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HomeMy WebLinkAboutBLD2006-00445 • MLA06-00433 Review Type: I MANUFACTURED! MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT#: BLD06-00445 Received Date: 8/1/2006 SITE ADDRESS: 4952 DABOB RD QUILCENE, 98376 APPLICANT: PHILIP R MILLER PHONE: 509-994-5486 COLLEEN E MILLER PO BOX 95 BRINNON WA 98320 SUBDIVISION: Block: Lot: PARCEL NUMBER: 701051017 Section: 5 Township: 27 N Range: 01 W CONTRACTOR/ SITE SERVICES LLC PHONE: 360-542-8301 DEALER: 1500 E COLLEGE WAY STE A-289 MT VERNON WA 98373 ggpp g55 Contractor's License SITESSL945CZ Expires 2 9/200$4-0536 REPRESENTATIVE: SITE SERVICES LLC PHONE: 360-844-8506 1500 E COLLEGE WAY STE A-289 MT VERNON WA 98273 PROJECT DESCRIPTION: NEW M/H (BEACON HILL 3443R) R tklivx � s 0 TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW 11( VALUATION MAKE: FLEETWOOD SETBACK: YEAR: 2006 BANK HEIGHT: LABOR & INDUSTRIES APPROVAL? SIZE: 48x24 SEWAGE DISPOSAL: ALT WATER SYSTEM: PWELL BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 3 Prop: 2 Total: 3 Total: 2 Routing Date: 311 }:_)(4) Type Amount Paid By: Date: Receipt: AApproved/Date Manufactured Homes $163.00 CJZ 08/01/06 83932J Potable Water Application $55.00 CJZ 08/01/06 83932 1$ 2006 Total: $218.00 Jefferson County Planning & Building Department - i 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 #: BLD06-00445 Received Date: 8/1/2006 SITE ADDRESS: 4952 DABOB RD Issue Date: 9/18/2006 QUILCENE, 98376 APPLICANT: PHILIP R MILLER COLLEEN E MILLER PO BOX 95 BRINNON WA 98320 SUBDIVISION: Block: Lot: TX 21 PARCEL#: 701051017 Section: 5 Township: 27 N Range: 01 W CONTRACTOR/ SITE SERVICES LLC PHONE: 360-542-8301 DEALER 1500 E COLLEGE WAY STE A-289 MT VERNON WA 98373 360-854-0536 Contractor's License SITESSL.945CZ Expires 2/9/2008 PROJECT DESCRIPTION: NEW M/H (BEACON HILL 3443R) MAKE: FLEETWOOD I Yli ,L_<< , , YEAR: 20t76 SIZE: 48x24 - X5 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 9/18/2007. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): Stormwater FINAL Approval: D -1-2-IVAL Blocking/Plumbing: dR q/S/17 Propane Tank/Lines AVA Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps: V .; , 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 `,..)-:..... e-',/-1--s z a ri Ilir ,....i.-1-€ it -, ',',pit, 344_,_,_,47.,„..,,'-vat; i)t.R..."..&7 ', e.',1',t:' ..- Q, ‘, __----- PERMIT # B1 ... 0 , - \ 1 .., , 7"/ it)00 c'eo " rec.:cif..•''.'.. / JEFEERSOAI COUNT BCD \ , \6\.,ro(v ' \ _____,.........— ci-c,:e., - -- vi. 1.10 i,i.-91 c.• , c•-,<;f.-..;;,,'n a z>.. -,.- -- CZ ',.. ... ! Chi i . ,.--, Stormwater B „IL) , I,.__ I Required o, Cnr i Clii i 0 i , ! i . 7.: REVISED S,I_TF3LAN dated i H 1 q 1, ,, i , L,0 Has been APPROVED I.U.I. •A i c V, .------------ . b JEFFERS C DEPTy.OF C D TIL) PM NT .4 : ,0 :-_-.---------- t SIGNATURE. i t 1 \ i _- -- _ ___ _ . . ... _ _. .... ... . _ • • SPECIAL CONDITIONS CASE # BLD06-00445 • 1.) The application was reviewed by the Jefferson County Department of Community Development staff on August 21, 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: Osprey; commercial forest lands adjacent. 2.) 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. 3.) The applicant is proposing to create or add 1152 square feet of impervious surface and 1152 square feet of land disturbing activities. JCC 18.30.060 and 18.30.070 require your proposal comply with Minimum Requirement#2 (Construction Stormwater Pollution Prevention) of the Department of Ecology Stormwater Management Manual for Western Washington to control stormwater, erosion and sediment during construction. BMPs shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 4.) The project shall comply with Construction Stormwater Pollution Prevention (SWPP) Elements#1 through #12 of the Department of Ecology's Stormwater Management Manual for Western Washington to control stormwater, erosion and sediment during construction. BMPs shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 5.) 