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HomeMy WebLinkAboutBLD2006-00150 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 #: BLD06-00150 SITE ADDRESS: 2614 CAPE GEORGE RD Issue Date: 04/21/2006 PORT TOWNSEND, 98368 Final Date: 1/31/2007 APPLICANT: JOHN W MERCHANT PHONE: CONNIE R MERCHANT 2580 CAPE GEORGE RD PORT TOWNSEND WA 983689404 SUBDIVISION: Block: Lot: + PARCEL NUMBER: 002124002 Section: 12 Township: 30 N Range: 02 W PROJECT DESCRIPTION: REPLACEMENT MFH (GREENBRIAR) SER# 9U-91-0628 U AB SERIAL NO. OR`484346 THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2003 EDITION. OCCUPANCY GROUP: TYPE OF CONSTRUCTION: SPRINKLER SYSTEM yes THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 1/31/2007 c--Ei3)_1-0 aCiC lA l _431 10r-1 Building Off la! Sig ture Date I:\F_BLD_Occupancy.rpt 10/29/19 • . 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#: BLD06-00150 SITE ADDRESS: 2614 CAPE GEORGE RD Received Date: 3/29/2006 PORT TOWNSEND, 98368 Issue Date: 4/21/2006 APPLICANT: JOHN W MERCHANT CONNIE R MERCHANT 2580 CAPE GEORGE RD SUBDIVISION: PORT TOWNSEND WA 983689404 Block: Lot: PARCEL #: 002124002 Section: 12 Township: 30 N Range: 02 W CONTRACTOR/ GOLDEN HOMES WY 101 PHONE: (360)681 7559 DEALER 261581 H SEQUIM WA 98382 INSTALLER: GOLDEN HOMES OF POU 19647 VIKING AVE NW PODULLSBJO VVA 98370 S 2643 Expires: PROJECT DESCRIPTION: REPLACEMENT MFH (GREENBRIAR) MAKE: SKYLINE YEAR: 2006 SIZE: 68X27 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 4/21/2007. CALL IN FOR THE REQUIRED INSPECTIONS THAT APP • JECT. Setbacks/Footing (C9NT NU S FOOTI , SLAB O PADS UR OUSED): ,K 6 Stormwater FINAL Approval: Blocking/Plumbing: . 60-'7194' Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps. HEALTH DEPARTMENT AND PUBLIC WORKS APPROVAL REQUIRED PRIOR TO FINAL INSPECTI THIS PERMIT IS VALID FOR ONE YEAR OR IT MUST BE PROPERLY RENEWED ON 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 IUILDING PERMIT APPLICA)N MLA06-00144 Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00150 Received Date: 3/29/2006 SITE ADDRESS: 2614 CAPE GEORGE RD PORT TOWNSEND, 98368 OWNER: JOHN W MERCHANT PHONE: CONNIE R MERCHANT 2580 CAPE GEORGE RD PORT TOWNSEND WA 983689404 SUBDIVISION: Block: Lot: PARCEL NUMBER: 002124002 Section: 12 Township: 30 N Range: 02 W CONTRACTOR: PHONE: PHONE: REPRESENTATIVE: KELLY ROHR GOLDEN HOMES PHONE: 360-697-3456 19647 VIKING AVE PROJECT DESCRIPTIOI REPLACE MFH (GREENBRIAR) TYPE OF WORK MOB SQUARE FOOTAGE: TYPE OF IMP NEW VALUATION MAIN: CODE EDITION: 2003 ADD'L: HEAT TYPE: EEE OCCUPANCY: HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: CONST TYPE: OTHER: GARAGE: SHORELINE: CONST TYPE: SETBACK: DECK: BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: PWELL BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 2 Prop: 2 Total: 2 Total: 2 Routing Date: , Type Amount Paid By: Date: Receipt: A roved/Dat E r, Permit $163.00 LYK 03/29/06 80952 Total: $163.00 APR 12006 Jefferson County Planning & Building Department .to 1 �.�, JACK WESTERMAN III ASSESSOR • Jefferson Count, Courthouse PO Box 1. Port Townsend, WA 98368 (360)385-9105 MOBILE HOME INFORMATION FORM OWNER'S NAME/MA.ILING ADDRESS: NAME: RA-- add ADDRESS: c a. 6 GC $2012{- PHONE NO. q�[� The purpose of this questionnaire is to obtain information r the current location of a mobile home or the previous ownership$dlolo ationeither 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 aj iother area. 1)MOBILE HOME DATA: (A) MAKE:5U\Yl.e, - , (B) MODEL ( i E Yl bvl G.