
BI -PD OCCURRENCE LIMIT $ 200,000
FIRE DAMAGE LIMIT $ 50,000
MEDICAL EXPENSE LIMIT $ 5 , 000
EMPLOYER'S LIABILITY INSURANCE LIMITS
BODILY INJURY BY ACCIDENT $ each Accident
BODILY INJURY BY ACCIDENT $ each Employee
BODILY INJURY BY ACCIDENT $ Policy Limit
Bodily Injury
YEAR, MAKE, TYPE OF BODY, LOAD CAPACITY
2
Excess Policy or Certificate Number
79 42 310 034R2 64 71
Agent Policy Number
200,000
COMBINED LIMITS OF PRIMARY & EXCESS INSURANCE
Property Damage
Aggregate Limit
(Garage Plan Only)
$
$
at `which time this
ANY ONE FIRE
ANY. ONE PERSON
,000 each person
,000 each Accident
,000 each Accident
•,000'
$ NIL ,000 each Accident
,000 each Vehicle
,000 each occurrence
IDENTIFICATION NUMBER
,000 retained limit
,000 each occurrence
,000 aggregate
Upon cancellation or termination of this policy or policies from any cause we will mail 10 days written notice to the
other interest shown below.
Notice of cancellation of the primary coverage automatically terminates excess coverage.
Certificate Issued To: ATTN: SHELL' E
Name , CITY OF TUKWILA Count fined "--
and • 6300 SOUTHCENTER BLVD SUITE 100 A ` ' X)0 , •
Address • TUKWILA WA 98188 BY
Authorizer Represeri a
OHIO Only: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an i rer, submits an application or
files a claim containing a false or deceptive statement is guilty of Insurance fraud.
This Certificate sunersedes anv nreviously issued certificate. /)1.
Date
POLICY NUMBER: 03482 64 71
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ. IT CAREFULLY.
ADDITIONAL INSURED OWNERS, LESSEES OR
CONTRACTORS •(FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person or Organization: CITY OF TUKWILA
COMMERCIAL GENERAL LIABILITY
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the
Schedule, but only with respect to liability arising out of "your work" for that insured by or for you.
CG 2010 11 85 : Copyright,. Insurance Services ' Office. Inc.; ,19,P4