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HomeMy WebLinkAboutBLD2004-00829 �"' t �UILDING PERMIT APPLICA!ON ML viewTy 718 Review Type:I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD04-00829 Received Date: 12/30/2004 SITE ADDRESS: 100 PINE DR PORT TOWNSEND, 98368 OWNER: LEZLIE E REHKOPF PHONE: (360) 385-5124 130 MAXWELL AVE PORT TOWNSEND WA 98368 SUBDIVISION: CAPE GEORGE VILLAGE DIV 4 Block: Lot: 39 PARCEL NUMBER: 940800039 Section: 13 Township: 30 N Range: 02 W CONTRACTOR: OWNER/BUILDER PHONE: (360) 561-8005 REPRESENTATIVE: BISHOP CONTRACTING LLC PHONE: (360)561-8005 4143 150TH AVE SW TENINO WA 98589 PROJECT DESCRIPTIOr NEW MANUFACTURED HOME TYPE OF WORK MOB SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION 84,900.00 CODE EDITION: 2003 ADD'L: HEAT TYPE: OCCUPANCY: HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: # OF STORIES: CONST TYPE: OTHER: SHORELINE: CONST TYPE: GARAGE: SETBACK: DECK: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: PUD PARCEL TAGS: YES NO BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA Exist: Exist: Wetland Erosion Prop: 2 Prop: 2 Seismic Streams Total: 2 Total: 2 Flood Way Floodplain Routing Date: / / /c C n F&W Landslide rl' Shoreline Aquifer Forest: Commercial Rural Type Amount Paid By: Date: Receipt: Approved/Date Permit $154.00 BAC 12/30/04 68839 APPROVED ^ Potable Water Application $52.00 BAC 12/30/04 68839 A rR E Total: $206.00 FEB - 2 2005 Jefferson County Planning 44 & Buildin eRartp.te • 0 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#: BLD04-00829 Received Date: 12/30/2004 SITE ADDRESS: 100 PINE DR Issue Date: 2/2/2005 PORT TOWNSEND, 98368 APPLICANT: KATHIE KING 27340 EL PUENTE ST SUN CITY CA 92586 SUBDIVISION: CAPE GEORGE VILLAGE DIV 4 Block: Lot: 39 PARCEL#: 940800039 Section: 13 Township: 30 N Range: 02 W CONTRACTOR/ BISHOP CONTRACTING LLC PHONE: (360) 561-8005 DEALER 4143 150TH AVE SW TENINO WA 98589 PROJECT DESCRIPTION: NEW MANUFACTURED HOME MAKE: FLEETWOOD YEAR: 2004 SIZE: 70X30 THIS PERMIT iS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 2/2/2006. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. / Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): 4 c b/0,- Stormwater FINAL Approval: Blocking/Plumbing: .;v GGNP44a 0u--- 5-f Ltp3 O . `�L.Qj,fi IA7--'' Propane Tank/Lines k AA Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps: 5 '.2 3• 0 C, 47,4*-- HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL 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 # BLD04-00829 1.) The application was reviewed by the Jefferson County Department of Community Development staff on January 31, 2005 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: Susceptable Aquifer Recharge Area (SUSC). 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.) 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. 5.) The applicant is proposing to create or add 2,801 square feet of impervious surface and 3,491 square feet of land disturbing activities. Sections 6.6 and 6.7 of the Jefferson County Unified Development Code requires the project applicant submit a stormwater plan meeting Minimum Requirements#1 through #5 of the Department of Ecology Stormwater Management Manual for Western Washington. The stormwater plan shall address measures 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. 6.) 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. 7.) A Medium Stormwater Plan has been submitted and approved by the Department of Community Development. Once the subject permit has been issued the applicant shall fully implement the provisions of the submitted plan and contact the Jefferson County Department of Community Development to arrange a schedule to inspect the property for plan compliance. A Certificate of Occupancy will not be issued until the Department verifies plan compliance. No clearing for roadways or utilities shall occur on the project site until clearing necessary for the installation of temporary sedimentation and erosion control measures have been completed. 8.) 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). 9.) The revised site plan as submitted on February 2, 2005 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 February 2, 2005 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 10.) 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. 11.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 12.) Not more than two (2) unlicensed or inoperable vehicles shall be stored on a 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). 