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HomeMy WebLinkAboutBLD2004-00197 • • 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#: BLD04-00197 Received Date: 3/29/2004 SITE ADDRESS: 102 W ISLAND VIEW AVE Issue Date: 4/9/2004 PORT TOWNSEND, 98368 APPLICANT: KAREN BLESSING 935 PIERCE ST PORT TOWNSEND WA 98368-8046 SUBDIVISION: IRONDALE Block: 124 Lot: 1-8 PARCEL#: 962112401 Section: 34 Township: 30 N Range: 01 W CONTRACTOR/ DEALER INSTALLER: JAIME KOZELISKY WAINS0626 Expires: 7/31/20(N 1112 S JACOB MILLER RD PORT TOWNSEND WA 98368 PROJECT DESCRIPTION: NEW MANUFACTURED HOME MAKE: GOLDENWEST YEAR: 2004 SIZE: 27 X 56 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 4/9/2005. REQUIRED INSPECTIONS: kr Setbacks/Footing (CONTINUOUS FOOTING, LAB r PADS USED — Blocking/Plumbinc GAO bkr Propane Tank/Lines // [ ] Zoning Final Approval: 1. /14 Stormwater FINAL Approval: Septic System Final Approval: Road Approach Final Approval: RA-Pb(-(^LI 0 [,j Final/Skirting/Vents/Porches/Steps: w &ow» g-2_9.— HEALTH DEPARTMENT AND PUB C WO KS 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 0 • MLA04-001 64 Review Type:I MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD04-00197 Received Date: 3/29/2004 SITE ADDRESS: 102 W ISLAND VIEW AVE PORT TOWNSEND, 98368 APPLICANT: KAREN BLESSING PHONE: (360)385-4002 935 PIERCE ST PORT TOWNSEND WA 98368-8046 SUBDIVISION: IRONDALE Block: 124 Lot: 1-8 PARCEL NUMBER: 962112401 Section: 34 Township: 30 N Range: 01 W CONTRACTOR/ DEALER: INSTALLER: JAIME KOZELISKY WAINS0626 7/31/2004 (360)385-3215 1112 S JACOB MILLER RD PORT TOWNSEND WA 98368 REPRESENTATIVE: PRESTIGE PROPERTIES/ PHONE: (360) 681-3094 KOZELISKY HOME SERVICE 261533 HWY 101 PROJECT DESCRIPTION: NEW MANUFACTURED HOME TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: GOLDENWEST SETBACK: VALUATION 63,500.00 YEAR: 2004 LABOR & INDUSTRIES APPROVAL? SIZE: 27 X 56 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PUD BEDROOMS: BATHROOMS: PARCEL TAGS: YES NO Exist: 3 Exist: 2 STORMWATER: YES NO AREA Plat Conditions Prop: Prop: Wetland Erosion Total: 3 Total: 2 Seismic Streams Flood Way Floodplain Routing Date: 3/2_ F&W Landslide ) Shoreline Aquifer Type Amount Paid By: Date: Receipt: A P RRO V E Manufactured Homes $154.00 KAS 03/29/04 62800 APR - 9 2004 Potable Water Application $52.00 KAS 03/29/04 62800 Total: $206.00 Jefferson County Planning ,,y_r & Building Departure t cji S JEFFERSON COUNTY•MUNITY DEVELOPMENT 621 SHERIDAN S)RT:-OW NSEND WA 98368 MANUFACTURED HOME INSTALLATION PERMIT APPLICATION NEW BUILDING 0 REPLACEMENT SIZE 2 7 x 5 6 ` YEAR 2004 MAKE Golden West COST $63 , 500 BEDROOMS: BATHROOMS: EXISTING 0 EXISTING 0 PROPOSED 3 PROPOSED 2 TOTAL 3 TOTAL 2 TYPE OF SEWAGE DISPOSAL: WATER SUPPLY: 0 SEWER 0 COMMUNITY SYSTEM 0 PRIVATE WELL 0 TWO PARY WELL c{INDIVIDUAL SYSTEM )O(Conventional >fa PUBLIC PERMIT#SEP 0 Alternative Name of water system: P U D Il 1 03 ac> Sg- IF WATERFRONT PROPERTY, DISTANCE TO BANK OR HIGH WATER LINE ft BANK HEIGHT ft By signing the application form, the applicant/owner attests that the information provided herein is true and correct to the best of their knowledge. Any material falsehood or any omission of a 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 liabilities,judgments,court costs, reasonable attomey's 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 it's employees,representatives or agents for the purpose of application review and any required later inspections. Access and right of entry to the applicant's property or structure shall be requested and shall occur during regular business hours. ! SIGNATURE � ✓ DATE 'f( ?