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• <br /> -3 Department of Labor and Industries `1'ZS �`l b r 132-0 AYY` <br /> Electrical Licensing&Certification it ELECTRICAL INSPECTION <br /> PO Box 44460 K. <br /> ----- Olympia,WA 98504 4450 ,. WITNESS STATEMENT <br /> • www.Lni.wa.gov/scs/eleetricat <br /> Please answer as many of the questions beio*as you can. Altho <br /> any information you can supply will help us with our investi ugh yqu may not be able to answer all the questions, <br /> investigation. You may.attach an extra sheet if needed. <br /> . Name: - <br /> • <br /> Mailing Address: R A e. l....-11 C <br /> a - e 0 State Zip Code <br /> Telephone Number y',g 5 j y 3 2 7 - g 4 4, c, - • <br /> Location of electrical work done <br /> C Ve-g =-T w r ! v . <br /> Date electrical work was done: — a.(�_ ` <br /> RECEIVED <br /> Who performed electrical work? TO NY 1,0,_ 13 i , (..--E : OCT 16 <br /> 2014 <br /> .What type of electrical work was done?(Be specific) bayi.&I <br /> SE /4-7-7"..r4-c /fet3 ...s-fie-e7— • <br /> Was payment made on work done? 0 No 0 Yes <br /> If yes,please indicate method of payment Q Credit card ❑Check CI Cash ❑Other—=plainbelow <br /> • <br /> Doyon have any additional information? <br /> 0 No gYes If yes,please add additional information <br /> EC' -4cff Sf(e�� <br /> Do you have any additional witnesses? 0 No BYes If yes,please add information below <br /> Name: 1'� <br /> 04'9 R t G c5 o N Cs 1.....7 J..,E� (k\c, 1/4k-r- c,N l-k.E N-t1 rz�. <br /> - Mailmz Address: <br /> City <br /> 9.0-. 'i 58 State Zip Code <br /> AKE 5TEv, s twoA 1205a5 <br /> Telephone Number (— a S - 3 3 5- ci a o 1Name: - <br /> - <br /> ' Mailine Address: City State Zip Code <br /> Telephone-Number Li 5 3a) _ / <br /> Date Sim ' ' <br /> F500-087-000 electrical inspection witness statement 7-03 0 <br />