Loading...
HomeMy WebLinkAboutBLD2005-00309 ill Ill 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#: BLD05-00309 Received Date: 5/12/2005 SITE ADDRESS: 120 E ALDER ST Issue Date: 6/17/2005 PORT LUDLOW, 98365 APPLICANT: GLENN FLOYD KARIN FLYOD 120 E ALDER ST PORT LUDLOW WA 98365-8756 SUBDIVISION: PARADISE BAY ESTATES Block: 7 Lot: 28 PARCEL#: 983400724 Section: 23 Township: 28 N Range: 01 E CONTRACTOR/ DEALER INSTALLER: WISE SERVICES WISES**977JA Expires: 4/1/2007 JAMES WISE SEDRO WOOLEY WA 98284 PROJECT DESCRIPTION: NEW MAN HOME FLEETWOOD MODEL#4430N MAKE: FLEETWOOD YEAR: 2005 SIZE: 40X27 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 6/17/2006. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. Setbacks/Footing (CONTI UOUS FO T G, B or PADS USED): ?rl_, ' cr ta. S.t-Q R6-10C K-4-ZZ-CD Fe-arieJc1S[�B Ok 5 Stormwater FINAL Approval: Blocking/Plumbing: e( /5, Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: nn � Final/Skirting/Vents/Porches/Steps: ('9& -(1 �4 '�' 05, HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUI D 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 # BLD05-00309 1.) A minimum of two (2) on-site parking spaces is required for the single-family residence. 2.) THE EXISTING MOBILE HOME WILL BE REMOVED PRIOR TO FINAL INSPECTION. 3.) The application was reviewed by the Jefferson County Department of Community Development staff on June 14, 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, the following ESAs were confirmed to be present on the subject property: Coastal Seawater Instrusion Protection Zone (SIPZ). 4.) 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. 5.) 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. 6.) The development will be serviced by public water and a well will not be utilized. If a well is required for potable water the applicant shall meet all of the Aquifer Recharge and SIPZ conditions. 7.) 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. 8.) The applicant is proposing to create or add 1,485 square feet of impervious surface and 1,485 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. 9.) 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. 10.) 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. 11.) Stormwater shall be retained and infiltrated on site. The owner shall control all sedimentation and erosion on the property. 12.) 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). 13.) The site plan as submitted Ake building permit application on May 12, 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 14, 2005 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 14.) 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. 15.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 16.) 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). 17.) 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. 18.) The building height is not to exceed 35 feet. 19.) Setback from East Alder St. right-of-way is no less than 10 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. 20.) 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. 21.) 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. 22.) 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. 23.) A septic permit(SEP05-00130) was approved May 11, 2005 for a capacity of 240 gallons per day. 24.) E. Alder St. (C506609) is a county local access road. A road approach is existing and an address of 120 E. Alder St. has been assigned to the parcel. 25.) This parcel was created through Paradise Bay Estates under AFN 142981, recorded September 20, 1954, Volume 4, page 5 with the Jefferson County Auditor's office. 26.) A Declaration of Restrictive Covenant was recorded April 22, 2005 under AFN 497319 with the Jefferson County Auditor binding lots 27 &28 of Block 7, Paradise Bay Estates for the purpose of meeting bulk and dimensional requirements and minimum land area. 27.) Based upon the constraints imposed by the new septic system the owner's of the property requested a reduction of the front yard setback from 20 ft. to 10 ft. The administrator granted this reduction on May 6, 2005. A copy of the letter granting this reduction is filed in the project file (MLA05-00299). JACK WESTERMAN III • .lciiers►n CouoirSrthonvr ASSESSOR 1'0 11«x 1220, Pori Tow Emend, W% 98368- . 