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HomeMy WebLinkAboutBLD2005-00453 • MLA05-00423 Review Type: I MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD05-00453 Received Date: 7/12/2005 SITE ADDRESS: 2981 WEST VALLEY RD CHIMACUM, 98325 APPLICANT: BRIAN BAUMUNK PHONE: (360)732-4271 PATSY L B BAUMUNK PO BOX 1464 PORT HADLOCK WA 98339-1464 SUBDIVISION: Block: Lot: + PARCEL NUMBER: 901274003 Section: 27 Township: 29 N Range: 01 W CONTRACTOR/ BISHOP ENTERPRISES PHONE: (360) 417-0861 DEALER: 982 LEWIS RD PORT ANGELES WA 98362 Contractor's License BISHOE*999MT Expires 07/24/2006 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NEW MFH MODEL: TRPL SERIAL NO. AM7664A TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: MODULINE SETBACK: VALUATION 112,541.00 YEAR: 2003 LABOR & INDUSTRIES APPROVAL? SIZE: 66 x 42 BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: PWELL BEDROOMS: BATHROOMS: Exist: Exist: Prop: 4 Prop: 2 Total: 4 Total: 2 Routing Date: APPP . VE1 Type Amount Paid Bv: Date: Recei pt: ApprovedlDate Manufactured Homes $157.00 KAS 07/12/05 76173 AUG 1 1 2005 Add. Manufactured Home ; $33.00 KAS 07/12/05 76173 Jefferson County Planning Potable Water Application $53.00 KAS 07/12/05 76173 &Building Department Total: $243.00Ots-k * i 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#: BLD05-00453 Received Date: 7/12/2005 SITE ADDRESS: 2981 WEST VALLEY RD Issue Date: 8/11/2005 CHIMACUM, 98325 APPLICANT: BRIAN BAUMUNK PATSY L B BAUMUNK PO BOX 1464 PORT HADLOCK WA 98339-1464 SUBDIVISION: Block: Lot: + PARCEL#: 901274003 Section: 27 Township: 29 N Range: 01 W CONTRACTOR/ BISHOP ENTERPRISES PHONE: (360) 417-0861 DEALER 982 LEWIS RD PORT ANGELES WA 98362 Contractor's License BISHOE*999MT Expires 7/24/2006 PROJECT DESCRIPTION: NEW MFH MODEL: TRPL SERIAL NO. AM7664A MAKE: MODULINE YEAR: 2003 SIZE: 66 x 42 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 8/11/2006. CALL IN FOR THE 1RED INSPECTIONS THAT APPLY TO YOUR PROJECT. etback ootin (CONTINUOUS FOOTING, SLAB or PADS USED): S -cis df/Ll,oi-ux '7/V"(Z -o( Stormwater FINAL Approval: Blocking/Plumbing: .716.00.ux e —ire-sea/A) die /� S/.S Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps: per (6),24t ro•J V942,---04 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 # BLD05-00453 1.) The application was reviewed by the Jefferson County Department of Community Development staff on August 9, 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: Type 5 Stream, Wetlands, Seismic Hazard Areas and Susceptible Aquifer Recharge Areas. 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.) 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. 5.) A Type 5 Stream (Fish and Wildlife Habitat Area) has been identified on the subject property. The stream will require a setback of 50-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. 6.) 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. 7.) Among the native conifer species which may be used in buffers or for re-vegetation 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 (Sam bucus Racemosa), Snowberry(Symphoricarpos Albus), Evergreen Huckleberry (Vaccinium Ovatum), Red Huckleberry(Vaccinium Parvifolium). 8.) The project components are more than 250' from the mapped/identified wetland. The requirement for a wetland delineation and report is waived based on maintenance of a 225' buffer from the wetland per UDC Table 3-3. 