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HomeMy WebLinkAboutBLD2006-00227 • 0 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 #: BLD06-00227 Received Date: 5/2/2006 SITE ADDRESS: 12 PETERSON RD Issue Date: 6/2/2006 PORT TOWNSEND, 98368 APPLICANT: LARRY V COX ANNE L VILVANDRE 12 PETERSON RD PORT TOWNSEND WA 983688723 SUBDIVISION: BROWN LARGE LOT SUB-DIV Block: Lot: 1 PARCEL#: 801065001 Section: 6 Township: 28 N Range: 01 W CONTRACTOR/ KOZELISKY'S HOME SERVICE INC PHONE: 425-776-0101 DEALER 1112 S JACOB MILLER RD PORT TOWNSEND WA 98368 Contractor's License KOZELHS027C3 Expires 1/6/2007 INSTALLER: GREGERSON'S HOMES INGREGE3H2O5R9 Expires: 7/28/200E 23930 HWY 99 N EDMONDS WA 98026 PROJECT DESCRIPTION: NEW M/H (CLASSIC) SER#30579 MAKE: SILVERCREST YEAR: 2005 SIZE: 66'X 27' THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 6/2/2007. CALL IN FOR THE REQUIRED INSPECTIONS THAT APP YOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTING{ SLA3 or PADS USED): ,r� 3 �.�,..) �/ ✓ Stormwater FINAL Approval:p Blocking/Plumbing: �KL— 0 ' 1 cS—O(o Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps: e-/ : 0-- 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 • . MLA06-0021 8 Review Type: I MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00227 Received Date: 5/2/2006 SITE ADDRESS: 12 PETERSON RD PORT TOWNSEND, 98368 APPLICANT: LARRY V COX PHONE: 360-732-0735 ANNE L VILVANDRE 12 PETERSON RD PORT TOWNSEND WA 983688723 SUBDIVISION: BROWN LARGE LOT SUB-DIV Block: Lot: 1 PARCEL NUMBER: 801065001 Section: 6 Township: 28 N Range: 01 W CONTRACTOR/ KOZELISKY'S HOME SERVICE INC PHONE: 425-776-0101 DEALER: 1112 S JACOB MILLER RD PORT TOWNSEND WA 98368 Contractor's License KOZELHS027C3 Expires 1/6/2007 Contractor's License GREGESH2O5R9 Expires 7/28/2006 INSTALLER: GREGERSON'S HOMES INC GREGESH2O5R9 7/28/2006 425-776-0101 23930 HWY 99 N EDMONDS WA 98026 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NEW M/H (CLASSIC) SER#30579 TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: SILVERCREST SETBACK: VALUATION YEAR: 2005 LABOR & INDUSTRIES APPROVAL? SIZE: 66'X 27' BANK HEIGHT: SEWAGE DISPOSAL: ALT WATER SYSTEM: PWELL BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 3 Prop: 2 Total: 3 Total: 2 Routing 3�te�. I I Type Amount Paid By: Date: Receipt: • Approved/Date's+ Manufactured Homes $163.00 LYK 05/02/06 81143 JUN Q 2 v ci Potable Water Application $55.00 LYK 05/02/06 81143 Total: $218.00 J@f2PSOn CWity Plannitio &Ruiltthe rtment • 0 7CK WESTERMAN III Jefferson Count., Courthouse ASSESSOR PO Box 1220, Port Toonscnd, W.% 98:368 (3603 38 i-9I 0 MOBILE HOME INFORMATION FORM OWNER'S NAME/MAILING ADDRESS: NAME: Le // ill •/ ,v/ ADDRESS: /a it.-re j 'rSOi/ , . /7 7c-L�1 iiS C?-1tC' [,t'if % ✓ (O PHONE NO. 3G e - 7j,Z- 0 735 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 37 I Ve r CY -57 (B) MODEL C/4SS'i - (C) YEAR ZOOS (D) LENGTH G / (E) WIDTH & ,/f I/ (F) SERIAL # c70 ?7 oe (G)YOUR PURCHASE PRICE (Do not include sales tax) �;700 PURCHASE DATE 5111hh/� V� 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 JEFFIh1SON COUNTY LAST YEAR? Yes N 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 Ll`9' (B)IF LOCATED IN MOBILE HOME PARK: `— NAME & ADDRESS OF PARK Lot/Space # (C) IF NOT LOCATED IN MOBIL HOME PARK: / NAME OF LAND OWNER: epr�' lI t hr ip/ e .0 wr , / /da,1-1 i'e LOCATION ADDRESS / 2 pe!eyccrj Li J Ali ti71`'scie�// C.(ww yc--� REAL PROPERTY PARCEL #/DESCRIPTION ro 1 cc, 3-co S gnatur of applicanC THANK YOU FOR YOUR HELP! MAY - 2 2006 4ei)s.s-eS 1 Q. JO COSSELL, Property Technician • • 26' 8"I I * w r7• O < O <A N o rt , - I _ N sal - m r- ; o UFJI I y > o M Ia-,N , 2 En a '- in L/1 n NIN G w i 1 1 Sa• . 5 rmmiii_ mom= E. . tic, 1/1111111111 MUM a 11,. —1-5 rif.‘ CD 0 W 11•' � ...