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HomeMy WebLinkAboutBLD2006-00197 • • MLA06-00cU7 BUILDING PERMIT APPLICATION ReviewType:I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00197 Received Date: 4/24/2006 SITE ADDRESS: 21 E HEMLOCK ST PORT LUDLOW, 98365 OWNER: MADELINE BRODIE PHONE: 21 E HEMLOCK ST PORT LUDLOW WA 983659742 PARADISE BAY ESTATES SUBDIVISION: Block: 5 ot: 3-4 PARCEL NUMBER: 983400504 Section: 22 Township: 28 N Range: 01 CONTRACTOR: GOLDEN HOMES OF POULSBO PHONE: 360-69r-3456 19647 VIKING AVE NW POULSBO WA 98370 Contractor's License GOLDEHP950KB Expires 5/18/2007 REPRESENTATIVE: GOLDEN HOMES OF POULSBO PHONE: 360-697- 456 19647 VIKING AVE NW 360-697- 606 POULSBO WA 98370 PROJECT DESCRIPTIOI M/H REPLACEMENT GREENBRIAR SER# 9U91-0674-U-A, 9U91-0674-U-B 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: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PUD BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 1 Prop: 2 Total: 1 Total: 2 Routing Date- Type Amount Paid By: Date: Receipt: ,A C Il OV Permit $163.00 LYK 04/24/06 81115 L,. Total: $163.00 MAYS° 2006 Jefferson County Planning & Building Department CBQSLuveN " ' Ae AD ,_._ ..._ .-_____ . ., -1 l': -,, V: \,..' k .r-- --- .._... ..__.L-....._,. . , NI nCie 1 im 3y/oche_ ", , R-cnii to&v-SI P-ov+ LAAct low v\i'A q S3 --iloo --(-70z-i .,..._-- , 1\ 11 v'WI v 1 It--1 vt_fj Ave. . 1.1.vv, 1 _ .(7,) ?Nis-Po ; o)A . 110 i A I .,..•-3 ' AP ROVED ._ -1-- , i D frt- Ataiiialk: 1 MN I 1 A- t%( • SE PLAN MAY 1 8 2006 JEFF' 0 TY ....c 1 12-cevAie, 'c.(A .. DEPT.OF C SIGNATURE- E PM ,,,.. • ,s. ki NI N...) I. Cd --. )•V '''J lb ...i --1 --'1 , -.. 0 1 1,3.. I . , 1-, 1 fri, . , ir , • , .0 /- ., 0,-,-;7(Sei 0 C_Q '. .p /6)3 c-P - --4L PERM # In ° SD JEFFERS06N COUNTYI DCI) r..... HHH-18-2 06 13.18 JEANETTE/SKYL I NE IIIP.O2/O2 a ____i;11;;YL___A=?f)1.AMIL a //% N. . N. — . irammomisAri.1.77-7.11171.1.1'----` . - . 1. rc,. ..,,. ._,......._, c_ . , _____ ,„ . .-r, 0 m � d r- 1 _ ' 111� wm F. 1 a uz IIIt x 7 -_ 'g RiVLSIONS _ . 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JEFFERSON COUNTY APR 2 4 2006 W q ,� DEPARTMENT OF COMMUNITY DEVELOPMENT '' �sf' -C 621 Sheridan Street• Port Townsend- Washington 98368 i 360/379-4450 • 360/379-4451 Fax p'� www.co.jefferson.wa.us/commdevelopment �`SBING Master Permit Application MLA: alp-; 1 IProject Description(include separate sheets as necessary): ' ' ivkavktkAchAv4 }iv,n fi - Ve (Z IVI/'ill ' �� Tax Parcel Q � o �0 Property . © O �j,° / r Number. l/ �"✓ Size. )d � rI (acres/ ua e feet) Site Address and/or Directions to Property: ZI y i/ p[. --C . , {VDv4- L. 4(ow, g g;I, -- Property Owner(s)of Record: Iv k41 Ai I.ib g I LCtt Cam' Telephone: Fax: email: Mailing Address: Zi( F ., V UO( - cS # 7Y-*' (A $ s"(O Applicant/Agent(if different from owner): ��AO Oct 1 A G�.( , WA• t,<f Q1 VA4.CIOb Telephone: JtA10_ (oil-- bli6tO Fax: J4oO-((o't1 q[QO(,0 email: Mailing Address: ljL-7 k/i V.4t /We/. M'vV. , povL(Stoi, W.-• q 3-1.0 W t kind of Permit?(Check each box that applies) wilding ❑ Variance(Minor,Major or Reasonable Economic Use) LI Demolition Permit ❑ Conditional Use[C(a),C(d),or CI** I I 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 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)* ❑ 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: .. LD SIGNATION OF AGENT I hereby designate a� to act a my agen in m ers relating to this pplicati n for permit(s). OWNER SIGNATURE 1 /i / -� Date: ( 2 I tf 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 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 an pir fat r" spections.Access and right of entry to this property shall be requested and shall o r only uring regular business hours. Signature: Date: t7/t C r 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 Ad"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if you are in coin fiance with the Jefferson County development code.The Applicant acknowledges that e,she r it holds individual and non-transferable res nsi • for adherin and complying with the ESA. The Applicant has read this disclaimer nd sirs and dates it below. Signature: Date: l i't t2t, C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04.doc OWNER 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 that they will be assuming the ponsibility of the General Contractor for the proposed project. APR 2 4 20E 0 Signature: � Date: _ J-A/2��69 h' UU GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: b o t w1 o—F u,lcloo (N90 )coy- - 2g45 ( ) MAILING ADDRESS: III0-1111i1Ct . 