17-105583i f
City of Federal Way
FILE
Community Development Dept.
RANDY THOMPSONNORTHWEST KIDNEY
33325 8th Ave S
STIRRETT JOHNSEN INC
Federal Way, WA 98003
5555 WESTGATE RD NW
Ph: (253) 835-2607 Fax (253) 835-2609
700 BROADWAY
Project Name: NW KIDNEY CENTER -FEDERAL WAY WEST
Project Address: 501 S 336TH ST
Plumbing
Permit #:17 -105583 -00 -PL
Inspection Request Line: (253) 835-3050
Parcel Number: 926480 0240
Project Description: Installation of plumbing fixtures for tenant improvements including level 3 oxygen piping.
Owner
Applicant
Contractor
RANDY THOMPSONNORTHWEST KIDNEY
STIRRETT JOHNSEN INC
STIRRETT JOHNSEN INC
CENTER
5555 WESTGATE RD NW
STIRRJ'281B6 (5/1/18)
700 BROADWAY
SILVERDALE WA 98383
5555 WESTGATE RD NW
SEATTLE WA 98122
SILVERDALE WA 98383
Drains 18 Drinking Fountains 1 Lavatories 9
Other Plumbing Fixtures 6 Showers 1 Sinks 6
Water Closets 2 Water Heaters 1
PERMIT EXPIRES Wednesday, 4 July, 2018
Permit Issued on Friday, January 5, 2018
I hereby certify that the above information is correct and that the construction on the above described property
and the occupancy and the use will be in accordance with the laws, rules and regulations of the State of
Washington and the City of Federal Way.
Owner or agent: 7 Date: S TrA-t 241S•
THIS CARD IS TO REMAIN ON-SITE ►-
Federal Way ,0iA Construction Ins ection Record
INSPECTION REQUESTS: (253) 835-3050
PERMIT #: 17105583 00 Address: 501 S 336TH ST Suite 110
Project: RANDY THOMPSON FEDERAL WAY WA 98003
Scheduled inspections may be failed if this card is not on-site. DO NOT LOSE THIS CARD. Inspections are listed as close to sequential order as possible
(read left to right, top to bottom). Please schedule inspections as appropriate. Work must not be covered until it is approved. Check with your inspector if
YOU are unsure about any of the inspections or the inspection sequence. On-going inspections are logged on the back of this card.
Plumbing Groundwork (4190) Rough Plumbing (4230) Final - Plumbing (4075
Approved to cover Approved Approved
By "� Date By Date By Date 'S
Plough Electrical
Final Electrical
Right of Way
Approved
Approved
Approved
By
Date
By
Date
By
Date
Medical Gas Services, LLC
6355 N E 151 s Street
Kenmore„ WA,98028
425-877-.9623
Medical Gas Line Verification
Report
Date: May 4, 2018
Job Number: 1362
Contractor: 'Stirrett Johnson, Inc.
Date(s) i Time(s) of Testing: May 4, 2018 — 1300hrs
Facility: Northwest Kidney Center Federal Way
501 S336 th ST
Federal Way, WA 9W03
Scope of Work: Installation of new medical oxygen,:system,
Our firm certifies that the verifier named in the report is properly trained and certified to perform
the activities required. All test and measurement equipment is properly calibrated and
maintained. As a representative of Medical Gas Services LLC, the verifier named in this report
has conducted testing and verification of medical gas piping systems and related equipment to
certify the faMowing on the aWve date.
I. General Findings:
A. Medical oxygen is in compliance With NFPA'99 (2012ed): Category 3
B. No crossed lines were found in the medical oxygen system in the tested areas on the
day of testing.
C. Medical oxygen meets minimum concentration.
D. Medical oxygen meets minimum flow and is at normal pressure.
E. Medical oxygen system components, in the area tested are, in compliance with NEPA
99 (2012ed).
(See Note, Comments and Recommendations)
F. Medical Gas Line Purity Test: PASS
G. Purge Gas: Lot #T0619701 (Central)
H. Attachments: Work sheet
Note: Existing Equipment and Systems
NF,PA 0(2012edj #5.1.1.4 — An exisfing system that is,not in strkt,coMpliance
with theprovisions -of this standard shall be;perrnitted to,be continued in use as
long as the authorityhaving jurisdiction has determined that such use does not
constitute a distinct hazard to life.
