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HomeMy WebLinkAboutPermit M2000-142 - LABEL RESIDENCESAVZV1T14T E log OOUOpJSO)J pqui Zit7.1-000ZIAT City of Tukwila Permit No: M2000 -142 Type: B -MECH Category: RES Address: 14418 42 AV S Location: Parcel #: OO4000 -0341 Contractor License No: ADAIRH *262R2 TENANT OWNER CONTACT CONTRACTOR ****** k* A*** kh**k kAtkkk* *kk*kkk *kkkkk *k *k'kk *k Permit Description: . NEW SINGLE FAMILY RESIDENCE 1- WATER HEATER 4-VENT FANS :LAUNDRY AREA, BOTH BATHROOMS AND KITCHEN UMC Edition: 1997 Signature; MECHANICAL PERMIT LABEL RESIDENCE 14418 42 AV S, TUKWILA WA 98168 LABEL SCOTT 14424 42 AV S, TUKWILA WA 98168 BOB HOLLIS 2303 93rd AVE SW, OLYMPIA WA 98512 ADAIR HOMES INC 1111 SW 170, BEAVERTON OR 97005 Print Name: 4. `-' / / 'C..!?��C.?r�� Title (206) 431 -3670 Community Development / Public Works • 6300 Southcenter Boulevard, Suite 100 • Tukwila, Washington 98188 V a l u a t i o n : Total Permit Fee: Dote: Status: ISSUED Issued: 10/27/2000 EYp i i es: 04/25/2001 Phone: Phone: 360-352 -8571 Phone: 360- 352 -7641 :t******* *k**** ** *:4 ' k k * A' k * * * * * k * * i •k k k * k * * * k k * * * * * * * * k * * * k k 1 A * * k * * * * * b 1, * * * * k * k k * * * * k * * k k * * * 10 herWITE wthorized Signature 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 this permit doer not presume to give .authority to violate •or cancel .the provisions of any other state or local l awes regulating construct ion car the pert'orn►anr t of work, I ,gym authorized to sign for and obtain this build 200.00 65.63 This permit shall become n u l l and v o i d if the work is not commenced within 180 days from the date of issuance, or if thr work Iz suspended or abandoned for a period of 180 days from the last inspection. Address: 14418 42 AV S Suite: Tenant: LABEL RESIDENCE Type: B --MECH Parcel #: 004000 -0341 •k* **.k*•k * h*** * **•A kk A* &** *•* A *Ic* A ****k** A*•***•A*k k•k** k* f *-k A* k* k k•k k* k** **** k**** Permit Conditions: 14 Electrical permits shall be obtained through the Washington State Division of Labor and Industries and all electrical work will be inspected .by that.'agency '(248-6630). WATER HEATER SHALL BE ANCHORED TO RESIST EARTHQUAKE, U.P.C. 510.5. No changes will be made to the plans unless. approved by the Engineer and the Tukwila Building Division.. All permits, - Inspection records, and approveyd pl en sha,l 1 . be evai leble yet the 1`ob site' prior to the start of any eon- `struction: these $`docu are, to be maintained and avrxi.l able until final inspection apprdval is granted:, S. All construction to be done :in conformance with approved p 1 an$, find requ i remen is of the Uniform Building Code. (1 997 Edition) .. as: emended, Uniform Meehanico1 Code (1997 Edition end bshington -State Energy Code (1997 Edition). Vttl'$.di ty of Pe`rmi t. The issuance of ,..a permit or approval o plan*, specifications, on.d ,computations shall not be con- strued to be a permit for, or 'an approval or any violation of; ` piny - af- 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 