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I °2 9� ^ 13� ALTERATION PERNII7 <br /> . ' ,Depaztment of Labor&Industrics <br /> • Factory Assembled Structures Section Do not cam IeOe�h�ded reu <br /> P�mit :' <br /> INSTRUGTIONS: � � <br /> 1. Complete�II spaea,Including the sfgn�turc bo:(m�rked wNh�e Xb InvoieeA - <br /> 2. Dnw a map on revene aWe of WHITE copy aay. <br /> 3. ForwaM rnmpkted permit�nd fea to the narat Li�l oflke. See Iift on revene. ��N <br /> 4. ConUct and uheduk the inspcctbn wlth the e�me L&1 ofliee wNhin 15 d�ys. - <br /> ' Owner lut n�me fint mme Day time pham . . . . . . � .. . � . . � . . � . <br /> �1p'E'�✓i�l _ .ic<Htt� �'��;► J� ✓ :3o?�j --��� -Ic:J..... _. _ <br /> - ---- - --__.. . <br /> _.... ___ _ . cny suu zir <br /> . nm�: ., <br /> _; } s�; 7:., .��-, �.� 1 v'�'',ii 71".. � „ i `UL(U.3 <br /> �� Irolalla/Contrector/Dnla Pha�n CaprkOor.�eDmationmimba <br /> i .r ' ( �7J'�)- '�� �j - ,�,O �j <br /> ) ! J� ,� � UT _ .._.__.. _..... __ _.._ _._ <br /> _ <br /> swe zir«a <br /> _ c�ty m <br /> nm� _ r s.✓o� '- =`2:i 3 <br /> a Z :,J �;�� � j . /.�,= „ �7T– <br /> , <br /> C6ec�the rpproprbte boxa in seeNon A and section B. ��c <br /> A B � Alteration Inspection(chxk appropriaa boxes below) s :' � � � <br /> ❑ Commerciel Cuech Air Conditionmg/Heat Pump <br /> suiwl No. Elxtticel <br /> Electricel Appliances <br /> �� Mobilc Home Fiie Safety <br /> sai�i Na Gea Fumece <br /> Gas Piping <br /> HUD Na plumbing <br /> � � � � � � �� c[urai Nb. .� <br /> ❑ Recreatioual Vehicle or ❑ Park Trailer Wood/Pellet Stove - -�— <br /> SaatNa Plan Review - - - - - - - - - - - - - - - - -- S <br /> u RV Inspection – –– –– – – –n – – – – – S <br /> . Model No.w elri Appem�l No. ReinspecHon – – – – – �q;� . . .. � ,!��� �. S <br /> < ,d <br /> Technical Inspection –– – – – – – – – – – – – – – S <br /> , i�� <br /> Note: This �mit ires one ,Br a ter d � urcbas�. (Non-re undable) <br /> Si�mc�ure of applican4 authorized reprcsm�ati � • Make chcek payeble to: Dept.of Labor&Industrie¢r' <br /> X �r%'.. : .; FEES DUE s � <br /> �Dep�rtm feodr r ��,j . . . � . �. � �� � . . <br /> � Reqrat a or Re,� denbd Maiaw of �pecNk vldstlo�s�t Wm6l�fai nlr�ed x�Yl�tlos� VIoI�tMY�wf . <br /> be correeted m¢ ImpeMfon reqaated hin 10 daya for tecratloa�l veriela aod 20 d�ye tor moblk hora�ad comrertid eMiciN : <br /> of the eoHee o � d� a.ee. �rni. oa aut�pP�Y �o tecAp�� �"�P�n°°s�' �� (� uelawfal to o1Gr fir nle,rmt,x Irfe!U' :: <br /> �ron-eomplyto k home,comme coach or r�xrcatbad vehkle. <br /> . . . . . . , . . . . . . . . . . . . .. <br /> .. . . ... . . .. . L <br /> I � . li,. . . . . .. ..: _. . ..:-• •---.:_.:... <br /> . . . . . . . . . . .. ... . . . . <br /> . . .. . . . .�.,� - � - <br /> „ _.... .. ...--''. <br /> 4 '•-- :.: <br /> ..._ ., ; . . . ..:. . <br /> .. . . . . ... .. . . . . . . <br /> . . . .. . .,�. . .� . :. _ <br /> . . . . .� . . . . . ._ . . .. . . ., . . . ?-.. . ., ._ ,. : :; <br /> . . ... . . . . . . . .� . . . . - � <br /> . . <br /> 'a' <br /> :. . ... .� . . . . ..' : <br /> j/� � � � ..... .:--...._.. . . .. . . . <br /> . . .. <br /> . .. � ,. . . .. .. . .. _ . . . . . <br /> . ..... ... . . . .... .. .. . . . . .. .. <br /> rl <br /> J � . . <br /> . . . . � . .� , ..�� .�.�.� ri� . . . . . . . . � . " <br /> � .. ' .. . . � ... <br /> � . .. <br /> . . . . . . . .. . . . . . . . . . . . . . . . . . ... . . . . .... . . . . <br /> , ... ... . <br /> ��C'b �u.._ _ . . ... ._ sa� <br /> ❑ Incl s requi hich muZ1 w pnd fxs submitoed rcinspectian• .' <br /> . . �,a,- . .. Taal p�ee : <br /> . ' � ��.: .. ' . . <br /> Dale � � . . �� . . . ��:. <br /> 4/� <br />