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HomeMy WebLinkAboutPermit PG11-007 - DR BENCA DDSDR BENCA DDS 200 ANDOVER PK E PG1 1 -007 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 PLUMBING /GAS PIPING PERMIT Parcel No.: 0223100099 Address: 200 ANDOVER PK E TUKW Project Name: DR BENCA DDS Permit Number: PG11 -007 Issue Date: 01/28/2011 Permit Expires On: 07/27/2011 Owner: Name: ANDOVER PLAZA LLC Address: 1501 N 200TH ST , SHORELINE WA 98133 Contact Person: Name: LARRY BRYAN Address: PO BOX 534 , NORTH BEND WA 98045 Email: FALLSPLUMBING @YAHOO.COM Contractor: Name: FALLS PLUMBING INC Address: PO BOX 534 , NORTH BEND WA 98045 Contractor License No: FALLSPI034KO Phone: 425 - 888 -0143 Phone: 425 -888 -0143 Expiration Date: 11/27/2011 DESCRIPTION OF WORK: PROVIDE NEW PLUMBING & FIXTURES FOR NEW DENTAL OFFICE. PROVIDE MEDICAL GAS SYSTEMS FOR NEW DENTAL OFFICE. INCLUDES INSTALLATION OF A 1" RPPA FOR IN- PREMISE ISOLATION PIPED TO DRAIN INTO A FLOOR DRAIN IN ADJOINING ROOM. RPPA REQUIRES ANNUAL TESTING, PASSING BACKFLOW TEST REPORT SHALL BE SUBMITTED TO PUBLIC WORKS. Value of Plumbing /Gas Piping: $28,000.00 Uniform Plumbing Code Edition: 2009 Fees Collected: $892.50 International Fuel Gas Code Edition: 2009 Permit Center Authorized Signature: � / VV AM-7 Date: I hereby certify that I have read and xa ed this permit and know the same to be true and correct. All provisions of law and ordinances governing this work will be complie with 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_uthorized to sign and obtain this plumbing /gas piping permit and agree to the conditions on the back of this t. Signature Print Name: a V V apt��,�t 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. Date: /49-//( doc: UPC -4/10 PG 11 -007 Printed: 01 -28 -2011 • • PERMIT CONDITIONS Permit No. PG 11 -007 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. 13: ** *FIRE DEPARTMENT CONDITIONS * ** 14: The attached set of building plans have been reviewed by the Fire Prevention Bureau and are acceptable with the following concerns: 15: Installation shall comply with NFPA 99, sections 5.3.3 thru 5.3.13 for Level 3 piped gas and vacuum systems. 16: Contact The Tukwila Fire Prevention Bureau to witness all required inspections and tests. (City Ordinances #2050 and #2051) 17: Any overlooked hazardous condition and/or violation of the adopted Fire or Building Codes does not imply approval of such condition or violation. 18: These plans were reviewed by Inspector 511. If you have any questions, please call Tukwila Fire Prevention Bureau at (206)575 -4407. 19: ** *PUBLIC WORKS DEPARTMENT CONDITIONS * ** 20: Contractor shall notify Public Works Project Inspector at (206)433 -0179 of commencement and completion of DOMESTIC WATER RPPA INSTALLATION minimum 24 hours in advance. RPPA shall be installed per manufacturer's specifications. 21: Prior to final Public Works sign -off the subject RPPA shall be tested by a certified tester and passing test report shall be submitted to Public Works Project Inspector. doc: UPC -4/10 PG 11 -007 Printed: 01 -28 -2011 22: There after RPPA annual tests sebe performed at owner's expense, and copilik test results shall be provided to Public Works Water Department, Minkler Shops at (206) 433 -1860. doc: UPC -4/10 PG 11 -007 Printed: 01 -28 -2011 CITY OF TUKWILA Community Developm Department Permit Center 6300 Southcenter Blvd., Suite 100 Tukwila, WA 98188 http://www.ci.tukwila.wa.us Plumbing/Ga•rmit No l — 007 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)00 %9 k �� ,4-{/,} e /G B�h�/' Site Address: Tenant Name: ✓ %C?? (r -,r, r /Z nc'9 lJh/_ S King Co Assessor's Tax No.: 0.2.2 3/0 0O97 . Suite Number: if Floor: / New Tenant: ar Yes ❑..No Property Owners Name: Mailing Address: City State Zip CONTACT PERSON — Who do we contact when your permit is ready to be issued Name: Mailing Address: E -Mail Address: 1941,111 b, °,, L- m / Day Telephone: iJ,S "es- C�,js}3 Po >3 spy I/-vvtll ga,, t �/'� 9eay, - A716 t1.11.9.OyA:40 /, fie- . City State Zip Fax Number: ''7125 S'}3 9 -a 6,-2 7 PLUMBING / GAS PIPING CONTRACTOR INFORMATION Company Name: Mailing Address: 4 //S P h/;,, f1/ Hj , �hL no /3 5341 Ale/r4 /3,0„cS RA, 9 S— Contact Person: •L,: s•r Br P\ E -Mail Address: U Contractor Registration Number: 1C I yo. 32 KO City State Zip Day Telephone: lj/:f. S' X 52.' — 0/41.3 Fax Number: t 7.S-8? - 2 Oz 7 Expiration Date: // / / ARCHITECT OF RECORD — All plans must be stamped by Architect of Record Company Name: Mailing Address: city Day Telephone: Fax Number: Contact Person: E -Mail Address: State Zip ENGINEER OF RECORD — All plans must be stamped by Engineer of Record Company Name: Mailing Address: -$SBgYy.�-iri'eo 1 54. a h51 4t r3?/ 2! , Gl" q city Contact Person: Day Telephone: E -Mail Address: Fax Number: H:\Applications\Forms- Applications On Line\2010 Applications \7 -2010 - Plumbing -Gas Piping Permit Application.doc Revised: 7 -2010 bh State Zip .2S 3 s73 6: ed .2 s3 _27.2 Le -� Page 1 of 2 Valuation of Project (contractor's bid pr.) $ �? �1 0 Scope f Work (please provide detailed information): -c LJ;c1 e ilia c4, %�4U;�, ? ;be,- 1" .--k "Ai "e S 4y 447w ( e' - ifiiCc___ /21"-o Lei d.4.. /4eel r.6a J 4-4 s Sys 471 5 /3P- Building Use (per lnt'l Building Code): Occupancy (per Int'1 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 1 Shower, single head trap Lavatory Wash fountain Receptor, indirect waste i I Sinks 2 .J Urinals Water Closet Building sewer and each trailer park sewer Rain water system — per drain (inside building) Water heater and/or vent Repair or alteration of water piping and/or water treatment equipment ) Industrial waste treatment interceptor, including trap and vent, except for kitchen type grease interceptors Repair or alteration of drainage or vent piping Each grease trap (connected to not more than 4 fixtures - <750 gallon capacity) Medical gas piping system serving 1 -5 inlets /outlets for a specific gas 3 Grease interceptor for commercial kitchen ( >750 gallon capacity) Each additional medical gas inlets/outlets greater l''`-`"'9I than 5 iir OA IQ q 1 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 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 OWNER OR AUTHORIZE NT: Signature: Print Name: Mailing Address: P© 6 5-3i/ H:A Applications \Forms - Applications On Line\2010 Applications \7 -2010 - Plumbing -Gas Piping Pennit Application.doc Revised. 7 -2010 bh Day Telephone: /d4. 8-0.4 City Date: f A 1/1 4/4, 9eaf>S State Zip Page 2 of 2 • �J���LA wqs 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.: 0223100099 Address: 200 ANDOVER PK E TUKW Suite No: Applicant: DR BENCA DDS RECEIPT Permit Number: PG11 -007 Status: PENDING Applied Date: 01/12/2011 Issue Date: Receipt No.: R11 -00062 Initials: User ID: Payee: WER 1655 Payment Amount: $178.50 Payment Date: 01/12/2011 01:58 PM Balance: $714.00 FALLS PLUMBING INC TRANSACTION LIST: Type Method Descriptio Amount Payment Check 9300 178.50 Authorization No. ACCOUNT ITEM LIST: Description Account Code Current Pmts PLAN CHECK - NONRES 000.345.830 178.50 Total: $178.50 doc: Receiot -06 Printed: 01 -12 -2011 • CCity 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.: 