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HomeMy WebLinkAboutBLD2005-00495 BUILDING PERMIT APPLICAN MLA05-00463 Review Type:I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD05-00495 Received Date: 7/27/2005 SITE ADDRESS: 251 WA WA POINT RD BRINNON, 98320 OWNER: EXCHANGE RESOURCES INC PHONE: 626-799-8776 8885 RIO SAN DIEGO DR#135 SAN DIEGO CA 92108 SUBDIVISION: Block: Lot: T 37+ PARCEL NUMBER: 602242002 Section: 24 Township: 26 N Range: 02 W CONTRACTOR: PHONE: PHONE: REPRESENTATIVE: LAURENCE DIMINO PHONE: (360)796-3068 PO BOX 218 BRINNON WA 98320 PROJECT DESCRIPTIOF NEW MF HM TYPE OF WORK MOB SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION 76,000.00 ADD'L: HEAT TYPE: CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: R-3 UNHEATED: # OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PWELL BEDROOMS: BATHROOMS: Exist: Exist: Prop: 2 Prop: 2 Total: 2 Total: 2 Routing Date: � 4: C1 Type Amount Paid By: Date: Receipt: Approved/Date Manufactured Homes $157.00 SLE 07/27/05 76406 /� P^ Potable Water Application $53.00 SLE 07/27/05 76406 /`1 rR O VE E Total: $210.00 SEP 2 6 2005 effer • 'unty Planning „alas& ildi ,artment 1 ,,.'`''5oN cO JEFFERS COUNTY W' )4.- DEPARTMENT OF COMMLN{F�B��1f �Of'MENT 621 Sheridan Street• Port 1toW tsetid i Washington 9)336> r \ 360/379-4450 • 360/379-4451'Fx . ,, , , ---, O www.co.jefferson.wa.us/cointi*velopment ,, , 1ING� i , 5 i i JULvU Z / LI;JJ 'Master Permit Application 1 MLA: I 3 Project Description(include separate sheet as necessar�r . r,l ` c" ' ,''`i' Tax Parcel 0 2 z Property Number: ©�� Size: / / • Z Z C're,5 (acres/square feet) Site Address and/or Directions to P operty: 25( W�LI:� o t ytt (40 d Property Owner(s)of Record: I i _ j,�.;'`�,`� XC- ilt . Res&►rce. Wl� Telephone: ‘2h - 41-&77 Fax: - - emai Mailing Address:/Zi 2-1-', tSeptcf cSo & ( CA- ?1 o3O Applicant/Agent(if different from owner): Lea/cell C e �j Ytk)IL Telephone: 360 — 6—OFax: email: Mailing Address: Po 80, ZI ec1 n K 0e c1 g326, What kind of Permit?(Check each box that applies) ifr.Building ❑ Variance(Minor, Major or Reasonable Economic Use) ❑ Demolition Permit ❑ Conditional Use[C(a), C(d), or C] ** ❑ Single Family ❑ Discretionary"D"or Unnamed Use Classification ❑ Garage Attached/Detached ❑ Special Use(Essential Public Facilities)** )Manufactured Home ❑ Boundary Line Adjustment ❑ Modular ❑ Short Plat"* Commercial* ❑ Binding Site Plan*" ❑ Change of Use ❑ Long Plat"* ❑Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments-- n Propane ❑ Plat Vacation/Alteration** Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** ❑ Stormwater Management ❑ Shoreline Management Substantial Development** [i Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance ❑ Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment ❑Wireless Telecommunication* ❑Jefferson County Shoreline Master Program Amendment ❑ Forest Practices Act/Release of Six-Year Moratorium * May require a Pre—Application Conference **Requires a Pre-Application Conference Please identify any other local, state or federal permits required for this proposal, if known: DESIGNATION OF AGENT I hereby designate C -"4 - 2), Wl l v1,j_to act as my agent in matters relating )to is pplication for permit(s). OWNER SIGNATURE Date: r 8 (5 - By signing this appli , e 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 know) ge. material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet may result in this perms being null and void. I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attorneys 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 r it later ins n . ccess and right of entry to this property shall be requested and shall nr'ir only during regular business hours. , ,, Signature: Date: J ;<J1��J —mil_ / 7 The action or actionst pplicant 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 under-taken 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 'n pliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transfer le r i ility for eeng to and complying with the ESA. The Applicant has read this discim r and_signs and dates it below. Signature: d " " ' Date: •✓ �6 G:\PemvtCenter\FC5l \DR.D FORMS\Master Permit Application 7-8-04.doc • OWNER BUILDER STATEMENT • i he sic,er of this stateme dges hereby certify that they are the Owners of the parcel ref renced herei i that they.- ar6 not licensed contactors that they v;ll be a responsibility of the General Contractor for the proposed proj�e . : 1 I ; t ( f j Signature: D t ! r - ae. / li _ - I rat ve,_ 2 ; r.