APPLICATION FOR MANUFACTURED HOME PERMIT
950 Steeple Square Court
Knightdale, NC 27545
(v) 919-217-2241
(f) 919-217-2249
www.knightdalenc.gov
P L A N N I N G D E P A R T M E N T
T O W N O F K N I G H T D A L E
PIN# __________________________________ Unique # ______________ Zoning: __________ Book of Maps: ___________ Page: __________
Acres: ________________ Census Tract: ___________ Flood Certification Required? Approved By: ____________________________
Water Supply: Public? Private? Wastewater: Public? Private? Lift Pump Required? Fee: ___________________________
Conditions of Permit: ______________________________________________________________________________________________________
APPROVED BY: ____________________________________________________________________________ DATE: ______________________
PERMIT # ES PERMIT # D-
Jurisdiction: KNIGHTDALE
Owner:
Address:
Project Address:
Dealer Name:
Number of Bedrooms (Both Finished & Unfinished): Number of Other Rooms:
Phone:
Dealer Phone:
Number of Baths:
Set Up Contractor:
Address:
Email:
Primary Contact:
Electrical Contractor:*
Address:
Directions:
DATE:SIGNATURE:
Lic.#
Zip:
Fax:
Phone:
Lic.#
Zip:
City/State:
City/State:
Phone:
City/State: Zip:
Subdivision/Mobile Home Park: Lot #
Utility Provider:
Project Cost:
Applicant/Owner/Agent Name: Phone:
Value:
Existing Deck? New Deck? Is Home Being Moved from Somewhere Else in Wake County?
List Existing Structures on Property:
Serial # UL/HUD #
Year: Make: Square Feet/Size: Color:
* Electrical work must be installed by contractor licensed in the State of North Carolina.
Exception: Any person may perform the work when both the manufactured home and the land on which it is placed are owned by that
person and the home is for their own use (not for rental purposes). Approval must be granted tot he applicant for wiring their home by
scheduling an appointment with their electrical inspector before any work is performed.
Applicant agrees to comply with all Building Regulations and other applicable laws to the use of the structure and facilities referred herein.
The permit issued for work shall expire by limitations six (6) months after the date of issuance if the work authorized has not commenced. If
after commencement, the work is discontinued for a period of 12 months, the permit shall expire. No work, authorized by any expired
permit, shall be performed until a new permit has been secured.
950 Steeple Square Court
Knightdale, NC 27545
(v) 919-217-2241
(f) 919-217-2249
www.knightdalenc.gov
P L A N N I N G D E P A R T M E N T
T O W N O F K N I G H T D A L E
APPLICATION FOR MANUFACTURED HOME PERMIT cont.
TOWN OF KNIGHTDALE / WAKE COUNTY BUILDING INSPECTIONS
AFFIDAVIT OF WORKERS' COMPENSATION COVERAGE
NORTH CAROLINA GENERAL STATUTES 87 AND 97
The undersigned applicant for Building Permit Number ______________, being the:
Unlicensed Contractor Owner Officer/Agent of the Contractor/Owner
License #:
do hereby positively declare under penalties of perjury that the person(s), firm(s), or corporation(s) performing the work
set forth in the permit (check one):
has/have three (3) or more employees and have obtained workers' compensation insurance to has/have one (1)
or more subcontractor(s) and have obtained workers' compensation insurance to cover them,
has/have one (1) or more subcontractor(s), who has/have no employees and have waived in writing their right to
coverage by their contractor or if required have their own policy of workers' compensation covering themselves,
has/have not more than two (2) employees and no subcontractors,
has/have paid the licensing tax for General Contractors as required by the Revenue Act of the State of NC,
has/have applied for permit where the project cost is under $30,000 and I am therefore exempt from Licensed
General Contractor requirements specified by G.S. 87-14,
has/have applied for permit under owner exception to the licensing requirements by mandating occupancy of the
premises for 12 months following completion of the project,
while working on the project for which this permit is sought. It is understood that the Wake County Inspections Division
may require certificates of coverage and/or waivers of workers' compensation insurance coverage prior to issuance of the
permit. This document must be signed by the owner of a proprietorship, partner in a partnership, officer or manager of a
LLC, or property owner (as the case may be) appearing as the contractor on the building permit.
NOTE: Signature to be either witnessed by a representative of the Town of Knightdale Planning Department or Notarized.
FIRM/PROPERTY OWNER NAME:
OFFICER/PARTNER/FIRM OWNER:
TITLE: SIGNATURE: DATE:
WITNESSED: PLAN REVIEWER
Sworn to and subscribed before me this ______ day of _____________________, 20_______. INITIALS ___________
NOTARIZED:
______________________________ (SEAL) My Commission
Signature of Notary Expires on ___________________, 20_______.
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