14.1^/. EMAIL: CONTRACTOR'S LICENSE -PAALg by, WA 7jlO WAINS "� NUMBER: 01 D _D Gnf"PqG 0�fL NUMBER ARCHITECT/ENGINEER: l� V S�' PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: New )Wood Existing: ❑ Sewer Addition ❑ Steel Proposed: Bank n Cimmunity System ❑ Alteration/Remodel ❑ Concrete Total: Heig t: :. ndividual System ❑ Repair ❑ Masonry 1 V SEP Permit# iS l;"P 1-ov . $ ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: _ I Setback: rl Private well r i Two Party Type of Heat: " Proposed: Public 14 ¢(. ' Total: I NI 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: i Underground Tank i Above ground Tank Size of Propane Tank: i Heat Stove i Cook Stove i Woodstove i Fireplace Insert 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 F 1 Ei,im-R Amoute _ Current Proposed _ Ct J Main Floor pb-e) 1,061) Consistency Review: 153, CC) 2"U Floor Base fee: 3fd Floor Additional Section: Mezzanine: Plan Check fee: Heated Basement State Surcharge fee: Unheated Basement Pot Water Review fee: Other Unheated 911/Rd Approach fee: tt SA tl1 Garage/Carport TOTAL: $ Q Decks Receipt Number: '3 1 1 t 15 Other Cash/Check Number: 3 ESTIMATED COST(REQUIRED) Date: h/ .Fair market value of all labor and materials foundation to finish , 0CY Initials: &24 C C:\Documents and Settings\mochil\Desktop\Master Permit Application 7-8-04.doc JACK WESTERMAN HI Jefferson C ty Courthouse ASSESSOR • PO Box 12RIF Port To•• s n:l, 983 8r4ii (360)385-9105 .. i'' MOBILE HOME INFORMATION FORM APR 2 4 2006 OWNER'S NAME/MAILING`` ADDRESS: NAME: jA6f G/!I!41Q- I2vid f t, ADDRESS: Zl . H-Orn(fxk- LAA.4(ovV , ‘A/-A- p PHONE NO. 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: S� 1ft' €) • R2 ' n (A)MARE; _(B) MODEL b ve ak I�Y IGIY (C) YEAR' I Q V� (D) LENGTH_ 2i 1 (E)WIDTH_ 0 O�{r'1I` - i.�4 (F)SERIAL#al l.4`11 -(1 j0"H -u_g (G)YOUR PURCHASE PRICE (Do not include sales taxi �,'r7cJ27 PURCHASE DATIE � ' /CY 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 (7/01 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, HOMEK: � NAME OF LAND OWNER: P4 act 1AR 2 7, U6( LOCATION ADDRESS 2.,1 l'i• - teNY1 0C ck • L((OW r vv • Ma r REAL PROPERTY PARCEL #/DESCRIPTION {S3 - `l 00 -9)L4 Aery,c, THANK YOU FOR YOUR HELP! Signature of applicant 4JO COSSELL, Property Technician • . 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 #: BLD06-00197 Received Date: 4/24/2006 SITE ADDRESS: 21 E HEMLOCK ST Issue Date: 5/30/2006 PORT LUDLOW, 98365 APPLICANT: MADELINE BRODIE 21 E HEMLOCK ST PORT LUDLOW WA 983659742 SUBDIVISION: PARADISE BAY ESTATES Block: 5 Lot: 3-4 PARCEL#: 983400504 Section: 22 Township: 28 N Range: 01 E CONTRACTOR/ GOLDEN HOMES OF POULSBO PHONE: 360-697-3456 DEALER 19647 VIKING AVE NW POULSBO WA 98370 360-697-4606 Contractor's License GOLDEHP950KB Expires 5/18/2007 PROJECT DESCRIPTION: M/H REPLACEMENT GREENBRIAR SER#9U91-0674-U-A, 9U91-0674-U-B MAKE: SKYLINE YEAR: 2006 SIZE: 27'X40' THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 5/30/2007. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): ] Stormwater FINAL Approval: i /� Blocking/Plumbing: g 29 OL O' 1 Propane Tank/Lines .1E-E 06, -00561( Zoning Final Approval: .Qp'� Septic System Final Approval (If not on sewer): L� II p f ot• Road Approach Final Approval: Fri UA L 1)S3'l5D Final/Skirting/Vents/Porches/Steps: O4 5)aaGP7- Pgd'AmE rSSctES /2 g/i 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 9:30 a.m. -4:30 p.m. HOT-LINE AVAILABLE 24 HOURS A DAY SPECIAL CONDITIONS APPLY- SEE REVERSE • • SPECIAL CONDITIONS CASE # BLD06-00197 1.) The application was reviewed by the Jefferson County Department of Community Development staff on May 17, 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: coastal SIPZ. 2.) 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. 3.) 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. 4.) 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. 5.) VOLUNTARY MEASURES OF 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. 6.) 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. 7.) 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. 8.) The property owner shall comply with Water Conservation Measures (per list maintained by the UDC Administrator). 