„ej+ GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: t MAILING ADDRESS: r' cfc; " EMAIL: ` t CONTRACTOR'S LICENSE Q �j WAINS -�+ NUMBER: PR.EF S cal j��t�� NUMBER 13� �j ARCHITECT/ENGINEER: PHONE ( ) FAx ( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type YSe of Sewage Disposal: New ❑ Wood Existing: 0 Sewer ❑ Addition ❑ Steel Proposed: Z. Bank 0 Community System 0 Alteration/Remodel ❑ Concrete Total: Z Height: Individual Syste ❑ Repair 0 Mason ry SEP Permit# ©'2 00 ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: pp y' Type of Heat: Proposed: - ❑ Private well ❑ Two Party ❑ Public 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: p Will you have Food Service? Yes / No If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply: 0 Underground Tank ❑ Above ground Tank Size of Propane Tank: ❑ Heat Stove ❑ Cook Stove ❑ Woodstove ❑ 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 For Office Use Only Current Proposed Atrtount Main Floor /d e Consistency Review . 2Nu Floor Base fee: r 3 Floor i 1 Additional Section: Mezzanine: Plan Check fee: Heated Basement ;---- State Surcharge fee: Unheated Basement ____,...--- Pot Water Review fee: Other Unheated /.- 911/Rd '` fee:' Garage/Carport /�' � �Yc,Y�k� ci • Decks / - , /7 4m 5-7 Receipt Number 1 ,tfcC, Other Cash/Check Number: ESTIMATED COST(REQUIRED) - k Fair market value of all labor and materials foundation to finish Date: ` 76 CIO c Initials:. . ` , G:\PermitCenter \FORMS\DRD FORMS\Master Permit Application 7-8-04.doc • • 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 #: BLD05-00495 Received Date: 7/27/2005 SITE ADDRESS: 251 A WAWA POINT RD Issue Date: 9/26/2005 BRINNON, 98320 APPLICANT: EXCHANGE RESOURCES INC 8885 RIO SAN DIEGO DR #135 SAN DIEGO CA 92108 SUBDIVISION: Block: Lot: T 37+ PARCEL#: 602242002 Section: 24 Township: 26 N Range: 02 W CONTRACTOR/ DEALER PROJECT DESCRIPTION: New Man Home to be Installed as ADU MAKE: SKYLINE YEAR: 2005 SIZE: 44 X 27 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 9/26/2006. CALL I=QUI RED INSPECTIONS THAT APPLY TO YOUR PROJECT. ��otin (C`9NTIN000S FOOTING, SLAB or PADS USED): Gfi'� /J�� ��� �� y� Stormwater FINAL Approval: Blocking/Plumbing: Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: � Final/Skirting/Vents/Porches/Steps:�l((��` _r HEALTH DEPARTMENT AND PUBLIC WORK 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 # BLD05-00495 1.) The application was reviewed by the Jefferson County Department of Community Development staff on August 22, 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: suburban shoreline designation; spotted owl/eagel; SUSC aquifer recharge area; coastal SIPZ. 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.) 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.) Critical Aquifer Recharge Areas may require special protection measures to mitigate water quality degradation. The submitted proposal does not require additional aquifer protection measures. However, during construction the project shall follow the Best Management Practices (BMPs) and facility design standards as identified and defined in the Stormwater Management Manual for the Puget Sound Basin. 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. 411 8.) VOLUNTARY MEASURES?COASTAL&AT RISK SIPZ: Water conservation measures: 1. Roof and other intercepted precipitation shall be routed to on-site detention ponds and/or other approved means and allowed to be released to the soil slowly. 2. Water collected from Storm water and roof catchments may be used for watering lawns and gardens. Unless catchment water has been treated to meet drinking water standards, there shall be no cross connections allowed between the potable supply and impounded water. 3. Water withdrawn from wells on each property shall not be used for watering of lawns and/or gardens. 4. Ground water withdrawn from each property shall be restricted to a rate of three (3) gallons per minute. 5. Installation of water conserving fixtures such as low flow toilets, faucets and shower restrictors and other water saving plumbing fixtures. 6. Landscaping plan (xeriscaping, native vegetation with minimal amounts of irrigation). Please NOTE that the above listed measures are not intended to be exhaustive, but rather is intended to be illustrative of the types of water conservation measures. 9.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ: 1. Installation of a flow meter. 2. On-going well monitoring for chloride concentration. 3. Submittal of monitoring data to County. 10.) MANDATORY MEASURES FOR COASTAL SIPZ: 1. For proof of potable water on a building permit application, applicant must utilize DOH-approved public water system if available. 