9.) The project is located in close proximity to an identified wetland and is subject to the delineation provisions of Section 3.6.9 of the Jefferson County Unified Development Code. Based upon the proposed location of the project in relation to the identified wetland, the applicant has agreed to maintain a buffer(setback) that exceeds the standard buffer requirements by fifty(50) percent. The applicant acknowledges the additional setback and agrees to maintain the extra 50 percent buffer, therefore, waiving the wetland delineation requirements of the Unified Development Code. 10.) 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 contain the following statement: "Wetland & Buffer- Do Not Remove or Alter Existing Vegetation." 11.) A permanent physical separation along the upland boundary of the wetland 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. • 12.) Critical Aquifer Recharge Areas may require special protection measures t•tigate 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. 13.) The identified Fish and Wildlife Habitat Area (Type 5 Stream), shall maintain a vegetative buffer setback of 50 feet. The setback shall be measured horizontally from the Ordinary High Water Mark (OHWM) to the manufactured home and garage. 14.) An additional setback of five (5) feet is required from the edge of the buffer area to the proposed manufactured home and garage. 15.) A permanent physical separation along the boundary of the 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. 16.) 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." 17.) The applicant is proposing to create or add 13484 square feet (9000 sq ft is driveway) of impervious surface and 12284 square feet of land disturbing activities. The project design (82-acre lot with most natural vegetation retained) and that the driveway accounts for over half impervious surface was factored in the determination of requiring a storm water plan for Medium Projects instead of a stormwater plan for Large Projects. 18.) 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. 19.) 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). 20.) The site plan as submitted with the building permit application on July 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 August 9, 2005 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 21.) This approval is for a manufactured home installation and an attaced garage 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. 22.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 23.) 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). 24.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 25.) The building height is not to exceed 35 feet. 26.) Minimum setback from West Valley Rd right-of-way is 20 ft. Minimum side and rear setbacks are 5 ft. Environmentally Sensitive Areas further impact setbacks. 27.) This parcel has been designated as Rural Residential 1:20 under the Jefferson County Comprehensive Plan Land Use Map effective August 28, 1998. 28.) A septic permit(SEP04-00196) was approved on March 17, 2005 for a system of 480 gallons per day. A septic permit(SEP05-00034)was approved on March 17, 2005 for a system of 240 gallons per day. 29.) West Valley Rd (C514109) is a local access road. The road approach is existing and an address of 2981 West Valley Rd has been assigned to the parcel. 