HomeMy WebLinkAboutPermit M99-0205 - TACO DEL MARra. �:�.�r" .l n. 1 Y �:.� ..... ,j..e ., , .. a 1..'h .. . .L4.•F �Y t'1�{��'i �.ir.� ..'r1~
M99 -0205
17424 Southcenter Pkwy.
Taco Del Mar
City of Tukwila C.
Community Development / Public Works • 6300 Southcenter Boulevard, Suite 100 • Tukwila, Washington 98188
Permit No: M99 -0205
Type: B -MECH
Category: NRES
Address: 17424 SOUTHCENTER PY
Location:
Parcel #: 262304 -9110
Contractor License No: SEAAISM081B9
TENANT TACO DEL MAR
OWNER MBK NORTHWEST Phone: 206 575 -8090
C/0 TRAMMEL CROW COMPANY. 17.560 SOUTHCENTER PY, TUKWILA WA 98188
CONTACT ROB KING , Phone: 206 -650 -1018
20503 88 AV W, EDMONDS, WA 98026
CONTRACTOR SEA -AIRE SHEETMETAL INC. Phone: 206 575 -8360
820 INDUSTRY DR, TUKWILA WA, AL ALDRICH 98188
******************************************** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * **
Permit Description:
SET HVAC UNIT ON CURB, DOWN DUCT INTO TENANT
SPACE. (PIPED AND WIRED UNDER SEPARATE PERMIT)
UMC Edition: 1997 Valuation:
Total Permit Fee:
** * * * * * ** tilt******************************* * * * ** * * * * ** * * * * * * * * * ** * * * * **
Permit Center(/ uthorized 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 does not presume to give authority to violate
or cancel the provisions of any other state or local laws regulating
construction or ie per o mance of work. I am authorized to sign for and
obtain this buil■ in': pe t.
I
Signature:
Print Name: bQ V.1144
MECHANICAL PERMIT
Io-;6
Phone:
Date: loit ll1
(206) 431-3670
Status: ISSUED
Issued: 10/25/1999
Expires: 04/22/2000
Title: Ol,% 04-6. coti
1,000.00
73.13
This permit shall become null and void if the work is 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: 17424 SOIJTHCENTER PY
Suite:
Tenant: TACO DEL MAR
Type: B-MECH
Parcel #: 262304-9110
CITY OF TUKWILA
•
Permit No: M99-0205
Status: ISSUED
Applied: 10/21/1999
issued: 10/25/1999
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Permit Conditions:
1. No changes will be made to the plans unless approved by the
Engineer and the Tukwila Building Divisjon.
2. All permits, inspection records and approved plans shall be
available at the Job site prior to the start of any con-
struction. Thee documents are to be maintained and avail-
able until final inspection approval is granted.
3. All constructfon to be done in conformance with approved
plans and requirements of the Uniform Building Code (1997
Edition) as amended, Uniform Mechanical Code (1997 Edition),
and Washington State Energy Code (1997 Edition).
4 Validity of Permit. The issuance of a permit or approval of
plans, ,specifications and computations shall not be .con-:
strued to be a permit for, or an approval of, any violation,
of any of the provisions 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 this ,
code shall be valid.
5. Manufacturers installation instructions required on site
for, the building inspectors review.
Project Name /Tenant:; ---
/ 'Dec.. h?
Value of Mechanical Equipment:
Site Address : City State /Zip:
? `f� 0 5 -1 — Tr-c (c4)t W�4-
Tax Parcel Number:
� O ' L l 0 ✓ q
Property Owner:
/??,3l« ,4' 4,' .