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). 6.) The revised site plan dated September 14, 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 September 17, 2006 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 7.) This approval is for a manufactured home and deck 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. 8.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 9.) 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. 10.) Minimum setback from Dabob Road right-of-way shall be 20 feet. Minimum side yard setbacks shall be 5 feet. Minimum rear(north) setback shall be 90 feet from the commercial forest lands per administrative variance granted on September 6, 2006. 11.) 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. 12.) Lighting fixtures shall be design and hooded to prevent the light source from eing 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. 13.) The building height is not to exceed 35 feet. 14.) A minimum of two(2) on-site parking spaces shall be provided for the single family residence. 15.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. 16.) An address of 4952 Dabob Road, Quilcene has been assigned to the parcel. Dabob Road is a county minor collector(C348808). 17.) A building permit(BLD94-0373) for a mobile home installation was cancelled on July 6, 1994. A septic permit(SEP94-0199)was cancelled on June 12, 1994. A well review (OTH 94-0201)was approved on July 5, 1994. A building permit(BLD06-0446) for a deck will be issued with the manufactured home permit(BLD06-0445). 18.) Per email dated March 15, 2004 from Jeff Davis, WDFW biologist, Osprey are no longer a priority species. 19.) September 6, 2006, the Development Services Manager, Stacie Hoskins granted a reduction to the required 250 foot commerical forest land setback to 90 feet. The setback of 90 feet applies to the north property boundary only. 20.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 21.) The parcel is served by an existing on-site individual well. icIg1( JACK WESTERMAN I• Jefferson Coll Courthouse 7 J ASSESSOR 1'O Box 1220. Port Townsend, V / Qj A 98368 (360)385-9105 MOBILE HOME INFORMATION FORM OWNER'S NAME/MAILING ADDRESS: A ADDRESS: Q C") •c6p1. Sf (V,;1 PHONE NO QQdf) 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 \';(\0.Cl�VE.i (B) MODEL (C)YEAR\C\5 1. (D) LENGTH S (E) WIDTH -\ (F) SERIAL # aZ (G►YOUR PURCHASE PRICE (Do not include sales tax) 0)6OO.C 21 PURCHAS DATE�3) ,o 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3) (A) FROM WHOM DID YOU PURCHASE MOBILE \vw�° ti1��0 . “1C`Iy1udQQ,„ ADDRESS I36-lq CAI wt :c C c- 3E► O\Mu0. OR Ca 5� (B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? Yes If Yes, Previous address of mobile. If No, What County was Mobile assessed in last year. 3)WHERE MOBILE HOME IS TO BE LOCATED: (A) WILL THE MOBILE HOME BE IN MOBILE ROME PARK? Yes No (B)IF LOCATED IN MOBILE HOME PARK: NAME &ADDRESS OF PARK Lot/Spare # (C) IF NOT LOCATED IN MOBILE t 1\On�iE\gARK��``;� NAME OF LAND OWNER: c 0 �.+A 'P LOCATION ADDRESS _\� c� Qoboh Rd 1 REAL PROPERTY PARCEL #/DESCRIPTION 10 165 I O I I off,g a-C A.1) _ 0,e-Q Qs)0„ Signature of applicant THANK YOU FOR YOUR HELP! Ci 3,3 e �COSSELL, Property Technician 4 - 11111:1 11"\C••• ..•••• I d 1 - , 1 - ).•1 i 1 -•••• t- • - ' • - - - 7.t• %it • Go 'II - • • t . 1: 1 -`t-V-t4"*•,‘ .