1996, 12-04 Permit 96010533 AlterationDepartment of Labor & In bes RIF
Factory Assembled Structts Secti
INSTRUCTIONS:
BLE
1. Complete an spaces, including the signature box (marked with an X).
2. Draw a map on reverse side of WHITE copy only.
3. Forward completed permit and fee 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.
Owner last
Address
Installer/Contractor/Dealer
Address
ALI/RATION PERMIT
Do not complete shaded areas
(Permit #
Insignia #
t—eY first n eC V7(5�mcphco7ne r� 1p' L��—� ` $
(6-)( ) (/f4
Check the appropriate boxes in section A and section B.
A
Commercial Coach
Recreational Vehicle or Li Park Trailer
Serial No.
Model No or Plan Approval No.
Signature of applicant or authorized representative
X / -
artrn
t 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.
City
Phone
( )
Date
State ZIP
wIpi 3 2.:
Contractor's registration number
State
ZIP+4
FEES
B ❑ Alteration Inspection (check appropii xes below) $75.00
Air Conditioninga#tFigtplT OF LABOR & INDUSTRIES
Electrical
Electrical Appliances
Fire Safety
Gas Furnace
Gas Piping
Plumbing
Structural
Wood/Pellet Stove — —serial No.
Plan Review
RV Inspection
Reinspection
Technical Inspection
DEC - 41996
REGION 6
SPOKANE, WA
Original Permit
No.
$70.00
$70.00
$50.00
$50.00/hr
Make check payable to: Dept. of Labor & hidustries
'Included are forms, required which must be completed and fees submitted before reinspection
Date Area office Inspector )(Total pages
F622-012-000 alteration permit 4-96 White -Olympia Green -Contractor Canary -Inspector Pink -Purchaser Goldenrod -Purchaser
FEES DUE