0223100099 Address: 200 ANDOVER PK E TUKW Suite No: Applicant: DR BENCA DDS RECEIPT Permit Number: PG11 -007 Status: APPROVED Applied Date: 01/12/2011 Issue Date: Receipt No.: R11 -00168 Initials: JEM User ID: 1165 Payment Amount: $714.00 Payment Date: 01/28/2011 11:11 AM Balance: $0.00 Payee: FALLS PLUMBING, INC TRANSACTION LIST: Type Method Descriptio Amount Payment Check 9323 714.00 Authorization No. ACCOUNT ITEM LIST: Description Account Code Current Pmts PLUMBING - NONRES 000.322.103.00.00 714.00 Total: $714.00 doc: Receipt -06 Printed: 01 -28 -2011 P6 If 067 77,57,;;.. ,9-•-r. ■-• T-7!-7.4•7;t7f. - INSPECTION RECORD Retain a copy with permit INSPECTION NO. PERMIT'NO. ' P-• CITY OF TUKWILA BUILDING DIVISION - Ow Southcenter Blvd., #100, Tukwila. WA 98188 (206) 431-3670 Permit Inspection Request Line (206) 431-2451 • • . r . Pro z jecb k - 8e/‘ LA Type of Inspection: ( Pi. -• 01-3. /1:4,- 64_5 Addres,y‘ 0 '7- 0 \ ju. „.. Date Called: ri Special Instructions: ,.. Date Wanted: a.m. (C.P.:ffir Requester: Phone No: 11(g Approved per appiicable codes. El Corrections required prior to app ova COMMENTS: Inspectr,.: ,A) REINSPECTION FEE REQUIRED. Prior to next inspection. fee must be paid at 6300 Southcenter Blvd.. Suite 100. Call to schedule reinspection. _INSPECTION RECORD Retain a copy with permit INSPECTION NO. PERMIT NO. CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd., #100, Tukwila. WA 98188 (206) 431 -3670 Permit Inspection Request Line (206) 431 -2451 Pwj ct: Dr lea 1 M. Type of Ins ectiti n: Ord Address: ' '91" A-1° Date Cal ed: 4C5 34/14/ Special Instructions: Date Wanted: . Phone No: opt Approved per applicable codes. - .0 Corrections required prior to.approval. COMMENTS: l -- t p..T Pi i is Ueo( Qtr m91,001/4. s'ec , vevdee! • C i- frcckc' will 10r'_rh�_ — • back its Lo -k-es -- re o -'f - by - "[` fc. . _. lid Inspector: vs Date: - 312_141v - REINSPECTION FEE REQUIRED: Prior to next inspection. fee must be paid at 6300 Southcenter Blvd.. Suite 1.00. Call'to.schedule reinspection. INSPECTION RECORD Retain a copy with permit INSPECTION NO. PERMIT NO. CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd., #100, Tukwila. WA 98188 (206) 431 -3670 Permit Inspection Request Line (206) 431 -2451 Project: 64* 3e.'vA- Ins Type of Inspection: r ,J4_. L i5( 0 it Address: /� _ I ` 7 ,t) v A- J V E Date CCUed: p 6 _n s. /'-'- y't Special Instructions: ,/ Date Wanted: .ra.m 3 —Z2 — rI p.m. ff Requester: Phone No: -1 2.S --466 —rs5io, Approved per applicable codes. Corrections required prior to approval. COMMENTS: Date: 3— 1 Inspe tor: REINSPECTION FEE REQUIRE :Prior to next inspection. fee must be paid at 6300 Southcenter Blvd. Suite 100. Call to schedule reinspection. GA1 INSPECTION RECORD Retain a copy with permit P&//-O 71 INSPECTION NO. PERMIT NO. CITY OF TUKWILA.BUILDING DIVISION Ar 6300 Southcenter Blvd., #100, Tukwila. WA 98188 • (206) 431-3670 Permit Inspection Request Line (206) 431-2451 Project: OR SAVe4 q)(1) S Type of Inspection: ANG,&11.-2.4/ P/ziirgeyA/4 Datpfalted: 6,,ts- so Livz.‘ • 1-4 ed Address: 713,e) 0 _444/bOYA-dP $24e g— Special Instructions: • . . . • . Date Wanted: c* -42‘' // 1 a.m. dicp Requester: _ _.... Phone No: , . I Approved per applicable,codes. • IlCorrections required prior to approval. COMMENTS: in kkfLi 44 S 1 ,c 1>-1.-- t("2 0 K---- k11 . lot 44--ek-R a LAJ -9›- --‘ -- ; Inspe or: • n REINSPECTION FEE REQUIRED. Prior to next inspection; fee must be paid at 6300 Southcenter Blvd.. Suite 100. Call to schedule reinspection. Ory •.. ZIMNBACPear."17tAoi.