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HomeMy WebLinkAboutPermit PG10-164 - MARTINEZ RESIDENCEMARTINEZ RESIDENCE 3207 S 136 ST EXPIRED I1 -19 -11 PG1O-164 City olikfukwila • Department of Community Development 6300 Southcenter Boulevard, Suite #100 Tukwila, Washington 98188 Phone: 206 - 431 -3670 Inspection Request Line: 206 - 431 -2451 Web site: http: / /www.ci.tukwila.wa.us Parcel No.: 8864000285 Address: 3207 S 136 ST TUKW Project Name: MARTINEZ RESIDENCE PLUMBING /GAS PIPING PERMIT Permit Number: PG10 -164 Issue Date: 11/30/2010 Permit Expires On: 05/29/2011 Owner: Name: MARTINEZ HERMINIA G Address: 3207 S 136TH ST , TUKWILA WA 98168 Contact Person: Name: DAVID KALLANDER Address: 4014 61 AV E , FIFE WA 98424 Email: DAVID @RANGERHEATING.COM Contractor: Name: RANGER HEATING & COOLING LLC Address: 4014 61 AV S , FIFE WA 98424 Contractor License No: RANGEHC905OM Phone: 206 913 -1123 Phone: 206 913 -1123 Expiration Date: 09/14/2012 DESCRIPTION OF WORK: INSTALLATION OF (4) GAS PIPE OUTLETS REVISION #1: WATER TANK RELOCATION Value of Plumbing /Gas Piping: $2,500.00 Uniform Plumbing Code Edition: 2009 Fees Collected: $143.85 International Fuel Gas Code Edition: 2009 Permit Center Authorized Signature: I hereby certify that I have read and e governing this work will be complied ami ith, Date: t 24 i 1 La ed this permit and know the same to be true and correct. All provisions of law and ordinances hether specified herein or not. The granting of this permit does not presume to give authority to violate or cancel the provisions of any other state or local laws regulating construction or the performance of work. I am authorized to sign and obtain this plumbing /gas piping permit and agree to the conditions on the back of this permit. Signature: Print Name: l )� Date: (Z ((--s Lo t I L-L-A-Ni O - 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. doc: UPC -4/10 PG10 -164 Printed: 12 -13 -2010 PERMIT CONDITIONS Permit No. PG 10 -164 1: ** *PLUMBING AND GAS PIPING * ** 2: No changes shall be made to applicable plans and specifications unless prior approval is obtained from the Tukwila Building Division. 3: All permits, inspection records and applicable plans shall be maintained at the job and available to the plumbing inspector. 4: All plumbing and gas piping systems shall be installed in compliance with the Uniform Plumbing Code and the Fuel Gas Code. 5: No portion of any plumbing system or gas piping shall be concealed until inspected and approved. 6: All plumbing and gas piping systems shall be tested and approved as required by the Plumbing Code and Fuel Gas Code. Tests shall be conducted in the presence of the Plumbing Inspector. It shall be the duty of the holder of the permit to make sure that the work will stand the test prescribed before giving notification that the work is ready for inspection. 7: No water, soil, or waste pipe shall be installed or permitted outside of a building or in an exterior wall unless, adequate provision is made to protect such pipe from freezing. All hot and cold water pipes installed outside the conditioned space shall be insulated to minimum R -3. 8: Plastic and copper piping running through framing members to within one (1) inch of the exposed framing shall be protected by steel nail plates not less than 18 guage. 9: Piping through concrete or masonry walls shall not be subject to any load from building construction. No plumbing piping shall be directly embedded in concrete or masonry. 10: All pipes penetrating floor /ceiling assemblies and fire - resistance rated walls or partitions shall be protected in accordance with the requirements of the building code. 11: Piping in the ground shall be laid on a firm bed for its entire length. Trenches shall be backfilled in thin layers to twelve inches above the top of the piping with clean earth, which shall not contain stones, boulders, cinderfill, frozen earth, or construction debris. 