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HomeMy WebLinkAboutBLD2005-00018 • • 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 #: BLD06-00018 Received Date: 1/17/2006 SITE ADDRESS: 111 W MARKET ST Issue Date: 1/30/2006 PORT HADLOCK, 98339 APPLICANT: ANNE TRACY (c(3 3 - - aa 111 W MARKET ST PORT HADLOCK WA 98339 SUBDIVISION: HARRISBURG Block: 6 Lot: 1-4+ PARCEL#: 956700601 Section: 2 Township: 29 N Range: 01 W CONTRACTOR/ DEALER INSTALLER: CANTERBURY CONSTRUC IPMEC*021NC Expires: 2/5/2007 PO BOX 2714 BELFAIR WA 98528 ,kco -1-1 _3 ` PROJECT DESCRIPTION: NEW MFH MAKE: YEAR: SIZE: THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 1/30/2007. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. Setbacks/Footing (C NTINUOUS FOOTING, SLAB or PADS USED): ,� O9 21/3Ob Stormwater FINAL Approval: Blocking/Plumbing: _ /-/C9-6' Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps: 7K _47 .- 0 8/j3 0 HEAL TH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PR OR 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 i • • MLA06-00013 Review Type: MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00018 Received Date: 1/18/2006 SITE ADDRESS: 111 W MARKET ST PORT HADLOCK, 98339 APPLICANT: ANNE TRACY PHONE: 360-344-4227 111 W MARKET ST PORT HADLOCK WA 98339 SUBDIVISION: HARRISBURG Block: 6 Lot: 1-4+ PARCEL NUMBER: 956700601 Section: 2 Township: 29 N Range: 01 W CONTRACTOR/ CANTERBURY CONSTRUCTION PHONE: 360-277-3045 DEALER: PO BOX 2714 BELFAIR WA 98528 Contractor's License CANTEC*021NC Expires 2/5/2007 INSTALLER: CANTERBURY CONSTRUCTION CANTEC*021NC 2/5/2007 360-277-3045 PO BOX 2714 BELFAIR WA 98528 REPRESENTATIVE: HUNT HOMES INC PHONE: 360-373-5001 3450 HWY 16 BREMERTON WA 98312 PROJECT DESCRIPTION: NEW MFH TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: SETBACK: VALUATION YEAR: LABOR & INDUSTRIES APPROVAL? SIZE: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: PUD BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 3 Prop: 2 Total: 3 Total: 2 Routing Date: Type Amount Paid By: Date: Receipt: l'Approved/pate Permit $163.00 LYK 01/17/06 7 9008 JAN 3° 7006 Potable Water Application $55.00 LYK 01/17/06 79008 Total: $218.00 Jefferson County Planning &Building Department JACK WESTERMAN11 .)eiierso uni, Courthouse ASSESSOR PIi Ito)" I 20. Port Townsend, WA 98368 (3611)»38 940 - 1 MOBILE HOME iNFORMAW 1 � :, I ` . ''� O�'1T FORM � OWNER'S NAME/MAILING ADDRESS: JAM 1 7 2006 NAME: ADDRESS: ►ll Lo •p., Tr;}PHONE NO. 3(o,O 3 N 4�,'� for �ar�1 o[•�C..- W IA CIS 3 3 The purpose of this questionnaire is to obtain information regarding either the current location of a mobile home or the previous ownership and location of a mobile home. This will help our office determine whether the mobile home is already on the tax rolls in Jefferson County or if it has been moved to this county from another area. l)MOBILE HOME DATA: (A) MAKE F I ee - - J©CC, (II) MODEL AIM.i?rt CC&V\O. (C) YEAR (ROWS. (D) LENGTH U / (E) WIDTH �.. ( O Ft. ti49 a g0a331 (F) SERIAL #Op.F44y$ASo 33•AGE (G) YOUR PURCHASE PRICE (Do not include sales tax) (11)j 5 7•c%URCHASE DATE 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3) (A) FROM WHOM DID YOU PURCHASE MOBILE ADDRESS (B) WAS MOBILE DOME 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)WHERE MOBILE HOME IS TO BE LOCATED: (A) WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes No (B)IF LOCATED IN MOBILE HOME PARK: NAME & ADDRESS OF PARK Lot/Space # (C) IF NOT LOCATED IN MOBILE HOME PARK: NAME OF LAND OWNER: � Try LOCATION ADDRESS I S f l W • �1���e* t�br4- 14a,d,Ioc.V.. .