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HomeMy WebLinkAboutBLD2004-00254 410 • 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#: BLD04-00254 Received Date: 4/19/2004 SITE ADDRESS: 92 COCO LN Issue Date: 5/21/2004 BRINNON, 98320 APPLICANT: RALPH W HAUPT PATRICIA L HAUPT 19468 SYMERON RD APPLE VALLEY CA 92307-4733 SUBDIVISION: SEAMOUNT ESTATES DIV 3 Block: Lot: 6 PARCEL#: 993400006 Section: 32 Township: 25 N Range: 02 W CONTRACTOR/ WASHINGTON HOME CENTER INC PHONE: (800)648-1113 DEALER PO BOX 176 CHEHALIS WA 98532 Contractor's License WASHIHC0770A Expires 03/19/201:5 PROJECT DESCRIPTION: REPLACEMENT MANUFACTURED HOME MAKE: SILVERCREST YEAR: 2004 SIZE: 41 X 42 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 5/21/2005. REQUIRED INSPECTIONS: j Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): f&• w414.. o(9Q6 6-/S--oj —. NI Stormwater FINAL Approval:v [ J Blocking/Plumbing: Aex.,,ii„�c: c TIE sy,?,,„6J; 6 7/ta/,.�19 [ ] Propane Tank/Lines N 1'! ! [ ] Zoning Final Approval: Aidtg j Septic System Final Approval: [ ] Road Approach Final Approval: yip ,. ,• Final/Skirting/Vents/Porches/Steps: Jrlcps9 . 7 A* HEALTH DEPARTMENT AND PUBLIC WORKS 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 0 6 MLA04-00214 Review Type:I MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD04-00254 Received Date: 4/19/2004 SITE ADDRESS: 313401 HWY 101 BRINNON, 98320 APPLICANT: RALPH W HAUPT PHONE: (92307-4733 PATRICIA L HAUPT 19468 SYMERON RD APPLE VALLEY CA 92307-4733 SUBDIVISION: SEAMOUNT ESTATES DIV 3 Block: Lot: 6 PARCEL NUMBER: 993400006 Section: 32 Township: 25 N Range: 02 W CONTRACTOR/ WASHINGTON HOME CENTER INC PHONE: (800)648-1113 DEALER: PO BOX 176 CHEHALIS WA 98532 Contractor's License WASHIHC0770A Expires 3/19/2005 REPRESENTATIVE: WASHINGTON HOME CENTER INC PHONE: (360) 790-9411 C/O CHUCK HAMPTON PO BOX 176 PROJECT DESCRIPTION: REPLACEMENT MANUFACTURED HOME TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: SILVERCREST SETBACK: VALUATION 126,625.00 YEAR: 2004 LABOR & INDUSTRIES APPROVAL? SIZE: 41 X 42 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PUBLIC BEDROOMS: BATHROOMS: PARCEL TAGS: YES --- Exist: 2 Exist: 2 STORMWATER: YES NO Prop: Prop: AREA Plat Conditions Total: 2 Total: 2 Wetland Erosion Seismic Streams Flood Way -Floodplain Routing Date: 1F&W Landslide 4-(2 ( � Shoreline //N�� C-' � Type Amount Paid By: Date: Receipt: App�QX L �te,004 Manufactured Homes $154.00 KAS 04/19/04 64306 IYIA Potable Water Application $52.00 KAS 04/19/04 64306 Jefferson County Planning & Building Depart nt Total: $206.00 n fl,/ el-) 01!), Sc III III JEFFERSON COUNTY COMMUNITY DEVELOPMENT 621 SHERIDAN ST,PORT TOWNSEND WA 98368 MANUFACTURED HOME INSTALLATION PERMIT APPLICATION 0 NEW BUILDING I REPLACEMENT - I _ SIZE Li / >4 I __ I f P YEAR ' 0 f t ! 1 MAKE ►I L11P�i APR 1 9 2004 .,' COST VIP-6 - &Z 7' ---- 1 ` C'G t STY BEDROOMS: l�Ftzi OPNEM. I BATHROOMS: EXISTING Z.- Z EXISTING PROPOSED Z PROPOSED a TOTAL Z TOTAL TYPE OF SEWAGE DISPOSAL: WATER SUPPLY: 0 SEWER 0 COMMUNITY SYSTEM ,,,� 0 PRIVATE WELL 0 TWO PARY WELL B INDIVIDUAL SYSTEM 1"Conventional I9IDUBLIC PERMIT#SEP 7.c; /C3 0 Alternative Sea I'YI©t cn f Name of water system: ----����'� � � '� �►?'U7]�?1t� IF WATERFRONT PROPERTY, C�F'sL�'� DISTANCE TO BANK OR HIGH WATER LINE -3 0 ft BANK HEIGHT /2-- 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. t- SIGNATUR ��+�� �` DATE - d/7 NAME(PLEASE PRINT) C4a r/6 S e /A. , *, FOR OFFICE USE ONLY CONSISTENCY REVIEW FEE _4 .OQ RECEIPT# 430 ° BASE FEE 15q, Q c u ADDITIONAL SECTIONS CASH/CK# j 6 / /1 SUBTOTAL Zp L , CC