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HomeMy WebLinkAboutBLD2005-00293 • • MLA05-00283 Review Type: MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD05-00293 Received Date: 5/6/2005 SITE ADDRESS: 25 OLD GARDINER RD SEQUIM, 98382 APPLICANT: DALE RICH PHONE: 193 SALAL WAY PO BOX 3175 SEQUIM WA 98382 SUBDIVISION: Block: Lot: T 45 PARCEL NUMBER: 002332010 Section: 33 Township: 30 N Range: 02 W CONTRACTOR/ B OAN CON.StfRUCTION rAod2Fv) L..;J�Afr)L,m►c-.eul PHONE: 360275-2194 DEALER: 5620 K1T$0 WAY (s1kc\'Pac R_4-,Snww _ a�3,`1D-4,,p�{c� BRMERTOt' WA 98312 cc 2 Contractor's License Expires 1/6/19992190 11101)E'IZl.l. �1a1� INSTALLER: B CAN CONSTRUCTION BCANMS*022BM 1/6/1999 360-275-2190 5620 KITSAP WAY BRMERTON WA 98312 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NEW MANUFACTURED HOME TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: LIBERTY SETBACK: VALUATION 80,000.00 YEAR: 2004 LABOR & INDUSTRIES APPROVAL? SIZE 49X27 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PUD BEDROOMS: . BATHROOMS: Exist: Exist: Prop: 3 Prop: 2 Total: 3, Total: 2 Routing Date: 5/J/a//C5 Y Cr.7„,„- Type Amount Paid By: Date: Receipt: A 13I5 daitV Permit $157.00 BAC 05/06/05 73062 V Li Potable Water Application $53.00 BAC 05/06/05 73062 JUN 2 2 2005 Total: $210.00 Jeff;s.onlr ty Planning • (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 #: BLD05-00293 Received Date: 5/6/2005 SITE ADDRESS: 25 OLD GARDINER RD Issue Date: 6/22/2005 SEQUIM, 98382 APPLICANT: DALE RICH 193 SALAL WAY PO BOX 3175 SEQUIM WA 98382 SUBDIVISION: Block: Lot: T 45+ PARCEL#: 002332010 Section: 33 Township: 30 N Range: 02 W CONTRACTOR/ MODERN LIVING LIMITED PHONE: DEALER 6119 PACIFIC HIGHWAY EAST FIFE WA 98424 Contractor's License MODERLL972DO Expires 4/14/2007 INSTALLER: DOUG SHARP WAINS 1887 Expires: 7/21/200: PORT ORCHARD WA PROJECT DESCRIPTION: NEW MANUFACTURED HOME MAKE: LIBERTY YEAR: 2004 SIZE: 49X27 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 6/22/2006. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY JO JOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTING, LAB)or PADS USED):( (0-2 7— Stormwater FINAL Approval: Blocking/Plumbing: a 0N/0 7 /c9/m3-1 Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps/ �N �S1`�`DyQ-1W /d '�6-- -' HEALTH DEPARTMENT AND PUB///L///IC 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 # BLD05-00293 1.) The application was reviewed by the Jefferson County Department of Community Development staff on June 8, 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: Special Aquifer Recharge Protection Area (SARPA), 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 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. 5.) The applicant is proposing to create or add 1,627 square feet of impervious surface and 2,067 square feet of land disturbing activities. Sections 6.6 and 6.7 of the Jefferson County Unified Development Code requires that your proposal comply with Minimum Requirement#2 (Construction Stormwater Pollution Prevention) of the Department of Ecology 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. 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.) 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. 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 on June 20, 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 June 20, 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 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). 13.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 14.) The building height is not to exceed 35 feet. 15.) Setback from Old Gardiner Rd. right-of-way is no less than 20 ft., setback from Hwy. 101 right-of-way is no less than 50 ft., setback from the private access easement 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.) A minimum of two (2) on-site parking spaces is required for the single-family residence. 