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HomeMy WebLinkAboutBLD2003-00617 • • MLA03-00547 Review Type: I MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD03-00617 Received Date: 9/26/2003 SITE ADDRESS: igAP-E -E-07GE RD PORT TOWNSEND, 98368 APPLICANT: BELINDA H GARTMAN PHONE: (360)379-1987 1624 31ST ST PORT TOWNSEND WA 98368 SUBDIVISION: Block: Lot: T13 PARCEL NUMBER: 001194003 Section: 19 Township: 30 N Range: 01 W CONTRACTOR/ DEALER: INSTALLER: S T D MOBILE HOME SERVICE STDMOHS022OT 6/11/2005 (360) 794-0132 10410 263RD AVE SE MONROE WA 98272 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NEW MANUFACTURED HOME TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: PALM HARBR SETBACK: VALUATION 63,000.00 YEAR: 2003 LABOR & INDUSTRIES APPROVAL? SIZE: 28 X 70 BANK HEIGHT: SEWAGE DISPOSAL: WATER SYSTEM: PARCEL TAGS: YES NO BEDROOMS: BATHROOMS: STORMWATER: YES NO Exist: Exist: AREA Plat Conditions Prop: 3 Prop: 2 Wetland Erosion Total: 3 Total: 2 Seismic Streams Flood Way Floodplain Routing Date: 9fricto3 Freis) F&W Landslide Shoreline Aquifer APPROV ED Type Amount Paid By: Date: Receipt: Manufactured Homes $151.00 RAC 09/26/03 60091 Potable Water Application $51.00 RAC 09/26/03 60091 OCT — 9 2003 Total: $202.00 Jefferson County planning ` & Buildin Department 1.0/9U1 L'dV31180NASWaOdial803N11211NON1d\3WOM:H 00 t z-1-7 lt/101 co-1+1 HOVOdddV OVO2i/1.1.6 2131VM 318V10d k `/ 31V0 OaS b i 1d1018f S 1_11 #)13/HSVOiii:74:7:: SN01103S l\fN011ldQ`d (7� 33d 3St/8 1'b #1d130321 00'L17 33d M3IA32i A0N3ISISN00 k„, ,. ,°�,'',. _' .: - A1N0 3Sl 301dd0 210d /('i//'7'�'(,�,{�} (INRid 3SV31d)BWtfN r 31da V 321l1VNJIS •Snot'ssaulsnq ieln6ai Buunp in000 Heys pue paisanbai aq peys aini0nils io Aiiadoid s,iueolidde NI 01 Ailua}o 1y6u pue ssaooy •suolioadsul ialel pannbai Aue pue Malnai uolleogdde }o asodind ayl io} swage io sanlleluasaidai 'saaAoldwa s,11 pue Aluno3 uosia}}ap of Ai1ua 0 1g6u pue ssaooe apin0id of aaiBe iayiin} i •llwiad slyl}o Buouei6 ayl}o aouanbasuo0 ul JO}o llnsai a se A1uno0 uosia}}ap lsuleBe aniooe AeM Aue un Aew gongM sasuadxa pue saw s,Aewoue algeuoseai 'slsoo iinoo 'siuew6pnf 'salilllgell lie lswe6e Alunoo uosia}}ap ssalwieq ploy pue Apuwepul 'ones of eei6e iayiin}I •plop pue pnu 6uleq ilwiad slyi ul loss.,Aew laioed uolieoiIdde slyl of ioadsai tow JauMo/lueo!Idde ayi Aq apew loe} leuaiew a }o uolsslwo Aue io pooyas1e} Ieualew AuV •e6paIMouI nays 0 lseq an of loaiioo pue anil sl ul9iay pep!Aoid uollewio}w ayi leyl slseue iauMo/lueol1dde ay1 'wio} uoileo!Idde NI Bulu6ls Ag 4 1HOI3H)1NVS 14 (N 3NI1 2131VM HOIH 210 NNV8 013ONV±SIO `)1213d021d 1N02132131YM Al j iri d :walsAs Je ennio eweN engewellV ❑ d3S#IIWd3d 0118fld ❑ Ieuogueiwo0 n W31SAS lYf141AIGNI 0 113M AHV'd OM! ❑ 113M 31VAI2id 0 W31SAS AIINf VW00 2i3M9S 0 :AlddflS 2131HM :1HSOdSla 3OVM3S 3O 3dAl l`d101 (� iViO1 ODS0d02id 03S0d02id 'in) E II V,' F [ If< ONIISIX3 ONIISIX3 , :SW0021H1b'8 :SW0021a38 '- . ,. `ram 1S00 „�0i �_ f 3JItfW DEPT. 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AttL Drt Townsend,WA 98368 SEP 2 6 t ,,3 .� ` � � - 160) 379-4450 or 1-800-831-2678 APPLICANT PLEASE PRINT OR TYPE ALL INFORMATION -;HECK BOXES THAT APPLY URoad Approach k- Road Approach Permit&Addres J General Permit Fee: $141.00 Fee: $141.00 'Fee: $141.00 EiUtility Class A ElUtility Class B \ W „i PAYearly Class A Fee: 20%of Class B Fee: $141.00 \'•• •• �� Fee: $141.00 t� :; County Road Name: ,-1�"%'j� 6CO./'G� / °`� V '�a ,� 1,1,..._, , ....,,kitt,-,,t-AtAtcoft-,,woe-Fm Intended use of County Right-of-Way is to construct,operate and maintainV t r%V4tQ Del'‘Xvz19- j{' ,1.- L�i'� C -o`av-t i), /�ivc I hereby designate tE ')f I /1-444-141-10 Applicant (Owner, Utility,or Authorized Representative.) to act as my agent In matters related to this application for er • s). /6 -2, Y '1,/ . ,./.P--i/e-e. Mailing Address Applicant Signature Date City-State-Zip Code � � Parcel Number .;.