DLI-Construction Codes and Licensing Division
443 Lafayette Road North
Saint Paul, MN 55155-4341
Submit by Email
Office Use Only
Type the following information or place check marks in the appropriate boxes, then print the form.
Application Approval Number
Single Section Home
Multi Sectional Home
Date of Manufacture as recorded on the home's Data Plate:
On Private Property
In a Manufactured Home Park
The home will be installed:
Proposed Start Date:
Describe the work to be performed under this application :_______________________________________________________________
Identify person responsible for the installation
MN Licensed Installer
Installer License #:
Above Installer is responsible for:
MN Licensed Electrical Contractor
Identify the person responsible for the Electrical
Work. NOTE: Any electrical work performed in a manufactured home
MN License #:
park requires a MN electrical license.
Elec Contractor Name:
: Identify the person responsible for the plumbing work.
MN License #:
Identify the person responsible for the Mechanical Work.
I hereby apply for installation approval and I acknowledge that: the plan review submittals and the information above is correct,
complete, and accurate; the work performed will be in conformance with the manufactured home's installation instructions,
Minnesota Building Codes, Minnesota Rules Chapter 1350, and/or 24 CFR Part 3285 and 3286. I understand this application is
not a permit and work is not to start without a Department approval, and that all work will be in accordance with the approved plan.
NAME OF APPLICANT ( PLEASE PRINT)
APPLICANT'S SIGNATURE: ____________________________________________ DATE: _______________
G/BCS/Word/MS/Installation/Plan Review/Manufactured Home Installation Plan Review Application