Phone: ( )
.Sv3 6 36 -Z.A9C)
Street Address: SGJ �E 4e4,S ad z City State/Zip:
�f95«t 7,5' L�'6S. d/2�X.Y3S'
Fax #: ( )
- ' S G 3 Cc- - r33 l
Contractor: , 4 - 11- S `�4�"- kitt..t�l A.L. �p�(Ll�'1
Phone:) 7 S -9 3Fo
Street Address: . City State /Zip:
Zo('f (3 G i4u - s ni r
Fax #: ( )
Contact Pe �, n:
/06 /�
Phone: ( I
266 asz. /peg
Street Address: - k City State /Zip:
2o.Z� S, ��' A 'J', to. t Li) A -, ?go
Fax #: ( )
`f25 ?7Y ' 352(
BUILDINGI: • NE ' OR NORIZtb'AdENT!, .; I .1 . I . , -° . , . i . , ; . I I
Signature: �'
Date:
Print name:
tr I -e(14. /
Phoi P' O - Iof
Fax #: (
Address: Zogb3 Qg 6tU, Gi ,
Citt ite WL�Ilf.6 5 Lt?'AA . ° 1802.6
CITY C(' TUKWILA
Permit Center
6300 Southcenter Boulevard, Suite 100
Tukwila, WA 98188
(206) 431 -3670
Mechanical Permit Application
A �
Application and plans must be complete in order to be accepted for plan' review.
Applications will not be accepted through the mail or facsimile.
i: :: :Mt 4 IkAL) hrOM,(t.:0EVitW ANb,d ktitdi.Af.AtOOt5tt0i fro gL FILLED ootUrArptc4NT)
Description of work to be done (please be specific):
FOR STAFF USE ONLY
E i ' 1 -lYNC- tU& t. T o R Cc t_Ge v3 - Do (40
t't tit, brkiVT 51 -
CE.t aKo SeVFAATE WeStA;5r)
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 co 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.
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.
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 ' ''' 4
request by the applicant as defined in Section 114.4 of the Uniform Mechanical Code (current edition). No application shall be
extended more than onC4,'' ' t
1
Date application accepted:
I o 4--1q
9/7/99
Date a Iication e)lpires:
Application, taken b': (initials)
' 8 '
W
V
Submittal Requirements
Floor plan and system layout
' 1
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 #1-1-15 .
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): I ` ,. /42a'4.r ..5 7`v .. ,
Specifications 'must be provided to show that replacement equipment complies with the efficiency ratings
and other applicable requirements of the Washington State Nonre Energy Code.
X weighing
Structural engineer's analysis is required for new and the replacement of existing roof equipment
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
RESIDENTIAL: Two complete sets of attachments required with application submittal
9121/99 "aw
ndscpitduc •
NOTE: Water heaters and vents are included in the Uniform Mechanical Code,- please include any water
heaters or vents being installed or replaced.
Submittal Requirements
New Single Family Residence
I Heat loss calculations with specifications or Form 1-1-6.
Chan a -out or re lacement of existin: mechanical e . ui s ment
Narrative of work to be done, including modification to duct work.
Installation of Gas Fireplace
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.
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11.—W.A.4-A*AA*4—A*.4.4*Aiqsick*
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TPHN8NI1 Number: P9800I75 Amottnt;!. 7O.I3 10/25/99 JO:4f
Pavment Metlhod: CHECK NoI:ation: Ii C CONSTRUCTION Initn
Permit No:: M99‘ 0203 Tvat H-MECH MECHANICAL PERMIT
Pilrol No: 262304-9110
tit o Addresisit 17421 SOUIHCENIER PY
Total Fees: 73.11
Thi 73 13 TctuI ALL Pmt 75.13
Ralancer. .00
, A 4 1c 4 *A*0*A*“ , *IrA*4**A" ,, A*..A.A* 4 Alt.A.skitit**!A* 4 -11AAW44A4k* - Ait:Alt - 0*
AcQount Code 0ecriotion Amount:
000/345.830 PLAN CHECK - NONPE8 14.63
000/322.100 MECHANICAL - NONRE5
025:210/26 9717 TOTAL 43
.„:
/ / ,frt Proje
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Type of Inspectio
AP P%
Addr s� s:
1 . 7 1 1e) A ,..