- ...A104415407 " • INSPECTION RECORD p Retain a copy with permit / G r t - 007. - INSPECTION NO. PERMIT N0. - CITY OF TUKWILA BUILDING DIVISION le—. 6300 Southcenter Blvd., #100, Tukwila. WA 98188 (206) 431 -3670 Permit Inspection Request Line (206) 431 -2451 Pro'ect: 2 T i .4- ' 0 7 ) Type of Inspection: Coro o ,1 o t J10 A ress: Date CaU d: er. -4, U /. Sp cial Instructions: • Date Wanted: t I a.m. -- 3 i l f c p.m Requester: Phone No: 42s-- 't-© 143 Approved per applicable codes: DCorrections required. prior to approval. COMMENTS: c V- ti),. JA./ G% JtJ, -� 6 j /. Av\i/ o r - i-,, x_i, 41° A..,—. li 1.1l•.�. lf't .. 0. �V it .• r4-. Si ,4'C'... /"c.! J' , ; 0 . tAi O eGjd•v �,� _t e_S I _ `__c'l Cc JO . . ,(:_',) , 5•' 1"S 0 4 to f J-P ' z (a 'C_A. m p h (010. 11 . .... . / • e 1 i 1 - REINSPECTION FEE REQUIRED. pPor to next inspection. fee must be • paid at 6300 Southcenter Blvd.. Suite 100. Call to schedule reinspection. r"Zi,-411"C+r.Tlr9"4• Z"Ire,r•^r••+er-- •••• . , .-.... .. -•' i. + - • •.•• .aFr's- • • -•as• ' r • • INSPECTION NUMBER INSPECTION RECORD Retain a copy with permit ti-- e17-7.,2 PERMIT NUMBERS CITY OF TUKWILA FIRE DEPARTMENT 444 Andover Park East, Tukwila Wa. 9 188 - - Project: 'k,‘ `,,,- ri vt. Type of Inspection: Hood & Duct: Monitor: Address: - Suite #: 1 f i A v Corgact Person: J ;,'")(-,----/- I fr /t.A.. /1--■ Special Instructions: Phone No.: ' 2(-- :-...,--e- __,,,....9 - Approved per applicable codes. Corrections required prior to approval. COMMENTS: Sprinklers: Fire Alarm: Hood & Duct: Monitor: Pre-Fire: -- i- - c Hrs.: - _.... r: itzv ,,,, 0, /1 _. . _ J. 1 !.... 1, , -; f'' / ,e1 (L ,,,.'' „,,:r ,--v-4-' ,r;,.; '4.- 'ILA, 4 ) . .-),7) ._, t..,:„.....--,..,. 4, , . r.;A‘. ,!-,---,....,..e LA i f`j-k. \ ';k1'../ , ' r r r-', / ,,,... ' ' - _.) i - - 74 -.. , —:2, , — 7,, • , Needs Shift Inspection: Sprinklers: Fire Alarm: Hood & Duct: Monitor: Pre-Fire: Permits: Occupancy Type: Inspector: ‘: - , ) , ,,-. \ ‘ , .,.. ,., rm,./LA .t.-) - Date: -- .,:', ) z . . 1 ,,, Hrs.: $80.00 REINSPECTION FEE REQUIRED. You will receive an invoice from the City of Tukwila Finance Department. Call to schedule a reinspection. Word/Inspection Record Form.Doc 1/13/06 T.F.D. Form F.P. 113 Airgas Medical Services NW Lynnwood, WA 98087 (425)741-8807 fax (425)968 -4620 http: //www.airgas.com Dental Gas Line Verification Report Date: 16 March 2011 Job Number: 200705 E- Mailed 03 -16 -11 / Doug Melum Contractor: Olympus Construction, Inc. Date(s) and Time(s) of Testing: 15 March 2011 / hrs0850 Facility: Dr. Patricia Benca, DDS Scope of Work: New Medical Gases, Dental Air and Dental Vacuum Our firm certifies that the verifier(s) named in the report are properly trained and certified to perform the activities required. All test and measurement equipment is properly calibrated and maintained. As a representative of Airgas Medical Services NW the verifier(s) named in this report have conducted testing and verification of Medical Gas piping systems and related equipment to certify the following on the above date. I. General Findings: A. Medical Gases are in compliance with NFPA 99(2005ed): Level 3, Dental "NOT FOR ANESTHESIA" B. No crossed lines were found in Medical Gases, Dental Air or Vacuum in the tested areas on the day of testing. C. Medical Gases meet minimum concentrations. D. Medical Gases and Dental Air are at normal pressure. E. Dental Vacuum is at normal level. F. Medical Gas and components in area tested are in compliance with NFPA 99(2005ed): Level 3, Dental: See (Note), (Comments), (Recommended Corrections) and (Corrections) G. Medical Gas Line Purity: PASS #PV01 Y007AA, (AG) H. initial Line Pressure Test: Pass City of Tukwila: Permit # D10 -308 I. Attachments: Final Tie -In and purities Note: Existing Equipment and Systems. NFPA 99(2005ed) #5.3.1.4 - An existing Level 3 system that is not in strict compliance with the provisions of this standard shall be permitted to be continued 01- AG.VR - Dental Gas Line (2005ed)- Rev1.1 Pg 1 of 1 Airgas Medical Services NW Lynnwood, WA 98087 (425)741 -8807 fax (425)968-4620 http:Uwww.airgas.com in use as long as the authority having jurisdiction has determined that such use does not constitute a distinct hazard to life. 11. Medical Gases A. Oxygen: 1. Static line pressure: 55 psig. 2. Oxygen concentration at outlet: >99.0% 3. Dynamic outlet free flow at outlet: >3.5 scfm B. Nitrous Oxide: 1. Static line pressure: 55 psig. 2. Nitrous Oxide concentration at outlet: >99.0% 3. Dynamic outlet free flow at outlet: >3.5 scfm 111. Dental Air and Vacuum: A. Dental Air: 1. Static Line Pressure: 85 psi 2 Oxygen Concentration At Outlet: 20.8% B. Dental Vacuum: 1. Static Line Vacuum: 12" HgV 111. Particulate Line Test: PASS V. Odor: PASS VI. Outlet: Porter A. Outlet Style: '/a turn Diss checks VII. Zone Valve: None VIII. Manifold / Alarm: A. Manifold: New 1. Brand: Porter 2. Model Number: 4222NOHF -1 3. Serial Number: 42H1 -1201 B. Alarm: New 1. Brand: Porter 01- AG.VR - Dental Gas Line (2005ed)- Rev1.1 Pg 2 of 2 Airgas Medical Services NW Lynnwood, WA 98087 (425)741 -8807 fax (425)968 -4620 httpJ/www.airgas.com 2. Model Number: 6251A 3. Serial Number: 625A -4629 IX. Dental Equipment: A. Dental Air: New 1. System air components in compliance with NFPA 99(2005ed). 2. Brand: Midmark 3. Model Number: P32 4. Serial Number: V1020379 5. Configuration: Triplex 6. Horse Power: .75 7. Intake: Inside other area 8. Pump: Oilless B. Dental Vacuum: New 1. System vacuum components are in compliance with NFPA 99(2005ed). 2. Brand: Midmark 3. Model Number: 056 - 3713 -01 4. Serial Number: V1051535 5. Configuration: Simplex 6. Horse Power: 2 7. Vented to the outside. C. Amalgam Separator: New 1. Brand: Solmetex 2. Model Number: HG5 -002 3. Serial Number: CC -K- 135058 X. Cylinder Storage: A. Location: Indoor B. Ventilation: Mechanical C. Cooling Sprinkler: Yes D. Door labeled: Yes E. 1 Hour Rated: Yes F. Cylinders Secured: Yes XI. Brazier: Larry Bryan — MG01 BRYANLJ 0240C A. Plumbing Contractor: Falls Plumbing XII.Witness: Doug Melum — Olympus Construction, Inc. 01- AG.VR - Dental Gas Line (2005ed)- Rev1.1 Pg 3 of 3 XIII. Comments: A. None XIV. Recommended Corrections: A. None XV.Corrections: A. None Tested By: Eric N. Burt 6th9tvXP -VoYci-- 6-zit, n oialzti- 67,it,eit -Ewa- 1,4, rt, letitt fry It iiiori- Eric N. Burt, ASSE 6020 Inspector 01- AG.VR - Dental Gas Line (2005ed)- Rev1.1 Airgas Medical Services NW Lynnwood, WA 98087 (425)741-8807 fax (425)968-4620 httpJ/www.airgas.com CRIA, en_ kZAA--- 6-tit A, k-Valt- &zit- IA, fart- 6thd A, liwii- 6LTL4kY2 .wzi- Pg 4 of 4 Airgas Medical Services NW Lynnwood, WA 98087 (425)741-8807 fax (425)968 -4620 http: //www.airgas.com Airgas Medical Services NW 425 -754 -1097 01- AG.VR - Dental Gas Line (2005ed)- Rev1.1 Pg 5 of 5 • its T • Jim Haggerton, Mayor Department of Comm r ; nit! It evelopment Jack Pace, Director January 20, 2011 Larry Bryan PO Box 534 North Bend, WA 98045 RE: Correction Letter #1 Plumbing /Gas Piping Permit Application Number PG11 -007 Dr Benca DDS — 200 Andover Pk E Dear Mr. Bryan, This letter is to inform you of corrections that must be addressed before your plumbing/gas piping permit can be approved. All correction