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20130220 Permit Pkg 05312013 o� City of Yelm Permit No.: 20130220 ,� Community Development Department Issue Date: 5/31/2013 �' (Work must be completed within 180 days) Building Division Phone: (360)458-8407 '" `"""'°" Fax: (360)458-3144 Applicant: Name: SOUNDBUILT NW LLC Phone: 253-848-0820 Address: PO BOX 73790 PUYALLUP WA 98373 Property Information: Site Address: 10033 DOTSON ST SE 98 Owner: SOUNDBUILT NW LLC Assessor Parcel No.: 78640109800 Subdivision: TAHOMA TERRA Lot: 98 Contractor Information: Name: SOUNDBUILT NW LLC Phone: Address: PO BOX 73790 PUYALLUP WA 98373 Contractor License No.: Expires: 0/00/0000 Project Information: Project: NEW RESIDENTIAL BUILDING Description of Work: LOT 98, PLAN 2414A-9-2 Sq. Ft. per floor: First 1126 Heat Type(Electric, Gas, Other): GAS Second 1319 Third Garage 629 Basement Fees: Item Contractor Fees NEW RESIDENTIAL BUILDING SOUNDBUILT NW LLC $16,935.77 MECHANICAL SOUND HEATING&AC $ 78.25 PLUMBING RAINIER VIEW ROOTER $ 125.00 TOTAL FEES: $17,139.02 ApplicanYs Affidavit: OFFICIAL USE ONLY I certify that I have read and examined the information contained within the application and know the same to be true and correct. I also certify that the proposed structure is in conformity with all applicable City of #Sets of Prints: Yelm regulations including those governing zoning and land subdivision,and in addition,all covenants, easements and restrictions of record. If a plying as a contractor, I further certify that I am currently Final Inspection: registered in the tate of W s gton. Si nature � Date d� �� i3 Date: Firm By' REC#: Q0128825 5/31%�013 9;30 AM OPER: CO TERM: 001 REF#: 1612� TRAN: 33.0000 BUILDING PERMITS 2013U215 16,994.43CR SDUNDBIJILT NW LLC 9871 QOTSON ST SE 73 Bl.�-RES1 16,784.68CR MECH 84.75CR PL 125.00CR TRAN: 33.00U0 BUILqING PERMITS 2Q130216 17,409.03CR SOl1NDBUILT NW LLC 9877 DOTSqN ST SE 74 BLQ-RFS1 17,182.28CR MECH 87.75CR PL 139.00CR TRAN: 33.OU00 BUILDTNG PERMITS 20�30217 17,488.91CR SOUNDBUILT NW LLC 9919 DOTSON ST SE 80 BLD-RES1 17,285.66CR MECH 78.25CR PL 125.00CR TRAN: 33.00Q0 BUILDING PERMITS 2U130218 16,575.51CR SOUNDBUILT NW LLC 9925 qOTSON 5'f SE 81 BLD-RES1 16,379,26CR MECH 78.25CR PL 718.00CR TRAN: 33.00OU BUILDTNG PERMITS 20130219 17,488.91CR SDUNDBUILT NW �.LC 9531 DOTSON ST SE 82 BLD-RES1 17,285.66CR MECH 78.25CR PL 125.00CR TRAN: 33.00U0 BIJILDING PERMITS 20130220 17,139.02CR SQUNpBUILT NW LLC 1Op33 DOTSON ST 5E 98 BLD-RE51 16,935.77CR MECH 78.25CR PL 125,OOCR TRAN: 33,0000 BUILDTNG PEf�MITS 20130222 16,972,98CR SOUNDBUILT NW LLC 9913 DOTSON 5T SE 7� BI.D-RES1 16,776.73CR MECH 78,25CR PL 118,OOCR TENDERED: 120,Ofi$.79 CHECK APPLIED: 12Q,068.79- CHANGE: � 0.00 YELM COMMUNITY SCHOOLS PO BOX 476 YELM