Date called:
d:
Sp cial instructions: /Datewante
R equester:
Phone:
INSPECTION NO.
CITY OF TUKWILA BUILDING DIVISION
6300 Southcenter Blvd, #100, Tukwila, WA 98188
Approved per applicable codes.
COMMENTS:
Inspector:
INSPECTION RECORD
Retain a copy with permit
Corrections required prior to approval.
Date:
3 $47.00 REINSPECTION
at 6300 Southcenter Blvd ' uite 100. Call to schedule reinspection.
Receipt No:
(206)431 -3670
EQUIRED. Prior to inspection, fee must be paid
Date:
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SPECIFICATIONS - GCS16 261 317 471 - 473
,... �-
Modei No.
Models
GCSte•
261.50
G .. 5.16 ..E
311.30
GCS 18~
311 -75
Gg16-
411.50
413.50
GCS16.
411.75.
413-75 ,
GCS16.
411.100
413 -100
GCS76X-
411.100
413.100
92,000
Heating capacity input (Btuhl - Natural Gas
50000
50,000
75,000
50,000
75,000
100,000
Heating capacity output IBtuh) - Natural Gas
38,000
38,000
50,000
56,000
57,500
37,000
50,000
57,000
67,500
78,000.
90,000
74,000
Nesting capacity input (Stun) -"LPG
50,000
.••.
Heating capacity output (Btuh) -- "
38.000
38,000
51,000
37,000
52,000
70.000
• • • •
tk F, U.E.
Natural Gas
73.0%
79.C%
78.1%
78.0%
79.6%
806%
80.5%
•►LPG
79,0%
79.0%
78,9%
78.0%
, 79.9%
51.0
California Seasonal Efficiency
Natural Gas ,
75.0%
75,0%
75.1%
73.3'/.
75.2%
77.1%
7 5.4%
..LPG
75.
75.0%
75.7%
73.5%
75.2%
77.1%
- • • -
*ARI Standard 270 SRN (bola)
8,0
8.0
8.0
*AR!
Standard
2101240
Ratings
Tots) cooling capacity (13tuh)
23,200
29,200
• 35,900
Total unit watts
2870
3320
3850
SEER (Btuh/Watts)
10.00
_ 10.0C
10.10
EER (StulNYa:tsl
8.70
5.80
9.20
Refrigerant (R•22) charge
3 lbs. 1 oz.
o tbs. 12 oz.
4 lbs. 14 oz.
Evaporator
Blower
Blower wheel nominal diameter x width (in,)
9 x 8
10 x 8
10 x 8
Motor horsepower
1/3
1/3
1/2
Evaporator
Cot)
Net face araa (sq. ft.)
3.2
3.2
4,1
Tube diameter (In.) & No. of rows
3/B -2
3'S -- 2
3,5 -- 2
Fns par inch
15
d.7
17
15
Condenser
Coil
Net face
aria Isel. h
Outer coil
8.7
3,7
Inner coil
- • • •
8.4
5,4
Tube diameter (in.) & No. of rows
3/8 --1
3/8 ••- 2
3/3 - 2
Fins per inert
20
20
20
Condenser
Fan
Dlameter (in.) & Number o1 blades
20 - 4
20 . 4
20 - 4
Air volume (elm)
2x50
400
2200
Motor horsepower
I 1/8
1/0
1!6
Motor watts
220
240
240
Gas Supply
Connections fpt pn.)
Natural
1/2
1/2
^
1/2
«.Lp�
1/2
7
112
1/2 • • • •
Recommended Gas
Supply Pressure (wc in,)
Natural
7
7
.eLpG
11
11
11 J - • • •
3/4
c ondensate drain size mpt (In.)
at weight of basic unit (Ibs.)
