Loading...
HomeMy WebLinkAboutBLD2004-00753 • • MLA04-00670 Review Type: 1 MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD04-00753 Received Date: 12/1/2004 SITE ADDRESS: 141 SENTINEL FIRS RD PORT HADLOCK, 98339 APPLICANT: DAVID GRISWOLD PHONE: (360) 301-1946 PO BOX 571 PORT HADLOCK WA 98339 SUBDIVISION: Block: Lot: T 54A PARCEL NUMBER: 921194046 Section: 19 Township: 29 N Range: 01 E CONTRACTOR/ OWNER/BUILDER PHONE: DEALER: REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NEW MANUFACTURED HOME SER# ORFLW4825352LP13 TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: FLEETWOOD SETBACK: VALUATION 34,800.00 YEAR: 1998 BANK HEIGHT: LABOR & INDUSTRIES APPROVAL? SIZE: 58 x 27 SEWAGE DISPOSAL: CON WATER SYSTEM: PWELL BEDROOMS: BATHROOMS: PARCEL TAGS: YES NO 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: / F&W Landslide ( Y Shoreline Aquifer g uifeifer Type Amount Paid Bv: Date: Receipt: APrr/lJate Manufactured Homes $154.00 BAC 12/01/04 68808 Potable Water Application $52.00 BAC 12/01/04 68808 JUN 3 0 Total: $206.00 Je jj unty pR ; :ors Foe. . '4i • • _. 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#: BLD04-00753 Received Date: 12/1/2004 SITE ADDRESS: 141 SENTINEL FIRS RD Issue Date: 6/30/2005 PORT HADLOCK, 98339 APPLICANT: DAVID GRISWOLD PO BOX 571 PORT HADLOCK WA 98339 SUBDIVISION: Block: Lot: T 54A PARCEL#: 921194046 Section: 19 Township: 29 N Range: 01 E CONTRACTOR/ DEALER PROJECT DESCRIPTION: NEW MANUFACTURED HOME SER # ORFLW4826362LP13 MAKE: FLEETWOOD YEAR: 1998 SIZE: 58 x 27 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 6/30/2006. CALL IN FOR TlifREQUIREDINSPECTIONSTHATAPPLY YOUR PROJECT. ,Q� cSetbac /Footing (CONTINUOUS FOOTIN SLA or PADS USED): 7 S* Stormwater FINAL Approval: Blocking/Plumbing: B_11Z-ps. b'zei.Az OK 8/VGSje Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: LL 30C q6 Q G / i "Final/Skirting/Vents/Porches/Steps: _X/RfINL k 1J G' l 0,e 8/ i.le,o � , HEALTH DEPARTMENT AND PUBLIC WORKS APP OVAL REQUIRED PRIOR TO FINAL INSPECTION THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS. Office Hours 9:00 a.m. -4:30 p.m. HOT-LINE AVAILABLE 24 HOURS A DAY SPECIAL CONDITIONS APPLY- SEE REVERSE • • SPECIAL CONDITIONS CASE # BLD04-00753 1.) The application was reviewed by the Jefferson County Department of Community Development staff on December 6, 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: Type 5 stream; Eagle; seismic; landslide 1; coazstal SIPZ. 2.) 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. 3.) 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. 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.) 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. 6.) 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. 7.) 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 Alter Existing Vegetation." 8.) All construction activities shall not encroach upon the landslide hazard area buffer. This includes the storage or preparation of materials. 9.) 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. 10.) 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. 11.) A Type 5 Stream (Fish and Wildlife Habitat Area) has been identified on the subject property. The stream will require a setback of 55-feet. The setback shall be measured horizontally from the Ordinary High Water Mark (OHWM). Fish and Wildlife Habitat Areas shall also have Buffers and Building Setbacks established. 12.) Stream 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. 13.) Among the native conifer spies which may be used in buffers or for re--•etation 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). 14.) The identified Fish and Wildlife Habitat Area (Type 5 Stream), shall maintain a vegetative buffer setback of 55-feet. The setback shall be measured horizontally from the Ordinary High Water Mark (OHWM) to any proposed development. 15.) An additional setback of five (5) feet is required from the edge of the stream buffer area to any proposed development. 16.) A permanent physical separation along the boundary of the stream buffer area shall be installed and permanently maintained. Such separation can include installing logs, trees, a hedgerow, or any other prominent physical marking approved by the UDC Administrator. 17.) Buffer perimeters shall be marked with temporary signs at an interval of one per parcel or every one hundred (100) feet, whichever is less. Signs shall be in place prior to and during construction activities. The signs shall contain the following statement: "Buffer- Do Not Remove or Alter Existing Vegetation." 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 FOR 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. 1!1 21.) The property owner shall co1 ly with Water Conservation Measures (pert maintained by the UDC Administrator). 22.) 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. 