NWKFW-5.4.18-VR-Medicai Gas Line Pg�. 1 of 2
Medical Gas Services, LLC
6355 NE 151at, Street
Kenmore, WA 98026
425477.13623
II. Medical Gases:
A. Oxygen:
1. Static Line Pressure: 53 psi
2. Dynamic Outlet Free Flow: >3.5 scfm
3. Oxygen Concentration: >99.0%
4. Delta Flow: PASS
M. Particulate Test: PASS
IV. Odor: None
V. Outlets / Inlets: (New)
A. Brand: Amico
B. Quick Connect Style: Ohio
VI. Zone Valves: (New)
A. Brand: Amico
B. Down line gauges: Yes
C. Labeled for Area Controlled: Yes
VII. Alarms:
A. Area Alarms: (New,)
1 Brand: Amico
2. Labeled for Area Monitored: Yes
Vlll. Brazier: Brian Sullivan
A. Brazier Number: SULLIBJ837BQ
B. Contractor: Stirrett Johnson, Inc.
Ix. Comments:
A. No sprinkler system. found in cylinder room.
X. Repom,mendations:
A. Provide some means,of preventing cylinders from exceeding 154F
Tested By: David Pomeranz — ASSE 6030 Verifier
NWKFW-5.4.18-VR-Medical Gas Line Pg. 2 of 2
Medical Gas Services, LLC
Level 3 Verification Check List
Reference NFPA 99(2012ed)
Job #:1362
Facility: Northwest Kidney Center Tested By: DP Test Date: 5.4.18
Facility: ® New ❑ Existing I Type of Facility: ❑ Dental ® Medical ❑ Veterinary ❑ Lab ❑ Other:
RViradirai f=acaa 17 wr)IjF:
Oxygen Line: ® New ❑ Existing
Nitrous Oxide Line: ❑ New ❑ Existing ® NONE
Line Pressure: 53 psi
Concentration: >99 %
Line Pressure: psi
Concentration: %
Flow Test: ( >-3,5 scfm) ® Pass ❑ Fail
Flow Test: SCFH (>:3.5 scfm ) ❑ Pass ❑ Fail
Particulate Test: ® Pass ❑ Fail
Particulate Test: ❑ Pass ❑ Fail
Odor: ® Pass (None) ❑ Fail,
Odor: ❑ Pass. (None) ❑ Fal,
Crossed Lines: ❑ Yes ® No 7Outlet
Brand: Amici
Quick Connect Style: Ohio
Location of Outlets: Wall
Cvlinrlar .gMrarra F-1 NONF
Tank Room: ® New ❑ Existing
Location: ® Inside ❑ Remote
Door Labeled: ® Yes ❑ No
IndiaidualtySecured: Z Yes ❑ No
Cooling Sprinkler: ❑ Yes ® No
1 Hour Rated: ® Yes ❑ No
Separate from Mechanical Equipment: Z Yes ❑ No
Electrical Switches/Outlets 5.above floor: ❑ Yes ❑ No
Volume Connected or Stored: ® <3000 ftp ❑ >30M ft'
Number of Cyrinders'Connected: °OX 8
Ventilation: ® Natural ❑ N/A
Ventilation: ❑ Mechanical ® N/A
2 Openings 1' of Floor & Ceiling: ® Yes ❑ No ❑ N/A
Exhaust Fan Runs Continuously: ❑ Yes ❑ No ® N/A
Minimum 72 int Free Area: Yes. ❑ No ❑ R/A
Draws Air from within V of Floor: ❑ Yes ❑ No 2 N/A
Vented directly to outside: Yes ❑ No ❑ N/A
Fan Connected to Essential Power: ❑ Yes: ❑ No Z N/A
Manifntrf l- NnNF;
Manifold: ® New ❑ Existing
Piping Labeled: ® Yes ❑ No
Brand: Amico
Flex Hoses < 5': ❑ Yes ❑ No / Rigid Copper ® Yes ❑ N/A
Model #: M3EC-S-HH-U-OXY
Check Valve DL of Regulator: ER Yes ❑ No
Serial #: 20180103-0033
Relief Valve5r%Above Norman Line Pres: 0 Yes C'i No �
A'farm / Warn nrr _'CvefaM 7 WnLlF:
Alarm: ® New ❑ Existing ❑ None - Not Required
Non -Cancellable Visual Alarm: ® Yes ❑ No
Brand: Amico
Cancellable Audible Alarm: ® Yes ❑ No
Model M Alert 2
HI / LO Line Pressure Alarm: ® Yes ❑ No
Serial #: NA
i Reserve In Use Alarm I Charge Over: Z Yes ❑ No
NWKFW-5.4.18-Chklst-Level 3 Verification Pg. 1 of 2
Medical Gas Services, LLC
Emergericy Shutoff/Zonae Valve. ❑ NODE
Valve: ® New ❑ Existing ❑ None — Not Required Brand: Amico
3 Part Valve: ® Yes ❑ No With Down Line Gauges: ® Yes ❑ No Sensor Location: ❑ UL ® DL
Labeled: Not Labeled
No Sprinkler Provided
NWKFW-5.4.18-Chklst-Level 3 Verification Pg. 2 of 2
�' 1 1 "OA\�
CROSS -CONNECTION SPECIALISTS, LLC
BACKFLOW PREVENTION ASSEMBLY
TEST REPORT
P.O. Box 731933
Puyallup, WA 98373
Cell: (253) 318-3156
Fax: (253) 840-0886
nancy@ccsbat.com
NAME:
SERVICE ADDRESS: 3D) t -r- 3 3 L -1-4S-r P t tAJ
LOCATION:
CROSS CONNECTION CONTROL FOR: -246 TYPE ASSEMBLY:
1�-r SIZE: ,'� , SERIAL NO.:
MANUFACTURER: MODEL: -.
