Loading...
HomeMy WebLinkAboutBLD2006-00349 110 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 #: BLD06-00349 SITE ADDRESS: 107 LUDLOW BAY RD Issue Date: 09/26/2006 PORT LUDLOW, 98365 Final Date: 8/30/2007 APPLICANT: STEPHEN L CHASE JR PHONE: 360-437-7627 PATRICIA ANN CHASE PO BOX 65156 PORT LUDLOW WA 983650156 SUBDIVISION: LUDLOW BEACH TRS 1 Block: Lot: PARCEL NUMBER: 968700106 Section: 16 Township: 28 N Range: 01 E PROJECT DESCRIPTION; NEW MFH (MARLETTE) THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2003 EDITION. OCCUPANCY GROUP: YYAG ,�� �� .�,p - ��� Q —Th TYPE v� �-t OF CONSTRUCTION. � �.-� �— SPRINKLER SYSTEM yes no THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 8/30/2007 Building Official Signature Date I:\F_BLD_Occupancy.rpt 10/29/19C • 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#: BLD06-00349 Received Date: 6/19/2006 SITE ADDRESS: 107 LUDLOW BAY RD Issue Date: PORT LUDLOW, 98365 9/26/2006 APPLICANT: STEPHEN L CHASE JR PATRICIA ANN CHASE PO BOX 65156 360' --vl> SUBDIVISION: PORT LUDLOW WA 983650156 LUDLOW BEACH TRS 1 PARCEL #: Block: Lot: PAR E 968700106 Section: 16 Township: 28 N Range: 01 E CONTRACTOR/ RAYO CONSTRUCTION DEALER 71 ELIZABETH LN PHONE: 360 310 0426 SEQUIM WA 98382 Contractor's License RAYOCC*964BZ Expires 1/9/2008 INSTALLER: HAI PHAM CONSTRUCTIONIAIPHI W/HERITAGE HOME OF SEQUIM LACEY WA Expires: 11/7/200� 98503-7975 PROJECT DESCRIPTION: NEW MFH (MARLETTE) MAKE: PACIFICA YEAR: 2006 SIZE: 64'X40' THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 9/26/2007. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPL •: YOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTINe, SLA: or PADS USED): / D4 Stormwater FINAL Approval: 3D d� Blocking/Plumbing: �� e 1 /E- Z / Propane Tank/Lines IU A Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: t � Final/Skirting/Vents/Porches/Steps: �EGK ` OT I -T0/'! -siA HEALTH DEPARTMENT AND PUBLIC WOR S APPRO AL REQUIRED PRIOR TO FINAL INSPECTIO THIS PERMIT IS VALID FOR ON YEAR OR IT MUST BE PROPERLY RENEWED N BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTI Office Hours 9:00 am. -4:30 p.m ONS. HOT-LINE AVAILABLE 24 HOURS A DAY SPECIAL CONDITIONS APPLY-SEE REVERSE • • SPECIAL CONDITIONS CASE # BLD06-00349 1.) The application was reviewed by the Jefferson County Department of Community Development staff on June 27, 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: T 4 stream, Osprey, wetlands, seismic, flood, SUSC aquifer recharge, coastal SIPZ. ype 2.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions that promote rapid infiltration of recharge waters to groundwater aquifers. 3.) A seasonal Type 4 Stream (Fish and Wildlife Habitat Area) has been identified on the subject property. Pursuant to JCC 18.15.315 Standard stream setbacks are required to be 100 feet, measured horizontally from the Ordinary High Water Mark (OHWM). 4.) The Category I estuarine wetland runs off site along the north and northeast sides of the property. The estuary barely extends on site at the very north tip of the property. JCC 18.15.340 requires a buffer of 150-feet, measured perpendicularly from the wetland edge, to be permanently maintained with no filling, grading, clearing, or other alteration of the wetland or its buffer allowed. A combination of factors restricting this lot provide no alternative building site other than the proposed site. This will require a buffer reduction. The maximum buffer reduction is 50%. This site quires a reduction to 78 feet for the Category I wetland. This buffer reduction will be mitigated by restoration plantings proposed in a report and mapping provided by wiltermood Associates Inc. Actual buffer mitigation will take place after consetruction on an "asbuilt" basis. Wetland buffers are areas that shall be maintained in their natural condition. The same wetland delination report prepared by Wiltermood Associates (4/6/2006) also delineates a Category III palustrine wetland running along the seaonal stream (Type 4 stream) drainage through a forested portion of the parcel. Jefferson County Code Chapter 18.15.340 requires a 50-foot setback, measured perpendicularly from the wetland edge, for a Category III wetland. This Category III wetland buffer does not require reduction. This setback is to be a buffer that is permanently maintained with no filling, grading, clearing, or other alteration allowed. 