MOBILE HOME PERMIT SET-UP APPLICATION
Permit no. Receipt No. Permit Fee Date Permit Issued Issued By
LOCATION OF MOBILE HOME
$
Address City State Zip Code
TAX MAP MOBILE HOME PARK
Page Block Lot Name Lot
SELECTED CHARACTERISTICS OF WORK
Description of Mobile Home:
Make __________________________________
Model _________________________________
Year __________________________________
Serial Number ___________________________
Decal Number ___________________________
Electrical Company _______________________
Date
Signature of Applicant
E
mail Address
NATURE OF WORK
□ 1. New Mobile Home Set-Up
□ 2. Moving/Relocation
□ 3. Other________________
Dimensions:_______ _______
SETBACKS (feet):
Front Yard _______ required
_____ provided
Side Yard _______ required (total)
with no side less than_______ _____ provided
Secondary _______ required
_____ provided
Rear Yard _______ required
_____ provided
Any previous requests for variance/special exception?
□ Yes
□ No If “yes”, Case No. _________
SOURCE OF
WATER SUPPLY:
________________________
SOURCE OF
SEWAGE DISPOSAL
(permit numb
er):
________________________
ZONING APPROVAL
FLOOD PLAIN DATA
AFFIDAVIT OF APPLICANT
1. No work will be started before permit card is posted or continued if the permit card is destroyed, lost or stolen.
2. This permit is void if job is not started within 6 months of application date.
3. Contractor and subcontractors will secure (if required) a business license before beginning work.
4. I will be responsible and
will pay for the business license of any contractor or subcontractor doing work on this project if found without a license.
5. The undersigned owner or agent understands that the approval of this application does not constitute a privilege to violate any applicable
governmental ordinances, codes or laws, and that any omission of or misrepresentation of fact without intention of the undersigned or any alteration
of change from this application without the approval of the Building Official, shall constitute sufficient ground for the revocation of any permit issued
which was based on the approval of this application. The permit does not authorize any encroachment upon public property.
FLOOD PLAIN
NAME MAILING ADDRESS
ZIP CODE TELEPHONE
OWNER
APPLICANT
CITY
□ YES
□ NO
WETLANDS
□ YES
□ NO
Verified by: ____________________________________________
X
REV 2 12/19
Verified by: ____________________________________________
