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Department of Labor and Industries ' ��,s��`�',..o <br />Elevator Section o�� ,r�,�,_ �y <br />PO Box 44480 � J <br />Olympia WA 98504-4480 ��<; ' ��'� <br />,b�,� � <br />Phone: (360) 902-6130 <br />Elevators.Lni.wa.gov <br />Conveyance Location <br />� � k <br />� � � ��.� `� � �ii bta4.f'�r,°c� N.!' `�6V�•,,�' �.. �r(.�� � <br />� ...� � C�ZS'� �.��CP <br />�� ��1`� � i��:cc�, F.t1� �, ,��s:: <br />� �.1.1 � ' 1 . E ., ���" 1° : � �!� � :_� �F;� � ; �F � )' <br />� , 4 � _ , �. <br />0'`Building Owner or Manager <br />A temporary 30 day operating certificate has been issued <br />Owner must purchase and post an annual operating <br />certificate before the 30 day temporary certificate expires <br />You will receive an application to be completed and <br />returned to L&I with payment. <br />Operating certificates must be conspicuously posted in <br />the conveyance. (RCW T0.87.090). <br />Installing Company <br />.�'- �, _ <br />, .\ ` , ,;=, f. <br />Date - � � � <br />� i�� - �', <br />�; , � <br />F621-034-000 Final Acceptance 02-2015 <br />White — Owner Canary — Contractor Pink — L&I <br />Final Acceptance <br />Submit one form per <br />Conveyance # � ' <br />Location (car #, etc.) <br />B � 5���c�zs� <br />ievance ,. <br />�;'� <br />❑ A-13 Re-inspection <br />Number of Re-inspection Hours Ins <br />, ,� <br />�` L 4 ! <br />�� <br />❑ Private Residence Owner <br />You are not required to purchase an annual operating <br />certificate. <br />If you would like an annual safety inspection, you may <br />purchase an annual operating certificate and receive an <br />inspection. <br />Print Name (Installer's Name) License # <br />� ; <br />� <br />;�_�: ��_�. ( '. .�. ; . ����` �;` ��'��� <br />�, G.� <br />Installer's Signature <br />� st: � <br />Index: EIRPT <br />