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HomeMy WebLinkAboutBLD2004-00458 r 0 ... 1 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#: BLD04-00458 Received Date: 7/6/2004 SITE ADDRESS: 32 S STROMBERG AVE Issue Date: 7/23/2004 PORT TOWNSEND, 98368 APPLICANT: JOHN L SCHULTZ ELIZABETH A JAHRMARKT 1406 E EARLL DR PHOENIX AZ 85014-5637 SUBDIVISION: IRONDALE Block: 145 Lot: 1-4 PARCEL#: 962114501 Section: 35 Township: 30 N Range: 01 W CONTRACTOR/ DEALER INSTALLER: JAIME KOZELISKY WAINS0626 Expires: 7/31/200z 1112 S JACOB MILLER RD PORT TOWNSEND WA 98368 PROJECT DESCRIPTION: NEW Manufactured Home MAKE: MARLETTE YEAR: 2004 SIZE: 27 X 59.8 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 7/23/2005. REQUIRED INSPECTIONS: A Setb cks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): ulP ?-®Y 4 Stormwater FINAL Approval: / [)( Blocking/Plumbing: tc-eckto& ¢`r6-oo�u,us a 1.4/t1M4,7�aa Q/Z&AL1 40/ [ ] Propane Tank/Lines NIA [ ] Zoning Final Approval: AO/ Y) Septic System Final Approval: gpci Road Approach Final Approval:PP pP ` 4PD-4 IL,S X Final/Skirting/Vents/Porches/Steps: 7),<-" .. r 5, ? s-1 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 HOT-LINE AVAILABLE 24 HOURS A DAY • • SPECIAL CONDITIONS CASE # BLD04-00458 1.) The application was reviewed by the Jefferson County Department of Community Development staff on July 16, 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: Critical Aquifer Recharge Area (SARPA), Coastal SIPZ, and stormwater. 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 parcel is located within a coastal SIPZ (seawater intrusion protection zone) according to the County GIS map. There are voluntary and mandatory measures identified in the Jefferson County Seawater Intrusion Policy(Resolution 44-22, effective September 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. 5.) 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. 6.) 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. 7.) 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. 8.) 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. 9.) 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. 10.) The applicant is proposing to create or add 2,990 square feet of impervious surface and 5,404 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 for a Medium Project. 11.) 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. 12.) A Stormwater Plan for a Medium Project 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. 13.) 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). 14.) The site plan dated July 16, 2004 as submitted with the building permit application (BLD 04-458) on July 6, 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 July 16, 2004 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 15.) This approval is for a 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. 16.) This property is Lots 1-4 of Block 145 of the Irondale Subdivision. The property is designated Rural Residentail 1 dwelling per 5 acres by the Jefferson County Comprehensive Plan adopted August 28, 1998. 17.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 18.) 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). 19.) A minimum of two off-street parking spaces shall be provided. 20.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. This proposal has approximately 29 percent impervoius surface. Note 15 of Table 6-1 allows existing lots of record less than an acre in size to meet the impervious surface requirement to the maximum extent possible. This proposal meets this requirement. 