WA 98597 Clerk; Cray Terminal: 1 Recei pt: 210121 Manual Receipt: NSOUNDBUILT NSOUNDBUILT SOUND BUIL.T NW LLC, HOMES PO BOX 7379Q PUYALLUP, WA 98373-0790 5/29/2013 11:44 AM 4ty___, Item Price 1 CPF MITIGATION 3015.00 MITIGATION 05-027/LOT 73/9871 DOTSON ST SE;YELM 1 CPF MITIGATION 3015.00 MITIGATION U5/U27//LO�i 74/9877 DOTSON ST SE; YELM 1 CPF MiTIGATIGN 3015.00 MITIGATION 05J�27/LOT 79/9�113 DUTSON ST SE;YELM 1 CPF MITTGATION 3015.00 MITIGATION 05-027/LOT BO/9919 pOTSUN ST SE;YELM 1 CPF MITIGATION 3015.00 MITIGATION 05-027/LOT 81/9925 nOTSON ST SE;YELM 1 CPF MITIaATION 3015.OU MITIGATION U2-027/LOT 82/9931 DqTSON ST SE;YELM 1 CPF MITIGATION 3015.00 MITIGATION 05-027/LOT 39/10041 JENSEN DR SE,YELM 1 CPF MITIGATION 3015.00 MTTIGATIQN 05-02�1/LOT 97/10027 DOTSON ST SE;YELM Subtotal ; 24120.00 Tax; 0.00 Total: 24120,00 Check 24120,00 16097 CITY UF YE�M �;�vl�0�.��--� RESIDENTU►L BUIL�ING PERMIT APP�ICATION fORM Project Address: /C'U 3 3 /.�tl�-s�,�,ST-.Ss�= Pa�ce�#: 7�SG �� Cj 9�� Subdivision:�� L.,,-,�.c. e r r�.Lot# 9� Pian#:.�t/i�r� 9�> Zon�ng: �New ConstrucGon ; Re-Modei/Re-Roof/Addition Home pccupation S+gn ' Plumbing C; Mechanical �� Mobi{e/Manufactured Home Piacement Other Project DescriptionlScope of Work: �.�..s��-u�-k- 2 s�:��., ,w� � S F� . Project Value:_�,��(Q� _� Building Area(sq. ft) 1� Floor �� 2nd Floor 3/1 Garage � 2-� Qeck Basement Carport �atio ZS�--/ #Bedrooms,,! `J #Bathrooms�� s, Heatin : S/ HEE�or EI.E�;TRiC (Circfe One) Are there any environmentaliy sensitive areas Icx:ated on the p�rca{7 ��--J H y�s, a completed�nvi�mental ch�;iclist rr►u$t accvmpany �rmit applfcation. `'v , 1�.; , ta ADDR�SS ��• ' +� EMAIL 1 t�<L_.� .�`.:�� ,, ��,,Cf{rr,�,�,r 5 c�,��t CITY a� STATE ? ' ZIP ;'S TELEPHONE ,.�' 3 �'a�` C .'<� •�< ,« � L(CENSE# ADDRESS • � _ , EMAIL_`?e•,�:�.c.��t�{�t°c r ;, ''c2,•��;�� ,ac� CITY��'t4��t. a STATE � ZI TELEPHd1T-IE�' n " �o� 7 -: - � �� E��:� t ti i�. TELEPHONE �} i- s..t� �. �;-.�,c ADORESS � ' x 7�79G� EMAIE.. �Lk,y �' .:e:� .��_ bc.;�th ;tr�c; �c.r�t CITY j� �r.��rya STATE t,...; r-1 ZIP �4"s 7"'� FAX ".,�.',5 3 . :. '^ � - [ �t ,.. CONTRACTOR'S UCENSE# ' � � � EXP DATE � �CITY LICENSE# �:�sr� tr �;.c+�: c<�r TELEPH4NE_�..�`�..�i - 93_�-_ j`�<fC::, ADDRESS t G- � �3�+�e:` EMAIL C{TY ;�'�a�c.M � �STATE L4,� ZIP 1�s �� FAX .;��i. 3 ._ �'�.:�s ��t 5_ C(�NTRACT4R' LS ICENSE� �' �n t v ' �' EXP DATE GITY LICENSE � �� ;�c��. 4�..., -� . ,r�.� TELEPHC?NE :`t� r _ y _ ADDRES .�"�.