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HomeMy WebLinkAboutPermit M2000-181 - FOSTERVIEW ESTATES - LOT 15M20O0 -181 Fosterview Lot 15 4250 S 137 P1 City of Tukwila , (206) 431 -3670 Community Development / Public Works • 6300 Southcenter Boulevard, Suite 100 • Tukwila, Washington 98188 MECHANICAL PERMIT Permit No: M2000 -181 Type: B -MECH Category: RES Address: 4250 S 137 PL Location: Parcel #: 261200 -0150 Contractor License No: DUJARD *204L0 TENANT OWNER CONTACT CONTRACTOR . *k *** k' kk** k*•****** k************ k* k**' k******* * * *kk*** *k **kk**** **-4 *** **k*k* Permit description: CAS FORCED AIR HEATER & WATER HEATER FOR NEW SFR UMC Edition: 1997 FOS TERV IEW ESTATES - LOT 15 4250 S 137 PL, TUKWILA, WA 98168 DUJARDIN DEVELOPMENT CO PC} BOX 5308, EVERETT WA 98206 JOHN KAPPLER 14311 SE 16th ST, BELLEVUE WA 98007 DUJAROIN DEVELOPMENT CO PO BOX 1059, SNOHOMISH WA 9829] k ** 4k** *k*k* * *** *A Signature: Valuation: Total Permit Fee: Status: ISSUED Issued: 09/20/2000 Expires: 03/19/2001 Phone: Phone: 425 -334• -5018 Phone: 425- 641 -5320 1,000.00 61.19 * k* k* k* k** 44tk kk: k** ** ***k *k *-A ** *A* F a.. ... C Perm Center 1 hor°ized Signature Date I hereby certify that I have read and examined this permit and now the same to _be true and correct. All provisions of law and ordinances govern #rig this work will be complied with, whether specified herein or not. The granting of this permit does not presume to give authority' to violate or cancel the provisions of any other state or local laws regulating construction o the performance of work. I am authorized to sign for and obtain this bu lding •-mot. D ate :_ : * Ia. Print Name:__ r V � ` ~4 ,t .� ' ` 1C:0 Ttt _AMeMR Vi ..�____ M...M a__AM This permit shall become n u l l and void If the work Is not commenced within 180 days from the date of issuan e, or If the work Is suspended or abandoned for a period of 180 days from the last Inspection. Address: 4250 S 137 PL Suite: Tenant: FOSTERVIEW ESTATES Type: B -t4iCH Parcel 4: 261 200 -0150 CITY OF TUKWILA LOT 15 Permit No: M2000-181 Status: TSSUE ( Applied: 08/16/2000 Issued: 09/20/2000 * * *. * *A **•A ** * * **A * * * * * * ** * ** A***** kA * * *A * **• * * * *f• * * * * *A• *A * *k *•** A *k *•k* * * *'k* Permit Conditions: 1. Any exposed insulations backng material shall have a Flame :Spread Rating of 25 or less. material shall bear identi- fication showing the f ire . performance rating thereof. 2 Plumbing permits shall be obtained. through the Seattle -king County Department of Public ..Heal th+ Plumbing Will be inspected by that agenc . i nc l ud S flg all gas piping: :(296 -4722) . ',E l ectr i ca.l. °permits shall be . obtained , through : .the Waahi ngton State DIVT' ion af `Labor: and .Industries and ell eleotric t1 ; work will be inspected by thdt: agency (248 - 6630):.`; .FUEL BURNING APPLIANCES MArNOt SLEEPING ROOMS LI . M. C . 304 'S . APPLIANCES,, " WHICH GENER /AYE A FLAME, SPARK OR GROWING XGNI `ION, :SHALL BE ELEVATED 18 INCHES ABOVE THE FLOOR';, WATER HEATER SHALL BE ,ANCHORED TO `RESZs7 EARTHQUAKE, U 510'.5. 7. No changes w i l,1 be made to the plans un l es`s approved b Eng;,fneer and ►he Tukwila Building Division. 8. Al) permits, inspection records, and approved plans shd.l l b .ava`ti lable at the job .site Prier to the start of any. con - F stl'Uct1on. ; TheselA.oduments are to be mainta►1eyed and avdi,l eble'=unti-1 final inspection approval is granted. 