HomeMy WebLinkAboutPermit M2000-116 - FOSTERVIEW ESTATES - LOT 14id LET S 9t7Zt7
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C of Tukwila (206) 431-3670
Community Development / Public Works • 6300 Southcenter Boulevard, Suite 100 • Tukwila, Washington 98188
Permit No: M2000 -116
Type: 8 -MECH
Category: RES
Address: 4246 S 137 PL
Location:
Parcel #: 261200 -0140
Contractor License No: DUJARD *204L0
MECHANICAL PERMIT
TENANT FOSTERVIEW ESTATES - LOT 14 Phone:
4246 S 137 PL, TUKWILA, WA 98188
OWNER DUJARDIN DEVELOPMENT CO Phone: 425 - 334 -5018
PO BOX 5308, EVERETT WA 98206
CONTACT JOHN KAPPLER Phone: 425 -641 -5320
14311 SE 16 ST, BELLEVUE, WA 98007
CONTRACTOR DUJARDIN DEVELOPMENT CO
PO BOX 1059, SNOHOMISH WA 98291
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Permit Description:
Perm
F.A. GAS FOR NEW SINGLE FAMILY RESIDENCE.
UMC Edition: 1997 Valuation:
Total Permit Fee:
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Signature:
Print Name;
.....
enter(;1,thori :ed Signature
Status: ISSUED
Issued: 08/21/2000
Expires: 02/17/2001
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-- :421:0 . a ..... -_
Date
I hereby certify that I have read and examined this permit and know the
same to be true and correct. All provisions of law and ordinances
governing this work will be complied with, whether specified herein or not.
The granting of t h i s permit does not presume to g i v e aL thor i ty to violate
or cancel the provisions of any other state or local laws regulating
construction or the perf or° ante of work, I am authorized to s i g n for and
obtain this i l:+ erm t .
4,000.00
61.19
Date:
aLe : mmcz - i t 1 e_i aus se•+�r �.a+a an: ac eta w.m ....... e:
This permit shall become null and void If the work 1s not commenced within
180 days from the date of issuance, or If the work is suspended or
abandoned for a period of 180 days from the last inspection,
Address: 4246 S 137 PL
Suite:
Ter #ant: FOSTCRVIEW ESTATES LOT 14
Type: B -MECH
Parcel N: 261200-0140
CITY OF TUKWILA
Permit No: M2000 --1 16
Status: ISSUED
Applied: 06/01/2000
Issued: 08/21/2000
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Permit Conditions:
1. Any exposed Insulations backing material shall have a Elaine
Spread Rating of 25 or less, and material shall bear identi-
fication showing the fire performance rating thereof,
Plumbing permits shall be obtained through the Seattle -King
County Department of Public Health. Plumbing will be
inspected by that agency, including all gas piping
(296- 4722).
3 . E l e c t r i c a l permits shall be obtained through the Washington
State Division of 'Libor and Industries and all electrical
work will be inspected by that agency (248 - 6630).
APPLIANCES, WHICH GENERATE A FLAME, SPARK OR GROWING
IGNITION, SHALL BE ELEVATED 18 INCHES ABOVE THE FLOOR,
U.M.C. 303.1.3.
5;. WATER HEATER SHALL BE ANCHORED TO RESIST EARTHQUAKE, U.P.C.
510.5.
6 . No • changes w i l l be made to the plans un l ess approved by the
Engineer and the Tukwila Building Division.
7, All permits, inspection records, and approved plans shall be
available at the job s i t e prior to the start of any con-
struction, These documents aro to be maintained and avail-
able until final inspection approval is granted.
A11 construction to be done in conformance with approved
plans and requirements of they Uniform B u i l d i n g Code (1997
Edition) as amended, Uniform Mechanical Code (1997 Edition),
and Washington State Energy Code (1997 Edition).
9, Validity of Permit. The issuance of a permit or approval of
plans, specifications, and computations shall not be con-
strued to be a permit fur, or an approval of, any violation
of any of the p r o v i s i o n s of the building code or of any
other ordinance of the jurisdiction, No permit presuming to
give authority to violate or cancel the provisions of thi
code shall be valid,
10, Manufacturers installation •instructions required on site
for the building inspectors review.