23.) The applicant is proposing to create or add 1648 square feet of impervious surface and 3066 square feet of land disturbing activities. 24.) 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). 25.) 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. 26.) The site plan as submitted with the building permit application on December 1, 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 June 13, 2005 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 27.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 28.) 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). 29.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 30.) The building height is not to exceed 35 feet. 31.) Minimum setback from ingress/egress easment rights-of-way and Sentinel Firs Road right-of-way shall be 20 feet. Minimum side and rear yard setbacks shall be 5 feet. If an ESA is present, then the more stricter setback shall apply. 32.) Exterior lighting for residential uses shall not exceed twenty feet (20') in height from the finished grade, excepting when such lighting is an integral part of a building or structure. Ground level lighting is encouraged. 33.) Lighting fixtures shall be designed and hooded to prevent the light source from being directly visible from outside the boundaries of the property. The intensity or brightness of all lighting, during construction and after project completion shall not adversely affect the use of surrounding properties or adjoining rights-of-way. 34.) A minimum of two on-site parking spaces shall be provided for the single family residence. 35.) An address of 141 Sentinel Firs Road has been assigned to the lot. The site is accessed via a private easement off of Sentinel Firs Road. (Sentinel Firs Road is a county local access road (C567009). 36.) A septic permit (SEP93-0472) was cancelled on October 21, 1994. A septic permit (SEP04-0279) will be issued with the building permit. A USR03-0101 case was finaled on December 6, 2004. 37.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. 38.) This proposal was sent to the Washington State Department of Fish &Wildlife (WDFW) for potential eagle habitat. WDFW found that the proposal did not conflict with eagle habitat. 39.) A Declaration of Restrictive Covenant for septic and building purposes was recorded on October 19, 2004 under AFN 490655. 40.) Proponent and/or contractor(s) shall comply with the conditions as set forth in the Hydraulic Project Approval issued on April 22, 2005 under Control Number 101107-1. The HPA expires on October 31, 2005. • ,���`'SON cO JEFFERSON�UNTY 4 � DEPARTMENT OF COMMUNITY DEVELOPMENT ` `-0 621 Sheridan Street • Port Townsend •Washington 98368MO? - , .> 360/379-4450 • 360/379-4451 Fax �qs, c3 www.co.jefferson.wa.us/commdevelopment xo . . `70 Master Permit Application MLA: 694 - !, Project Descriptiondin 'e separate sheets as necessary): /'" r 1 G� !r/G' e e/ A-J«-I e_ Tax Parcel /2 1/` l/G' 4f if Property Number: �� / cf zf(2 Size:�,5(7(j� (a quare feet)Site Address and/or Directions to Property: I _S e Property Owner(s)of Record: /),AL./6 (-/e/ k--fi.-' Telephone: L,t ;• , .J ,1 - f V V4, Fax: email: Mailing Address: !47 /'X .57,' - � fad --,,, ,. i 0 l k'.:i S' Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies) Building ❑Variance(Minor,Major or Reasonable Economic Use) ❑ Demolition Permit ❑Conditional Use[C(a),C(d),or C]** ❑ Single Family ❑ Discretionary"D"or Unnamed Use Classification ❑ Garage Attached/Detached ❑Special Use(Essential Public Facilities)** Manufactured Home ❑ Boundary Line Adjustment ❑ Modular ❑ Short Plat** ❑Commercial* ❑ Binding Site Plan** ❑ Change of Use ❑ Long Plat** ❑Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** ❑ Propane ❑ Plat Vacation/Alteration** ❑Allowed"Yes"Use Consistency Analysis ❑Shoreline Master Program Exemption/Permit Revisions** ❑Stormwater Management ❑Shoreline Management Substantial Development** ❑ Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance ❑Temporary Use ❑Comprehensive Plan/UDC/Land Use District Map Amendment ❑Wireless Telecommunication* ❑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: DESIGNATION OF AGENT I hereby designate e i. Z to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Date: f/ ?"L'Lf 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 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 its employees,representatives or agents for the sole purpose of application review and any required later inspections.Access and right of entry to this property shall be requested and shall occur only during regular business hours. 1_,)‘"' 4 Signature: = .-r . r`- �/ „'�` "�--c�� Date: �� J � 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 actions)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 res sibility forr�adhering to and,complying with the ESA. The Applicant has read this disclaimer aryl signs_and dates it below. Signature: .�y7.