� (C) (D) LENGTH ILO b (E) WIDTH_2�,s D � — (F)SERIAL (G)YOUR PURCHASE PRICE (Do not include sales tax) fa 7rp ov - 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: `PURCHASE DAT�3 6 (IFNEW MOVE TO QUESTION 3) (A) FROM WHOM DID YOU PURCHASEn MOBILE C C S 4(A4 oV1.LQy_ ti`�.tJ3 ADDRESS ( Iv Bl WAS MOBILE HOME ASSESSED IN ��y � FFER ON COUNTY LAST YEAR?Yes , 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, NAME OF LAND OWNER: • OME PARK: LOCATION ADDRESS i CA, 6 e UY2A- bwn REAL PROPERTY PARCEL #/DESCRIPTI CD - 2}-1 - G 8 3(.1) THANK YOU FOR YOUR HELPS Signat of a pp -hcant SSN ' JO I COSSELL, Property Technician • • /OPT WINDOW / ; CORNER ' R 1 / UB 11 I n B 8 OP c CORNER TUB B. I• 68'-0" * — i , �— 11N�N a / , , _ 7 I 41 ....r 1g ISM a6 I01=1L� I ( 11 �•�•_•_••�••� '•r•a !ono FAMILY ROOM -e '6 Dp _�m�—oomo�..�.p! me GARDEN TUB .ii .rma..�im�_ �.. •iinii ......�M 111111� I i, III gg� AlI i11MWI1111 11 11 �'1 � MINEMOMMIME ommono N e.l c vt� CATHEDRA.,.PU-OU- MASTER /L BEDROOM SITTING BEDROOM ' OT"► 'Ct No.1 AREA woo LIVING ROOM I 14' 10' • 18'1" 2 1 -�_ __ Sl'1 C� Vt�'L 1252CT/6828(1,836 SQ.FT.)4BEDROOM-2BATHS-CATHEDRAL THRU-OUT 1 '�-." 1' • ' • OWNER BUILDER STATEMENT • The signer of this st ement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that they will b ssu in responsibility of the General Contractor for the proposed project. Signature: Date: -b GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: Gt c en _s 0,( Pcats l)c (= D)u of l S Zp (po)o't1 y c1a, MAILING ADDRESS: ((,'((4)L11 Y l K\h ,A.,. ... i7 u tsb O EMAIL: CONTRACTOR'S LICENSE J WAINS NUMBER: C -e L t - 9 5'0. k 5 NUMBER ARCHITECT/ENGINEER: 1 C\60�\"-1 0`t1C. = kj k - PHONE ( ) FAX:( ) MAILING ADDRESS: -, \_ . t `^rl EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: y New y Wood Existing: ❑ Sewer ❑ Addition ❑ Steel Proposed: 2 Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual Syste, gi ❑ Repair ❑ Masonry SEP Permit# '1 1 ❑ Demolition 0 Other: Bedrooms: 7ater Supply: • Existing: Setback: Private well Iwo Party Type of Heat: Proposed: 'Z- ❑ Public t-on�•:.0 .i \Pt- Total: Name of System: If this is a Commercial Proiect you must ans er th following: Number of Parking Spaces: Current: Proposed: Z_ er of ADA Parking Spaces: Number of occupants(includes owners,tenants, mpl es,etc) Cu nt Proposed IBC Occupancy: IBC Type of cc s ion. Wi you have Food Service? Yes / No If this is a Propane Tank and/or Appliance In tallation it, ark al items below that apply: I Underground Tank I Above ground Tank S' e of Propane Tank: I Heat Stove I Cook Stove I Woodstove i Fireplace Ins i Hot Water Tank I Pellet Stove I 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 r Th/ � Current Proposed i" 1) `/IQ,/� U Main Floor Consistency Review: 2"u Floor I .� 3 t, Base fee: 3f°Floor Additional Section: Mezzanine: Plan Check fee: Heated Basement State Surcharge fee: Unheated Basement Pot Water Review fee: , -4.t. mkt... , Other Unheated ( ,',, '✓ 911/Rd Approach fee: _* Garage/Carport l�c)kl r TOTAL: $ 3 s i Decks �' Receipt Number: veil 5a Other Cash/Check Number: 3� ESTIMATED COST(REQUIRED) -----UA Fair market value of all labor and materials foundation to finish 3` Initials: C:\Documents and Settings\mochil\Desktop\Master Permit A licatic04.9o$ 2006 6 _._J • 4r�`tiON co ____. ._._ JEFFERSCOUNTY ---- • DEPARTMENT OF COMMUNITY DEVELOPMENT .F? '4 ` 621 Sheridan Street • Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax �gS, NG�O� www.co.jefferson.wa.us/commdev }te�t g � I Master Permit Application -, 0 i (0 — V\A' MLA: Project Description(include separate sheets as necessary): r LJ('ML1.L p ry) �`»-- 1 n ci-C. tIGh n ima ri o f c� C ►�tJ a rYtx . Ae4Acu.e.+NAA2A- Tax Parcel Number: CG'2 2 y L t]Z Property Co— / � Size: 4° 4� j (acres/square feet) Site Address and/or Directions to Property: 2U 1 e .0 1743C Property Owner(s)of Record: r a j- __kA ci ci Telephone: 3If 0 (a)43- O 0 G( 1 Fax: email: Mailing Address: Savy)c ttc ci }-e, Applicant/Agent(if different from owner): k_e l LA V_O 1j2 -(..c O en 1-toy-Y1 i S Telephoner 0 -(QG11 ,?)t c.P Fax-. 