DATE t POTABLE WATER coc 00 4Lq I c„j n„r 911/ROAD APPROACH C`{ (u�',1..;»>� TOTAL 2_ G:\PermitCenter\FORMSIBLDG FORMS\MOBILEAP I'p 'PLEASE MAIL TO- P S ")EFFERSON COUNTY ASSESSOR JACK WES JEFFERSON COUNTY COURTHOUSE ASSE R PO BOX 1220,PORT TOWNSEND WA 98368 (360)385-9105 MOBILE HOME INFORMATION FORM OWNER'S NAME / MAILING ADDRESS:Sj THIS IS NOT A TAX STATEMENT NAME: �j� /J LL T The purpose of this questionnaire is to obtain information regardng either the current location of a mobile home or the ADDRESS: 11 y41 S th fOh Pee • pr ownership and location of a mobile home. This will � p1C�y/7 b73� help our office determine whether the mobile home is already 6,7/1° f�7 on the tax rolls in Jefferson County or if it has been moved to - / - y Z this county from another area. Please see reverse side for TELEPHONE NO- d 70 7 additional information. 1) MOBILE HOME DATA: 6.35 y�,�'!/ (A) MAKE �k)//1 e. (B) MODEL G ev br IAA � C�(C) YEAR�—w5 (D) LENGTH / 7i (E) WIDTH // (F)SERIAL NUMBER ///1;51 I (G) YOUR PURCHASE PRKE(DO NOT INCLUDE SALES TAX)F g 6,1 (H) PURCHASE DATE 2/Z O/b y 2) PREVIOUS OWNER/ LOCATION OF MOBILE HOME: (A) FROM WHOM DID YOU PURCHASE MOBILE �(X ij /1/1�i`-e Y1 ( YYte,, 60 ,.L`�-ec i 4e ADDRESS p© Z� �7N j C11ch /lc ) Wlq . �rj �7?-- (B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? YES NO (IF NO,WHAT COUNTY?/1/7 —/VQ,(,(/' IF YES,WHAT WAS PREVIOUS ADDRESS OF MOBILE? 3) WHERE MOBILE HOME IS TO BE LOCATED: (A) WILL THE MOBILE HOME BE IN A MOBILE HOME PARK? YES NO (B) IF LOCATED IN A MOBILE HOME PARK: NAME 8T ADDRESS OF PARK SPACE NO. (C) IF NOT LOCATED IN A MOBILE HOME PARK: NAME OF LAND OWNER: RQ I p r'\ I 1A,in n LOCATION(ADDRESS) (f 97_ Co co pj(,C� ) j j�/nnc�, IA)�T� /e3 ao REAL PROPERTY PARCEL NUMBER/DESCRIPTION -7 //J - 40o -De)42I spao1oL1 h fi �S'( k DI`0-- J071 --ly-dJ THANK YOU FOR YOUR HELP! /,t)}/a SIGNATURE ( KELLI LARSON, roperty Technician THIS FORM CONFORMS TO THE STANDARDS OF THE STATE DEPARTMENT OF REVENUE AND IS SUBJECT TO AUDIT VERIFICATION. APR- T 9 2004 - - l.r - - e _ . • - zezevAikf . .iiir- 9,. .,No -A ,.. -,,w - - r n� rr� ,fiLiiiiii:- _ rr , . • , t . ' `-- - _ - - _ . , , ; . ; 1.. 6.4, ,,, . , : . ,;.,.• 42_ . . 3v ' : . . , _I:_ 0 ' -1,6if gKi-t___Ji ium.i___. , _ , ' _____ ..t..__ ., , ' . . .,< , . .1_._ . - r t y 44 I r. . . ° - > - r 1 - APPROVED _ L't,?-c-6._:_ .. 44 SITE PLAI4 -----_ - _ tP -- MAY 2.0 : Q4 1 storm :M; p�q JEFFE?RSOWCOUN fY f• DEPT.OF M UNITY'DEV - P R"`1 u � � SIGNATUR • SPECIAL CONDITIONS FOR ME t BLD04-00254 1.) The application was reviewed by the Jefferson County Department of Community Development staff on April 26, 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: Conservancy Shoreline Designation, Bald Eagle Habitat Areas, Spotted Owls Habitat Areas, Level I & II Landslide Hazard Areas, Susceptible Aquifer Recharge Areas and Coastal Seawater Intrusion Protection Zones (SIPZ). 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.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions that promote rapid infiltration of recharge waters to groundwater aquifers. 4.) Geologically Hazardous Areas in Jefferson County are characterized by slope, soil type, geologic material, and groundwater that may combine to create problems with slope stability, erosion, and water quality during and after construction or during natural events such as earthquakes or severe rainstorms. 5.) The project location is characterized by bedrock and a geotecnical report is not required for this proposal. Buffers shall be maintained to the maximum extent practicable. 