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HomeMy WebLinkAboutBLD2006-00467 • 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#: BLD06-00467 Received Date: 8/11/2006 SITE ADDRESS: 15 HOPE LN Issue Date: 11/8/2006 PORT TOWNSEND, 98368 APPLICANT: JERRY R LINDSEY 1865 W UNCAS RD PORT TOWNSEND WA 98368-9397 SUBDIVISION: MAT'S LONG PLAT Block: Lot: G+ PARCEL#: 970600007 Section: 7 Township: 30 N Range: 01 W CONTRACTOR/ KOZELISKY'S HOME SERVICE INC PHONE: (360)385-3215 DEALER 1112 S JACOB MILLER RD PORT TOWNSEND WA 98368 Contractor's License KOZELHS027C3 Expires 1/6/2007 PROJECT DESCRIPTION: NEW MFH (SERIAL NO 20802) HUD NO IDA001332 MAKE: YEAR: SIZE: THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE:IS 11/8/2007. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): Stormwater FINAL Approval: Blocking/Plumbing: �i-C17 Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps: `t( ( -)...1-Q`1 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 • • MLA06-00461 Review Type: I MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00467 Received Date: 8/11/2006 SITE ADDRESS: 15 HOPE LN PORT TOWNSEND, 98368 APPLICANT: JERRY R LINDSEY PHONE: 1865 W UNCAS RD PORT TOWNSEND WA 98368-9397 SUBDIVISION: MAT'S LONG PLAT Block: Lot: G+ PARCEL NUMBER: 970600007 Section: 7 Township: 30 N Range: 01 W CONTRACTOR/ KOZELISKY'S HOME SERVICE INC PHONE: (360)385-3215 DEALER: 1112 S JACOB MILLER RD PORT TOWNSEND WA 98368 Contractor's License KOZELHS027C3 Expires 01/06/2007 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NEW MFH (SERIAL NO 20802) HUD NO IDA001332 TYPE OF WORK MOB MANUFACTURE[) HOME: SHORELINE: TYPE OF IMP NEW MAKE: SETBACK: VALUATION 15,000.00 YEAR: BANK HEIGHT: LABOR & INDUSTRIES APPROVAL? SIZE: SEWAGE DISPOSAL: CON WATER SYSTEM: 2WELL BEDROOMS: BATHROOMS: Exist: Exist: Prop: 2 Prop: 2 Total: 2 Total: 2 Routing Date: o \\OOL(C - - Type Amount Paid Bv: Date: Receipt: Approved/Dat cp e t s4 i i. Manufactured Homes $163.00 KAS 08/11/06 83981 Potable Water Application $55.00 KAS 08/11/06 83981 NOV S 2006 Total: $218.00 <e!am., County Kann ;n- I'IBnartmar, • 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#: BLD06-00467 Received Date: 8/11/2006 SITE ADDRESS: 15 HOPE LN Issue Date: 11/8/2006 PORT TOWNSEND, 98368 APPLICANT: JERRY R LINDSEY 1865 W UNCAS RD PORT TOWNSEND WA 98368-9397 SUBDIVISION: MAT'S LONG PLAT Block: Lot: G+ PARCEL#: 970600007 Section: 7 Township: 30 N Range: 01 W CONTRACTOR/ KOZELISKY'S HOME SERVICE INC PHONE: (360)385-3215 DEALER 1112 S JACOB MILLER RD PORT TOWNSEND WA 98368 Contractor's License KOZELHS027C3 Expires 1/6/2007 PROJECT DESCRIPTION: NEW MFH (SERIAL NO 20802) HUD NO IDA001332 MAKE: YEAR: SIZE: THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 11/8/2007. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): Stormwater FINAL Approval: Blocking/Plumbing: Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/SkirtingNents/Porches/Steps: 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 • • SPECIAL CONDITIONS CASE # BLD06-00467 1.) The application was reviewed by the Jefferson County Department of Community Development staff on August 22, 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: SUSC aquifer recharge area. 2.) Aquifer Recharge Areas in Jefferson County are characterized by porous geological formations that allow percolation of the surface water into the soils and the underlying zone of saturation. Aquifers are geologic formations that contain sufficient saturated permeable material to yield significant quantities of water to wells and springs. Aquifers serve as the source of drinking water within most of the rural portions of Jefferson County. 3.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions that promote rapid infiltration of recharge waters to groundwater aquifers. 