HomeMy WebLinkAboutPermit M94-0165 - SZYPERSKI HELEN1
tiPE.RshI
11-eLen
(e,p re6)
Permit No: M94 -0165
Type: B -MECH
Category: RES
Address: 13749 MACADAM RD S
Location:
Parcel #: 322920 -0046
Contractor License No: NORTHWH103R2
TENANT SZYPERSKI HELEN Phone:
13749 MACADAM RD S, TUKWILA WA 98168
OWNER SZYPERSKI KATHERINE A Phone:
13749 MACADAM RD S, TUKWILA WA 98168
CONTRACTOR NORTHWEST WATER HEATER, INC. Phone:
2800 THORNDYKE AVENUE WEST, SEATTLE, WA 98199
CONTACT BUFFY GROW Phone:
2802 S MADISON, SEATTLE, WA 98112
Signature:_
Print Name :_
MECHANICAL PERMIT
Valuation:
Total Permit Fee:
- 121(1) Title:
Date: till
(206) 4313670
Community Development / Public Works • 6300 Southcenter Boulevard, Suite 100 • Tukwila, Washington 98188
Status: ISSUED
Issued: 11/07/1994
Expires: 05/06/1995
EXPIRED
206 431 -2796
206 431 -2796
206 282 -4700
206 322 -8191
*****************************,********,***** * ** * * * * * * * * * * * * * * * ** * * * * * * * * * **
Permit Description:
INSTALL 75,000 BTU GAS FURNACE.
UMC Edition: 1991
2,700.00
24.00
* ************* *********** ************* ***** * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
1 - 1 - 9.4
Permit Center Authorized 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 the performance of work. I am authorized to sign for and
obtain this buildin permit.
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.
AMOUNT
OWING:
04 . C4
CONTACTED
Or
1/ 1
DATE NOTIFIED
- (Q
t 0 . a - `7
BY:
(init.)
2nd NOTIFICATION
BY:
(init.)
3RD NOTIFICATION
BY:
(init)
PLAN CHECK
NUMBER
EPARTME
O BUILDING -
initial review
O FIRE
O PLANNING
O OTHER
O BUILDING -
final review
O BUILDING
OFFICIAL
CITY OF Tl1KV; .A
Department of Community Development — Permit Center
6300 Southcenter Boulevard - #100, Tukwila, WA 98188
(206) 431 -3670
Mechanical Permit Application Tracking
PROJECT NAME
SITE ADDRESS
INSTRUCTIONS TO STAFF
• Contacts with applicants or requests for information should be summarized in writi g by staff so
that the status of the project may be ascertained at any time.
• Plan corrections shall be completed and approved prior to sending to the ne s department.
• Any conditions or requirements for the permit shall be noted in the Sierra stem or summarized
concisely in the form of a formal letter or memo, which will be attached • the permit.
• Please fill out your section of the tracking chart completely. Where i • ormation requested is not
applicable, so note by using "N /A ", date and initial.
DEPARTMENTAL REVIEW
"X" in box indicates which departments need to review
TE1
REVIEW COMPLETED
INIT:
INIT:
IN .
INIT:
INIT:
PPPROVED
(ROUTED)
7 9 pP K1 ) � I VE NO
OY6CTION:
REFERENCE FILE NOS.:
UMC EDITION (year):
roject.
EMENTS / COMMEN
Sent - Date Approved -
U Sprinklers
L) Detectors
DEPT. LETTER DATED: INSPECTOR:
U N/A
ZONING: IBAR/LAND USE CONDITIONS? Q Yes No
SCREENING REQUIRED? O Yes 0 No
01/07/93
SITE ADDRESS SUITE #
VAL E OF CONSTRUCTION - $
PROJE T NAME/TENANT
t16 v1 S \. . SVi
ASSESSOR ACCOUNT #
.� -'_ t
0 Other:
T OF WORK: New /Addition Q Modifications Q Repair
DESCRIBE WORK TO BE DONE: Ci 06
PHONE
ADDRESS � _ 1. C SA
: ::TYPE : 'RATING /SIZE :.:
• . : : :;
_ ./�
NUMBER: OF: UNITS >;i:>
1
Orr( ° ►r - ``1�I0OD
CONTRACTOR - I4l/(� 1io� >�
l
PHONE
ADDRESS -_
4. `�
b.