requests from each department must be addressed at the same time and reflected on your drawings. I have enclosed comments from the Building Department and Public Works Departments. Building Department: Dave Larson at 206 431 -3670 if you have questions regarding the attached memo. Public Works Department: Joanna Spencer at 206 - 431 -2440 if you have any questions regarding the attached memo. Please address the attached comments in an itemized format with applicable revised plans, specifications, and /or other documentation. The City requires that two (2) sets of revised plans, specifications and /or other documentation be resubmitted with the appropriate revision block. In order to better expedite your resubmittal, a `Revision Submittal Sheet' must accompany every resubmittal. I have enclosed one for your convenience. Corrections /revisions must be made in person and will not be accepted through the mail or by a messenger service. If you have any questions, please contact me at (206) 431 -3670. Sincerel Bill Rambo Permit Technician encl File: PG11 -007 W: \Pennit Center \Con'eetion LeIers',201 I \PG11 -007 Correction Letter #1.DOC 6300 Southcenter Boulevard, Suite #100 0 Tukwila, Washington 98188 a Phone: 206 - 431 -3670 e Fax: 206 - 431 -3665 Tukwila Building Division Dave Larson, Senior Plan Examiner Building Division Review Memo Date: January 14, 2011 Project Name: Dr. Benca DDS Permit #: PG11 -007 Plan Review: Dave Larson, Senior Plans Examiner The Building Division conducted a plan review on the subject permit application. Please address the following comments in an itemized format with revised plans, specifications and /or other applicable documentation. (GENERAL NOTE) PLAN SUBMITTALS: (Min. size 11x17 to maximum size of24x36; all sheets shall be the same size). (If applicable) Structural Drawings and structural calculations sheets shall be original signed wet stamped, not copied.) 1. A dentist office is required to have a Reduced Pressure Principle Assembly (RPPA) on the water service to this tenant isolating other tenant spaces in the same building. Please provide size, manufacturer, model number and RPPA cut sheet. Also please show on the plan where it will be located. Should there be questions concerning the above requirements, contact the Building Division at 206 -431- 3670. No further comments at this time. • • PE' HCOP Y PLAN REVIEW /ROUTING SLIP ACTIVITY NUMBER: PG11 -007 PROJECT NAME: DR BENCA DDS SITE ADDRESS: 200 ANDOVER Original Plan Submittal _ X Response to Correction Letter # 1 _ DATE: 01 -21 -11 Response to Incomplete Letter # _ Revision # After Permit Issued DEPA TMENTS: o1•1 W [I Bui ding Di (/ ision r oFks �l �1 Fire Prevention Structural Planning Division ❑ Permit Coordinator n DETERMINATION OF COMPLETENESS: (Tues., Thurs.) DUE DATE: 01-25-11 Complete Incomplete n Not Applicable ❑ Comments: Permit Center Use Only INCOMPLETE LETTER MAILED: LETTER OF COMPLETENESS MAILED: Departments determined incomplete: Bldg ❑ Fire ❑ Ping ❑ PW ❑ Staff Initials: TUES /THURS ROUTING: Please Route Structural Review Required REVIEWER'S INITIALS: No further Review Required DATE: APPROVALS OR CORRECTIONS: Approved Notation: Approved with Conditions DUE DATE: 02 -22 -11 Not Approved (attach comments) n REVIEWER'S INITIALS: DATE: Permit Center Use Only CORRECTION LETTER MAILED: Departments issued corrections: Bldg ❑ Fire ❑ Ping ❑ PW ❑ Staff Initials: Documents /routing slip.doc 2 -28 -02 PERTPcOPY • PLAN REVIEW /ROUTING SLIP ACTIVITY NUMBER: PG11 -007 PROJECT NAME: DR BENCA DDS SITE ADDRESS: 200 ANDOVER PK E X Original Plan Submittal