Project Name enant:
5 }U■ V t GLA !IS 1.k5 1-04 o 1
Value of M �` u}'�t:
`_ ` '
Site Addres `, ��. t h C._. • City
`F 2 500 a _
State/Zip:
Tax Parcel O! �
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Phone: ( )
•
Property Owner
Street Address: City State/Zip:
Fax #: ( )
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Fax #: (
Contracto
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0 ar IDe,.veJ o-pme n I
Phone: (yz-S)
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City / State/Zip:
Street A d dress: r d� 6V� 6J Ci , State/Zip:
Fax #: (�/2.S)
Contact` rsonp � , t'4'
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Street Addres : r C'
61-
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te/Zip:
'1 6067
Fax #: ( 2.6-) 2.6-)
Cot 11 -. 1s .
DU!LWINO OWNER.OR AUTHORIZE A ,ENTt
`_ ` '
Signature.
Dale:
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Print name: _ _a
Address:
te'• , u l. � r ex
Phone: (
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Fax #: (
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City / State/Zip:
CITY OF TU, VILA
Permit Center
6300 Southcenter Boulevard, Suite 100
Tukwila, WA 98188
(206) 431 -3670
Mechanical Permit Application
Application and plans must be complete in order to be accepted for plan review.
Applications will not be accepted through the mail or facsimile.
MECHANICAL:PERMITREVIEW AND APPROVAL REQUESTED: (TO REFILLED OUT RYAtICANT)
Description of work to be done (please be specific):
l/1NQ
sued; perniil.doc
Current copy of Washington State Department of Labor and Industries Valid Contractor's License. If not available at the time of
application, a copy of this license will be required before the permit is issued OR submit Form H•4, "Affidavit in Lieu of Contractor
Registration ".
Building Owner /Authorized Agent: If the applicant Is other than the owner, registered architect/engineer, or contractor licensed by the
State of Washington, a notarized letter from the property owner authorizing the agent to submit this permit application and obtain the
permit will be required as part of this submittal,
HEREBY CERTIFY THAT i HAVE READ AND EXAMINED THIS APPLICATION AND KNOW THE SAME TO DE TRUE UNDER
PENALTY OF PER JURY DV THE LAWS OF THE STATE OF WASHINGTON, AND I AM AUTHORIZED TO APPLY FOR THIS PERMIT.
Expiration of Plan Review • Applications for which no permit is issued within 180 days following the date of application shall expire by
limitation. The building official may extend the time for action by the applicant for a period not exceeding 180 days upon written
request by the applicant as defined in Section 114.4 of the Uniform Mechanical Code (current edition). No application shall be
extended more than once.
Date a plication accepted:
*00
Date application expires:
l f — J
Application by: (initials)
3 ‘)
U)
115
LL
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ifi
§
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P
t3�
✓
Submittal Requirements
Floor plan and system layout
Roof plan required to identify individual equipment and the location of each installation (Uniform
Mechanical Code 504 (e))
Details and elevations (for roof mounted equipment) and proposed screening
' Heat Loss Calculations or Washington State Energy Code Form #H -7
H.V.A.C. over 2,000 CFM (approximately 5 ton and larger) must be provided with smoke detection shut-
off and will be routed to the Fire Prevention division for additional comments (Uniform Mechanical
Code 1009). • .
Specifications must be provided to show that replacement equipment complies with the efficiency ratings
and other applicable requirements of the Washington State Nonresidential Energy Code.
Structural engineer's analysis is required for new and the replacement-of existing roof equipment
weighing 400 pounds and greater (Uniform Building Code 1632.1). Structural documentation shall be
stamped by a Washington State licensed Structural Engineer,
Mechanical Permits
COMMERCIAL: Two complete sets of drawings and attachments required with application submittal
ttrs
otircpiaciof
NOTE: Water heaters and vents are Included in the Uniform Mechanical Code — please include any water
heaters or vents being Installed or replaced.
RESIDENTIAL: Two complete sets of attachments requirea with application submittal
SI{i>Irlittal Rt'(luirpments
New Sin: le Famil Residence
Heat loss calculations or Form H.6.
Equipment specifications.
Chan: e-out or replacement of existing mechanical equipment
Narrative of work to be done includin modification to duct work,
installation of Gas Fire . lace
Narrative with specification of equipment and chimney type.
if using existing chimney, provide a letter by a certified chimney sweep suiting that the chimney is in safe
condition.
NOTE: Water heaters and vents are Included In the Uniform Mechanical Code — please Include any water
heaters or vents being installed or replaced.
