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HomeMy WebLinkAboutPermit PG11-079 - WESTFIELD SOUTHCENTER MALL - PAC SUNPAC SUN 650 SOUTHCENTER MALL PG1 1 -079 City &Tukwila 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.TukwilaWA.gov PLUMBING /GAS PIPING PERMIT Parcel No.: 9202470010 Address: 650 SOUTHCENTER MALL TUKW Project Name: PAC SUN Permit Number: Issue Date: Permit Expires On: PG11 -079 08/22/2011 02/18/2012 Owner: Name: WESTFIELD PROPERTY TAX DEPT Address: PO BOX 130940 , CARLSBAD CA 92013 Contact Person: Name: Address: Email: AMY DIEKEVERS 75 60 ST SW , WYOMING MI 49548 AMYD @PRECISIONPERMITS. C OM Contractor: Name: HARDESTY & ASSOCIATES INC Address: 1991 VILLAGE PARY WAY 180 , ENCINITAS, CA 92024 Contractor License No: HARDEAI066PP Expiration Date: 11/17/2011 Phone: 616 - 493 -9334 Phone: 760- 944 -0499 DESCRIPTION OF WORK: TENANT IMPROVEMENT TO INCLUDE DEMOLITION OF EXISTING RESTROOMS AND REPLACE WITH (2) NEW RESTROOMS. RESTROOMS WILL INCLUDE (1) WATER CLOSET, (1) LAVATORY AND (1) FLOOR DRAIN. A MOP SINK AND DRINKING FOUNTAINS ARE ALSO ADDED. Value of Plumbing /Gas Piping: Fees Collected: Electrical Service Provided by: $11,400.00 $326.81 Permit Center Authorized Signature: I hereby certify that I have read and governing this work will be complie Uniform Plumbing Code Edition: 2009 International Fuel Gas Code Edition: 2009 Date: �' 1 ed 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 p construction or the performance of work. on the back of this permit. Signature: e to give authority to violate or cancel the provisions of any other state or local laws regulating am authorized to sign and obtain this plumbing /gas piping permit and agree to the conditions Date: 8 -22— // Print Name: J QS(1 67l (fee 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 PG11 -079 Printed: 08 -22 -2011 • • PERMIT CONDITIONS Permit No. PG 11 -079 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 11 -079 Printed: 08 -22 -2011 CITY OF TUKWILA Community Development Department Public Works Department Permit Center 6300 Southcenter Blvd., Suite 100 Tukwila, WA 98188 http:; %tivw w.ci.tukivila.wa.us Building Permit No. itik�, ( Mechanical Permit No. t (-0 Plumbing /Gas Permit No. 1`-Q7 Public Works Permit No. Project No. (For office use only) 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 Site Address: r �J King Co Assessor's Tax No.: .262z 3 U '-) G v 7 ( 90 00 -e k ✓�" t Suite Number: Floor: New Tenant: .,....Yes ❑..No Tenant Name: P !• Property Owners Name: tA) e-, 7 f 1 t'-� C Mailing Address: ‘,..2‘00 5e04-MIC -ea 'k/2._ vt/LIA) alCI City State Zip CONTACT PERSON -- who do we contact when your permit is ready to be issu Name: AAA1 1� (e4e t e( Mailing Address: l7 ' t o11‘ J f- Day Telephone: 6? / ( `ir q 3 Z f Lk) IOWA //cIa2 E -Mail Address: Ci F1'1 C e -eC jJ /C? / 7: C Fax Number: r get s qF3 State Zip (1(:) L/ C7, 95-5A GENERAL CONTRACTOR INFORMATION — (Contractor Information for Mechanical (pg 4) for Plumbing and Gas Piping (pg 5) Company Name: Mailing Address: City Day Telephone: Fax Number: Contact Person: E -Mail Address: Contractor Registration Number: State Zip Expiration Date: ARCHITECT OF RECORD — All plans` must be wet stamped by Architect of Record Company Name: Mailing Address: Contact Person: E -Mail Address: gawp GI City �} Day Telephone: 4/80 l c - 'IW o Fax Number: 9&O q' .