„1,_ / e Telephone No. Flagging Color&Date ACKNOWLEDGEMENTS By signing the application form,the applicant attests that the information provided herein Is true and correct to the best of their knowledge and agrees to al conditions on the permit. I also certify that this application is being made with the full knowledge and consent of all owners of the affected property. Any material falsehood or any omission of material fact made by the applicant/owner with respect to this application packet may result in this permit being null and void. I further agree to save,Indemnify and hold harmless Jefferson County against all liablities,judgment,court costs,reasonable attorneys fees and expenses which may in any way accrue against Jefferson County as a result of or In consequence of the granting of this permit. I further agree to provide access and right of entry to Jefferson County and Its employees,representatives or agents for the sole purpose of application review and any required later inspection. This right of entry shall expire when the County concludes the application has complied with all applicable laws and regulations. Access and right of entry to applicant's property shall be requested and shall occur only during regular business hours. The action or actions Applicant will undertake as a result of this permit may negatively impact upon one or more threatened or endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the"Endangered Species Act"or"ESA." Jefferson County makes no assurances to the appicant that the actions that will be undertaken because this permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if you are in compliance with the Jefferson County Development Code The Applicant acknowledges that he,she or it holds individual and non-transferable responsibiity for adhering to and complying with the ESA. The Applca has read this disclaimer signs and dates it below. , -"----:. e-s4,-.1.^...r-- .774? -71e5 ''--) (APPLICANT OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE) See kli/la MAKE CHECK PAYABLE TO JEFFERSON COUNTY ..-s� Updated 12/19/01 i 11 MANUFACTURED/MOBILE HOME INSTALLATION PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD03-00617 Received Date: 9/26/200: SITE ADDRESS: CAPE GEORGE RD Issue Date: 10/9/200: PORT TOWNSEND, 98368 APPLICANT: BELINDA H GARTMA 1624 ST -5t,."...z-5Kn PART TOWNSEND WA 98368 SUBDIVISION: Block: Lot: T13 PARCEL#: 001194003 Section: 19 Township: 30 N Range: 01 W CONTRACTOR/ DEALER INSTALLER: S T D MOBILE HOME SER\BMOHS0220T Expires: 6/11/200! 10410 263RD AVE SE MONROE WA 98272 PROJECT DESCRIPTION: NEW MANUFACTURED HOME MAKE: PALM HARBR YEAR: 2003 SIZE: 28 X 70 THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 10/9/2004. REQUIRED INSPECTIONS: [ ] Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): ,L it l /EM ,L.Ah�� �L is_Ly_d3 Vrz Blocking/Plumbinq:SjrwriNG ®n%GDsc 6Gock/Nc Ac.,„?/ y [ ] Zoning Approval: [ ] Septic System Approval: [ r Final/Skirting/Vents/Porches/Steps: - HEALTH DEPARTMENT APPROVAL REQUIRED PRIOR TO FINAL INSPECTION BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS. Office Hours 9:00 a.m. -4:30 p.m. SPECIAL CONDITIONS APPLY-SEE REVERSE HOT-LINE AVAILABLE 24 HOURS A DAY • SPECIAL CONDITIONS CASE # BLD03-00617 1.) The application was reviewed by the Jefferson County Department of Community Development for the presence of Environmentally Sensitive Areas (ESAs). The Department conducted a review and has concluded that the property DOES NOT contain Environmentally Sensitive Areas. However, future proposals will be subject to a new ESA review and conditions may be added if new ESAs are found on the property. 2.) The applicant is proposing to create or add 3,812-square feet of impervious surface. Sections 6.6 and 6.7 of the Jefferson County Unified Development Code requires that your proposal submit a Medium Parcel Stormwater Plan . 