• : . _ ; I c7. CO • - • - 14) ^ I 1 • • r sponore. ^r- • • Aal I--. • �:�;oN coo JEFFERSur•COUNTY • RECEIVED / � DEPARTMENT OF COMMUNITY DEVELOPMENT )-' '� 621 Sheridan Street• Port Townsend •Washington 98368 -Y.; 360/379-4450 • 360/379-4451 Fax �' p$ www.co.efferson.wa.us/commdevelo ment .141 IN— Master J p N Master Permit Application MLA: dNJ f DCD Project Description(include separate sheets as necessary): NE ii0 M 1 t Eptc--ru re&- 1--oM 6-. Tax Parcel Property Number: 701051017 Size: 2.72 a (acres/square feet) Site Address and/or Directions to Property: 4952 Dabob Road,Quilcene,WA 98376 Property Owner(s)of Record: Phillip&Colleen Miller Telephone:509-994-5486 Fax: email: Mailing Address: PO Box 95,Brinnon,WA 98320 Applicant/Agent(if different from owner): Cindie Charles,Site Services LLC Telephone: 360-542-8301 or 360-661-2914 Fax:360-854-3536 email: dndie@siteservicesllc.us Mailing Address: 1500 E College Way,Suite A-289 Mount Vernon,WA 98273-5637 — What kind of Permit?(Check each box that applies) OBuilding I Variance(Minor,Major or Reasonable Economic Use) [j Demolition Permit ❑Conditional Use[C(a), C(d),or C]** d Single Family ❑Discretionary"D"or Unnamed Use Classification Q Garage Attached/Detached OSpecial Use(Essential Public Facilities)** Q Manufactured Home ❑Boundary Line Adjustment O Modular [Short Plat** Q Commercial* °Binding Site Plan** El Change of Use ❑Long Plat** Q Address i Road Approach (°Planned Rural Residential Development(PRRD)/Amendments** El Propane ❑Plat Vacation/Alteration** ❑Allowed"Yes"Use Consistency Analysis ❑Shoreline Master Program Exemption/Permit Revisions*" ❑Stormwater Management ❑Shoreline Management Substantial Development** OSite 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 Pm-Application Conference Please identify any other local, state or federal permits required for this proposal, if known: k t DESIGNATION OF AGENT I hereby designate- °-"°°�'- (" �, it V , to act as my agent in matters relating to this application for permit(s). ,Q Y / OWNER SIGNATURE �DS� of y �� 1l, Date: 07/27/2006 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 inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the applic/ation that he or she wants prior notice. Signature:(,,L. 1 Ai' !antJf.r'i. ,k .&. l,(.)ti it-4--) L( C..— Date: o7/27/206 The action or actions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or endangered species and could lead to a potential"take"of an endangered species as those terms are defined in the federal law known as the "Endangered Species Act"or"ESA."Jefferson County makes no assurances to the applicant that the actions that will be undertaken because this permit has been issued will not violate the ESA. Any individual,group or agency can file a lawsuit on behalf of an endangered species regarding your action(s)even if you are in compliance with t e Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-tran rab/r J ponsibility for adhe httoo an complyingwith the ESA. The Applicant has read this disclaimer nd signs and dates it below. Signature: t/�'✓l/ llil.l.44 r a C Date: d 4 D:\PemutCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05-2.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,�ssu in t he responsibility of the General Contractor for the proposed project. Signature: Date: tit GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: Site Services LLC (1, h' (360 )542-8301 or 360-661-2914 ( 360 ) 854-0536 MAILING ADDRESS: 1500 E College Way,Suite A-289,Mount Vernon,WA 98273-5637 EMAIL: cindie@siteservicesllc.us CONTRACTORS LICENSE WAINS NUMBER: SITESSL945CZ NUMBER 1667 ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: El New ❑ Wood Existing: 2-- ❑Sewer ❑ Addition 0 Steel Proposed: .