Fillable Printable Form 120-116-000
Fillable Printable Form 120-116-000
Form 120-116-000
F120-116-000 fas account application 10-02 Page 1
APPLICATION TO ESTABLISH AN FAS DEPOSIT ACCOUNT
WITH THE DEPARTMENT OF LABOR AND INDUSTRIES
FAS (Factory Assembled Structures) Deposit accounts are established primarily for businesses or other
entities that are not currently licensed or registered with the department aselectrical or construction
contractors but are legally required to purchase work permits from the Department.
The deposit account allows the business or entity to deposit money with the Department and request
transfers from this account for the purchase of permits and other Departmental business.
This account is subject to all legal attachments.
To request the establishment of this account, please
provide the following information and submit to:
Dept. of Labor and Industries
PO Box 44430
Olympia, Washington 98504-4430:
Please allow seven to ten days for processing to establish your account.
APPLICATION TO ESTABLISH FAS DEPOSIT ACCOUNT
COMPANY/BUSINESS NAME: (limited to 30 characters)
COMPLETE ADDRESS:
Physical Address
City State Zip
Mailing Address
City State Zip
Daytime Phone number
UBI Number
Fax number
F120-116-000 fas account application 10-02 Page 2
SERVICES REQUESTED:
(Check those that apply)
PLAN REVIEW
INSIGNIA
NLEA
INSPECTIONS
OTHER
DEDUCT FEES ACCORDING TO WAC 296:
(Please mark an X on the appropriate line)
_____ WAC 296-150C-3000Commercial Coaches
_____ WAC 296-150F-3000Factory Built Housing & Commercial Structures
_____ WAC 296-150M-3000Manufactured Homes
_____ WAC 296-150P-3000Recreational Park Trailers
_____ WAC 296-150R-3000Recreational Vehicles
_____ WAC 296-150T-3000Factory Built Temporary Worker Housing Structures
_____ WAC 296-150V-3000 Conversion Vendor Units & Medical Units
PRINCIPAL NAMES: First and last names as well as signatures of the individuals who will be authorized
to sign request forms should be listed below. These individuals will be authorized to disperse funds from
the account, in payment for the services noted above.
Print Name Signature
Do you wish to receive correspondence from the department via e-mail or written format?
(Check one)
E-mail Written (US Postal Service)
E-MAIL ADDRESS
F120-116-000 fas account application 10-02 Page 3
The owner/ member of the business requesting the account must sign this form and have his/her
signature notarized.
Print Name
Signature (signature must be owner/member of business requesting account) Date
Notary Seal Here
Subscribed and sworn to before me on this
the ____ day of ________, ______
Notary Signature:
Notary Public in and for the State of
Residing in
My commission expires
For Departmental use only:
MA ACCT number assigned:
Assigned by: Date of completion
CUSTOMER’S CERTIFICATIONS AND ASSURANCES
By submitting this application, the Customer identified above understands that establishment of
the FAS deposit account is intended for direct deposit and transfer of funds between the
Customer and L&I for the purchase of FAS related permits and other official Department
business transactions. L&I will forward a statement of account to the Customer each month.