37$
412
404
422
Shipping weight of board unit (Ibis)
433
}
463
464
505
Electrical characteristics
205/230v BOha 1 ph
298/230v
60hz 1 or 8 h or 460v 60ht 3 ph
L8•6209CD8 LO.62090K • • • -
•' Optional LPG Conversion Kit
LB-520300A u.62090DE1
L5•82090DA
+ Optional Conoenser Coil Guards
, LB•52199CB
Optional Outdoor Air Dampers (Manual! ••(Net Wt.)
Char media site (In,l
I
+
0A018 -41 (12 bed
5 x 17 x 1
151470 (1/2")
Optional Roof Curb Power Entry Kit !conduit Si!,)
optional Roof Mounting frame - (Net Wcight)
RMF16.41(73 lbs.)
Optional
Economizer Dampers
With
Gravity Exhaust
Exhaust
Model
No•
3 Position (Not Weight)
REMD16.41 (4611!
Modulating (Net Weight)
{ REM016M -41 (a8 lbs.) - ��
Number and size
of filters tin.!
Indoor
•(1) 18x 25x 1
butd0or
(1) 14 x 26
.....
x 1 (aluminum mesh)
(110 Its.)
Optional
Horizontal
Economizer
Dampers
Made(
No.
3 Position (Net Wu9ht)
EMDH16-41
Modulating (Nett/Ueightl
EMDH10M -41 1110 lbs.)
Number and size
of Alters (ind
Indoor
(1) 20 24 x 1 (flb rglase)
Outdoor
111 x 24
GEDH16•55
F09.68
x 1 (aluminum mesh)
(4 lbs.) Use with EMONt6
Optional Gravity ExheuSt dampers
- (Net Wo■oht)
Step•Down -
I
i t
Optional Ceiling Supply and
Return Air Diffusers
iNot Weight)
-
D65 (67 lbs.)
(37 lbs.)
Flush
Transition
� �
SRT14•6$ (20 lbs.)
Metro-mechanical, W973, W7400. Pro•stat, 77300 Control S terns
Optional Controls Selection
Optional Down -Flo Units Commercial Controls
• ,ttCornmercieJ Controls P LaLIM m _
tGnnual Cual Urilizatlon E ieienty Wind on
Box
-
1
1 Furnish('
lithe ma raoulatione.
231413
• and factory
Installed q C�IVED
DOE teat arecmaurda and F
rtr F r Pt vv,Ln
LENNOX KENT , UJA
Fax: X 6- 872 -4613
Mg - 2 c d S
*Sound rating Number In accordance with AR) Standard 270.
Rated in aocordence with ARl standard 210/240 and 005:95°F outdoor air temperature end 80'F db /67•3 wb interiny wet evaporator air.
•'For CPt3 units, e field Changeover sit ix required and must be ordered extra. NOn "X" models Only.
t1Furnlshed as standard. Consists of factory installed controls ham and economiser wiring harness,
elndoo• fitter is not furnished with economizer. REMD16 utilizes filter furnished with 13C516 unit.
9-- •
Oct 19 '99 17:15
P. 02
out `u '. 1999
PERMIT CENTER
•
' /
'CONSTRUCTION COMPANY. INC.
Redmond, WA (425) 885 - 3797
Parkway Plaza Jobalte (206) 574 -0925
Respond by: 4/15/99
Cost Change Requested: N/A
From:
PARKWAY PLAZA
' Cis. 4- t = 1, goo Lr
ce-i t -7-- 755" LASS
RESPONSE
FIELD QUESTION
DESIGN CLARIFICATION / VARIATION
REQUEST
Company: KPFF
Attention: Jarod Winnen
Job Number: 1113 Reference Number: 283
Job Name: Parkway Plaza
Item: HVAC framing
Specification/Drawing Reference: Kpff HVAC framing details for Sprint PCS dated 8/19/98
DESCRIPTION
Sierra built HVAC support framing for 2 HVAC units in the retail space adjacent to Sprint PCS
using the details as provided by KPFF on 8/19/98. Please review the attached HVAC locations,
and verify the same details are adequate. Please provide a stamped detail for our building
inspector.