LINE PRESSURE
P.S.I. ASSEMBLY IS: KNEW ❑ EXISTING ❑ REPLACEMENT ❑ OLD SERIAL NO.
Is this a proper installation? YES
Water Service found ON
Remarks:
NO Approved Assembly? YES
OFF Water Service left ON OFF
Air Gap Inspection: Supply Pipe Diameter: Separation:
❑ Midwest 845-5
Test Equipment: Make Used ❑ Midwest Model 845-5 Serial No.
❑ Midwest 845-5
1 CERTIFY THE ABOVE REPO T TO BE TRUE: Michael Williams
Initial Test By: Cert. No.
Sfonature
Repaired By:
Cert. No
RK
Confined Space ❑
Pass ❑ Fail ❑
10082688 03/20/17
03150654 Calibration Date 0&, 5-- IV
08162654 08/11/17
B4977
Date
Date
Repair Test By: Signature Cert. No. Date
I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment.
DCVA/RPBA
DCVA/RPBA
RPB
A
PVBA/SVBA
INITIAL TEST
CHECK VALVE NO.
I
CHECK VALVE NO.2
AIR INLET
LEAKED
❑
LEAKED
❑
OPENED AT ¢ PSID
OPENED AT
PSID
HOLD TIGHT
E,
HOLD TIGHT
❑
DID NOT OPEN
El
#I CHECK ��
� PSID
PASSED ❑
CHECK VALVE
FAILED ❑
st�
PSID
PSID
AIR GAP OK?
HELD AT
PSID
YES
NO ❑
LEAKED
❑
NEW
PARTS
Cleaned
❑
Cleaned
❑
Cleaned
❑
Cleaned
❑
AND
Replaced
❑
Replaced
❑
Replaced
❑
Replaced
❑
REPAIRS
TEST AFTER
REPAIRS
LEAKED
❑
LEAKED
❑
OPENED AT
PSID
AIR INLET
PSID
HOLD TIGHT
❑
HOLD TIGHT
❑
#1 CHECK
PSID
CHK VALVE
PSID
PASSED ❑
❑
PSID
PSID
FAILED
Is this a proper installation? YES
Water Service found ON
Remarks:
NO Approved Assembly? YES
OFF Water Service left ON OFF
Air Gap Inspection: Supply Pipe Diameter: Separation:
❑ Midwest 845-5
Test Equipment: Make Used ❑ Midwest Model 845-5 Serial No.
❑ Midwest 845-5
1 CERTIFY THE ABOVE REPO T TO BE TRUE: Michael Williams
Initial Test By: Cert. No.
Sfonature
Repaired By:
Cert. No
RK
Confined Space ❑
Pass ❑ Fail ❑
10082688 03/20/17
03150654 Calibration Date 0&, 5-- IV
08162654 08/11/17
B4977
Date
Date
Repair Test By: Signature Cert. No. Date
I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment.
NAME
SERVICE ADDRESS:
LOCATION:
CROSS -CONNECTION SPECIALISTS, LLC
BACKFLOW PREVENTION ASSEMBLY P.O. Box 731933
TEST REPORT Puyallup, WA 98373
Cell: (253) 318-3156
Fax: (253) 840-0886
_ �.� nancy@ccsbat.com
CROSS CONNECTION CONTROL FOR: !y`tCt TYPE ASSEMBLY:
MANUFACTURER: ►" )kT:r!5 MODEL: r �"� SIZE: �" SERIAL NO.:
17
r^
LINE PRESSURE `� P.S.I. ASSEMBLY IS: ANEW ❑ EXISTING ❑ REPLACEMENT ❑ OLD SERIAL NO.
Is this a proper installation?
Water Service found ON
Remarks
YES NO _
OFF
Approved Assembly?