- ENGINEER OF RECORD — All plans must be wet stamped by Engineer of Record Company Name: Mailing Address: till N Z Contact Person: ' t'1q%/re ea:o9 /511k e an+c 4jt14j- Ao -ejj, X z.. 0 4 E -Mail Address: H:Wpplications \Forms - Applications On Line\2009 Applications \I -2009 - Permit Applicaluon.doc Revised: 1 -2009 bh City State Zip Day Telephone: f2 0 Z Z U /5 e5 1 Fax Number: Page 1 of 6 BUILDING PERMIT INFORM,.fION - 206- 431 -3670 Valuation of Project (contractor's bid price): $ /9 6, G7O0 Existing Building Valuation: $ Scope of Work (please provide detailed information): Tenant improvement of entire existing retail space including storefront, sales area, fitting rooms, stock room, toilet rooms, and hallway. Will there be new rack storage? lif" Yes 0.. No If yes, a separate permit and plan submittal will be required. �Ol �ls /l��U�'` -' — ��1�G✓n Oat (lir Provide All Building Areas in Square Footage elol 1s` Floor 2 "dl lour 3rd Floor Interior Remodel Addition to Existing Structure 3O.S? C) d Type of ConstructionI IBC tii -13 Type of Occupancy per IBC 37752' I Mr— Floors thru Basement Accessory Structure* Garage Detached Garage Attached Carport Detached Carport Covered Deck Uncovered Deck PLANNING DIVISION: Single family building footprint (area of the foundation of all structures, plus any decks over 18 inches and overhangs greater than 18 inches) *For an Accessory dwelling, provide the following: Lot Area (sq ft): Floor area of principal dwelling: Floor area of accessory dwelling: *Provide documentation that shows that the principal owner lives in one of the dwellings as his or her primary residence. Number of Parking Stalls Provided: Standard: Will there be a change in use? ❑ Yes Compact: Handicap: No If "yes ", explain: FIRE PROTECTION /HAZARDOUS MATERIALS: 0 Sprinklers m Automatic Fire Alarm ❑ None ❑ Other (specify) Will there be storage or use of flammable, combustible or hazardous materials in the building? ❑ Yes No If "yes', attach list of materials and storage locations on a separate 8-1/2" x 11 " paper including quantities and Material Safety Data Sheets. SEPTIC SYSTEM ❑ On -site Septic System — For on -site septic system, provide 2 copies of a current septic design approved by King County Health Department. H:\Applications\Forms- Applications On Line \2009 Applications \1 -2009 - Permit Application. doc Revised: 1 -2009 bh Page 2 of 6 PUBLIC WORKS PERMIT INFORMATION -- 206- 433 -0179 Scope of Work (please provide detailed information): Call before you Dig: 1- 800 - 424 -5555 Please refer to Public Works Bulletin #1 for fees and estimate sheet. Water District ❑ ...Tukwila ❑...Water District #125 ❑ ...Water Availability Provided Sewer District ❑ ...Tukwila ❑ ...Sewer Use Certificate ❑ .. Highline ❑ ...Valley View ❑ .. Renton ❑...Sewer Availability Provided ❑ .. Renton ❑ .. Seattle Septic System: ❑ On -site Septic System — For on -site septic system, provide 2 copies of a current septic design approved by King County Health Department. Submitted with Application (mark boxes