�� t*3'' `5t- t� �,t��.l� � EMAIL ��; �� ,,'.,��- c �zy�;� -- CITY . a. � STATE t,� ZIP�� i 1 �` FAX CONTRACT R'S LICENSE� -.: t ' - EXP DATE CITY LICENSE# ,�-, Copy of mitigaGan agreement with Yelm Community Schools, if applicable. �hKaby c�etlfy thst tl+�abow IrMortnattqn{s cornct snd thst tho constructio�o�.and tM xc►�ancy and tM us�of tM sbow d�serfl�d prop�rty wtti b�(n�ccordsnc�wrtth t1►�t�nws,rul�s and n�Qulitfont at tM StaO�of YVashltpto�snd tM Clty at YNm. �...,r��.C. ,/��:1 � _ Applfa�iM's 3�hsturo + �.,, Data OMmsr/Contrsctor tr's Ag�nt I'�ontncbor's Agsnt(Plsas�circl�ar�e.) A�� Permt�s an non-trsnstenbl�and witl expin if w�ork authorized by such pit�rnit�not bpun within 181?days ot hsuanc�,o�if wark is guspendsd or abartdan�rd for a pstiod af da �� C]��,�� MAY 15 2013 IOS Yet�n Avenue Wes! (960)4 $S Yelrn, WA 9859? (860)438-�1 www.ct.ytlm.rva.ua ,.w..... THOMA �ERRA - PH. 2- DI V. .� _ , tr�� LOT- 98 7�- � � � � ' � /� � W unu E�, �/� EASEMENT ��►�/ �2`� �,`J;� � 6 AP 26s�• � �, � a� ' � , � r'�h � ` i`� �� . O� � � ;�h�o ` ,``�� /�� ,�'�p• ` /� � `` �\, 2p, � O a � � SILT''`��r � r \ S S�S�g. � �-,, ,�_ �cE ,.DRIVEWAY��< .._ dS•• 7 � �; � cca+s,rwc,�oN ., % ' F 6',S. � c�:"�z .k `�, s 0��' � , ,e�p, � �, ,�h . `y' � '�` \ F ' ♦/ � / 3 � `' ; =�' cy�c � � 4,� 1 j q� DR�S� �9. �' �� 'e h ,I�K `,",. ��, � `� � �e� � � � �9 2 / ��' ``� PORCH �� } � / f c`��,�'99\ ' �, / �RO�, ��.., � �9��,q� �,� � �� m ,cy � � � 7S, f ��0' � p �a N. � N a�4� S co �f � �N�4� S6. � ,,� y 3�6oRos — _ �ORYWELWiLt4 D �� Q� O _ — L a� �� h - - _ P�� 5 un�nEs C� �.a1� EASEMENT ��0 �9""�'1i�V EV 7�, - is �135'19'E � Z Z �� Y �� 33 IMPERVIOUS AREA s � / A��,.� ROOF= 2015 S.F. �+----�-• � �'(,-1/� l� DRIVEWAY & _ ..__.....___..._.,.,...,,.�. /�L �C�21 � �� /( SIDEWALK= 1097 S.F. TOTAL= 3112 S.F. LOT S.F.= 6430 � � NOTES: `� � ' � � SCALE: 1"=20' 1. FRONT PORCH FOUNDATION AND STEP TANK LOCATION SHALL BE STAKED OUT FOR SET BACK INSPECTION. O �O 2O 4O 2. STEP TANK IN VIOLATION OF THE REQUIRED CITY OF YELM 5' MINIMUM SETBACK TO FOUNDA110N � THURSTON COUNTY SHALL BE BACK FILLED wi7H C�F. 10033Dotson St SE 3. CONNECT PVC ROOF DRAINS TO DRYWELL. SOUNDBUILT yelm, WA 98597 HOMES, INC. CONTACT INFO P.O. BOX 73790 PARCEL# 78640109800 ANGELA: (253) 848-0820 PUYALLUP, wa 98373 PH: (253) 848-0820 FAX: 253 539-0514 LOT S.F.=6079 PZ 5/21/13 R2.0 Prescriptive Energy Code Compliance for Single Family and Duplex Housing: Zone 1 Project lnformation Contact Information Soundbuiit Homes 2414 This set of forms has been developed to assist permit applicants documenting compliance with the Washington State Energy Code, (2009 edition). This set is for structures built under the IRC and located in Climate Zone 1. The following forms provide much of the required documentation for plan review. The details noted here must also be shown on the drawings (WSEC 104.2). This form is not a substitute for the energy code itself. To obtain a copy of the energy code, go to the following web address. http://www.energy.wsu.edu/code Glazing lo Glazing U-Factor poor 9 2 Vaulted Wall1z Wall•int4 Wall•ext4 5 Slabb Option �'ea : Ceiling 3 Above Below Below Floor on %of Floor Vertical Overhead" U-Factor Ceiling Grade Grade Grade Grade R-49 or R_21 R-21 R-10 �I 13% 034 0.50 0.20 R-38 R-38 Int.