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Department of Labor and Industries <br />Elevator Section <br />F <br />PO Box 44480 <br />_ <br />Olympia WA 98504-4480 <br />Phone: 360-902-6130 <br />Fax: 360-902-6132 <br />www.Elevators.Lni.wa.gov <br />Oew ❑ Alteration ❑ Annual <br />❑ Non -Annual <br />Permit Valid " / 1 Q Z <br />Permit ID # <br />, � 9 3 5- <br />Date <br />Building or Location Name� i <br />Altion <br />�/ l� <br />Cf 1Building <br />or LAddress <br />'l <br />U der w� <br />Installer's Name and City <br />D / <br />Description of Alternation: <br />Inspection Report <br />*One Conveyance per Report <br />❑ 30-Day Permit ❑ Other: <br />Inspectio9 R_ep yested Date Insp <br />6'3//Y/20- <br />Code Box ❑ A-13 <br />Correction Notice A: 00 <br />Print Contact Name <br />Print Mechanic's NE <br />Contact's Signature <br />Mechanic's Signature <br />'Z __- <br />Y <br />Conveyance nu <br />Location Number <br />Gs1.e 3 <br />fL <br />•O 2 3 <br />and Type <br />Reinspection Hours <br />❑ Invoice May Follow <br />MI� 4 C o L J ice_ Inspector's Signature <br />G) t_ 1 , (-,I .\C t L�t <br />Contact Phone Number <br />Mechanic's License Number <br />rvtc.+�owv�C- �+L <br />1I A, <br />Print Inspector's Nam <br />D I/1it Index EIRPT <br />�_o <br />F621-002-000 Inspection Report 02-inspector Pink — On -Site Representative <br />White — Central Office Canary — <br />