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HomeMy WebLinkAboutBLD2006-00186 Sj ILDING PERMIT APPLICATTN MRL y Review 178 Type:I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00186 Received Date: 4/17/2006 SITE ADDRESS: 54 MAY ST PORT HADLOCK, 98339 OWNER: CURTIS WYMAN PHONE: (425) 673-7223 JULIE WYMAN 23280 29TH AVE W BRIER WA 98036 CHALMER'S 1ST ADDITION SUBDIVISION: Block: 5 Lot: 14-16 PARCEL NUMBER: 942600510 Section: 3 Township: 29 N Range: 01 W CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOr NEW MFH TYPE OF WORK MOB SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION 57,890.00 ADD'L: HEAT TYPE: EEE CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: SHORELINE: CONST TYPE: GARAGE: SETBACK: DECK: BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PUD BEDROOMS: BATHROOMS: Exist: Exist: Prop: 3 Prop: 2 Total: 3 Total: 2 Routing Date: 1iIoly 61? Type Amount Paid By: Date: Receipt: A Plapiov E Total: 10%nni Jeffe MAYrson Countyh Plang & Building Department 060 C Neck • • 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#: BLD06-00186 Received Date: SITE ADDRESS: 54 MAY ST 4/17/2006 PORT HADLOCK, 98339 Issue Date: 5/16/2006 APPLICANT: CURTIS P WYMAN JULIE A WYMAN 23280 29TH AVE W BRIER WA 98036 SUBDIVISION: CHA ER'S1STADDITION Block: 5 Lot: 14-16 PARCEL#: 942600510 Section: 3 Township: 29 N Range: 01 W CONTRACTOR/ HERITAGE HOME CENTER PHONE: (800) 446-1166 DEALER 259335 HWY 101 SEQUIM WA 98382 INSTALLER: HERITAGE HOME CENTERWAINS0116 Expires: 7/31/20M 259335 HWY 101 SEQUIM WA 98382 PROJECT DESCRIPTION: NEW MFH - REPLACEMENT OLD MFH ALREADY REMOVED, NEW ONE GOING IN SAME SPOT MAKE: MARLETTE YEAR: 2006 SIZE: 48 X 26.8" THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 5/16/2007. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): j 15rao Stormwater FINAL Approval: I ),;Blocking/Plumbing: (o 1—©(o • Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps: ` h7 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 • a SPECIAL CONDITIONS CASE # BLD06-00186 1.) The application was reviewed by the Jefferson County Department of Community Development staff onApril 24, 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: Special Aquifer Recharge Protection 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.) Critical Aquifer Recharge Areas are defined as Seawater Intrusion Areas, and Special Aquifer Recharge Protection Areas and the following land uses located within Susceptible Aquifer Recharge Areas (1)All Industrial Land Uses (2)All Commercial Uses (3)All Rural Residential Land Uses requiring a Discretionary Use or Conditional Use Permit(4) All Rural Residential Land Uses with nonconforming uses that would otherwise require a Discretionary Use or Conditional Use Permit (5) Unsewered Planned Rural Residential Developments (6) Unsewered residential development with gross densities greater than one unit per acre. All of the above listed uses shall be subject to the applicable requirements and standards of the Jefferson County Unified Development Code. 4.) 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. 5.) The applicant is proposing to create or add 1280 square feet of impervious surface and 1280 square feet of land disturbing activities. Sections 6.6 and 6.7 of the Jefferson County Unified Development Code requires that your proposal shall adhere to Best Management Practices (BMPs). 6.) 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. 7.) The project shall comply with Construction Stormwater Pollution Prevention (SWPP) Elements#1 through #12 of the Department of Ecology's Stormwater Management Manual for Western Washington to control stormwater, erosion and sediment during construction. BMPs shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 8.) 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). 9.) The site plan as submitted with the building permit application on April 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 May 1, 2006 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 10.) This approval is for a manufactured home only. Any future permits on this site are subject to review for consistency with applicable codes and ordinances and does not preclude review and conditions which may be placed on future permits. 