coda she✓ l l be 7. Manufacturers-installation instructions required on site for the but ld 1ng inspectors review. I hereby curt lf,y that t have read these oond i t ions' and will comply with them -ens outlined All provisions of law ,and ordinances gOVerning this work will be comp l i end with, whether specified herein or not, The granting °cf:, this. permit <does not presume to give authority to violate or cancel, the provisions of any , other work or ` local' .laws regulating conger Otani i. ~ or the per�f or once of work. ,14 CITY OF TUKWILA Permit No: M2000 -142 Status: ISSUED Applied: 07/05/2000 Issued: 10/27/2000 CST OVVIIIIMPOWIRMISMIMMIMP tt : Project Name/Tenant: 5cerr /' ` � 2 -� Value of M an Equipment 2009ci Address : I r Site I / 2r ' � � d, ,c-C y it( i �f fi Tax Parcel • oc) ©3 VC) "0/ Property Owner: 5C-Ori (- �-� A Phone: cp) 3^ y 72....„5 Street Address: V7, e, SO . , Z , 1'v'' 0 AV it'd tat • Cr Fax #: ( 7 06fg7,-C) 72,0 Contractor: , / _ pfrigi Phone: (360.32.-9.5-7 I Street Andress: 01 9.3Ae /,� r � s - -, ,1 © G r i mm i 0 r Fax #: ( (, ?c/3,© Phone: ( 36C0 3 z..•e'C7l Fax #: (340 9y3'0 70/ Contact Person: �,L Street Address . _? 0 vice �� _, mss - ® T �et Sta ln: CITY OF TUIt . ✓ILA Permit Center 6300 Southcenter Boulevard, Suite 100 Tukwila, WA 98188 (206) 431 -3670 FO • AFF USE ONLY Project Number: Permit Number: 012100 41111 M 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 PERMIT REVIEW AND APPROVAL REQUESTED: (TO REFILLED OUT BY APPLICANT) Description of work to be done (please be specific): 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 H44, "Aflldavit 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 bo required as part of this submittal. I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION AND KNOW THE SAME TO BE TRUE UNDER PENALTY OF PERJURY BY THE LAWS OF THE STATE OF WASHINGTON, AND I AM AUTHORIZED TO APPLY FOR THIS PERMIT. Print name: Phone: ( Z - y7 Date: to, Fax 0: City/Slate/Zlp: a k ' t r . ) / $ 11 9 /4 BUILDING OW Signature: Address: 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. D to application accepted: pat applic • n expire • Appl atio n • (initials) 10, imp 411, allP 11/2/99 mech pernill.eloc A TH . RIZE P IMAM ,,%a Ptiff /.i>' //1er �-_� /1 � ✓ 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 a. •licable re•uirements of the Washington State Nonresidential Ener: 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. ,.a9 mlwpmcdac New Single Family Residence Heat loss calculations or Form 1-1.6. Equipment specifications. Chang -out or replacement of existing mechanical eq uipment Narrative of work to be done includin modification to duct work, StoJ 4 • Mechanical Permits COMMERCIAL: Two complete sets of drawings and attachments required with application submittal 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 required with application submittal Submittal Requirements 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 stating 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. 