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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 e Ct'a- S' c eq t s first name o r,t•,. 4 5 c'sy ♦ t 7a. Phone ( ) City ALTERATION PERMIT Do not complete shaded areas !Perntli$tt '�. i:.� +.tiastiho��h a 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