21.) The building height is not to exceed 35 feet. 22.) The front setback is 20 feet fr,�P the edge of the right-of-way Stromberg Avenue (east). The side setback to Prospect Avenue is 20 feet from the edge of the right-of-way (determined by assessors maps and survey),which is located to the north. There is a 20 foot side setack to alley located to the south. There is a 5 foot rear setback from the western property line. 23.) Septic Permit(SEP 02-225)was issued 10/16/02 and the applicant has applied for an address (RAP 04-165) off of Stromberg Avenue from the Jefferson County Public Works Department. • • MLA04-00419 Review Type: I MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD04-00458 Received Date: 7/6/2004 3 SITE ADDRESS: ,,S STROMBERG AVE PORT TOWNSEND, 98368 APPLICANT: JOHN L SCHULTZ PHONE: (602) 677-2747 ELIZABETH A JAHRMARKT 1406 E EARLL DR PHOENIX AZ 85014-5637 SUBDIVISION: IRONDALE Block: 145 Lot: 1-4 PARCEL NUMBER: 962114501 Section: 35 Township: 30 N Range: 01 W CONTRACTOR/ JAIME KOZELISKY PHONE: (360)385-3215 DEALER: 1112 S JACOB MILLER RD PORT TOWNSEND WA 98368 Contractor's License WAINS0626 Expires 7/31/2004 INSTALLER: JAIME KOZELISKY WAINS0626 7/31/2004 (360)385-3215 1112 S JACOB MILLER RD PORT TOWNSEND WA 98368 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NEW MFH TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: MARLETTE SETBACK: VALUATION YEAR: 2004 LABOR & INDUSTRIES APPROVAL? SIZE: 27 X 59.8 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PUD PARCEL TAGS: YES NO BEDROOMS: BATHROOMS: STORMWATER: YES NO Exist: Exist: AREA Plat Conditions Prop: 2 Prop: 2 Wetland Erosion Total: 2 Total: 2 Seismic Streams Flood Way Floodplain Routing Date: F&W Landslide vs/al Shoreline Aquifer Type Amount Paid By: Date: Receipt: Approved/Date Manufactured Homes $154.00 KAS 07/06/04 66439 APPROVED Potable Water Application $52.00 KAS 07/06/04 66439 JUL 2 3 2004 Total: $206.00 Jefferson County Planning & nilding Department APPROVED I SITE PLAN vco- 0,-A- Pae1962ft150t -.. - - 6orxlele Div 6,BSc 145,Lots 1-4 JUL 16 2004 Section 35 rc an section rveti� Ni. 1 2004 Township 30N Rarpe fW 4 lit Scab;1 =t'in JEFFERSON COUNTY'EUN ELI Scala:l it= 'print in DEPT.OF CO, couN�pcD 7h 1606.5 sq rt. SIGNATURE: SLF�ERSO Planned Structure*. fl==DN 99'6' OEbv.136 srar4rw ---- —" ,/ „Elev.135 24'6' 4 ` b rip' seRemovAreak Remove A 1 1 I 26' s.Pk took 1 1 was' O O 7�0' 8.0.Darra \I t2'Trannert 5'llin. um, I z IIi�b� a 2' tro' ! fr 20 Stairs 0' A5'x 8 Alley 6r'"'"k l a taro' S E!'33'la-EM 27'x g ...-� i \k NeS33'te'W T 20 Home t,o• 22T�x 5®'66 s `(20 0') \I` 60' 2'0' 7Iro' �._� _ 16'0' ..b Bei %\� // Prospect Ave. Stairs! 20.0. 5'Stairs 6 \ meter 31'6' IL 3T B' _ 1�. 1-\\Iii/uo• elerrion �\C�rti Driveway C.\tea 6. 1 R s x s �. Ie 0Ebv.133 srar+rw Y Elev.133' 1 O�[ • pA -81 O /�� •O !A ervit Stromberg Ave. -sd_ �pp� 7 As 8 APPROVED ���p STOR1V�WATER PLAN ❑ Electric TeIICATV"— r JUL 14am JEFF SON COUN ! DEPT.OF C NITY EV P SIGNATURE: � . l tormwater Pollution Prevention Fslan MLA: 04-419 Parcel: 962114501; Irondale Div. 6,Block 145, Lots 1-4 Owners: John Schultz and Elizabeth Jahrmarkt Designated Agents: David Tonkin and Karen Samuelson Best Management Practices will be followed as appropriate and necessary for both construction and permanent stormwater pollution prevention on this site. Sub-contractor responsible for these activities: Shold Excavating. Construction Stormwater Pollution Prevention. o Unnecessary clearing will be avoided by appropriate means such as marking clearing limits. o A single construction entrance will be utilized and will be stabilized through the use of a stabilized pad of quarry spalls. Permanent Stormwater Pollution Prevention. o A stormwater retention pit with five cubic yards of drainrock will be constructed approximately ten feet from the NE corner of the home between the home and the intersection of Prospect Ave. and S. Stromberg Ave. Raingutter downspouts will be directed into this pit. o Foundation drains will be installed if they are deemed necessary after examination of the site. %O a VP } . APPROVED N JUL i e 2004 STORM pTER PL JEFFERSON COUNTY DCD JUL . 