19.) 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. 20.) A septic permit (SEP05-00122)was approved June 9, 2005 for a capacity of 360 gallons per day. 21.) Access is from a private access easement. A road approach is not required and an address of 25 Old Gardiner Rd. has been assigned to the parcel. F t •re kilo _________ t 48,0' I I_1,6 I KITCHEN -l_ aN11VC -- MASTER I_ l_l' j«I '0`r:rre• 1_ 9Ta9r ryp.`�1 BEDROOM -I_I_I 1_.±.L.I....1. <.;..... `C:J 14'-0'x 17-T I I_(. ■, I__t-.I k• is I I_ xR.a Cp . , -J 7 [ / Q WING -. f ROOM i ,/ 1R-IPsi6'-5' ttS SECOND �,1 THIRD n BEDROOMlo I BEDROOM i 10-Sa17.7' -I I. 9-10'a9.0" h , N LIBERTY ANNIVERSARY DOUBLE WIDE HOUSE SQ. FT. 1272 QG285263 09L34906XU DECK SQ. FT. 265 TOTAL. 1537 OPTIONS SHOWN: DLX. EXTERIOR PKG. 40 GAL. HOT WATER TANK EXTERIOR FAUCETS 2EA. FIBERGLASS TUB/SHOWER METAL FAUCET PKG. OPTIONAL FRONT PORCH 16SF. WOOD ENTRY 8 ' EXTERIOR SIDEWALLS 5. 5/12 ROOF PITCH ARCHITECTURAL SHINGLES ADD KITCHEN PANTRY LIGHTED BATH FANS 2 EA. ROCKER SWITCHES REAL OAK CABINETS TILE BACKSPLASH THRU-OUT TILE SELF-EDGE THRU-OUT TILE BATH COUNTER TOPS ACRYLIC KIT. SINK ' PORCELIAN LAVS BREAD BOARD ADD 3653 WINDOW ENLARGE WDO. 6 ' SLIDING GLASS DOOR GRID WINDOWS ADD 3036 WINDOW ADD 7612 TRANSOM WDO. 3 EA. APPLIANCE PKG. #1 TAPE AND TEXTURE DRY AREAS. TAPE AND TEXTURE KIT. BATHS ROUNDED CORNERS LET THERE BE LIGHT PKG_ CHROME BATH PKG. PLANTATION BLINDS LEVER HANDLES 6# 1 /2" CARPET PAD DLX. CARPET UPGRADE LINO LOG SIDING $9000. 00 9LT. EXTERIOR DOOR EXTEND BASE CABINETS PRICE AS SHOWN: ci479-4663Ti 2-8-05 4663'":„..„ ' -- ---- - JACK WESTERMAN III Jeiieruow Cownokurth.nse ASSESSOR PO KimI220. art Tows-usewd. 1VA 9113611 (:11i0) :38a-110:i .. r r 41_ _..�A.... `... MOBILE HOME INFORMATION FORM MAY - 6 2005 OWNER'S NAME/MAILING ADDRESS: NAME: D/4tf c6 t ADDRESS: / % 3 SA L .. 4� = M _t: PHONE NO. 6 S I-' The purpose of this questionnaire is to obtain information regarding either the current location of a mobile house or the previous ownership and location of a mobile home. This will help our office determinorwhether the mobile home is already on the tax rolls in Jefferson County or if it has kripi,tiksved to this county from another area. I►MOBILE HOME DATA: 40„. (A)MAKE L/i , (B)MODEL &6,795;2 3 (C)YEAR 2/ (D)LENGTH ✓ I / rr�i (E)WIDTH (F)SERIAL # iV V/ ( ST/e ticT(oAJ (G)YOUR PURCHASE PRICE (Do not include sales tax) 6 g; yOd PURCHASE DATE 5705 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3) (A) FROM WHOM DID YOU PURCHASE MOBILE +Lc VC. ADDRESS sC a 0 k IrSR Ct/ l iCewteAr ✓� Gi'/1-- (II)WAS MOBILE HOME ASSESSED IN JEFFERS N COUNTY LAST YEAR?Yes No If Yes, Previous address of mobile. If No,What County was Mobileersted in last year. 3)WHERE MOBILE HOME IS TO BE LOCATED: .� t,E ,411, y` (A)WILL THE MOBILE HOME BE IN MOBILE H0114 PARK? Yes No (B)IF LOCATED IN MOBILE HOME PARK: NAME & ADDRESS OF PARK Lot/Space# (C) IF NOT LOCATED IN MOBILE HOME PAR NAME OF LAND OWNER: b/ ""L-L�" fC LOCATION ADDRESS "6. t)LE) 6/1- 0 ' - .41 S C��f?l�✓f L4 REAL PROPERTY PARCEL#/DESCRIPTION V O -3 3 O l 0 1 , Signature of applicant THANK YOU FOR YOUR HELP! SS�XX 4JO COSSELL. Property Technician �wg'SON cOr, JEFFERSON WNTY , DEPARTMENT OF COMMUNITY DEVELOPMENTS 2005 0 :- '4 621 Sheridan Street• Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax �q o www.co.jefferson.wa.us/commdevelopment 1111 SINGS Master Permit Application MLA: 05—IDE 3 Project Description(include separate sheets as necessary): Tax Parcel Property Number: 0 0 ;L, 3 3 2 0 ( 0 Size: 3 •07 acrt 5 (acres/square feet) Site Address and/or Directions to Property:05 Old tjarj)r,et. ?6) d- R Al els_ Property Owner(s)of Record: .1)aje_ /R,,t;, Telephone: (360) (Si- 3'/3 Fax:(360)a et-gy6 5— email: dale opyC. . ) i7ob tar?