HomeMy WebLinkAbout200 BRUENN AVE
TUBING AND PIPE
5' 034332 18 28.95 lb.
6' 034333 18 34.74 lb.
7' 034335 18 40.53 lb.
8' 034337 18 46.32 lb.
9' 034339 18 52.11 lb.
10' 034340 18 57.90 lb.
10' 6" 034342 'li" 18 60.80 lb.
11 ' 034341 18 63.69 lb.
12' 034345 18 69.48 lb.
13' 034347 18 75.27 lb.
15' 034349 18 86.85 lb.
JWg,~~i~~'
5' 034431 12 45.50 lb.
6' 034433 12 54.60 lb.
7' 034435 12 63.70 lb.
8' 034437 12 72.80 lb.
9' 034439 12 81.90 lb.
10' 034440 12 91.00 lb.
10' 6" 034443 12 95.55 lb.
11 ' 034441 12 100.10 lb.
12' 034442 12 109.20 lb.
13' 034447 12 118.30 lb.
14' 034449 12 127.40 lb.
15' 034450 12 136.50 lb.
Special Note: Please call us for all your special needs: Drilled Posts, Welded Plates, Post Bending, etc.
""""~"'1-{',,, ~_AFA MASTER ~ HALCO@ J-l1
\~" Prices & Specifications Subject To Change Without Notice.
~~~~ For Policy and Terms, Please Refer to Page COV-1.
Copyright@ Master-Halco, Inc. 1999 Rev. 10/99
TUBING AND PIPE
FULL WEIGHT
5' 034550 1 94.85 lb.
6' 034554 1 113.82 lb.
7' 034555 1 132.79 lb.
8' 034557 1 151.76 lb.
9' 034559 1 170.73 lb.
10' 034560 1 189.70 lb.
10' 6" 034564 1t'" 199.10 lb.
11 ' 034561 1 208.67 lb.
12' 034562 1 227.64 lb.
13' 034563 1 246.61 lb. !
14' 034569 1 265.58 lb.
15' 034570 1 284.55 lb.
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5' 034591 1 142.75 lb. I
6' 034582 1 171.30 lb.
T 034583 1 199.85 lb.
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8' 034584 1 228.40 lb. !
9' 034585 1 256.95 lb.
10' 034571 1 285.50 lb.
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10' 6" 034572 1 299.78 lb. I
11 ' 034573 1 314.05 lb. ,
12' 034575 1 342.60 lb.
13' 034577 1 371.15Ib.
14' 034579 1 399.70 lb.
15' 034589 1 428.25 lb.
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Special Note: Please call us for all your special needs: Drilled Posts, Welded Plates, Post Bending, etc.
J-18 MASTER @ HALCO@ ;_AFA .,...~..,.:..
Prices & Specifications Subject To Change Without Notice. ~~-~ '..~.,.
For Policy and Terms, Please Refer to Page COV-1. ~ir"".jl}
Copyright @ Master-Halco, Inc. 1999 Rev. 10/99
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APPLICANT: DOWNER ~ONTRACTOR DAUTHORIZEDAGEN~ ~ '
Site Address: Tax Account Number:
Jib 'r'eJrn e...'r
Owner: Address:
Contractor: f~ Fl~/$O'1 ~e..-~ -:I.h cI ~ Address: /-fooo ~Y'; I Lk -RJ..s6
fln-t br~Cl.."J LOA cr9?30~
Contractor License#: PAQ FI F 1 1 q -:fA Expiration Date: 0.3 4 I 0 1... )
Contact Person: \.J.)oJ~y A.. Beu~Y" Contact Phone#: 6"c>-g'] I -:3 2.2.1
5htb'on -R~ oS
Check the type of application for below:
o SF RESIDENTIAL NEW 0 COMMERCIAL NEW 0 GARAGE
o DUPLEX 0 COMMERCIAL REMODEL 0 ACCESSORY BLDG
o MANUFACTURED HOME 0 COMMERCIAL ADDITION 0 SIGN
o RESIDENTIAL REMODEL 0 COMMERICAL REPAIR 0 DEMO
o RESIDENTIAL ADDITION 0 MULTI-FAMILY 0 GRADING (Cubic yards: )
o RESIDENTIAL REPAIR 0 TENANT IMPROVEMENT ~ OTHER:8'ch~\""'t Ll~k ~1!:<...>
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Scope of Work Proposel:i:
Square Footage: Dwelling: Garage: Decks:
IS THIS PROPERTY WITHIN 200 FEET OF A SHORELINE? YES NO )(
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, a ua'tlon:~ ,.L,i an~~\;s.~e.w"Jlj'es.':-: :'S0': - '~emu1t,!ee.v:, :" j, '''''':,;: ,,' ","W:fZJ.,1~~ ~Slt '!t,1\1:~~
~ q ^ 1JLI ~~ Ot 5 ' Ene'gy. SSG 00 - " =>. 4a-.b
~F u~ ......1- State. $ 4.50 d-J.