`la REAL PROPEIITY PARCEL #/DESCRIPTION 95f c0 G1 01 Lo f 5 LIG. . (e4a.1% ppoc fkdaff. w1 PTN V kek S+. THANK YOU FOR YOUR HELP! Signat of applicant 6JO COSSELL, Property Technician • • Display Model #2 �— LEETIIIICIOD 3 Bedrooms • 2 Baths • 1,600 Square Feet `■:5 ::3C.ai:.i .Tr'!, --- ❑❑ o� 'I M■RNING-UG 'ii'ia urrii a!ii■iiu7ii� °"° g _ mu , ROOM"iiiii■i . ''■■Q'. ue ■ B-TxT-6" ■ ■.■>t■a! ■ .■ ■at■sr..av to ■■ • r as■■■s■..■u■s■■■■■■�■r.■rr DINING o ■ • ■ ■■ta■ L_ BEDROOM#3 r MI ��r u' jug mill AREA DEN ir-6•X18�-0" m6•x13 0^ 4-1.1-..:r■=gi: �%i�n ' r I'-' unurY.t-+■;LL "O,, .`, , . GUEST 1 f !1 CLOSET 6Uf MTa��■ `•', I O LIDBEr 26'-6. 4 44- us■■. _ . `~ tO� IlIlUUIIW , 5JNR ■ ■■ r■■ zit na smolt 7_ -s7fi�i:PM - t r■• r MASTER O ^ ! .•=- BEDROOM LMNG ROOM O.•. ■ ;M• i 13,10'X13'-D" iii"■--BAm- _ BEDROOM#2 �'ti Sli■r■ UL: It7-2"X 8'-70" CD ter ED i 10 WIDOW EN77F.ANCE V -E \'', ,, 0 Price Includes: f r f b-, k: 11 __-_ �r -Super Good Cents Insulation Package: ;-)i 1 i I -R 38-19-33 Thickness i JAN 1 7 2006 -Low-E Dual Pane Vinyl Windows 1 -Energy Star Appliances Price Includes: -Foam Display m Tape Sealed Seams to reduce drafting -Whole-House Ventilation Fan -2x6,Exterior Walls-NO 2x4's -Cabinet Overhead in Kitchen-Right of Sink -James Hardi Cement Siding-NO PRESSWOOD -Corner Buffet in Kitchen -Tape&Texture Throughout(Including Closets and Pantries.) -Rocker Switches Throughout -Rounded Tape&Texture Corners Throughout -Upgrade Wall to Wall Carpet Throughout(25oz.) -Porcelain Sinks&Single Lever Faucets Throughout -Passafe Door from Master to Utility -T&T Window Sills and Bullnose Ledge -2'x 2 Glass Skylight in Each Bath -22 cu.ft Side-by-Side Refer with Ice and Water -Exterior Faucet -Dishwasher -4"Exterior Bottom Trim -Deluxe Self-Clean Whirlpool Range -(3)Pairs of Shutters on Front Door Side -4"Ceramic Tile Backsplash Throughout -Set Back Frame(for Concrete Foundation) -Ceramic Bullnose Counter Edge -(Features List Available) -Raised Panel Oak Cabinets in Kitchen -Drawers over Doors Cabinet Design -Brushed Nickel Hardware -Oval Soaking Tub and 48"Shower in Master Bath - 1-Piece Fiberglass Tub/Shower in Guest Bath -Raised Panel White Interior Doors Throughout -5"Baseboard Moldings -Living Areas -Fluted Rosette Door Molding-Living Areas -Metal Mini-Blinds&Valances -50 Gallon Hot Water Heater NIF'D.- 12"Front Door Side and Endwall Eaves HUNTHOMES, INC. -And Much More(Standard Features Sheet Available) 3450 HWY. 16 W. -RREMER'1ON, WA 911312 *Prices,Features,and Availability are Subject to Change without notice or Obligation. PH:(360)373-5001-MX:(360)377-2999 Measurements are approximate. • SPECIAL CONDITIONS CASE # BLD06-0 0018 • 1.) The application was reviewed by the Jefferson County Department of Community Development for the presence of Environmentally Sensitive Areas (ESAs). The Department conducted a review and has concluded that the property DOES NOT contain Environmentally Sensitive Areas. However, future proposals will be subject to a new ESA review and conditions may be added if new ESAs are found on the property. 