which apply): ❑ ...Civil Plans (Maximum Paper Size — 22" x 34 ") ❑ ...Technical Information Report (Storm Drainage) ❑ ...Bond ❑ .. Insurance ❑ .. Easement(s) Proposed Activities (mark boxes that apply): ❑ ...Right -of -way Use - Nonprofit for less than 72 hours ❑ ...Right -of -way Use - No Disturbance ❑ ...Construction/Excavation /Fill - Right -of -way ❑ Non Right -of -way ❑ ❑ ...Total Cut ❑ ...Total Fill ❑ ...Sanitary Side Sewer ❑ ...Cap or Remove Utilities ❑ ...Frontage Improvements ❑ ...Traffic Control ❑ ...Backflow Prevention - Fire Protection Irrigation Domestic Water cubic yards cubic yards ❑ .. Geotechnical Report ❑ .. Maintenance Agreement(s) ❑...Traffic Impact Analysis ❑ ...Hold Harmless — (SAO) ❑ ...Hold Harmless — (ROW) ❑ .. Right -of -way Use - Profit for less than 72 hours ❑ .. Right -of -way Use — Potential Disturbance ❑ .. Work in Flood Zone ❑ .. Storm Drainage ❑ .. Abandon Septic Tank ❑ .. Curb Cut ❑ .. Pavement Cut ❑ .. Looped Fire Line ❑ ...Permanent Water Meter Size... ❑ ...Temporary Water Meter Size .. ❑ ...Water Only Meter Size ❑ ...Sewer Main Extension Public ❑ ❑ ... Water Main Extension Public ❑ WO# WO # WO# Private ❑ Private ❑ ❑ .. Grease Interceptor ❑ .. Channelization ❑ .. Trench Excavation ❑ .. Utility Undergrounding ❑ ...Deduct Water Meter Size FINANCE INFORMATION Fire Line Size at Property Line Number of Public Fire Hydrant(s) ❑ ...Water ❑ ...Sewer ❑ ...Sewage Treatment Monthly Service Billing to: Name: Day Telephone: Mailing Address: Water Meter Refund/Billing: Name: Mailing Address: City State Zip Day Telephone: City State Zip H \Applications \Forms•Applications On Line \2009 Applications \1.2009. Permit Application. doc Revised: 1 -2009 bh Page 3 of 6 MECHANICAL PERMIT INFORMATION _ 206 = 431 -3670. MECHANICAL CONTRACTOR INFORMATION Company Name: Mailing Address: City State Zip Day Telephone: Fax Number: Contact Person: E -Mail Address: Contractor Registration Number: Valuation of Mechanical work (contractor's bid price): $ 1 5 CO- Expiration Date: Scope of Work (please provide detailed information): Tenant improvement to include (1) new nominal 10 -ton split system heat pump, all new duct distribution, (2) toilet exhaust fans Use: Residential: New .... ❑ Commercial: New .... ❑ Replacement .... ❑ Replacement .... Fuel Type: Electric ® Gas ....0 Other: Indicate type of mechanical work being installed and the quantity below: Unit Type: Qty Unit Type: Qty Unit Type: Qty Boiler /Compressor: Qty Furnace <100K BTU 0 Air Handling Unit >10,000 CFM 0 Fire Damper 0 0 -3 HP /100,000 BTU 0 Furnace >100K BTU 0 Evaporator Cooler 0 Diffuser 19 g 3 -15 HP /500,000 BTU 0 Floor Furnace 0 Ventilation Fan Connected to Single Duct 2 Thermostat 1 15-30 HP /1,000,000 BTU 0 Suspended/Wall /Floor Mounted Heater 0 Ventilation System 1 Wood/Gas Stove 0 30 -50 HP /1,750,000 BTU 0 Appliance Vent 0 Hood and Duct 0 Emergency Generator 0 50+ HP/1,750,000 BTU 0 Repair or Addition to Heat/Refrig/Cooling System 0 Incinerator - Domestic 0 Other Mechanical Equipment 0 Air Handling Unit <10,000 CFM 1 Incinerator — Comm /Ind 0 H:\Apphcations\Fonns- Applications On Line\2009 Applications \I -2009 - Permit Application.doc Revised: 1 -2009 bh Page 4 of 6 • YLL