9.:Al t' ponstr t,Gzion to be done in conformance with approved p l ans'_and requirements of the Un i t orm B u i l d i n g Code : (1997 Edition) as amended, Uniform Mechanical Code t 199/ Ed i`t ion`)r and Washington Sate Energy Code (199/ d i t; ion) ; 1 t} Validity of Permit, , The issuance of e , pe or approva1 . o plans, spei i f i t .bona, and coniputat; i ons shall no 1; bey strued to; be a Permit fur, or an approval of, any. violation ,of any of :*e prow! l s 1 ons Of the :.building code or of en 'y .other +ores inAfce of the Jurisdiction,,. No permit pr,e i ng to give authoritAo violate o,r c ince1 the provisions of this dodo shall be valid, 11. Manufacturers inatdllation instructions required on site for the building inspectors— review. ct Name/Tenant: t" - L ' 4 I S Value of Mechanical Equipment: 1 000. G Site Address : 4 1.05 .4 0 �, 4, 1- 1* th , Print name: of e- tJGt3R. a th.ocx. City State/Zip: Tax P�� Property Owner: t .. Phone: ( )4 . - 4-. 40,0 Street Address: p • .. ()Li E t � � t i aQ.( � ` , f' City i__ City State /Zip: Fax #: ( )� 3�4 h s O k i A Phone: ( ) Fax #: ( ) Contractor: Street Address: Contact Person: r't •' i S Q ` • Phone: ( ) 4.2r,6,4( ,."lyze, Street Address: 1 t ` . y State/Zip: Fax #: ( ) 4-7r— t — 531 �1 i BUILDING:OWNER OR AUTHORIZED A ENT: Signature: ....4k . . .. Phone: ) Date: Date: Fax #: ( „2 ) Print name: of e- tJGt3R. a th.ocx. - Address: t A irt k i 40.5 _. -_� City/State/Zip: CITY OF TU!, JILA 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 PERMIT REVIEW AND APPROVAL (TO BE FILLED. OUT RVAPPLICA Description of work to be done (please be specific): 11/2/99 meth pennil.doc W t-F - a+4 ,..�... lowaseMINNINIMMIMIIIENYV 10 Currant 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 Agents If the applicant Is other than the owner, registered archltecdengineer, or contractor licensed by the State of Washington, a notarized loiter from the property owner authorizing the agent to submit this permit application and obtain the permit will be required as part of this submittal, I HEREBY CERTIFY THAT I HAVE READ AND EXAMINED THIS APPLICATION AND KNOW THE SAME TO DE TRUE UNDER PENALTY OF PER JURY BY 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 applic• on accepted: ( 410 Date application expires: 2 Applicati t n by: (initials) 3 Mechanical Permits COMMERCIAL: Two complete sets of drawings and attachments required with application submittal RESIDENTIAL: Two complete sets of attachments required with application submittal V tine istrepso aac Submittal Requirements NOTE: Water heaters and vents are included in the Uniform Mechanical Code — please include any water heaters or vents being installed or replaced. Submittal Requirpn, mts Now Single Family Residence Heat loss calculations or Form H•G. Equipment specifications, NINIMMINNIK Chan e•out or re lacement of existin mechanical e . ul - ment Narrative of work to 12suisme, including 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 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. 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 requirements of the Washin ton State Nonresidential Ener Cade. Structural engineer's analysis is required for new and the replacementof existing roof equipment weighing 400 pounds and greater (Uniform Wilding Code 1632.1). Structural documentation shall be stamped by a Washington State licensed Structural Engineer, 3 Mechanical Permits COMMERCIAL: Two complete sets of drawings and attachments required with application submittal RESIDENTIAL: Two complete sets of attachments required with application submittal V tine istrepso aac Submittal Requirements NOTE: Water heaters and vents are included in the Uniform Mechanical Code — please include any water heaters or vents being installed or replaced. Submittal Requirpn, mts Now Single Family Residence Heat