� 1'g R-10 R-30 2, Adv. R-49 or R-21 R-21 R-10 �II 25% 0.32 0.50 0.20 R-38 R-38 Int.' TB R-10 R-30 2, Adv. R-49 or R-21 R-21 R-10 OIII Unlimited 030 0.50 0.20 R-38 R-38 Int.' TB R-10 R-30 2, Adv. See WSEC table 6-1 for footnotes Glazing Schedule Attached to Document Does not apply. (SEE INSTRUCTIONS) Usin�Prescriptive Option III.All glazing and � doors meet maximum U-factor.Alternate heating size method submitted. � Option I or II,Glazing to floor area limit(WSEC 602.7.2) � Area weighted window,skylight or door U-factor(WSEC 602.7.2) � As part of the heating system sizing calculation (IRC M1401.3 &WSEC 503.2.2) Radiant slab: ❑ R-10 foam insulatian, continuous with thermal break(WSEC 502.1.4.9) Chapter 9 Options Total of 1 Credit Reauired Opt. O t. Descri tion 1 a Hi h Efficienc HVAC Equipment 1 1 A � 1 b �li h Efficienc HVAC E ui ment 2 � 1c Hi h Efficienc HVAC E uipment 3 � 2 Hi h Efficienc HVAC Distribution S stem � 3a Efficient Buildin Envelo e 1 � 3b Efficient Buildin Envelope 2 � 3c Su er-Efficient Buildin Envelo e 3 � 4a Air Leaka e Control and Efficient Ventilation � 4b Additional Air Leaka e Control and Efficient Ventilation � 5a Efficient Water Heatin R��.�� 5b Hi h Effiecienc Water Heatin � 6 Small Dwellin Unit � 7 �ar e Dwellin Unit MAY 15 2013 � 8 Renewable Electric Ener y "1200 kwh � Total Credits �- 1.00 WSEC Prescriptive Worksheet(2010 edition)Zone 1 WSUEEP10-010 Copyright 2010 Glazing Schedule Project Information Contact lnformation 2414 Conditioned Floor Area 2445 Sum of UA for Heating System Sizing 104.7 Sum of All Glazing Areas From Below 268 Glazing to Floor Area Ratio 10.96% 602.7.2 Exception Ratio(not to exceed 1%)� Exterior poors Plan Component Door Percent Width Height Glazing Door poor ID Descri tion Ref. U-factor Glazed Qt. Feet �"`n Feet �"`n Area Area UA Ent Door '0.200 1 3 6 ' $ 20.0 4.0 ` Fire Door exem t door) D.540 1 '2 8 6 a 17.8 9.6 1 One Exempt Swinging Door<24 Square Feet Sum of Glazing Area, Door Area, and UA (do not inc/ude exempt door) 37.8 13.6 Area Weighted U= UA/Area 0.36 Sum of Area and UA for Heafing system size only(inc/ude exempt door) 37.8 13.6 Vertical Glazing(Windows, Glazed doors using Exception 602.6#1) Plan Component Giazing Width Height Glazing ID Description Ref. U-factor Qt. Feet �"`n Feet �"`n Area UA den 0.340 1'` 5 6' 30.0 10.20 kitchen r 0'.340 1 4 4 6 18.0 6.12 dinin room 0.340 1 6 8 48.0 16.32 dinin room 0:340 '' 1 6 1 6.0 2.04 ' reat room ' 0.340 1 6 6 36.0 12.24 ent °_��' 0:340 1 1 6 6' 9.0 3.06 u er ent 0.340 3 2 2 12.0 4.08 bedroom 3 :: 0':340 1 5 4 s ` 22.5 