2.) The applicant is proposing to create or add 1600 square feet of impervious surface and 1600 square feet of land disturbing activities. 3.) 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. 4.) 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). 5.) The site plan as submitted with the manufactured home installation application on January 17, 2006 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 January 30, 2006 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 6.) This approval is for a manufactured home installation 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. 7.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 8.) 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). 9.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 10.) The building height is not to exceed 35 feet. 11.) 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. 12.) 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. 13.) Minimum setback from West Market Street and Alder Street rights-of-ways shall be 20 feet. Minimum south and west(side and rear) setbacks shall be 5 feet. 14.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. 15.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. 16.) The lot is served by PUD #1 water. 17.) The lot was created through the Harrisburg Subdivision on July 15, 1881. 18.) A septic permit(SEP05-0418) was approved on January 24, 2006. A road approach permit(RAP05-0231) was approved on September 12, 2005. 19.) An address of 111 West Market Street, Port Hadlock has been assigned to the parcel. West Market Street is a county local access (C637209). 20.) A Declaration of Restrictive Covenant was recorded on January 10, 2006 under AFN 507298 to consolidate the lots for septic and building purposes only to meet minimum land area requirements. • 21.) MANUFACTURED HOMES INSTALLATION SET UP MANUAL MUST BE ON SITE FOR ALL INSPECTIONS AND A ADDITIONAL INSTALLATION MANUAL MUST BE SUBMITTED TO JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT N oo • r,, JEFFE ON COUNTY e r fj DEPARTMENT OF COMMUNITY DEVELOPMENT".. irrillik ` ' 621 Sheridan Street • Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax � www.co.jefferson.wa.us/commdevelopment gq�, Ne�O Master Permit Application MLA: Q - B. Project Description (include se arate sheets as necessary): Tax Parcel Number. CC Property +j �� (?C� (� Size: 3 0 i © 1,-- 5 , F t. (acres/sque Site Address and/or Directions to Property: !j � Si- V zil'r�e � 5bc�v1c�l9c� �� � -i3-: Property - C Owner(s)of Record: pt y ,A e T r eA c i Telephone: 2j\O 1j li 4 - 1.4 a. a 7 Fax: email: A k F/2-14 6 `/ )M Mailing Address: \\\ \/-` . YYA rA C 1�r k ' l?0 -1 1-4 cvi l 0.! I \k)I\ , q g 3 1 `c Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies) 'fit,Building ❑Variance(Minor, Major or Reasonable Economic Use) 0 Demolition Permit O Conditional Use[C(a),C(d),or Cj** Single Family 0 Discretionary"D"or Unnamed Use Classification u Garage Attached/Detached 0 Special Use(Essential Public Facilities)** VModularManufactured Home r r ❑ Botrnlary Line Adjustment *" . > 0 Short Plat** ❑ Commercial* ' '� 0 Bind g Site Plan** ❑ Change of Use 0 Lon Plat** ❑ Address 0 Road Approach JAN 1 2,:elan ed Rural Residential Development(PRRD)Amendmm -0 Propane 0 Plat acation/Alteration** ❑ Allowed"Yes"Use Consistency Analysis 0 Sjitreline Master Program Exemption/Permit Revisions** ❑ Stormwater Management ment ❑ Shoreline Management Substantial Development*" ❑ Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance ❑ Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendr ❑Wireless Telecommunication* 0 Jefferson County Shoreline Master Program Amendment 0 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( 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 t: 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 pai 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 attomey's fees at 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 appl review and any required later inspections.Access and right of entry to this property shall be requested and shall occur only during regular busine hours. Date: I / 04 The action or actions Applicant will undertake as a resu 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 thi 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 even if you are in compliance with the,Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and n transferable responsibility for ad to and complyin with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: Date: I,)— v C.\Do....:r(`u..fe�\prD,.re\TDr• r.(1n1,e%1i. . o • . __ __ __ . SI a BUILDER STATEMENT The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and they will be assuming the responsibility of the neral Contractor for the proposed project. Signature: V1 Date: / — / -- 0((': GENERAL CONTRACTOR OR MANUFACTURED Ho E INSTALLER: PHONE: FAX: Hi)n± Home- -4- 1ic . (34O) 37' 5-00j (360) 377-y MAILING ADDRESS: 3 HSD H W1 /6/ ix,Airern er toll 11,A. �S i i EMAIL: CONTRACTOR'S --LICENSE CF' 4.-- G C WAINS NUMBER: , - tSokati1 COI S S.- ARCHITECT/ENGINEER: ( Y-4 V.I. \ C..r * (:-) 7) i N < PHONE ( ) FAX:( ) MAILING ADDRESS: ` 1 EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Dispos X New CX.,Wood Existing: 0 Sewer ❑ Addition 0 Steel Proposed: a Bank Height: ❑ Community System ❑ Atteration/Remodel 0 Concrete Total: Individual System ❑ Repair ❑ Masonry 5 SEP Permit# 0 ` - L)/ ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: ❑ Private well ❑ Twc Type of Heat: Proposed: lc,Public 4= 1 e`4 r k e. Total: Name of System: ?V 1 If this is a Commercial Protect 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: ❑ Heat Stove ❑ Cook Stove 0 Woodstove 0 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 prr lines, tank location and size,distances from the propane tank to all property lines,buildings and septic system componi including the reserve area. Square Footage Current Propoaed .i i'. Main Floor Heated EH Bld App Review: i r- 2 °Floor Heated -7= Consistency Review: ' Other Heated -1` ,' -' Base fee: f 1 ems: C I((` . ( op Mezzanine r 1. � Additional Section jAN i I L;'. t t‹-r- jtit r�x - Heated Basement .�,. `'-k,.,,,�-Cp� , Plan Check fee: ;- i Unheated Basement • r_: . State Surcharge fee: : . : Vie, ri --_..