Water Service left ON
YES NO
OFF Confined Space ❑
11 )f
Air Gap Inspection: Supply Pipe Diameter: Separation: Pass ❑ Fail ❑
❑ Midwest 845-5 10082688 03/20/17
Test Equipment: Make Used Midwest Model 845-5 Serial No. v' � /f
03150654 Calibration Date
❑ Midwest 845-5 08162654 08/11/17
I CERTIFY THE ABOVE REF)ORTjT0 BE TRU - Mic ael Williams �+
Of
Initial Test By: Cert. No. 84977 Date
Signature
Repaired By:
Repair Test By:
Cert. No. Date
Cert. No. Date
Signature
I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment.
D_CVA/RPBA
DCVA/RPBA
RPBA
PVBA/SVBA
INITIAL TEST
CHECK VALVE NO.
I
CHECK VALVE NO
2
AIR INLET
LEAKED
❑
LEAKED
❑
OPENED AT 3,, PSID
OPENED AT
PSID
HOLD TIGHT
El
HOLD TIGHT
—2—
DID NOT OPEN
El#1
CHECK 7 PSID
PASSED 'k`
CHECK VALVE
FAILED ❑
/
PSID
PSID
AIR GAP OK?
HELD AT
PSID
6 I GL✓✓
YES E] NO[:]
LEAKED
NEW
PARTS
Cleaned
❑
Cleaned
❑
Cleaned ❑
Cleaned
❑
AND
Replaced
❑
Replaced
❑
Replaced ❑
Replaced
❑
REPAIRS
TEST AFTER
REPAIRS
LEAKED
❑
LEAKED
❑
OPENED AT PSID
AIR INLET
PSID
HOLD TIGHT
❑
HOLD TIGHT
1:1#1
CHECK PSID
CHK VALVE
PSID
PASSED ❑
❑
PSID
PSID
FAILED
Is this a proper installation?
Water Service found ON
Remarks
YES NO _
OFF
Approved Assembly?
Water Service left ON
YES NO
OFF Confined Space ❑
11 )f
Air Gap Inspection: Supply Pipe Diameter: Separation: Pass ❑ Fail ❑
❑ Midwest 845-5 10082688 03/20/17
Test Equipment: Make Used Midwest Model 845-5 Serial No. v' � /f
03150654 Calibration Date
❑ Midwest 845-5 08162654 08/11/17
I CERTIFY THE ABOVE REF)ORTjT0 BE TRU - Mic ael Williams �+
Of
Initial Test By: Cert. No. 84977 Date
Signature
Repaired By:
Repair Test By:
Cert. No. Date
Cert. No. Date
Signature
I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment.
CROSS -CONNECTION SPECIALISTS, LLC
BACKFLOW PREVENTION ASSEMBLY
TEST REPORT
P.O. Box 731933
Puyallup, WA 98373
Cell: (253) 318-3156
Fax: (253) 840-0886
nancy@ccsbat.com
NAME: ' v S -"T t-1
�V >; S
! PW CY C6-A)T
DCVA/RPBA
SERVICE ADDRESS:
�' '�� '(
3 ���
'S% ''t .!?Q� f L it �)A
LOCATION:
I All
CROSS CONNECTION CONTROL FOR: "�6,/ S V a — TYPE ASSEMBLY:_
MANUFACTURER: MODEL. l' 09 SIZE: SERIAL NO.:
LINE PRESSURE P.S.I. ASSEMBLY IS: 1% NEW ❑ EXISTING ❑ REPLACEMENT ❑ OLD SERIAL NO.
Is this a proper installation? YES NO _
1"
Water Service found ON OFF
Remarks
Approved Assembly? YES
Water Service left ON OFF
NO
Confined Space ❑
"
11
Air Gap Inspection: Supply Pipe Diameter: Separation: Pass ❑ Fail ❑
❑ Midwest 845-5 10082688 03/20/17
Test Equipment: Make Used �' Midwest Model 845-5 Serial No. 03150654 Calibration Date '
'7 - 4;,7.
❑ Midwest 845-5 08162654 08/11/17
I CERTIFY THE ABOVE REPO TO BE T?J: Michael Williams
Initial Test By: Cert. No. 84977 Date
Signature
Repaired By:
Cert. No
Date
Repair Test By: Signature Cert. No. Date _
I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment.
DCVA/RPBA
DCVA/RPBA
RPBA
PVBA/SVBA
INITIAL TEST
CHECK VALVE NO.
l
CHECK VALVE NO
2
OPENED AT 3 /"ZIPSID
AIR INLET
OPENED AT
PSID
LEAKED ❑
LEAKED ❑
HOLD TIGHT
E
HOLD TIGHT
13`
DID NOT OPEN
1:1#1
CHECK
�� 7 PSID
PASSED
CHECK VALVE
FAILED ❑
PSID
PSID
AIR GAP OK?