6 3ERS ONUI DEPT OF FFECOti• 11TYCO��NT ELFbPa,AY'JU-- �NTURE. SIG. Effective Date: July 15, 2004 JACK WESTERtI N III .__u._ J FERSON COUNTY ASSESSOR EEs FFERSON COUNTY COURTHOUSE ASSESSOR __ t —" POBOX 1220, PORT TOWNSEND WA 98368 `;' (360) 385-9105 COPY — � , MOBIL=HOML'`INFOf�MATION FORM OWNER'S NAME / MAILING ADDRESS: JEPT. OFC2 t'� - `H/S/S NOT A TAX STATEMENT NAME: t v(.0 ICa 0-Y.i 6 KA?EN The purpose of this questionnaire is to obtain information ADDRESS: / IXFr �D regarding either the current location of a mobile home or the previous ownership and location of a mobile home. This will�� �-�,�n p ,� y h ��� help our office determine whether the mobile home is already ILJL !f AJ1 ) C?3 on the tax rolls in Jefferson County or if it has been moved to this county from another area. Please see reverse side for TELEPHONE NO: G — %LtL T additional information. 1) MOBILE HOME /fDATA: (A) MAKE /a/iL r7& (B) MODEL / OSTQ (C) YEAR�,� tf `. �( •% 0� '' r tVe.- amict-Tb (D) LENGTH ? (E) WIDTH ti( (F)SERIAL NUMBER �}02 33?(p (G) YOUR PURCHASE PRICE(DO NOT INCLUDE SALES TAX) (H) PURCHASE DATE 2) PREVIOUS OWNER / LOCATION OF MOBILE HOME: (A) FROM WHOM DID YOU PURCHASE MOBILE L-oE/J 77 G H(Va ,( fS QC_14 M, ADDRESS .2 933.S kcO>f/c) I ; c Q(1,4) C/ gz (B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? YES (NO7 (IF NO,WHAT COUNTY? ) 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 (Na?) OP' t` (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: LOCATION (ADDRESS) 'fT / C' REAL PROPERTY PARCEL NUMBER/DESCRIPTION I /_(I S-0t /1e .S 6 5 I C ; 2 THANK YOU FOR YOUR HELP! cjiac;� /y _ �. ��, ,/ SIGNATURE KELLI LARSON, roperty Technician THIS FORM CONFORMS TO THE STANDARDS OF THE STATE DEPARTMENT OF REVENUE AND IS SUBJECT TO AUDIT VERIFICATION. .,‘,., ON eo� JEFFERSON�NTY _ I W g� �r� DEPARTMENT OF COMMUNITY DEVELOPMENT { ! - ' "4 621 Sheridan Street • Port Townsend •Washington 9>Q S'- - __. '' 360/379-4450 • 360/379-4451 Fax 1 wv vw.co.jefferson.wa.us/commdevelopment ww.co.jefferson.wa.us/commdevelopment l� J U L - 6 7N Master Permit Application {{ 4 _ MLA: _��"� — Ito( �-erl. Ur G ", ;t ,.,r „, Project Description(include separate sheets as necessary): ,___.__. MNsry/...L ff6 c'ol c- Tax Parcel r Property 11 Number: 1 1 i '- r CD C Size: C)„./,.a CiAc'r r,c, (acres/square feet) Site Address and/or Directions to Property: Slt;+ afNEA Or Si r j` E=RC,AY; , ,f }_sPc-cam A Property Owner(s)of Record: t l/\) a'_1-1tL Z. t, i 2_- ,E' - 7-/ j /'P p. 7" Telephone: 6 > 7 7- Fax: Z();,t 7 "' .6 - .email: Mailing Address: / 0� �: &i9i'ZLL h,s, PHOENIX Az. YSC-(t¢- Applicant/Agent(if different from owner): 6A Y/ ASKp/v � A fig Fiv ••S%N1 -9�.L..S cam, Telephone: 3 t,c ti q"C Fax: email: PI Ycf N D)' W,pot.,c ,/, Mailing Address: /L/( F&&�,d L`=11Lb bk 1 PcJ C Tctwisf N } L�1/ 9'1 ‘. '" What kind of Permit? (Check each box that applies) &I/Building ❑ Variance(Minor,Major or Reasonable Economic Use) n Demolition Permit ❑ Conditional Use[C(a),C(d),or C]** 'Single Family ❑ Discretionary"D"or Unnamed Use Classification ❑53arage Attached/Detached ❑ Special Use(Essential Public Facilities)** M'Manufactured Home ❑ Boundary Line Adjustment ❑ Modular ❑ Short Plat** ❑ Commercial* ❑ Binding Site Plan** ❑ Change of Use f ❑ Long Plat** l'Address 'Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** ❑ Propane ❑ Plat Vacation/Alteration** 0 Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** S tormwater Management ❑ Shoreline Management Substantial Development** ❑ Site Plan Approval Advance Determination (SPAAD)* ❑ Shoreline Management Variance ❑ Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment ❑Wireless Telecommunication* 0 Jefferson County Shoreline Master Program Amendment ❑ Forest Practices Act/Release of Six-Year Moratorium * May require a