5.) Wetland Buffers are areas that shall be maintained in their natural condition.The wetland delineation report prepared by Wiltermood Associates (4/6/2006) delineates a Category III palustrine wetland running along the seaonal stream (Type 4 stream) drainage through a forested portion of the parcel. Jefferson County Code Chapter 18.15.340 requires a 50-foot setback, measured perpendicularly from the wetland edge, for a Category III wetland.This setback is to be a buffer that is permanently maintained with no filling, grading, clearing, or other alteration allowed. The same report also delineates a Category I estuarine wetland running off site along the north and northeast sides of the property. Jefferson County Code Chapter 18.15.340 requires a 150-foot setback from a Category I wetland, measured perpendicularly from the wetland edge, to be permanently maintained with no filling, grading, clearing, or other alteration of the wetland or its buffer allowed. A combination of factors restricting this lot provide no alternative building site other than the proposed site. This will require a buffer reduction for the Category I estuarine wetland. The maximum buffer reduction is 50%. 6.) 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 or Stream Buffer- Do Not Remove or Alter Existing Vegetation." 7.) A permanent physical separation along the upland boundary of the stream and wetland buffer areas shall be installed and permanently maintained. Such separation can include installing logs, trees, a hedgerow, or any other prominent physical marking the DCD Administrator. approved by 8.) An additional setback of five (5) feet is required from the edge of the stream buffer area to the proposed development. 9.) 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 be in place prior to and during construction activities. The signs shall contain the following statement: "Buffer- Do Not Remove or Alter Existing Vegetation." • 10.) VOLUNTARY MEASURES OF COASTAL &AT RIS • Water conservation measures: K •SIPZ: 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. 11.) 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. 12.) The revised site plan submitted on June 19, 2006, the engineered stormwater site plan by Maclearnsberry Engineering with its changes to the site plan, and the pre-project proposed restoration and wetland/stream buffer site plan, dated September 13, 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(s), dated September 18, 2006, shall be resubmitted for review and approval by Jefferson County Department of Community Development. Final approval of the mitigation plan will take place on an "as built" basis, following construction of the home and garage and prior to final building inspection and Certificate of Occupancy. 13.) This approval is for a single family manufactured home building ly. Any permits on this site are subject to review for consistency with applicable n des and future 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.) A minimum of two (2) on-site parking spaces is required for each single-family residence. 16.) Setbacks from Ludlow Bay Road and private access easement rights-of-ways shall be a minimum of 20 feet. Minimum setback from the Type 4 stream with mitigation shall be 100 feet plus a 5 foot buildng setback. Minimum setback from the Category III wetland shall be 50 feet. Minimum setback from the Category I wetland shall be 150 feet. Otherwise side yard setbacks shall be 5 feet. Minimum building setback from slope is 9 ft as slope is approximately 27 feet high and International Residence Code requires house edge to be a a minimum of 1/3 height of slope. 17.) The lot is served by Olympic Sewer and Water. 18.) The approved home site is more than 200 feet from the ordinary high water mark and subsequently outside of shoreline jurisdiction. 19.) Maximum lot coverage is not to exceed 45%. Lot coverage is defined as the amount of impervious surface which includes roof tops, driveways, concrete, etc. 20.) Per MPR Code Section 3.17, Accessory dwelling units (ADU's) shall not be allowed in the MPR-SF zone. All • 21.) The applicant is proposing to create or add 4973 square • 5720 square feet of land disturbing activities. JCC 1 8.30 060 and 118 30 070 require and the project applicant submit a stormwater plan meeting Minimum Requirements#1 through#5 of the Department of Ecology Stormwater Management Manual for Western Washington. The stormwater plan shall address measures to control stormwater, erosion and sediment during construction and shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 22.) Buffers are areas that shall be maintained in their natural condition, however, minor pruning or alteration of vegetation may be permitted as long as the function and character of the buffer are not diminished. 