4.) Critical Aquifer Recharge Areas may require special protection measures to mitigate water quality degradation. The submitted proposal does not require additional aquifer protection measures. However, during construction the project shall follow the Best Management Practices (BMPs) and facility design standards as identified and defined in the Stormwater Management Manual for the Puget Sound Basin. 5.) The applicant is proposing to create or add 938 square feet of impervious surface and 1000 square feet of land disturbing activities. 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 on August 11, 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 November 8, 2006 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 9.) This approval is for a manufactured home only. Any future permits on this site are subject to review for consistency with applicable codes and ordinances and does not preclude review and conditions which may be placed on future permits. 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 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. 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.) Minimum setback from Hope Lane right-of-way shall be 20 feet. Minimum side and rear yard setbacks shall be 5 feet. 14.) 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. 15.) 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. 16.) The building height is not to exceed 35 feet. 17.) A minimum of two (2) on-site ping spaces shall be r home. p provided for the manufactured 18.) An address of 15 Hope Lane, Port Townsend has been assigned to the parcel. Hope Lane is a private road (P566). 19.) The parcel was created through the Mats Long Subdivision recorded on January 28, 1999 under AFN 419437. 20.) The parcel has been designated as RR 1:10 under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. 21.) A two-party well agreement has been recorded on October 30, 2006 under AFN 517009 for Lots F (well is located on Lot F) and Lot G. 22.) A boundary line adjustment (EXM00-0026) was withdrawn on July 13, 2000. A building permit (BLD02-0687) for a detached shop was finaled or April 21, 2003. A septic permit (SEP96-0319) was finaled on March 21, 2000. 23.) PRIOR TO FINAL BUILDING INSPECTION, SCALED AS-BUILT DRAWINGS OF SEWER LINES INSTALLED MUST BE SUBMITTED TO ENVIRONMENTAL HEALTH WHICH INCLUDES THE SIZE OF PIPE, LOCATION, DEPTH AND ELEVATION FROM BOTH THE HOME AND SHOP BUILDINGS TO THE SEPTIC TANK. JACK WESTERMAN. Jefferson ►tr Courthouse ASSESSORtett. v fox 12�0, 1►or I 4,I.I, /I:� 9it:3(iit 4440 (:360)385-910:3 �'� ).� ` ' ; q, x `� MO111LE HOME INFOItMATION FOIE .ov ^ OWNER'S NAME/MAILING ADDRESS: NAME: 2 Z %/ Lfr. �.�.y LILI11CitJUIH I11U!YII 01;1 ADDRESS: f a'6 5 /,Jftli vniC4f 19,94— 7„.$ ..,yfuw ,.cam. 7fj / PHONE NO. 37f 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 N4it vii (B) MODEL //vI TPA 00/3 3 04C)YEAR j el n (D) LENGTH (E) WIDTH /`1 (F) SERIAL # &O 80 492 (G) YOUR PURCHASE PRICE (Do not include sales tax) JSOO `-Y PURCHASE DATE 7 5 Z 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3) (A) FROM WHOM DID YOU PURCHASE MOBILE ffOarier jkJA m ADDRESS O i ` eA,°k d K X i //- (B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR?() No If Yes, Previous address of mobile. J/9.0,7 If No, What County was Mobile assessed in last year. 3)WHERE MOBILE HOME IS TO BE LOCATED: (A) WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes No (B)IF LOCATED IN MOBILE HOME PARK: NAME &ADDRESS OF PARK !v4 Lot/Space # (C) IF NOT LOCATED IN MOBILE HOME PARK: NAME OF LAND OWNER: J,t w y LOCATION ADDRESS /C fieVfe: L,rani s REAL PROPERTY PARCEL #/DESCRIPTION Lori G ,Q.��TS Ly..0 G 'lie 'THANK YOU FOR YOUR HELP! eQQ JO COSSELL, Property Technician 0 • • 6 0-d #m • • Lin/r/p-if oll le,pi9#2 Los,j • ______L_3,2___._t 7 ill ze 7. • end R46,01 • • i • `\ • )264144 L' i ;/i-lv ° • • 1 ' • i / o ))/'' )< iT 6 RECEIVED • • r U 1 1 Luu`s • I JEfftHSUN COUNTY Ili I ¢gON co 6' JEFFERS. COUNTYIII g DEPARTMENT OF COMMUNITY DEVELOPMENT 621 Sheridan Street • Port Townsend • Washington 98368 q. .. , ,1 360/379 4450 • 360/379-4451 Fax 1,9. 