11.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 12.) 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). 13.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 14.) Minimum setback from May St right-of-way is 5 ft. Minimum side and rear setbacks are 5 ft. 15.) The building height is not to exceed 35 feet. 16.) This parcel has been designated as Rural Residential 1:5 under the Jefferson County Comprehensive Plan Land Use Map effective August 28, 1998. 17.) A septic permit (SEP95-00027)was finaled on April 19, 1995 for a 3-bedroom system. 18.) May St (C635209) is a local access road. The road approach is existing and an address of 54 May St has been assigned to the parcel. 19.) This parcel was created through the Chalmer's Addition to Irondale, filed of record October 25, 1909 in Plat Book 2, page 128 with Jefferson County Auditor's office. 20.) A minimum of two (2) on-site parking spaces are required for the single family residence. 21.) The proposal is to develop across separate parcels. Setback requirements will not allow for the development to span over lot lines. For the purpose of meeting bulk and dimensional requirements and minimum land area, a Declaration of Restrictive Covenant has been recorded under AFN 511217. 22.) A Declaration Covenant Irondale/Hadlock Sanitary Sewer No Protest Agreement was recorded May 15, 2006 under AFN 511216 with the Jefferson County Auditor. 23.) The proposed manufactured home will be placed on the exact same location as the old one, which was removed before the Wymans closed on April 17, 2006. • I Fig 1Ealitlirt Model #4828-9737-6 26'-8" x 48' Approx. 1280 SF RECEIv t. WA k. Optional Deluxe JEFFERSON COUNTY OCO .- %di Master Bath _im�`f., BttTH AEI :VII /g • fVI w/f+ Wit ■ - ■ ow El I. -, UTILITY I I I , Iw , 8'-10' KITCHEN DINING ! BATH,,-1' BDRM. 2 `aoia.a 11'-0' 1 8'-8' 1 1, d - • 9 -r. rum.•� PORCH 1 II avr.FFIz 1 • i 8' 0' 1:_i1 0 BA.-2 A 'fi j I i 78'-10• @ill C) ti• _..aviu : 704.1' ... ,-/ Rif !I 1 MST. EDRM. i.T c. ,; LIVING ROOM 3' 19'-4' 12'-8- r. BDRM. 3 {: 10'-3' 1 lAii: 1 • W.I.0. i 3'-r �• II Optional Por �� Optional Recessed Entry TLC. :DRY.-4 3'-9' 10'-3' Optional Den Maar,114116&. IPO Bedroom 3 (5) JACK WESTERMAN& Jefferson ntr Courthouse ASSESSOR PO !Box 11J. Port Townsend. SV t 98368 MOBILE HOME INFORMATION FORM OWNER'S NAME/MAILING ADDRESS: "& NAME: Cn.'o:1-``; d- \r,,.,\ e_ L yvv-.4+-Z JEFFE1 S1N COW( OCO a3 U ADDRESS: ) ? /+u4r . L � fi as'«4F. GA-i14 z)kv._. E7 PHONE NO. /Z i L/ 3 - `7:2 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. 1)MOBILE HOME DATA: (A) MAKE /7) ar 1-e- (B) MODEL Pi e31 Ed t i U 1, (C) YEAR ©C? (D) LENGTH `/ 3 (E)WIDTH Si'0 (F)SERIAL # r t- GCin ©reteir- Cp q 04 (G) YOUR PURCHASE PRICE (Do not include sales tax).>O 1 {O — PURCHASE DATE Vinia 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3) (A) FROM WHOM DID YOU PURCHASE MOBILE 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)WHERE MOBILE HOME IS TO BE LOCATED: (A)WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes e (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: � �., . i of- ., .`,e„ 'L'.2)4-0-.:hn LOCATION ADDRESS -1 n)/4y J.% el r-1" 0ovc110c<k tiii 7 9 '3 j 7 REAL PROPERTY PARCEL #/DESCRIPTIONE Cilia a (j s I c) X 6�,S /y-/S// occk ,� Ck I t s Frs ' di fibn fp(,,f, 44— FL'A Signature of THANK YOU FOR YOUR HELP! dr n JOIM COSSELL, Property Technician ON co 44, d. JEFFERS•COUNTY • ,.� DEPARTMENT OF COMMUNITY DEVELSPIiIENT i., : , '4 621 Sheridan Street • Port Townsend •Washington 5$38 `'Li _ 360/379-4450 • 360/379-4451 Fax i's• gyp" www.co.jefferson.wa.us/commdevelopment • � of Master Permit Application MLA: 0 - 1 Ze Project Description (include separate sheets as necessary): JEFFERSON COOP n „f CL.''I.; 4h 3 Li\ iry e Y c vt�, ' ff Ct.. t (�'.o t® t !f�o 1'�` -_ Tax Parcel Number: el l 6;00 j/ Property Size: �1,) `:y() ,L t,„f (acres/square feet) Site Address and/or Directions to Property: „S j'�'t�(e 77 1' Property Owner(s)of Record: CL-•� �_: t' 71-#-, I, ?