23.) Not more than 2 unlicensed vehicles shall be stored on any lot 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 Chapter 18.30 JCC. Outdoor storage of 3 or more junk motor vehicles is prohibited except in those districts where specified as an autormobile wrecking yard or junk (or salvage) yard and allowed as a permitted use in Table 3-1 or Chapter 18.18 JCC, and such storage shall meet the requriements of JCC 18.20.100, Automobile wrecking yards and junk (or salvage) yards. In no case, shall any such junk motor vehicles be stored in a critical area. 24.) 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). 25.) The lot is designated as MPR SF 4:1 under the Jefferson County Comprehensive Plan Land Use Map effective August 28, 1998. 26.) The lot was originally created as part of Ludlow Beach Tracts recorded on April 5, 1948 (AFN113358). The lot was involved in a subdivision and became part of the Amended Dunkle Short Plat as Parcel B. It was recorded on January 8, 1979 (AFN 255058). Further segregation took place through the Louie R. Timmerman Estate Segregation recorded on October 19th, 2001(AFN448730). 27.) A SPAAD with Economic Use Variance for reduction of stream buffer was applied for in 2005 (MLA05-00655) and ZON05-00055. On June 19, 2006, this application was submitted for building a manufactured home and on August 4, 2006, an application was submitted for construction of a detached garage (pole building) (MLA06-445). A road approach already exists and an address on Ludlow Bay Road (a county road) will be assigned. The applicant withdrew the Application for a SPAAD and Economic Use Variance on June 15, 2006. 28.) All construction activities shall not encroach upon the buffers. This includes the storage or preparation of materials. 29.) Buffers shall remain naturally vegetated. where buffer disturbance occurred during construction replanting with native vegetation shall be required. Minor pruning of vegetation to enhance views may be permitted on a case-by-case basis with prior approval by the Jefferson County Department of Community Development. 30.) Call Jefferson County Permit Center, Development Review Division for inspection of erosion control measures. (360) 379-4463 31.) Construction of structures on these residential lots are subject to the following setbacks: A) minimum front yard setback shall be 20-ft from Ludlow Bay Road and B) mimimum side setback from adjacent neighbor shall be 5 ft. 32.) All noise emitting machinery that cannot in any other way operate below the maximum permitted noise level shall be housed in a sound-attenuating structure. 33.) 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. 34.) An engineered Stormwater Site Plan and Drainage Report 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. 4 35.) A Certificate of Occupancy will not be issued until the Departmenteri • tinal mitigation restoration and enhancement with native plantings is inpursuant to a reviewed and approved buffer mitigation plan. Biololgist Mudra Bergan of Wiltermood Associates Inc, WDFW, WDOE, and Jefferson County Dept. of Community Development will review and approve the mitigation plan on an "as built" basis. The fifth-wheel vehicle will only be allowed to remain on the restoration site on a permanent basis if approved by WDFW, WDOE and Jefferson County. The approval will only be granted after review of the "as built" restoration plans. 36.) 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 37.) The buil1000dingfeet.height is not to exceed 35 feet. 38.) PRIOR TO FINAL BUILDING OCCUPANCY, PROPONENT SHALL SUBMIT A WRITTEN LETTER FROM MATHEW MACLEARNSBERRY, P.E. STATING THAT THE PROPOSAL WAS CONSTRUCTED IN ACCORDANCE WITH THE REQUIREMENTS OF THE "DRAINAGE REPORT FOR CHASE RESIDENCE" DATED AUGUST 24, 2006 AND STORMWATER SITE PLAN DATED AUGUST 22, 2006 AS PREPARED BY MATHEW MACLEARNSBERRY, PE OF MACLEARNSBERRY ENGINEERING, P.S. MACLEARNSBERRY ENGINEERING, P.S. Civil Engineers 0 Land Planners i DRAINAGE REPORT FOR CHASE RESIDENCE . APPROVED `� STORMWATER PLAN 4 Al ir, 2 5 2006 ii 3 11w(hit . JEFFERSON COUNTY ` DEPT.OF CO,./ UN' . ,EVELOPMENT ` SIGNATURE: :Lna14' -- imp PERMIT # BID GD� o � �� IP 0600349 0i° n1C JEFFERSON COUNTY OCO WE‘Vc % OA° Prepared for: STEPHEN & PAT CHASE c.w.0 I E,, w4 04 WAS t1 j� P� AUGUST 24, 2006 4. 