•—i 1= - r R --< k - -. -, , I .o (JQ N c- ■ o� h...3 i, ; 115 II11■ I " --I5. ,�, I g jj I■ o ■ mI III■ , . Ila..a -z e — • ioI ;e . ` Mace sELr , III I I. dG/ 1 Er-.. < ar II O rj o a Pa = D a w D X3 w ^ Aa� 0 C) �� RAT%Ear I j, D cc) co Q i 3 rn o o Ro iy I i I I CA CDw °° °'IQ 0 0 a Q I 1 ¢* I I I I ffl I I C 6l I , = I I co �• 3 U O oD ; N m y < t = v, ..... O � Q �. <D m m cl— -.. id . i m 10) OH _ o /� _�. O cB U1 Iv O • CD5 J A O 1 . r Q , • • SPECIAL CONDITIONS CASE # BLD06-00227 1.) The application was reviewed by the Jefferson County Department of Community Development staff on 5/31/06 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: slight landslide hazard & adjacent to Commercial Forest. 2.) The proposed residence would be located on a flat area on the parcel approximately 200 feet from the 25 percent slope located on the parcel. The existing driveway goes up the 25 percent slope (that is relatively flat) so no geotechnical report was required. The landowner submitted a written request to reduce the setback of the proposed residence from the parcel to the west designated Commercial Forest. The landowner is seeking to reduce the setback from 250 to 135 feet. The area adjacent to the proposed residence on the Commercial Forest Property contains a residence and is not in active forest management. The setback from the Commercial Forest land was determined to be appropriate based on the landowner acknowledgment of impacts associated with forest management, topography of the property, and approved location of the septic system (SEP 03-11) issued on 2/2/05. 3.) Jefferson County has determined that the use of real property for agriculture and forestry operations is a high priority and favored use in the county. The county will not consider to be a nuisance those inconveniences or discomforts arising from such operations, if such operations are consistent with commonly accepted best management practices in compliance with local, state, and federal laws. If your real property includes or is within five hundred (500) feet of real property designated as Rural Residential 1:10 or 1:20, Rural Industrial, Rural Commercial, Agriculture, or Forestry, you may be subject to inconveniences or discomforts arising from such farming and forestry operations, including but not limited to noise, tree removal, odors, flies, fumes, dust, smoke, the operation of farm and forestry machinery during any 24-hour period, the storage and disposal or manure, and the application of permitted fertilizers and permitted pesticides. One or more of these inconveniences may occur as a result of agricultural and forestry operations which are in conformance with existing laws and regulations. 4.) Among the native conifer species which may be used in buffers or for re-vegetation include, but are not limited to: Grand Fir(Aibes grandis), Sitka Spruce (Picea Sitchensis), Shore Pine (Pinus Contorta), Douglas Fir(Pseudotsuga Menziesii), Western Red Cedar (Thuja Plicata), and Western Hemlock (Tsuga Heterophylla). Among native tree species which may be used includes: Vine Maple (Acer Circinatum), Big-Leaf Maple (Acer Macrophyllum), Red Alder(Alnus Rubra), Pacific Madrone (Arbutus Menziesii), Quaking Aspen (Populus Tremula), Black Cottonwood (Populus Trichocarpa), Bitter Cherry (Prunus Emarginata), Oregon White Oak (Quercus Garryana), Cascara (Rhamnus Purshiana), Pacific Willow (Saliz Lasiandra), and Scouler's Willow (Saliz Scouleriana). Among the native shrub species which may be used are: Sevice-Berry(Amalanchier Alnifolia), Red Osier Dogwood (Cornus Stolonifera) Salal (Gaultheria Shallon), Ocean Spray(Holodiscus Discolor), Indian Plum (Oemlaria Cerasiformis), Pacific Ninebark (Physocarpus Capitus), Red Flowering Currant(Ribes Sanguineum), Wild Rose (Rosa Nutkana), Swamp Rose (Rosa Pisocarpa), Willows (Salix ssp.), Red Elderberry (Sam bucus Racemosa), Snowberry (Symphoricarpos Albus), Evergreen Huckleberry (Vaccinium Ovatum), Red Huckleberry(Vaccinium Parvifolium). 