3.) The project shall adhere to the Best Management Practices (BMPs) to control stormwater, erosion and sediment during construction. BMPs shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 4.) A Medium Parcel Stormwater Plan has been submitted and approved by the Department of Community Development. Once the subject permit has been issued the applicant shall fully implement the provisions of the submitted plan and contact the Jefferson County Department of Community Development to arrange a schedule to inspect the property for plan compliance. A Certificate of Occupancy will not be issued until the Department verifies plan compliance. No clearing for roadways or utilities shall occur on the project site until clearing necessary for the installation of temporary sedimentation and erosion control measures have been completed. 5.) The site plan as submitted with the building application on 9/26/03 has been reviewed for consistency under the UDC, and has been approved by Jefferson County Department of Community Development. Any modifications, changes, and/or additions to the stamped, approved site plan dated 10/09/03 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 6.) This approval is for a manufactured dwelling only. Any future permits on this site are subject to review for consistency with applicable codes and ordinances and does not preclude review and conditions which may be placed on future permits. 7.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined by the amount of impervious surface which includes roof tops, concrete, gravel, etc. 8.) The building height is not to exceed 35 feet. 9.) Blue Sky Drive is classified as a private road and requires a minimum 20-foot setback. The side and rear lot lines require a minimum 5-foot setback. All setbacks shall be measured perpendicularly from the lot line to the proposed development. 8 a JEFFERSON COUNTY ;. 1 DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street• Port Townsend•Washington 98368 360/379-4450.360/379-4451 Fax '. ` •(StS43 http://www.co.jefferson.wa.us/commdevelopment/ STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# 0 3 00 5 (1.7 PROJECT/APPUCANT NAME: I(ii‘..-IN 14 (�' g.2 ir'f ie N1 c1 v A Please answer all of the following questions to the best of your ability. Where the question calls for depiction on a site map, the applicant may choose to either incorporate the elements into the general plot plan for the Master Land Use Application or to submit a separate stormwater site plan map. Project Overview 1. Describe the proposed developed conditions of the site. Indicate position and relative size of proposed improvements on the site map. 1 EX -t,Q ExtsI-,vt L).ivc V.;e'.y -r I4, is'. IN. • Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. L€.'d 1 S/,j 1 f- ..5. f o IQ--c_ S — .1 A k-i 3. Describe the existing v9etation. Indicate native vegetation areas on the site map. /may,w- i t fi `t i u ti.att Ly= I r e,A j tic cL F AY. 4. Describe the existing soils. Indicate soil type on the site map. . C v 0 5. Describe the existing site hydrology(i.e.,drainage;behavior of water on the site—above,below, and on the ground). Indicate existing stormwater drainage to and from the site on the site map. Depict separate drainage basins on-the site map, if applicable,and indicate acreage of each. J 1 6. Describe any excess levels of noise generated by the proposed use or activity: r1 04 i It- stormwater site plan template—rev.10/1/2003 5 7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams, steep slopes,etc.)on the site. Indicate location on the site map. Zti1. • 8. Describe the general vicinity of the site,including adjacent land uses and structures, utilities,roads,and sensitive/critical areas (streams,wetlands,lakes,steep slopes,etc.). (Pod '5 5-ieer Spa to 5 Permanent Stormwater Control Plan This portion of the Stormwater Site Plan consists of the selection and installation of the appropriate stormwater control BMPs and facilities to remain in place after construction of the project is completed. "Medium" size projects are required to have the totals calculated of all impervious surfaces, pollution-generating impervious surfaces, and pollution-generating pervious surfaces to verify that the thresholds for treatment facilities and flow control facilities are not exceeded. 