FORM: MOHO-1
CITY OF LACEY
Co
mmunity and Economic Development Department
420 College Street SE
Lacey, WA 98503
(360) 491-5642
CASH OR CHECK ONLY PLEASE
MANUFACTURED HOME PLACEMENT PERMIT APPLICATION
N
OTE: THIS APPLICATION MUST BE ACCOMPANIED BY TWO FULLY DIMENSIONED PLOT PLANS SHOWING THE NUMBER OF
FEET BETWEEN THE NEW HOME AND EXISTING BUILDINGS ON EITHER SIDE, AND DISTANCE TO PROPERTY LINES AND
PARK ROADWAY.
Type of Permits (check one): ( ) Building ( ) Plumbing ( ) Electrical
P
roject Address ____________________________________________________ Parcel Number ____________________________
M
obile Home Park ______________________________________________________ Space Number_________________________
Mobile Home Information Make ___________________ Model __________________ Value __________________
S
ize ____________________ Year ___________________
Owner _______________________________________________________ Phone Number ______________________________
A
ddress ________________________________________ City ____________________ State _________ Zip _______________
Contact Person ________________________________________________ Phone Number _____________________________
C
ell Phone _________________________ Fax Number _________________________ E-mail _____________________________
A
ddress ________________________________________ City ____________________ State _________ Zip _______________
Contractor ________________________________________________ Phone _________________ Fax ___________________
Address ____________________________ City _______________ State ______ Zip _________ E-mail ____________________
Contractor’s License Number ____________________________ Expiration _________ City Bus. Reg. _______________________
Plumb Contractor ________________________________________ Phone __________________ Fax __________________
Address ____________________________ City _______________ State ______ Zip _________ E-mail ____________________
Contractor’s License Number ____________________________ Expiration _________ City Bus. Reg. _______________________
Elec Contractor _________________________________________ Phone __________________ Fax ___________________
Address ____________________________ City _______________ State ______ Zip _________ E-mail ____________________
Contractor’s License Number ____________________________ Expiration _________ City Bus. Reg. _______________________
I hereby certify that the above information is correct and that the construction on, and the occupancy and the use of the above-
described property will be in accordance with the laws, rules and regulations of the State of Washington.
_
_______________________________________________________ ________________________________________
Applicant’s Signature Date
_
_______________________________________________________
Print Applicant’s Name
click to sign
signature
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