loss calculations or Form H•G. Equipment specifications, NINIMMINNIK Chan e•out or re lacement of existin mechanical e . ul - ment Narrative of work to 12suisme, including 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 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. i As4A.VA MAAAA7kAAA4:4 * *b*A*A +• A. h.44 ***i * *k *AA*4.4414 AA4.4**4* * -AA*A CITY O TUKWILA, WA d '' t C✓> � 1 txAt�i Mx1 AA****4 *** ** AA* * * *A *44 44 4 4 AAAA *s% h * *4+1*k,A ****** * TRANf3MXT Fh.irber: x9800161 f Amt,orit: 61.19 09/20/00 09:20 Payment Method: CHEC( Natat:tano DUJt H IN DEVELOP Init: TLf Is •s r 1. r .. I+ ■, .t... r. r I.r •, r •. or •. • r r w .+ • o M r s. •. w Y .. N a tN M. .. • . • r +. r •• r •..I... N .-. V .. tti •s •• ► t'trait Not—A2000-1A1 Typo: fl-MI:CH MECHANICAL PERMIT Parcel Ho: 261 -•0150 i to Addromm v 4250 43 137. PL This Payment 61.1 1 u * * * * **** *** * *4* Account Coda 0000/3 000/322.100 w Is iostr11.44.4. 4l Total Foes: 61.19 al ALL. Pmtet 61.19 Oaltenras .00 ****** 4****** ** * *4 * *+ * * *+ * * * * * * * * * *ba * *' Daacription Amount PLAN CHECK t7E9 12.24 MECHANICAL M ICJ -. 40.95' s. 1. w b ..'.• I. b .t. b �> .► .' < • .r .:.. M .. F I.. t+ w .Is /� I' 1. �. .... 1. w f. .. b 4. / I 4 w W 09/22 7i0 TOTAL 2743 . PERMIT NO.: � Z000 — 191 MECHANICAL PERMIT APPLICATIONS INSPECTIONS 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 1400 Fire Final 01800 Final Mechanical 04015 Special -Smoke Control System CONDITIONS 0001 No changes to plans unless approved by Bldg Div 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 permits shall be obtained through King Co 0027 Validity of Permit 0003 Electrical permits obtained through L & 1 0036 Manufacturers installation instructions required on silo "BTU maximum allowed per 1997 WA State Energy Coda" 0041 Ventilation Is required for all new rooms & spaces "Fuel burning appliances "Appliances, which generate,..." "Water heater shall be anchored..,," i1111ltlo umli �: TENANT NAME: FOSS er ' e FEES Basic Fee (Y/N) Supplemental Fee (YIN) 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 HP /500,000 SITU (qty) to 30 HP/1,000,000 BTU (qty) to 50 i-IP/1,750,000 BTU (qty) over 50 HP/1,750,000 BTU (qty) Air Handling Unit to 10,000 clip (qty) over 10,000 an (qty) evaporative Cooler (qty) Ventilation Fan (qty) Ventilation System (qty) I food (qty) Incinerator — Domestic (qty) Incinerator — Comm /Ind (qty) Other Mechanical Equipment (qty) Other Mechanical Pee (enter $$) Add'I Fees — Work w/o Permit (Y/N) Insp Outside Normal Hours (hrs) Relnspections (hrs) Miscellaneous Inspections (hrs) Add'I Plan Review (hrs) Plan Reviewer: Permit Tech: Date: 6 AMMOINIMMIOMMEI pate :, ° 1 ~ 1 P it ierif1 — 1.0 e 1 •.p lion: . . tie c e . Special instructions: Date w nte.: 40 12- ester: O. r Ph • . -r O INSPECTION RECORD Retain a ropy with permit INSPECTION NO. CITY OF TUKWILA BUILDING DIVISION 6300 Southeenter Blvd, #100, Tukwila, WA 981 Sa Approved per applicable codes, COMMENTS: Receipt No: Date: PERMIT NO, 206)431 -3670 Corrections required prior to approval. CD $47.00 REINSPECTION FEE REQUIRED. Prior to inspection, fee must be paid at 6300 Southcenter Blvd. Suite 100, Call to schedule reins ' ection. i§ �o jest : [1.�1 L4.3 Lb C Type of In ctlon: Address: D SO . 13 pa, Date called: ‘ I � -- pedal Instructions: Date wan Requ ter: (LW c) g 3c) - ci`& COMMENTS: Inspector: Date: $47.00 REINSPECTION FIE REQUIRED. Prior to inspection, fee must be paid at 6300 Southcenter Blvd. Suite 100. Call to schedule reins action. Receipt No: Date: INSPECIION NO. CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd, #100, Tukwila, WA 98188 Approved per applicable codes. INSPECTION RECORD Retain a copy with permit Ptem t NO, 915 (206)431-3670 Corrections required prior to approval, lg • •' View L-4 4-1-Al Type of !lip s i - a ci j iPt, 1 :514,41,‘ 9 1_- Date called: 0 CO i l' Special instructions: kor i g Date wanted l- lo 4 7 ii . :41 4 Requester: r .64eA Pho, . 