7,UL.) - Log 1 4 lF 6 LC email: Mailing Address: 1t.tL.it41 tJiKtv"1Gi ANe, lb ut( t q.6310 What kind of Permit?(Check each box that applies) 0 Building n Demolition Permit ❑ Variance(Minor,Major or Reasonable Economic Use) ❑ Single Family ❑ Conditional Use[C(a),C(d),or CI** Li Garage Attached/Detached ❑ Discretionary"D"or Unnamed Use Classification `H Manufactured Home ❑ Special Use(Essential Public Facilities)** ❑ Modular ❑ Boundary Line Adjustment ❑ Commercial* ❑ Short Plat** ❑ Change of Use ❑ Binding Site Plan** ❑ Long Plat** 0 Address I Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** ❑ Propane ❑ Plat Vacation/Alteration** ❑ Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** ❑ Stormwater Management ❑ Shoreline Management Substantial Development** ❑ Site Plan Approval Advance Determination(SPAAD) 0 Temporary Use ❑ Shoreline Management Variance ❑ Wireless Telecommunication* ❑ Comprehensive Plan/UDC/Land Use District Map Amendment ❑ Forest Practices Act/Release of Six-Year Moratorium ❑ Jefferson County Shoreline Master Program Amendment *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: I hereby designate�C�• DESIGNATION OF AGENT r: to act as my agent in matters relating to this a plication for permit(s). OWNER SIGNATUREK.16 Date: By signing this application form,the owner/agen attests that the information provided heroin,and in any attachments,is true and correct to the best of his,her or it's knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet may result in this permit being null and void. I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs,reasonable attomey's fees and expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit. I further agree to provide access and right of entry to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any required la r inspections.Access and right of entry to this property shall be requested and shall occur only during regular business hours. �. Signature: /`L e� / G Date: y / 47 The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the "Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if you are in compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-trans ra le responsibility f o and complying with the ESA. The Applicant has read this disGaia�er a signs and dates it below. Signature: s Date: 0 d C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04.doc I A 0 (4)Ad-- VV)Q.4-\--- -c-Z k_,,,_6t es 1 --- W 20' tie ?<<p3 �_�� _ MAR 2 9 2006 I 1 4 c9 `,�°i-� �,,,Jo'.1 S �.. -_-- ;LvELOPhiENT it \,\,14(4_4tN J � �3As j ,se v v.1, Ptt; .ri - tlitAv)Af ,z8. 1 ' . t5 ' ' ' 7 r ---14 4-DeAe.i.. . .4 11111 . DiesE -NI S' , --.. ' '• I k {o, ... . Y' , Cl `n .r1 ! . Koci, 5 ',Qv ,,-`3 5 ,, r -- J Ca „ `Pave.~f 1;„. d ;v%ng ow a -Z\ 1 , )" 3\) 0 (.) '11. ' 4- ---. F i 1 _ Iry J Csi ,i' I ti I ` c . l I ,. ,,, lc' 0 $ I V g 1 -1 , ,_\,-, / / iYie/ t, 1 li) f •4::, c., ir c,-.2 I ® I' Q PERMIT # ID xo 6 / 4/\V /'/ K k--- ( ' (2;e}vitseci V r';--1) [7t. ii; E li V C.E., v , JEFFERSON COU TY DCD 't,-, APR 12 Z)06 REVISED SI `PL • a .. dated 1210 o - f S. ? 00 t0 `-ete •4,, ii Has been APPROVED S '� , � / b JEFFERS I CO Requ��ed ,k NG.OF , .,�, . ► ; 1 e 1 s o SIGNA :����_ .A_��►-� �.t- • SPECIAL CONDITIONS CASE # BLD06-00150 • 1.) MANUFACTURED HOME SERIAL NUMBER MUST BE SUBMITTED TO JEFFERSON COUNTY DEPT OF COMMUNITY DEVELOPMENT PRIOR TO FINAL 2.) The application was reviewed by the Jefferson County Department of Community Development staff on April 6, 2006 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: wetlands; seismic; SUSC aquifer recharge area. 3.) 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. 4.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions that promote rapid infiltration of recharge waters to groundwater aquifers. 5.) 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. 6.) 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. 