9. Describe the developed site hydrology,as proposed. Indicate whether stormwater will be fully dispersed (i.e., per BMP T5.30 in the Manual)or,if not,what types of stormwater flow control will be utilized for the site or specific threshold discharge areas within the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. /44y R0 Vi ) (- 0 t 1 t is-e 04s hvt- , te-, � J Q r uk4-iu vac -i- iry 1 mot' t v,1 re f di prtrIt 10. If the project requires the use of stormwater treatment facilities,describe the types of stormwater treatment facilities proposed for use on the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. [This is normally for large"projects or projects that involve the potential for dispersion of contaminants.] • 11. Describe the performance goals and s dards applicable to the project. 12. Describe the flow control system. stormwater site plan template—rev.10/1/2003 6 13. Describe the water quality system. ////4 14. Describe the conveyance system analysis and design. 5 r,,,zi rict-u,, °r F 15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material. no Y1.<.,- 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Uniform Building Code. 11/4% 17. Describe the proposed surfacing material. CAA..)--% t..( d 18. Describe methods for restoration of the site. J r-#Is s • 19. An Operation and Maintenance Manual is required for each flow control and treatment facility. [This is normally required for "large"projects only and only those for which facilities are required to control flow or treat runoff.] If included,list the Manuals here. IA 14A 20. List here and include any special reports or studies conducte to prepare the Stormwater Site Plan. 0 A — 21. List other necessary permits and approvals as required by other regulatory agencies. If those permits or approvals include conditions that affect the drainage plan or contain more restrictive drainage-related requirements,describe those conditions or restrictions here. AO l'Ve_ stormwater site plan template—rev.10/1/2003 7 CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN(SWPPP) The Construction SWPPP addresses sediment and erosion control during construction. The BMPs indicated by the applicant in the template that follows must be installed on the ground during all construction phases of the project. The proponent is responsible for preventing sediment and erosion impacts to environmentally sensitive areas and off-site areas. Consult the Construction Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet for guidance, particularly with rural residential development. SECTION I—CONSTRUCTION SWPPP NARRATIVE 1. Construction Stormwater Pollution Plan Elements. Describe how each of the Construction SWPPP elements has been or will be addressed. Identify the type and location of BMPs used to satisfy the required element. If an element is not applicable to the proposal,justify in writing. Descriptions of the 12 Elements are found at section 2.5.2 of the Manual(beginning on page 2-15). • 12 Required Elements—Construction SWPPP 1. Mark Clearing Limits. iM i n L WI tj, I e ci.okrAtor, • 2. Establish Construction Access. C.5 _ r15 f try �� 1 rt ce c 13T„I v'e (.42-Fi 3. Control Flow Rates. %00 Veit k 1ic � 3etr rt�r' 4. Install Sediment Controls. /06 / f) ! + vl "r'ri g,r-- 5. Stabilize Soils. r � e d $ 5 v W , c-L, 1tk\ 6. Protect Slopes. r -c C. to v 7. Protect Drain Inlets. ' 8 stormwater site plan template—rev.10/1/2003 12 Required Elements—Construction SWPPP(continued) 8. Stabilize Channels and Outlets. S' f"lt �� t lit( 9. Control Pollutants. t -t y p, tit 10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site). 11. Maintain Best Management Practices(BMPs). 4-P 12. Manage the Project. 