MBING AND. GAS PIPING PERMIT INFORMATION: -4206-43 V3670 PLUMBING AND GAS PIPING CONTRACTOR INFORMATION Company Name: Mailing Address: City State Zip Day Telephone: Fax Number: Contact Person: E -Mail Address: Contractor Registration Number: Expiration Date: Valuation of Project (contractor's bid price): $ 1 16:34C:) CC' Scope of Work (please provide detailed information): Tenant improvement to include demolition if existing restrooms and replace with (2) new restrooms. Restrooms will include (1) watercloset, (1) lavatory, and (1) floor drain. A mop sink and drinking fountain are also added. Building Use (per Int'l Building Code): 7L-73 Occupancy (per Int'l Building Code): M- mercantile 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 y pe: Qty Fixtur Type: e Qty, Bathtub or combination bath/shower 0 Bidet 0 Clothes washer, domestic 0 Dental unit, cuspidor 0 Dishwasher, domestic, with independent drain 0 Drinking fountain or water cooler (per head) 2 Food -waste grinder, commercial 0 Floor Drain 1 Shower, single head trap 0 Lavatory 2 Wash fountain 0 Receptor, indirect waste 0 Sinks 1 Urinals 0 Water Closet 2 Building sewer and each trailer park sewer 0 Rain water system — per drain (inside building) 0 Water heater and/or vent 1 Industrial waste treatment interceptor, including trap and vent, except for kitchen type grease interceptors 0 Each grease trap (connected to not more than 4 fixtures - <750 gallon capacity) 0 Grease interceptor for commercial kitchen ( >750 gallon capacity) 0 Repair or alteration of water piping and/or water treatment equipment 1 Repair or alteration of drainage or vent piping 1 Medical gas piping system serving 1-5 inlets/outlets for a specific gas 0 Each additional medical gas inlets/outlets greater than 5 0 Backflow protective device other than atmospheric -type vacuum breakers 2 inch (51 mm) diameter or smaller 0 Backflow protective device other than atmospheric -type vacuum breakers over 2 inch (51 mm) diameter 0 Each lawn sprinkler system on any one meter including backflow protection devices 0 Atmospheric -type vacuum breakers not included in lawn sprinkler backflow protections (1 -5) 1 Atmospheric -type vacuum breakers not included in lawn sprinkler backflow protections over 5 0 Gas piping outlets 0 H:\ pplicationsWorms- Applications On- Line\2009 Applications \I -2009 Permit Application. doc Revised: 1 -2009 bh Page 5 of 6 PERMIT APPLICATION NOTES — Applicable to all permits in this application 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. Building and Mechanical Permit The Building Official may grant one or more extensions of time for additional periods not exceeding 90 days each. The extension shall be requested in writing and justifiable cause demonstrated. Section 105.3.2 International Building Code (current edition). Plumbing Permit The Building Official may grant one extension of time for an additional period not exceeding 180 days. The extension shall be requested in writing and justifiable cause demonstrated. Section 103.4.3 Uniform 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" Signature: Print Name: Mailing Address: 7 THORIZEp A ENT mg j'J'� �t Day Telephone: o PU1t " Lives) tO yo r /jig Date: L/ 3'35/ AI LJg5y5 State Zip Date Application Accepted: Date Application Expires: `,� Staff Initials: ` v 1E` 4 ( 1� �y I H.