7.) Wetland 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." 8.) 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. 9.) 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. 10.) The applicant is proposing to create or add 2500 square feet of impervious surface and 2000 square feet of land disturbing activities. 11.) 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. 12.) A Stormwater Site Plan 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. 13.) 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). 14.) The revised site plan dated April 12, 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 April 19, 2006 shall be resubmitted for review and approval by Jefferson County Department of Community Development. •15.) This approval is for a manufactured home replacement only. Any future site are subject to review for consistency with applicable codes and ord nances and does not preclude review and conditions which may be placed on future permits. 16.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 17.) 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). 18.) The building height is not to exceed 35 feet. 19.) Cape George Road is classified as a Minor Collector and requires a minimum 20-foot front yard setback. The sides and rear of the property shall maintain a minimum 5-foot setback. However, the applicant shall maintain a 225-foot setback from the identified wetland area. 20.) Exterior lighting for residential uses shall not exceed twenty feet (20') in height from the finished grade, excepting when such lighting is an integral part of a building or structure. Ground level lighting is encouraged. 21.) Lighting fixtures shall be designed and hooded to prevent the light source from being directly visible from outside the boundaries of the property. The intensity or brightness of all lighting, during construction and after project completion shall not adversely affect the use of surrounding properties or adjoining rights-of-way. 22.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 23.) A minimum of two (2) on-site parking spaces shall be provided for the manufactured home. 24.) The parcel has been designated as RR 1:5 under the Jeffeson County Comprehensive Land Use Map effective August 28, 1998. 25.) The parcel is served by an individual on-site well. Well review was conducted under USR 00-0098 and approved on January 2, 2001. 26.) An address of 2614 Cape George Road, Port Townsend has ben assigned to the parcel. Cape George Road is a county minor collector(C622808). 27.) A well review (USR00-0098) was approved on January 2, 2001. A critical area review (CAR99-0465) for a septic system was finaled on November 15, 1999. A septic permit (SEP99-0307) was finaled on December 12, 2000. A building permit(BLD01-0060) for a manufacture home installation was finaled on April 29, 2002. 28.) THIS BUILDING PERMIT WILL NOT BE FINALED UNTIL THERE IS VERIFICATION THAT THE EXISTING MOBILE HOME, BLD91-60, HAS BEEN REMOVED AND DISCONNECTED FROM THE SEPTIC SYSTEM. THE PERMITTED SEPTIC SYSTEM HAS A 2 BEDROOM (240 GALLON PER DAY) MAXIMUM CAPACITY y • • RETURN ADDRESS L472 °C g"'"`ro" MANUFACTURED HOME /icEnsinc APPLICATION ®TITLE ELIMINATION ❑TRANSFER IN LOCATION ❑REMOVAL FROM REAL PROPERTY Anyone who knowingly makes a false statement of a material fact is guilty of a felony,and upon conviction may be punished by a One,imprisonment,or both. (RCW 46.12.210) fl MANUFACTURED HOME TPO/PLATE NUMBER YEAR MAKE LENGGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER WIN) / 2006 Skyline 1, ' / Z,'t ,9U-91-0628-U-AB mi LAND LEGAL DESCRIPTION ON PAGE 3 MANUFACTURED HOME WILL BE 0 AFFIXED ElREMOVED REAL PROPERTY TAX PARCEL NUMBER 002124002 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION 12/30/2W SW SE © GRANTOR(S)REGISTERED/LEGAL