2. If public water is unavailable, a qualifying alternative system may be used as proof of potable water or an individual well may be used as proof of potable water subject to the following requirement: a. Chloride concentration of a laboratory-certified well water sample submitted with building permit application. 3. If public water is unavailable, a qualifying alternative system may be used as proof of potable water. 11.) The property owner shall comply with Water Conservation Measures (per list maintained by the UDC Administrator). 12.) The applicant is proposing to create or add 1788 square feet of impervious surface and 4400 square feet of land disturbing activities. 13.) 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. 14.) 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). 15.) The site plan as submitted with the building permit application on July 29, 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 22, 2005 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 16.) This approval is for a manufactured home ADU 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. 17.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 18.) 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). 19.) Maximum lot coverage is notTo exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 20.) The building height is not to exceed 35 feet. 21.) 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. 22.) 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. 23.) Minimum setback from Wa Wa Point Road right-of-way shall be 20 feet. Minimum side yard setbacks shall be 5 feet. Minimum setback from from shoreline is 600 feet per submitted site plan received on July 29, 2005. 24.) Residential developers and individual builders shall be required to preserve shoreline vegetation and reduce the associated risk of erosion during construction and any future activity which may impact the stability of the shoreline. 25.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. 26.) The parcel has been designated as RR 1:5 under the Jeffeson County Comprehensive Land Use Map effective August 28, 1998. 27.) An address of 251A Wa Wa Point Road, Brinnon has been assigned to the ADU. Wa Wa Point Road is a county local access road (C269509). 28.) The proposal was not sent to WDFW as the proposed structure is 600 feet from the shoreline. 29.) A septic permit (SEP76-0146)was finaled on September 30, 1976. A building permit (BLD92-0701) for a woodstove installation was cancelled on October 30, 1992. A boundary line adjustment(SUB01-0030)was finaled on January 2, 2002. A septic permit (SEP05-0200) will be issued with the building permit for the ADU. A building permit (BLD05-0496) for a deck will be issued with the ADU manufactured home. ✓., • RETURN ADDRESS Washington Federal Savings PO Box 2848 Sequin WA 98382 Lh�STATE OF WfASH,NGTON MANUFACTURED HOME PLEASE CHECK ONE D=�tmento -EI ITLE ELIMINATION IICEflSIflG 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) 2006 SKYLINE 28 X 44 4159CT3CK1-3/4B CATH © LAND LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE XEI AFFIXED ❑ REMOVED REAL PROPERTY TAX PARCEL NUMBER LOT BLOCK PLAT NAME SECTION/TOWNSHIP/RANGE PTN 1 24-26-2W © 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 Richard D. Cusick NAME OF ADDITIONAL REGISTERED OWNER Laila J. Cusick ADDRESS CITY STATE ZIP CODE 1212 Lyndon St South Pasadena CA 91030 NAME OF LEGAL OWNER Washington Federal Savings NAME OF ADDITIONAL LEGAL OWNER ADDRESS CITY STATE ZIP CODE PO Box 2848 Sequim WA 98370 GRANTEE NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGISTERE 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 L � NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR REGI ERED OWNER(S)SIGNATURE State of Washington Signed or attested County of before melon 4, by Richard D. Cusick Signature4ff. £1 zi` PRINT NAME OF REGISTERED OWNER TARY 0 AGENT by Laila J. Cusick Y21+ PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NO ARY County/Office No.OR Title AND: Dealer No.OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date 4 TITLE COMPANY CERTIFICATION I certify that the legal description of the land and ownership is true and correct per the real property records. NAME(TYPED OR PRINTE ) TITLE COMPANY/PHONE NUMBER SIGNATURE/POSITIO 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: g 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) BL G PERMIT OFFICE/PHONE# BLDG PERMIT# �kp ) 3l�- L\L\50 v5-tUtH SIGNc.fQ teL /POSIT DAT TD-420-729 MANUF HOME APPL(R/8/90)0 Page 1 of 2 • • 6 SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR)<LIMINATION OF TITLE/REMOVAL FROM REAL PROPERTY. Signature of Legal Owner and Title,IF APPLICABLE k 't(U; 1 ( ``. I' Signature of AdcJMrftp)L egalOwnerandTitle,IF APPLICABLE N07.F SEAL OR STg40./././ I NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE �� oi'. • 1� ?StateofWashington Signed or attested °O " Ca • e'''� '. CLALLAM 12/ 0/07 1:3 .V County of before me on -cz.P APRIL m`; , * 3 by ELIZABETH KLIPPERT Si natur ei 2009 PRINT NAME OF LEGAL OWNER NOTARY R AGENT �/20 OF Nb.