A~ mn, ~ ~kh no penni. i, i"ued within 180 day' fnllnwing the date nf applicatinn ,hall e"Pi" by limitation, =d plan,
and other data submitted for review may thereafter be returned to the applicant or destroyed by the building official. The building
official may extend the time for action by the applicant for a period not exceeding 180 days on request by the applicant shmving
that circumstances beyond the control of the applicant have prevented action from being taken. No applicant shall be extended
more than once. In order to renew action on an application after expiration, the applicant shall resubmit plans and pay a new plan
review fee.
APPLICANT'S SIGNATURE: ~rt\,,--1roM~e"-l1n <L.. . DATE: 7/10 /0 I
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:~_ " "',..' --=~~ Id: ront130 Keyword: UACT User: VAL 07/17/01
. t.routing- maintenance. BLDGPERMIT W ~ 'ECH/PLBG
0373 Applicant: MYRVANG, STEVE CAR-CHIT
. PING Address: ,828 BlROADWAY AVE
~jlfRROOMERTON - 239 4th Street- Bremerto A 98337 Line: 2' of 8
'gned complete
BUILD 8UILDIN PLAN CK A oved 07/10/01 07/10/01 07/10/01
BUILD 1 BtJIL.r>ING s.signed07/10/01 07/10/01 . _I. ./. .
BUILD 2 LANP USE Assigned 07/10/01 07/10/01 . _I. ./..
BUILO 3 PUBLIC WORKS Assiqned 07/10/0107/10/01 _. /. _/_ .
BUILD 4 UiflLITlES Assigned07f10I01 07110j01 -- f. - f . .
BUILD 5 FIRE .Assigned 07j10jOl 07/10/01. ../../..
BUILD 8 CROSS .CONllfECTt Assigned 07f1QfOl 07/10/01 ..I..f..
BUILD BUILDINGP CK partial 07/10/01 -. f . . f. . ../-.j.. I
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PERMIT e'ENi'D 1d: rout130 Keyword: UACT User: VAL 07/17/01
Activitydocu.ment routing-maintenance. BLDG PERMIT-NO MECH/PLB
Permit Ho: 01-0314 Owne.r:BREMERTON SCHOOL DISTRICT
St.atus: PEN:l>ING AddreSS: 20:0 BRtJENN AVE
Route: 1 Current Route Line.: 1 of 5
Packet Units Description statiOn Status ReoeiveQA$signed Complete
_ k,,,
BUILD BUILD1NG PLAN' CK STRT...B....VW Approved 07/17/01 07/11/01 07/11/01
BUILD 1 B'OILJ!)lNG BLOO ....LC Assigned 01/17/01 07/17/01 .../. .f.-
BUILD 2 LAND USE PLNG -LW Assigned 07/17/01 fJ7/17/01 - ./_ _j. .
BUILO 3 PU&LtC WORKS PUBWKS-PW Assigned 07/17/01 0'/11/01 .../.../..