HELD AT
PSID
YES
NO ❑
LEAKED
❑
NEW
PAR'I'S
Cleaned
❑
Cleaned
❑
Cleaned
❑
Cleaned
❑
AND
Replaced
❑
Replaced
❑
Replaced
❑
Replaced
❑
REPAIRS
TEST AFTER
REPAIRS
LEAKED
❑
LEAKED
❑
OPENED AT
PSID
AIR INLET
PSID
HOLD TIGHT
❑
HOLD TIGHT
❑
41 CHECK
PSID
CHK VALVE
PSID
PASSED ElPSID
FAILED ❑
PSID
Is this a proper installation? YES NO _
1"
Water Service found ON OFF
Remarks
Approved Assembly? YES
Water Service left ON OFF
NO
Confined Space ❑
"
11
Air Gap Inspection: Supply Pipe Diameter: Separation: Pass ❑ Fail ❑
❑ Midwest 845-5 10082688 03/20/17
Test Equipment: Make Used �' Midwest Model 845-5 Serial No. 03150654 Calibration Date '
'7 - 4;,7.
❑ Midwest 845-5 08162654 08/11/17
I CERTIFY THE ABOVE REPO TO BE T?J: Michael Williams
Initial Test By: Cert. No. 84977 Date
Signature
Repaired By:
Cert. No
Date
Repair Test By: Signature Cert. No. Date _
I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment.
NAME
CROSS -CONNECTION SPECIALISTS, LLC
BACKFLOW PREVENTION ASSEMBLY
TEST REPORT
P.O. Box 731933
Puyallup, WA 98373
Cell: (253) 318-3156
Fax: (253) 840-0886
nancy@ccsbat.com
SERVICE AC
LOCATION:
CROSS CONNECTION CONTROL FOR: i V✓ «- iTYPE ASSEMBLY:
MANUFACTURER: � � �'> MODEL: � �I��1 �� `SIZE: SERIAL NO.:
LINE PRESSURE P.S.I. ASSEMBLY IS: []NEW ❑ EXISTING ❑ REPLACEMENT ❑ OLD SERIAL NO.
Is this a proper installation? YES NO
Water Service found ON OFF
Remarks:
Approved Assembly? YES Y
Water Service left ON OFF
NO
Confined Space ❑
11 11
Air Gap Inspection: Supply Pipe Diameter: Separation: Pass ❑ Fail ❑
Midwest 845-5 08162654 08/11/17
Test Equipment: Make Used ❑ Midwest Model 845-5 Serial No. 03150654 Calibration Date 02/24/17
❑ Midwest 845-5 10082688 03/20/17
1 CERTIFY THEEAVE REPORT TO B TRUE: Nancy Perry
Initial Test By: �I (A U) � n` -t-' Cert. No. B2463 Date Fj1di
y Signature
Repaired By: Cert. No. PERRYNJ949Q9 Date
Repair Test By: Signature Cert. No. B2463 Date _
I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment.
DCVA/RPBA
DCVA/RPBA
RPBA
PVRAISVBA
CHECK VALVE NO.
I
CHECK VALYE—NO-2
AIR INLET
INITIAL ,NEST
OPENED AT
PSID
OPENED AT
PSID
LEAKED ❑
LEAKED ❑
HOLD TIGHT
❑
HOLD TIGHT
EJ
DID NOT OPEN
❑
#1 CHECK ` �
PSID
PASSED ❑
CHECK VALVE
FAILED ❑
��`
PSID
PSID
AIR GAP OK?
HELD AT
PSID
YES
NO ❑
LEAKED
❑
NEW
PARTS
Cleaned
❑
Cleaned
❑
Cleaned
❑
Cleaned
❑
AND
Replaced
❑
Replaced
❑
Replaced
❑
Replaced
❑
REPAIRS
TEST AFTER
REPAIRS
LEAKED
❑
LEAKED
❑
OPENED AT
PSID
AIR INLET
PSID
HOLD TIGHT
❑
HOLD TIGHT
❑
#1 CHECK
PSID
H
CK VALVE
PSID
PASSED ❑
FAILED ❑
PSID
PSID
Is this a proper installation? YES NO
Water Service found ON OFF
Remarks:
Approved Assembly? YES Y
Water Service left ON OFF
NO
Confined Space ❑
11 11
Air Gap Inspection: Supply Pipe Diameter: Separation: Pass ❑ Fail ❑
Midwest 845-5 08162654 08/11/17
Test Equipment: Make Used ❑ Midwest Model 845-5 Serial No. 03150654 Calibration Date 02/24/17
❑ Midwest 845-5 10082688 03/20/17
1 CERTIFY THEEAVE REPORT TO B TRUE: Nancy Perry
Initial Test By: �I (A U) � n` -t-' Cert. No. B2463 Date Fj1di
y Signature
Repaired By: Cert. No. PERRYNJ949Q9 Date
Repair Test By: Signature Cert. No. B2463 Date _
I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment.
