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HomeMy WebLinkAboutPermit PG11-123 - CORT FURNITURECORT FURNITEJRE 1230 ANDOVER PK E PG1 1 -123 Parcel No.: Address: City oft'ukwila • 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 3523049069 1230 ANDOVER PK E TUKW Project Name: CORT FURNITURE Permit Number: Issue Date: Permit Expires On: PG11 -123 Owner: Name: Address: Contact Person: Name: Address: Email: GRAY CAT COLLECTIVE LLC 5430 45TH AVE W , SEATTLE WA 98199 MARY RYAN PO BOX 3749 , MISSION VIEJO CA 92690 MARY@PERMITRESOURCES.COM Contractor: Name: BERGMAN BROS Address: 4300 EDISON AV , CHINO CA 91710 Contractor License No: BERGMB *0330N Phone: 949- 582 -3735 Phone: 909 - 627 -3651 Expiration Date: 11/30/2012 DESCRIPTION OF WORK: NEW SEPARATE SEX TOILET ROOM & RELOCATION OF EXISTING SINK & INSTALLATION OF NEW DOUBLE BASIN SINK. Value of Plumbing /Gas Piping: Fees Collected: Electrical Service Provided by: $20,000.00 $325.50 Uniform Plumbing Code Edition: International Fuel Gas Code Edition: Permit Center Authorized Signature: /4/0‘4"� ._ Date: I hereby certify that I have read and ex_ �d thi• rmit and know the same to be true and correct. All provisions of law and ordinances 2009 2009 l/ governing this work will be complied 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 perform o 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: Date: 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 11 -123 Printed: 10 -13 -2011 • • PERMIT CONDITIONS Permit No. PG11 -123 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 -123 Printed: 10 -13 -2011 CITY OF TUKWILA Community Development Department Permit Center 6300 Southcenter Blvd., Suite 100 Tukwila, WA 98188 http://www.TukwilaWA.00v Plumbing/Gas Permit No. 6 II 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 Site Address: Tenant Name: 1 ).3 b A't d ov e�- r�r k Eccs4- C our+ Foe n;\ ur R er�tu l King Co Assessor's Tax No.: Suite Number: Floor: New Tenant: ❑ Yes ❑ ..No Property Owners Name: Mailing Address: City State Zip CONTACT PERSON -!who do outset when you Permit ti r Issued Name: J eetz 1 R•y Mailing Address: �!�i %Z�'�r^ 7 JO c.iuL r Day Telephone: — 1 T 1 132- 3 3� 2d (3 -M -i.JJ o,J ViFo 26`to City J Ag. Z i E -Mail Address: 4Pb12J+►•1rirrIJULAA ll•�1FaxNumber: l /d jv ait?1 PLUMBING / GAS PIPING CONTRACTOR INFORMATION —r Company Name: . V Mailing Address: City Day Telephone: Fax Number: Expiration Date: Contact Person: E -Mail Address: Contractor Registration Number: State Zip ARCIIITECT OF RECORD - AU plans must be stamped -by Architect of Record Company Name: Mailing Address: Contact Person: E -Mail Address: IT O her t &-. L-YO rt A n 1 AS S a C i a-f eS (06 !Slyer- Ro4c1 soik 11,5" SCh :U - Pat"k ZL 6617 6 City S to Zip Day Telephone/: (� 4 7) b r Fax Number: t'l ) 6 7 ( -42.0o Toe 6-ea givr9an Jr• ENGINEER OF RECORD - All plans must be stam,'ped by Engineer of Record Company Name: Mailing Address: Contact Person: Letr_Ctin 8,AKle Inc. OO 6303 ( (It ((Oa Overta., Pie f. City State Zip Day Telephone: \ 13 3 S 3 6 I Fax Number: (.9 13) 3 83-2 g 3 J_ h r'; 5 +o phrr- K. t--C1r Sow E -Mail Address: H.\Applicalions\Fortns- Applications On Line\2010 Applications \7 -2010 - Pltnnbing -Gas Piping Permit Application.doc Revised: 7 -2010 bh Page 1 of 2 • Valuation of Project (contractor's bid price): $ Z4 000 Scope of Work (please provide detailed information): Jt/t +/ CeReet 2VIG 5 crie % /Ger`ROOd( 7 '1-- /261..oL'T,cd of CY /s7t.