BUILD BUILDING PLAN CK E,NO-B - Partial 07/17/01 .../../.... .. ,./',. -/-.
F1=Help; ES'C=E:xi tcurrent screen_
I * Equal Opportunity Employer *
BREMER TON PERMIT~~NTE~- 1
286 4th Street~ Bremerton~ WA 98337 I
Phone: (360) 478-5275 FAX: (360) 478-5278
BUILDING PERMIT I
Job Addr: 200 BRUENN AVE, Permit No: 01-0374 i
Location: BREMERTON SCHOOL TRANSPORTATION & MAINTENANCE'fACILITY Status: PENDING I
Parcel No :.,~', ',(~,',"',","':", Applied: 07/10/2001
,:;;".' ;~ Issued:
Applicant: PACIFIC IRON & FENCE INC 360-871-3229 Expires:
4000 ARVICK RD PORT ORCHARD WA 98366
Owner: BREMERTON SCHOOL DISTRICT
200 BRUENN AVE BREMERTON WA 98312
Contractor: PACIFIC IRON & FENCE INC 360-871-322Lic #: PACIFIFl19JA Exp: 03-20-02
4000 ARVICK RD SE PORT ORCHARD WA 98366
Subcontr:
Desc: 8 FOOT CHAIN LINK FENCE WITH 32' DOUBLE DRIVE GATE
*********************************************************************************************
Valuation * Permit Fees: 139.25 Total Calculated Fee: 234.26
6,299.28 * Plan Check Fees: ':1, 90.51 Additional Fees: .00
* Other Fees: 4.50 Total Permit Fee: 234.26
I *********************************************************************************************
This permit shall become null and void if the building or work authorized by this permit is not commenced within
180 dayS from the date of such permit, or if this building or work authorized by such permit is suspended or
abandoned at any time after the work is COt'OfI1enced for a period of 180 days.
NOTICE - It is the responsibility of the permit holder, not the City of Bremerton or Building Official to see
to it that required inspections are made. The permit holder must notify the Building Official when yeady foy
inspections. Failun~ of the peymit holdey to notify the Building Official of Yequin~d inspections may yesult
in the stoppage of the woyk until such time that the peymit holdey can substantiate to the building official
that the concealed woyk meets or exceeds code yequiyements. Any demolition, testing, oy financial purden shall
be boyne diyectly by the peymit holdey. Failuye to substantiate code yequiyements will indemnify the City
against any and all responsibility oy liability connected with the construction.
I heYeby ceytify that I have yead and examined this peymit and know the same to be tyue and coyyect. All
pyovisions of laws and oydinal1Ces goveyning this type of woyk will be complied with whethey specified heyein
oy not. The gyanting of a permit does not pyesume to give authoyi ty to violate oy cancel the pyovisions of
any other state oy local law regUlating construction oy the peYfoymance of constyuction.
Signatuye: Date:
I certify that I am exempt fyom the yequiyements of the state contyactoy's registyation law, undey
Section 3, Chaptey 126, laws of 1967.
Signatuye: Date:
***************************
Permit Center--Approved By: Date:.
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.~ BREMERTON PERM:CT CENT-ER !
286 4t-h 5tnlet. Bremerton~ WA 98337
'-~ Phone: (360) 478-5275 FAX:: (360) 478-5278
Building Permit No: 01-'0374
Job Address: 200 8RIJEN!\I AVE 2,t,~~tI.JS : ISSUED
LOc8_tion: 8REMERTON SCHOOI_ TRANSPOfH?')T ION S. j'.1(.;,INTE!\IANCE F I 88ued: 08/09/-;:'()O1
I Ass! Acct No: E~~pi tee";: 02 ,',/() .5/( :;20()2 1
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R E QUI RED INS P E C T ION S I
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Item: 01100 FOUNDATION-FOOTINGS Dept= 8L.DG Oivision: ,I
Item: 01200 FOUNDATION-WALLS Dept: 8l..Di~ . Div,i.s.1.c)n: 'I
Dept: BLDG . . .