NAME
CROSS -CONNECTION SPECIALISTS, LLC
BACKFLOW PREVENTION ASSEMBLY
TEST REPORT
SERVICE ADDRE S: �---�'
LOCATION:> h l CC
P.O. Box 731933
Puyallup, WA 98373
Cell: (253) 318-3156
Fax: (253) 840-0886
nancy@ccsbat.com
CROSS CONNECTION CONTROL FOR: W' '` -bc �\ TYPE ASSEMBLY:
MANUFACTURER: MODEL_ F SIZE: SERIAL NO.:
LINE PRESSURE �-� P.S.I. ASSEMBLY IS: ❑NEW ❑ EXISTING ❑ REPLACEMENT ❑ OLD SERIAL NO
Is this a proper installation? YES NO _
Water Service found ON OFF
Remarks
Approved Assembly? YES
Water Service left ON OFF
NO
Confined Space ❑
Air Gap Inspection: Supply Pipe Diameter: Separation: Pass ❑ Fail ❑
Midwest 845-5 08162654 08/11/17
Test Equipment: Make Used ❑ Midwest Model 845-5 Serial No. 03150654 Calibration Date 02/24/17
❑ Midwest 845-5 10082688 03/20/17
I CERTIFY THE ABOVE }}REPORT TO IPE TRUE: Nancy Perry
Initial Test By Cert. No. B2463 Date
Signature
Repaired By: Cert. No. PERRYNJ949Q9 Date
Repair Test By:
Cert. No
B2463
Date
Signature
I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment.
DCVA/RPS
�VA/RPBA
RPBA
PVBA/SVBA
CHECK VALVE N0.1
CHECK VALVE NO.2
AIR INLET
INITIAL TEST
OPENED AT
PSID
OPENED AT
PSID
LEAKED
LEAKED ❑
HOLD TIGHT
HOLD TIGHT
❑
DID NOT OPEN
❑
91 CHECK
PSID
PASSED ❑
CHECK VALVE
FAILED ❑
PSID
PSID
AIR GAP OK?
HELD AT
PSID
YES ❑
NO ❑
LEAKED
❑
NEW
PARTS
Cleaned
❑
Cleaned
❑
Cleaned
❑
Cleaned
❑
AND
Replaced
❑
Replaced
❑
Replaced
❑
Replaced
❑
REPAIRS
TEST AFTER
LEAKED
❑
LEAKED
❑
OPENED AT
PSID
AIR INLET
PSID
REPAIRS
HOLD
HOLD TIGHT
❑
HOLD TIGHT
❑
#1 CHECK
PSID
CHK VALVE
PSID
PASSED El
❑
PSID
FAILED
Is this a proper installation? YES NO _
Water Service found ON OFF
Remarks
Approved Assembly? YES
Water Service left ON OFF
NO
Confined Space ❑
Air Gap Inspection: Supply Pipe Diameter: Separation: Pass ❑ Fail ❑
Midwest 845-5 08162654 08/11/17
Test Equipment: Make Used ❑ Midwest Model 845-5 Serial No. 03150654 Calibration Date 02/24/17
❑ Midwest 845-5 10082688 03/20/17
I CERTIFY THE ABOVE }}REPORT TO IPE TRUE: Nancy Perry
Initial Test By Cert. No. B2463 Date
Signature
Repaired By: Cert. No. PERRYNJ949Q9 Date
Repair Test By:
Cert. No
B2463
Date
Signature
I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment.
CROSS -CONNECTION SPECIALISTS, LLC
BACKFLOW PREVENTION ASSEMBLY P.O. Box 731933
TEST REPORT Puyallup, WA 98373
Cell: (253) 318-3156
Fax: (253) 840-0886
(j nancy@ccsbat.com
NAME: ._.� V��-i � V) Tl � Z C,t
SERVICE ADDRESS:
LOCATION:
CROSS CONNECTION CONTROL FOR: -� r�'� S C- TYPE ASSEMBLY:
MANUFACTURER: � t (r MODEL -LF ( is ova SIZE: SERIAL NO.:
LINE PRESSURE P.S.I. ASSEMBLY IS: [NEW ❑ EXISTING ❑ REPLACEMENT ❑ OLD SERIAL NO.