9.) The applicant is proposing to create or add 1080 square feet of impervious surface and 1000 square feet of land disturbing activities. 10.) 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. 11.) 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). 12.) The site plan as submitted with the manufactured home installation application on April 24, 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 18, 2006 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 13.) This approval is for a replacement 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. 14.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 15.) 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). 16.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 17.) Minimum setback from Ease Hemlock Steet and Paradise Bay Road rights-of-ways shall be 20 feet. Minimum side and rear yard setbacks shall be 5 feet. 18.) 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. 19.) 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. 20.) The building height is not to exceed 35 feet. 21.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. 22.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. 23.) An address of 21 East Hemlock Street, Port Ludlow has been assigned to the parcel. Ease Hemlock Street is a county local access (C506209). 24.) The lot was created through the Paradise Bay Estates Subdivision on September 20, 1954 under AFN 142981. The plat was corrected on April 4, 1955. 25.) A Declaration of Restrictive Covenant was recorded on May 22, 2005 under AFN 511452 to consolidate the lots for building and septic purposes only. 26.) The lots are served by PUD#1 water. 27.) A septic permit(SEP89-0355)was finaled on January 17, 1990. A buildng permit (BLD90-0013) for a mobile home was fimaled on January 8, 1990. • • RETURN ADDRESS Madeline Brodie 21 E.Hemlock Street Port Ludlow,WA 98365 STATE OF WASHWGTON � �� MANUFACTURED HOME /icEnsinc ®TITLE ELIMINATION APPLICATION ❑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 fine,imprisonment,or both. (RCW 46.12.210) D MANUFACTURED HOME TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) 2006 Greenbriar Ltd 40'/28' 9U91-0674-U-AB © LAND LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE ElAFFIXED 0 REMOVED REAL PROPERTY TAX PARCEL NUMBER 983400504 LOT BLOCK PW.T NAME OR W SECTION/TONSHIP/RANGE QUARTER/QUARTER SECTION 3And4 5 ��.�rc'r �� oy`^ GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS i I NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER Madeline Brodie NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 21 E.Hemlock Street Port Ludlow WA 98365 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 Madeline Brodie 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 Jefferson before me on Madeline Brodie by Signature PRINTED NAME OF REGISTERED OWNER NOTARY OR AGENT by PRINTED NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY County/Office No.OR Title Notary Public AND: Dealer No.OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date D 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. El BUILDING PERMIT OFFICE CERTIFICATION I certify that• N 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. Nt6.1%4E CITPED OR PRINTED) BLDG PERMIT OFFICE/PHONE# BLDG PERMIT# NA4Kk.Q Y�'t1Q_. K¢1(� Cad) 3�"la-L\45 �L--von-�o 1q7 IG a�K � ` \ ,, t,A)Q - '` R l e �61-ram '�JDA ' TD-420-29 M HOME APPL �R//2//0h2)EEX•TJof rT1�1.- �(� ( ) (W)Page I of 2 SW‘V StreamLine Mobile-Manufactured Home Application Rev.7/18/2006 • • I MANUFACTURED HOME—FROM SECTION 1 TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) 2006 40'/28' Greenbria 9U91-0674-U-AB Ltd III 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 REGISTERED OWNER(S)SIGNATURE State of Washington Signed or attested County of before me on by Signature PRINTED NAME OF REGISTERED OWNER NOTARY OR AGENT by PRINTED NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY County/Office No.OR Title AND: Dealer No.OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date DLAND DESCRIPTION(A legal description of the land can be obtained from the local County Assessor's Office.) Lot 3 And 4,Block 5,Paradise Bay Estates,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 T7Y(360)664-8885. TD-420-729 MANUF HOME APPL(R/2/02)EXT(W)Page 2 of 2 StreamLine Mobile-Manufactured Home Application Rev.7/18/2006