/I/ O'L-7 NAME(PLEASE PRINT) Karen B e s s i n g FOR OFFICE USE ONLY CONSISTENCY REVIEW FEE 48.00 RECEIPT# (0- E?l.x BASE FEE j�� 0i7 ADDITIONAL SECTIONS CASH/CK# I 0 I SUBTOTAL DATE 3 .1/ D POTABLE WATER O )r/S,/ 911/ROAD APPROACH � y f' (/ f !D TOTAL r /n J G:PermitCenteAFORMS\BLDG FORMS\MOBILEAP K 1 �4 I cg k, - -;/ s It w I; •A' 0" ---- %�l a Z o z / P z tJ CVU G w1 i ; i <1,02� 1 x3 a ►--' a- w o _.tea...._..,_•r+� '',q z o aQ �� 2 laa {-- 0�? o K ta Nni �`-i .. h a9 0 1- ,I, i 4 .,_______ , . ''-- k z - N.L (-E)_ . kC Vri \,4i '4 i # in yQ k) - 0 / lF c — t Se — — t RSO JEFFE 9 / \ COUNTY N UUU / ,y'` . / �e k Ro _ � A' ti 83 � �i . % T- 3 L ck, 4. fie- %- V) • • SPECIAL CONDITIONS CASE # BLD04-00197 1.) The application was reviewed by the Jefferson County Department of Community Development staff on April 7, 2004 for the potential presence of Environmentally Sensitive Areas (ESAs) under the provisions of the Unified Development Code (UDC). After an initial Geographic Information Systems mapping review and an investigative site inspection, the following ESAs were confirmed to be present on the subject property: Special Aquifer Recharge Protection Area. 2.) Aquifer Recharge Areas in Jefferson County are characterized by porous geological formations that allow percolation of the surface water into the soils and the underlying zone of saturation. Aquifers are geologic formations that contain sufficient saturated permeable material to yield significant quantities of water to wells and springs. Aquifers serve as the source of drinking water within most of the rural portions of Jefferson County. 3.) Critical Aquifer Recharge Areas are defined as Seawater Intrusion Areas, and Special Aquifer Recharge Protection Areas and the following land uses located within Susceptible Aquifer Recharge Areas (1)All Industrial Land Uses (2)All Commercial Uses (3)All Rural Residential Land Uses requiring a Discretionary Use or Conditional Use Permit(4)All Rural Residential Land Uses with nonconforming uses that would otherwise require a Discretionary Use or Conditional Use Permit(5) Unsewered Planned Rural Residential Developments (6) Unsewered residential development with gross densities greater than one unit per acre. All of the above listed uses shall be subject to the applicable requirements and standards of the Jefferson County Unified Development Code. 4.) The applicant is proposing to create or add 3,340 square feet of impervious surface and 5,800 square feet of land disturbing activities. Sections 6.6 and 6.7 of the Jefferson County Unified Development Code requires that your proposal submit a stormwater plan meeting Minimum Requirements#1 through#5 of the Department of Ecology Stormwater Management Manual for Western Washington to control stormwater, erosion and sediment during construction and shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 5.) A Stormwater Plan was submitted April 8, 2004 and approved by the Department of Community Development April 9, 2004. 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. 6.) Jefferson County determined that this proposal is categorically exempt from review under the State Environmental Policy Act(SEPA) pursuant to WAC 197-11-800(1)(b)(i). 7.) This parcel was created through the Irondale Division No 5 subdivision April 2, 1910 and recorded under AFN 29795, Vol 2, p 135 with the Jefferson County Auditor. 8.) This parcel is a legal nonconforming parcel designated Rural Residential 1:5 under the Jefferson County Comprehensive Plan Land Use Map effective August 28, 1998. 