Is this a proper installation? YES
Water Service found ON
Remarks
NO Approved Assembly? YES
OFF Water Service left ON OFF
NO
Confined Space ❑
33
Air Gap Inspection: Supply Pipe Diameter: Separation: Pass ❑ Fail ❑
11 Midwest 845-5 08162654 08/11/17
Test Equipment: Make Used ❑ Midwest Model 845-5 Serial No. 03150654 Calibration Date 02/24/17
❑ Midwest 845-5 10082688 03/20/17
I CERTIFY THE ABOVE REPORT TO BE TRUE: Nancy Perry
Initial Test By: Cert. No. B2463 Date
Signature
Repaired By: Cert. No. PERRYNJ949Q9 Date _
Repair Test By: Cert. No. B2463 Date _
Signature
I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment.
DCVA/RPBA
DC V _ PBA
RPBA
PVBA/SVBA
CHECK VALVE NO.
I
CHECK VALVE N0.2
AIR INLET
INITIAL TEST
OPENED AT
PSID
OPENED AT
PSID
LEAKED ❑
LEAKED ❑
HOLD TIGHT
El
HOLD TIGHT
❑
DID NOT OPEN
❑
#1 CHECK
PSID
PASSED ❑
CHECK VALVE
FAILED ❑
PSID
PSID
AIR GAP OK?
HELD AT
PSID
YES ❑
NO ❑
LEAKED
❑
NEW
PARTS
Cleaned
❑
Cleaned
❑
Cleaned
❑
Cleaned
❑
AND
Replaced
❑
Replaced
❑
Replaced
❑
Replaced
❑
REPAIRS
TEST AFTER
REPAIRS
LEAKED
❑
LEAKED
❑
OPENED AT
PSID
AIR INLET
PSID
HOLD TIGHT
❑
HOLD TIGHT
1:1#1
CHECK
PSID
CHK VALVE
PSID
PASSED ❑
FAILED ❑
PSID
PSID
Is this a proper installation? YES
Water Service found ON
Remarks
NO Approved Assembly? YES
OFF Water Service left ON OFF
NO
Confined Space ❑
33
Air Gap Inspection: Supply Pipe Diameter: Separation: Pass ❑ Fail ❑
11 Midwest 845-5 08162654 08/11/17
Test Equipment: Make Used ❑ Midwest Model 845-5 Serial No. 03150654 Calibration Date 02/24/17
❑ Midwest 845-5 10082688 03/20/17
I CERTIFY THE ABOVE REPORT TO BE TRUE: Nancy Perry
Initial Test By: Cert. No. B2463 Date
Signature
Repaired By: Cert. No. PERRYNJ949Q9 Date _
Repair Test By: Cert. No. B2463 Date _
Signature
I certify that this report is accurate, and I have used WAC 246-290-490 approved test methods and test equipment.
8ECE(VED
PERMIT APPLICATION
CITY Or- V 17 2017
t /�%� NOV PERMIT CENTER + 33325 811 Avenue South +Federal Way, WA 98003-6325
Federal
j% �/ ERAL WAy 253-835-2607 + FAX 253-835-2609 + permitcenterracityoffe.derahaav.com
CITY OF
GDM UNITY DEY 0 MEM'
PERMIT NUMBER —Z _ C D g 3 _ /— TARGET DATE � � � ` � /
SITE ADDRESS
SUITE/UNIT #
501 S. 336th Street, Federal Way, 98003
PROJECT VALUATION
ZONING
ASSESSOR'S TAX/PARCEL #
$
9 2 6 4 8 0_ 0 2 4 0
TYPE OF PERMIT
❑ BUILDING ® PLUMBING El MECHANICAL ❑ DEMOLITION ❑ ENGINEERING ❑ FIRE PREVENTION
NAME OF PROJECT
NW Kidney Center Federal Way West
��'i C-- - /•A 1 O r 1, S �J r— �'1 C -A /1'1� ►^Q r.'� i t
-yl
PROJECT DESCRIPTION
r
'. 14 til
Detailed description of u ork to
I � V7 e• 1 3 (�
be included on this permit only
J
NAME
Randy Thompson RH Foundation Plaza, LLC
PRIMARY PHONE
206-720-3765
PROPERTY OWNER
MAILING ADDRESS
E-MAIL
700 Broadway
randy.thompson@nwkidney.org
CITY
Seattle
STATE
WA
ZIP
98122
NAME
Stirrett Johnsen
PHONE
MAILING ADDRESS 5555 Westgate Rd
E-MAIL
CONTRACTOR
CITY
Silverdale
STATE
WA
ZIP
98383
FAX
WA STATE CONTRACTOR'S LICENSE #
STIRRJ*281 B6
EXPIRATION DATE
05 01/ 18
FEDERAL WAY BUSINESS LICENSE #
20 -04 -100200 -00 -BL
NAME
Melinda Monroe
PRIMARY PHONE
360-308-2080
APPLICANT
MAILING ADDRESS
5555 Westgate Road NW
E-MAIL
melinda.monroe@sjimech.com
CITY
Silverdale
STATE
WA
ZIP
98383
FAX
NAME
Melinda Monroe
PRIMARY PHONE
PROJECT CONTACT
(The individual to receive and
respond to all correspondence
MAILING ADDRESS
5555 Westgate Road NW
E-MAIL
melinda.monroe@sjimech.com
CITY
STATE
ZIP
FAX
Concerning this application)
Silverdale
WA
98383
PROJECT FINANCING
NAME
❑ OWNER -FINANCED
When value is $5,000 or more
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
(RCW 19.27.095)
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I certify that to the best
of my knowledge, the information submitted in support of this permit application is true and correct. I certify that I will comply with
all applicable City of Federal Way regulations pertaining to the work authorized by the issuance of a permit. I understand that the
issuance of this permit does not remove the owner's responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
I further agree to hold harmless the City of Federal Way as to any claim (including costs, expenses, and attorneys' fees incurred in
the investigation and defense of such claim), which may be made by any person, including the undersigned, and filed against the city,
but only where such claim arises out of the reliance of the city, including its officers and employees, upon the accuracy of the
information supplied to the city as a part of this application.