7.65 bedroom'4/ la room 0.340 1 5 4 6 ' 22.5 7.65 bedroom2 0.340 1 5 4 20.0 6.80 master bath 0.340 1-' S 4 20A 6.80 master bedroom 0.340 1 6 4 ' 24.0 8.16 Sum of Area and UA 268.0 91.12 Area Weighted U= UA/Area 0.34 WSEC Prescriptive Worksheet(2010 Edition) WSUEEPIO-010 Copyright 2010 Overhead Glazing Plan Component Glazing Width Height ID Descri tion Ref. U Qt. Feet �"°h Feet �"°n Area UA Sum of Area and UA Area Weighted U= UA/Area Doube Glazed Garden Windows Section 602.7.2 Exception Plan Component Width Height ID Description Qt. Feet �"`n Feet �"°n Area UA Sum of Area Sum of Area X 3(This tota!is automatically included in the glazing area total.) Glazing UA for Heating System Size On/y=Area X 0.63 WSEC Prescriptive Worksheet(2010 Edition) WSUEEPIO-010 Copyright 2010 Simple Weating System Size: Climate Zone 1 Project Information Contact lnformation Soundbuilt Homes 2414 Indoor Design Temperature 70 Outdoor Design Temperature 17 Design Temperature Difference(OT) 4T=Indoor-Outdoor Design Temp 53 Conditioned Floor Area 2445 Conditioned Volume 21,302 Glazing Copy Sum of UA from Glazing Schedule 105 Attic U-Factor X Area = UA R-49 0.027 1447 39.1 R-38 Advanced 0.026 Single Rafter or Joist Vaulted Ceilings U-Factor X Area = UA R-38 Vented 0.027 � � Above Grade Walls U-Factor X Area = UA R-21 0.056 2760 154.6 Floors U-Factor X Area = UA R-30 0.029 1504 43.6 I Below Grade Walls U-Factor X Area = UA 2' Depth Walls 0.042 3.5' Depth Walls 0.041 7' De th Walls 0.037 �--� Slab Below Grade F-Factor X Len th = UA 2' Depth 0.59 3.5' Depth 0.64 7' Depth 0.57 Slab on Grade F-Factor X Length = UA R-10 2' perimeter 0.54 - R-10 Full-Heated 0.55 Sum of UA 342 Envelope Heat Load 18124 Btu/Hour Sum of UA X 4T Air Leakage Heat Load 12193 Btu/Hour ((Volume X 0.6)X 0�X.018)) Building Design Heat Load 30317 Btu/Hour Air Leakage+Envelope Heat Loss Building and Duct Heat Load ': i 1.15 34865 Btu/Hour If ducts are located in unconditioned space:Sum of Building Heat Loss X 1.15 If ducts are located in conditioned space:Sum of Building Heat Loss X 1 Maximum Heat Equipment Output 150% 52298 Btu/Hour Building and Duct Heat Loss X 1.50 WSEC Prescriptive Worksheet(2010 Edition) WSUEEP10-010 Copyright 2010 � �2Gi,��, �..z� : --- D��t t�sti�� Cal�ula#o� (1�� Cv�s�ru�ti��J _ House address or lot#: �j, � C� � Conditioned Floor Area: �� r : Duct tester (ocation: pQ� _ _ Pressure tap location: �,.�r- 1�Q�?��. Ring (if applicable): Open 1 2 3 � � ,��' �- .- At Roug#�-�n {Tvta� Leakage) Test Method & Test2 � Calculated Stand"aFdl CFM�° �Target Air Handler Present 5 6 CFM�per 100 sf of CFA .06 X CFA 5 CFM� � Air Handier not Pres2nt � • .04 X CFA 5 CFM <_4 CFM�per 100 sf of CFA . � � Post Cor�s��c#ion � � Tes� Metf�od & �TestZ Caiculated � Standardl CFM� Target �. Air Handler Pres�nt(Total•Leakage) ,08 X CF/X_< ' CFiV1 <_S CFiUI�per 100 sf of CFA � , 'S , Air Handler Present(Leakage to Exterior) ,06 X CFA<_ CFM� � <_6 CFM�per 100 sf of CFA -- - 1. Test results must comply with one of the Standards options. 