Time Extension Requested: N/A
Originator: David Buckholtz Firm: Sierra Date: 4/15/99
Firm: Date:
RECEIVED
OC1 Z
FICLD20C:\I 103 Data Share \I I03\DCVR\OCVR 70.doe Sierra Construction Company, Inc.
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RECEIVED
CITY OF TUKWILA
OCT 2 1 1999
PERMIT CENTER
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NAME:
SEA -AIRE
SHEET METAL INC
PLEASE DELIVER THIS MESSAGE TO:
IL
TELEPHONE :. (0 a4,7D
FROM: AL 41.�e,k.
REGARDING:
Zoe.4 L e.x
•• •
( )HARD COPY TO FOLLOW
uspo delivery
DATE :
OF: F 4
FAX: '7
cPOC) 3 -/"' 64PS�
('06) 5 5 -8360 (206) 575 -8363
PHONE : (253) 826 -2935 FAX: (253) 826 -2936
Mq9 - og
CONTRACTORS LICENSE NO. SEAAISMO8189
INSTALLATION
HEATING • AIR CONDITIONING • SHEET METAL
tt`/ /44
s S7a. -- 3B74
AA< i
RECEIVED
CITY OF TUKWILA
PERMIT CENTER
NUMBER OF PAGES( )
cover included
10 -21 -1999 6:09AM FROM
19/20/1999 19:11 2538262(
SEA -AIRE
SHEET METAL INC
PLEASE DELIVER THIS MESSAGE TO:
NAME:
TELEPHON .ad)4I& S8
PROM:
PAX
�• 575 -8360
PHONE : (253) 826 -2935
06) 575 -83
FAX: (253) 826 -2936
5EAAIRE SHEET METAL. PAGE 01
• INSTALLATION
HEATING • AIR CONDITIONING • SHEET METAL
P. 2
•
( )HARD COPY TO FOLLOW
uepo delivery
2014 136th Ave E,. Sumner WA 98390
CONTRACtoNS LICENSE NO SEAAISINO IB9
NUMBER OF PAGES(
cover included
RECEIVED
CITY OF TUKWILA
OCT 2 1 1999
PERMIT CENTER
Date: 1 4116/99 I
Para Sent
I owe& a amir ghat)
I 2
I
' Job No.:
97522
An:
David Suoldioliz I Company Name:
Siena Construction
Prone
Arad Winnen I. For Na: -
(208) 5740041
likaardiner
10te Camera Mschanical
lisamsga:
Davkt
Attached Is a stamped letter verifying Ma use of the previous calculations
and details. Hopefully it MI set* the building department.
Arai .
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Common. Vito*
FAX COVER SHEET
111 SW Oh Avon" lag Porflan$, MN ONO 12742411 Fist Ma nr-reee
• RECEIVED
CITY OF TUKWILA
OCT '2 1,1999
PERMIT CENTER
•
}
EMI Convelling Engineers
ApOA15,19
It Oat Buokbtt
n o greo8on CeaPar4►, ba
12600 BaAeosntsr Agog
Tuksiln, WA 0019/1
HE Pakwsy Blttmranisr
Kb COMM
Tukwila, WA
Door Dsvkl:
Jurod Omen
IMONMINUf7101110.164
&god August 19, 10N are
Mom* odouldlom tionlisd b WbDamald� M r Comport, vsiikig is atuokral adsg of raaf msohs iod oupporlo
at to Sprint paAon of to Pad A bulling. The osioullons aairm that Id dotal n su00iofmt for to
support of a WI NW" hos Ism 1,900 bo. Wild h to some maim btu, some root tamkmt. Klir
Cwwm=wise i ts arms balk% and Newts the sons iodt ning, so Is pinto dstdis, mWinasd
�Ids�6y 84Mtiof Wan based on tms rrgeisemms�eb d is 1067 UrmMbrrn ddldtmp Cods, os
Ityou Iwo erN guidons ar mph Ulm" heasudon, Om of
t t t S, W. Fit10 Avenue, Suite 2300 tFvU,nt, Oft 17201 •!111 (SO4 227 -3151 ter (3033 327.7530
SsuUls IotU uud ass IrrrrlaSs los Arp Soo IMssr): See Slogs
ems ir-- ..._.,
RECEIVED
CITY OF TUKWILA
OCT 2 1 1999
PERMIT CENTER
/ / ...SIERU&
CONSTRUCTION COMPANY. INC.