Item: 01700 FRAMING Dl\Jlsl.;')n; :1
I Item: 01800 INSULATION Dept: BLDG Division:
Item: 01900 SHEETROCK NAILING Dept: 8LDG Division: I
I Item: 02700 FINAL--BLDG Dept: BL.DG Division: I
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*********************************************************************************
I TESTING: Must be recognized by the Washington Association of 8uilding Officials,
[ SPECINSP: Must be registered with the State of WA
ST OF l.JA: state of WA Dept. of Labor and Industries 478-4921 1
[ HEAL.TH: 8remerton/Kitsap Health District 4 7<3-~5~:3SI
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I ALL INSPECTIONS PERFORMED 8Y THE CITY OF 8REMERTON MllST BE SCHEDULED THROUGH THE
! PERMIT CENTER, ( 360) 478-5275"
i *********************************************************************************
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',x;." BREMERTON PERMI"- CE,....ITER
\:\>'\1 286 4th Street~ Bremerton" l-JA 98337
-tt, Phone: (360) 478-5275 FAX: ( 360,) 478-5278
BUILb;r;NG PERMIT,..:
Job Addr: 200 8RUfNN AVE Permit, No: 01-03711. 1
! Locat.ion: BREMERTON SCHOOL TRANSPORTATION & MAINTENANCE FACILITY St.c1tus: ISSUED
Parcel !lio:- APplied: O,7/Ji)/2001 I
r Issued: Ol~/O';l,/!?GOJ.
r App1.ica.nt: PACIFIC IRON & FENCEINC 36()-87.1" ,..;3229 E:<pil'e2:: O~?/O5/2002
I 4000 ARVICK RO PORT ORCHARD WA 98366
[:
I O\~ner ; BREMERTON SCHOOL DISTRICT
l 200 BRUENN AVE BREMERTON WA 983J2
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Contract.or: PACIFIC IRON & FENCE INC 36Q-871-322Lic ~:- PACI~IF1)9JA Exp: 03-20-02
4000 ARVICK RO Sf PORT ORCHARO WA 98366
Subcontr:
Desc: B FOOT CHAIN LINK FENCE WITH 32' DOUBLE DRIVE GATE
. ", "',)1,':,
1111****1*111********..*******.*.****.******************************************************~r~~~0l
Valuation * Permit Fees: 139"25 Tot;3l CalcuJat.ed Fee: ,;34"2{~i; ',.i);:::
6,299.28 Plan Check Fees: 90.51 Additional Fees: .00 ' - '," :~'
*
* Other Fees: 4.50 Total Permit Fee: 234.26,
********************~l**l****f*******~m******************************************************
/,:ii::rhi~ p@rmit ~1'1It\U ~€:1tJfM! l'll.tll ii\f1d Vf:Ji.d ;Hi tf~ t;~JHdil'l!~ Q~' wctk ",u1;,h(~Yi:t.q;,d 1:;)1' thj,~ pl\lrmH: i,~ not cC)fom~n(;~d 1,.lith:i'n
'ISO. da.X$ 1'1'0111 the date of !%luch pe'rm:l.t., 01" if this buildins 01" WOYk iZl.l.I.HKw'iz:e.d b,' $u,ch p<iirmit is $'U$'f.)(*\1d~'d ';11"
abandoned at an)' timeaHey the \voyk is) comrn'~ncw for $ period of 180 diA,'S"
NOnCE: - 1t. b the Y&SPOl1$ibil H,y of: tha pl~ymi:f:. holder-, not the City elf Byemerton or Buildi'l'iS Otficil'l,l. to see
