2002, 03-12 Permit App 02002259 Relocate MHDepartment of Labor & Industries
Factory Assembled Structures Section
INSTRUCTIONS:
1. Complete all 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 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.
Owner list name
Address
CS
Installer/Contractor/Dealer
S+Lt . v. 'Sam
Address
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Ct'a- S' c eq t
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first name
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7a.
Phone
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City
ALTERATION PERMIT
Do not complete shaded areas
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Day time phone
(Sbt) Ci
City
I,
Date
yam
State ZIP ,
Contractor's registration number
State ZIP+4
Check the appropriate boxes in section A and section B. FEES
A
RECEIVED Commercial Coach B a Alteration Inspection (check appropriate boxes below) s ee"",
Wood/Pellet Stove — —
Air Conditioning/Heat Pump
Electrical D
Electrical Appliances
Fire Safety
Gas Furnace
Gas Piping
Plumbing
Structural
Plan Review
Mobile Home Vie'
Serial No.
.,
HUD No.
ijRecreational Vehicle or
Serial No.
' ,t-) taiS
Park Trailer
Model No. or Plan Approval No,
RV Inspection
Reinspection
MAR 1 2 2002
REGION 6
SPOKANE, WA
Serial No::..
Technical Inspection
Original Permit::
No
Note: This permit expires one year after date of purchase. (Non-refundable)
" S grtature of applicant or authorized representative 1 Make check payable to: Dept. of Labor & Industries
Department use only
Request approved or j Re�t 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 atictcoWmerclal coaches
n}�...
of the notice of violation date. (This does not apply to technical inspections). It'Is unlawful to offer for saln rent, or lease anv
non -complying mobile home, commercial coach or recreational vehicle.
Included are forms required which must be completed and foes submitted before reinspection.
CDate Area office Inspector Total pages
F622-012-000 alteration rrnit 10.9e ch
Pe White -Olympia Canary -Inspector Green -Contractor Pink -Purchaser Goldenrod -Purchaser