Date: 4/15/99
Name: Jarod Winnen
Company: KPFF
Fax No.: (503) 227 -7980
From: David Buckholtz
Fax Cover Sheet
No. of pages sent (including cover sheet): 6
Subject: Parkway Plaza — DCVR #283
Reply requested? Yes
Server /1103/correspondence/KPFF RFI fax cover aheef.doc
Message: Please review the attached DCVR. A response is needed quickly.
Thank you. David.
RECEIVED
CITY OF TUKWILA
OCT 2 1 1999
Please call David at (206) 574 -0925 if all copies are not receivEft MI7' CENTER
SIERRA
CONSTRUCTION COMPANY, INC.
www�wwww�
Date: 12/1/98
Name: Roger Stange
Company: Benner Stange Associates
Fax No.: (503) 670 -0235
From: David Buckholtz
Fax Cover Sheet
No. of pages sent (including cover sheet): 2
Subject: Parkway Plaza Supercenter — Kits Camera
Message: Roger: Attached is the roof plan for location of HVAC units at
Kits Camera. Call Todd or myself at the jobsite should you have an
questions, Thank you, David.
Reply requested?
Please call David at (206) 574 -0925 if all copies are not received. RECEIV
CITY OF TU KWILA
• C r �tic.(r.l . rz (r � � � • OCT 2 1 1999
r
Ssrwr/ 1113 /conespondsnce/archN.cl/B . nnsr Slangs rax.doc PERMIT CENTER
CGo
PLAN REVIEW /ROUTING � IP
ACTIVITY NUMBER: M99 -0205
PROJECT NAME: TACO DEL MAR
XX Original. Plan Submittal
DATE: 10 -21 -99
Response to Incomplete Letter #
Response to Correction. Letter # ._ Revision # _ After Permit Is Issued
DEPARTMENTS:
Bui L Division
Public Works
DETERMINATION OF COMPLETENESS: (Tues., Thurs.)
Complete
Comments:
APPROVALS OR CORRECTIONS: (ten days)
Approved
\PRROUTE.DOC
5/99
Fire Prevention
Structural
Approved n Approved with Conditions
n
n
REVIEWER'S INITIALS:
Planning Division n
GRIN Permit Coordinator
DUE DATE: 10 -26 -99
Incomplete ri Not Applicable
TUES /THURS ROUTING:
Please Route n Structural Review Required ri No further Review Required
Approved with Conditions n Not Approved (attach comments)
CORRECTION DETERMINATION: DUE DATE
Not Approved (attach comments)
REVIEWER'S INITIALS: DATE:
DUE DATE 11 -1 8-99
REVIEWER'S INITIALS: DATE:
DATE:
•
REGISTERED AS PROVIDED BY LAW AS
CONST CONT GENERAL
REGIST. # EXP. DATE
CCO1 SEAAISM081B9 04/18/2000
EFFECTIVE DATE • 01/29/1992
SEA.AIRE SHEET METAL•.INC
2014 136TH., E ; •
T: sigIvire
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\\`\� ���qu uu nn�pp���ER WA 9839 0
0 Isvi " DEPARTMENT OF LABOR AND INDUSTRIES
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# •. s OF wPS' J ���
I HEREBY CERTIFY THAT THIS IS A TRUE
AND EXACT COPY OF THE ORIGINAL DOCUMENT
-fDaht0Aq 503()
Notary ^' Public
VV �
In and For the State of
Commission Expires
S
Residing In
Cf TY A
SEP 1 6 1999
PERMIT CENTER