9.) W Island View Ave is a platted public right-of-way and a private road identified as P397. The County does not maintain the road. A road approach permit was approved March 5, 2004 and an address of 102 W Island View Ave was assigned to the parcel. 10.) Potable water is provided to this parcel by Jefferson County PUD#1. 11.) A septic permit (SEP03-00258)was finaled February 10, 2004 for a system with capacity of 360 gallons per day. 12.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 13.) The building height is not to exceed 35 feet. 14.) Minimum setback from western, southern and eastern parcel boundaries is 20 feet. Minimum setback from the northern parcel boundary is 5 feet. 15.) A minimum of two (2)on-site parking spaces are required for the single family residence. 16.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 17.) Not more than two (2) unlice d or inoperable vehicles shall be stored o y lot less than one-half acre unless totally screened from view of neighboring dwellings and rights-of-way. Such screening shall meet all applicable performance and development standards specific to the district in which the storage is kept, and shall be in keeping with the character of the area. Screening shall meet the requirements of Unified Development Code (UDC) Section 6. Outdoor storage of thirteen (13)or more unlicensed or inoperable vehicles is prohibited except in those districts where specified as an automobile wrecking yard or junk (or salvage)yard and allowed as a Permitted Use in Table 3-1 of the UDC, and such storage shall meet the requirements of UDC Section 4.10. In no case, shall any such unlicensed or inoperable vehiclesbe stored in an Environmentally Sensitive Area (ESA). 18.) A Declaration of Restrictive Covenant was recorded October 31, 2003 under AFN 477324 binding Block 124, Lots 1-8 of Irondale Division No 5 for development purposes only. 19.) The site plan as submitted with the building application on March 29, 2004 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 April 9, 2004 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 20.) This approval is for a New Manufactured Home 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. Av , s0N �, (Mk , JEFFERSON COUNTY APR -8 .2004 4 11 DEPARTMENT OF COMMUNITY DEVELOPMENT �► '' .„ 621 Sheridan Street • Port Townsend •Washington 98368 JEFFERSON COUNTY UCU 360/379-4450 • 360/379-4451 Fax G'' http://www.co.jefferson.wa.us/commdevelopment/ STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# /YI Li}V / / ' / PROJECT/APPUCANT NAME: 7*--tZ4j/ �% f 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. .2--,• A s 6• ' ` ,,, S,71E' �.e,,.. . ,. Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. %�'.4.�T 1Co G t -T� 5 G°��ee ���� 6 S ,/ Zoo ' 754're7e- 9 R--/A. cce%Gd ate- t✓cc��7�.�r-G9d / c,p6rz-e• 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. (-1: 172-CEO S l../ 1-' dol.St-go b.-./ ,C.-q i cs- 4-y 4. Describe the existing soils. Indicate soil type on the site map. 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. _ . I ,_ .4. — i cam, L_ , I0-CeJ AP' • . . 6. Describe any excess levels of noise generated by the proposed use or. tivi . ORM �� �'tATER PLAN •I. Irj, JEFFERS.,Ni COUNTY , Sf,, t uM r,1,'rTY DI Vlil('. �,�_ c� : EN�t S stormwater site plan template—rev.10'1/2003 r„ _ 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. f?/v,f7- 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.). r "� 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.&-c��' )1--k-pt _Gr.ry;y ,6-..-61 It,4 G--k'A ,y-Ars -S ( ' �ac 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.] • 7 :e17`- tj'L//jz ir-d 11. Describe the performance goals and standards applicable to the project.'7,4 ,e--FF/ /7' .6- fly/fr ' ��v d / �j"4,n /�i-‘r--5'E 12. Describe the flow control system. .