Pre-Application Conference **Requires a Pre-Application Conference Please identify any other local, state or federal permits required for this proposal, if known: T ju N, DESIGNATION OF AGENT I hereby designate NO '% K)N, r M lE/v 2-lit :'_E-t9:,Ato act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Date: By signing this application form,the owner/agent attests that the information provided herein,and in any attachments,is true and correct to the best of his,her or it's knowledge. Any material falsehood or any omission of a material fact made by the owner/agent 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 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 inspections.Access and ri ht of ntry to)this property shall be requested and shall occur only during regular business hours. -"`"--). /� Signature: f-e-kC-t,'�:[ t=-r T�c-i-k�.- _ \` A r✓ 1 Date: lI l• c�t The action or actions Applicant will undertake as a result of the issuance 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 applicant 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-tr,asf,Tble responsibility for ad(F '_ring to and co�pp.Tying"wit a ESA. The Applicant has read this dis lamer and signs and dates it below. Signature: t,C ,{,-''Lek � :-Ig-k 0K '�Ci_ f{at �_-AL Date: 7 17 e) \\Permitserver\Home\permit\Peterb\Draft forms\Master Permit Application 6-30-2004.doc • OWNER BUILDER STATEMENT • The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that they will be assuming the responsibility of the General Contractor for the proposed project. Signature: Date: GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: _ Fax: 02) ( 1 �R% 1 • k,>4/CO/1-�..I n p� p vi�_-.� a; ,,_11 �� (3t:i`')a_�;5 �-n3 i S" (�( _ ) �� _ MAILING ADDRESS: l//?5. 'TACCJ I`'iiLLl_I''�f�1},1iR 3r%4 +':r6/3 1 EMAIL: f<}Z'N'vf '('-If1 f%j Erf /;s e-rT " CONTRACTOR'S LICENSE WAINS NUMBER: (` f NUMBER 0,(?✓ i ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: N �,e ood _Existing: ` Sewer Addition Steel Proposed: Bank Community System Alteration/Remodel Concrete Total: Height: individual System Repair Masonry Demolition Other: Bedrooms: Water Supply: Existing: C` Setback: Private well Two Party Type of Heat: Proposed: C-i%-Z-T-�:iL�-Ric a AfAci; Total: , Na ebof System: =AJ PCB—2. S If this is a Commercial Project you must answer the following: Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces: Number of occupants(includes owners,tenants,employees,etc) Current Proposed IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply: U Underground Tank Li Above ground Tank Size of Propane Tank: U Heat Stove CI Cook Stove U Woodstove I i Fireplace Insert ❑ Hot Water Tank El Pellet Stove U Other Is this appliance being installed in a Manufactured/Mobile Home? Yes / No When applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all property lines, tank location and size,distances from the propane tank to all property lines,buildings and septic system components, including the reserve area. Square Footage For Office Use Only Current Proposed Amount Main Floor Consistency Review: 4 2"u Floor Base fee: 15 `t- 3`°Floor Additional Section: Mezzanine: Plan Check fee: Heated Basement State Surcharge fee: t?'' Unheated Basement Pot Water Review fee: Et 5 Other Unheated 911/Rd Approach fee: 'Garage/Carport TOTAL: $ -131 Decks Receipt Number: lu W Other Cash/Check Number: 3"Q 3 ESTIMATED COST(REQUIRED) Date: 11 •Fair market value of all labor and materials foundation to finish / �f' Initials: (d� \\Permitserver\ lame\permit\Peterb\Draft forms\Master Permit Application 6-30-2004.doc RETURN ADDRESS FIRST FEDERAL SAVINGS AND LOAN ASSOCIATION OF PORT ANGELES PO BOX 351 PORT ANGELES, WA 98362 ATTN: SHAILA ALLEN /77 NAT''CUF""`°�WASIi1NGTON MANUFACTURED HOME PLEASE CHECK ONE ``/ '�" TITLE ELIMINATION JEflSIflG APPLICATION (TRANSFER IN LOCATION Anyone who knowingly makes a false statement of a material fart gidlty OREMOVA! 