C�
IDLI.00)
ZVV ' 1
WA. ST. CONTRACTOR'S LICENSE #
Y- '�
,4,
BUILDING USE (office, warehouse, etc.)
EXP. DATE
.
NATURE OF BUSINESS:
WILL THERE BE A CHANGE IN USE? 0 No Q Yes IF YES, EXPLAIN:
WILL THERE BE STORAGE OR USE OF FLAMMABLE, COMBUSTIBLE OR HAZARDOUS MATERIALS IN THE BUILDING?
0 No 0 Yes
IF YES, EXPLAIN:
PROPERTY OWNER ,
.n
fg
DATE
BASIC PERMIT FEE
$15.00
PHONE
ADDRESS � _ 1. C SA
2 .
q•OC)
_ ./�
ZI p15c11t )
— 7Q
CONTRACTOR - I4l/(� 1io� >�
l
PHONE
ADDRESS -_
4. `�
b.
C�
IDLI.00)
ZVV ' 1
WA. ST. CONTRACTOR'S LICENSE #
Y- '�
,4,
M .( -
EXP. DATE
.
DESCRIPTION
AMOUNT
RCPT #
DATE
BASIC PERMIT FEE
$15.00
UNIT(S) FEE
q•OC)
PLAN CHECK FEE
- -----
OTHER:
TOTAL -
IDLI.00)
CITY OF TUKWILA
Department of Community Development - Building Division
6300 Southcenter Boulevard, Tukwila WA 98188
(206) 431 -3670
PLAN CHECK
NUMBER
CON
0
PRIN
q LI'o L(DS
APPLICATION MUST BE FILLED OUT COMPLETELY
MECHAk.CAL PERMIT
APPLICATION
FEES (for staff use only)
DATE APPLICATION EXPIRES
AC ERSON
7,144
ADDRESS 4 All
DATE
PHONE ` )g
CITY/ZIP tr f , I_ /'p�
PHONE -[��
I:: HEREBY CERTIFY: THAT I HAVE. READ AND. EXAMINED THIS APPLICATION AND KNOW THE:SAME;TO BETRUE
AND CORRECT, AND I.:'AM AU HORIZED':TO •APPLY ^FOR THIS PERMIT.
BUILDING OWNER $I
APPLICATION SUBMITTAL In order to ensure that your application is accepted for plan review, please make sure to till out the
application completely and follow the plan submittal checklist on the reverse side of this form. Application and plans
must be complete in order to be accepted for plan review.
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.
VALUATION OF CONSTRUCTION The valuation is for the work covered by this permit and must be filled in by the applicant. This
figure is used for budget reporting purposes only and not to calculate your fees.
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 304(d) of the Uniform Mechanical Code (current
edition). No application shall be extended more than once.
If you have any questions about our process or plan submittal requirements,
please contact the Department of Community Development at 431 -3670.
DATE APPLICATION ACCEPTED
to qL
03114.w.
SUE61ITTAL CHECKLT
MECHANICAL
n Two (2) sets of mechanical plans, which include:
• Floor plan
• System layout
• Elevations (for roof mounted equipment)
• Heat Loss Calculations
Completed mechanical permit application (one for each structure or tenant)
Structural calculations stamped by a Washington State licensed engineer may be
required if structural work is to be done (2 sets)
Note: Hood and duct systems require a building permit for the duct shaft.
Water heaters and vents are included in the UMC — please include any water heaters or
vents being installed or replaced.
Project: ' ' 1 7� s
Type of inspection: Cam m A
Address:
13'? � yVla Ca..,
Date called;.:
r - 3a - 1
Special instructions:.
--, 2-79f
Date wanted:
,.
a.m.
Requester:
Phone No.:
.
CITY OF TUKWILA BUILDING DIVISION
6300 Southcenter Blvd., #100, Tukwila, WA 981881 i,k
INSPECTION RECORD
Retain a copy with permit
INSPECTION NO.
Inspector:
` F
PERMIT NO.
Date:
_ y 7
$42.00 REINSPECTION FEE REQUIRED. Prior to inspection, fee must
be paid at 6300 Southcenter Blvd., Suite 100. Call to schedule reinspection.
