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Department of Labor Iand Industries <br />Elevator Section <br />PO Box 44480 <br />Olympia WA 985044480 <br />Phone:360-902-6130 <br />Fax:360-902-6132 <br />www.Elevators. Lni wlgov <br />New ❑ Alteration ❑ Annual <br />Inspection Report <br />*One Conveyance per Report <br />N <br />❑ Non -Annual ❑ 304Day Permit ❑ Other: <br />Permit Valid ntil <br />Permit ID # <br />Date Inspection <br />,, 3 <br />Requested <br />, ... v3 <br />Date Ins ected <br />(j Z 3 ZG <br />Building or oca ion Name <br />Conve ance Number and Type <br />Building or Location Address <br />/ <br />11c1 �i�( i%' <br />`Ly 24 <br />Location Number <br />InstallertffNanie and City <br />rrrn� "� <br />ff <br />n / <br />H6Lc / <br />lL <br />Description of Alternation: <br />Code Box Correction Notice A: ❑ A-13 ��' <br />rlti�BS,C�I l�1L� 00 ef01M 1 <br />i <br />Reinspection Hours <br />❑ Invoice May Follow <br />Print Contact Name <br />Contact's Signature <br />Contact Phone Number <br />Print Mechanic's Name <br />Mechanic's RSignature. <br />Mechanic's License Number <br />Print Insd Name <br />p <br />1� <br />Inspector's'Signature <br />r) e <br />I <br />F621-002-000 Inspection Report 02-2015 <br />White —Central Office Canary —Inspector Pink — On -Site Representative <br />Index EIRPT <br />