✓b C/A/0' 4 lvstVL f /v4/ ®F ,v0"14/ 74:uB(4" B.l2R/ S1/4t/K Building Use (per Int'I Building Code): 89-rat /.✓ES f Occupancy (per Intl Building Code): 8 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 ^� d- Shower, single head trap Lavatory 3 Wash fountain Receptor, indirect waste Sinks Urinals Water Closet it 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 1PEYtMi' T1ONJ>` 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 OWNE OR AUTHORIZED AGEN T. Signature: e - nt Name: Mailing Address: f). 0 • g 6 X 14 Pri lDate Application Accepted: C Date: 8 .1!• .i Day Telephone: l 4 • C$ Z• 4 f 37 gtbl e )4' aio.1V.CJ0 City State Zip Date Application Expires: Staff Initials: HAApplicationtTonwApplic Lions On Line \2010 Applications\7 -2010 - Plumbing -0as Piping Permit Applicationdoc Revised: 7 -2010 bh Page 2 of 2 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.TukwilaWA.gov Parcel No.: 3523049069 Address: 1230 ANDOVER PK E TURIN Suite No: Applicant: CORT FURNITURE RECEIPT Permit Number: PG11 -123 Status: APPROVED Applied Date: 08/11/2011 Issue Date: Receipt No.: R11 -02250 Payment Amount: $260.40 Initials: TLS Payment Date: 10/13/2011 03:11 PM User ID: 1670 Balance: $0.00 Payee: B & B CONTRACTORS INC TRANSACTION LIST: Type Method Descriptio Amount Payment Check 70979 260.40 Authorization No. ACCOUNT ITEM LIST: Description Account Code Current Pmts PLUMBING - NONRES 000.322.103.00.00 260.40 Total: $260.40 doc: Receiot -06 Printed: 10 -13 -2011 • r - -- wq City of T ukwila ; Department of Community Development 6300 Southcenter Boulevard, Suite #100 Tukwila, Washington 98188 Phone: 206 -431 -3670 Fax: 206 - 431 -3665 Web site: http: / /www.TukwilaWA.gov Parcel No.: 3523049069 Address: 1230 ANDOVER PK E TUKW Suite No: Applicant: CORT FURNITURE RECEIPT Permit Number: PG11 -123 Status: PENDING Applied Date: 08/11/2011 Issue Date: Receipt No.: R11 -01734 Payment Amount: $65.10 Initials: WER Payment Date: 08/11/2011 11:42 AM User ID: 1655 Balance: $260.40 Payee: RGLA SOLUTIONS INC TRANSACTION LIST: Type Method Descriptio Amount Payment Check 54305 65.10 Authorization No. ACCOUNT ITEM LIST: Description Account Code Current Pmts PLAN CHECK - NONRES 000.345.830 65.10 Total: $65.10 doc: Receiot -06 Printed: 08 -11 -2011 r INSPECTION RECORD Retain a copy with permit INSPECTION NO. PERMIT NO. CITY OF TUKWILA BUILDING DIVISION ti - D&tt z 6300 Southcenter Blvd., #100, Tukwila. WA 98188 (206) 431-36 . Petniit inspection Request Line (206) 431-2451 ,_ Project:: Type of Inspection: Add reSt: ' .1 0 :AN 4 .bexAR f‘z F Date Called: Special Instructions: _ • •• • .. .. • . ' Date Wanted:. alh- (.• • p.m. Requester: Phone No: 9 Oc -2.02 -52 ao - 'proved per applicable codes. COMMENTS: • . Corrections required prior to approval. • Fler 4 (to....N • ri RElf1SPCTION FEE REQUIRED. P ior to rlext inspection. fee must be pai a)4300 Southcenter Blvd.. Suite 100. Call to schedule reinspection. • INSPECTION RECORD Retain a copy with permit IN ECTION -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 d► ?//-/2 3 Pro ect: (t # 1 /i? /RF Type of Inspection: tt..AM,L.... Corrections required prior to approval. Address: • • . /0236 4AideWQ PA( 6 Date Called: COMMENTS: Special Instructions: • • • 4 Date Wanted: . /2 — 2/- / / Requester: Phone go ' -205- 522() ' Approved per applicable codes. Corrections required prior to approval. COMMENTS: • a.- „. „.....,,,, 1 IIns•ecto Date: 1 / ► A.i e /2- d 6 // E j SPECTION FEE REQ0IRED. Prig to next inspection. fee must be paid at 6300 Southcenter Blvd.. Suite 100. Call to schedule reinspection. 