Receipt No.: \5
it
(206) 431 -3670
171 Approved per applicable codes. Corrections required prior to1approval.
COMMENTS:
L u //
Date:
COMMENTS: N _ ._ A.. L. ,r
IVl "51 1
11161.1,74M 7.
/
/4_1 . rte /z* ` h , /-- i _
Date Called; ,
Special Instructions:
p t)s,5 t 1 ,
4,
, 00 '
V
D Wanted : / �O h � �I( i . mm,
Requester. o i
2 fri (.4 4 4 5a-olio_ // ,
Phone No.:(Va L+ —700
A 64, i 1--- 5 4-4 r fir- ?A.
4 - , ', 0/(a.„ $.e.... ukal ,:/-
1 3 /..- L, 7 3- G -,,
5 f d If r.4
v-ai /.�A ail . / 0444-10
4
ro ect'
k,�/7(1t' kee
IVl "51 1
ype o nspect on -^ • ■
*" t OCL\
Address:
Date Called; ,
Special Instructions:
p t)s,5 t 1 ,
4,
, 00 '
V
D Wanted : / �O h � �I( i . mm,
Requester. o i
Phone No.:(Va L+ —700
INSPECTION RECORD
Retain a copy with permit
CITY OF TUKWILA BUILDING DIVISION
6300 Southpenter Blvd #100, Tukwila , WA 98188
/,.
ER
(206) 431 -3670
❑ Approved per applicable codes. it;( Corrections required prior to approval.
Inspectd,y// 44_ "614e ... Date: a .►,.,� 45
❑ $30.00 REINSPECTION FEE REQUIRED. Prior to reinspection, fee must be paid at
6300 Southcenter Blvd., Suite 100. Call to schedule reinspection.
Receipt No
Dale:
CITY OF TUKWILA, 'WA • IRANSMIT
*****4****i(A********* ****************.*******************fr*Arn
TRANSMIT, Number l' 94001452 :Amotint: " • "24.00 11107/94 14;2E;
Permit No M94-Q165 Type": 0-MI CH MECHANICAL 'PERMIT
Par ce1 Nc 32292.0.-0046 11/97/94
Site Addreeil 11749" MACADAM RD S • -
Payment Methed CHECK Notation: WOE INCORPORATED 3:nit: SU]
144. / e****.4.******k*hAk4 *******“***********.it***********Alc******A
Account Code : 1 : DeSOription
000/322100'• • ,' MECHANICAL - RES
.1, Total' , (This Payment):
Total Fees:
Total All Payments:
Balance:
24.00
24.00
.00
Paid
24.00
24.00
GENERA 24.00
GENERA 30.50
TOTAL 54.50
CHECK 54.50
CHANGE 0.00
7152A000. 1507
Address: 13749 MACADAM RD S
Suite:
Tenant: SZYPERSKI HELEN
Type: B -MECH
Parcel #: 322920 -0046
CITY OF TUKWILA
*•k•k•k•k'k A• k** *'* **•k* * **•k *•k•k•k *•k *•*•A* k**•k *•k k **** k• k- k- k• k• k**** 'k ** *•k•k * * **
Permit Conditions:
1. "NO WORK SHALL BE DONE . I7.
, N" ;l'G` THOSE. MODIFICATIONS OR
REPLACEMENT OF EX T, NG. = A AP PL IA NCES Az "'DESCRIBED. ON THIS
I:C
ORIGINAL MECHANAL-- PERMIT '! ,. =i1 •..., 4
2. P1umb1ng permits '';hall. obtained 'through°,tiie �Cetla -1 ing
Coun Depar7ttoe . of ! .Pub ;; 131 o' Health ��.:P, hi
i um.ng 4 wi l 1 `• ::h.
inspected by..;.t`hat i`nc1ud,ing, ,a1'1 gas �yr� i Ong
(296-4722P �, ' .,
, ., , ., fv r: °t' % , ,.