30.) A minimum of four(4) parking spaces are required for the single family residence and accessory dwelling unit(ADU). • 31.) A stormwater plan for a mediun project has been submitted and approved by the Department of Community Development. Once the subject permit has been issued the applicant shall fully implement the provisions of the submitted plan and contact the Jefferson County Department of Community Development to arrange a schedule to inspect the property for plan compliance. A Certificate of Occupancy will not be issued until the Department verifies plan compliance. No clearing for roadways or utilities shall occur on the project site until clearing necessary for the installation of temporary sedimentation and erosion control measures have been completed. / ON c0G JEFFERS,COUNTY • W� 3 DEPARTMENT OF COMMUNITY DEVELOPMENT ~' '\ ' `.4 621 Sheridan Street• Port Townsend•Washington 98368 360/379-4450. 360/379-4451 Fax Nix. www.00.jeifierson.wa.us/commdevelopment Master Permit Application MLA: 05_ Lic9:3 Project Description(include separate sheets as necessary): yftt5faI ( )A ne1,v flan -ecActoPecl i(orne Tax Parcel O .� L� 0 Property , Number. 1 0 criv 5 (acres/square feet) Site Address and/or Directions to Property: a.el g- f We 6'{. Oa t t e 1 p r,J ` Property Owner(s)of Record: I?c 1'sk.r, '- Pa{ Ay Bat)ran.ur.1( Telephone: 3 F,O—') ? D L] 7 i Fax: J email: Mailing Address: )i 0 Q 19(,)4 Gc r }{a cd 1()C 1<, Applicant/Agent(if different from owner): c2, ;;ti n p En t r'r-)r j S e S Telephone: '�f,.('—Li(1--0 1 t I Fax: 1 email: Mailing Address: 1 F.a. kt'.u,)o t Rel. pi..r1 rici(vj 5 WA q P.3 tc. a What kind of Permit?(Check each box that applies) ❑Building CI Variance(Minor,Major or Reasonable Economic Use) ❑ Demolition Permit U Conditional Use[C(a),C(d),or Cj** ❑ Single Family ❑ Discretionary"D"or Unnamed Use Classification Garage Attached/Detached Cl Special Use(Essential Public Facilities)** Ili Manufactured Home ❑ Boundary Line Adjustment ❑ Modular U Short Plat** ❑ Commercial* ❑ Binding Site Plan" ❑ Change of Use CI Long Plat** ❑ Address I Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** ❑ Propane CI Plat Vacation/Akeration** ❑ 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 0 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 1V1 PI el d 1� vl i 5 ho f to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE �� Date: b --I .1 O5 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. P�F / I further agree to save,indemnify and hold harmless Jefferson o of gai I IitiliIitigs, grr its, r' osts,reasonable attomey's fees and expenses which may in any way accrue against Jefferson Cotrlty a-resn Are e Ming of this permit I further agree to provide access and right of entry to Jeffersor'Cogrity and its employees,represe es cr agents for the sole purpose of application review and an required later inspections.Access and right of entry to this Drtrty 11 sted a all occur only during regular business hours. I � � --- Signature: � (JGLU w.. 4_ Date: Co ( -1 _° The action or actions Applicant will undertake as a result of the itsuarice ofthis porn*n y egatfty i ac upon one or more threatened or endangered species and could lead to a potential"take"of an ehdaiige'?epee in the federal law known as the "Endangered Species Ad"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-transf( b respons lity for adhering,,)and complyi with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: ! 14-- ,j') Date: �' (_7 -O C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04.doc 0 OWNER BUILDER STATEMENT Th.