4, . . G t� 4 �z ; fie{, ,p a zs 9 41 1(800) 600-4600 •(<s 4'crsTEAti c, ,' SIONAL !EXPIRES C/4 I ire159 Wyatt Way NE P.O. BOX 65382 Bainbridge Island WA 98110 Port Ludlow WA } :., '.' ,n 98365 (206) 842-7716 (360) 437-0430 • (206) 780-2408 (facsimile) OF SE:R V IC F. (206) 780- 2408 (facsimile) • CHASE DRAINAGE REPORT Site Description The Chase project is a 1.5 ac. single-family residential development consisting of the southerly portion(Parcel B )of lot 4 of Ludlow Beach Tracts. Access to the site is from Ludlow Bay Road via an easement across Lot 1 of the Amended Dunkle Short Plat. (see Figure 1-vicinity map). A category III wetland with associated type 4 stream is located on the southerly portion of the site. The site slopes towards the east and is divided into two moderately sloped terraces, which are separated by a steep slope. Vegetation on the two terraces is sparse and the balance of the site(primarily the wetland area) is forested. The underlying soils are identified as Cassolary-Kitsap complex and Lummi silt loam. These soil types are primarily classified in SCS group"C"limiting the potential for stormwater infiltration.(see Figure 2) Proposed Improvements The owners of the property desire to construct a 2640 sf single-family residence and an 864 s£ detached garage. The proposed onsite gravel driveway will be extended in to the property from the south. The driveway will be nine feet in width and approximately 163 • feet in length for an area of 1469 sf. Considered as impervious surface, the driveway together with the two structures totals 4973 s£ Applicable Standards The project is subject to the development standards of Jefferson County and Washington State Department of Ecology Stormwater Management Manual. The development proposal will create more than 2000 sf. but less than 5000 sf of new impervious surface. In addition the development will convert less than 3/4 of an acre of native vegetation (pervious surface)to landscape. Consequently,this proposal must comply with Minimum Requirements 1 —5 of the DOE manual. These are addressed as follows: Minimum Requirement# 1: Preparation of Stormwater Site Plans A stormwater site plan has been prepared illustrating the proposed improvements and permanent mitigating measures described herein. Minimum Requirement#2: Construction Stormwater Pollution Prevention(SWPPP) Incorporate into the stormwater site plan are the SWPPP requirements for temporary Erosion and sedimentation control as they apply to construction and site stabilization. These include clearing limits, silt fencing,a gravel construction entrance and specif- ications for best management practices(BMP'S)such as mulching and hydroseeding. The Elements( 1-12 )that are applicable to this project have been addressed. (( l • -gs S�F • Minimum Requirement# 3:Source Control of Pollution The limited size and nature of this development suggests that pollutant levels will be Minimal. Implementation of the recommended erosion control BMP'S should adequately address construction related pollutants, ie. sediment transport. Pollutants associated with vehicular traffic on the access driveway will be mitigated by dispersion of runoff through vegetative ground cover. Minimum Requirement#4: Preservation of Natural Drainage Systems and Outfalls The existing flow path of stormwater runoff from the site will be maintained after development of the site. Runoff from the site is currently un-concentrated sheet flow. The proposed dispersal system will mimic this condition to the maximum extent possible. Minimum Requirement# 5: On-site Stormwater Management The proposed development is greater than 22,000 sf and the underlying soils are not adequate for an infiltration system. The increase in stormwater runoff as the result of development of the site will be mitigated by installing an on-site dispersal system consistent with section 3.1.2 of the Stormwater Management Manual. The on-site vegetated flow path will be a minimum of 50 ft. to the top of bank of the steep slope. Two trenches will be provided totaling 75 ft. in length so as to disperse runoff from the building downspouts and the access driveway. Critical area buffer enhancement will also be provided on-site along the dispersal flow path. Dispersal System Sizing The proposed dispersal system will be installed and configured in conformance with figure 3.6.