Response to Correction Letter # DATE: 01 -12 -11 Response to Incomplete Letter # Revision # After Permit Issued DEPARTMENTS: '``\ull<<dl Ivlslon c ors Ill -Fire Prevention Structural Planning Division Permit Coordinator u DETERMINATION OF COMPLETENESS: (Tues., Thurs.) Complete Incomplete DUE DATE: 01-13-11 Not Applicable n Comments: Permit Center Use Only INCOMPLETE LETTER MAILED: LETTER OF COMPLETENESS MAILED: Departments determined incomplete: Bldg ❑ Fire ❑ Ping ❑ PW ❑ Staff Initials: TUES/THURS ROUTING: Please Route 7] Structural Review Required n No further Review Required REVIEWER'S INITIALS: DATE: APPROVALS OR CORRECTIONS: DUE DATE: 02-10-11 Approved Approved with Conditions n Not Approved (attach comments) Notation: REVIEWER'S INITIALS: DATE: Permit Center Use Only CORRECTION LETTER MAILED: �� t Departments issued corrections: Bldg' Fire ❑ Ping ❑ PW Staff Initials: Documents/routing slip.doc 2 -28 -02 • 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: 1/2 1 / 11 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: DA- . gezlie.e.1 , .700 Gahv er) F Project Address: Contact Person: •, My. �G ft-007 Phone Number: VArtreir- sP{C3 Summary of Revision: I 1 R f ffk cfu l4e, ‘.50 itc�"tem W a npe. ,O/a lit to /`71 r- 4 ✓4;11 ire A a I j� AVM env CP1UKWf A UAN 2 1 2011 Sheet Number(s): "Cloud" or highlight all areas of revision includin date of re i Received at the City of Tukwila Permit Center by: Er—Entered in Permits Plus on 1"--)-1 — I I H:Wpplications\Fotms- Applications On Line\2010 Applications \7 -2010 - Revision Subminal.doc Created: 8-13-2004 Revised: 7 -2010 FALLS PLUMBING,INC. P O BOX 534 NORTH BEND, WA.98045 [425] 888 -0143 / FAX [425] 888 -2027 LIC.# FALLSPIO34KO VENDOR City Of Tukwila DATE 1/20/2011 DESCRIPTION Re; Dr. Benca, D.D.S. Permit # PG11 -007 In regards to your correction letter we will be installing a 1" Watts 009gt reduced pressure principle backflow device in the mechanical room in the se corner of suite no more than 5' AFF. The premiss isolation is existing in hot box @ water meter. If you have any questions 1 can be reached @ 425 888 -0143 Sincerely Larry Bryan CORRECTION v6k 007 RECEIVED JAN 252011 PUBLIC W� RKS RECEIVED JAN 21 2011 •� TR LKing County Department of Natural Resources and Parks Wastewater Treatment Division Non - Residential Sewer Use Certification • 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 within five years of disconnect. Pleas -e7 Print orrf Type .20 /Vf1l goil tor-- clam 4--.;:s Property Street Address City is/4, 9esigr ifwfb1i ?r �q L-L 6 State ZIP Owner's Name Subdivision Name Lot # Subdiv. # Block # Budding Name Of applicable) Owners Phone Number (with Area Code) Property Contact Phone Number (with Area Code) Owner's Mailing Address /501 /11 ,2& 2"1'fr SA cr.... /, a , JY4 `!' 33 • For King County Use Only Account # No. of RCEs Monthly Rate A. Fixture Units Fixture Units x Number of Fixtures = Total Fixture Units Kind of Fixture Fixture Units No. of Fixtures Total Fixture Units Public Private Public Private Bathtub and Shower 4 4 Shower, per head 2 2 Dishwasher 2 2 Drinking fountain (each head) 1 .5 Hose bibb (interior) 2.5 2.5 Clotheswasher or laundry tub 4 2 1 4/ Sink, bar or lavatory 2 1 // g .