**!*14***************** ***k*************** * *k * * * *kk * *k* * * * ***t
CITY OF TUKWILA, WA - TRANSMIT
** h ** * * * * * *k * *• *** k** ** ** * *** * *•*A* **** ** *** * ** * *•k **** * * **** * * * ***
TRANSMIT Number: R010]484 Amount: 47.00 11 /21 /01 09:13
Payment Method: CHECK Notation: PUGET HEATING CO Init: KAS
Permit No: M2000 -116 Type: S -MECH MECHANICAL PERMIT
Parcel No: 261200 -0140
Site Address: 4246 S 137 PL
Total Fees: 108.19
This Payment 47.00 Total ALL Pmts: 108.19
Balance: .00
** k******* k*** k**** kk* *'*** *** * * *A* ** ** * * *4 ** * * * **h ** *A ** * * **
Account Code Description Amount
000/322.800 BUILDING INVESTIGATION 47.00
I MW 11/21
ig
Tti Iti Paym*nt
0 * *4 * *4 ** *J.
Account; Codu
000/ 345.030
000/322.100
U w •S •a r• M si M *1 u. or AN M ON et
aw 45
aq
4: AA*** *00004 * ***** 14 ** * *A* A* * *** *A * *,A4A4k *A *k* *fit**
TV-OF:: TUKWrLA WA ;PANSMIT
J4 'f�.A * * * ** * * *4 * * * *4*h *4a ** :i # #;k * ***AA*A4 *4k*A ** ***
1'MANSMI T Humb+,r s R9f100344 Amounts .- 61.1 i+ OH/21 / 00 0 �q3
;P nt Mothntir E:HCCR. Rotations DJARDXU DEVELOP, Intbs TL8
is Y • t a W_. M r a a r • c r r on M J t • op ra •:• a p a I" a V . • • . r w . • .. r+ t. r a«♦ 1« aa 4. fa a u a r O. 14 •• 44 r u a s q all a:• .1 a w. N•_
ls*rmit Nos M2000 -116 Typo: RAMI:CH MECHANICAL PERMIT
Parcel Nos 261200-0140
it* Addrusia r 4246 0 137 PL
Totn1 Runup 61.19
61.19 1 fv1 tll.l. Pnt.u: 61.19
Bold/nos .00
0' k **11 * * *''S14 *4 **0 *Ir.1 0#*4 *4400d *A*4* *A*4** *440
Dti*t•r* i p It 1 On
PLAN CHECK R KEO
MECHANICAL RES
l (t41t$
1.2.24
40.915
i •a r. a •a +•a • ♦ Of •a k H a a< t r+ • ` a' r• ■a •t A 1a tit •; t. W W 1a a M iS t. •a r r.
7248 01 /23 9710 TOTAL 1772 ■04
;S;
PERMIT NO.:
MECHANICAL PERMIT APPLICATIONS
INSPECTIONS
0
0
CO NDITICONS
0
e
00002 Pre-construction
00050 WSEC Residential
00060 WA Ventilation/Indoor AQC
00610 Chimney Installation/All Types
00700 Framing
01080 Woodstove
01090 Smoke Detector Shut Off
01100 Rough -in Mechanical
01101 Mechanical Equipment/Controls
01102 Mechanical Pip/Duct Insul
01105 Underground Mech Rough-in
01115 Motor Inspection
i400,... Fire Final
01800 Final Mechanical
04015 Special -Smoke Control System
0001 No changes to plans unless approved by Bldg
Dlv
0014 Readily accessible access to roof mounted
equipment
0016 Exposed insulation backing material
0019 All construction to be done in conformance
w /approved plans
0002 Plumbing penults shall be obtained through King
Co
0027 Validity of Permit
0003 Electrical permits obtained through I. & 1
0036 Manufacturers installation instructions required
on site
"BTU maximum allowed per 1997 WA State Energy Code"
0041 Ventilation is required for all new rooms &
spaces
"Fuel burning appliances
"Appliances, which generate...."
"Water heater shall be anchored..."
Additional „ onditions:
TENANT NAME: Fosiery' 'qv P.s.tcolf,S Lest .