4360)38. -910:: MOBILE HOME INFORMATION FORM MAY 12 2005 OWNER'S+NAME/MAILING ADDRESS: to NAME: L N/1r `'' /69-0/ '-�v y ADDRESS: /2(f £• A&D� r PT LIAktf& itrA. 9e 36c- PHONE NO. 360 43) c ' e/ The purpose of this questionnaire is to obtain information regarding either the current location of a mobile home or the previwus-ownership and location of a mobile home. This will help our office determine whether the mobile home is already on the tax rolls in Jefferson County or if it has been moved to this county from another area. 1)MOBILE HOME DATA: (A) MAKE Ft £1Jd j (B) MODEL if"[ 30 AI (C)YEAR OS (D) LENGTH 'd'(J l (E)WIDTH t i (F)SERIAL # (G)YOUR PURCHASE PRICE(no not include sales tax) � � ` PURCHASE DATE 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3) (A) FROM WHOM DID YOU PURCHASE MOBILE C'ci 0j-i Co ei,a t 02e4t ea, ADDRESS -q6 ( �-2‘ L),4(& .b11 /1►7 I- V Ei 'uZt a4 '',4�Z-! `t (B)WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? Yes If Yes, Previous address of mobile. If No, What County was Mobile assessed in last year. /(,./ - Lt i 3)WHERE MOBILE HOME IS TO BE LOCATED: (A) WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes (B)IF LOCATED IN MOBILE HOME PARK: NAME & ADDRESS OF PARK Lot/Space # (C) IF NOT LOCATED IN MOBILE H iE PARK: NAME OF LAND OWNER: HOME PLd yA LOCATION ADDRESS 11.0 & . t9L/Z 0 3 T Paler t(4 to(Alai Loa_ 9P 6S REAL PROPERTY PARCEL #/DESCRIPTION % 3 IW 7 Z03`fai 713 Signature of 111 PP THANK YOU FOR YOUR HELP! 6r iSSQ � X JO COSSELL, Property Technician 111/ • MLA05-00299 Review Type: MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD05-00309 Received Date: 5/12/2005 SITE ADDRESS: 120 E ALDER ST PORT LUDLOW, 98365 APPLICANT: GLENN FLOYD PHONE: 360-437-7681 KARIN FLYOD 120 E ALDER ST PORT LUDLOW WA 98365-8756 SUBDIVISION: PARADISE BAY ESTATES . Block: 7 Lot: 28 PARCEL NUMBER: 983400724 Section: 23 Township: 28 N Range: 01 E CONTRACTOR/ WISE SERVICES PHONE: 360-856-2717 DEALER: JAMES WISE 5504 TENNESON RD SEDRO WOOLEY WA 98284 Contractor's License WISES**977JA Expires 4/1/2007 INSTALLER: WISE SERVICES WISES**977JA 4/1/2007 360-856-2717 JAMES WISE SEDRO WOOLEY WA 98284 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NEW MAN HOME FLEETWOOD MODEL#4430N TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: FLEETWOOD SETBACK: VALUATION 49,826.00 YEAR: 2005 LABOR & INDUSTRIES APPROVAL? SIZE: 40X27 BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: PUD BEDROOMS: BATHROOMS: Exist: 2 Exist: 2 Prop: Prop: Total: 2 Total: 2 Routing Date: 13 a 5 - Type Amount Paid By: Date: Receipt: Q � ��//E ID Permit • $157.00 BAC 05/12/05 72981 �l Potable Water Application $53.00 BAC 05/12/05 72981 JUN 1 7 2005 Total: $210.00OPP* Jeff ty Planning t & 1 • tme RV,. MAD allOWNER BUILDER STATEMENT lb 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: J' 124 L. (. ) 49& r1jkbile S &RV(CL.l' ( 3( )) -7'70--'?L4S ( ) MAILING ADDRESS: 3 77 -S' , 5 U at:./t G a cub EMAIL: CONTRACTOR'S LICENSE 14fta,/4,6 !,t, Le.. Agg233 WAINS / / NUMBER: NUMBER 0(O �Cr ARCHITECT/ENGINEER: PHONE ( ) FAX ( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: vC, New VC Wood Existing: -2 ❑ Sewer ❑ Addition Steel Proposed: Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: 21 Height: c Individual System ❑ Repair ❑ Masonry SEP Permit# i:Tic ""-i ❑ Demolition CI Other: Bedrooms: Water Supply: Existing: 2 Setback: ❑ Private well ❑ Two Pa Type of Heat: Proposed: rty L 67 I Public C Cf Total: Z Name of System: ,:`tr; r 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: p Will you have Food Service? Yes / No If this is a Propane Tank and/or Appliance Installation permit,mark all items below that a PI ❑ Underground Tank 0 Above ground Tank Size of Propane Tank: Al 0/1/i--;:- ❑ Heat Stove ❑ Cook Stove LI Woodstove ❑ Fireplace Insert ❑ 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: -'1 9 2NU Floor Base fee: ` 3"1 Floor —1 1" Additional Section: _._...