3: Electricayl��iper s sha,l:1`'be obtained through they .Washing°ton,
State Dtt isio'ri`��..of' labor and Irid•jst,4ies and a1I elect,'i .
work w-fl-l' be inspected by t hat agency (248 - 6630') .4, ,
4. 'All petY inspection and approved plans ,, l , c bi
avai 1; b') e then. job site p rior. ; ....to' the start of any, Olin,r>'' ; f
stru�P�`t,.iorW docuntants atr.6 " maintained and a,v ,16
ab1e final inspection..- a�pprova, ` -is _granted. �,r ,rr r �. yr\o'
5. Al l construct Ion to, -�be" „ done F iii - con fprmancet ,with approve "' ti
p1A:ns and reg >irements of 't j , g `
``' fie 11,ni�o'miB�rild��n Code t�199`1� `
Ed ti`on) as,; amended 'Lin iforf` Mech nic 1f Codes (1991 Ed4t 'toil ),,
ant rWash1ngton State' E ,ergy'Code ('�1994//�Ed Ed . "' „�' #� # '
6. Val ; 4,.441ty lx gf' Pe.rmft'�. T.ihe �i,`s 6 or approval , o.f,
p1ans9, s'pe;cifications,i' ntti�' computat y shaI l not be ^'conic.,
str ° ued to x be e periii'itt { or an ap
;pr,va
;o= l”- =rof any v i of ail - 6' E �
of any ojf t ;ti .p i s i ons of the �fbu 1 1 t,i:ng,,'co or of anyk; 3 i P
othe.� rdi =i'naice'�of the jut isdicti1 � . 3 sn to
giv grs
e!, h
, tority to violate or can 'l Vi 'pt permit preumi
v'i�f tons o
'1 thvite
code O 1 `{. w o e va rid . . i t .� ,,, a 6'4,
r. F' N SITE
S SST O ST .0 T N' E O UIR D �►
MANUFAI(�t`'�lRER., IN. A�.LATI N IN Ij �C f'Q�� � � �����
FOR THE; I .INSPECTOR'? REV, iwt.. ,,, • '” r,.
1 .ti n vt►D G; '
et o
Permit No: M94 -0165
Status: ISSUED
Applied: 10/28/1994
Issued: 11/07/1994
..
"I spM
'U' OR 'F'
VALUL
aE
HUT LOSS
FACTOR
(K° a TI
SQ. FT. (SF)
LINEAR FT. ILI)
CUBIC FT. ICF)
SECTION 4 (Continue
•
r - --
HEAT LOSS ITEM
HEAT I04S
(BTU /HR)
HEAT LOSS ITEM
Floor (Continued)
'U' OR 'F'
VALUF
HUT LOSS
iACTO*
(46' A T)
SQ.
LINEAR
CUBIC
I
. (SF)
. (LE)
. (CF)
HEAT 1.035
(ITU /HR)
W)ndosss, SkyllghW . Doors
« Single Pane
1.200
55.2
SF
Concrete Slab
Double Pane
(Per FL of Perimeter)
Metal Frame
.900
41.4
• ' /
Sr
Or, Grade • No Insulation
.730
33.6
Lt
_
Wood or Vinyl Frame
.750
34.5
•
SF
On Grain - R.5 Perimeter
.580
26.7
LF
Wood Dr. 1?4" Solid Cote
.330
15.2
st
5-4
On Grade • R•10 Perimeter
.540
24 8
LF
Dr. 11/4"
r" W /Panel,
.570
26,2
�
,.'
SF
(
Below Grade • t:ninsulated
.530
24.4
LF
_Wood
Metal Dr. W /t) Thermal Break
,400
18.4
:
SF
Other
' ', 'a ur_
Infiltration (Mr Cult, of volume)
- . ......
.022
;AM
_ ,
1 0
t _-
Other
Sr
+
;sr ' : Imo . •
Wail (Net Area)
•
(
Prc 19(k1 1,2 AC H
Wood Studs - Above Grade
Post 1980 .6 ACM
.011
.5
Cr
No In ■ulatIon
,25n
11.5
/li;)
SF
0
R -7
,103
4.7
5F
E r J -a,w.. ..30t
R - 11
.088
4.0
Sr
A) Total Structural Heal Lass
5tu.IIR
R•19
.062
2.9
SF
(Add all btu /hr from sections 1 - Si
-
OP
Concrete • Above Crude
I) Duct Loss Line A x -
BTL. HR
No Insulation
.752
34,6
Sr
for Owns within I feared Space O.