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 IDENTIFfCATION-NUMBER(VIN) X 26..8 �76. ,Hn A/B LAND LEGAL DESCRIPTION ON PAGE REAL PROPERTY TAX PARCEL NUMBER MANUFACTURED HOME WILL BE EN AFFIXED U REMOVED 962-114-501 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION 1-4 145 Irondale Div 6 GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS 16 2 1 NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER DAVID TONKIN NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER KAREN SAMUELSON ADDRESS CITY STATE ZIP CODE 141 FOXFIELD DR PORT TOWNSEND WA 98368 NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER FIRST FEDERAL SAVINGS AND LOAN ASSOC. NAME OF ADDITIONAL LEGAL OWNER n01.CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE PO BOX 351 PORT ANGELES WA 98362 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 Owner and Title, IF APPLICABLE NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE Ak. 'f BA.„• State of Washington Signed or attested ..•�>-••• .�/��i� County of JEFFERSON before me on 8-12-2004 co �pTA • o� bySignature(--.,l�UwwNr DAVID TONKIN 08 09 _ PRINT NAME OF REGISTERED OWNER NOTARY OR AGE 'OU B��G :/?' by KARFN SAMa1FI SON �� '3t " �. i-9 ,•���? PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY ffice No.OR ///// O1 WI '3\\ TitleOTADEALERSHIP POSITION/AGENT/NOTARY RY AND: Notary Expiration lerio o. ate OR Pi TITLE COMPANY CERTIFICATION I certify that the legal description of the land and o>'mership is true and correct per the real properly recoras. 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. © BUILDING PERMIT OFFICE CERTIFICATION I certify that: v-the manufactured home has been affixed to the real property as described. It a building permit has been issued for this purpose and the attachment will be inspected upon completion. NAM�(TYPED ` PRINTED) .., 0- BLDG PERMIT O6C1� N 2-145/0 BL04- 004t% SI URE/P ITIoN "v'li W�Lt![) ) 1.�J��►1 ✓l�^' 5) A1tr TD420-72 MANUFHOMEA .L(R/2/02)OR( age 1of2 ANUFACTURED HOME FROM SECTION 1 TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICI.E IDENTIFICATION NUMBER(VIN) X liQ2 33 7 SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR ELI TION_OF TITLE/ EMOVAL FROM REAL PROPERTY. Signature of Legal Owner and Title, IF APPLICABLE e-i, Signature of Additional Legal Owner and Title,IF APPLICABLE NOTARY`\1 I IRi�Ff)rf,,,�// 1 NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE `` �p. .. ..... ei, State of Washington of CLALLAN Signedattested on 11-16 _ :�c -( Ø1 $LL - .l : Xp �. _ �' FIRST FEDERAL SAVINGS & LOAN Cgnature ��-�-- i A ""3 IO O PRINT NAME OF LEGAL OWNER O ARY OR A T Ge L Sc S'' �,y SHA eikv I LA ALLEN LOAN CLOSER LAURA J RUSHTON 0:%,.h ..0�0 ,.'�• PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTARY ""`����j County/Office No.OR /iilllA$Hiii if l N,NN' I Title DEALE SHIP POSITION/AGENT/NOTARY Y AND: Dealer No.Notary Expiration Date 3/10/05 g LAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office LOTS 1 TO 4,RLOCK 145, MRONDALE DIVISION NO. 6,AS PER PLAT RECORDED IN VOLUME 2 OF PLATS,PAGE 139,RECORDS OF JEFFERSON COUNTY,WASHINGTON. SITUATE IN COUNTY OF JEFFERSON, STATE OF WASHINGTON. 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. DE L R NAME(TYPED OR PRI TED) WA DEALER NUMBER DATE OF SALE ii ,1 i Pii/. /#71- fieVi 6)14 r S 24,/,,-(.4 A/‘7,_ PURCHASE PRICE TAX JURISDICTION AX RATE DEAL 'S UT IZED 1,3 `72 E!2?-e)-^ 64 l,�dltr/;,;} GG QC'' USE TAX EXEMPT Sale to a Certified Tribal member on the reservation(attach notarized statement of delivery). 4� 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 OFFICENFS OPERATOR NUMBER SIGNATURE DATE ' 0 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 TTY(360)664-8885. r' 420-729MANOF HOME APPL(R/2/02)OR(W)Page2of2