---_. Other Unheated 1- -. �� .: Pot Water Review fee: C1t� n( Garage/Carportel'�- SUBTOTAL _ i Zi -II C Decks i x K_h 911/Rd Approach fee: c Other iir ¢� TOTAL: $ L f '7/, C .a'j, 1 I/ �=*I �;�����..y,.; Receipt Number: i 6 n� tik L'4 F. 4 r:. ;_= Cash/Check Number: l Gi (1. ESTIMATED COST(REQUIRED) Date: _ .Fair market value of all labor and materials foundation to finish +1 I I /)(I Initials: / • • • . RETURN ADDRESS FIRST FEDERAL SAVINGS bE LOAN ASSOCIATION P.O. BOX 351 PORT ANGELES, WA. 98362-0055 ATT: TINA HOPPE <t f SHINGTON MANUFACTURED HOME PLEASE CHECK ONE L41 " ` ®TITLE ELIMINATION licEnsinc 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) 2005 FLEETWD 27 X 60 U r,1'L i 1 ij l-1 2j I J t S A-G l 3 © LAND LEGAL DESCRIPTION ON PAGE REAL 70PERTYTAXPARCELNUMBER MANUFACTURED HOME WILL BE ®AFFIXED �'' REMOVED 95600 601 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION 1-4 6 HARRISBURG VOL 1 PG 21 OF PLATS CQ GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS 16 1 1 NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER ANNE KRISTINE SACKETT NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 111 WEST MARKET STREET PORT HADLOCK WA 98339-9636 NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER FIRST FEDERAL SAVINGS&LOAN ASSOCIATION NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE PO BOX 351 PORT ANGELES WA 98362-0055 GRANTEE NAME DEPARTMENT OF LICENSING 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 APPLICABLg<:,' " Signature of MAitional Registered Owner and Title, IF APPLICABLE nisi AL,d6/Sx P NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE ' J' ;yam..•' ' . State of Washington Signed or attested � • '�OTA ':2 County of JEFFERSON before me on 03/29/06 •JAN. 19, 2008 : = ANNE KRISTINE SACKETI ��-- by Signature r• �' •• ' J B LAG �0\ PRINT NAME OF REGISTERED OWNER (•f Y OR AG • N. l/ / •• ,��\` by PRINT NAME OF REGISTERED OWNER PRINTED NAME 6F NOTARY //,/��IWASN\``\ NOTARY County/Office No.OR Title AND: Dealer No.OR /-'17-'0 r DEALERSHIP POSITION/AGENT/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 prthe 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. NljMje(TYPED OR PRINTED) PERMIT OFFICE/PHONE BL uk1Ca.r4- ( U\ 31l/ 46� �' DO ^ SI UA vita_ 71,170 ��TD-42079MNUFHO •APPL(R/2/ ) R W Pag f � � • • 1AANUFACTURED HOME - FROM SECTION 1 TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) 2005 FLEETWD 27 X 60 6 SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES /REMOVAL OMREAL PROPERTY. Signature of Legal Owner and Title, IF A PS BLE ELIMINATION OF 11‘` �'Y 1 ){ �` �R(�� (/ ;Z / Signature of Additional Legal Owner and Title,IF APPLICABLE NOTARY SEAL OR STAMP I NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE \\����1111111t/////f� I State of Washington /2/n/Jj��� Signed or attested \\` y P KEL4„/41 County of (�I cat /Lt before on I' • 't Ry A •, I T/157 tea era 1 Signature ... / O ,� NAME OF LEGAL OWNER NO ARY AGENT N 1•01iO5!201o•I,b 7 fa ij -v,, f_1DGr] d r Am A Keller t p 11 B��G `PRINT NAME O'LEA OWNER PRINTED NAME OF NOTARY . '9 ti• Count/Office No.OR n /, �� ••• ��.�itle No to AND: County/Office No.OR C)��/iU " ,QF•w AC.�,'\� DEALERSHIP POSITI N/AGENT TARP Notary Expiration Date / piLAND �RITIk W A legal description of the land can be obtained from the local County Assessor's Office LOTS 1 THRU 4 INCLUSIVE,BLOCK 6 OF SUPPLEMENTAL PLAT OF THE TOWN OF HARRISBURG, AS PER PLAT RECORDED IN VOLUME 1 OF PLATS,PAGE 21,RECORDS OF JEFFERSON COUNTY. SITUATE IN THE COUNTY OF JEFFERSON,STATE OF WASHINGTON. 8 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 HUNTS HOMES L�/ �� , /,, /,c PURCHASE PRICE TAX JURISDI ION/TAX RATE DEALER'S AUTHORIZED SIGNATURE Gi LiUSE 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 TTY(360)664-8885. 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