4/ 2. Adjacent Areas. a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas,roads). b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400 yards). /1,0 SI rt' 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to the site. fib /] stormwater site plan template—rev.10/1/2003 9 b. Description of special requirements for working in or near environmentally sensitive areas. /14 — 4. Erosion Problem Areas. Description of potential erosion problems on site in the context of the characteristics of the on-site soils(e.g.,erodibility,settleability,permeability,depth,texture,soil structure). 5. Construction Phasing. a. Construction sequen1 re r Nr t 0 (4to e. 0? rp6 fn re b. Construction phasing(if proposee ?owe(- icolk411 Sewer" 0 rtritve_. t A 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). I. Provide a proposed construction schedule. 4 II. Wet Season Construction Activities. a. Proposed wet season construction activities. b. Proposed wet season construction activities for environmentally sensitive areas. 7. Financial/Ownership Responsibilities. a. Identify the property owner responsible for the initiation f bonds and/or other financial securities. At\ b. Describe bonds and/or other evidence of financial re nsibility for liability associated with erosion and sedimentation impacts. ;,, p\ 8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable. a. Sediment Ponds/Traps. b. Diversions. . A c. Waterways. - d. Runoff/Stormwater Detention Calculations stormwater site plan template—rev.10/1/2003 10 .1 SECTION II—EROSION AND SEDIMENT CONTROL PLAN Sediment and erosion control measures may be depicted on the master land use application plot plan,a stormwater site plan,and/or a separate Construction SWPPP site plan. This is a checklist to ensure that the following are depicted on a site plan: • 1. General. a. Vicinity Map b. Jefferson County Approval Block c. Erosion and Sediment Control Notes 2. Site Plan. a. Legal description of subject property. b. North arrow. c. Indicate boundaries of existing vegetation(e.g.,tree lines,pasture areas,etc.). d. Identify and label areas of potential erosion problems. e. Identify FEMA base flood boundaries and Shoreline Management boundaries(if applicable). f. Show existing and proposed contours. g. Indicate drainage basins and direction of flow for individual drainage areas. h. Label final grade contours and identify developed condition drainage basins. i. Delineate areas that are to be cleared and graded. j. Show all cut and fill slopes indicating top and bottom of slope catch lines. 3. Conveyance Systems. a. Designate locations for swales,interceptor trenches,or ditches. b. Show all temporary and permanent drainage pipes,ditches,or cut-off trenches required for erosion&sediment control. c. Provide minimum slope and cover for all temporary pipes or call out pipe inverts. d. Shows grades,dimensions,and direction of flow in all ditches,swales,culverts and pipes. e. Provide details for bypassing off-site runoff around disturbed areas. f. Indicate locations and outlets of any dewatering systems. 4. Location of Detention Best Management Practices(BMPs). Identify location of detention BMPs. 5. Erosion and Sediment Control Facilities. a. Show the locations of sediment trap(s),pond(s),pipes and structures. b. Dimension pond berm widths and inside and outside pond slopes. c. Indicate the trap/pond storage required and the depth,length,and width dimensions. d. Provide typical section views through pond and outlet structure. e. Provide typical details of gravel cone and standpipe,and/or other filtering devices. f. Detail stabilization techniques for outlet/inlet. g. Detail controlrestrictor device location and details. h. Specify mulch and/or recommended cover of berms and slopes. i. Provide rock specifications and detail for rock check dam(s),if applicable. j. Specify spacing for rock check dams as required. k. Provide front and side sections of typical rock check dams. I. Indicate the locations and provide details and specifications for silt fabric. _ m. Locate the construction entrance and provide a detail. 6. Detailed Drawings. Any structural practices used that are not referenced in the Ecology Manual should be explained and illustrated with detailed drawings. 