to it that required inspections are made" The pey'mi t holder' must noti"fy tho", Bui Idi'il9 Off icial ~Ih~n Ye~\dy for
i. \"l$pect. 10\"l$" failu.re 001' the permit holdey tel notify the Bwildin;;i Offid,,;J, ,=,f n,'qui'red i.'(I$p€ctie,n", InS.y '(~ljH
in thl!l? $toppas~ of th,,, "Jo'rk unt:l.l ,'Such Umetf';llt the peymit hold",'y can $!,lb:stl::\ntiat(1tf) th~ bui!.cli.n<.? offidaJ
that the. ccl'...~::ea1.l!,d v-,c)'rk meets (lY e;.((;~de, cc!d~ yequ.i.y",nwn'l:.s. ,\'1'1)0' de'liIo1Hic'r1, t€'$t.ing, Cli- fin:i\'f1Ci".1 bu.'n:!!:\'r1 shall
be bcn"f\'<?f dhec.t1 >' b;1 th>!'! p",'Yf11it. hr)ldey, Fai Iu n? to $uh$t.~l.nti,a te cr:.oo r,,,qui YeffNmt$ wi 11 i. 'f1(~mni fly th,? Ci i;y
;;l,9<1l,inst an)' anj ,dl 'n?$po\lsibil ity 0\' Ii-a.bili 1::.)1 cO\'1r'1ect.:..ed 1;.1\ th the CC\lfz't ruc:ti.on,
I h>!'!,ebY"'f:>1:n't.ify that I h::ave yead and ~li"~amin,",d -\:h1$ p<s>\'mi.t and knn(d t.h,,, ",ame t.;;; b;,. t.Y!le ,HK:1 co,"'("ct... /111
No',,,p.'(ovlfzd.on$ of la-lA'S 'Rnd on:linan:::e:\" gClVenli\lg thi $ 'b'p,,,,, of ,,10i"'[;' \,;:1 U be 1';;0111") 1!.€'ci v,lith ".>hethei"' $if~€'\.-:-if i,~'d h'nei 1'1
Or' r~:)'I:.. rh~ gnantins. of a PICYmit~ do>lS<'l> not. pre$ume to gi,\i<? "vJ.t.:hoy'i,t.y to vi01",+."" 0'( c,z,.ncel t..he pn:JVi"'d.m'I'9' ,:,f
any oU." .tate 0; ,~, ~"""'atin. :",~b"ction OY >,he ,erloy"",,,,e4 "'2'''-'cti"".
Signa tuye :~.Q .tsC...t.l~k~::~~_..__,__,._ _ 1):1\t.", ;',_... g ^~_..~_L._".__..._.._._,_._,_.
I ce;ytif:>' that' I a,111 e>(empi:, fn:>111 the requiyements of t.he ,;:t.a.te c:c,ntnat1i,:w.'I", I'E'Sii,.,'tya,t.ii;.n la..J; unde~'
Section :3, C;hiZlPter 126, laws of 1%7. \ Oate'~-L___
Sisnahtrel~0.~~,...._._..__
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Permit Center--Approved
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\i'.'\ E\REMERTO~',l PEF:hIT CENTER
PERMIT CONDITIONS
Pe'rrnitNo;. 01-0374 ~, I:, ,-; Pafje: 1
===:==========================================~:=================~====~=~====~
Job Add)' eelS ;. 2008RUENN AVE {-4Ppl 1.EH:l: ().7 ,/" 1. t~; ,./ 2 ()<) 1
f.~1SSr Acct. Nc, ;. Approved :: 08/0':;'/2001
Location: 8REMERTON SCHOOL TRANSPORT A T 10"1 3.- MAINTENANCE FIssued;. 08/09/200:1
ApplIcant: PACIFIC IRON & FENCE INC
~ 0"" Tier ;. 8REMERTON SCHOOL DISTRICT
I Contl-actor = Pr:;lCIFIC IF(ON & FENCE INC
I'
I Desc'(.iption:
r 8 FOOT CHAI.~~ LINK FENCE hllTH 32' DOUBLE DP l'v't:
GATE
CO'fldi t~i on~s:
I
f P,srmit !-!/older's ~~ )r
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I Permit. No:' OjR~0374 T;;p'-? ~ ".' F>ERNIT'''NO Mi?,;:CI",/ I
.
S~i t AVE.
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TUBING AND PIPE
FULL WEIGHT
5' 033801 36 13,60 Ib,
5'6" 033802 36 14,96 lb.