•tV,9-e C—. (- Gcru. et . 24ci` ' , . , APR -8 2004 stormwater site plan template—rev.10/1/2 JEFFERSON COUNTY DAD 13. Describe the water quality system. `4f2 14. Describe the conveyance system analysis and design. If 7.„-feef3,rixe_. 15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material. 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Uniform Building Code. 17. Describe the proposed surfacing material. 18. Describe methods for restoration of the site. Zig u S�/f2�- 2 r sYL. 4OZ 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. 20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan. 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. APR 8 2004 stormwater site plan template_rev.,0/,/2003 JEFFERSON COUNTY DCD • 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. - �✓ 2. Establish Construction Access. /re,Att- cG 4;roc,/ 3. Control Flow Rates. t� Y 4. Install Sediment Controls. 5. Stabilize Soils., /71/(- 6. Protect Slopes. 7. Protect Drain Inl ts. PanY � r /A./ APR -8 2004 JEFFERSON COUNTY DCD stormwater site plan template-rev.10/1/2003 8 12 Required Elements—Construction SWPPP(continued) 8. Stabilize Channels and Outlets. 9. Control Pollutants. 10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site). `-Z 7 U,1 c-L _ 11. Maintain Best Management Practices(BMPss. `—T6 L gpe,5.1 12. Manage the Prrooject. w/.L cZ _1 -s, .-cs FE- 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). 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to the site. / ""' Agier1W7- APR -8 2004 JEFFERSON CO stormwater site plan template—rev.10/12003 9 b. Description of special requirements for working in or near environmentally sensitive areas. 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). G 7AyY 5. Construction Phasing. a. Construction sequence , / ', • �.� EGG — G--,te.- ( to 1 . b. Construction phasing(if proposed) 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). I. Provide a proposed construction schedule. /Yl.8-7 / ,J14✓l_ IS - ddef 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 of bonds and/or other financial securities. v==. b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation impacts. 8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable. a. Sediment Ponds/Traps. b. Diversions. ` c. Waterways. d. Runoff/Stormwater Detention Calculations R — 11 stormwater site plan template—rev.10/12003 JEFFERSON COUNTY DCD 10 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 also certify that this application is being made with the full knowledge and consent of all owners of the affected property. (LANDOWNER OR AUTHORIZ REPRESENTATIVE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: APR -8 2004 JEFFERSON COUNTY DOD 12 stormwater site plan template—rev.10/1/2003 RETURN ADDRESS 6C,Wk v) b1e5,e7D, (\ -2 " 9 ? Q1 ( P \-)6YA. "Tt&wax'n 01 (V) 9 -s' .'..A., LJ STATE OF WASHINGTON MANUFACTURED HOME rag*mixr•�' 'i�D=artment of ❑TITLE ELIMINATION lICEnSInG APPLICATION DTRANSFER IN LOCATION Anyone who knowingly makes a false statement of a material fact is guilty DREMOVAL FROM REAL PROPERTY of a felony, and upon conviction may be punished by a fine,Imprisonment,or both.