-- Bank 0 Community System ❑ Alteration/Remodel ❑ Concrete Total: Z. Height: Q Individual System O Repair ❑ Masonry SEP Permit# ❑ Demolition 0 Other: Bedrooms: Water Supply: Existing: 3 Setback: 0 Private well 0 Two Party Type of Heat: Proposed: --- 0 Public e- �ort1Pri Aim_eke- Total: 3 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: []Underground Tank 0 Above ground Tank Size of Propane Tank: ❑Heat Stove ❑Cook Stove ❑Woodstove DFireplace Insert 0 Hot Water Tank 0 Pellet Stove 0 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: ^5GU 2na Floor Heated Consistency Review: l L3 (10 J I c t Other Heated Base fee: L /p3u0 Mezzanine Additional Section: � Heated Basement Plan Check fee: Unheated Basement State Surcharge fee: Other Unheated Pot Water Review fee: q O 0.) Garage/Carport SUBTOTAL /�`1 1 Decks 911/Rd Approach fee: exlsn,36, Other TOTAL: $ .1-1 1 , nD I Receipt Number: 5 32 Cash/Check Number: c90^3 J LI ESTIMATED COST(REQUIRED) Date: , Ql r�/ I N .Fair market value of all labor and materials foundation to finish l , Initials: D:\PernritCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05-2doc • • RETURN ADDRESS 171 STATE OF WASHINGTON PLEASE CHECK ONE Departmrnt of MANUFACTURED HOME APPLICATION TITLE ELIMINATION liCEnSinG ❑TRANSFER 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) &074039 1995 MARLT 28 X 52 ,H011009 © LAND LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE ) AFFIXED El REMOVED REA7 01 E 0 Y 5 1 PO 1 / NUMBER LOT BLOCK PLAT NAME SECTION/TOWNSHIP/RANGE 5-27-1W © 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 Philip R. Miller NAME OF ADDITIONAL REGISTERED OWNER Colleen E. Miller ADDRESS CITY STATE ZIP CODE P.O. Box 95 Brinnon WA 98320 NAME OF LEGAL OWNER Washington Federal Savings NAME OF ADDITIONAL LEGAL OWNER ADDRESS CITY STATE ZIP CODE P. O. Box 2848 Sequim WA 98382 GRANTEE NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGISTERED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title,IF APPLICABLE Signature of Additional Registered Owner and Title,IF APPLICABLE NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE State of Washington Signed or attested County of before me on by Signature PRINT NAME OF REGISTERED OWNER NOTARY OR AGENT by PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY County/Office No.OR Title AND: Dealer No.OR DEALERSHIP POSITION/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: the manufactured home has been affixed to the real property as described. 0 a building permit has been issued for this purpose and the attachment will be inspected upon completion. NAME TYPED OR PRINTED) BLDG PERMIT OFFICE/PHONE k BLDG PERMIT# Ash\�. �r\nfz S u KwI a- L3(00) ')"l a y�S� BL D 0 6-0 0 4 4 5 SIGNAT RE/POSI.TIO(� <� q 11 1101 TD-420-72 MANUF HOME AFPL(R/8/9 )OR Page 1 of 2 • • 6 SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR E,LI INATION O,F ITLE//REMOVAL FROM REAL PROPERTY. SiSignature of Legal Owner and Title,IF APPLICABL / t jy, ( 9 9 Signature ��l Q[d,3l Owner and Title,IF APPLICABLE Nc$k)=4 ,n i; ‘�r� NOTARIZATIOWCERTIFICATION FOR LEGAL OWNER(S)SIGNATURE -,..-`V:.'VO°�y NFI.o' 1171.. tatfWashington Signed or attested � APRIL . .� eoCounty of CLALLAM before me on 11/96/06 • 2009 ny ELIZABETH KLIPPERT Signatur771V-� • �'• PRINT NAME OF LEGAL OWNER NOTARY®R AGENT ,��4%31,APOO`�`�I by PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTAR County/Office NoSOR �iflllI11111 Title AND: Dealer No.OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date04/03/Oq D LAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office That portion of the West 1/2 of the West 1/2 of the Southwest 1/4 of the Northeast 1/4 of Section 5 , Township 27 North, Range 1 West , W.M. , lying Northerly of the Quilcene-Dabob Road. Situate in the County of Jefferson , State of Washington . El 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. DEALER NAME(TYPED OR PRINTED) WA DEALER NUMBER DATE OF SALE PURCHASE PRICE TAX JURISDICTION/TAX RATE DEALERS AUTHORIZED SIGNATURE ❑ USE TAX EXEMPT Sale to a Certified 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 10 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 TDD(360)664-8885. TD-420-729 MANUF HOME APPL(R/8/98)OR Page 2 of 2