7. Other Pollutant BMPs. Indicate on the site plan the locations of BMPs to be used for the control of pollutants other than sediment(e.g.,concrete wash water). 8. Monitoring Locations. Indicate on the site plan the water quality sampling locations to be used for monitoring water quality on the construction site. Sampling stations should be located upstream and downstream of the project site. stormwater site plan template—rev.10/1/2003 11 • {r Stormwater Site Plan Changes If the designer wishes to make changes or revisions to the originally approved Stormwater Site Plan,the proposed revisions shall be submitted to DCD prior to construction. The submittal shall include substitute pages that include all proposed changes, revised drawings showing any structural changes,and any other supporting information that explains and supports the reason for the change. Final Corrected Plan Submittal • If the project included construction of conveyance systems,treatment facilities,flow control facilities,or structural source control BMPs (not standard on-site stormwater management BMPs),the applicant shall submit a final corrected plan ("as-builts")when the project is completed. These should be engineering drawings (stamped by a licensed civil engineer) that accurately represent the project as constructed. APPLICANT SIGNATURE By signing the Construction SWPPP worksheet, I as the applicant/owner attest that the information provided herein is true and correct to the best of my knowledge. I certify that this application is being made with the full knowledge and consent of all owners of the affected property. //6)% c• 3 (LANDOWNER OR AUTHORIZED REPRESENTATIVE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: 12 stormwater site plan template—rev.1 N21H1 13 • RETURN ADDRESS STATE OF WASHINGTON (]licEnsInG _a.me,, MANUFACTURED HOME 'LEASE CHECK ONE APPLICATION TITLE ELIMINATION ❑TRANSFER IN LOCATION ❑REMOVAL FROM REAL PROPERTY Anyone who knowingly makes a false statement of a material fact is guilty of a felony,and upon conviction may be punished by a fine,imprisonment,or both. (RCW 46.12.210) MANUFACTURED DOME TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) +335937 2004 PALMH 70/27 PH206587 © LAND LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE ElAFFIXED ❑REMOVED REAL PROPERTY TAX PARCEL NUMBER 001 194 003 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION // © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE 2 COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER Donald Gregory NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER Patricia A.Gregory ADDRESS CITY STATE ZIP CODE 2885 Keller Ct Napa CA 91558 NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMB Same as Registered Owners NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER Same as Registered Owners ADDRESS CITY MN 55121 GRANTEE NAME Donald Gregory and Patricia Gregory, I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE /ARE THE REGIS OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title,IF APPLICABLE ljr Signature of Additional Registered Owner and Title,IF APPLICABLE / NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION^��I FOR REGISTERED OWNER(S) IGNATURE State of Waount tvn C - Signed or attested t�y County of Jefferson 7T/Ari -- before me on _ Donald Gregory d Signature Aotten ,,„byPRINTED NAME OF REGISTERED OWNER NOTARY OR AGENT A� r•I., MARIA Y.JOHNSON v �. COMM.#1644220 bym Patricia A.Gregory 7 c 5.'h ice" to % ? r c Notary Public-Califomla Ls: PRINTED NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY '1; ,,:: NAPA COUNTY -- County/Office No.OR '� / �/� jb My Comm.Exp.Feb 10,2010 AND: Dealer No.OR `� DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date 4 TITLE COMPANY CERTIFICATION I certify that the legal description of the land and ownership is true and correct per the real property records. NAME(TYPED OR PRINTED) TITLE COVV VA"71''/PI'IONE NUNIDER First American Title Of Jefferson County (360)385-1322 SIGNATURE/POSITION DATE Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs. © BUILDING PERMIT OFFICE CERTIFICATION the manufactured home has been affixed to the real property as described. I certify that: Ll a building permit has been issued for this purpose and the attachment will be inspected upon completion. NA E(TYPED OR PRINTED) BLD PERMIT OFFICE/PHONE# BLDG PERMIT# KA—HA‘t.