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: q i 4\0_40 Gn-i ►'50_5 _ (366) '!/7- 6K6i (360) Y/7-/ 993 2MAILING ADDRE S: q a Lew i 5 Rd 0I/, �9/1 i EMAIL: CONTRACTORS LICENSE WAINS (� // 7 ,/ NUMBER: `j1 St,��1 G C �E �� 1 NUMBER ,37 ARCHITECT/ENGINEER: PHONE ( ) FAX: ( ) MAILING ADDRESS: EMAIL — Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: l$ New a Wood Existing: 0 Sewer ❑ Addition 0 Steel Proposed: 40 Bank 0 Community System ❑ Alteration/Remodel ❑ Concrete Total: Height RI Individual System C 0 Repair 0 Masonry SEP Permit#C g 4 y f �_ 4. ❑ Demolition 0 Other: Bedrooms: Water Supply: Existing: Setback: N Private well ❑ Two Party Type of Heat: Proposed: • t/ ❑ Public /�'t;fr I C Total: Name of System: If this is a Commercial Project you must answer the following: Number of Parking Spaces: Current Proposed: Number of ADA Parking Spaces: Number of occupants(includes owners,tenants,employees,etc) Current Proposed IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply: ❑ Underground Tank ❑ Above ground Tank Size of Propane Tank: 0 Heat Stove ❑ Cook Stove ❑ Woodstove El Fireplace Insert 0 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 ay c: y'' ,y �. q FoeQfticr �UseDNy ,�4 Current Proposed x ` Main Floor z ,r_ z �, � x � y j 2 Floor 'her ,�.. 3' Floor " Mezzanine: S ' i ' 'cv a , aHeated Basement - e ^ e i Unheated Basement ,`. (' «'.,1$c c .i ��': _ S ti . ., }. L rr*.�4 •Other Unheated -¢ % • raft, t ' a ` Garage/Carport 'a ` " �� Decks .v Numbers `, 4" x ,,,, � ; + . ' Yfi.t l r ! i KCY`a ��_ ,:< F:A '. Other ipasl/t t.1 sx r'4,: ., r $ � r,+; ESTIMATED COST(REQUIRED) ` \ `'" , •Fair market value of all 1 labor and materials f'/o/undation to finish r, i r - 5 sr A, .- .. G:\PeanitCenter\FORMS\DRD FORMS\Master Pennit Application 7-8-04.doc • • CERTIFICATE OF OCCUPANCY Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 (800) 831-2678 PERMIT #: BLD05-00453 SITE ADDRESS: 2981 WEST VALLEY RD Issue Date: 08/11/2005 CHIMACUM, 98325 Final Date: 09/12/2006 APPLICANT: BRIAN BAUMUNK PHONE: (360) 732-4271 PATSY L B BAUMUNK PO BOX 1464 PORT HADLOCK WA 98339-1464 SUBDIVISION: Block: Lot: + PARCEL NUMBER: 901274003 Section: 27 Township: 29 N Range: 01 W PROJECT DESCRIPTION: NEW MFH MODEL: TRPL SERIAL NO. AM7664A THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2003 EDITION. OCCUPANCY GROUP: ta 4L4'4ê !4,mg, . 114 04 3,4,e, TYPE OF CONSTRUCTION/ S Abpta t g b9 Li r. SPRINKLER SYSTEM yes Co) THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 09/12/2006 AQ_CO 6,1tAiJ c l 9 ►5/0(6 Building Official Signature Date I:\F_BLD_Occupancy.rpt 10/29/19c It . . . 1.9 .. Ilk i I ::111. . • 4 • . 1:___.c.r, , :.,..,,..: _._.) .,,,„ i . ., c......„ , . 1. ,....„ , .,.. . • ir 1,1,. . 7.......4 c...1 . 1 mall tato .. I - I.- it *.z. c....: ,Ne a • ,.� Jr . .. - rl i {I I• C)AI ETh . 11 77Ai, . rilaliMIM r---N .s, . . 14.7 la . .1 -I :. ...:7.11— ) 1 a. .. x (N..) c� ht 1V.u. . ,- jr. . 1 • - -• < . .(;)I • • ____ . . • (\ \\fr., ....) . I-I! li, ..„ t, .....„. 13 ...,......... :.......!1 (iN: , JACK WVESTERMAN me Jefferson Couit'ourthoase ASSESSOR iro Box 1220. fort Tonnsend. WA 98368 (360)385-91 /5 MOBILE E INFORMATIO Q OWNER'S NAME/MAILING ADDRESS: ti • JUL 1 2 1005 2) NAME: 6rir,n 5 PaisY RaQmUn 1< • Grn Jc.P; nUNTY ADDRESS: Pb- g crx J yj,ut E v c N G��bG�C C D�PJ. nr frpr, ,?;�"t�?u 1;EVEL.