(enclosed) Ten feet of trench will be installed per 700 sf of contributing impervious surface area and the maximum length per trench section will be 50 feet. This requires two trench sections sized as follows: Section one %Z of house+ %of garage = 1320+432 = 1752 sf. Trench length=(1752 /700) (10)=25 ft. Length provided=25 ft. Section two '/z of house+ %2 of garage+driveway = 1320+432 + 1469=3221 sf. Trench length=(3221 /700)(10)=46 ft. Length provided=50 ft. • �� A C.,r1:1\): \ C ‘ cy- \\. . ID _ pipe O.D. II ..--U / 1 rrnn mn -end cap or p lug tow to second dispersal tie nc h i■a 111 It Q 4: -clean out wte from pipe it necessary oe•o0 0 --4"or6"perbraed pipe laidflatlevel 4� �o I notched _ , ' ae grade board -A4 `n 2'`x 2'notches Q. •A 9 ,v type IC B wJsolid cover(locking) 18"C..C. 2 . a xYPe 1 CB '�J go/solid coke.r II A Lo a . infl� 1. pipe (max design fbm {0.5 C FS per trenc h) Gio 90 v clean out%re from pipe a _� fbvr to other PLAN branching CB's as recessartr NTS pipe O.D. I 1+�'O.C. galvanized boles 1'-0 ' 1'-0 2, >.in.ls.."44.-- cFk ' T • 2 x12'-1 :'��� s ° f` f 2"grade n n ` pressure li , ¢ board notches treated grade 1 • o ° 4"ore?'perforated 13 board .y ;., 9 _9 pipe lad flat NOTES: 4"x 4'support post , 46 clean(<5%fines) 1.This trench shall be construced so Qpo . it/2 -3f+"washed rick as o prevent point dischargeand.hr icigF � a a p � \' erosion. filter fabric =F i' 2.Trenches may be planed no cbser than 50 feet t,one another(100 feet "1594 max fcr fl av ccrrtrnlhwater quaff ity ab rg fbwli ne) treat mert in rural areas. 3 Trench and grade board must be level.Algn to folbw conooursofsite. SS E CTI ON A-A 4.Support post spacing as required by NTS soil conditions to ensure grade board remains level. Figure 3.6 Standard Dispersion Trench with Notched Grade Board -4'''sli'(\ '-?t---7 D RI:: ( \,-,., , ,, , . ,., ;o rv,rr III 4..f ii [ilsn [1k.mi\i Piu August 2001 Volume Ill-Hydrologic Analysis and Flow Control BMPs 3-13 Er-11321 Topo USA®5.0 YTO — 0 .--.01.: :•. ,'..:::`:-., ,x. ,---"'L - .,.:'....-: ':.:'. . . _ ,: ,.. • ,;`,.'"..:,i .--- : ..40;'•'• " .: The,T'Affr, 41k, 40,1„. —.----/L— .. • Eu • X g t1:44 N * i SITE7 -A SKIFF IN D LOIN I „ , a PARAThs_ ...J , 1 0 S HERITAGE 1.14 § . . rCIPSIDE Cr i, .4 . g IZ) ty 4-4 A Vt A 7 ,ci, AtJ Ct ce sEp,wg Pt -, cill' I SW" -3 I 4 1 0 . . i I. ), /o, o \ o p 4 ayn.00kos k 1 ‘,. A m Data use subject to license le * an=2?:. "4=11111Ziai.,:--11 2004 DeLorme Topo USA®5 0 'F www delorme corn A Mk(17 E) o 1.143 MO PO INIO me1, Data Zoom 13-6 --k 1Th ( , A .\---,z FIGURE 1 - ,., S.-.\ 'i • , , ..-r) r MLA06-00331 Review Type: MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00349 Received Date: 6/19/2006 SITE ADDRESS: LUDLOW BAY RD PORT LUDLOW, 98365 APPLICANT: STEPHEN L CHASE JR PHONE: 360-47��� PATRICIA ANN CHASE PO BOX 65156 PORT LUDLOW WA 983650156 SUBDIVISION: LUDLOW BEACH TRS 1 Block: Lot: PAR E PARCEL NUMBER: 968700106 Section: 16 Township: 28 N Range: 01 E CONTRACTOR/ RAYO CONSTRUCTION PHONE: 360-310-0426 DEALER: 71 ELIZABETH LN SEQUIM WA 98382 Contractor's License RAYOCC*964BZ Expires 1/9/2008 Contractor's License HAIPHC*999PP Expires 11/7/2007 INSTALLER: HAI PHAM CONSTRUCTION HAIPHC*999PP 11/7/2007 (360) 455-4158 W/HERITAGE HOME OF SEQUIM LACEY WA 98503-7975 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NEW MFH (MARLETTE) TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: PACIFICA SETBACK: VALUATION 164,300.00 YEAR: 2006 LABOR & INDUSTRIES APPROVAL? SIZE: 64'X40' BANK HEIGHT: 28 SEWAGE DISPOSAL: SEW WATER SYSTEM: LUDLOW BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 3 Prop: 3 Total: 3 Total: 3 Routing Dat : Type Amount Paid Bv: Date: Receipt: Approved/Date Permit $163.00 LYK 06/19/06 83604 SEP Potable Water Application $55.00 LYK 06/19/06 83604 Jefferson County Planning Add. Manufactured Home $34.00 LYK 06/19/06 83604 & Building Department Total: $252.00 • • a i' V'' ...--, e Cm r VN O 1 cr) -_ co o v y ro° - �AC 1 MEt, d 1 A a .., _ a I: ; 61. lb 1mi. 11 m 10 v.1 ga. ii ® �� g 41 9 jC • i x ..fir ti ,.:.J .., _ ..____,________.,.F. vi Lr , C..� ^ •T ,�d 4. I a l 1 � CI ® 1=4 174 _ , ■ , t - Fri; o it vtr iwwwow 1. -t. a vII vg'K ['....; rI1 � ' , , _ i.1111 C I+11e I : b3233N! -*e A q#IZi(ir ® I 0 ' . I i I ' t. ■1 g� _-,�. • o� ,,V.b i -ter ��.. 1 ; ■■■ ao tJt tea. p z _ di • " • %,k-i - g.IF •, J o y ii / RI LSY 0 ifi, g 0 -----.. K.) .. Z d JACK WESTERMAN Il Jefferson Co r l'ourthousc ASSESSOR Po Box 1224111Rsort Townsend, 90368 (360) 38 -910 MOBILE HOME INFORMATION FORM OWNER'S NAME/MAILING ADDRESS: NAME: ie ye .1 rtn (,C ?41 C)),aSC� ADDRESS: PHONE NO.(.3‘d ) 3 ? ` W 27 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 / t R r l a Q' (B) MODEL F 1 > C R (C)YEAR L !