Application for MANUFACTURED STRUCTURE
BUILDING SERVICES DIVISION
1700 Civic Drive DuPont, WA 98327
P: (253) 912-5217 F: (253) 964-1455
www.dupontwa.gov
.
PERMIT NUMBER:_______________________________
SFR Commercial: Type of Use:________________________ Other ___________
(i.e. Business, Day Care, Food Service, Government, Retail)
Project Includes: Detached Garage Deck
Project Address: Parcel Number:
Owner of Building / Tenant: Phone Number: ( )
Address:
Applicant: Phone Number: ( )
Address:
Contact Person: Phone Number: ( ) Email:
Contractor: Contact Person:
Address: Phone Number: ( )
State Contractor’s License: City Business License:
SCHEDULE OF FEES (OFFICE USE)
Valuation $_______________________
Permit Fee $__________
(Table 1-A, UBC)
Plan Review Fee $__________
(75% of permit fee)
Subtotal $______________
Deposit (if any) $__________
TOTAL $________________
I certify that I am the: Owner Contractor Agent
I hereby certify that I have read and examined this application and state
that the above information is correct. I agree to comply with all City
Ordinances and State Laws, whether specified herein or not.
***By leaving the contractor information section blank, I hereby certify
further that contractors (General or Subcontractors) will not be hired to
perform any work in association with this permit.
Signature of Applicant/Authorized Agent Date
PRINTED NAME
Value of Work (required):
Description of Work (be very specific):
Manufactured Structure: Make:_____________ Model:_____________ Year:_____________
Hauler:_____________ Installer WAINS No:_____________
Square Footage: 1
st
Floor_______ 2
nd
Floor_______Garage_______ Other ( )______Total_________
Number of: Bedrooms__________ Bathrooms__________ Fireplace __________
0
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