`) y MARY LOU WILLIAMS •.... .„ PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTARY I/, Y I Pt1',0 ffi ` I Title AND: County/Office No.OR I DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date()4/03/09 D LAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office S1/2 N1/2 1 , 24-26-2W as attached hereto and made a part hereof 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 DEAL R NU ER DATE OF SALE Golden Homes , Inc . tV\ 62 • 10/31/05 PURCHASE PRICE TAX JURISDICTION/TM RATE DEAL R' AU RI D SIGNATUR $72 , 045 . 00 S, 4O . ❑ USE TAX EXEMPT Sale to a Certified Tribal member on the reserv-aTon(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 for-m. 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 TDD(360)664-8885. TD-420-729 MANUF HOME APPL(R/8/98)OR Page 2 of 2 • • RETURN ADDRESS Washington Federal Savings Mary Lou i AJ W Washi. J-on St Sequim, WA 98382 Llr7;IA EI0F7 f SHINGTON MANUFACTURED HOME AS CHECK ONE XITLE ELIMINATION liCEnSinG APPLICATION ['TRANSFER IN LOCATION Anyone who knowingly makes a false statement of a material fact is guilty ['REMOVAL FROM REAL PROPERTY of a felony, and upon conviction may be punished by a fine,imprisonment,or both.(RCW 46.12.210) D MANUFACTURED HOME TPO/PLATE NUMBER X3 6 I'L I N E LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) GvIVJ 28 X 44 4159CT 3CK1-3/4B CATH © LAND LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE )AFFIXED ❑ REMOVED �V [[,,REAr6:15PEF}j4LL T�1X LL P6F6 L NUMBER ffn GL 1 BLOCK PLAT NAME ST4ONO((��ONNS,�ILP�RANGE 0 GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE LL ILL�tq�1l COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS 2 1 NAME OF REGISTERED OWNER RICHARD D. CUSICK NAME OF ADDITIONAL REGISTERED OWNER LAILA J . CUSICK ADDRESS CITY STATE ZIP CODE 1212 LYNDON ST SOUTH PASADENA CA 91030 NAME OF LEGAL OWNER WASHINGTON FEDERAL SAVTNC,S NAME OF ADDITIONAL LEGAL OWNER ADDRESS CITY STATE ZIP CODE 191 W WASHINGTON ST SFQIJTM WA A8382 GRANTEE NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/A THE REGISTERE (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 ! _.,...A.NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION OR REGIST ED OWNER(S)SIGNATURE Sta Washington Signed or attested t of before me on byRichard D. C ' k Si n ture PRINT NAME OF REGISTERED OWNER .NOTARY OR AGENT byLaila J. Cusick PRINT NAME OF REGISTERED OWNER PRINTED A TARP Coun ice No.OR Title AND: Dea .OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration 4 TITLE COMPANY CERTIFICATION I certify that the legal description of the land and ownership is true and correct per the real property records. NAME(TYPED OR PRINTED) TITLE COMPANY/PHONE NUMBER SIGNATURE/POSITION DATE Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs. © BUILDING PERMIT OFFICE CERTIFICATION I certify that: J4 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# gahke - na- s.tk�( C�J(n0 �'l ' L�L���C:� 05-00495 TuR(E6t: . � �[L n h � IDATE TD-420-72 MANUF HOME APPL(R/8/98)OR Page 1 of 2 • • , 6 SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR�IMINATJON F TI /REMOVAL FROM REAL PROPERTY. Signature of Legal Owner and Title,IF APPLICABLE ' ` IL Signature of Adapillitml Owner and Title,IF APPLICABLE NOTA`` � c YAW//I/A�' NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE `� Q• Q MISSIONec••�4 E3iate of Washington Signed or attested ' .C, 1 County of CLALLAM before me on 07 2 07 3 �hr_= ELIZABETH RLIPPERT Signature/ 1/ f�//J/ 6 U j r ., 2009 .� ^ RINT NAME OF LEGAL OWNER NOTARY 0R AGENT ��i 2 r I MARY LOU WILLIAMS � ' •waste:,... � >.j$ PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTARY ////'n 11111 "‘\\\) Title AND: County/OfficeDeler No.OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date 04/01/09 D LAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office Ptn Gl 1 , 24-26-2W as attached hereto and made a part hereof . D 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 8 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 TDD(360)664-8885. TD-420-729 MANUF HOME APPL(R/e/98)OR Page 2 of 2 217•gY