1991, 12-30 Permit: 00468 Plumbing Alteration570.00
575.00
550.00
$50.00/br
mos INSIGNIA REMAINS? PROPERTY 50+''.
.DEPT._ i'T 0 r,
':STATE ANO-ANNISTRIE ,' I. --I,
F'iila0a"F'N0 INOUfTRlE6':c `.,
414.22-030-000 P - r -
u� v
i.
HAVINO BEEN IN L HOMES.
communise011i 4322340. A
IPAOVEOAE 1.0 REMILAIIGAISIE OR,NEMS-„MENT III KW JNS-+_
MOBILE HONE REARING ApFRAR1MENlIYSILNIASHALL NOT NAVE 115 LNN51N1-� ,
TION PW ppIXCONVERIIOpUII E55 APflOVAI IS' FIRST OBTAINED NT AND IFIPIFIPIG ..a
AITEn1_INDUSTRIES. SELLER
!WARMER, Of U,00R AND ” CERTIFIES TO .1
IN
2 8 8 5�A S GF1 2w "'�'• cnMPn_I .
ALTERATION PERMIT
Do not cum tete shaded areas -
1th the signature X in It. •
only.
office listed on the back.
office In which you submitted the Permit
'Involm N.-
Owner
Address
Ian name
Ja-ddSL
coat /890 9 Y
Installer/Contractor/Dealeru _ • /447;v?
Add(/rebs a,•',n1 4/ac/0 1�Q^��'`��(','l/^ ,/%'044.o
Ead
Check the appropriate boxes in sectlon•A and section B.
A Commercial Coach
Serial No...
first name
0017/0
Day time phone
(sd9) -9a 6 - 99
D/aate
-3o-9/
AMobile Home
Recreational Vehicle or ❑ Park Trailer
Serial No. '
Model No. or Plan Approval No...
(Signamr•of applicant or auth ri ed rcpresen 1 tive
X / %' 0
feparvnent use only:... ,r •'t/f,...
,JY Request APPROVED or ❑ tion -Of Wash
- Request DENIED because or Specltic.VfolaingtonRides And Regulations.
Violations Must Be Corrected And Reinspection Requested Wlthiti'10 Days For Recreational Vehicles And 20 Dayss For Mobile:
' Homes and Commercial Coaches of the notice or violation date. (This does not apply to Technical Inspections). IR Is Unlawful To
Offer For Sale, Rent, or Lease Any Non -complying Mobile Home, Commercial Coach or Recreational Vehicle...,., .
1 .9n°y. 4:-. c: � r" ' $4,75)1...«l.c-�:.', ►/1:1 rch 4 • ' ,
t L ACco i?c�a face- w ti ld tel: C9 x;'."524°•. 1 e S itz v/yZ .. .
Ij jtc.<
Z - 1Qd1°A►. .+. - , ...= Lu .GRA , ... .
PImo+pAt)is �' Iii- Ali-ci: N!i. .itc 9i,-13.00, "�* -. pe4Ing..
City
Phone
(Se ) ?-a/00
' City
State ZIP
W
99o2'
Contractors registration number
/5-3A)/,Ain g09lie
State ZIP+4
OR 990/
•"" .,.. FEES
Alteration Inspection (check appropriate boxes below) $75.00
Air Conditioning/Heat Pump
J'." ;• r O1/02/92F�117AF11 T^ B *1:
Electrical Appliances
Fire Safety ' CHECK• $75•]0
Gas Furnace - .•
Gas Piping' - • -
Plumbing
Structural
Wood/Pellet Stove -
Plan Review
RV Inspection ,
Re -Inspection- - - - -
Technical Inspection
(Serial No.
IOnginal Permu -
No.'
Make check payable to: Dept. of Labor & Industries
FEES DUE $ 75;oo
Included Are Forms Required Which Must Be Completed And Fees Submitted Before Reins$Fection.
Area office:• nspector
Date , ,
F622-012-000 Alteration Permit 9/91
(Total pages
White -Olympia Green -Contractor Canary -Inspector Pink -Purchaser Goldenrod-Purchas