4 4 35 6 4 96, 0 A • 4 Receipt No: INSPECTION RECORD Retain a copy with permit INSPECTION NO. CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd, #100, Tukwila, WA 98188 Date: 1.0111110“.■••••■•••••••••••■■ Date: PtML1'NO. (206)4313670 0 Approved per applicable'codes, Corrections required prior to approval. COMMENTS! J !WM REINSPECTION FEE REQUIRED. Prior to Inspection, fee must be paid at 6300 Southcenter 0Ivd Suite 100. Call to schedule reins Wien. ii P ect: Type of Inspe pn: Ad ress: a • •, . . �: mil ' ate called: Date want •'7 : . ,m Special instructions: Reques . .+1 , . P ie : *.r.. COMMENTS: I t INSPECTION RECORD • Retain a copy with permit INSPECtION NO. CITY CIF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd, #100, Tukwila, WA 98188 E l Approved per applicable codes, Corrections required prior to approval, •f r1 Z c oo PERMIt NO. (206)431 -3670 $49,00 REINSPECTION FEE REQUIRED, Prior to inspection, fee must be paid at 6300 Southcenter Blvd„ Suite 100. Call to schedule reinspection, Receipt No: Date: MNIMPMIIIIMOINIVIMIRAIMPOW Project: � � ! V� �'� � � _ Typ� Ins action: •o -bey i p c - 1 Hr .c.�!'i Address: YziQ 1 `7 0 Date C. lied: z %1o` Special instructions: L0* 15" Date wanted: a.m. 7-2- 01 ..m. Re u er: , ���� I®�Yl - yu5A- 14 4-x4 Phone: 42.5- 34-'11I 'Approved per applicable codes. COMMENTS: INSPECTION RECORD Retain a copy with permit INSPECTION NO, CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd, #100, Tukwila, WA 981 PERMIT NO, (206)431 -367 Corrections required prior to approval. J $47.00 REINSPECTION FEE REQUIRED, Prior to inspection, fee must be paid at 6300 Southcenter Blvd., Suite 100. Call to schedule reins' action. Receipt No: Date: COMMENTSt Type Insctio woreormtr • . a • 11111111111PM~ . . AP • I k et: % T Type Insctio INSPECTION RECORD Retain a copy with permit INSPECTION NO CITY OF TUKWILA BUILDING DIVISION • 6300 Southcenter Blvd, #100, Tukwila, WA 9818 1 1 PERMIt NO. (206)431.36 ED Approved per applicable codes. aCorrections 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.ectian. Receipt No; Date: COMMENTSt Type of Inspe o)4 h - ri M 9r +1 , )4° USi stns 2 ♦ *... . . ,;.. r U ,. Special instructions: ( _ L oy l5 (fat wanted: to A 0 'Y , \ _� Lf '\ 4 S Y S e ke i E-. l { 1 pi Mt /ta '. /1/ .. - ,iJh '' t-___ hi 1 u e e fr , rno 111110 Protect: t fvt aM) Type of Inspe o)4 h - ri Address: / Date Special instructions: ( _ L oy l5 (fat wanted: to a.m. .m Reg Phone: I . "? - /1/ : � PECTION REJ "Y,., INSCORD Retain a copy with permit INSPECttON NO, CITY OF TUKWILA BUILDING DIVISION 6300 Southcenter Blvd, #100, Tukwila, WA 98188 D Approved per applicable codes, taCorrections 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 reinspection. a. msd§ 4� September 24, 2001 Mr. John Kappler 14311 SE 16th St. Bellevue, WA 98007 City of Tukwila Steven M. Mullet, Mayor Department of Community Development Steve Lancaster, Director RE: Permit Status M2000 -181 Site Address: 4250 S. 137th PI Last Inspection: 3 -2241 Dear Mr. Kappler: In reviewing our current permit files, it appears that your permit for installation of furnace and water heater at Posterview Estates Lot 15 issued on September 20, 2000, has not received a final inspection as of the date of this letter 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 provision 