�P�!ENT PHONE NO. 3 �p - 7 3�,— 9211 The purpose of this questionnaire is to obtain information regarding either the current location of a mobile home or the previous 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 M et l�`i"(\f- (B)MODEL Tlpp Pl. (C)YEAR 1QO?j (D) LENGTH 6 bll II 1 (E)WIDTH -1 (F)SERIAL # � M`t 66y� (G)YOUR PURCHASE PRICE (Do not include sales tax) I I).)Sy 1 ,0 0 PURCHASE DATE 3-I)a661 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IFii NEW MOVE TO QUESTION 30 (A) FROM WHOM DID YOU PURCHASE MOBILE k)A 5V1 . CYM e CC,c ke c lI A C - ADDRESS (B► WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR?Yes No If Yes, Previous address of mobile. If No, What County was Mobile assessed in last year. 3)WIIERE MOBILE HOME IS TO BE LOCATED: (A)WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes No (II)IF LOCATED IN MOBILE HOME PARK: NAME &ADDRESS OF PARK Lot/Space # (C) IF NOT LOCATED IN MOBILE HOME PAR IA n NAME OF LAND OWNER: 8 f a,v ? �C�.Tc. lJj ext_AYr\lirAll LOCATION ADDRESS al 1 + pal`e_ o REAL PROPERTY PARCEL #/DESCRIPTION 5 027 T c 9 R /tQ (0/ 5,6 Signati(re of a plicant THANK YOU FOR YOUR HELP! CJODI COSSELL. Property Technician • 0 • , I ...........r.„...6........a.-----...6-4. imilr , �� ` ii •• 1 1.z) . cam/' '4 1 p /ii A' so - K_z. - It:: .._....., 1,... • „, 4 • . w�rifM_ ws 6 . •I • . - s,.. • tor -". x UM -- ---.... w ...,.,,� c,?, zp, X` (\.) I; . El ' i • 64 • 0 • I at ar A -1 �: •cry �`% ,--, v ii, . ps. b...1 711baiiiiiiii0 . 7''' '.- P sc:,< _ _______- IT Eifigiri \ " - - ' • 1'. . • • • .ivii...„,,. ........„,„,„,„„,,„.„..........4.. • Mali E . . . 7, • .01 CV . 7 1 . SA . 1 •, 0prow t I . 1 cN) , 1,1 • • - •- • iN ...,' 4 • t 'i< `t • in • ,,,. • • • . . . e El, I `. '" t - ` hL JULa c ) 1 1 2 . 2005 i .may • • • . ,5 PE TIT # BID JEFFERSON COUNTY _ 4 , DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street • Port Townsend•Washington 98368 ,6FFFDSON COUNTY DCQ 360/379-4450. 360/379-4451 Fax httpJ/www.co.jefferson.wa.us/commdevelopment/ STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# OS- d3 PROJECTJAPPLICANT NAME: f` a h - PCt,fs Y IIa u m b r k 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. "n1.enri,43,ecl home a) ,//fie //7 /G//&'o, kna// rc A r'e o64:1-- ADM 4 trca y 15 Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. SeQ n 4/ RiaO ( in nvic, /%' Qf' j1rof1. 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. C.jdoc%J en 3 S i'des ra s S' +J In -�,�i fli d('k tek 4. Describe the existing soils. Indicate soil type on the site map. N! 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 appliicable,and indicate acreage of each. PA c:" re, •f !,i1 rr 6. Describe any excess levels of noiti entglie4 ed use or activity: j C. STORMWATER PLAN j LI {[E AUG . - U 2005 _• _ 1 JEFFERSON COUNTY stormwater site plan template—rev.1072001 DEPT.OF C( NITY qEV 1.01/4 SIGNATURE: 4 ' • 7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams, steep slopes,etc.)on the site. Indicate location on the site map. 0..1\ / 5 Ea_5ar.a. iy 'dd1 . a`f toP- ` cow j firr‘Afte S-(rP.eN.CIN,5 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,qtc.). Ss fc tt1111 be. la,a.-fe an ha'ah� uovtcl Ioc tti rox- asa 1f - t-o , A.0att�>i.d tot�n P- L. 'pInd I��'rra 11c all r*--P, 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. raei)(- �� Rtc-6 -u>;l1 \ ) svi,G&L LtoC.1L 5 �1nd rt�n 6c{' A d '(\O v V•A\ C c©-k yr, J 10. If the project requires the use of stormwater treatment faclities,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. 