00 -i r Account. Cade 000/:145.030 00q /32 1.100 • *6 -lilr: **44. A *44,4 X44* 4 *d4A *14A*A *4*AAA h4A*A *$/.,44 XTY O T MIA op- i� TPANfMIT 4:l *A * *�!*44,14,+*4 *kA 4+ *• *J4g *:t 9414A44944.4 * *•44AA *4.k,1* fit >AA *A*A *944 TRAPIBHPt Numbers .P900CM: Amounts G5.G 1 it) 27/00 13:29 Payment Methods; CHECK Notation: 9CO T I.AREL Inits TLn .. M .. • i e. .l r/ h M M • ..... r . a 1. . r .. r .. r r. M . e a. •:.- I. •. .. m. .o • . ♦. r . a ti .. a ..... • . a. • • - • ♦ s +• 1 .. •+ I: a. •.. F .. par"a i t Not M2000-142 types it •Mr•.CH MECHANICAL. PERMIT Purct1 Nos 009000 -0341 Otte Addresu s •1441 tt 42 AV 0 T4?W I'wetcs 63.63 This P yment; 65.43 TiJi.1 AIL Notes 66.63 Oniunc're .00 * * * *+1 ** * * 0* *444# **•*3'***" *d**iA4#****oiA *d***A44 4 #4040,41,4 1##A*A# I)aiic r i p t t Amount PLAN CHECK - REV 13.0 MECHAiNICAL. .. Itr13 32.$0 . N a- a n W s a .• .. /.. •. NI M h +11 D h f l I•I M ♦t ra tM •• 'I a'. ' .. M i1 •! •. ♦... •M •t S .... J! .. M a M e • 1 tw 1 h .I a. •• h M r •- in N .. $ u. .• • i M .. PERMIT NO.: N MECHANICAL PERMIT APPLICATIONS INSPECTIONS ❑ 00002 Pre- construction ❑ 00050 WSEC Residential fit 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/Controis ❑ 01102 Mechanical Pip/Duct Insul 01105 Underground Mech Rough -in 01115 Motor Inspection 1400 Fire Final 01800 Final Mechanical 04015 Special -Smoke Control System CONDiTIONS If 0001 No changes to plans unless approved by Bldg Div ❑ 0014.,.,,.., Readily accessible access to roof mounted equipment 0016 Exposed insulation backing material 0019 MI construction to be done In conformance w /approved plans 0002 Plumbing portraits shall be obtained through King Co 0027 Validity of Permit 0003 Electrical permits obtained through L & 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 generato,.,." "Water heater shall bo anchored...," e gtldltlanal Copoltions: TENANT NAME: SC-OAi" .46 I FEES Basic Fee (YIN) Supplemental Fee (Y/N) Plan Check Fee (Y/N) Furnace/Burner to 100,000 BTU (qty) Over 100,000 BTU (qty) Floor Furnace (qty) Suspended/Wall/Floor-mounted Heater (qty) Appliance Vent (qty) Heating/Refrig/Cooling Unit/System (qty) Boiler /Compressor to 3 HP /100,000 BTU (qty) to 15 1-IP /500,000 BTU (qty) to 30 HP /1,000,000 BTU (qty) to 50 HP/1,750,000 BTU (qty) over 50 HP/1,750,000 BTU (qty) Air Handling Unit to 10,000 cfm (qty) over 10,000 eh (qty) Evaporative Cooler (qty) Ventilation Fan (qty) Ventilation System (qty) Hood (qty) Incinerator — Domestic (qty) incinerator .- Comm /Ind (qty) Other Mechanical Equipment (qty) Other Mechanical Fee (enter $$) Add') Fees — Work w/o Permit (Y/N) insp Outside Normal Hours (hrs) Reinspections (hrs) Miscellaneous Inspections (hrs) Add') Plan Review (hrs) Plan Reviewer: Permit Tech: Date; '7-18-00 Date: e `4.00 ` roject: 1 --6 l 1 e ckCIC0 C--L . T e of Insect on: • LJ ' ...r._....o. / Address: 4 4 1 g `4 .. fi L. _ -- Date 1 /1 Special instructions: Kc C r■ h c v Se c 4- -4 t.,,-,4 co oc.:f ,Sc $(1-1 1 , �� r i , .1 , tr n ak.t• c.-I- r% C t,..