6' 033803 36 16,32 Ib,
6'6" 033814 36 17,68 lb.
7' 033805 36 19.04 Ib,
8' 033807 36 21,761b,
8'8" 033808 36f, 23,58 Ib,
9' 033809 36 24.48 lb.
10' 033810 36 27,20 Ib,
10' 6" 033813 36 28,56 lb.
11 ' 033818 36 24.97 Ib,
12' 033820 36 32,64' Ib,
w
5' 034101 26 18.25 lb.
5'6" 034102 26 20.08 Ib,
6' 034103 26 21,90 Ib,
6'6" 034104 26 23,73 Ib,
7' 034105 26 25,55 lb.
8' 034107 26 29,20 Ib,
8'8" . 034108 26 31,651b,
9' 034109 26 32,85 lb,
9'8" 034111 26 35,28 Ib,
10' 034110 26 36,50 Ib,
10' 6" 034112 26 38.33 lb.
11 ' 034114 26 40,151b,
12' 034115 26 43.80 Ib,
13' 034117 26 47.451b,
14' 034125 26 51.101b,
15' 034119 26 54,751b,
Special Note: Please call us for all your special needs: Drilled Posts, Welded Plates, Post Bending, etc,
J-16 MASTER @ HALCO@ ~_AFA '~)
Prices & Specifications Subject To Change Without Notice. ~~-- ~'* ,<5"
For Policy and Terms, Please Refer to Page COV-1. 't-~-t-,,:t<}~
Copyright@Master-Halco, Inc. 1999 Rev. 10/99
eIT)' OF BREl\'IERTON
NOll-Residential Building Permit Checklist
Applicant:
Building: Permit;;: Date:
~er Sheet ("/occupancy & type of consll ~Ian (dimensioned)
~pe of Work ~ Zomng District [ndte.ted
: Completed Application L-.J Contractor Verification
.. ! Bid or Floor :\rea Breakdown ! i Landscaping
- .----,
: I Floor Plan ! I Parking Plan
\:...praming Plan (cross-section) i-----I -
~ SEPA Checklist (if applicable)
~ations . ~te Plan Review Questionnaire
: oundatlOn Plan I : Vicinity y[ap
,----, J
~ Barrier Free Compliance ~ Special Land l'se Conditions
Or Pennits .
: : ArchitecturallEngineered Drawings ~ Sign Permit .-\pplicable
'--' - -
:~ Street & Ctility Permits required . : Plumbing Plan
; : :\t[echanical Plan ~ Cross Connection
----'
~ ~'REC Stamp/Compliance ~ Fire Department Info
Liahtimz Alarm S vstem
- ::I _ -
:\tlechanical _ SprinklerSystem
-
_ _ Envelope -
: Erosion Control Plan _ Stonn Drainage Plan
-...
~ WSVL-\Q Compliance ~ Health Depanment Approval
Comments:
~t 6-e v'\ ('-1 -
e\My Documcnts\Commerical Checklist.doc
LJst printed 02/26/9l) 9:35 AM
".
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BREMERTON PERMIT CENTER ..
, '. " '. .. ,.,>
286 4th St..ree.t~fJremerto'f1~ WA 98337 ",'--'.