\Applications \Forms - Applications On Line \2009 Applications \I -2009 - Permit Application. doc Revised: 1 -2009 bh Page 6 of 6 SET RECEIPT Copy Reprinted on 08 -22 -2011 at 12:56:31 08/22/2011 RECEIPT NO: R11 -01824 Initials: WER Payment Date: 08/22/2011 User ID: 1655 Total Payment: 2,810.80 Payee: HARDESTY & ASSOCIATES SET ID: 0822 SET NAME: Temporary Set SET TRANSACTIONS: Set Member Amount D11 -161 2,284.90 M11 -075 264.45 PG11 -079 261.45 TOTAL: 261.45 TRANSACTION LIST: Type Method Description Amount Payment Check 71908 2,810.80 TOTAL: 2,810.80 ACCOUNT ITEM LIST: Description Account Code Current Pmts BUILDING - NONRES MECHANICAL - NONRES PLUMBING - NONRES STATE BUILDING SURCHARGE 000.322.100 000.322.102.00.0 000.322.103.00.0 640.237.114 TOTAL: 2,280.40 264.45 261.45 4.50 2,810.80 Cift of Tukwila. • Department of Community Development 6300 Southcenter Boulevard, Suite #100 Tukwila, Washington 98188 Phone: 206 - 431 -3670 Fax: 206-431-3665 Web site: hits: //vww. ci. tukwila. wa. us SET RECEIPT RECEIPT NO: R11 -01163 Initials: WER Payment Date: 06/08/2011 User ID: 1655 Total Payment: 1,735.76 Payee: PRECISION PERMIT SERVICE SET ID: 6 -8 -11 SET NAME: PAC SUN SET TRANSACTIONS: Set Member Amount D11 -161 EL11 -0523 M11 -075 PG11 -079 TOTAL: 1,482.26 122.03 66.11 65.36 1,482.26 TRANSACTION LIST: Type Method Description Amount Payment Check 8036 1,735.76 TOTAL: 1,735.76 ACCOUNT ITEM LIST: Description Account Code Current Pmts ELECTRICAL PLAN - NONRES 000.345.832.00.0 PLAN CHECK - NONRES 000.345.830 TOTAL: 122.03 1,613.73 1,735.76 : 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: . Type of Inspection: Address: • . e)45 0 _SO 6 t.1-1 OA (4- t t Date Called: Special Instructions: . . • Date Wanted:. ( 1 -- 1— 1 1 CE:in-D p.m. Requester: Phone No: Approved per applicable codes. ElCorrections required prior to approval. COMMENTS: ECTION FEE REQUIRED. ior to next inspection. fee must be at 6300 Southcenter Blvd.. Su e 100. Call to schedule reinspection. • r . i.• • rw INSPECTION RECORD Retain a copy with permit INSPECTION NO PERMIT NO. • • • CITY OF TUKWILA BUILDING DIVISION •6300 Southcenter Blvd., #100, Tukwila. WA 98188 R (206) 431 -3670 Permit Inspection Request Line (206) 431 -2451 Projett 4-in CB -5211 Typ of Inspection: le v v G Pl o t Ad'dr s: �C ok Date Called: Special Instructions: • • . / Date Wanted :. I iv n 4 (� p.m. Requester: Pho 406 —e —D7 73 Approved per applicable codes. ECorrections required prior to approval. COMMENTS: EINSPECTION FEE REQ RED. Prior to ext inspection, fee must be paid at 6300 Southcenter Bl d.. Suite 100. Call to schedule reinspection. i- INSPECTION RECORD Retain a copy with permit INSPECTION NO. PERMIT NO. CITY OF' TUKWILA BUILDING DIVISION 6300 Southcenter Blvd., #100, Tukwila. WA 98188 fik (206) 431 -3670 Perrnit Inspection Request Line (206) 431 -2451 PG r/ Projet .` - / .eect.._ $2LA Type of Inspection: £f v 0,49 t,v "IC Ad ress;.. 