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0 Washington State Department of Boiler/Pressure Vessel/Water Heater <br /> Labor & Industries '`-Installation or Reinstallation Permit <br /> Boiler Section NOV0 a 2a19 <br /> PO Box 44410 Submit one permit for each object installed. <br /> Olympia WA 98504-4410 : i= ,,.--1 Installer responsible for permit fee of $56.16 <br /> Phone: 360-902-6400 <br /> Email: Boiler@Lni.wa.gov For L&I Use Only— Permit Number: <br /> www.Lni.wa.00v/Boilers <br /> Link to form instructions Invoice Number: <br /> Section A. Installer applying for permit completes this section only. <br /> 1. Installer Permit Billing Info 2.Owner 3, Location of Installation <br /> Name Name <br /> f ` cc & t�G�rt v Name <br /> YM m t+Cv 1�i1i-E C�rt tel� �i _Lep\Y1n(i,c,. Cc (s,A,A, Ctv.,t. <br /> Street Address Street Address Street Addr <br /> 93:1 C �� �-In b.f- SL ago I 14 `�-- / .-ve 1 4 IA <br /> City, tate,Zip Code {� c City, State,Zip Code` p City, State, i Code <br /> 6� v\,A` r\ l g 0 A \ C. v e.r'e' i\ ` g'ozo / L\,e s tt-'. w A 49&a <br /> 6ontact Na,�}}e/Title I7-Contact Name/Title C tact Name/Title <br /> r.40 /<owtc.14-U `MCA yep Uane 0\pAC <br /> Office Number Phone Number Phone Number <br /> Vols^ 37c3 ‘ 70o f as- 90 S--- ?70 1 'Aa,S- 01) 6 )ef0 <br /> Cell Number Cell Number Cell Number <br /> 1 r' 33_5— 7Ac <br /> Email Address !- Email Address Email Address <br /> is i a•n, iZ o ork a.ro g .:J CI:0111E\ <br /> 4.Contractor Registration# 5.Type- is oiler 6.Location in Building <br /> -.mac 0(4 NISCH „2,--)a©S Pressure Vessel Water Heater. 6ckge eq-- <br /> I certify that I will perform the work described above in accordance with: Boiler and Unfred Pressure Vessel <br /> s RCW 71 • and WAC 296 Chapter 104. <br /> \--.. , Mb gc ,0,4 Pc)Arkok ri LD ii ,h, <br /> 7.Installer Signature* 8.Installer Printed Name 9.Date <br /> *Not required if submitted electronically <br /> Section B. L&I Boiler Section Use Only <br /> Date Permit Issued Assigned Inspector Authorized Inspection Agency Phone Number <br /> Verified By Comments/Special Instructions <br /> Section C. Assigned Inspector Use Only <br /> Jurisdiction# Date of Inspection Inspection Type Issue Cert. NCR Certificate Duration <br /> ❑ Ext ❑ Int ❑ Yes ❑ No [' Yes ❑ No ❑ 12 mo ❑ 24 mo <br /> Manufacturer National Board# Serial/Other Number ASME/Other Symbol <br /> Specific Location of Object Type of Object <br /> Fuel Type Input(BTU/KW) Year Build Object Use <br /> MAWP Max Temp MDMT Vessel Size(Sq Ft/HS) Number of SV SV Pressure SV Capacity(units) <br /> Inspector's Name Inspector's Signature WA Commission Number <br /> Comments: <br /> F620-032-000 Boiler/Pressure Vessel/Water Heater Installation or Reinstallation Permit 01-2019 <br /> 1 <br />