12. Describe the flow control system. l ,, — Jill 12 2(105 Sr rKft f114 t sCll1A17Y _..r r. •t t?tat stormwater site plan template—rev.10/1/2003 44 6 i - c • • 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. J 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Uniform Building Code. 17. Describe the proposed surfacing material. 18. Describe methods for restoration of the site. 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. 1111 JUL 1 2 -20u5 t_- I t ty stormwater site plan template—rev.llY1/2003 JEVEE cur. 7 • • ; 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 2.52 of the Manual(beginning on page 2-15). 12 Required Elements—Construction SWPPP 1. Mark Clearing Limits. Pr9 Pr w;ll be wiII ie. (avndri€.s 6f o t Qcre 2. Establish Construction Access. ow A yyro x_ 9Q X 1 O t ro 1 Mad re /o Acme LiL) 3 j h , ri'n�S PON( c,om?e,e4;r vN 3. Control Flow Rates. DctuP uic 1 11 be arcked for natorc1/41 Irunoff, l r) e cc e_s S cif d re h e e -E r-`Cmr 'h cyrn-e_ n s te,,l kth oY 4. • Install Sediment Controls. 5. Stabilize Soils. Jdi hee.dl°d j Slops ore mii Inlet) 6. Protect Slopes. 4//A 7. Protect Drain Inlets. ' ;i 8 stormwater site plan template—rev.10/1/2003 Sr • • • 12 Required Elements—Construction SWPPP(continued) • 8. Stabilize Channels and Outlets. M/-A 9. Control Pollutants. 10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site). NA 11. Maintain Best Management Practices(BMPs). A/I4 12. Manage the Project. "(IA Adjacent Areas. a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas,roads). ' v 14 b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400 yards). M 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or a scent dl 'Rom e spa � �I iv/ NA I Ga JUL 12 005B stormwater site plan template—rev.10/1/2003 9 • • • .2 b. Description of special requirements for working in or near environmentally sensitive areas. ✓ 1 /fir 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). 'L)C n P. -- Construction Phasing. a. Construction /suence J11/A 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. Th6y -MI-0 Au . and s II. Wet Season Construction Activities. a. Proposed wet season construction activities. b. Proposed/ wet season construction activities for environmentally sensitive areas. A 7. Financial/Ownership Responsibilities. a. Identify the property owner responsible for the initiation of bonds and/or other financial securities. ►G,tr, 9 Paisi t atsrr tifi Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation impacts. Engineering Calculations. Provide Design Calculations on a separate sheet f• ,'i: folrOwi rfiapp/icable., \ a. Sediment Ponds/Traps. b. Diversions. c. Waterways. - J U L 1 2 2005 ,' r d. Runoff/Stormwater Detention Calculations stormwater site plan template—rev.1N12003 10 • • , • ~i • 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(was-buitts')when the project is completed. These should be engineering drawings (stamped by a licensed civil engineer) that accurately represent the project as constructed. _ -- APPUCANT 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. 7� o� / 7 /2_0 lL N z/• ESENTAT1VE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES,IF NEEDED: • s t � t� i-1 1 l JUL 1 2 2005 I,:: JFFFCeCN COUNTY rvTT.u� ;;I CON,Nki I', Lt:IEL0Fi i,..{'s� stormwater site plan template—rev.10V1/2003 12 • .i_ m > • run) ifiret , 5 sc yd_ t'0 (ii ..;-- __, ___. ...._.._.. .. \ -1 ..