-- Mezzanine: Plan Check fee: Heated Basement State Surcharge fee: Unheated Basement Pot Water Review fee: Other Unheated q 911/Rd Approach fee: Garage/Carport � Y; ; TOTAL: $ . 417`. Decks Receipt Number: f aqpV 'b l Other Cash/ Number: , ESTIMATED COST(REQUIRED) Date, •Fair market value of all labor and materials foundation to finish Et g " Initl* MAY G:\PemvtCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc '69 9°N cps JEFFERSON uNTY ' DEPARTMENT OF COMMUNITY DEVELOPMENT ` '-c 621 Sheridan Street • Port Townsend •Washington 98368' 360/379-4450 • 360/379-4451 Fax �p� www.co.jeffersonwa.us/commdevejp�pet�t2 � FIING Val 5 ��1(� Master Permit Application MLA: 0 p1 1 .. . Project Description(include separate sheets as necessary) `_ ___ _. Tax Parcel _ Property lh Number: 't <'aj .72 5lP3 (-{(,0 '"7'2. (-I Size: �!i WO S' IT (acres/square feet) Site Address and/or Directions to Prope . /'2/) . R6 Z�72 S' r Pa1erL u icev Property Owner(s)of Record: ( 5 L /U/L' 6 .. "R(i 'a -- g 412 IX- J—) X-A Telephone: '7 O 4 3>--'6,f/ Fax: email: Mailing Address: /Z 0 E' p C.l)�12. S`7- PORT CiiI L 2w Cx'A- Q P 36C 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 Cj** ❑ 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 A/o ` ❑ 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 any required later ins ctions.Access and right of entry to this property shall be requested and shall occur only during regular business hours. ��,l Signature: Date: LP- All-1 CZ 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 Jeffersonf.County development code.The Applicant acknowledges that he,she or it holds individual and non-transfera le e onsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer,,and signs and dates it below. Signature: Date: / - / 1-1 /�� G:\PemvtCenter\FORMS\DRD FORMS\Master Permit Application 7-8-04.doc • • RETURN ADDRESS Glenn L. Floyd Karin I . Floyd 120 E. Alder St . Port Ludlow, WA 98365 (47 S oTAF WASNINGTON 'L A CH CK ON:.�TE mOm,o, MANUFACTURED HOME APPLICATION ®TITLE ELIMINATION lICEnSInG ['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) MANUFACTURED HOME TP+3770 NUMBER 2006 MAKE LENGTH/WIDTH(FEET)2 vE0RFL5T4830756FE1N3 © LAND (J�� ZLEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE ® AFFIXED ❑ REMOVED REq TSIDEFIT6T,(U(P�yf}�EJ.NUMBER 83 400 724 & 2 o BLACK PLAT NAME ��JJ�� !L{} ((JJ SE/CTLIO,jN/TO�cWNSI�HIP/RANGE / 8 / Paradise Bay Estates © 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 Glenn L. Floyd NAME OF ADDITIONAL REGISTERED OWNER Karin I . Floyd ADDRESS CITY STATE ZIP CODE 120 E. Alder St . Port Ludlow WA 98365 NAME OF LEGAL OWNER Washington Federal Savings NAME OF ADDITIONAL LEGAL OWNER ADDRESS CITY STATE ZIP CODE 191 W. Washington St . Sequim WA 98382 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 State of Washington Signed or attested County of before me on by Glenn L. Floyd Signature PRINT NAME OF REGISTERED OWNER NOTARY OR AGENT byKarin I . Floyd 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 A 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 PERMITOFFICE CERTIFICATION I Certify that: the manufactured home has been affixed to the real property as described. 0 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 II BLDG PERMIT N 't a' h (�n Jey)- Otto)�'`7(.- 4L/5( f _DO5 SIGNAy{1RE/P C9 D TE TD•4 0.7 9( ANUF HO L(R/8/9e)OR Page 1 012 • D 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 LAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office Lots 27 and 28 , Block 7 , Paradise Bay Estates , according to Plat recorded in Volume 4 of Plats , page 5 , records of Jefferson County , Washington . • 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 ❑ 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 TOO(360)664-8885. TD-420.729 MANUF HOME APPL(R/B/98)OR Page 2 of 2 F. I , n _ 1• DEPT. SIGNAT SITE PLAN JUN 1 d 2005 Gee/v,v d- K h1a �:760XD l 2 p E, F -cUo"12 s7-- po�-� bUD60cv, cv4 9A365 9�3 4W 7-L3 ykfQ '72 4 vrnpr 7'-AA/A -... �Y. Pos6"D 44 x 27 VALVES It Ise w,o Y �NG ll C;/Al Dl�pt O el7lSib6" B6dc 14 12 � Lo�417/b/1N \YS7-EM, /F<&A 50 cu to z'7, E7E(S77M6L tpm Itj a� � I7 /0 c y,� �'F M � O � v ma �r O W WE MAY 12 2005 1.