12: The issuance of a permit or approval of plans and specifications shall not be construed to be a permit for, or an approval of, any violation of any of the provisions of the Plumbing Code or Fuel Gas Code or any other ordinance of the jurisdiction. doc: UPC -4/10 PG10 -164 Printed: 12 -13 -2010 City oftukwila Department of Community Development 6300 Southcenter Boulevard, Suite #100 Tukwila, Washington 98188 Phone: 206 - 431 -3670 Inspection Request Line: 206 - 431 -2451 Web site: http: / /www.ci.tukwila.wa.us Parcel No.: 8864000285 Address: 3207 S 136 ST TUKW Project Name: MARTINEZ RESIDENCE PLUMBING /GAS PIPING PERMIT Permit Number: PG10 -164 Issue Date: 11/30/2010 Permit Expires On: 05/29/2011 Owner: Name: MARTINEZ HERMINIA G Address: 3207 S 136TH ST , TUKWILA WA 98168 Contact Person: Name: DAVID KALLANDER Address: 4014 61 AV E , FIFE WA 98424 Email: DAVID@RANGERHEATING.COM Contractor: Name: RANGER HEATING & COOLING LLC Address: 4014 61 AV S , FIFE WA 98424 Contractor License No: RANGEHC905OM Phone: 206 913 -1123 Phone: 206 913 -1123 Expiration Date: 09/14/2012 DESCRIPTION OF WORK: INSTALLATION OF (4) GAS PIPE OUTLETS Value of Plumbing /Gas Piping: Fees Collected: $1,500.00 $96.60 Permit Center Authorized Signature: . 0■1 I hereby certify that I have read and governing this work will be complied x ith Uniform Plumbing Code Edition: 2009 International Fuel Gas Code Edition: 2009 Date: ned this permit and know the same to be true and correct. All provisions of law and ordinances whether specified herein or not. The granting of this permit does not presume to give authority to violate or cancel the provisions of any other state or local laws regulating construction or the performance of work. I am authorized to sign and obtain this plumbing /gas piping permit and agree to the conditions on the back of this permit. Date: I ( `( 0 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. doc: UPC -4/10 PG 10 -164 Printed: 11 -30 -2010 PERMIT CONDITIONS Permit No. PG 10 -164 1: ** *PLUMBING AND GAS PIPING * ** 2: No changes shall be made to applicable plans and specifications unless prior approval is obtained from the Tukwila Building Division. 3: All permits, inspection records and applicable plans shall be maintained at the job and available to the plumbing inspector. 4: All plumbing and gas piping systems shall be installed in compliance with the Uniform Plumbing Code and the Fuel Gas Code. 5: No portion of any plumbing system or gas piping shall be concealed until inspected and approved. 6: All plumbing and gas piping systems shall be tested and approved as required by the Plumbing Code and Fuel Gas Code. Tests shall be conducted in the presence of the Plumbing Inspector. It shall be the duty of the holder of the permit to make sure that the work will stand the test prescribed before giving notification that the work is ready for inspection. 7: No water, soil, or waste pipe shall be installed or permitted outside of a building or in an exterior wall unless, adequate provision is made to protect such pipe from freezing. All hot and cold water pipes installed outside the conditioned space shall be insulated to minimum R -3. 8: Plastic and copper piping running through framing members to within one (1) inch of the exposed framing shall be protected by steel nail plates not less than 18 guage. 9: Piping through concrete or masonry walls shall not be subject to any load from building construction. No plumbing piping shall be directly embedded in concrete or masonry. 10: All pipes penetrating floor /ceiling assemblies and fire - resistance rated walls or partitions shall be protected in accordance with the requirements of the building code. 11: Piping in the ground shall be laid on a firm bed for its entire length. Trenches shall be backfilled in thin layers to twelve inches above the top of the piping with clean earth, which shall not contain stones, boulders, cinderfill, frozen earth, or construction debris. 