_-i c,--',--i t,,,0,vt Telephone:r-(L..-- 611 ---7 ,3 Fax: -J email: C "-.�10-1 G"Et i 2_.�r_f Cc' :�cr,1 t Mailing Address: 3y� r% wCJAve L✓ li:a "c r vv4, /l-C4' Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies) LI 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)** X'Manufactured Home ❑ Boundary Line Adjustment ❑ Modular ❑ Short Plat** ❑ Commercial* ❑ Binding Site Plan** ❑ Change of Use ❑ Long Plat** ❑ Address l i Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** ❑ Propane ❑ Plat Vacation/Alteration** El Allowed"Yes" Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** ❑ Stormwater Management ❑ Shoreline Management Substantial Development** ❑ Site Plan Approval Advance Determination (SPAAD)* ❑ Shoreline Management Variance ❑ Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment ❑Wireless Telecommunication* ❑ Jefferson County Shoreline Master Program Amendment ❑ Forest Practices Act/Release of Six-Year Moratorium *May require a Pre-Application Conference **Requires a Pre-Application Conference Please identify any other local, state or federal permits required for this proposal, if known: DESIGNATION OF AGENT I hereby designate to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Date: By signing this application form,the owner/agent attests that the information provided herein,and in any attachments, is true and correct to the best of his,her or it's knowledge. Any material falsehood or any omission of a material fact made by the owner/agent with respect to this application packet may result in this permit being null and void. I further agree to save,indemnify and hold harmless Jefferson County against all liabilities,judgments,court costs, reasonable attorney's fees and expenses which may in any way accrue against Jefferson County as a result of or in consequence of the granting of this permit. I further agree to provide access and right of entry to Jefferson County and its employees, representatives or agents for the sole purpose of application review and any req)ired later inspectio Access and right of entry to this property shall be requested and shall occur only during regular business hours. / Signature: �,,,/��- t,'t t/ �; /; Date: ��.: , i The action or actions Applicant will u dertake 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 ip oompliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non- transferable rereilpyi-isibijitylor ac}heri to and complying with the ESA. The Applicant has read this disclaimer and s//3/C(. s aates it below. Signature:( .�,' C L. 9 Date: G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc 40 BUILDER STATEMENT III The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that they will be astsuining e respont'lity of the General Contractor for the proposed projec Signature: f:y�_ .....„,(/' _. Date: 4/ I 7 C' G GENERAL CONTRACTOR OR MA UFACTURED HOME INSTALLER: PHONE: FAX: H -c1•-\-c cf1, Holti.c. C 4? I t - I (�) ) f99 - 11 l z ( ) MAILING ADDRESS:, { ,s-c13' ' to,/ /Q 1 S'`-y�,•,,,,, /L co z. EMAIL: CONTRACTOR'S LICENSE /1 ,7 WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: ❑ New K Wood Existing: ❑ Sewer Ii Addition LC Steel Proposed: Bank Height: [1 Community System 11 Alteration/Remodel ❑ Concrete Total: , /4 Li Individual S st m 11 Repair ❑ Masonry j I SEP Permit# - Z3" ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: 11 Private well ❑ Two Party Type of Heat: Proposed: .3 j i kd'Public C. 0 �,W Total: l 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: 1:i Underground Tank t i Above ground Tank Size of Propane Tank: ❑ Heat Stove ❑ Cook Stove 11 Woodstove ❑ Fireplace Insert ❑ Hot Water Tank C7 Pellet Stove Li 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 Current Proposed For Offic&il}se ly ` it, • : Amount Revision Main Floor Heated EH BId App Review: 2nd Floor Heated Consistency Review: r-. 