13.) Pre-existing legal lots of record less than one acre in size in Rural Residential districts are subject to the stormwater requirements in UDC Section 6.7 and must meet the"Area of Impervious Surface Coverage"to the maximum extent practicable as determined by the Administrator." Lot coverage is defined as amount of impervious surface, which includes rooftops, driveways, concrete, etc. 14.) The building height is not to exceed 35 feet. 15.) Setback from Pine Dr. right-of-way is no less than 20 ft., side and rear setbacks are no less than 5 ft. If an environmentally sensitive area (ESA) is present, then the more restrictive setback shall apply. 16.) 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. 17.) 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. 18.) This is a legal non-conforming parcel designated as Rural Residential 1:5 under the Jefferson County Comprehensive Plan Land Use Map effective August 28, 1998. 19.) This parcel is served by a public water supply. 20.) A septic permit (SEP04-00289)was approved January 6, 2005 for a capacity of 240 gallons per day. 21.) Pine Dr. (P128) is a private local access road. An address of 100 Pine Dr. has been assigned to the parcel. 22.) A minimum of two (2) on-site parking spaces is required for the single-family residence. 23.) This parcel was created through Cape George Village Division 4 under AFN 169199, recorded August 26, 1965 , Volume 4, pages 75 - 76 with the Jefferson County Auditor's office. 24.) Stormwater shall be retained and infiltrated on site. The owner shall control all sedimentation and erosion on the property. ��• ••� .,.,. .,.,r- a.'i. lI,...r+ uurlur-aGLlnlg LLL JbU Jb .i /15 p. 4 • • ka4 liq �: ► ilt%1 v -..,...... tie,--- - 0=✓'n .$-em c( G .2 Of .3 pfrc.e l 9 yQ a`c i `3 9 S-c ' , J 3 Ts. 30,E Ile Li1- (lb C-iiY55 ;0" e4/0„ Qd,'C3.,z ix'1k± Xa'rr i/ L 01 31 1 - I. ry t S ✓tom , r are AM i ( \ -4 1 _ } # - 1 1 t ss. ' raSOP t 3� I.= =f e;\. ts., 0)- „.____ ___ (4 h 0 h 4 i� 1u r ,e-. -s on -11 --4 -ri ?al WIlt ...xi ..41 ,.b -4'.).,• i t t� Sep k- , _ 1.1 :e ,,...„/ - -*. ' ,, - ,,' Y i r� -14ft ks, a t • Ils�i•r-,v r 1 \ I t s- - APPROVED .....o lat."' 1 - v ti SITE PLAN FEB - 1 2005 1. /91.r JEFFERSO CO DEPT.OF Ciir7,>, V P . SIGNATURE:/ • JEFFERSON COUNTY ' ] 1. cE VIE T1J; DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street • Port Townsend •Washington 98368 *Q1 �_ 360/379-4450 • 360/379-4451 Fax r r r< 1, r, i IN4rNG` http://www.co.jefferson.wa.us/commdevelopment/ JEFFE SU Lu i riJ j STORMWATER SITE PLAN SUBMITTAL TEMPLATE IMLA# 0 ( r' 7 i 7 PROJECT/APPLICANT NAME: ^Pi T� Jt 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. Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. 4. Describe the existing soils. Indicate soi,tvpe 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. 6. Describe any excess levels of noise generated by the proposed use or activity: NV� Fil STORNIWATER {LAN F E B - 1 2005 stormwater site plan template—rev.10/1r 003 S JEFFERSON COUbLTY DEPT.OF cOpi,rgyfmivE1.0 MINT SIGNATURE: A • w • 7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams, steep slopes,etc.)on the si e. Indicate locatio on the site map. 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.). 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. g, 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. n ,ll t 2v � ; 1 1b cr, � �! r 5;0'r< r / ;>:, i 1". 10. If the project requires the use of stormwater treatment facilities, describe the types of stormwater treatment facilities proposed for use on the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. [This is normally for large"projects or projects that involve the potential for dispersion of contaminants.] 11. Describe the performance goals and standards applicable to the project. 5 k 03 r,::k 12. Describe the flow control system. stormwater site plan template—rev.10/12003 6 • • 13. Describe the water quality system. 14. Describe the conveyance system analysis and design. 15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material. tfrr 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Uniform Building Code. No 17. Describe the proposed surfacing material. i<�„) T"L a -%( e""eC <_ 18. Describe methods for restoration of the site. iziK ,ir1r, + /11a�,+ gra5 5 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. stormwater site plan tentemplate—rev.10/1/2003 7 i • • 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. �-zv'<:i ,:i -3t) pi ra%. - 2. Establish Construction Access. rlV i.law .i.S nit A4.-a y vt e-,), eas 3. Control Flow Rates. 4. Install Sediment Controls. '1;• -e , 12 v 5. Stabilize Soils. V2.1 Cyt� � KS--- 6. Protect Slopes. 7. Protect Drain Inlets. stotrnwater site plan template—rev.10/1/2003 8 • • 12 Required Elements—Construction SWPPP(continued) 8. Stabilize Channels and Outlets. .nf J 9. Control Pollutants. 10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site). 