2. Test CFM,�must be e�ual to or less than the calcufates�targs#. � � � A��L�e�� t�s�i�� Cr��(��c�� es#� Standard � � Tested ��culated Test Resul� � � � CFMSo - � • ((� CFM50 X O.Q55)= � CFA X 144))=SLA Q.00!03� S LA ��d -� ��•� G{IV1(j2CI L7�/ ..JT l�= SL.A ' � �� _�-�.�'� GI o55QrJi � � Acug�-�n: After installation of the com�lete air dis7;b�*tion systerrr b!�t before in��!lation oi insulation and sheet roc.'�.. �llo�rrs fas access to al! duct seams and connections for re-e��luation af saa!int�g�it+![T 5i2Y7dard �s not met in intiti�i ts�_ ��s��ns�rn�c39o�: �t or near fina3 inspec�ion. T5e hom�mus be co�rn�l�te enou;fi to�rQssuriza t�e h�or�n�ta 25��. Ta�a�L�aka�=: Agareaation of the entirz systems duct ieakage in a duct t�st. ifla?<agq ta E�flPicra Ag�reg�tion of al! duct system lea4s to th��_rie�o�F ih�CF�,in a dvct tesk. CF�I: Conditioned floor area ��`�,�: Cubic�eet o�r minut�of air lea4aafl az 25�ascals of pr=�.;ure _ ��i�l:o: Cubic feet per rninute of air leakage at 50�ascals o�prassure Pas�a��aa): Llnit o`pr2ssurz � -- SLA: Specific leakage area - .T. ..f � a ' � , , .. � � � �� , � •� Duct Leakage Affidavit Permit#: �-O / � �+ 2"2� House address or lot number: `'J. 1�� 1�1c�'� � ��,� City: ' ��`.C�Y� Zip: Cond. Floor Area (ft2): �y � � Source(circle one): Plans Estimated Measured ❑ Duct tightness testing is not required for this residence per exceptions listed at the end of this document Air Handler in conditioned space? ❑ yes no Air Handler present during test? �s ❑ no Circle Test Method: Leakage to Outside Total Leakage Maximum duct leakage: Post Construction,total duct leakage: (floor area x.08) = CFM@25 Pa Post Construction, leakage to outdoors: (floor area x .06) = CFM@25 Pa Rough-In,total duct leakage with air handler installed: (floor area x .06) _��CFM@25 Pa Rough-In,total duct leakage with air handler not installed: (floor area x .04) = CFM@25 Pa Test Result: ! � CFM@25Pa Ring (circle one ifi applicable): Open 1 2 3 Duct Tester Location: � � Pressure Tap Location: � � I certifiy that these duct leakage rates are accurate and determined using standard duc#testing protocoi. Company Name: �� _Technician� �C�J�-� � � � �. Technicia� Signature� _ Date:��"'� � Phone i�lumber:� �� Washington State Energy Code reference: 503.10.3 Sealing.All ducts,air handlers,filter boxes,and building cavities used as ducts shall be sealed.Joints and seams shall comply �roith Section M1601.3 of the International Residential Code or 603.9 of the International Mechanrca!Code. Duct