OWNERS) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS 1 I NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER Robert E.Judd NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 2614 Cape George Road Port Townsend WA 98368 NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER Frontier Bank NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 10705 Silverdale Way NW Silverdale WA 98383 GRANTEE NAME Robert E.Judd I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGISTERED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE:Signature of Registered Owner and Title,IF APPLICABLE t) gois Signature of Ad ;$istered Owner and Title,IF APPLICABLE NOTA�j NESUsSV p'116 NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE .`� ••••��Yv A: to of Washington• • � 8 Signed or attested •• •EOMM/Ss:.••,j�_ 0. County of Jefferson bef me on �'''I- Z. �y.•O 0�9 �V Robert E.Judd Signature 171 • .A • 2 PRINTED NAME OF REGISTERED OWNER NOTARY OR AGENT z...,�408 • � PRINTED NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY •• • •' ���� County/Office No.OR i,qs •• ,,4htIe Notary Public AND: Dealer No.OR 'v—(,,—Q c< " tiINGTON % DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date ® TITLEgaitGniV,Y% CERTIFICATION I certify that the legal description of the land and ownership is true and correct per the real property records. NAME(TYPED OR PRINTED) TITLE COMPANY/PHONE NUMBER SIGNATURE/POSITION DATE Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs. gi BUILDING PERMIT OFFICE CERTIFICATION I certify that: the manufactured home has been affixed to the real property as described. a building permit has been issued for this purpose and the attachment will be inspected upon completion. NAjvfE(TYPED OR PRINTED) BLDG�O���Fop/OII1E��� BLDG BLD06-0��# 150 S G AT �OSYTI str ,),‘Aiti r n_ Q ��a8 a TD-420-72 MANUF HO•E APPL(R/2/02)EXT(W)Page I of�2 vN,u CO StreamLine Mobile-Manufactured Home Application Rev.8/8/2005 • • MANUFACTURED HOME—FROM SECTION 1 TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VXHICLE J•NTIFICATION NUMBER(VIN) 2c ca SkyW L ��' 'X 2-75' 1-0(e2$-u-rr$ IN SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR E I N OF T •EMOVAL FROM AL PROPERTY. Signature of Legal Owner and Title,IF APPLICABLE 111) CA-�e Signature of Additional Legal Owner and Title,IF APPLICABLE ,Z0A/ 7E7Q. 414.417Wk NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR OWNER(S)SIGNATURE of Washington // Signe or attested C I M•MICKEL EN County of /�/T,�IjP before meeon NOTARY PUBLIC, by •'AZr D Ow., Signs r •Mae& STATE OF WASHINGTON PRINTED NAME OF AECICTE%B OWNER NOTARY OR AGENT Lye.\ COMMISSION EXPIRESN1 by L C/L, / C'1 .`li' .eczs cx/ AUGUST 31,2000 PRINTED NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY County/Office No.OR p It a AND: Dealer No.OR Qd/e/ t h DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date D LAND DESCRIPTION(A legal description of the land can be obtained from the local County Assessor's Office.) , ,Por.N 1/2 of SW 1/4 of SE 1/4 of Sec.12,T 30 N,R2W WM,County of Jefferson,State of WA. DEALER'S REPORT OF SALE I CERTIFY THAT THIS INFORMATION IS CORRECT,THE VEHICLES IS CLEAR OF ENCUMBRANCES EXCEPT AS SHOWN. ANY REQUIRED SALES TAX HAS BEEN COLLECTED. DEALER NAME(TYPED OR PRINTED) WA DEALER NUMBER DATE OF SALE PURCHASE PRICE TAX JURISDICTION/TAX RATE DEALER'S AUTHORIZED SIGNATURE 0 USE TAX EXEMPT Sale to a Certified Tribal member on the reservation(attach notarized statement of delivery). 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 OFFICE/VFS OPERATOR NUMBER SIGNATURE DATE ® 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 AuditorNehicle 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 call(360)902-3600 or TTY(360)664-8885. TD-420-729 MANUF HOME APPL(R/2/02)EXT(W)Page 2 of 2 StreamLine Mobile-Manufactured Home Application Rev.8/8/2005