5, gip / �`�l Date Called: ----,, Special Instructions: • . ;- • Date Wanted:. (7 ��-^ -'"' a m ( ., p.m. Requester: Phone No: - 760-- 1( -03 '73 giAppr..oved 'per applicable codes. D-Corrections required prior to approval. COMMENTS: Date: R IN PECTION FEE REQU ; ED. Prior to n -xt inspection. fee must be p- id -t 6300 Southcenter Blv... Suite 100. Call to schedule reinspection. • P I If • PLAN REVIEW /ROUTING SLIP ACTIVITY NUMBER: PG11 -079 DATE: 06-08-11 PROJECT NAME: PAC SUN SITE ADDRESS: 650 SOUTHCENTER MALL X Original Plan Submittal Response to Correction Letter # Response to Incomplete Letter # Revision # After Permit Issued DEPARTMENTS: bL t rS uilding vlsiZ on Pte( Fire Prevention Structural Planning Division Permit Coordinator 11 DETERMINATION OF COMPLETENESS: (Tues., Thurs.) Complete Incomplete n DUE DATE: 06-14 -11 Not Applicable Comments: Permit Centerllse Only ' ' • • • INCOMPLETE LETTER MAILED: LETTER OF COMPLETENESS MAILED: Departments determined incomplete: Bldg ❑ Fire ❑ Ping ❑ PW ❑ Staff Initials: TUES/THURS ROUTING: Please Route t Structural Review Required ❑ No further Review Required ❑ REVIEWER'S INITIALS: DATE: APPROVALS OR CORRECTIONS: DUE DATE: 07 -12 -11 Approved ❑ Approved with Conditions Tyl Not Approved (attach comments) ❑ Notation: REVIEWER'S INITIALS: DATE: Permit Center Use Only CORRECTION LETTER MAILED: Departments issued corrections: Bldg ❑ Fire ❑ Ping ❑ PW ❑ Staff Initials: Documents/routing stip.doc 2 -28 -02 Contractors or Tradespeople Pinter 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 HARDESTY & ASSOCIATES INC UBI No. 601423943 Phone 9497232230 Status Active Address 500 E Balboa Blvd License No. HARDEA1066PP Suite /Apt. License Type Construction Contractor City Newport Beach Effective Date 10/17/1994 State CA Expiration Date 11/17/2011 Zip 92661 Suspend Date County Out Of State Specialty 1 General Business Type Corporation Specialty 2 Unused Parent Company Other Associated Licenses License Name Type Specialty 1 Specialty 2 Effective Date Expiration Date Status HARDESI099DGHARDESTY& STONE INC Construction Contractor General Unused 3/7/1991 7/2/1993 Archived Business Owner Information Name Role Effective Date Expiration Date HARDESTY, ROBERT D Cancel Date 01/01/1980 Bond Amount HARDESTY, ROBERT E 7 01/01/1980 wa13466 HARDESTY, WILLIAM S Until Cancelled 01/01/1980 HARDESTY, LORI A /2009 01/01/1980 PLATTE RIVER INS CO ALLEY, RICHARD Agent 01/01/1980 09/01/2009 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 7 MERCHANTS BONDING CO (MUTUAL) wa13466 09/08/2009 Until Cancelled $12,000.0009/14 /2009 6 PLATTE RIVER INS CO 40069657 09/01/2003 Until Cancelled 09/01/2009 $12,000.00 09/08 /2003 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 16 SCOTTSDALE INS CO BCS0023302 10/25/2010 10/25/2011 $1,000,000.00 10/25/2010 15 SCOTTSDALE INS CO BCS0020742 10/25/2009 10/25/2010 $1,000,000.00 10/27/2009 14 FIRST SPECIALTY INS CORP IRG57154 10/25/2008 10/25/2009 $1,000,000.00 10/31/2008 13 STEADFAST INS SC03557421 08 10/25/2006 10/25/2008 $1,000,000.00 10/25/2007 12 TOEADFAST INS SC03557421 07 10/25/2006 10/25/2007 $1,000,000.00 10/30/2006 11 CO ADFAST INS SC03557421 06 10/25/2004 10/25/2006 $1,000,000.00 10/27/2005 Summons /Complaint Information No unsatisfied complaints on file within prior 6 year period https: // fortress .wa.gov /lni/bbip/Print.aspx 08/22/2011