FEES
Basic Fee (Y/N)
Supplemental Fee (Y/N)
Plan Check Fee (YIN)
Furnace/Burner
to 100,000 BTU (qty)
Over 100,000 BTU (qty)
Floor Furnace (qty)
Suspended/Wall/Floor- mounted Heater (qty)
Appliance Vent (qty)
ileating/Refrig/Cooling Unit/System (qty)
Boiler /Compressor
to 3 f- IP/100,000 BTU (qty)
to 15 HP /500,000 BTU (qty)
to 30 HP /1,000,000 BTU (qty)
to 50 HP /1,750,000 BTU (qty)
over 50 UP/1,750,000 BTU (qty)
Mr Handling Unit
to 10,000 efitt (qty)
over 10,000 cfiu (qty)
Evaporative Cooler (qty)
Ventilation Pan (qty)
Ventilation System (qty)
Hood (qty)
incinerator — Domestic (qty)
Incinerator Q Comm /Ind (qty)
Other Mechanical Equipment (qty)
Outer Mechanical Fee (enter SS)
Plan Reviewer.
Permit Tech:
Add'i Fees = Work w/o Permit (Y/N)
Imp Outside Normal Hours (hrs)
Reinspections (hrs)
Miscellaneous Inspections (hrs)..,„,„„.,.„„... . . .............
Add'I Plan Review (hrs)
Date: &7 .
Date:S (6
Proje :
b y view -- 1.64 I
Type of inspection:
Mph- ► , ,�
Addres :
date called:
Special instructions:
Date wanted: w _ r
a.m.
.m.
Reques er:
p o � .� \y, (�r��
+r 1 - � �"
Receipt
Date;
S 7,00 REINSPECTION FEE ' EQUIRED. Pri • r to inspection, fee must be paid
t 6300 Southcenter Blvd, Su 100, Call to sche, ute reins' ection.
eJ t No; ^� Date:
^ +I
INSPECTION RECORD
Retain a copy with permit
INSPECTION NO.
CITY OF TUKWILA BUILDING DIVISION
6300 Southcenter Blvd, #100, Tukwila, WA 98188
Approved per applicable codes.
COMMENTS:
Corrections required prior to approval,
Alamo- /IL
PERMIT NO.
(20 6y0
Address.
Special instructions:
Inspector.
Receipt No:
$47.00 REINSPECTION FEE REQUIRED. Prior to inspection, fee must be paid
at 6300 Southcenter Blvd. Suite 100. *Call to schedule reins ectlon.
Date:
INSPECTION RECORD"
Retain a copy with permit
INSPECTION NO.
CITY OF TUKWILA BUILDING DIVISION
6300 Southcenter Blvd, #100, Tukwila, WA 9818
PERMIT NO.
(206)431-3670
Approved per applicable codes. Corrections required prior to approval,
COMMENTS'
126
Project:
../.4: 4 .
.4 -
Type of his - ion: ,
Fr, 4r c f
d ,ress: # i
7* F /
Date called:
S eci struction :
Date wan(
Of p
Requ :
Ph 4PS_L11111‘04____
$47.00 REINSPECTION FEE'REQUIRED, Prior to inspection, fee must be paid
t 6300 Southcenter Blvd. Suite 100. Call to schedule reins colon.
Receipt No: Date:
INSPECTION RECOR
Retain a ropy with permit
INSPtCIION NO.
CITY OF TUKWILA BUILDING DIVISION
6300 Southcenter Blvd, #100, Tukwila, WA 9818
PERMIT NO.
(206)431-3670
0 Approved per applicable codes,
'
Cdrrections required prior to approval,
•••
• ��"
( ,mss Yv
Type pin pecti •
I�., t, - dt
ress:
5.
Date called:
Special instructions:
14
____________
Date wanted: I .m
fo 1,._ .m.
Request
rttiileitd
. ,... 3:5t...
INSPECTION RECOR
Retain a copy with permit
INSPECTION NO
CITY OF TUKWILA BUILDING DIVISION
6300 Southcenter Blvd, #100, Tukwila, WA 98188
E l Approved per applicable codes. ACorrettions required prior to approval
COMMENTSs
PERMIT NO.
(206)431.3670
$47.00 REINSPECTION FEE REQUIRED. Prior to inspection, fee must be paid
at 6300 Southcenter Blvd., Suite 100. Call to schedule reins • ection.
18
Project• ,
, le t
• 0 '
Type of In ction:
A A
Address:
•
1
Date called:
d
c
S 'eclat instructions:
Date want •
O
Request
�*!