12: The issuance of a permit or approval of plans and specifications shall not be construed to be a permit for, or an approval of, any violation of any of the provisions of the Plumbing Code or Fuel Gas Code or any other ordinance of the jurisdiction. doc: UPC -4/10 PG 10 -164 Printed: 11 -30 -2010 CITY OF TUKWII* Community Development Department Permit Center 6300 Southcenter Blvd., Suite 100 Tukwila, WA 98188 http://www.ci.tukwila.wa.us Plumbing/Gall/Inuit No. ("11 _ Q� Project No. (For office use only) PLUMBING / GAS PIPING PERMIT APPLICATION Applications and plans must be complete in order to be accepted for plan review. Applications will not be accepted through the mail or by fax. * *Please Print ** SITE LOCATION King Co Assessor's Tax No.: Site Address: zi Zvi S I; ,fk ST• Suite Number: Tenant Name: . r•10,04ALt (0/(/4 NA -4vj / N Z New Tenant: Property Owners Name: W-wt (NIA V - tt.TfiV S Mailing Address: Ztfl 5. / 36744 ST- Floor: ❑ Yes ❑ .. No -%U%!.v(c.4 City Gu-tek- State Zip CONTACT PERSON — Who do we contact when your permit is ready to be issued Name: r 0 KA -u.44NO 06— Mailing Address: 4(0/y (a a' e E -Mail Address: ?Y-N ( f 4A/t4 a R../ / f .- . CO ✓t'1 Day Telephone: ZO(o . , ((Z g City State Zip Fax Number: 0 - 1-(C(9. Z7 7? PLUMBING / GAS PIPING CONTRACTOR INFORMATION Company Name: 144/\/Cc1,C1_ - (T.�C1.0:7A'4 I Coo (...4 r i Mailing Address: `17(tt ((( 6 0 Contact Person: 7) AL/CI /Cfvl rL E -Mail Address: t,Av (d) (C ixi--".G q /Z- 14-e7-r r/'f . CO w1 Contractor Registration Number: gliAlCk c f -c.. q W C-O v`-1 Fea City Day Telephone: Fax Number: (,t44 State u0(0- 9(s. zoo. -co . 78cY / Expiration Date: D `t ( Z O ( Z ARCHITECT OF RECORD — All plans must be stamped by Architect of Record Company Name: Mailing Address: City Contact Person: Day Telephone: E -Mail Address: Fax Number: State Zip ENGINEER OF RECORD — All plans must be stamped by Engineer of Record Company Name: Mailing Address: City Contact Person: Day Telephone: E -Mail Address: Fax Number: State Zip H:\Applications\Forms- Applications On Line\2010 Applications \7 -2010 - Plumbing -Gas Piping Permit Application.doc Revised: 7 -2010 bh Page 1 of 2 Valuation of Project (contractor's bid prill $ t cDQ • Scope of Work (please provide detailed information): /N B loc -i1/7 o7V c-o V ri- Cy) Gow Building Use (per Int'l Building Code): Occupancy (per Int'l Building Code): Utility Purveyor: Water: Sewer: Indicate type of plumbing fixtures and/or gas piping outlets being installed and the quantity below: Fixture Type: Qty Fixture Type: Qty Fixture Type: Qty Fixture Type: Qty Bathtub or combination bath/shower Bidet Clothes washer, domestic Dental unit, cuspidor Dishwasher, domestic, with independent drain Drinking fountain or water cooler (per head) Food -waste grinder, commercial Floor Drain Shower, single head trap Lavatory Wash fountain Receptor, indirect waste Sinks Urinals Water Closet Building sewer and each trailer park sewer Rain water system — per drain (inside building) Water heater and /or vent Industrial waste treatment interceptor, including trap and vent, except for kitchen type grease interceptors Each grease trap (connected to not more than 4 fixtures - <750 gallon capacity) Grease interceptor for commercial kitchen ( >750 gallon capacity) Repair or alteration of water piping and/or water treatment equipment Repair or alteration of drainage or vent piping Medical gas piping system serving 1 -5 inlets/outlets for a specific gas Each additional medical gas inlets /outlets greater than 5 Backflow protective device other than atmospheric -type vacuum breakers 2 inch (51 mm) diameter or smaller Backflow protective device other than atmospheric -type vacuum breakers over 2 inch (51 mm) diameter Each lawn sprinkler system on any one meter including backflow protection devices Atmospheric -type vacuum breakers not included in lawn sprinkler backflow protections (1 -5) Atmospheric -type vacuum breakers not included in lawn sprinkler backflow protections over 5 Gas