„, A-44 ►'` Date ante : "7 I to 11 l • m Ic uestert�yy C a 'LI Phohe: Cdr, -"-,Pt— --' 4 1 : .5 INSPECTION RECORD Retain a copy with permit INSPt:CIION NO CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd, #100, Tukwila, W) S (206)431-3670 • I PERMIT NO. l Approved per applicable codes. El Corrections required prior to approval. COMMENTS: $47.00 REINSPECTION FEE REQUIRED. Prior to Inspection, fee must be paid at 6300 Southcenter Blvd., Suite 100, Call to schedule reins ection. 11111110111 COMMENTSs J111111 IIMINLI1 M fld►' 41,M111 WA M . NW . A g R r' aT llllllll�M P. • 0 ♦ A■■. 1, ,te 9 — i • `1 Special instructions: 10 (A4td. or. (A FfM s y;,i- to * 4N c t/ reit te 410 -111l's#ri. • r D. . ted: 1I P . IMIEVEINIIIMEMEME MI, . 1 ' Projec ' ! 7 • . f Inspec on: Cdr • : � , L A g AV Dat c• et]: • Special instructions: 10 (A4td. or. (A FfM s y;,i- to * 4N c t/ reit te 410 ! D. . ted: 1I R + ester: .. • # PI ., p I II •�' '4 ...• 1 Ai •! "`!"" INSPECTION IteC RD Retain a copy with permit INSPECTION NO. CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd, #100, Tukwila, WA 98188 roved per applicable codes. PERMIT NO: (206)431.36 orrections required prior to approval. $47.00 REINSPECTION AU REQUIRED. Prior to inspection, lee must be paid at 6300 Southcenter 81vd. Suite 100. Call to schedule reinspoction. Receipt No: Date: ets ik2 Project: � . .! i .�..! • Type of Inspecti•n: , , 1 ddress:_a 4 $ 9 .-_ 1 S Date called: .5 41(0 Date wante • • - a.m. . ,m. , Special instructions: s r Phgne � aepyester: - � \ COMMENTS: Inspector: Receipt No: .17 INSPECTION RECOk ' Retain a copy with permit INSPECTION NO. CITY OF TUKWILA BUILDING DIVISION '6300 Southcenter Blvd, #100, Tukwila, WA 98188 Date: M Do do.. /fir PERMIT NO. (206)431 -36 Approved per applicable codes. ] Corrections required prior to approval. Q $47,00 REINSPECTION FEE EQUIRED, Prior to inspection, fee must be paid at 6300 Southcenter Blvd., Suite 100. Call to schedule reins ' ectian. C COMMENTS: Type of inspection: H.34, Date called. Address: /q4-1 Special instructions: Dat wa ed: a a Q 1) P " i . .581 A .e ,A c, a. w ... ek r yr Project: 1 , . %» Lbc ac . f ic 4. Type of inspection: H.34, Date called. Address: /q4-1 Special instructions: Dat wa ed: a a Reque ter: P one: i . .581 • t s t $ f lt ♦ 4. INSPECTION RECORD Retain a copy with permit INSPECTION NO CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd, #100, Tukwila, WA 9818 PERMIT NO (206)4314 (pproved per applicable codes. Q Corrections required prior to approval. $47.00 REINSPECTION FEE REQUIRED. Prior to inspection, fee must be paid at 6300 Southcenter Blvd, Suite 100. Call to schedule reins.ection. Receipt No; Date: 1 A COMMENTS: i c nu Ty .f inspection: ARIIII • II , ► SOA 41 t.! a,m, p.m, 111 *Ai. . ' / I aI '. b L M mil► t h \ p • Project: / i c nu Ty .f inspection: Address: bate Ile Special instructions: Date a t : / ;a:, 0 / a,m, p.m, Req este : il Phone: d "r5 _ b L E• '•-� INSPECTION RECORD Retain a ropy with permit INSPECTION NO CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd, #100, Tukwila, WA 98188 PERMIT NO (206)431 -3 0 Approved per applicable codes. 