...A
4 f I
INSPECTION RECOR
Retain a copy with permit
INSPECtION NO,
CITY OF TUKWIIA BUILDING DIVISION
6300 Southcenter Blvd, #100, Tukwila, WA 98188
(206)431 -3670
Approved per applicable codes. El Corrections required prior to approval.
COMMENTS:
$47.00 REINSPECTION CEE REQUIRED. Prior to inspection, fee must be paid
at 6300 Southcenter Blvd., Suite 100. Call to schedule reins ectlan.
Date:
Project
)
Typ r f Inspection:
Address:
4 7- ,- 5.
1 -! h e 1
Date c. led.
3 2.1
0
.•a�,•.
Special instructions:
L o
19
Date anted:
- z L b
a.m.
Requ - ter:
Phone:
`"(ZS - 3'3 'I- t. 111
•
. A
_' Yt
TikApproved per applicable codes.
COMMENTS:
INSPECTION RECOR
Retain a copy with permit
INSPECTION NO.
CITY OF TUKWILA BUILDING DIVISION
6300 Southcenter Blvd, #100, Tukwila, WA 9818
PERMIT NO.
Corrections required prior to approval,
$47.00 REINSFECTION FEE REQUIRED. Prior to Inspection, foe must be paid
at 6300 Southcenter Blvd., Suite 100. Call to schedule reins ' ection.
Project:ll
i Oi rr1/ IPty - 1
A
Type of Inspecti
1�►C
{ /�
h, E, v, _1._
Ad. teas:
1
Date called:
Special instructions:
Date wanted: a,
Requester: -""
r
Phone:
INSPECTION NO.
INSPECTION RECORD
Retain a copy with permit
PERMIT NO.
CITY OF TUKWILA BUILDING DIVISION
6300 Southcenter Blvd, #100, Tukwila, WA 98188 (206)431 -36
COMMENTS:
611111111 •
IR IM . :.
i
Inspector:
Data:
0-01.
Approved per applicable codes, Worrections required prior to approval.
0 $47.00 REINSPECTION FEE REQUIRED. Prior to Inspection, fee must be paid
at 6300 Southcenter Ole, Suite 100. Call to schedule reins action.
Receipt No: Date:
INSPECTION RECO
Retain a copy with permit
INSPECTION NO.
CITY OF TUKWILA BUILDING DIVISION
— 6300 Sou ► ent r Blvd #k10 s, u wi a, WA 9818
Woo-- 1 lb
PERMIT NO
(206)431 -3670
ype of I pection.
Date called:
Date wanted:
Requester:
a .m.
.m.
Phone:
Special instructions:
Approved per applicable codes. Corrections required prior to approval.
COMMENTS:
Receipt No:
Date:
Q $47.00 REINSPECTION FEE REQUIRED. Prior to inspection, fee must be paid
at 6300 Southcenter Blvd., Suite 100. Call to schedule ruins action.
October 1, 2001
Mr, John Kappler
14311 SE 18 SL
Bellevue, WA 98007
City of Tuk',vila Steven M. Mullet, Mayor
Department of Community Development Steve Lancaster, Director
RE: Permit Application No M2000.116
Dear Permit Holder:
In reviewing our current records the above noted permit has not received a final inspection by the City of
Tukwila Building Division, Per the Uniform Building Code and /or Uniform Mechanical Code, every permit
issued by the Building Official under the provisions of this code shall expire by limitation and become null
and void if the building or work authorized by such permit is not commenced within 180 days from the date
of such permit, or if the building or work authorized by such permit is suspended or abandoned at any time
after the work is commenced for a period of 180 days.
Based on the above, you are hereby advised to:
• Call the City Of Tukwila Permit Center at (208) 4313870 to schedule o
progress / Anal inspection
A progress Inspection is intended to determine if substantial work has been accomplished since issuance of
the permit or last Inspection: or if the project should be considered abandoned.
If such determination is made, the Budding Code does allow the Building Official to approve a one.tlpjg
extension uo to 1 BO dava, Extension requests must be In writing and provide satisfactory reasons why
circumstances beyond the applicants control hove prevented action from being taken,
In the event you do not call for the above inspection or request and receive an extension prior to 10/16/01,
your permit will become null and void and any further work on the project will require a new permit and
associated fees,
Thank you for your cooperation in this matter.