0 www.co.jefferson.wa.us/commdevelopment Master Permit Application AMLA: 0U— 462 Project Description (include separate sheets as necessary): C� �n �L/!coal % LTljL C /LBi/J3✓� °Ai. i'': 1 / ._i�l0 '\ Property Tax Parcel Number: � ']p �+C'�ic9(y 7 r Size: /0, 00 `7,g ACieee3 (acres/square feet) Site Address and/or Directions to Property: / /4.,,, ;J Property Owner(s)of Record: LT,Z.:,2.y f;;urvsrc../ Telephone: 35 6`7oii. 3'/ - O 3r, Fax: email: Mailing Address: /•'ti ti_ e.,,/1J,- vvGsr ,i,,,1 14:1-irr Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit? (Check each box that applies) Building 0 Variance(Minor,Major or Reasonable Economic Use) ❑ Demolition Permit ❑ Conditional Use[C(a),C(d),or CI** ❑ Single Family ❑ Discretionary"D"or Unnamed Use Classification Garage Attached/Detached ❑ Special Use(Essential Public Facilities)** f Manufactured Home ❑ BoundaryLine Adjustment ID Modular at 1 ❑ Commercial* ❑ Short Plat ❑ Change of Use ❑ Binding Site Plan** ❑Address ❑ Long Plat** ❑ Road Approach ❑ Planned Rural Residential Development(PRRD)/Amendments** ❑ Propane ❑ Plat Vacation/Alteration** ❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** • ❑ Stormwater Management 0 Shoreline Management Substantial Development** ❑ Site Plan Approval Advance Determination (SPAAD)* ❑ Shoreline Management Variance ❑ Temporary Use - ❑ Comprehensive Plan/UDC/Land Use District Map Amendment ❑Wireless Telecommunication* ❑ Jefferson County Shoreline Master Program Amendment ❑ Forest Practices Act/Release of Six-Year Moratorium *May require a Pre—Application Conference Please identify any other local, state or federal permits required for this proposal,/ff known: ion ference I hereby designate DESIGNATION OF AGENT 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 ontry to Jefferson County and its employees,representatives or agents for the sole purpose of application review and any require ter inspections ccess and right of entry to this property shall be requested and shall occur only during regular business hours. f y Signature: ,A,-,/ J ..I Date: 7' /.j -1�=s6' 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 con}piOnce with the Jeffers County development code.The Applicant acknowledges that he,she or it holds individual and non- transferable resP9nsi.lity for adheri o co lying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: yj7--0/? iQ !f�/, Date: 777 l (y-- 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 assumin responsibility of th np I Contractor for the proposed project. Signature: 4? - rt- _ Date: - 1 GENERAL NTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: ' ozitt- is K. la � fc, rf ( 34,./ ) JP"- ;2 i s ( ) AILING ADDRESS: 1`I X S 7��"3 ,,0;i c Lam( f EMAIL: CONTRACTOR'S LICENSE f?y_sa J—ric,AniJ»> , WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX: ( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: XNew or-Wood Existing: _ ❑ Sewer ❑ Addition `0 Steel Proposed: c� Bank Height: 0 Community System ❑ Alteration/Remodel [1 Concrete Total: �//, A Individual System -v 3 1 ❑ Repair ❑ Masonry SEP Permit# g6 ❑ Demolition 0 Other: Bedrooms: Water Supply: Existing: _ _ Setback: t I Private well /,Two Party Type of Heat: Proposed: k a Public i�csrvr�i Total: /Y/l Name of System: If this is a Commercial Project you must answer the following: Number of Parking Spaces: Current: Proposed: Number of ADA Parking Spaces: Number of occupants(includes owners,tenants,employees,etc) Current Proposed IBC Occupancy: IBC Type of construction: Will you have Food Service? Yes / No If this is a Propane Tank and/or Appliance Installation permit,mark all items below that apply: 10 Underground Tank CI Above ground Tank Size of Propane Tank: ❑ Heat Stove 11 Cook Stove ❑ Woodstove ❑ Fireplace Insert ❑ Hot Water Tank ❑ Pellet Stove Il 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: I p .bb 2Floor Heated Consistency Review: �55 Other Heard A ` Base fee: 1 5.cab Mezzanine Additional Section: -— Heated Basement / • Plan'Check fee: Unheated Basement State Surcharge