'Corrections required prior to approval. ED $47.00 REINSPECTION FEE REQUIRED. Prior to Inspection, fee must be paid at 6300 Southcenter Blvd. Suite 100. Call to schedule reins'ection, f F#4•' -1 tl-ciA11' ‘4 V WO • F JLF COPY r'r1!irarstand that the Pilfer C ,,_I, a pe Residential Energy ever Electric - Upright Feratutellv • Oradfo d Whets 181110 registaered to the ... 0001.1104 standard. • 1" Non-CPC foam Insulation— surrounds tut* surface. Available on all models. • Heat trips -- oti upright models equipped with two factory InetMwd 'Met trace. • factory !metalled nippie.••dor longer water host* life. Feeler 1nstillsnion. No special dielectric fittings to buy IN Fully automatic oontrolw4wt acting surface•mount thermostats for automatic temperature control, Factory installed sensitive energy cutoff for safety to prevent overheating, • groat Neat transfer with immersed elements- -upoly heat directly and efficiently to the water, 0c►ew•in stria, M Vltrtterlaso lining --this exclusive glass formulation iu applied under pressure to oor+lepletely atop' the tank interior for y.vr of extra service. Protects against rust snct corrosion, Wlii not crock or peel. II Protective magnesium onode rood -- Inhibits consort of tank interior tot long trouble -free service, • Paotwty IAiMlior Ny$r Oto total Performance Corr► -.cold MiIN .wament reducing devbe. Mops prevent sediment buthf up in lank. Imams fir% host d0irvory of hot water Mile minimising temperature build up at tup of lank. • ,$P relief yaks openlAg. ill models haw special tapping on top of tank, • two year limited warranty on parts. • Nix or ten yew limited werrinty on 'feel tents -- hoavy gauge steel automatically formed, rolled and welded to **sure a continuous worn for goo lining. MANUFACTURE) UND1R ONE OR MORE OF THE FQt t OWING U.5. PATENTS: 4,411,2M; 4,01,184: •,001.•40; 4.07 7.010; 4.$01,350; 4,111,683; 4,881,N61; 4,887,10$, .1,004,4 ?4; 5,00 0,123; 5.013.031; 5,042,345: 5,001,690; 6,002,110: 8,115,787: 5.102.38b: 5,277,171; 8,341. 770; 5.4151070. OTHER U.S. AND frONLIGN PATENT APPt.ICATIONS PENDING. CUIIMENT CANADIAN P*►i jNT$: 1./72,914: 1,200,443; 1,200,032, '+llama* W$?$ •s►wife. rrassnnit a rkrrnrnr<r may CANINNOtuft Ot 4" l 9n I1,$4I,llai M ZOOOp4z fe11tr :mete: ,.4 •, •M. seas •• ♦aril r. • RECEIVED CITY OF TUKWILA JUL w 5 2000 PERMIT CENTER • Upright Metric Nt h I I itllrM w. iAMMlebti wM vier* AIAd MM rvemet, Nolo Ire UAW *Om O M wool IM •asee n1 Oterpeeril I$MSMMq 14e vet flair iOOO I OWIN M ION wM tl M ptNrth, trnlN. awr$e WON. Other wows We eveitil<tryN es%fierokeelerww IMO 11,010 wets erNtM. *YiNOweft•rei p+*/ $ W Vit �NOIM VIM /i 11110f If 10 '1' NI M 10V'1 �a wit , to • McVey * MN MA�1�, P41%400 Mem Ngr�1Mirek Sinop A1MMI IA MOW Wet. AM WNW /IroMNIM•, II' (11ren) ?d 1 AU Nc. Val eenfteeveme, It• namm►. Au Ntedi1001flty et 100 poi reel Are » (0901 vet. 1$0 Poi t+�/rUiry /rleetlre 114114 N/41. Ater4M sulk war 1•1e'10' for mower oivitffleetion. OM11M11M eviooleelim Irr N le eff. pe WO *obi M iIONWAM will for •.Y.... C v fell IMAwagq C4010 IlM1Ww Me • 11.11MN MfMrinly M re$Mr �I i l *' IN 110 O M N1140. TRIM 111■4" eirMutlrtle Mw mentakfol v 0 OM w ti trvuetry INV.; sM aM1 M rvflul In oho wpm of biers durrnl the VW wwrrrsy who/ Nneloelw el 01004 end ro.