1 INSPECTION NO. INSPECTION RECORD Retain a copy with permit a 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 Project: ,_� (� / ( � /A.)!Ili/ e Typ of Inspection: /v Q v f tE' C't...),`" Y Address: l2_ 0 loki6tikio £. Date Called: Special Instructions: / Date Wanted:. —.---1.m ,. / 1 —2-3 -1 ( p.m. Requester: Pho7 S No_,3140S -I5'O1 Approved per applicable codes. Corrections required prior to approval. COMMENTS: ,of 1r ,A__5 RA U f Inspector: Date: ! t 2 ? -- REINSPECTION FEE REQUIRED. Prior to next inspection, fee must be paid at 6300 Southcenter Blvd., Suite 100. Call to schedule reinspection. • 4• • 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 P61( -IZ3 Project: a- Ff'a,`7V'e Typ f Inspection: 1 uSFr PL.) 418 --- Address: iii i A .06oui_s t. Date Called: Special instructions: 0.53-6 '" • (.o 0" . Date Wanted: a.m. i( - Z Z —l� --�- Requester: Phone No: S _ 3 '4 O _ j rg ( �• 7 d Approved per applicable codes. Corrections required prior to approval. 4 COMMIENT5:. 0 Al /) . _1. % 0 a �J A • f> /•'0 )i_LA:- . •\ / -a( A &) . ''. ,9.�`�'-" e„, •0 n . ? P ) `F1 v (.1- r•_)`'24 • -4(.. ACe4 A .1..) Iv .,1--- ,-- ..,- To.....;.1( I i ..iki Inspector: 6tA - .10 Date:' I ? REINSPECTI ©N FEE REQUIRED. Prior to next inspection, fee must be • paid at:6300 Southcenter Blvd.. Suite 100. Call to schedule reinspection. • u :INSPECTION RECORD '.':•'`.:Retain a copy with permit Rr..• INSPECTION NO: • ' ':•.: CITY •OF'TUKWILA BUILDING DIVISION s. •. 6300 Southcenter Blvd., #100, Tukwila. WA 98188 t (206) 431 -3670 .• .Permit Inspection' Request Line (206) 431 -2451 11 t , t, i� PG( -123 PERMIT NO. • Pro ' =t:. •. --4 r. •f Typ of Inspection: ZDL16it mac/ PLJibt13 Address:. • - . . t 3 O .. o fir• F, ; . Date Called: Special • Instructions: - ' • . Date Wanted: . / I'r i 1 p.m. Requester: Phone O :� — 72•0ge— 6 f 10 Approved per applicable codes. a Corrections required prior to approval. COMMENTS: :,,i- 1 N o0 .erV B(04 it IR ItAk i)-. • NSPECTLON FEE RE IRED. Dior to next inspection, fee must be id at 6300'Southcente Blvd., Suite 100. Call to schedule reinspection. 1 L. •: INSPECTION. NO. INSPECTION RECORD Retain a copy with permit 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: i t1t2'43,1ti. Type of Inspection: GI�dk1n�tJ td0 Address: - • lX2te- ci.S CVVe dZ Pic L Date Called: Special .instructions: • . . • Date Wanted:. 1i-1-1( am. p.m. Requester: Phone No: ,a..5 3- y05 -3q —i 1 Approved per applicable codes. QCorrections required prior to approval. • 'COMI�1tEt S: !Date: !I- 7 •- 1 fE }ISPECTION FEE REQUi ED. Prior o next inspection. fee must be p4id at 6300 Southcenter Blv& Suite 100. Call to schedule reinspection. • Citj' of Tukwila Jim Haggerton, Mayor Department of Community Development Jack Pace, Director August 22, 2011 Mary Ryan Permit Resources PO Box 3749 Mission Viejo, CA 92690 RE: Correction Letter #1 Plumbing /Gas Piping Permit Application Number PG11 -123 Cort Furniture —1230 Andover Pk E Dear Ms. Ryan, 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. 1 have enclosed comments from the Public Works Department. At this time the Building Department has no corrections. 