- Sink, Clinic flushing 8 8 Sink, kitchen 3 2 Sink, other (service) 3 1.5 Sink, wash fountain, circle spray 4 3 Urinal, flush valve, 1 GPF 5 2 Urinal, flush valve, >1 GPF 6 2 Urinal, waterless 0 0 Water closet, tank or valve, 1.6 GPF 6 3 A / 2. Water closet, tank or valve, >1.6 GPF 8 4 Total Fixture Units Residential Customer Equivalent (RCE) 20 fixture units equal 1.0 RCE Total No. of Fixture Units 20 RCE 3 5' Property Tax ID # az; 3 /0 4009 47 Party to be Billed (if different from owner) City or Sewer District Date of Connection Side Sewer Permit # Please report any demolitions of pre - existing building on this property. Credit for a demolition may be given under some circumstances. Demolition of pre- existing building? ❑ Yes ❑ No Was building on Sanitary Sewer? ❑ Yes ❑ No Was Sewer connected before 2/1/90? ❑ Yes ❑ No Sewer disconnect date: Type of building demolished? Request to apply demolition credit to multiple buildings? ❑ Yes ❑ No B. Other Wastewater Flow (in addition to Fixture Units identified in Section A) Type of Facility /Process: Estimated Wastewater Discharge: Gallons /days Residential Customer Equivalents (RCE): 187 gallons per day equals 1.0 RCE Total Discharge (gal /day) _ 187 C. Total Residential Customer Equivalents: (add A & B) A B r' 7 IT) J,7 RCE RCE RECEIVE JAN 12 2011 PERMIT CENTER Pursuant to King County Code 28.84, all sewer customers who establish a new service which uses metropolitan sewage facilities shall be subject to a capacity charge. The amount of the charge is established annually by the King County Council at a rate 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. All future billings can be prepaid at a discounted amount. Questions regarding the capacity charge or this form should be referred to King County's Wastewater Treatment Division at 206 - 684 -1740. 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 correc ed data for deW ination of a revised capacity charge. Signature of Owner/Representative —° ) 9 P �J�rJ .. -.... � J Date / � /-z. / % Contractors or Tradespeople Potter Friendly Page 1 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 Phone Address Suite /Apt. City State Zip County Business Type Parent Company FALLS PLUMBING INC 4258880143 Po Box 534 North Bend WA 98045 King Individual UBI No. Status License No. License Type Effective Date Expiration Date Suspend Date Specialty 1 Specialty 2 601779989 Active FALLSPI034K0 Construction Contractor 5/20/1997 11/27/2011 Plumbing Unused Other Associated Licenses License Name Type Specialty 1 Specialty 2 Effective Date Expiration Date Status FALLSP'077NP FALLS PLUMBING Construction Contractor Plumbing Unused 8/17/1993 7/26/1997 Archived Business Owner Information Name Role Effective Date Expiration Date AIKEN & FINE PS Agent 01/01/1980 Bond Amount BRYAN, LARRY J Owner 01/01/1980 YLI262481 BRYAN, SELENA A Owner 01/01/1980 Bond Information Page 1 of 2 Bond Bond Company Name Bond Account Number Effective Date Expiration Date Cancel Date Impaired Date Bond Amount Received Date 4 OLD REPUBLIC INS CO YLI262481 12/08/2006 Until Cancelled $6,000.00 12/14/2006 3 STATE FARM FIRE & CAS CO 98CL56363 10/30/2001 Until Cancelled 12/08/2006 $6,000.0011/13/2001 04/07/2008 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 14 OOHIO CAS INS BR053698061 11/12/2008 11/12/2011 $1,000,000.00 10/12/2010 13 OHIO CASUALTY GROUP 53698061 11/12/2008 11/12/2008 $1,000,000.00 04/07/2008 12 OHIO GROUP 53698061 11/12/2007 11/12/2008 $1,000,000.00 11/12/2007 11 WESTERN NATIONAL ASSUR CO GL300007897 11/12/2005 11/12/2008 01/05/2008 $1,000,000.00 10/22/2007 10 WESTERN NATIONAL ASSUR CO GL300007897 11/12/2004 11/12/2006 $1,000,000.00 11/08/2005 Summons /Complaint Information Cause County Complaint Judgment Status Payment Paid By 06 -2- 32094 -8 CASCADE SAWING Et DRILLING INC KING Date 10/06/2006 Amount: $1,020.59 Date: Amount: $0.00 Open Date: 12/11/2006 Amount: $1,924.52 Contractor https://fortress.wa.gov/lni/bbip/Print.aspx 01/28/2011