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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