6.) Buffers are areas that shall be maintained in their natural condition, however, minor pruning or alteration of vegetation may be permitted as long as the function and character of the buffer are not diminished. 7.) Among the native conifer species which may be used in buffers or for re-vegetation include, but are not limited to: Grand Fir(Aibes grandis), Sitka Spruce (Picea Sitchensis), Shore Pine (Pinus Contorta), Douglas Fir(Pseudotsuga Menziesii), Western Red Cedar (Thuja Plicata), and Western Hemlock (Tsuga Heterophylla). Among native tree species which may be used includes: Vine Maple (Acer Circinatum), Big-Leaf Maple (Acer Macrophyllum), Red Alder(Alnus Rubra), Pacific Madrone (Arbutus Menziesii), Quaking Aspen (Populus Tremula), Black Cottonwood (Populus Trichocarpa), Bitter Cherry(Prunus Emarginata), Oregon White Oak (Quercus Garryana), Cascara (Rhamnus Purshiana), Pacific Willow(Saliz Lasiandra), and Scouler's Willow(Saliz Scouleriana). Among the native shrub species which may be used are: Sevice-Berry(Amalanchier Alnifolia), Red Osier Dogwood (Cornus Stolonifera) Salal (Gaultheria Shallon), Ocean Spray(Holodiscus Discolor), Indian Plum (Oemlaria Cerasiformis), Pacific Ninebark (Physocarpus Capitus), Red Flowering Currant(Ribes Sanguineum), Wild Rose (Rosa Nutkana), Swamp Rose (Rosa Pisocarpa), Willows (Salix ssp.), Red Elderberry (Sambucus Racemosa), Snowberry(Symphoricarpos Albus), Evergreen Huckleberry (Vaccinium Ovatum), Red Huckleberry(Vaccinium Parvifolium). 8.) Marine shorelines and islands are susceptible to a condition that is known as seawater intrusion. Seawater intrusion is a condition in which the saltwater/freshwater interface in an aquifer moves inland so that wells drilled on upland areas cannot obtain freshwater suitable for public consumption without significant additional treatment and cost. Maintaining a stable balance in the saltwater/freshwater interface is primarily a function of the rate of aquifer recharge (primarily through rainfall)and the rate of groundwater withdrawals (primarily through wells). The Washington Department of Ecology is the agency with statutory authority to regulate groundwater withdrawal for individual wells in Jefferson County. New development, redevelopment, and land use activities on islands and in close proximity to marine shorelines in particular should be developed in such a manner to maximize aquifer recharge and maintain the saltwater/freshwater balance to the maximum extent possible by infiltrating stormwater runoff so that it recharges the aquifer. ill9.) The parcel is located within astal SIPZ (seawater intrusion protection ie)according to the County GIS map. There are voluntary and mandatory measures identified it the Jefferson County Seawater Intrusion Policy(Resolution 44-22, effective Septembe-23, 2002)that apply to well drilling proposals and building permit applications on existing lots of record. A Coastal SIPZ is defined as: all islands and area within one-quarter mile of marine shoreline, but no history of chloride concentration above 100 mg/L in groundwater sources within 1000 feet. 10.) A vegetative buffer of 30-feet shall be permanently maintained from the top or edge of the Landslide Hazard Area. All buffers shall be measured perpendicularly from the top of the Landslide Hazard Area. 11.) Landslide Hazard Areas and their associated buffers shall remain naturally vegetated. Should buffer disturbance occur during construction, the Unified Development Code (UDC)Administrator shall require replanting with native vegetation. No alterations shall be made to the Landslide Hazard Area or its associated buffer without prior authorization by the UDC Administrator. 