piping outlets t/ `1 PERMIT APPLICATION NOTES - Value of Construction — In all cases, a value of construction amount should be entered by the applicant. This figure will be reviewed and is subject to possible revision by the Permit Center to comply with current fee schedules. Expiration of Plan Review — Applications for which no permit is issued within 180 days following the date of application shall expire by limitation. The Building Official may grant one extension of time for an additional period not to exceed 180 days. The extension shall be requested in writing and justifiable cause demonstrated. Section 103.4.3 International Plumbing Code (current edition). I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION AND KNOW THE SAME TO BE TRUE UNDER PENALTY OF PERJURY BY THE LAWS OF THE STATE OF WASHINGTON, AND I AM AUTHORIZED TO APPLY FOR THIS PERMIT. BUILDING NER OR AUTHOKIZED AGENT: Signature: \ ,._) Print Name: (�f}V(O 4- c.441 -N p E, (t- Mailing Address: `/O /`"( (p(/r- Avg Cs Date: /(7.5b /(t) Day Telephone: ZO(0. c?' ( ' . / r Z 3 (3r GcA P ,9 `Ye `7' City State Zip Date Application Accepted: Date Application Expires: Staff Initials: H:\Applications\Forms- Applications On Line\2010 Applications \7 -2010 - Plumbing -Gas Piping Permit Application.doc Revised: 7 -2010 bh Page 2 of 2 Ci, of Tukwila, Department of Community Development 6300 Southcenter Boulevard, Suite #100 Tukwila, Washington 98188 Phone: 206 -431 -3670 Fax: 206 -431 -3665 Web site: http. /hvww. ci. tukwila. wa. us SET RECEIPT RECEIPT NO: R10 -02482 Initials: JEM Payment Date: 12/13/2010 User ID: 1165 Total Payment: 224.35 Payee: DAVID T KALLANDER, RANGER HEATING & COOLING SET ID: 1213 SET NAME: MARTINEZ RESIDENCE SET TRANSACTIONS: Set Member M10 -176 PG10 -164 TOTAL: Amount 177.10 47.25 177.10 TRANSACTION LIST: Type Method Description Amount Payment Credit C MC 224.35 TOTAL: 224.35 ACCOUNT ITEM LIST: Description Account Code Current Pmts MECHANICAL - RES 000.322.102.00.0 PLUMBING - RES 000.322.103.00.0 177.10 47.25 TOTAL: 224.35 • City of Tukwila Department of Community Development 6300 Southcenter Boulevard, Suite #100 Tukwila, Washington 98188 Phone : 206-431-3670 Fax: 206 - 431 -3665 Web site: http: / /www.ci.tukwila.wa.us Parcel No.: 8864000285 Address: 3207 S 136 ST TUKW Suite No: Applicant: MARTINEZ RESIDENCE RECEIPT Permit Number: PG10 -164 Status: APPROVED Applied Date: 11/30/2010 Issue Date: Receipt No.: R10 -02397 Initials: User ID: JEM 1165 Payment Amount: $96.60 Payment Date: 11/30/2010 12:59 PM Balance: $0.00 Payee: DAVID T KALLANDER, RANGER HEATING & COOLING TRANSACTION LIST: Type Method Descriptio Amount Payment Credit Crd MC Authorization No. B65575 ACCOUNT ITEM LIST: Description 96.60 Account Code Current Pmts GAS - RES 000.322.103.00.00 96.60 Total: $96.60 doc: Receiot -06 Printed: 11 -30 -2010 INSPECTION NO. CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd., #100, Tukwila, WA 98188 INSPECTION RECORD Retain a copy with permit 2-, (206)431 -3670 Project: I) k1.- Alh4„4,.O T P 'e./�J // /.. `✓a!� /1 -2.6 frZeZ.,/#4' 710 4P .-s-. ill Type of Inspection: Address: ' 3 7,97 � � Date Called: Special Instructions. p i e, 0- e-zer - r5/fr./2/ ,l,Pi..4,.L 0 v ," , ,� / ,0`s4, V-- Date Wanted: a.m. S- 2A0-"/ / Requester: Phone No: 7 do-9/3-//2,3 ❑ Approved per applicable codes. Corrections required prior to approval. COMMENTS: I) k1.- Alh4„4,.O T P 'e./�J // /.. `✓a!� /1 -2.6 frZeZ.,/#4' 710 4P .-s-. ill 'J�A/ c/ )r" .J 14-71,1A ,.f'h1/yJ 2,71/ 2) S.,,,,c„ --,o S o ./;e7 ,ae G 71" 4 - .4043/9 j', i j) S c eLeif uvH��.r.r _ 7211£ 4 .. , in fr-,, I.,,,// /.. ` (..,4S f'k"-/ 4 1) R,�,o t..� Ye, s s ,,4.-, 7 e,,., ,17�41-, p i e, 0- e-zer - r5/fr./2/ ,l,Pi..4,.L 0 v ," , ,� / ,0`s4, V-- 19e,ep_. 