(D) LENGTH (E) WIDTH ) O r (F) SERIAL # (G) YOUR PURCHASE PRICE (Do not include sales tax) I v 1 3 au PURCHASE DATE� -21:7,( 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3) (A) FROM WHOM DID YOU PURCHASE MOBILE ADDRESS (II) 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 DOME IS TO BE LOCATED: (A) WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes No (B)IF LOCATED IN MOBILE HOME PARK: NAME &ADDRESS OF PARK Lot/Space# (C) IF NOT LOCATED IN MOBILE HOME PARK: �R ^ NAME OF LAND OWNER: „5-1,e, �`` E r Pi C RS LOCATION ADDRESS / 7 L 1i1_p)0 1'J REAL PROPERTY PARCEL #/DESCRIPTION 76 / Q Q/ (it/ 1 v XZ N1�'��� Ll C/910-,A Sign ure of applicant- _ THANK YOU FOR YOUR HELP! 4s�-e Q Q JUN 1 9 2006 JO COSSELL, Property Technician 1 '71 0 . 1, rt,. ,... co 0 V V At k, r <-1 \ I. •.-- - .T.se,.' ID 9,9 '9•94,,°<1 ‹i \ , ., j ....1 Art., , - g•,-,I.i.., 0 r '' .% , f . .. 1. . fa‘..) r,.4 :::,,,,,,;..-;.,..:•;„.?..7.:3- SITE PLAN il cc 1 U. -it '-,•••''', . -.• 7:: • IL p. : -.: .c„.. w s,. . il )-r1.. ,:,,,,... h J /. / . :0 it ,...,,, •,.,•,, - ,.,.. . ,.. , 1 ,11:4*, ,-,L , F'•1 ',11- . -;S:'• :.-P.' I 8 2806 I . . ,', 1/4-'" •r- '41 ';-;:f1 - -- • . • 1.-- 03to '1. ..,-YrIL '• . 4; JEFFERSON COUNTY •, a_> •,,, -44 :.• I' • L 41) ,-tC)/ 7 ib-.1) .kLe":4'' , : , I 1 :').'.:.9'',. . :PI :, .;•'..16'.4t, ..21'..7 ,bEFT.OF CO,• '. ITY EVELOPMENT f ..:,, -, .:,. : -.. '1_ . .. . . ,.:,..‹..', ..--:••• ...' ,' Jr--- •. " .,,,t-k-i. i ' - -- .-IONATURE: ;,...„AP-..,.....,„..? , 4/ Air „.•''' • c • i • •• :.-:- - L - . ipic„.. /rimy. . ...: .-:;',:.:7 L''-:'.---'.''':'-'' ''....' '''. ' it-• ' ''''''''''.'d'' :'- .' •-• -'''L'". LL - •SII -A -'.'..,•.: ...':,813-01 . / W '::' -.- :.. : -:-L...::•"::-•."'.4.'-'..::-,::.f, .,...,• IP:, ' ',—,7i :-.-_,:::_,It)ii--,,f-'-'4'.': . ,..,11...4 . , .,,-,--- .,L'iii-,,,fr;r--..-', ., ••• . 44, . ' . ' ' .....' '.. '.*:441 ::-.''''''' ''. 1 ;:...'i.414\-'''.:-1 L'..:.''' '1' , : 'LL . LL'• '' .::./7'.: ''"'l?:- ''' r :r_x.,.:,: ,. ,,,,,,!..,..- :,:•:....:..:,, .4 -.....,.:,-;Livt- .i,:.,. -1, -.'' ,,':.-...,. : , • . ,.: - -- - •ta-N' . • ) ::.i..: ' .',,'0 . 1 • '-• .V•,. .:'''' : . •:• .r.-:• I I .,'A". i' ' '::.• .-\-7-V L.-. . L L 1.,-...E. , :. • •:',,..,i''''..-,:- .,,,:;.'::`:',".,,:::'?..::--,,,:--.1...•:: ••• ' ' ;_'.' '',r '11,7,1, -4°!,)-71" 1. ' ta II 1 ' iz''''. .. ..:'.4164.:.'-.H!--•..'''..',.::: .:':-'-':: :-,- •:-'':'., ' : - -.1.- *. lw ' rikli/1 '''..ri I 1: .,••••••••',"--;'....,,,:,-,.::',!•:::::.:.'',.'.:,..,-E-L.A0,..,:':' ::::; :',.:':,••., -,4 :All-...::,-,.:.-Id - 3 ....7"L -• d .>.cl ''''l 'A..,, i'L,'.: :: 1p ; .... '- ''t.a'S .L'i .-'4.'r ‘It:' ' .. . , .vo...'Wfilt‘y it.li ,....,,..7.. .,i.!,..,:•::.... r ' .'''..';::,;t: '-,•,''','''.' :1. . 1 il. E ', 4 • is ... x-1,1,—....1 , i .• •• • •.',„••••-;:-. .:::;..1., ...',: •;•-:-•'...-',.',„.1.. • -,,, ''\\';':....',:„..,:l i . .1 •• • -:.A..:::4;i:riOrverat I'Laiij" ‘ , -A :,-,,,,,,,_,:4$. ., , ..,. ,. . ... • • , -i ..L.;g '.4.,k,,IL,74-1':iIi:;', :;'e'D3''.. '''...- .1.;, . ... , ,r.,.:..:::::::::::::;,..',"..?--:j•:: ',.' Ce 'Ai = 9i : . ,._.•..14,,,?..,. --,--:'--1' :.'-:'..• ..-;',- .i:,::. . ' . L.- ::'. '-::,:..,'..,;:i :.: - .-• .-..7.1.4'--,. - - `.' --- . --i';-N=0.3-,..-1,' 'ID-) '•. •••W&.•.$1--:., " :• • : : .-.• .,- _,-,:•..i-•:;_,•:- .K,::•;== , -,',='',-- •.:- --',,,,,..-:•- -- = ; -:-•,. :-.,9-t:•-' '-.A?,-;,. :• . •'.14,1"-:?. ..rn I rs,eili • . ,••.•• •,.4,2%:,.-.,..... .. . . . . .- . ... . .. ' r '-''' . -t. • 1- • ,.. ... ,..„ ... ..„. , .. :,. .,... , L.L ' '..1±.';:-:...-7:.,,-1,•:,'=..*.-,:;„:j.......':.=i,'::,,.'•,•,': - di I: •.1.;-'15, - • , . ..,.:. -•• • ,, :, . . , L,,,,,. --:_, • , r-$04;• • ::•tt\ - . . 4 . .•.„ --, .-:, - ::-.= i. :,. - . • 0,ipIps #41, . --..., \ . , ,• • , 1 /14 oS/ - ‘•'L':.::-. - L.''',- vvr.,-ov C 13-- 1 viki ..-,. ...... .,.... H.,..-.:-- ,. ' . 4 . A er .0.. :,.' • o : ,,,4,....L..,,,,,::..; .., SI........,....,., ,r,.. .1 ..,, N.A A \ ,... .) L',.... • , „f V C ,,. r• '. . Ar.d.' •• • • . . ' . t .4 Alt*. 0. , filialgidial .•..., , '' .., ,..4plivir li!. et.. , 4suNit• •.... ' ....'. . .. . ' \r\ tr• `41‘.1...._. , ma +4 ... A/1(M./ i 411!"41114‘11, , 1 • .414 --.... . '77 „, 1 - I -.............___ bi• SZILS Man MILSCO ,4., E• ftclItilY..\11t, ''''' \c‘• k..,10 ir*reilCaL , • .m„*),„iii,_ . , 1 •i . .. ' 1‘ir57 --- 0 rtiLvitifl SC44- it) , ,42„ov, cooti-i . . . . fI .._ ,.. . 1 \ IL /1510. H . (_ ,41- , s-v:10.10 .5 tet 17-10 to I - \ s r. \ I __ . , r.3‘. \\\\ -. . - E(!) , •J,L sp \ .V • 'A- . . A 1 / fria.w. vini.,4,...