12.) Prior to and during approved construction activities, the perimeter of the landslide Hazard area buffer shall be marked with a temporary sign. The sign shall be placed in such a manner that it can be directly observed from the construction area. The sign shall contain the following statement: "Landslide Hazard Area and Buffer- Do not Remove or A ter Existing Vegetation." 13.) All construction activities shall not encroach upon the buffer. This includes the storage or preparation of materials. 14.) The applicant shall permanently separate the boundary of the Landslide Hazard Area Buffer from the remainder of the subject property through installing logs, trees, a hedge row, or any other prominent physical marking approved by the UDC Administrator. 15.) Critical Aquifer Recharge Areas may require special protection measures to mitigate water quality degradation. The submitted proposal does not require additional aquifer protection measures. However, during construction the project shall follow the Best Management Practices (BMPs)and facility design standards as identified and defined in the Stormwater Management Manual for the Puget Sound Basin. 16.) To help prevent seawater from intruding landward into underground aquifers, all new development activity on Marrowstone Island, Indian Island and within 1/4 mile of any marine shoreline shall be required to infiltrate all stormwater runoff onsite. 17.) The applicant shall fully adhere to all conditions and requirements of the eagle habitat management plan. 18.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ: Water conservation measures: 1. Roof and other intercepted precipitation shall be routed to on-site detention ponds and/or other approved means and allowed to be released to the soil slowly. 2. Water collected from Storm water and roof catchments may be used for watering lawns and gardens. Unless catchment water has been treated to meet drinking water standards, there shall be no cross connections allowed between the potable supply and impounded water. 3. Water withdrawn from wells on each property shall not be used for watering of lawns and/or gardens. 4. Ground water withdrawn from each property shall be restricted to a rate of three (3) gallons per minute. 5. Installation of water conserving fixtures such as low flow toilets, faucets and shower restrictors and other water saving plumbing fixtures. 6. Landscaping plan (xeriscaping, native vegetation with minimal amounts of irrigation). Please NOTE that the above listed measures are not intended to be exhaustive, but rather is intended to be illustrative of the types of water conservation measures. 19.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ: 1. Installation of a flow meter. 2. On-going well monitoring for chloride concentration. 3. Submittal of monitoring data to County. 20.) MANDATORY MEASURES OR COASTAL SIPZ: 1. For proof of potable water on a building permit application, applicant must utilize DOH-approved public water system if available. 2. If public water is unavailable, a qualifying alternative system may be used as proof of potable water or an individual well may be used as proof of potable water subject to the following requirement: a. Chloride concentration of a laboratory-certified well water sample submitted with building permit application. 3. If public water is unavailable, a qualifying alternative system may be used as proof of potable water. 