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 Witte 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, if a final inspection is not called for within ten (10) business days from the date or this letter, the Permit Center will close your tile and the work completed to date will be considered non-complying and not in conformance with the Uniform Building Code and /or Mechanical Code. Please contact the Permit Center at (206) 431.3670 if you wish to schedule a final inspection. Thank you for your cooperation in this matter. Sincerely, gat (1.14) ,,tytt,,0 * ) Kathryn A. Stetson Permit Technician Xc; :P4fmit File No. Mzg 9 1;$1 Duane Griffin, Building Official 6300 Southcenter Boulevard, Suite #100 • Tukwila, Washington 98188 • Phone: 206.431.3670 • Fax: 206.431.3665 Project Name: _ __.'t ,,, ; }• "nt�. . FDA . V WO �;•ili t--' L+ 15 Address: ST . Is-r‘ P1 • Residential Building Permit Number: / . 1. Prescriptive Option W.S.E.C. Chapter 6, (check building permit option used): ❑ I. ❑ II ❑ iii. a iv, ❑ v. ❑ vi. ❑ vii. ❑ VIII. 2. House Square Footage (HSgFt) 3, Heating System installed, (check system type below): ❑ a. Electric Resistance /21 BTU/h per sq. ft. ❑ b. Electric (forced air) /24 BTU /h per sq. ft. I c, Other Fuels (gas, heat pump) /27 BTU /h per sq. ft � E OPY 1 11 , 1 ; 4 rretir.•? ti+ 't• . r " ,., , P ' 4. Equipment: a. Make itte b, Model , or c. Size in B TU'sD ������ "�' 5. Caiculation/(HSgFt), 1108 (see line 2 .. y... _..._,. above) a, b, or c above) ---77 ' • Maximum Size _,..,.... ' • --�- BTU /h X l^`1 (see line 3 r '141 'Z» BTU Equipment A pplicant's Signature: 7/9/96 CITY r c 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, Clifii?(t ��I kr` `l.i ._ PERMIT APPLICATION #: 1 ' t 1006 IS M20x (SI SEP 1 2. 2O(10 H -6 RECEIVED CITY OF TUKWILA AUG 1 6 2000 PERMIT CENTER • ACTIVITY NUMBER: M2000 -181 DATE: 8- 16.2000 PROJECT NAME: FOSTERVIEW ESTATES LOT 15 SITE ADDRESS: 4250_S 137 PLACE XX_ _ Original Plan Submittal Response to Correction Letter # _Revision # After Permit Is Issued Response to Incomplete Letter # DEPARTMENTS: B it n Division Public Works Q DETERMINATION OF COMPLETENESS: (Tues., Thurs.) Complete Comments: TUES /THURS ROUTING Please Route REVIEWER'S INITIALS: REVIEWER'S INITIALS: NNININININNNNINNNNINNN \PRROUTE.DOC 5/99 PERMIT COORD COPY PLAN REVIEW /ROUTING SLIP Fire Prevention Structural Incomplete Structural Review Required APPROVALS O CR ORREC,TIONS: ((en days) Approved El Approved with Conditions a O C ON E N ON: Approved El Approved with Conditions REVIEWER'S INITIALS; Planning Division Permit Coordinator DUE DATE: 8.172000 Not Applicable DATE: No further Review Required DATE: DUE DATE: 9.14 -2 W Not Approved (attach comments) DUE DATE „,, ._..,�. Not Approved (attach comments) EI DATE: F635.05240013/97) . A.N.PP11.0. I . NnMwAMn M/ 1 I1■11 II 0.41a 1 r ---- -• Detach And Display Certificate r -- - Ut • �t y •t . M 1623, alm • •, DEPARTMENT OF LABOR AND INDUSTRIES REGISTERED AS PROVIDED BY LAW AS CONST CONT GENERAL DATE:', COQ DUJARD,r2Cr4L04irt/6400 j " DUJARDIN'DEVELOPMENT CO . ' PO• BOX 1059 SNOHOMISH WA 98291 -1059 a Detach And Display Certificate PLEASE DETACH AND SIGN CERTIFICATE BEFORE PLACING IN BILLFOLD REGISTERED AS PROVIDED BY LAW AS CONST CONT GENERAL R.EGIST . EXP. DATE CCOI DUJARD *204L0 12/16/2000 E$FECTIVE'DATE 06/20/1980 DUJARDIN• DEVELOPMENT, CO PO BOX SNOHOMISH WA, 98291 -1059 Signafura Issued by DEPARTMENT OF LABOR AND INDUSTRIES I .,an.IM••∎••.,N,.r. ^•••••••••••%”•••• • • • • 1. •• fr.........T.... ..,,•� • • t..r, OEfACH TO DISPLAY CEP' • •CATE._! Please Remove And Sign Identification Card Before Placing In Billfold F923.032.0001392)