HomeMy WebLinkAboutBLD1999-00669 Department of Labor&Industries ���'ss�TE"� ALTERATION PERMIT
Factory Assembled Structures Section
111 Do not complete shaded areas
INSTRUCTIONS: � (-Permit#
1. Complete all spaces,including the signature box(marked with an X).
Invoice#
2. Draw a map on reverse side of WHITE copy only.
3. Forward completed permit and fees to the nearest L&I office. See list on reverse.
4. Contact and schedule the inspection with the same L&I office within 15 days. Insignia#
\ J
Owner last name first name Day time phone Date
( r)
Address City State ZIP
Installer/Contractor/Dealer Phone Contractor's registration number
( )
Address City State ZIP+4
Check the appropriate boxes in section A and section B. FEES
A ❑ Commercial Coach B ❑ Alteration Inspection(check appropriate boxes below) $
Serial No. Air Conditioning/Heat Pump
Electrical
�'� Electrical Appliances
�J Mobile Home
Fire Safety
Serial No.
Gas Furnace
Gas Piping
HUD No. Plumbing
Structural
DRecreational Vehicle or Park Trailer Serial No.
❑ Wood/Pellet Stove— —
Seral No. Plan Review $
RV Inspection $
Model No.or Plan Approval No Original Permit Reinspection Na $
Technical Inspection $
Note: This permit expires one year after date of purchase. (Non-refundable)
(—Signature of applicant or authorized representative Make check payable to: Dept.of Labor&Industries
FEES DUE $
Department use only
❑ Request approved or ❑ Request denied because of specific violations of Washington rules and regulations. Violations must
be corrected and reinspection requested within 10 days for recreational vehicles and 20 days for mobile homes and commercial coaches
of the notice of violation date. (This does not apply to technical inspections). It is unlawful to offer for sale, rent, or lease any
non-complying mobile home,commercial coach or recreational vehicle.
❑ Included are forms required which must be completed and fees submitted before reinspection.
(Date Area office Inspector Total pages 1
F622-012-000 alteration permit 10-98 White-Olympia Canary-Inspector Green-Contractor Pink-Purchaser Goldenrod-Purchaser