— —=( 2 /t Date: %i t'�) G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc 0 OWNER BUILDER STATEMENT The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,"key are not licensed contractors and that they will be assuming the responsibility of the neral Contractor for the proposed project. s'� r //f! Signature: " �-��-�r .., Date: ` 3 04/ GENERAL CONTRACTOR OR FACTURED HOME INSTALLER: PHONE: r •— , ��{.//tf/ (,/,' �£ e _ (M ) -1 �15 % ( ) � :, MAILING ADDRESS: ,/ pr •J 7/ l J/,7 M«C, ,4 EMAIL: , CONTRACTOR'S LICENSE WAINS I T. DECn - 1 20A 0 NUMBER: NUMBER `t ARCHITECT/ENGINEER: PHONE ( .) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: X New Wood Existing: _ El Sewer ❑ Addition ❑ Steel Proposed: _ Bank 0 Community System ❑ Alteration/Remodel ❑ Concrete Total: Hei t: Individual System ❑ Repair ❑ Masonry SEP Permit# O Demolition ❑ Other: Bedrooms: i Water Supply: Existing: X Private well ❑ Two Party Type of Heat: Proposed: 3 0 Public Flee Mic— Total. '' Name of System: If this is a Commercial Protect you must answer the following: Number of Parking Spaces: Current Proposed• • umber of ADA Parking Spaces: Number of occupants(includes owners,tenants,employees,etc) u nt 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: O Underground Tank ❑ Above ground Tank Size of Propane Tank: O Heat Stove ❑ Cook Stove ❑ Woodstove ❑ Fireplace Insert ❑ Hot Water Tank ❑ Pell t t e ❑ 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 kplr`Office''Use Only ¢'"`"*.' '� x ` ' �,�"' Current Proposed c'g, iz Main Floor Cot�tlpy Review: � '�•?.� ,� 9� i J '� "ra s z'�r. i €,. mot' 2Nu Floorgi y ua 4 ��� �� a te; 4... 7t'a $^Ha 3°Floor / Addtiunal Section " , _�' ;_ ili Mezzanine: j Plan Check � fee 4' 7' a \` `1 k t ; ( , Y. 5 r. A e ^' n 'rs .Y }b;:4 . xc F / State'Surcatgefee . ,,Heated Basement 6 Unheated Basement /kr/- j ; Water k ,fix - . � It** .„ 4.,...,:,..,... „:,,,,,::.,,r1 Other Unheated j/ ,^� 91 d Ap ash fee ti , ;`ro ,"... , ' 1G (/ Garage/Carport147 I; ' % n J .1 ,It.3i+ `t$t sue, '-- �a a• s�, '. :' :' Decks 0 t 1u ' a Recelpm �};, y ., ,.y fi r;' A y • 'Other Cash/Check.Nu . a / 4a IT,* . � S774 % : ESTIMATED OST(REQUIRED) Date: %.' "� ' : , "' t A 4- I •Fair me alue of all labor and materials foundation to finish ` } a h Initials: Qn� !ee # 4't4ts IL G:\P tCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc • • RETURN ADDRESS L415TA�.Tc,c,F« <�<r i4,HINGTON MANUFACTURED HOME PLEASE CHECK ONE n ERITLE 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 j.pL/ 3 V YE i s H e e l Ll x TFi�E�) VEO IDENTIFL1/v"ICAT q lN s IN3s 2 L./ )3 © LAND (_IJ MA LEGAL DESCRIPTION ON PAGEU( RE 2,(PROPERTYTaX PARCEL NUMBER MANUFACTURED HOME WILL BE 0 AFFIXED ❑ REMOVED I ql(7, 0'1 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE s,q l z4,v 11 QUARTER/QUARTER SECTION 594 © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERD OWNERS NUMBER OF L L OWNERS 1(0 NAME OF REGIS RED OWNER (( DOL CUSTOMER ACCOUNT NUMBER NAME OF ADDITIONAL REGISTERED to )a bai ER L) I. (V{' `I Y l0l l DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE P D x)x 57 ► P Hu_,J)v cc W - 's33c7 NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER /104-e . NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER 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: ...e.:....... 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 State of Washington T Signed or attested l/l� County of ✓e before me on t.2 / /U by UL,4 Ltdl t�OW&V(SL0 g 4 Si nature �.D A PRINT NAME OF REGISTER NER NO Y OR AGENT Y� by PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY / �, I 1 County/Office No.OR i jV 10) Title 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 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: I-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(I>PED OR PRINTED) BLDG PERMIT OFFICE/PHONE# BLDG PERMIT# A \\ � Q� f):1)114nt( 0\ 9- 15O r���c c 75� SIGNAT /POSIT •`'\ iA/1/ L AT ia icib5 TO-420-729M NUF HOME APPL(R/2/02)OR( ) age lof2 • • MANUFACTURED HOME - FROM SECTION 1 TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) X 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 NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE State of Washington Signed or attested County of before me on by Signature PRINT NAME OF LEGAL OWNER NOTARY OR AGENT by PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTARY County/Office No.OR Title AND: Dealer No.OR 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) S 1 °1 T. Z q ►ti PN. E 'TA-x .5" 9M 5-e-q •iovk Lo , w 64 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 NAME(TYPED OR PRINTED) WA DEALER NUMBER DATE OF SALE PURCHASE PRICE TAX JURISDICTION/TAX RATE DEALERS AUTHORIZED SIGNATURE 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 OFFICENFS 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 cal(360)902-3600 or TTY(360) 664-8885. TD-420-729 MANUF HOME APPL(R/2/02)OR(W)Page 2 of 2