SIGNATURE: l V\ S/., - �J� - —"
DATE
PRINT NAME: Melinda Monroe
Bulletin #100—.lanuary 29, 2016 Page l of 2 k:AHandouts\Pennit Application
VALUE OF MECHANICAL WORK
MECHANICAL PERMIT
Indicate how many of each type offixture to be installed or relocated as part of this project. Do not include existin fixtures to remain.
AIR HANDLING UNITS FANS GAS PIPE OUTLETS OTHER (Describe)
AIR CONDITIONER FIREPLACE INSERTS HOODS (commercial)
BOILERS FURNACES HOT WATER TANKS (Gas)
COMPRESSORS GAS LOG SETS REFRIGERATION SYST
DUCTING GAS PIPING WOODSTOVES
GENERAL INFORMATION
CRITICAL AREAS ON PROPERTY? WATER PURVEYOR SEWER PURVEYOR VALUE OF EXISTING IMPROVEMENTS
No Lakehaven Lakehaven_ 2,312,000
EXISTING/PREVIOUS USE LOT SIZE (In Square Feet( EXISTING FIRE SPRINKLER SYSTEM? PROPOSED FIRE SUPPRESSION SYSTEM?
Office Building 108,820 Yes X No i Yes x No
RESIDENTIAL -NEW OR ADDITION
AREA DESCRIPTION (in square feet) I EXISTING I PROPOSED TOTAL FOR OFFICE USE
FIRST FLOOR (or Mobile Home)
COVERED ENTRY
GARAGE ❑ CARPORT ❑
Area Totals
EXISTING I PROPOSED I TOTAL
ESTIMATED SELLING PRICE $ ( # OF BEDROOMS
Bulletin #100 — January 29, 2016 Page 2 of 2 k:\Handouts\Permit Application
VALUE OF PLUMBING WORK
PLUMBING PERMIT
$ 214,000
Indicate how many of each type offixture
to be installed or relocated as
part of this project. Do not include existinq fixtures to remain.
BATHTUBS for Tub/Shower combo)
9 LAVS (Hand sinks)
2 TOILETS
1 WATER PIPING
DISHWASHERS
RAINWATER SYSTEMS
URINALS
6 OTHER (Describe)
18 DRAINS
_1 SHOWERS
VACUUM BREAKERS
RPBP
1 DRINKING FOUNTAINS
6 SINKS (Kitchen/Utility) �_
WATER HEATERS (Electric)
HOSE BIBBS
SUMPS
WASHING MACHINES
45 TOTAL FIXTURES
GENERAL INFORMATION
CRITICAL AREAS ON PROPERTY? WATER PURVEYOR SEWER PURVEYOR VALUE OF EXISTING IMPROVEMENTS
No Lakehaven Lakehaven_ 2,312,000
EXISTING/PREVIOUS USE LOT SIZE (In Square Feet( EXISTING FIRE SPRINKLER SYSTEM? PROPOSED FIRE SUPPRESSION SYSTEM?
Office Building 108,820 Yes X No i Yes x No
RESIDENTIAL -NEW OR ADDITION
AREA DESCRIPTION (in square feet) I EXISTING I PROPOSED TOTAL FOR OFFICE USE
FIRST FLOOR (or Mobile Home)
COVERED ENTRY
GARAGE ❑ CARPORT ❑
Area Totals
EXISTING I PROPOSED I TOTAL
ESTIMATED SELLING PRICE $ ( # OF BEDROOMS
Bulletin #100 — January 29, 2016 Page 2 of 2 k:\Handouts\Permit Application