tightness testing shall be conducted to verify that the ducts are sealed.A signed affdavit documenting the test results shall be provided to the jurisdiction having authority by the testirg agent.N/hen required by the building official,the test shall be conducted in the presence of department staff. Exceptions: 1.Duct tightness test is not required if the air handler and all ducts are located tivithin conditioned spaca. 2.Duct testing is noi raquired if the furnace is a nondirect vent type combustion appliance installed in an unconditioned spac�. A maximum of six feet of connected ductwork in the unconditioned space is allowed.All additional supply and return ducts shall be within the condiiioned space.Ducts outside the conditioned soace shall be sealed with a mastic type duct sealant and insulated on the extarior+r�ith R-8 insulation for above grade ducts and R-5�vater resistant insulation when�,vithin a slab or earth. U N � � O Q N � � � N � � � lf') �-. 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Box 731933 TEST REPORT Puyallup, WA 98373 Cell: (253) 318-3156 Fax: (253) 840-0886 nancy@ccsbat.com NAME: �t4 �D�A" 1 �21�.A L�T- I v SERVICE ADDRESS: I�� I- �t��S'f'L_�?- S� �F C.-I'h LtIA _ LOCATION: ��Q�SS 4� DEwA� K FR�M /�►�f-c T r'2 CROSS CONNECTION CONTROL FOR: ��R�G�-7-/O✓✓ TYPE ASSEMBLY: D� V� MANUFACTURER: fi�gGO MODEL: g-�D SIZE: � r` SERIAL NO.: n � -��S 9� LINE PRESSURE �� P.S.I. ASSEMBLY IS: �NEW ❑EXISTING ❑REPLACEMENT ❑OLD SERIAL NO. I)C�.VA/IiN13A ll('V�#/121'13�1 Rp13A PVBA,/SV�A INITIAL TEST �x�x vni.�-� �o� c��:.s,,.�v�t,�-r:�o,� aiR irri.�:r LEAKED � LEAKED OPENED AT PSID OPENE;D A7 PSID [IOLD'I�IGH1� � HOLD TIGH7� DID NOT OPEN � tll CHECK I'S1D PASSED � cHr.cK v�l_vr-_ FAILED ❑ � , � Psrn � , � ��sm nta��r orc�� xELn nT� ��sln YI�S� NO� I,I�;AKF,D � NEW PAR'TS Cleaned � Cleaned � Cleaned � Cleaned � AND Replaced � Replaccd � Rcplaced � Replactd � REPAIRS TEST AFTER REPAIRS I.rAKI:D � I.I:AKEU � c)PI:N1:D AT PSID AIR INLET f'SID IIOI_D "TIGH�T � HOI.I)TIGHT � lll CHECK PSID CHK VALVE PSID PASSED ❑ i>s►n F�sio FAILED ❑ Is this a proper installation? YES �._ NO Approved Assembly? YES � NO Water Service found ON OFF � Water Service left ON OFF � Confined Space� Remarks: Air Gap Inspection: Supply Pipe Diameter: �� Separation: " Pass ❑ Fail ❑ ❑ Midwest 845-5 10082688 11/30/12 Test Equipment: Make Used � Midwest Model 845-5 Serial No. 06062183 Calibration Date 07/26/12 � Watts TK-99 243078 g-�/- j3 I CERTIFY THE ABOVE EPORT TO BE TRUE: Michael Williams Initial Test By: _ f��`'° Cert. No. B4977 Date 12�� / � Signature Repaired By: Cert. No. Date Repair Test By: Cert. No. Date Signature I cer�i/i�lhat this r•epor•t is acc�ira�e, and 1 liave iised WA('246-290-490 approved�est melhods and test eqtrzpmeiil.