11. Maintain Best Management Practices(BMPs). 12. Manage the Project. 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. stormwater site plan template—rev.1IY12003 9 • • b. Description of special requirements for working in or near environmentally sensitive areas. kfr 4. Erosion Problem Areas. Description of potential erosion problems on site in the context of the characteristics of the on-site soils(e.g.,erodibility,settleability,permeability,depth,texture,soil structure). 5. Construction Phasing. a. Construction sequence 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. -oAp;1 Fi.� - 1, .j 2 a - 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. oG✓n.L✓ . b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation impacts. 8. Engineering Calculations. Provide Des' Calculations on a separate sheet for the following,if applicable. a. Sediment Ponds/Traps. b. Diversions. c. Waterways. d. Runoff/Stormwater Detention Calculations ''"► stormwater site plan template-rev.10/1/2003 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 AUTHORIZED RESENTATIVE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES,IF NEEDED: "RECIL )A7 Ef ) } r JE��ERSO to Otis 12 stormwater site plan template—rev.10/12003 RETURN ADDRESS First American Title Company of Jefferson County P.O. Box 598 Port Townsend, WA 98368 L1ST"r 'F' S1-1IN'TON MANUFACTURED HOME "L AS CHECK ONE INATIONJICEflSiflG APPLICATION EITRANSFER 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 LENGTHNVIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) 2004 Fleetwood 70 X 30 WAFL 3 31A: and B18 2 8 6-BA13 © LAND Barrington LEGAL DESCRIPTION ON PAGE REAL PROPERTY TAX PARCEL NUMBER MANUFACTURED HOME WILL BE 0 AFFIXED tJ REMOVED 940-800-039 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION 39 Cape George Village,Division 4 El GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS 1600 1 1 NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER KATHIE KING NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 27340 EL PUENTE SUN CITY CA 9 NAME OF LEGAL OWNER • DOL CUSTOMER ACCOUNT NUMBER SOUND COMMUNITY BANK NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 10200 E.MARGINAL WAY SOUTH SEATTLE, WA 98168 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 APPLICABLEab ,If 1<{ J Signature of Additional Registered Owner and Title, IF APPLICABLE NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE State of Washington Signed or attested County of before me on by Signature PRINT NAME OF REGISTERED OWNER NOTARY OR AGENT by PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY County/Office No.OR 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 the manufactured home has been affixed to the real property as described. ID a building permit has been issued for this purpose and the attachment will be inspected upon completion, NAM (TYPED OR PRINTED) LDG PE IT OFFICE/PHONE# BLDG PERMIT# �kh•ir 1k,SuK� �3�V 31�1- 445O �jD04Ali SIGN URE/PSI ION ///��� ' / ^ J.l�� ) DAT;b& , E 1) TD-420-7 9MAN FH' a APPL(R// )OR(W) age1 oft ANUFACTURED HOME - FROM SECTION 1 TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN)x 2004 SIGNATURE OF LEGAL OW FleetwoodO 1 70 30 WAFL331A and B18286—BA13 NER�r1rirJ SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR ELIMINATION OF TITLE� /R OVAL FROM REAL PROPERTY. Signature of Legal Owner and Title, IF APPLICABLE A@t�J LJL5L�1" Signature of Additional Legal Owner and Title, IF APPLICABLE NOTA� �t�ATAMP �� Ill I NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE 1 .c\ R '4i 1 Ii,,, , State of Washington IG (1f f Signed or attested Ohl_ �_U 5 �hy-....\$ION�c+A (�,,1 County of I before me on V r OTAq `mavl�v�e, IPv i cue, ,P� , ,�i ,l - b Signature 'U 5.+� N; I! y PRINT NAME OF LEGAL OWNER 9 ature TARY OR AGENT p /°UBLIG 'by �CGCr�1cV av1�i LA ' III A••.. .0 I PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTARY I,,,-'2'%5-9.01.../c.; 1 iv 11 psi bI I y Count/Office No.OR /}'7 1 O Title AND: Dealer No.OR O t/ 111' F',/1/As\'� I DEALERSHIP POSITI !AGENT/NOTARY Notary Expiration Date D LAND WBORTPTION (A legal description of the land can be obtained from the local County Assessor's Office LOT 39 IN CAPE GEORGE VILLAGE,DIVISION NO.4,AS PER PLAT RECORDED IN VOLUME 4 OF PLATS,PAGES 75 TO 76,RECORDS OF JEFFERSON COUNTY,WASHINGTON. la 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 DEALER'S AUTHORIZED SIGNATURE ❑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.0 0 APPLICATION MOBILE HOME, ,�FEE ELIMINATION FEE USE TAX SUBAGENT FEES 915 . 00 25.00 TOTAL FEES&TAX 1 IMPORTANT: Once the application has been approved by the County Auditor/Vehicle 49 . 00 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. TO-420-729 MAN OF HOME APPL(R/2/02)OR(W)Page 2 of 2