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. Sincerely, � P Bill Rambo Permit Technician encl File: PG11 -123 W:\Pennit Cen ter \Correction Letters \2011\PGI1 -123 Correction Letter #1.doc 6300 Southcenter Boulevard, Suite #100 • Tukwila, Washington 98188 • Phone: 206 - 431 -3670 • Fax: 206 - 431 -3665 PUBLIC WORKS DEPARTMENT COMMENTS DATE: August 17, 2011 PROJECT: Cort Furniture 1230 Andover Pk East PERMIT NO: PG 11 -123 PLAN REVIEWER: Contact Joanna Spencer (206) 431 -2440 if you have any questions regarding the following comments. 1) Applicant shall submit attached Non - Residential Sewer Use Certification form executed by the owner or his representative. Please list only new plumbing fixtures and not the ones being replaced in kind. W :Other /Joanna /PG 11 -123 HERMIT COORD CAPS PLAN REVIEW /ROUTING SLIP ACTIVITY NUMBER: PG11 -123 DATE: 09/16/11 PROJECT NAME: CORT FURNITURE SITE ADDRESS: 1230 ANDOVER PK E Original Plan Submittal Response to Incomplete Letter # X Response to Correction Letter # 1 Revision # after Permit Issued L DEPARTMENTS: Buildi g Division b is Works Fire Prevention Structural Planning Division Permit Coordinator n ❑ DETERMINATION OF COMPLETENESS: (Tues., Thurs.) Complete [Y] Incomplete n DUE DATE: 09/20/11 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 Is* Structural Review Required n No further Review Required n REVIEWER'S INITIALS: DATE: APPROVALS OR CORRECTIONS: DUE DATE: 10 /18 /11 Approved ❑ Approved with Conditions Ek Not Approved (attach comments) Notation: REVIEWER'S INITIALS: DATE: Permit CenterUse Only CORRECTION LETTER MAILED: Departments issued corrections: Bldg ❑ Fire ❑ Ping ❑ PW ❑ Staff Initials: Documents /routing slip.doc 2 -28 -02 • PE T D PLAN REVIEW /ROUTING SLIP ACTIVITY NUMBER: PG11 -123 PROJECT NAME: CORT FURNITURE SITE ADDRESS: 1230 ANDOVER PK E X Original Plan Submittal Response to Correction Letter # DATE: 08 -11 -11 Response to Incomplete Letter # Revision # After Permit Issued DEPARTMENTS: -Btalldin" "Divi ion �uublic orks Fire Prevention Structural Planning Division Permit Coordinator n DETERMINATION OF COMPLETENESS: (Tues., Thurs.) Complete Incomplete DUE DATE: 08-16-11 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: nNo further Review Required DATE: n APPROVALS OR CORRECTIONS: DUE DATE: 09-13-11 Approved ❑ Approved with Conditions n Not Approved (attach comments) Notation: REVIEWER'S INITIALS: DATE: Permit Center Use Only CORRECTION LETTER MAILED: ). ).—tt Departments issued corrections: Bldg ❑ Fire ❑ Ping ❑ PW 'Cr 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 Fax: 206 - 431 -3665 Web site: http://www.ci.tukwila.wa.us Revision submittals must be submitted in person at the Permit Center. Revisions will not be accepted through the mail, fax, etc. Date: q- /•Z • 11 Plan Check/Permit Number: PG 1 1-123 ❑ Response to Incomplete Letter # ® Response to Correction Letter # 1 ❑ Revision # after Permit is Issued ❑ Revision requested by a City Building Inspector or Plans Examiner Project Name: Cort Furniture Project Address: 1230 Andover Pk E Contact Person: As/40y itY4A1 Phone Number: alsiq• $82.3/35 Summary of Revision: /UM./ AEc1'/ t:,‘ EAtTi441+ tar Cmm , OF r t,A SEP16Zp» '-'6444114744 To, CeKti.P. cs41 " 0, . Sheet Number(s): "Cloud" or highlight all areas of revision including date of revision Received at the City of Tukwila Permit Center by: ql, Entered in Permits Plus on r r \applications \forms- applications on line \revision submittal Created: 8 -13 -2004 Revised: King County Department of Natural Resources and Parks Wastewater Treatment Division • Non - Residential Sewer Use Certification • To be completed for all new sewer connections, reconnections or change of use of