5.) The applicant is proposing to create or add 1,760 square feet of impervious surface and 2,560 square feet of land disturbing activities. Sections 18.30.060 and 18.30.070 of the Jefferson County Code requires that your proposal comply with Construction Best Managment Practices (attached). 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.) 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). • 8.) The site plan as submitted with the building permit application application (BLD 06-227) on May 2, 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 31, 2006 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 9.) This approval is for a manufactored 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. 10.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 11.) 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). 12.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 13.) The building height is not to exceed 35 feet. 14.) Minimum front setback from the edge of the right-of-way of Peterson Road is 20 feet. Minimum side yard setbacks are 5 feet from property lines. Minimum rear setback from the western property designated Commercial Forest is 135 ft, which was reduced from 250 feet. 15.) This parcel is Lot 1 of the Brown Large Lot Subdivision recorded Volume 1 page 30 of plats on December 7, 1992 with the Jefferson County Auditor. This parcel is designated Rural Residential 1 dwelling per 10 acres by the Jefferson County Comprehensive Plan adopted August 28, 1998. 16.) A minimum of two (2) on-site parking spaces are required for the single family residence. 17.) A Septic Permit(SEP03-11) was issued on 2/2/05 for this parcel. A forest practice application (FPA 2600704) was issued 5/23/97. This application is over 6 years from the date of the harvest so issues of moratorium are not applicable to this proposal. There was an existing RAP for this parcel. An address of 12 Peterson Road has been assigned to this parcel. 1111 • ��4gON COr, JEFFERSON COUNTY A7 ,\o DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street • Port Townsend • Washington 98368 360/379-4450 • 360/379-4451 Fax .qs, 0 www.co.jefferson.wa.us/commdevelopment AY 2 TI ; Master Permit Application MLA: D(n- Is Project Descrip'on (inc ude separ to sheets as ne essary): Tax Parcel Number: 30 I eb J 0/'7 ( Property �� r"] ,� �( C) %� lJ l Size: I / (acres/square feet) Site Address and/or Directions to Property: so r - r bco iik Wtid_ Property Ow er(s)of Record: tifizesi / t X yi • ) yr)y) i 1S E, V U] (e Telephone: (p(') 7 ' - 7 j Fax: email: Mailing Address: ' ] S }m Applicant/Agent(if different from owner): NI Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies) ❑Building ❑ Variance (Minor, Major or Reasonable Economic Use) ❑ Demolition Permit ❑ Conditional Use[C(a),C(d),or Cl** ❑ Single Family ❑ Discretionary"D"or Unnamed Use Classification ❑ Garage Attached/Detached 0 Special Use(Essential Public Facilities)** A'Manufactured Home ❑ Boundary Line Adjustment ❑ Modular ❑ Short Plat** ❑ Commercial* 0 Binding Site Plan** 0 Change of Use ❑ Long Plat** ❑Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** 0 Propane ❑ Plat Vacation/Alteration** ❑Allowed"Yes" Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** 0 Stormwater Management 0 Shoreline Management Substantial Development** 0 Site Plan Approval Advance Determination(SPAAD)* ❑ Shoreline Management Variance ❑Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment ❑Wireless Telecommunication* ❑ 