~
R -11 Furred In
.105
4,8
SF
For Duct% In Unheated Spares
-
Concrete Block . Above Grade
1. ninsulated Ducts 20%
'r • •
No Insulation
.549
25,3
SF
Insulated to R -5 or Less 10%
Filled with Insulation
.450
20.7
5F
Insulated to st•b or More 5`4.
R -11 Furred In
.091
4.2
Sr
rot Ducts Burled in Slab 15 °n
Concrete • Fielow Grade
? ,, Ducts Exposed Directly to OutiIur,rs, add ST. to
Unheated Spaces factors
No Insulation
.278
12.8
St
R -11 Furred In
.062
2,9
5F
Cl 46° is T Deter Heating Load
' - c ; • � etu-tia
/ `,']� � -7• a
R -19 Furred In
,041
1.9
SF
(t me A * B1
R - 10 Rigid txterlor
.064
2.9
SF
I)) Correction for Other Design Temperature:
OSENICEIV I
Other
'Y o-
Ceiling (Net Area)
e T = 70' • (Outdoor Design Tempt = 70-__ _
(:vrrrrrlon Factor a T + 46' - + 46
E) Design Heating Load (DHL)
5TL iiR
No Insulation
.400 18.4
SF
46' A T f)HI x Correction facto,
R•7
134 '.2
'7
St
,
� - " -
(Line C x Line 131 .
- 11
.091 4.2
tit
F) Minimum Reeomrtaonded Furnace Output
i _.2 1111„ rte
L . .
_ R
R -19
.049 2.3
St
UHL Plus 10% Overdoing Factor
/
r)
R•30
.036 1.7
5F
(tine E x 1.1)
R•3A
.031 1.4
Sr
G) Maximum Alowed Furnace Output
Sit. HR
Other
DHL Plus 509F. Oversising Factor
r
(Cathedrals • add 20% areal
ili 44104111111116118.7"
Hoof
MENINIEZ MOM
(t ine E x 1 5)
r
Wood gum over Crawl
Recommended Furnace
.
Nn inaulauott
F6 2
' J
SF
(Model e): -•
R. I I
.056 2 1
SF
Furnace Autput: _!,I`
[, • BTU •HR
R•19
.041 '1.9
ss
_
R•30
.029 1.3
5F
_ , , 7 . e 1 l I
REST Ehl 1AL HEATING LOAD CAL'`ULATION
WFS 10 /9 93).
4%-
Style House
X00
Heated Sgnare Footage
SNO 1 lUllUiSN 1
(LOWER SIZING (Air Plow Or 75 -- 100 CFM per rolRiater):
Cubic Contents x 3 5 Air Changes •I 60 Minutes =
Cubic. Cont pa y x 5 Air Changes + 60 Mlnrrips
No w/u rttgisters x 75 - 100 -
ZhtOI P6/61/01
r In
4
Min. C.F.M.
Max. C.F.M.
C.F.M. Req.
i .A.
... et i.co
0 •
SW= 4' ;
PASIagi%
e.3
Certlill'a f at
/ 0
SPeC■41 Delivery Fee
Restricted Delivery Fee
Return rincuipt Showing
to Whom & Date Delivered
it / 0
Return necelot Showing to Whom.
Date, and Addressee's Address
i fITAL Postage
S
$uStniatk or Dal/ Ale14
1.ke:0 .41
-.•
i 1.0 ;',
..... tis
4. ..7 o
z
0
ct
1 1 I
A
!t,
tJ
4 "I h
liektyovvi f oible
h.
P 112 198 145
- .711-7tV1 1 475?ItT;r5-76,Vi.F.7.: , ;17,7;ttr , 3 1,74. .;
n the reireitieside?..
'•■• 4
fi)
' ;4q
Receipt for
'14 1 1 Vi
Certified Mail
No Insurance Coverage Provided
p05 1.1 1 0 sy „ . 111.,,LS, Do not use for International Mail
See Reverse)
■•or. t.Ati..
tr
January 27, 1997
Bully Grow
2802 E. Madison
Seattle WA. 98112
Dear Permit Holder
On September 11, 1995 you were notified your permit number M94-0165 would expire
on October 17, 1995. Since September 11, 1995 our records indicate that no inspection
or extension requests were made.