21.) The applicant is proposing to create or add 1722 square feet of impervious surface and 1722 square feet of land disturbing activities. Sections 6.6 and 6.7 of the Jefferson County Unified Development Code requires that your proposal shall adhere to Best Management Practices (BMPs). 22.) 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). 23.) The site plan as submitted with the building permit application on April 19, 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 May 20, 2004 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 24.) This approval is for a replacement 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. 25.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 26.) Not more than two (2) unlicensed or inoperable vehicles shall be stored on any 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). 27.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 28.) The building height is not to exceed 35 feet. 29.) Minimum setback from Coco Ln right-of-way is 20 ft. Minimum side and rear setbacks are 5 ft unless an environmentally sensitive area (ESA)exists, then the stricter setback shall apply. 30.) The standard setback for residential structures, including common appurtenant structures such as garages and workshops, shall be thirty(30)feet or one (1)foot for each foot of bank height, whichever is greater. This setback shall be measured from the bank's edge when the bank's height exceeds 10 feet. When the bank's height is less than 10 feet, the setback shall be measured from the ordinary high water mark. The setback shall not exceed 100 feet. 31.) The project shall comply with Construction Stormwater Pollution Prevention (SWPP) Elements#1 through #12 of the Department of Ecology's Stormwater Management Manual for Western Washington 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. 32.) A minimum of two(2)on-site parking spaces are required for the manufactured home. 33.) This parcel has been designated as Rural Residential 1:5 under the Jefferson County Comprehensive Plan Land Use Map effective August 28, 1998. 34.) A septic permit(SEP75-00103)was finaled on October 2, 1975 for a system of 240 gallons per day. 35.) Coco Ln is a private road (P412). The road approach is existing and an address of 92 Coco LN has been assigned to the parcel. • 36.) This parcel was created through Seamount Estates Division 3 under AFN 24234, filed of record July 24, 1974 in Volume 5 of Long Plat, page 98-99 with Jefferson County Auditor's office. 37.) A building permit (BLD91-00097)was issued on April 3, 1991 for a mobile home installation and a covered patio. The manufcatured home proposed under this application is located in approximately the same footprint as the mobile home previously on site. 38.) Washington State Department of Fish &Wildlife (WDFW)commented on the application May 6, 2004 determining the proposal will not have significant impact on spotted owl. The site was historically cleared and no viable spotted owl habitat is within the immediate vicinity of the proposal. 39.) Existing manufactured home to be removed prior to final inspection. 40.) Washington State Department of Fish &Wildlife commented on the application May 10, 2004 and determined that an eagle plan is required for this proposal. 