/,Co••- Mailing Address: /".O • j�o K 3/7 5` Se ca-c e cam, / Gj4. 1'3�5 .2 Applicant/Agent(if different from owner): a(..-) --e Telephone: Fax: email: Mailing Address: Wt9t kind of Permit?(Check each box that applies) IMBuilding ❑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 0 Special Use(Essential Public Facilities)** JNanufactrwed Uom' ' ❑ Boundary Line Adjustment ❑ Modular 0 Short Plat** ❑Commercial* ❑ Binding Site Plan** 0 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)* ❑ 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 to 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 attorney'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 an required later inspections.Access and right of entry to this property shall be requested and shall occur only during regular business hours. Signature: 72c-e- (1 Date: ,f '5 -. 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-transferablxnsibili ffr adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: p Date: S " c— U G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 7-8 J4.doc Oil 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: GENERAL4ONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAx ! L�/v ) /:(1 n olv` {(��K') 2-7)—c)--i 7c (54;.G') Z.-7 s-- -. /?L. MAILING ADDRESS: -":7,a G r/ :7.,9p, <,[` V � 'v �✓ 'EMAIL: CONTRACTOR'S LICENSE p^ f WAINS NUMBER: /V( /E - - fit' 2 NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAx:( ) 1 t MAILING ADDRESS: EMAIL I t 1 Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: i New ct Wood Existing: 0 ❑ Sewer O Addition 0 Steel Proposed: q Bank 0 Community System O Alteration/Remodel ❑ Concrete Total: 4 Height: ilndividual System O Repair 0 Masonry SEP Permit# O Demolition 0 Other: Bedrooms: Water Supply: Existing: Setback: ❑ Private well ❑ Two Party Type of Heat: Proposed: 3 Fir-Public ,�s _l e Total: Name of System: Pt.i i) I If this is a Commercial Project you must answer the following: Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces: c Number of occupants(includes ownars,tenants,employees,etc) Current Proposed F: IBC Occupancy: :Type of construction: Will you have Food Service? Yes / No CCP If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply: I C) Underground Tank ❑ Above ground Tank Size of Propane Tank: �, ❑ Heat Stove ❑ Cook Stove ❑ Woodstove D Fireplace Insert El Hot Water Tank ❑ Pellet Stove ❑ 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: 2Nu Floor Base fee: t`5 7:0V 3ro Floor Additional Section: Mezzanine: Plan Check fee: J . Heated Basement. State_Surcharge fee: Unheated Basement Pot Water Review fee: Other Unheated 911/"4 epproach fee: /-‘ ____ R(k.._ Garage/Carport TOTAL: $ Act 0 0 Decks Receipt Number -73a Other Cash/Check Number: -�63%4-c.- /r 7 /5 G ESTIMATED COST(REQUIRED) Date; —4 C�f� /` •Fair market value of all labor and materials foundation to finish s ) 6‹A..) Initials: J a; G:\PcmtitCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc av++1r {4 RETURN ADDRESS OLYMPIC PENINSULA TITLE CO. P. 0. Box 1479 Sequim, WA 98382 02083935 DF 1/1ST9TF=n'n'C 7F WA.SHINGTON, MANUFACTURED HOME - TITLE ELIMINATION iicEf S j f G 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) 2004 LIBERTY 48 X 28 09L34906XU © LAND LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE AFFIXED ❑ REMOVED REAL��oRERT3YzA�(PA�cL�NUMBER LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE U[, •j LQUARTERR/QUARTER SECTION © GRANTOR(S) REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS 2 1 NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER MAGIN P. FERNANDEZ, JR. NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER PATRICIA S . FERNANDEZ ADDRESS CITY STATE ZIP CODE 2_ OF6_6_02 161ST AVENUE SE COVINGTON, WA 98042 NAME LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER BOEING EMPLOYEES CREDIT UNION NAME OF ADDITIONAL LEGAL OWNER DOL CI ISTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 127701 Gateway Drive Tukwila WA 98168 GRANTEE NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGIS ERED O ER(S)O THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title, IF APPLICABLE Signature of,A,cic)+(tQloq ie gistered Owner and Title, IF APPLICABLE NOT RSESAM If, I NOTARIZATION/CERTIFICATION FOR EGISTE D 0 ER(S)SIGN 44..VV\�t NN VV . " " � State of Washington 61 Signed or ested _: Q'o +0TAI 44o� County of before me on2-at ✓U J 464, A NT- ' �s by IJA A P€f1�/i� C Signature S j • = �,• PRIAME OF REGISTERED OWNER NOTARY OR AGENT IIIIIY�i-er ;�C,7. PRINT NAME OF REGISTE D OWNER PRINTED NAME OF NOTARY W'AA S ., I `` ii County/Office No.OR 1iyit I Title I� AND: Dealer No.OR lJy % DEALERSHIP POSITI /AGENT/NOTARY Notary Expiration Date 4 TITLE COMPANY CERTIFICATION 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 1 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# t-_ n 514ktdf N26) t5r1q 450 BLD 05-00295 SIGNA U E/PO TI DATE tdrA L JJ1((1.rrLL'77��11V� 'el 051 oa LI007 TD-420-72 MANUF HOME APPL( /2/0 )OR(W) age 1of2 FINALED 10-20-05 { ) • MANUFACTURED HOME - FROM SECTION 1 TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) 2004 LIBERTY 48 X 28 109L34906XU 6 SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR ELI ATION OF TITLE/REMOVAL FRO REAL ?PROPERTY. Signature of Legal Owner and Title, IF APPLICABLE , 2 if)ttA Signature of1,,5Jy. igrjal Legal Owner and Title, IF APPLICABLE +`y `��; _ NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE I ' .��— I State of Washington �1 .;���f; ,jp�, T�'C3' � 9 Signed or attested IV' •• F-i � �� County of -- before me on . C_'l,' st Z v NV iq / xC1) On eM.. � m by i�7/lSf�- �'L�A''" C� g I�\t�-�;�: A t 'm►, c, :: rrV;� .�-+r-C � Signature j.,f Li,AC'� `l , f. r'`'-.a. ue1(� \\` PRINT NAME OF LEGAL OWNER NOTARY OR AGENT `ll r ` .,� Z �•';� by tr I PRINT NAME OF LEGAL WNER -- PRINTED NAME OF NOTARY C1 .G'"bt VV) ������, County/Office No.OR ���,»N%%��f'� Title ✓ AND: Dealer No.OR DEALERSHIP POSIT! /AGENT/NOTARY Notary Expiration Date r , f ' D LAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office) PARCEL 1 AS SHOWN ON A SURVEY OF A PORTION OF THE SOUTH 1/2 OF THE NORTHWEST 1/4 OF SECTION 33 , TOWNSHIP 30 NORTH, RANGE 2 WEST, W.M. RECORDED IN VOLUME 3 OF SURVEYS , PAGE 92 , UNDER AUDITOR ' S FILE NO. 258251 , RECORDS OF JEFFERSON COUNTY, WASHINGTON. El 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 APPLICATION MOBILE HOME FEE ELIMINATION FEE USE TAX SUBAGENT FEES TOTAL FEES&TAX MPORTANT: 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 p, E © b,„ Eis,l,i1A, n\ . 1 Ili JUN 2 e 2005 _P.) - j` 3 // A n� /J r-- , 7.._ rn JEFFERSON COUNTY a og c T, / J DEPT. OF COMMUNITY DEVELOPMENT • 1: - — ,► .- .\ r .. I ',..''' $i. f i' I i t 13(5 3c . 1 A .1 aim 1 Icn j I IlI, k 6 I I I I, m I, ram- m 3v' co t, r �`� !a �° �` I I APPROVED V • r\ 1 SITE PLAN } 1 q ;� 1 JUN 2 0 2005 ;. , ./ --c) \ J 3 G' i DEPT.OFJE• FERS•NCO . SIGNATURE: IV�,�%., • ' > t,,' \f) 1 - 4. \, ,..........4...... A. fi N f /N..M +� J � i Gam. ii, \ 4\ ,d DQtvEwAV , z a 1$.4 1., A \H 0 WN. �v .1. . 1 \ i "-7: t 0 ' O vqf NIo L-.___ �._ t DOS ._.___ . __ -- . _ . _ . _ . —.. ..1.. g'�4 L, - m \ , q` c) C . k . 11./ I \ -,#-...'7' m �' I a , Po,�ve£ aez.6? .✓� y v i. fit i , �, v e.l W 0 r 13"H t' -C it _ �_ s. I U.S to I e .