Due to the expiration of your permit, as of January 27, 1997 this permit is now closed
without the benefit of a final inspection. Any further work on the project will require a
new permit application submittal and additional fees. Any new submittal will require
compliance with the current edition of the Uniform Building Code.
If your project has been completed please contact the permit center for proper closure
procedures. A final inspection and approval will be required. If you have any questions
or need further assistance please contact Kelcie Peterson at the City of Tukwila Permit
Center at (206) 431 -3672
Sincerely,
l�,
Kelcie Peterson
Permit Coordinator
City of Tukwila
Department of Community Development Steve Lancaster, Director
`9el,tr50%
Sent Certified mail #P 112 198 145
FILE p
Jo . Rants, ayor
E >:ps�, F.
RED
6300 Southcenter Boulevard, Suite #100 • Tukwila, Washington 98188 • (206) 431-3670 • Fax (206) 431-3665
Sep 11, 1995
BUFFY GROW
2802 S MADISON
SEATTLE, WA
98112
Sincerely,
1
RE: SZYPERSKI HELEN
Dear Permit Holder:
Our records indicate that on Oct 17, 1995 one hundred and eighty days will
have passed with no inspections having been called for under Tukwila
Mechanical Permit Number M94 -0165. Unless you call for an
inspection, or obtain a written extension from the Tukwila Building
Official prior to that date, your above referenced permit will become null
and void on Oct 17, 1995.
If your project is complete please call for final inspection. If you are
actively working on your project please contact our office.
If you have any questions or need further information to obtain an
extension on your permit please call the Tukwila Building Divison at
431 -3670.
City of Tukwila
Department of Community Development Steve Lancaster, Director
Kelcie Peterson
Permit Coordinator
Department of Community Development
FILE COPY
John W. Rants, Mayor
6300 Southcenter Boulevard, Suite #100 • Tukwila, Washington 98188 • (206) 431-3670 • Fax (206) 4313665
Apr 06, 1995
BUFFY GROW
2802 S MADISON
SEATTLE, WA
98112
RE: SZYPERSKI HELEN
Dear Permit Holder:
Sincerely,
City of Tukwila
via
A ' ing Permit C=' rdinator
Department of C. unity Development
John W. Rants, Mayor
Department of Community Development Steve Lancaster, Director
Our records indicate that on May 06, 1995 one hundred and eighty days will
have passed with no inspections having been called for under Tukwila
Mechnical Permit Number *M94 - , 0165. Unless you call for an
inspection, or obtain a written extension from the Tukwila Building
Official prior to that date, your above referenced permit will become null
and void on May 06, 1995.
If your project is complete please call for final inspection. If you are
actively working on your project please contact our office.
If you have any questions or need further information to obtain an
extension on your permit please call the Tukwila Building Divison at
431 -3670.
6300 Southcenter Boulevard, Suite #100 • Tukwila, Washington 98188 • (206) 431-3670 • Fax (206) 431-3665
' ' ,. , REGISTRATION J1UeBEp ;.; :'';'• •'
, ., OPMAto10.4TE• '
E cOi :
Y I�(NO;99JZ,
NQ I1H
Q 4 1s
, .0:4i0201.5
' ,'. _ _ REGISTRATION NUMWER't'
ERPIPAmNQATE
'.:b1
` '. I.'
• NDR7HWW103R7
0.rEC
12/221'04
12/22/90
J.
'f,Gi- !1.. -u. ?i: $'i a: i:: �..!:. e•: i:. a�+ u�+ raM. r-. nn- r. r, no, w�. uHnaar„ �� .•e.r. «rcnr.u+szrs..>.+s:aar,,•x r.,.,..w< � .....,.,_.. _.,....- ...__...._.__....._..._
C
i ,AEGi$TEREU A$.PROVIUEO 9Y LAbi 'AS
• li' rr.'f
.t •NofTHWE8T Wtn' HTR YNC /DAVIS 'SM..'
2800 THORNDYKE AVE W
BEATT).E WA 98199
' ,. SIGNATURE
ISSUED BY
OF LABOR AND INDUSTRIES
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SIONATUR
Is • D BY DE • • T ENT OF.LABOR AND INDUSTRIES
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It." NO R'tU W F St'' v A? � k N. A I Eft 1 ANC.
., 2800 1 It ♦ .. _
URHUYKE AVF' W
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WA 98 X99 •
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