41.) As per the approved Eagle Plan dated May 20, 2004, the applicant shall retain all known perch trees and conifers >/=24 inches diameter at breast height (d.b.h.). The applicant shall also retain >/=50% of pre-clearing or pre-construction conifer stand with diameter distributions representative of the original stand (>6 feet tall). Windowing and low limbing of trees is acceptable provided no more than 30% of the live crown is removed. I:\F_BLD_Permit_Buildng.rpt 10/29/19 w RETURN ADDRESS ?D 1 9. tech) ria6t. cgs'.e9 1, • 14Ie L�7�SLLI/1l TATEOntof NGT°N Department of MANUFACTURED HOME PLEASE CHECK ONE [TITLE ELIMINATION licEnsinG APPLICATION TRANSFER IN LOCATION Anyone who knowingly makes a false statement of a material fact is guilty REMOVAL 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 YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) ® LAND ;' LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE ,Ig AFFIXED El REMOVED REA ROPERTY TAX PARCEL NUMBER LOT [. , BLOCK PLAT NAME SECTION/TOWNSHIP/RANGE © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS NAME OF REGISTERED OWNER r.RLph - }-Ptu t , NAME OF ADDITIONAL REGISTERED OWNER FAy A 1 tciA A A L!2 ADDRESS CITY STATE ZIP CODE NAME OF LEGAL OWNER NAME OF ADDITIONAL LEGAL OWNE /l)eQ e7 1 ate f912 ""- ;j ADDRESS CITY STATE ZIP CODE GRANTEE 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 Ownerand Title,IF APPLICABLE • NOTARY?,, •l ST ' ,, NOTARIZATION/CERTIFICATION FOR REGISTERED NER(S)SICC HNA youN, , "' � ( ) TURE 4'' y, `�atateofWashington Signed or attested � 1 County of /� before me on �+- .a.�SL t b ', gJ tee ,- ,a y m ►� Signature k( t. � PRINT AME F E I TERED WNER NOTARY OR AGEN �e ��IA byes tL,� � - p REN A. K se PRINT NAME OF REGISTERED WNER PRIN E NAME OF NOTARY �.� County/Office No.OR "�jr0 ' L . �ITIYI DEALE SHIP POSIT AND: Notary Expiration Dealer oDa e OR �/� � 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: tyl the manufactured home has been affixed to the real property as described. ❑ a building permit has been issued for this purpose and the attachment will be inspected upon completion. NAME(TYPED OR PRINTED) BLDG PERMIT OFFICE/PHONE# BLDG PERMIT# K ,h.x., A U4—UU254 �y1�1.�,��,1GaY�" �Jjlea�) � ��� ���ca SIG URE/POSITION ��)) DATE Al ` .ca;, \ C ,v?tl.a."l��Yk�'7r,14 T-' ��—l�a TD-420-72 MANUF HOME APPL(R/8/98)OR Page 1 of 2 / v L1 6 SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR ELIMINATION OF TITLE/REMOVAL FROM REAL PROPERTY. Signature of Legal Owner and Title,IF APPLICABLE Signature of Additional Legal Owner and Title,IF APPLICABLE _AZ{ ` ' V `-. ulat„.../ NOTARY V,46.VA'6t,T AP I NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE 0t(ez tt i State of Washington ,Signed or attested D 1r County of ,I before me on O ta. i,ifit'J• t��1 NGt.�!e 15• ,,7tzieti Signature 0 :0 • CCi 1, y PRINT NAME'OF*LEGAL OWNER OTA R NT ,� t. '(1f3LIC I�v � :17;2 , 1(40WRIO� �j S7 '•, ) r PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTARY aA�iA�"•�'.d?9 Q •°" �_ County/Office No.OR ells O�t"q, \\a Title AND: Dealer No.OR /l�'7/��+ &I% `0� I DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date g LAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office P K'- e / VI)t..c.c,rn E_s'a F '1rc: - 6,., friva 9 s ®f' ,Vie/= S et r1:11 8 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 NAME(TYPED OR PRINTED)-- ry WA DEALER NUMBER DATE OF SALE / t(,.c215 h {od'1 // rie PURCHASE PRICE [ TAX JURISDICTION/TAX RATE DEALERS AUTHORIZED SIGNATURE/2 I-m7 S �3O '` cL wa'2z L cJ ,221, ❑ USE TAX EXEMPT Sale to a"'ertified Tribal mdmber 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 tehave been completed correctly,and the applicant has sufficient documentation to proceed with the recording of this form. NAME(TYPED OR PRINTED) COUNTY OFFICENFS OPERATOR NUMBER SIGNATURE DATE Da 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 cal(360)902-3600 or TDD(360)664-8885. TD-420-729 MANUF HOME APPL(R/8/98)OR Page 2 of 2