fee: _ __— Other Unheated Pot Water Review fee: "t,l) ,bL Garage/Carport SUBTOTAL f /,A Decks 911/Rd Approach fee: IS(--fnq Other TOTAL: $ `I"1 l 00 Receipt Number: �� 8 Cash/Check Number: 4-2&5 TIMATED COST(REQUIRED) Date: � ) 0/ •Fair market value of all labor and materials foundation to finishi W Initials: (F42-) G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc 0 • RETURN ADDRESS ST,T `'FWf"H`NGT -L AS CH CKONE ❑«�" MANUFACTURED HOME TITLE ELIMINATION /icEnsinG APPLICATION MTRANSFER 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) @ $3L 197 HAMM - 1 X r'l Zo?oZ © LAND LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE AFFIXEDREAL PROPERTY TAX PARCEL NUMBER 0 REMOVED ci10t 00 004, LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION 1 ti kP 301J �� Se idn 07Q 5 ���� i'! ��fi $E 1 lOul(arty 1 .r/ © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS NAME OF REGISTERED OWNER 'DOL CUSTOMER ACCOUNT NUMBER °( .o Ba1— J'J DP NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER HI ADDRESS r. p CITY STATE/TE ZIP CODE 7 r pZc�4 U C`K v .4 1"f. -r �'`l t g 14'L w `J I o d(P Z NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER fZo 2T J OD NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER 1J (A ADDRESS CITY STATE ZIP CODE d a1y Cikp-e-- (7corF 2d, Polk- 1acA5-61 1 \A/n- q g 3(2 S GRANTEE NAME J CKI Lindsey I DO SOLEMNLY ATTEST UND R 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 .6 L;9 (t / Signature Registered Owner and Title, IF APPLICABLE N I NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE �,pvli I State of Washington �/\1 Signed or attested ('\t n Or •�-�Q County of • �� �(�if?)� " g b' �,remeon 1 Veta im/ Jr —I °847dy„ Rbt y Signature /y AN ♦ar. 10 PRINT NAME OF REGISTERED OWNER .0 '-Y O' /L � O,c�gt►C � bY I � PRINT NAM OF REGISTERED OWNER PRINTED NAME 0 NOTARY �SHIN46C) County/Office No.OR fl II Title AND: Dealer No.OR&( 2t1 b DEALERSHIP POSITION/AG NT/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. N ME(TYPED OR PRINTED) TITLE COMPANY/PHONE NUMBER ' 1 —�t� "lb' F1�sfi Aram 1 c�-c 1ii tie 3V o SIG UPI /POSIT ON }}cc -' , *f 11. C/1(ft 1 i�42 . 1 i /Z11� 0 P(nalize this appl .n th a icensing Agent within 10 calendar days of the date Title Company Representative signs. © BUILDING PE• , T OFFICE CERTIFICATION I certify that: ❑ the manufactured home has been affixed to the real property as described. a building permit has been issued for this purpose and the attachment will be inspected upon completion. NAME(TYPED OR PRINTED) BLDG PERMIT OFFICE/PHONE# BLDG PERMIT# [1J r� KrA-44h A n 51.4 -e-11-- Lao 0) 37et-,4 4 5D b(io-co l;U- -tl`_-_ SIGN RE/POSIT!D WOW 9 I n�� � y1 I /' G DATE i^OVID TD-420-7 9MANUF HOME APPL(R//02)O 1of2 �.J .+ l O� • • MANUFACTURED HOME - FROM SECTION 1 TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) ( ' ,;;L)o Hi-1 u (`)c\ L,7 X Li 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 Signature of Additional Legal Owner and Title, IF APPLICABLE NOT OR STAMP NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE GY H. ,gyp, J&A c• State of Washington �`� 'qe.„12.9j)N Signed or attestedNOTggy O County ofbef r me on I by Zitgk Signature EXP.08/11/2010 PRINT NAME OF LEGAL OWNER TARY OR A4\4 ENT by R .,-s ,� p CJ O PRINT NA E OF LEGAL OWNER PRINTED NAME�NOTARY fJBL-1 G L. County/Office No.OR 0�Q pp WAsov- Title AND: Dealer No.OR ` ��'Z(]j .,` DEALERSHIP POSITION/I,GENT/NOTARY Notary Expiration Date LAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office) „I\.1\ Gi( ` • 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 DEALER'S 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) y�= 4 I certify that the above application appears to have been completed correctly,and the applicant has sufficieny*umentation ta,proceed with the recording of this form. NAME(TYPED OR PRINTED) COUNTY OFFICE/VFS OPER4TOR 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 TTY(360) 664-8885. 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