-.7t-.. ITV. 71 ,7. 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I 4 ' - ' ' , Ls) -.. - - A o ti 1 ......\- _- .-;-,0 o ‘,...3-, ___e._ 3 I . i, ---. ....,-.-.2 o -o irr• P 0 .13> 21 .0It• Q1--- itft TS F; -0 74 Ind\ l'\ 1 1 - < .,...-- 0 , / b so 4t a) c ..< o it ki) . \ ko)(\i''' \ c1-6) 2. up c ' 1 / --1- s5 C? --'s 1:3 \ ?A ' I 1 . c , ...., al i, P-P • , t, , 0 , ' al o m t .0 1 .._ n• ,-) IIP lr- a,, 80 L----- I •v"---C) Q - M CID 01:j 3 1"44 (A $". , ... 1 1".)f\c‘ --)) e s 62 t t?,g M til p',:l t-1 w ..2., . c .--; -9- -' - 0 • F\E 'T i 9 . . . , • If l , , co I -. 1 \ c ,....... 3 6 9 4.4 to • Ib ff. , cir v . ocn . sv , cru , 1 I: — ..4 ec i I 4)3 II r" cz......______.. ,J - 4 ., - .1 (A n , 1M / I / i ° / A 1=-74 C..:'r) -• tit V IP ....rz• •.... , ......< o i.. CI_ -.P.1 rn jj 00 - 1.1., ...". --; ...";,...- • 0 RETURN ADDRESS FIRST FEDERAL SAVINGS &LOAN P O Box 351 Port Angeles, Wash. 98362 AT-.' /far; �r Sr)TAr.�me OF.rgWfASI(11�GTON MANUFACTURED HOME PL AS CHECK ONE 11 T{TLE ELIMINATION ! I lkEflS1flG APPLICATION OTRANSFER 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) ,003 rCC ut1,11E (o X 9d 1 Ig- Q 911 q- RE © LAND LEGAL DESCRIPTION ON PAGE REAL PROPERTY TAX PARCEL NUMBER MANUFACTURED HOME WILL BE ®AFFIXED 0 REMOVED 901-274-003 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION W1/2 SE 1/4 SEC 27 © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS 16 2 1 NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER BRIAN GREGG BAUMUNK NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER PATSY LOUISE BENTON BAUMUNK ADDRESS CITY STATE ZIP CODE 2981 W VALLEY RD CHIMACUM WA 98325 NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER FIRST FEDERAL SAVINGS AND LOAN ASSOCIATION NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE P 0 BOX 351 PORT ANGELES WA 98362 GRANTEE NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGISTERED OWNERS •F THIS VEHICLE AND THIS INFORMATION IS ACCURATE: / Signature of Registered Owner and Title,IF APPLICABLE �� I ':l di.�..,,3 .� I a /ft:.ip--- / t_ Signature of 1A'dditional Registered Owner and Title,IF APPLICABLE f i. a ``\NP MC, .4n rosmP'0�i NOTARIZATION/CERTIFICATION F ' REGISTERED OWNER(S)SIGNATURE �.`y�•••" •���// State of Washington J Signed or attested 7-o -b ••�0TAR ••.'f/ County of �' eYS ��- before me on 2' 5 Y JAN. 19,2008:•z= by Erl&n Gr ,}�,tct✓rrecK,lC Signature/// (' -- PRINT NAME OF REGISTERED OWNER N/rf OR AGENT 9J,• t;°�: by 1J5 ZOLUSQi,DCJa i E•Cumuwc . o// �': Ile-/C ddeLt / �` ��`�` PRINT yXME OF REGISTERED OWNER PRINTED NAME OF NOTARY .///OjpIW ASN``•• Title NO�Q Y"'( County/Office No.OR �j AND: Dealer No.OR DEALERSHIP POSI N/AGENT/NOTARY Notary Expiration Date El 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. a building permit has been issued for this purpose and the attachment will be inspected upon completion. NAME PED OR PRINTED) BLDG PERMIT OFFICE/PHONE# BLDG PERMIT# & �hte� wed- _ � 3'1 - 4�5U 0 OS% 00 VS.3 SIGNAT,RE/POSIT) N Q jGt I 1O ' ITE ia0-1 TD-420-729 ANU HO .L(R/2/02OR(W)Page1of2 • ! MANUFACTURED HOME - FROM SECTION 1 TPOIPLATE NUMBER YEAR MAKE LENCTHAVIDTH(FEET) !VEHICLE IDENTIFICATION NUMBER(VIN) aOb3 tYWI1I1Ile. to(0' X4),' I 11 f7.3. - ag11q - A 6( 0 SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR ELIMINATION OF TITLE/ MOVAL FROM REAL PROPERTY. Y Signature of Legal Owner and Title, IF APPLICABLE :c-e- "(-'-�-e - �1 --c-c�j Signature of Additional Legal Owner and Title,IF APPLICABLE NOTARY YSSIt0 if MMP I NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE .A.' k ••.... �. 