►neloN.en MN )I FN. /90 Residential Eneigy Saver Electric- Upright Energy Savor M.M16 Them tntateru moll 01 oxoe d ter peAom1lr+0e sisrldwds fl$tebll$hid undo A$P RAE $lmndwd 11011b 10112. Mote NAIC* requitement.. 4111 Ye V T N W n0si MIIM 141114411 WO, Ileffsekolv Msi t« tsfl. Mqq f M sh, IHMM 10 0 . le, NM, 1e1 wit, M. mo, Mt Si IN, III. t1 10 NN 1 H et 11 . 11 10 M r r.M Y . t11/ 41 j �4 11 1 ..1 ■ .,rrr .w ::' 1.. ., M), 1 .. N iiii "' 't 111 1, 1 it / • / , • I J_ • • , • , .. r re • .• ri AID . /y) 11 e, "• Iles • eel.. MNDPQII wrinr C1:41• A Y QN UM1Tl0 W MF4ty; ProtNte ye4ir Uwt)IlmerN N 1 Wa$ Ilnea wetor heeler II 0a ire tme Mw memo ter Node wNleIWel froreaw'M'N. �► wrerion wfut+rt ter wNtMMy mfwl. the MMM MI 00 /11011iEf1 *II a wows. toe Nov W ow monufrkiiiiii fewo Nro 01 enieeine One no ' 0l0Nrt en coot w some Ne1W 00 net et** IMfti elfllne Mt wwnllntlp0, tWO 1smpi1e ilglr id MO warranty Mdtleer w$I1 ter NNW, M 2000 - iyz INE" apt MOTE ‘ 0 M P 0 11 A 1 1 9 N AAtli , iM1 t • AT11 Sehm/$004110410a0 0004$$•4000 forvica/10041$4411113 Womintyll000434 gill 11 IMt�1'IMNNn 7r100h0101114414400 Toiefoot/111111011141407110 In Oim4Mdon 1100413/11 A Whohrgako Commitment To Your Suomi Mow 014 SA RECEIVED CITY OF TUKWItA JUL - 5 2000 PERMIT CENTER c PERMIT COORD COPY PLAN REVIEW /ROUTING SLIP ACTIVITY NUMBER: M2000 -142 DATE: 7 -5 -20 PROJECT NAME: SCOTT LABEL SITE ADDRESS: 14418 42 " d AVE S XX Original Plan Submittal Response to Correction Letter # __Revision # After Permit Is Issued DEPARTMENTS: Bu !ding Division II C. 0 Public Works ❑ Fire Prevention Structural DITIRMINATION OF COMPLETENESS (Tues., Thurs.) Complete Ej Comments: APPROVALS OR CQRRE TIQNS: (ten days) Approved ❑ Approved with Conditions REVIEWER'S INITIALS: Incomplete ❑ TUES /THURS ROUTING: Please Route ❑ Structural Review Required REVIEWER'S INITIALS: 1PRROUTE.000 5/99 CORRECTION DETERMINATION,: Approved ❑ Approved with Conditions ID REVIEWER'S INITIALS: .,Response to Incomplete Letter # Planning Division Permit Coordinator No further Review Required ■ DUE DATE : z-G -2000 Not Applicable El DATE: DUE DATE: 8 -3 -00 Not Approved (attach comments) ❑ DATE: DUE DATE Not Approved (attach comments) LI DATE: APR-19 -2000 09:49 SISIONONNI616...• .. ... • • • • a rei$4f.na I$ 91$ DEPAR''1`MENT UOP LABOR AND INDt1STRIES . IMOXSTZRSD AS P*OVXDSD SY LAW AS CONIT CONT. GIKtRAL ADAXR HOM*$ /NC 1111 8 H•170TH 81*AVIIRTON OR 97005 ..4299 W HUH 1 K r'IUI'IC•: "u1. i u , r•i +--• Much And Di.vpisy Cetliriwtc ■--- -_ 1 SCIIIOTSRZD AS PROVIDSD SY LAW AS CONS? COIL? O IIIL M SXP DATS CCO1 �T 1N 3$2R$ 11/15 /2000 SII►$t.MTIVS ,DAYS , 12/09/1974 291 ► UOMIL INC *11 • N 170TK ' r NMAVUTON ,Olt, 070011 -4299 L. SIgnsture Mod by DBPARTMI NT OP LABO AND WDUSTRLBS Please Remove And Sign Identification Cud Before Placing In Billfold