14,litz--4, _ ,,,'4 p r,'j it7Avoef r .I.,,4./..I.r/a`4_. InSpect'br: Date: II $60.00 REINSPECTIdfJ FEE REQUIRED. Prior to inspection, fee must be paid at 6300 Southcenter Blvd., Suite 100. Call to schedule reinspection. Receipt No.: Date: INSPECTION RECORD Retain a copy with permit INSPECTION NO. PERMIT NO. CITY OF TUKWILA BUILDING DIVISION{ 6300 Southcenter Blvd., #100, Tukwila. WA 98188 12— (206) 431 -3670 Permit Inspection Request Line (206) 431 -2451 PG(( -I(el • Proje tA , i �-� J` s o Typgo0 0 6�tt+- .—d-91 6 AC Address: $re7�sY:�e1� 5 t /31 Date Called: COMMENTS: Special Instructions: 04 (S 6 (/ 17 Date Wanted: Requester: , 0 Phone o/ / 3 _ I( 2-3 0 Approved per applicable codes. Corrections required prior to approval. COMMENTS: 3 0 , 0 G 1 9 „ , , , . . . . A l Inspec rM Date: 1Llcif>_(� n REINSPECTION FEE REQUIRED. Prior to next inspection. fee must be paid at 6300 Southcenter Blvd., Suite 100. Call to schedule reinspection.. City of Tukwila Jim Haggerton, Mayor Department of Community Development Jack Pace, Director DAVID KALLANDER 401461AVE FIFE WA 98424 RE: Permit No. PG10 -164 MARTINEZ RESIDENCE 3207 S 136 ST TUKW Dear Permit Holder: In reviewing our current records, the above noted permit has not received a final inspection by the City of Tukwila Building Division. Per the International Building Code, International Mechanical Code, Uniform Plumbing Code and/or the National Electric Code, every permit issued by the Building Division under the provisions of these codes shall expire by limitation and become null and void if the building or work authorized by such permit has not begun within 180 days from the issuance date of such permit, or if the building or work authorized by such permit is suspended or abandoned at any time after the work has begun for a period of 180 days. Your permit will expire on 11/19/2011. Based on the above, you are hereby advised to: 1) Call the City of Tukwila Inspection Request Line at 206 - 431 -2451 to schedule for the next or final inspection. Each inspection creates a new 180 day period, provided the inspection shows progress. -or- 2) Submit a written request for permit extension to the Permit Center at least seven (7) days before it is due to expire. Address your extension request to the Building Official and state your reason(s) for the need to extend your permit. The Building Code does allow the Building Official to approve one extension of up to 180 days. If it is determined that your extension request is granted, you will be notified by mail. In the event you do not call for an inspection and/or receive an extension prior to 11/19/2011, your permit will become null and void and any further work on the project will require a new permit and associated fees. Thank you for your cooperation in this matter. Sincerely, Bill Rambo Permit Technician File: Permit File No. PG10 -164 6300 Southcenter Boulevard, Suite #100 • Tukwila, Washington 98188 • Phone: 206 - 431 -3670 • Fax: 206- 431 -3665 05 -02 -2011 City of Tukwila Jim Haggerton, Mayor Department of Community Development Jack Pace, Director DAVID KALLANDER 4014 61 AV E FIFE WA 98424 RE: Permit No. PG10 -164 3207 S 136 ST TUKW Dear Permit Holder: In reviewing our current records, the above noted permit has not received a final inspection by the City of Tukwila Building Division. Per the International Building Code, International Mechanical Code, Uniform Plumbing Code and /or the National Electric Code, every permit issued by the Building Division under the provisions of these codes shall expire by limitation and become null and void if the building or work authorized by such permit has not begun within 180 days from the issuance date of such permit, or if the building or work authorized by such permit is suspended or abandoned at any time after the work has begun for a period of 180 days. Your permit will expire on 06/14/2011. Based on the above, you are hereby advised to: 1) Call the City of Tukwila Inspection Request Line at 206 - 431 -2451 to schedule for the next or final inspection. Each inspection creates a new 180 day period, , provided the inspection shows progress. -or- 2) Submit a written request for permit extension to the Permit