4O//i State of WCountyton of Signed or attested / / ,t-Y'` ••••••• � C�1/Ql� g before me on Z. } Y �� U•„� tzl / f, t hooky 4/ Ill/ Signature aik.es_ O y\ _ PRINT NAME OF LEGAL OWNER TAR RAGENT z ,,\4 Jm 0�.ly zit./ ,65n ew5, �,004 C/ .,r,- Amy Keller •.••Q Q •�•' `Q" P INT NAME F LEGAL OWNER PRINTED NAME OF NOTARY `�1 1 County/Office No.OR ���/�� 'ST•••••••�.F\ ��. Title 0 7 7r' AND: Dealer No.OR /S//Lj 1//, /TATE • \\� I DEALERSHHH�ffP O ITION/AGENT TARY Notary Expiration Date ©LAND Ifk0t PTION (A legal description of the land can be obtained from the local County Assessor's Office THE WEST 1/2 OF THE SOUTHEAST 1/4 OF SECTION 27,TOWNSHIP 29 NORTH,RANGE 1 WEST,W. M.,JEFFERSON COUNTY,WASHINGTON. SITUATE IN THE COUNTY OF JEFFERSON,STATE OF WASHINGTON. a DEALERS 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 JURISDICTIONrrAX RATE DEALER'S AUTHORIZED SIGNATURE L/t/. )`� /' r% .. I li (2, Q 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 I APPLICATION I MOBILE HOME FEE ELIMINATION FEE USE TAX I SUBAGENT FEES I I I 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/2102)OR(W)Page 2 of 2 i RETURN ADDRESS FIRST FEDERAL SAVINGS &LOAN- R0 Box151 Port Angeles, Wash. 98362 Mar; NI L/h srl7rc�cwAsluncron MANUFACTURED HOME 1111 11-ya tg aCda0ii I 77STAInOF of TITLE NATION licEnsInG APPLICATION EJTRANSFERI 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/WIDTHIFEET) VEHICLE IDENTIFICATION NUMBER(VIN) 003 Aowoconct co(o' X 9 ?' IIg- a91 - 1AB C— © LAND LEGAL DESCRIPTION ON PAGE REAL PROPERTY TAX PARCEL NUMBER MANUFACTURED HOME WILL BE !J AFFIXED 0 REMOVED 901-274-003 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION WI/2 SE 1/4 SEC 27 © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS 16 2 1 NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER BRIAN GREGG BAUMUNK NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER PATSY LOUISE BENTON BAUMUNK ADDRESS CITY STATE ZIP CODE 2981 W VALLEY RD CHIMACUM WA 98325 NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER , FIRST FEDERAL SAVINGS AND LOAN ASSOCIATION NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE P 0 BOX 351 PORT ANGELES WA 98362 GRANTEE NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGISTERED OWNER(S F THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title, IF APPLICABLE_ ._ Signature of 1Ad�ditional Registered Owner and Title,IF APPLICABLE_ I C{,�rill.l., 1,� N �AitifY /dIQ MP �``P MC, q0'��9 NOTARIZATION/CERTIFICATION F REGISTERED OWNER(S)SIGNATURE ` F% •••.••• Q /i' e t eY'S c7y.. g i y ,• � �/ State of Washington J Signed or attested �O: �pTAq y•'1 County of before me on 21 7_.D b 77. 2008 �j rI a.) g k JAN. 19, :O` by � rGyg DOWNER•t Signature ! GENT _ PRINT/NAME OF R6G15TE�R7ED OWNER N OR AGENT �,/ �' ���T,•,�U B�-\ 'C?:` by?�T.S y LOGt�s�E t,1-J �Cuhtuw�� e`y C /z"!�-/-Ccdiie-Gt .� ` PRINT ice)AME OF REGISTERED OWNER PRINTED NAME OF NOTARY f/ Op W Rs����` Title ,V O�d 1"` AND: County/Off No.OR DEALERSHIP POST WAGENT/NOTARY Notary Expiration Date 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 to the manufactured home has been affixed to the real property as described. El 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* &a os• VS.3 SIGNATURE/POSITION DATE TD-420-729 MANUF HOMEAPPL(R/2/02)OR(W)Page 1 of 2