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(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 ac s and right of entry to Jefferson County and its employees, representatives or agents for the sole purpose of application review and a required I er in' pe ions. ss and right f entry to this property shall be requested and shall occur only during regular business hours. --�/� / Signature: 1( i(i Cl/k Date: `�/c"—"-/° 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 complianc with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non- transferable r po)i ib y rah m to o omplyij� with t/e ESA. The Applicant has read this disclaimer and s' s and t s't below. Signature: '�/ t j�) �`j�r�; /� , ' ` Dater l W • • 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 t spon ability of the Gene I Contractor for the proposed project. �'Signature: ,11 ttitk(11 ' ! Date: 5! D Co GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: F-Ac: c ell _ c�c LSD�l 1 �- r�i �.n � 1�1 010 1 - - . MAILING ADDRESS: V I•- ,`j �QEMAIL: 1 'CONTRACTOR'S LICENSE ends "l7J(- 9 �(?'P\(,I WAIN ctm le it)zo`-I�_n Sk v NUMBER: 'e es - ZD G R NUMB R I,J RIn S OlJ g4' ARCHITECTfEN@t ., PH 3 �'" ' l C$ c 1 }COZc � K� ( �f�d �5 5zr �yl >1�� (� 3 l20 MAILING ADDRE S: KC Z E LH 602- i7C3 EMA Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: VNew VWood Existing: 'Z. Li Sewer ❑ Addition I 1 Steel Proposed: Bank Height: ❑ Community System ❑ Alteration/Remodel LI Concrete Total: Z.. <Individual System, ❑ Repair ❑ Masonry SEP Permit# 0 5,_ 1 f ❑ Demolition L I Other: Bedrooms: Water Supply: Existing: -3 Setback: 'JC Private well LI Two Party Ty of H at: Proposed: 0Public �-Q.0 ilk (, Total: j Name of System: If this is a Commercial Protect you must answer the followipe Number of Parking Spaces: Current: P posed: Number of ADA Parking Spaces: Number of occupants(includes owners,tenants,em yees,etc) Current Proposed IBC Occupancy: IBC Type of con ruction: 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: I a r B,—' ❑ Heat Stove X Coo Stove I I Woodstove LI Fireplace Insert ❑ of Water Tank L] Pellet Stove L1 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 Office Use Only Amount Revision Main Floor Heated EH Bld App Review: 2nd Floor Heated Consistency Review: itio In. Other Heated Base fee: I CZ. q) Mezzanine Additional Section: Heated Basement Plan Check fee: ____-_, Unheated Basement State Surcharge fee: Other Unheated Pot Water Review fee: CIO • ap Garage/Carport SUBTOTAL ( I Decks 911/Rd Approach fee: Ih n Other TOTAL: $ 1I oo Receipt Number: I i 43 Cash/Check Number: 11547 ESTIMATED COST(REQUIRED) Date: �'� �Vj •Fair market value of all labor and materials foundation to finish DU Initials: RETURN ADDRESS OLYMPIC NORTHWEST ESCROW, TNC_ 1480 NW SID UHINCK RD. #100 STT,VERr)AT,E, WA 98383 ATTN: PATRICIA L. DUNLAP (PATTY) 360-337-0118 Manufactured Home �-�/ "L A CH CKON dWASHIN6TDM STATE DEPARTMENT OF t TITLE ELIMINATION LICENSING Application DTRANSFER IN LOCATION Anyone who knowingly makes a false statement of a material fact is guilty DREMOVAL FROM REAL PROPERTY of a felony, and upon conviction may be punished by a fine, imprisonment,or both.(RCW 46.12.210) © MANUFACTURED HOME TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) 2005 Silvercrest 66 X 28 118-30579-AB © LAND LEGAL DESCRIPTION ON PAGE a [AFFIXED REAL TY TAX PARCEL NUMBER MANUFACTURED HOME WILL BE ❑ REMOVED 801 065001 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION 1 Brown Large Lot Subdivision © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS Jefferson 2 1 NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER Larry V.Cox COX**LV511NS NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER Anne Louise Vilvandre VILVAAL502OB ADDRESS CITY STATE ZIP CODE 12 Peterson Road Port Townsend