existing connections. • This form does not apply to repairs or replacements of existing sewer connections within five years of disconnect. Please Print or Type For King County 17�e Only Account # No. of RCEs Monthly Rate Property rty S et 0 Address bO)E, P Property Tax ID # 352 30 14 r c, l W/ • 6/86 City State ZIP 1..c6 d rkli0 Owner's Name Subdivision Name Lot # Subdiv. # Block # Building Name ` (if applicable) ( ) Vi` • i. t3 t `� Owner's Phone Number (with Area Code) ( y2 , �, 1$ t6 Property Contact Phon Number (with Area Code) Owner's Mailing Address Li %I•�ti�1k C••oct.lw -�G S ,�,�Was Sewer connected before 2/1/90? ❑ Yes ❑ No '� 3 Sewer disconnect date: ti/�, �� ' / S t6- I`� O Type of building demolished? '�Y�'il/l.Pi�llh�1� , tk /3 50 0 6 Request to apply demolition credit to multiple buildings? ❑ Yes ❑ No Party to be Billed (if different from owner) City or Sewer District / t. k�''V /t 4 Date of Connection Side Sewer Permit # Please report any demolitions of pre - existing building on this property. Credit for a demolition may be given undersom circumstances. Demolition of pre- existing building? ❑ Yes 11d1Vo Was building on Sanitary Sewer? ❑ Yes ❑ No 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 Z Z Hose bibb (interior) 2.5 2.5 Clotheswasher or laundry tub 4 2 Sink, bar or lavatory 2 1 1 % Sink, Clinic flushing 8 8 Sink, kitchen 3 2 Sink, other (service) 3 1.5 I 1.6 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 1, 1 Water closet, tank or valve, >1.6 GPF 8 4 Total F'xture Units 11.G B. Other Wastewater Flow (in addition to Fixture Units identified in Section A) Type of Facility /Process: GT1e(1 L '�l t 1-t t LC— 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 Equival (add A & B) su162011 'ERMIT CENTER Residential Customer Equivalent (RCE) C 0 R R E C 10 w 20 fixture units equal 1.0 RCE RCE No. of Fixture Units = RCE LTR# n' `'S 20 fro 12-ct RCE A B o v Total N IHZ2 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 corrected data for determination of a revised capacity charge. Signature of Owner /Representative —�,_. Date 9 . I-41 • 1 Print Name of Owner /Representative Y >9. �� 1058 (Rev. 9/07) White — Kinn County Yellow — Local Sewer Aoencv Pink — Sewer Customer Contractors or Tradespeople Pier Friendly Page • General /Specialty Contractor A business registered as a construction contractor with LEI 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 BERGMAN BROS UBI No. 601817190 Phone 9096273651 Status Active Address 4300 Edison Avenue License No. BERGMB'033ON Suite /Apt. License Type Construction Contractor City Chino Effective Date 9/15/1997 State CA Expiration Date 11/30/2012 Zip 91710 Suspend Date County Out Of State Specialty 1 General Business Type Corporation Specialty 2 Unused Parent Company B Et B CONTRACTORS INC Business Owner Information Name Role Effective Date Expiration Date BERGMAN, MARK C Cancel Date 01/01/1980 Amount BERGMAN, DANIEL L 11 01/01/1980 C2088538603 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 4 WESTERN SURETY CO 69595078 10/03/2003 Until Cancelled $12,000.00 10/24/2003 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 11 National Fire and Marine Ins C C2088538603 08/31/2008 08/31/2012 $1,000,000.00 09/01/2011 10 VALLEY FORGE INS CO 2093452205 08/31/2007 08/31/2008 $1,000,000.00 08/30/2007 9 LIBERTY INS EGLSF184569025 08/31/2005 08/31/2007 $1,000,000.00 09/18/2006 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 /Print.aspx 10/13/2011