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Homeowners Manufactured Mobile Home Variance Request F622-054-000 - Washington

Homeowners Manufactured Mobile Home Variance Request Form. This is a Washington form and can be used in Claims Workers Comp .
 Fillable pdf Last Modified 11/17/2011
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Department of Labor and Industries Factory Assembled Structures PO Box 44430 Olympia WA 98504-4430 HOMEOWNER'S MANUFACTURED/MOBILE HOME VARIANCE REQUEST Guidelines for investigating homeowner's manufactured/mobile home variance request Homeowner submits to central office or local field office A completed F622-054-000 Homeowner's Manufactured/Mobile Home Variance Request form The inspection fee (Variance inspection fee as shown in WAC 296-150M-3000) Note: When a request form and permit is taken at a local field office please fax a copy to the FAS plan review section at (360) 902-5229. Central office 1. 2. 3. 4. 5. 6. Deposits the fee if not taken at a local field office Assigns a number (sequential by year) Logs in the request (eventually on a computer program which will show status) Assigns the request to a regional supervisor to have an inspector do an inspection, a return date due will be shown on the variance request application The supervisor will assign an inspector to do an investigation The inspector will do the investigation and return to central office by or before the due date (NOTE: if an inspector is doing an alteration inspection and the customer needs to do a variance request, the inspector will: do the investigation while at the home and send the investigation report to central office; and give a blank variance request form to the customer to complete and send in. Central office will: note the date received; review the investigation; review the customers comments; seek information from other sources if appropriate; and Approve or deny the variance request and send back to the customer. If denied, central office will explain its reason for denial. 7. 8. F622-054-000 homeowner's manufactured mobile home variance request 07-10 American LegalNet, Inc. www.FormsWorkFlow.com HOMEOWNER'S MANUFACTURED/MOBILE HOME VARIANCE REQUEST [Applies only to the installations performed by a previous owner(s) and does not apply to any home during the warranty period] Owner Location City Phone FAX State Email ZIP Contact address if different from location Fee See WAC 296-150M-3000. Includes processing and inspection. Reason for Variance: (Additional pages may be attached) Why Requirements Cannot Be or Were Not Met: How the Alternate Method Achieves a Reasonable Level of Conformance: Send this form and the fee to L&I at the address on the first page of this form. Date Signature L&I Use Only Date Received at L&I Date Return Due Assigned to Date Received Disapproved Variance # Date Assigned to Alteration Application # Variance is Approved Reason for Denial: Date Signature of Chief, Factory Assembled Structures F622-054-000 homeowner's manufactured mobile home variance request 07-10 American LegalNet, Inc. www.FormsWorkFlow.com
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