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Department of Labor and IndAtries <br />Elevator Section <br />PO Box 44480 <br />Olympia WA 98504-4480 <br />Phone: 360-902-6130 <br />Fax: 360-902-6132 <br />www.Elevators.Lni.wa.gov <br />New ❑ Alteration ❑ Annual <br />r' t <br />Inspection Report <br />ii' *One Conveyance per Report <br />:.b 4 <br />❑ Non -Annual ❑ 30-Day Permit ❑ Other: <br />PermiMtTValid Until <br />'I <br />Permit <br />ID # <br />Date Inspe ion Requested <br />D/ate I spected <br />FBuilding <br />\} <br />or Location <br />Name <br />Co6veyancle Number and Type <br />Building or Location <br />4 ? !D <br />Address <br />1z <br />I <br />9e2U <br />Location umber <br />r <br />illtwreiorff <br />, <br />Installer's Name and City <br />Description of Alternation: <br />Code Box <br />Correction Notice A. r; kr <br />Reinspection Hours <br />❑ Invoice May F0110W <br />Print Contact Name <br />Contact's Signature <br />Contact Phone Numt3er <br />Print Mechanic's Name <br />Mechanic's Signature <br />Mechanic's License Number <br />_— <br />�� <br />Print Inspectors Nam <br />Inspector's Signature f t k + <br />F621-002-000 Inspection Report 02.2015 <br />White —Central Office Canary —Inspector Pink — On -Site Representative <br />Index ElRPT <br />