- l .n ,51.4t ,.~. 01) 67q-L/y3c) 3t �0: -c c71-1 S GN�fURE/POSITS N *DA E �l Lea. ,-m tr I tAlut c-., R 11(), TD-420-129 MANUF HOME APPL(R/2/02)EXT(W)Page 1 of 2 • • MANUFACTURED HOME—FROM SECTION 1 TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) ' VEHICLE IDENTIFICATION NUMBER(VIN) +335937 . 2004 70 /27 PH206587 PALMH 6 SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR EL INATION OF TIT /RE VAL FROM REAL PROPERTY. Signature of Legal Owner and Title,IF APPLICABL �, Signature of Additional Legal Owner and Title,IF APPLICABL NOTARY SEAL OR STAMP ^OTARIGA`i'ION/C-RTIi'7CAI ION FOR REGISTERED HN--. O SIGN uKE State of W)•' ;n - Signed or attes J uoLmy of /t' r di before me on /�°"J I ` by �! v< if J 'ter �/ Si nature 1 �""'''i MARIA Y.JOHNSON i .�•. ,�., g NOTARY OR AGENT .- .,, .9 COMM.#1644220 ) a ____ ,,, .,r Notary Publir.Catifomla Ypoil d �4 1 All r'a C 1, I'"WVI& i- (Jo (/tom NAPA COUNTY b f •RINTED NAME OF REGISTE•++0 R INTED NAME OF NOTARY ^t a My Comm.Exp.Feb 10,2010 _ County/Office No.OR ,,,,,0� Title / ND: Dealer No.OR (0,. DEALERSHIP POSITION/AGENT/NOTARY; Notary Expiration Date D LAND DESCRIPTION(A legal description of the land can be obtained from the local County Assessor's Office.) That Portion of Sections 19 and 30,Township 30 North,Range 1 West,W.M.delineated as Parcel 1 of Survey,Recorded in Volume 8 of Surveys,Pages 166 and 167,records of Jefferson County,Washington. Situated in the County of Jefferson,State of WA. 8 DEALER'S REPORT OF SALE I CERTIFY THAT THIS INFORMATION IS CORRECT,THE VEHICLES IS CLEAR OF ENCUMBRANCES EXCEPT AS SHOWN. ANY REQUIRED SALES TAX HAS BEEN COLLECTED. DEALER NAME(TYPED OR PRINTED) WA DEALER NUMBER DATE OF SALE ' PURCHASE PRICE TAX JURISDICTION/TAX RATE I DEALER'S AUTHORIZED SIGNATURE $300,000.00 1 0 USE TAX EXEMPT Sale to a Certified Tribal member on the reservation(attach notarized statement of delivery). 9 COUNTY AUDITOR/AGENT LICENSING OFFICE APPROVAL: (Not for use by Subagents) I certify that the above application appears to have been completed correctly,and the applicant has sufficient documentation to proceed with the recording of this form. NAME(TYPED OR PRINTED) COUNTY OFFICE/VFS OPERATOR NUMBER SIGNATURE DATE 10 TITLE FEES FILING FEE APPLICATION MOBILE HOME FEE ELIMINATION FEE USE TAX SUBAGENT FEES TOTAL FEES&TAX IMPORTANT: Once the application has been approved by the County Auditor/Vehicle Licensing Office,take your application form to the County Recording Office. Retain proof of the recording fees paid. If the Recording Office retains your original application form,obtain a certified copy of the recorded form. APPLICANTS: Once recorded, you must return to a Vehicle Licensing office to file the Manufactured Home Application,paying all required fees. Vehicle licensing subagents charge a service fee. For full instructions on completing this form for Title Elimination,Removal from Real Property or Transfer in Location,see form TD-420-730,Manufactured Home Application Instructions. The Department of Licensing has a policy of providing equal access to its services. If you need special accommodation,please call(360)902-3600 or TTY(360)664-8885. TD-420-729 MANUF HOME APPL(R/2/02)EXT(W)Page 2 of 2 A & 1, 1Lfr1at co-4et �3 ac - - .04 _ 670.�_ .. — -- - f , r r i— — I 1 _-_ .___.r i s- I --} 1 • i - IT: I E I • ti, r. i', , i , . . , ,• . \ ti • r ' I ti. t l I I L.... _._ I.. �W • I y _ , II t� r's•-• `44/ i( , I 1 ,_ gib i ,i,.„ , , ,....y/ i . .„..„.r, . Y 1 1 I h I ; 40 ... / 1 ; : )I (.) 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