- #4iii--i•ir4:-- i A Asii-isotearm..atesoo,djiic. Ns- - . --„„.tausw V7A 98367-93AI Sti., 4,411tvli , -g t-M __--- i SZI ./- /, . . ,, —..../4„. ..) 09, ..,,, ,, ¢SON eO JEFFERS COUNTY ,______:.,,_;:_,1 • r..a--- a DEPARTMENT OF COMMUN11 1f EVELOPMENT ' i t, r3 621 Sheridan Street • Port Townsend-•Washington 983 1 i 1 1 360/379-4450 • 360/379-4451 Fax i �� O fr > � www.co.jefferson.wa.us/commdevelopEWNt 1 9 i I[. HIND L. ,I Master Permit Application � m n L• U(p- 5 Project Description(include separate sheets as necessary ). ' :` r''' ,I_� \ �; Al t Pick n i cc �k+4( v,'/ c?.- o\r 1-, . () 4>6cc � Tax Parcel Number: O'y. i hs `��' A Property 7 0"P 18 r, Size: A ; _3 le t/c c rL$ (acres/square feet) Site Address and/or Directions to Property: � J / 4(AIM-h' AP.) \G( J Property Owner(s)of Record: L-- .r'J 1', ij]-1_,_i.) j� . /' "j'N) r, c 3 G. A f 1.i1 o.: e. Telephone:; ' v,}`-):-S ? ` )k A '3f42O IA3-'olal,2t email: Mailing Address: ',G-4 j Qrt yC )j,a y k,l, P.i. .). w h `jam r .)2)J a 4): i ti v 1 j 0 .-<-? Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit?(Check each box that applies) S Building ❑Variance(Minor, Major or Reasonable Economic Use) l❑ Demolition Permit ❑ Conditional Use[C(a), C(d),or C]** ASingle Family ❑ Discretionary"D"or Unnamed Use Classification �,�6arage--Attaehed red- ❑ Special Use(Essential Public Facilities)** ,.Manufactured Home ❑ Boundary Line Adjustment ❑ Modular ❑ Short Plat** ❑ Commercial* ❑ Binding Site Plan** ❑ Change of Use ❑ Long Plat** ❑Address ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** Al Propane ❑ Plat Vacation/Alteration** 0 Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** • 0 Stormwater Management ❑ Shoreline Management Substantial Development** 0 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 required later inspecti12(i& / .Access an right of entry to this property shall be requested and shall occur only during regular business hours. `� / il' /gnature: � 1 vDate: i) J The action or actions Applicant will undertake aslt of the issuance of this permit may negatively imp ct 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- transferable responsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: Date: G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc 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 responsibility of the General Contractor for the proposed project. Signature: Date: GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: r.1 (✓�,1, ( H cP Yn U.S (- ev Q, '7� 'f6.))(6 ( ) MAILING ADDRESS: ./ 3 3 )., .. A ) EMAIL: CONTRACTOR'S LICENSE WAINS A l , NUMBER: NUMBER ) / a ARCHITECT/ENGINEER: PHONE ( ) / ` FAX: ( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: ❑ New ❑ Wood Existing: ❑ Sewer ❑ Addition LI Steel Proposed: Bank Height: ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: •)) / ❑ Individual System ❑ Repair ❑ Masonry f",!/'`'''" SEP Permit# ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: I I Private well Li Two Party Type of Heat: Proposed: ❑ Public Total: 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 i Underground Tank ;$(1. Above ground Tank Size of Propane Tank: -' `C,' L. ; i i Heat Stove I] Cook Stove C] Woodstove LI Fireplace Insert ❑ Hot Water Tank ❑ Pellet'Stove ❑ Other Is this appliance being installed in a Manufactured/Mobile Home?(Yes / No When applying for a permit to install a propane tank you must also bmit 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 1 EH Bld Ai p Review: 2 /J i On-I a 2nd Floor Heated Consistency Review: clp Other Heated Base fee: i b 5 Mezzanine Additional Section: 4 Heated Basement Plan Check fee: Unheated Basement S 8ti n c fec: icp/ 131riqe jI `x) Other Unheated Pot Water Review feb: Garage/Carport SUBTOTAL ,Z-Ki 9ectt5 t'Gr h 961),zq Approach fee: I Other TOTAL: $ •4C I .d) Receipt Number: . 43: Cash/Check Number: 1 ' / _9 ESTIMATED COST(REQUIRED) Date: lU •Fair market value of all labor and materials foundation to finish l 7 1 r c C Initials: - G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc • • RETURN ADDRESS Tic or Title Company 13106 SE '240th, Suite 110 _ Kent, WA 98031 — 'L AS CH CKON r WASHINGTON STATE DEPARTMENT OF Manufactured Home Li• LICENSING Application TITLE ELIMINATION OTRANSFER IN LOCATION Anyone who knowingly makes a false statement of a material fact is guilty REMOVAL FROM REAL PROPERTY of a felony, and upon conviction may be punished by a fine,Imprisonment,or both.