Center at least seven (7) days before it is due to expire. Address your extension request to the Building Official and state your reason(s) for the need to extend your permit. The Building Code does allow the Building Official to approve one extension of up to 180 days. If it is determined that your extension request is granted, you will be notified by mail. In the event you do not call for an inspection and /or receive an extension prior to 06/14/2011, your permit will become null and void and any further work on the project will require a new permit and associated fees. Thank you for your cooperation in this matter. Sincerely, Bill Rambo Permit Technician File: Permit File No. PG10 -164 6300 Southcenter Boulevard, Suite #100 • Tukwila, Washington 98188 • Phone: 206 - 431 -3670 • Fax: 206 - 431 -3665 • City of Tukwila Department of Community Development 6300 Southcenter Boulevard, Suite #100 Tukwila, Washington 98188 Phone: 206 -431 -3670 Web site: http: / /www.ci.tukwila.wa.us REVISION SUBMITTAL Revision submittals must be submitted in person at the Permit Center. Revisions will not be accepted through the mail, fax, etc. Date: (Z- I (3 ( (O Plan Check/Permit Number: ❑ Response to Incomplete Letter # Response to Correction Letter # Revision # ( after Permit is Issued Revision requested by a City Building Inspector or Plans Examiner Project Name: Project Address: 5Z-0-7 S. (S "(04- ST_ -TJ L-V (LA Contact Person: Av c J lLe4 -t-L r3 •-v‘- Phone Number: ZOCo • `t (3 . ((Z Summary of Revision: AO r 0-No Of- r✓1-44 1-j/K (Z-434-0 Cr.49—k bJ —O OX I S'i7 A/1, PC-tJ a-c 6(0.\--c, f 6A-5 P(2(oet-G t'G r -a-r ( f--. anvgnitifett 'DEC 11 3• 2010 CFQ Sheet Number(s): - - -- "Cloud" or highlight all areas of revision including date of revision - = Received at the City of Tukwila Permit Center by: eV\' t21th \�� ❑ Entered in Permits Plus on H:Wpphcations\Forms- Applications On Lin62010 Applications \7-2010 - Revision Submittal.doc Created: 8 -13 -2004 Revised: 7 -2010 0. :l. -` -- 5.77-* Contractors or Tradespeople Plier Friendly Page • General /Specialty Contractor A business registered as a construction contractor with L &I to perform construction work within the scope of its specialty. A General or Specialty construction Contractor must maintain a surety bond or assignment of account and carry general liability insurance. Business and Licensing Information Name RANGER HEATING 8 UBI No. 603021557 COOLING LLC Phone 2069131123 Status Active Address 4014 61St Ave E License No. RANGEHC9050M Suite /Apt. License Type Construction Contractor City Fife Effective Date 9/14/2010 State WA Expiration 9/14/2012 Date Zip 98424 Suspend Date County Pierce Specialty 1 Heating /Vent /Air - Conditioning And Refrig (Hvac /R) Business Type Limited Liability Company Specialty 2 Unused Parent Company enses License Name Type Specialty 1 Specialty 2 Effective Date Expiration Date Status RANGEH`928RN RANGER HEATING Construction Contractor Heating /Vent /Air- Conditioning And Refrig (Hvac /R) Unused 12/15/2008 12/15/2010 Re- Licensed Business Owner Information Name Role Effective Date Expiration Date KALLANDER, DAVID THOMAS Partner /Member 09/14/2010 QUY, SEAN RYAN Partner /Member 09/24/2010 Bond Information Page 1 of 1 Bond Bond Company Name Bond Account Number Effective Date Expiration Date Cancel Date Impaired Date Bond Amount Received Date 1 Great American Ins. Co. 0763303 09/07/2010 Until Cancelled $6,000.00 09/14/2010 Assignment of Savings Information No records found for the previous 6 year period Insurance Information Insurance Company Name Policy Number Effective Date Expiration Date Cancel Date Impaired Date Amount Received Date 1 COUNTRY MUTUAL INS CO AM9069166 08/25/2010 08/25/2011 $1,000,000.00 09/14/2010 Summons /Complaint Information No unsatisfied complaints on file within prior 6 year period Warrant Information No unsatisfied warrants on file within prior 6 year period https : // fortress. wa. gov /lni/bbip/Pri nt. aspx 11/30/2010