Sincerely,
i4 &moo
Kathryn A, Stetson
Permit Technician
Xc :, iPermit File No,M2000.116 //
Duane Griffin, Building Official
6300 Southcenter Boulevard, Suite #100 • Tukwila, Washington 98188 • Phone: 206-431-3670 • Fax: 206-431-3665
Project Name:
■ . N.. ' . " ` r k s Lo -
Address:
Reeldential Building Permit Number,
Prescriptive Option W,S.E.C. Chapter 6, (check building permit option used):
❑ i, ❑ II ❑ Ili. la IV, ❑ V. ❑ VI, ❑ VII. ❑ VIII.
2. House Square Footage (HSqFt)
14
3. Heating System installed, (check system type below):
❑ a. Electric Resistance /21 BTU/h per sq. ft. FILE Ca Y
❑ b. Electric (forced air) /24 BTU /h per sq, ft.
III c. Other Fuels (gas, heat pump) /27 BTU /h per sq. ft. f
•- ~.
4, Equipment:
a. Make �/oWc1r_._
b. Model .
c. Size in BTU's
_ ,_,8(2 _ ._ _.____._._._
5. Calculation/(HSgFt) I (see line 2 above)
-
BTU /h X 1 (see line 3 a, b, or c above)
�._,._., BTU Equipment Maximum Size
CITY Or TUKWILA
Permit Center
6300 Southcenter Boulevard, Suite 100, Tukwila, WA 98188
Telephone: (206) 431 -3670
Prescriptive Heating System Sizing for
Single Family Homes - New Construction
Washington State Energy Code Chapter 9, Climate Zone 1 RECEIVSO
CITY OF TUKWILA
PERMIT APPLICATION #1121)00.. (11
H -6
JUN 1 2000
ERMIV CENTER
Applicant's Signature:
7/9/96
Date:
ACTIVITY NUMBER: M2000 -116 DATE: 6 -1 -2000
PROJECT NAME: FOSTERVIEW ESTATES - LOT 14
SITE ADDRESS: 4246 S. 137 PL
XX Original Plan Submittal Response to Incomplete Letter #
Response to Correction Letter # Revision # After Permit Is Issued
PEPARTMENTS
Bui�di"ng Division
P ublic Works
Complete
Comments:
REVIEWER'S INITIALS:
MOM{ twc
SPO
PERMIT COORD COPY
PLAN REVIEW /ROUTING SLIP
Fire Prevention
Structural
DETERMINATION OF COMPLETENESS: (Tues., Thurs.)
Incomplete ❑
APPROVALS OR CORRECIONS: (ten days)
CO ECTION DETE MIN TION:
Approved E Approved with Conditions
REVIEWER'S INITIALS:
DATE:
Planning Division ❑
Permit Coordinator
TUES/THURS ROUTI G:
Please Route Structural Review Required [2] No further Review Required
REVIEWER'S INITIALS:
DUE DATE 7 -4 -2000
r ;
DUE DATE: 6 -6 -2000
Not Applicable ❑
Approved ❑ Approved with Conditions Eri Not Approved (attach comments) ❑
DATE:
DUE DATE
Not Approved (attach comments) LT__,
DATE:
F6:3.9324X O 1 R1971
..11••■•11..
e�-� -- Detach And Display Certificate -
---- Detach And Display Ceniflcata
f: 11 . 11 OETACH TO DISPLAY CEP" , CATE,.t
� ---•1111
PLEASE DETACH AND SIGN
CERTIFICATE BEFORE PLACING
IN BILLFOLD
.nan.w.rnrn- nnMMU. At A..
P42$4)32 000 097)
DEPARTMENT OF LABOR AND INDUSTRIES
REGISTERED AS PROVIDED- BY LAW AS
CONS? CONT GENERAL
Fncr E
1111. 1111. M DATE'
eco anal RD zo¢z;0 » IVZ6.1220
"DUJARDIN`DEVELOPMENT CO
PO BOX 1.059
SNOHOMISH WA 98291 -1059
F - 1 -- tEGISTERED AS PROVIDED BY LAW
CONST CONT GENERAL
REGIST. # EXP. DATE
CCO2. DUJARD *204L0 12/16/2000
E8'FECTIVE`DATE 06/20/3.980
DUJARDIN= Dammam CO
PO BOX' 1009
SNOHOMISH WA, 98291 -1059
Signature
Issued by DEPARTMENT OF LABOR AND INDUSTRIES I
Please Remove
And Sign
Identification
Card Before
Placing In
Billfold
• •iI' //i