Phone: (360) 478::::5275 FAX: (360) 478-5.278 "'. j
BUILDING. PERMIT f
Job .Addr: 200 8RUENN AVE Permit No; 01-0374 i
loe~tion: BREMERTON SCHOOL TRANSPORTATION & MAINTENANCE FACILITY Status: PENDING 1
,.... Parcel No:" Applied: 07/10/2001 ;'
..' Issued: I
'. Applicant: PACIFIC I~ON :& FENCE H:C 360:t371-3229 Expires:' ~I
. 4000 ARVICK AD PORT DRLHARD WA 983'.1
t Olimer: 8REMERTON SCHOOL D.tISTRICT .j
200 8RUENN AVE BREMERTON WA 98312 1
Contractor: P'ACIFIC IRON 8, FENCE TNt 360-871'-322Uc #:: PACIFIF119JA f)(p:: 03-:~jwA",tfJ I
I.. ..,... 4000 ARVICK RO SE PORT ORCHARD tlJA 98366 ~f,,[J'.~
SUb\.ol!tr. ~r~- 't
I: Dese: 8 FOOT CHAIN LINK F ENeE WITH 321 DOUBLE DRIVE GATE wbll' jJ " ' '1
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!.. ValUation * ~.. e..s. .)l9fiS rv '/rdaf.1:i~aa;~ 1~1A "I 23cL26
I, 6,299.28)1i; ~ F88~': O,~ 5>1e/' Ad 'Xl ", Fe 'fi .OOJ
, I ther Fee~: f" To Per--rni . 234,,26 1
l. ..................:aP.........1' ,._.~~1!.., .~. ,.~' - ..................1
I This permit shall beCOt'lle null ~ Vt"lW~t~/b~~~JlI\L.-;i:ted Jt~~Emllit is mt C~) ~ncppnl~1JJ J
;. 1$0 dayS 'I' YOM the d~t1/Jl!1f h ~t, ot~ this.. ~ )J~~')~i~ b)' ,,~ch Pl!!'r'fl1it i$l ~nW"r~' 1'1
!, aha at~J.i )~0$ ctM er~f l~iii," l11i ~~Jtli' .
I. '. ) f) II' I '/.,,) ~ 1"11 '.,
~ NOTI - I i he Y,~~i Ii t.Y~YO hOlde=,' 0 City of eyefl1eyt~o11~ ins o~' ".. ;0 see .1
t t10 hat equi A~eet.j.~\~. t p~~i ~del" must m~i fy Bw.;?/~~;jpiY- n ady for
r Fait.r;:;"'nee C~iO ,1i Pi' t 1 to), he Buildi ng Off' , ~ f "eq1..;,i y \~tio) s ay result. ,)
~ age of the :.\ -' 1 e tim ~ the penna r ~.deY C $ti3:rrtls.t:Jfi!~he!,l ding offi cial .
~ , -' a1~ \,lOyk, t$ ,_' co~ '(f&qLliyemfffnt~)~~moliti1fl~tl'l'l9. 0'1' f'l$.I'1Ci.al buYC:ie:n shs.nl
~.I ~ b::wflot '''ec.. Y b, Y. t.~,' t," tiel", F~U.' l.Ll.?)" . t'Ylu~J~~!i~ot, \~"rt"ement ,1 1 \ll::w>>mrrify the CH}"
: a.gaimt an and all /Jif7f:J.1 tii ity 01' 1.i~~\~t 'j:Of::lVt~ ~.on$tyuctiOl1' .
r I MY*by C~~. '\f}" tL~ ihavt' Y'fJe ."fJ.m ~}d' tL'i~rmit :illOO kn.,,)I^!~M s,"\me~' be YU and co\-yecL All
!.,. p'(ovi$io\1$ 01': ': :i!,ndlJ4' y 'na; ~r!r:fr.n'ing 1.:tpk;~r:;r; \,IO'(k \'J:IY~) CC~1iJS~\'Jith ~ _theY $'P*",:;Hi~~ heyein
:. or l1O~, The- .1.119 er J. ce ,t?1':..rr4 to 9Weau'l.:hopV .0 'i .;te 01" Ai.'l the. pYOVH'LOfl$ e.f "
i any othe'r' st. at~ \ loe .' ,W1}irY?f:ii, r-'~~$t~ion or: the ~ft)'nn$,l'1CeCO\1$b..',lctio . t
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Sisnatun:: . 't-~- Oa:l:;e: , --'-- "
I certi h' that I ;!;. . the state .)
, Section 3, ChaPt",,1126. 1967,. .
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\ Signatunr,,: ..... . . _ _ _ Date:. __~_
****__.*.1.1.*1************
Permit Center-"Appro\/ed By=_____~ \
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