(RCW 46.12.210) D MANUFACTURED HOME TPO/PLATE NUMBER Y AR MAKE LENGTH/WIDTH(FEET)VEHICLE IDENTIFICATION NUMBER(VIN) EI LAND LEGAL C l �loideo � 5 i X SCRIPTION7 PA MANUFACTURED HOME WILL BE El AFFIXEDR PROPERTY TAX PAR EL UMBER 0 REMOVED ��, 1 1 7 - (�,� LOT a BLOCK 1 PLAT NAME SECTION/TOWNSHIP/RANGE tY On C\01( CO/ if- n © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE •COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS NAME OF REGISTERED OWNER }� K( V C M/l I✓ ) 3 ! rC NAME OF ADDITIONAL REGISTERED OWNER \✓ ADDRESS ITY STATE ZIP CODE Cl'Y.,) k ((..f3 • rb‘A —TI)E- VIA C i ILQA CI 3-34 NAME OF LEGAL OWNER -=`i 13-1- 1 4 ICU bvu')L NAME OF ADDITIONAL LEGAL OWNER ADDRESS CITY STATE ZIP CODE - 0 )-os-I-h c Ave NE e1Ic Via -- (IgeC - GRANTEE t NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGISTERED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title,IF APPLICABLE' { { Signature of Additional Registered Owner and Title,IF APPLICABLE NOTAR 4hLtdgtyr P 4.`,`,',%ySY D. �* i NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE .`�P,. • ��,� State of Washington ` Signedorattested .• �QxA0 ; " County of +° � before me on �Q� CP,,: O•1 7' ; 1 by kg re'1 e/ S/ Signature jag /- A/0'Th • PRINT NAME OF REGISTERED OWNER OT RY OR NT .• e ,.°NM by �4 v" r>rf�wn ,` 1HH1{t1 t0 �` I Title PRINT NAME OF REGISTERED OWNER PRINTED NA County/Office oF No.OR lY int" I /`�'O/a Thb`� e- AND: Dealer No.OR DEALERSHIP PO ION/AGENT/NOTARY Notary Expiration Date© �—C I-3 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 COMPANY/PHONE NUMBER SIGNATURE/POSITION DATE Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs. 0 BUILDING PERMITOFFICE CERTIFICATION I certify that: I� property ad ❑ athe building permanufacturedmit hashome beenhas issuedbeen for thisaffixed purposetothereal and the attachments will describe b.e inspected upon completion. NAME(TYPED OR PRINTED) BLDG PERMIT OFFICE/PHONE# BLDG PERMIT# K k\,. �. j,f..k rN- cc 6 .5-10\--44 0 4— 00 V ? SIG.�N/p�� E/POS10L 1 t DATE TD-420.7 9 2MANUF HOIAPPL R/8/98 OR Page 1 of 2 k � ` �� ( ) 9 6 SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR ELIMIN fa,'OF TIT E/F�EM V L FROM REAL PROPERTY. Signature of Legal Owner and Title,IF APPLICABLE �'/' , �f j C-K FIRST Signature of Additional Legal Owner and Title,IF APPLICABLE MUTUAL BANK(, NOTA jj98 1fbFiI �7MP I NOTARIZATION/CERTIFIC Ulm ATIONFOR LEGAL OVIINER(S)SIGNATURE \\\.•••'' *** 4 +�.� I State of Washington //, /_ Signed or attested �53 fr�.p; I County of 1� 15 10 before me on °t *VTAR . FIRST MUTUAL BAND '` , �C/ --+-- by {{^"��, pp r�� a Signature _ a+ r J elf Bt fit' PRINT NA E ILLAlt 1 , A.VP P NOTARY Y ® I PRINT NAM OF LEGAL OWNER PRIN ED N•ME OF. OTA- l�r1�j�r ..,,�r ikS.VM °�``\ I Title County/Office No.OR �/ G. AND: Dealer No.OR I DEALERSHIP POSITI /AGENT/NOTARY Notary Expiration Date154) D LAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office 7.) 1 1 0c/ , 12.4 OF 6vt nCi ( V iI C( cs.. ( cyct kei in \id ry-Le Z. OF P‘ck-i-S n Pa t") a 5 I ve c v veld (oLv1ash ( ncji---01 0 DEALER'S REPORT OF SALE I CERTIFY THAT THIS INFORMATION IS CORRECT.THE VEHICLE IS CLEAR OF ENCUMBRANCES EXCEPT AS SHOWN. ANY REQUIRED SALES TAX HAS BEEN COLLECTED. DEALER N TYPED OR PRINTED) , WA DEALER NUMBER DATE OF SALE f r—c57;� c 'ap_e_A GS 4 4440 5-20-04 PURCHASE PRICE TAX JURISDICTION/TAX RATE DEALER'S AUTHORI SICaNATU E $63 , 150 Jefferson ❑ 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) a na t,F 3J I certify that the above application appears to have been completed correctly,and the applicant has sufficient do cprrotr; I r9 eedwith the recording of this form. ,°'� , • s; NAME(TYPED OR PRINTED) COUNTY OFFICENFS OPAR`NUM14aE9. VA;+4, a SIGNATURE DecEr`" . • it »,E in TITLE FEES FILING FEE APPLICATION MOBILE HOME FEE ELIMINATION FEE USE TAX �`�j ).'„d�„ W 1�{ NT`F-S .11 dfi tat 310 TOTAL FEES 8 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 cal(360)902-3600 or TDD(360)664-8885. TD-420-729 MANUF HOME APPL(R/8/98)OR Page 2 of 2