WA 98368 NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER Washington Federal Savings NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 425 Pike Street Seattle WA 98101 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 APPLICABL - /�' " Signature of,M4itittralal Registered Owner and Title,IF APPLICABLE Y o ( 1 CLLO / NOT.ecr7kE4LC/5Sti ,Ft, I NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE �Q`;.".s\ON CClJco A;y,O t?,I State of Washington Signed or attested e • County of I / , before me on t, J. + I . r I. ; Q�sv\pTARY � ;. �s . f. ?O ,�..® ;;y ! ''i I n Signature �.t ! ,. "� 0 V PU�.,0 •'Q , PRINT NAME OF REGISTERED OWNER NOTARY OR AGENT J t -9 '•.. 4-1.� I PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY C unty/Office No.OR ``',F�tF Y•A••• ' I ' DEALERSHIP POSITION/AGENT/NOTARY `Notary Expiration Date • 11 O ... Title AND: Dealer No.OR ' 4 TITLE COMPANY CERTIFICATION I certify that the legal description of the land and ownership is true and correct per the real property records. NAME(TYPED OR PRINTED) TITLE COMPANY/PHONE NUMBER SIGNATURE/POSITION DATE Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs. ® BUILDING PERMIT OFFICE CERTIFICATION I certify that: ligthe manufactured home has been affixed to the real property as described. ID a building permit has been issued for this purpose and the attachment will be inspected upon completion. NAME(TYPED OR PRINTED) BLDG PERMIT OFFICE/PHONE# BLDG PERMIT# � \L lni VKci1/fi (6(PO) 31C]- 4L(5() B�O(o-OOdD-� SI A R'EC/PQ ION 'V y I �Y_ itt't' 0\ 5/ DATE/c TD-420-72 /^(R_(//6/06)W Page 1 of / Vl,r tr I. MANUFACTURED HOME-FROM SECTION 1 TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) 2005 Silvercrest 66 X 28 118-30579-AB 6 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 ( f ' l '-; �/ . ' E. ^�I1 litt Signatz,V df It jatN I Owner and Title,IF APPLICABLE ``� A skl..Bp� `I. /�,, I NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE Q�'p�� F�'Oi'��>J State of Washington Signed or attested �"g APRIL N County of CLALLAM before me on 02/09/07 3 �*:•N� 2009 Al. �by ELIZABETH KLIPPERT Signature-rd� 6 °.�atc/ .� ..), . .. PRINT NAME OF LEGAL OWNER NOTARY OI AGENT y •O e'• v I F OT W:••ONE �`� by MARY LOU WILLIAMS PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTARY '''��R 111 ````` County/Office No.OR Title AOTAP( Pt/73LI G AND: Dealer No.OR I DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Daten4/n3/n9 D LAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office) LOT 1,BROWN LARGE LOT SUBDIVISION,AS PER PLAT RECORDED IN VOLUME 1 OF LARGE LOTS,PAGE 30 AND 31,RECORDS OF JEFF1 RSON COUNTY,WASHINGTON. SITUATE IN THE COUNTY OF JEFFERSON,STATE OF WASHINGTON. 0 DEALER'S REPORT OF SALE I CERTIFY THAT THIS INFORMATION IS CORRECT.THE VEHICLE.IS C ^R OF ENCUMBRANCES EXCEPT AS SHOWN. ANY REQUIRED SALES TAX HAS BEEN COLLECTED. DEALE NAME(TYPED OR PRINTED) A , WA DEALER NUMBER DATE OF SALE PURCHASE PRIG TAX JURISDICTI N/TAX RATE DEAL 'O'IZED SIGNATURE /G�(�; / Vic C'')4,4',. + ,/ /G' 0 USE TAX EXEMPT Sale to a Certified Tribal me berN.n the res ation(attach notarized statement of delivery). 9 COUNTY AUDITOR/AGENT LICENSING OFFICE APPROVAL: (Not fo 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 MI 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. TD-420-729 (R/6/06)W Page 2 of 2 n-12 Cam . Ui IIIi • I ! HHJ111T l.._ !._.__.t. ._.._ _fi __,... _, ! _ 1. . _r. _ w I D i i I i 1 v.-„ 1 } f t r 1 I- i i . _ v9 D - .-. Gm � _. y .._.. ___ _ r , . T ; � , 1 I i n i V'r nir ...\"S I t i —a r 0 X ! �e 1 hd ; d s. , c �"�..__- '--. .__�,.. Via _ ... .._ .,r,_ c� : �o h , : " oa C 1 ' 17 ''AA 1t • , 7C r 1 WI • ,, \ W 04+- r : ' -,--kfl- , :- • . 01° z, r F i 4 ---0 , , . 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