(RCW 46.12.210) D MANUFACTURED HOME TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) 2006 Marlette 68 X 40 HER025188ORABC © LAND LEGAL DESCRIPTION ON PAGE L "AFFIXEDREAL PROPERTY TAX PARCEL NUMBER MANUFACTURED HOME WILL BE 0 REMOVED 968700106 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION 4 Ludlow Beach Tracts © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS 2 1 NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER Stephen L.Chase,Jr. NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER Patricia Ann Chase ADDRESS CITY STATE ZIP CODE 107 Ludlow Bay Road Port Ludlow WA 98365 NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER US Bank,N.A. NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 4801 Frederica Street Owensboro KY 42301 GRANTEE NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE RE ST ED OW R(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: A Signature of Registered Owner and Title, IF APPLICABLE /I yam•..<a..,1,,� r. Signs e f WO ?99ggistered Owner and Title,IF APPLICABLE _ 1-C/"/i a117L e!'(12 — -~Ne1 ,sEAL•N.c. ,1 p•P ►► I NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE �Q� , )",o•,'1i � State of Washington Signed or attested ti" Y:'O t,OTAf�).,. '.� S County of l 'C1 bef re me on , f. ' :0 111;` • bv.S --NyA'M�EOFREGISTERED t i Ei���. ,t~ Signatur STA R' G /p�T►� f I (f)�•. PUBS\Ci o 3M` L V �,t ill rl ... y i i r:► ,1>v�, C�t 1, Yt� ►►►4�(, "' " >AV�' ...w� PRINT NAME OF REGISTERED OWNER PRINTED NAM 0 NOTARY Ei ii IdV .• o I 7 County/Office No.OR /•,,-- i "` \A VO6S'' I Title �l rf\k,, V)lk I('--'" AND: Dealer No.OR l 11:► DEALERSHIP POSITWLN/AGENT/NOTARY Notary Expiration Date 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: Q8'the manufactured home has been affixed to the real property as described. El a building permit has been issued for this purpose and the attachment will be inspected upon completion. NAME TYPED OR PRINTED) BLDG PERMIT OFFICE/PHONE# BLDG PERMIT# 4-1A V2r5u.Kp,,4 (3&oo')37I1-4450 o(0-oo319 SIG E/PO ITIQNfltit 4.)2 "` 1V/L i 21 5)DAT�9TD-420-72 (R/6/06)W Pa 7 • • MANUFACTURED HOME-FROM SECTION 1 TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) 2006 MARLETTE 68 X 40 HER025188ORABC 6 SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR EUMINATION OFF TITLE/REMOVAL FR REAL PROPERTY. Signature of Leal Owner and Title,IF APPLICABLE v v `1 US8 ft h( Signs Owner and Title,IF APPLICABLE TARP, AL OR STAMP NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE State of Washington 11� � Signed or attested County of W A 1 YI(' before me on I)12 S f c'1 It Wil by [tS/^ dv1(y ,t Signature (..` /�i(v 1. &(---- NOTARY PRINT NAME OF. GAL OWNER NOTARY OA{AGENIC 7 L' ���iii )t1 cvt� f� C.1- , by 4.' by NAME OF LEGAL OWNER PRINTEDVAME OF NOTARY County/Office No.OR 2 = Title t--eib\r 2 Li AND: Dealer No.OR 1 I l Z.c/Zo/O DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date DD C YTION A legal descHption of the land can be obtained from the local County Assessor's Office) #1 T t portion of Lot 4, "Ludlow Beach Tracts", according to the .r P t thereof recorded in Volume 3 of Plats, at page 27, records d o efferson County, Washington, lying Southerly of the following cribed line: Commencing at the Southwest corner of said Lot 4; thence North, along the West line thereof, a distance of 653.44 feet to the true point of beginning of the herein described line; thence North 70`02'10" East a distance of 106.40 feet to the East line of said Lot 4 and the terminus of said described line. 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 CLEAR OF ENCUMBRANCES EXCEPT AS SHOWN. ANY REQUIRED SALES TAX HAS BEEN COLLECTED. DEAL NAME(TYPED OR PRINTE ) WA DEALER NUM ER DATE OF SALE PU R E TAX JU�R/ISDICTIONrr ATE DEAL"� HORI �/SI NA RE„I/7/ n 0E^/t.• ,( i ?. CIUSE TAX EXEMPT Sale to a riffled Tribal member on the reservation(attach notarized statement of delivery). 9 COUNTY AUDITOR/AGENT LICENSING OFFICE APPROVAL: (Not for use by Subagents) I certify that the above application appears to have been completed correctly,and the applicant has sufficient documentation to proceed with the recording of this form. NAME(TYPED OR PRINTED) COUNTY OFFICENFS OPERATOR NUMBER SIGNATURE DATE 1Q. 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/8/06)W Page 2 of 2 N � h � _(Am 0�3 m=M Z WNm D 0m� Z a 1 m y Z; nnuz E XWSE T e T z CIO 0 c x � o o ti 0 014Os 0 0 0 va a 0 z I 5' I `, om 0 5' rn (l (A -r� DECK D C m D G) ;1 cn m m 0 1 Z N r O -1 O 00 z O m O A O� O z O c) N U Z 47 C Iwo ar awr arw. anwtt 6E�19i 41� (n