153_ cc Other Heated Mezzanine Additional a ion: --43Heated Basement ) Plan Check fee: Unheated Basement o 4 State Surcharge fee: 4. Other Unheated -- Pot Water Review fee: 6 ./r� r Garage/Carport Z . c SUBTOTAL UV Decks 911/Rd Approach fee: E4.1. L`rI CI Other 0. ‘) Lo r� TOTAL: $ 4t� 1 .,GAL v (/; \ Receipt Number: '1 lb '1 5 C"` Cash/Check Number: 1 ESTIMATED COST(REQUIRED) Date: L J�� 'Fair market value of all labor and materials foundation to finish Initials: i G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc RETURN ADDRESS Jefferson Title Company P. O. Box 256 Port Townsend, WA 98368 44; " 7`"'"`_ MANUFACTURED HOME 1:14*R14- rXigtz•1'r1 $TITLE ELIMINATION licEnSinG 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) n MANUFACTURED HOME T=C PL ATE NUMBER YEAP MAKE LENGTH/WIDTHIFEET) VEHICLE IDENTIFICATION NUMBER(VIN) 2006 Marlette26' 8)(48 HER0251030RAB LAND LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE R P �R�y,�xr�AqG NUMBER �pC AFFIXED REMOVED t tde n 4-16 B5 K PLAT NAME OR SECTION/TOWNSHIPIRANGE QUARTERIOUARTER SECTION Chalmer's First Addition Q GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER RISER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS 1600 1 NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER Amy K. Arey • NAME OF ADotTioNAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER Jeffery Arey ADDRESS CITY STATE ZIP CODE NAME OF LEGAL OWNER ` DOL CUSTOMER ACCOUNT NUMBER Countrywide Home Loans NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER A.:;DRESS CITY STATE ZIP CODE GRANTEE NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGISTERED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title,IF APPLICABLE Signature of Additional Registered Owner and Title,IF APPLICABLE NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE State of Washington Signed or attested County of before me on by Signature PRINT NAME OF REGISTERED OWNER NOTARY OR AGENT by PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY Title County/Office No.OR D DEALERSHIP POSITION/AGENT/NOTARY AND: Dealer No.OR Notary Expiration Dale 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 �1l I certify that: the manufactured home has been affixed to the real property as described. 0 a building permit has been Issued for this purpose and the attachment will be inspected upon completion. . NAME(TYPED OR PRINTED) BL PERM��OFFICE/PHONE#_ BLDG PERMIT tl SIGSkAyRE i PO TION (t A ` DA 'D-420.729MANUF HOME AP A.(W2,02)0R(W Page 10(2 • • • MANUFACTURED HOME - FROM SECTION 1 YPO PLATE NUMBER YEAR MAI(E ENC�T NVID FEET) VEHICLEIOENTIFICATION NUMBER(VIN) 2006 "Marlette 6 X 8 HER0251030RAB a SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR ELIMINATION OF TITLE/REMOVAL FROM REAL PROPERTY. Signature of Legal Owner and Title,IF APPLICABLE Signature of Additional Legal Owner and Title, IF APPLICABLE NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE State of Washington Signed or attested County of before me on by Signature PRINT NAME OF LEGAL OWNER NOTARY OR AGENT by PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTARY County/Office No.OR Title AND: Dealer No.OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date uLAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office Lots 14 through 16 inclusive, Block 5, Chalmer' s First ' Addition to Iropdale, as per plat recorded in Volume 2 of Plats, page 128, records of Jefferson County, Washington. • a 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. DEALSNAME(TYPED OR PRINTED WAD LER NUMBER DATE OF SALE 7x/ A�F- / 7/✓� el e_4e'i' 't 3 Y.5 I-2 s-06 PUR,,y E PRICE p, TAX JURISDICTION/T RATE DEALER"- 0 SIG7. , /- �]USE TAX EXEMPT Sale to a Certified Tribal member on the reservation(attach notarized statement of delivery). D 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 I TYPED OR PRINTED) COUNTY OFFICENFS OPERATOR NUMBER . SiGNA 7,,RE DATE 10 TITLE FEES FILING FEE APPLICATION MOBILE HOME FEE ELIMINATION FEE USE TAX SUBAGENT FEES 9.00 15.00 24.00 TOTAL FEES 3 TAX MPORTANT: Once the application has been approved by the County Auditor/Vehicle 49.00 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. `D.420-729 MANUF HOME APPL(W2'02)OR(W)Pape 2 of 2 --r e•-• -- Z .... ,....., • M srt 1 Li C)IL,A, z aaNA\. - JaU-a .. .1 ------. - -t' ...... ,.., et, _ 0 ........ 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