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HomeMy WebLinkAboutBLD2006-00505 MLA06-00487 Review Type: I MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLLD06-00505 Received Date: 8/30/2006 SITE ADDRESS: 5'3rGARY AVE PORT TOWNSEND, 98368 APPLICANT: KOZELISKY'S HOME SERVICE INC PHONE: 360-385-3215 1112 S JACOB MILLER RD PORT TOWNSEND WA 983689211 SUBDIVISION: IRONDALE Block: 126 Lot: 9-13 PARCEL NUMBER: 962112604 Section: 34 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 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: NEW M/H TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW VALUATION MAKE: GOLDEN WES SETBACK: YEAR: 2006 LABOR & INDUSTRIES APPROVAL? SIZE: 66 X 28 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: OTHER BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 3 Prop: 2 Total: 3 Total: 2 Routing Date: ) <-PLec- .813i Z. Type Amount Paid By: Date: Receipt: Ai Approved/Date Manufactured Homes $163.00 LYK 08/30/06 84769 Potable Water Application $55.00 LYK 08/30/06 84769 SEP 28 2006 Total: $218.00 Jefferson County Planning: & Building Department • • 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 #: BL�06-00505 Received Date: 8/30/2006 SITE ADDRESS: 53 ARY AVE Issue Date: 9/28/2006 PORT TOWNSEND, 98368 APPLICANT: KOZELISKY'S HOME SERVICE INC 1112 S JACOB MILLER RD PORT TOWNSEND WA 983689211 SUBDIVISION: IRONDALE Block: 126 Lot: 9-13 PARCEL#: 962112604 Section: 34 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 PROJECT DESCRIPTION: NEW M/H MAKE: GOLDEN WES YEAR: --2(306 a00� ��`����0 kf`301 - ) SIZE: X-28—` 5 a -4 art \tcl'r!t u)C0 (or a crk •b . t�v' THIS PERMIT IS VALID FOR ONE YEAR. S 'L C (,2p4--C THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. trA(.Oi re.Cks THE EXPIRATION DATE IS 9/28/2007. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): ?•CC Sra p,*0 -2,- Of) Stormwater FINAL Approval: Blocking/Plumbing: BLoek,,rt //cDa��s 44 ,,//,,0-- Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps:, , Clt' 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 # BLD06-00505 1.) The application was reviewed by the Jefferson County Department of Community Development staff on September 26, 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: SARPA 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 are defined as Seawater Intrusion Areas, and Special Aquifer Recharge Protection Areas and the following land uses located within Susceptible Aquifer Recharge Areas (1)All Industrial Land Uses (2)All Commercial Uses (3)All Rural Residential Land Uses requiring a Discretionary Use or Conditional Use Permit(4)All Rural Residential Land Uses with nonconforming uses that would otherwise require a Discretionary Use or Conditional Use Permit(5) Unsewered Planned Rural Residential Developments (6) Unsewered residential development with gross densities greater than one unit per acre. All of the above listed uses shall be subject to the applicable requirements and standards of the Jefferson County Unified Development Code. 5.) The applicant is proposing to create or add 3000 square feet of impervious surface and 3100 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. 6.) 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. 7.) 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. 8.) A Stormwater Site Plan 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. 9.) 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). 10.) The site plan as submitted with the building permit applications on August 30, 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 26, 2006 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 11.) This approval is for a manufactured home installation and self-supporting unheated garage 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. 12.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. • 13.) Not more than 2 unlicensed vehicles shall be stored on any lot unless totally 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. 14.) Minimum setback from North Gary Avenue right-of-way shall be 20 feet. Minimum side and rear yard setbacks shall be 5 feet. 15.) 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. 16.) 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. 17.) The building height is not to exceed 35 feet. 18.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 19.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. 20.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. 21.) An address of 53 North Gary Avenue, Port Townsend has been assigned to the parcel. North Gary Avenue is a private road (P489). 22.) The parcel was created through the Irondale Subdivision#5 on April 2, 1910 under AFN 29795. 23.) The parcel is served by Quimper PUD#1 water. 24.) A Declaration of Restrictive Covenant was recorded on August 17, 2003 under AFN 425920 for the purpose of consolidating the lots to meet minimum on-site septic requirements and to allow structures to be placed over common lot lines as the county does not have a zero lot line setback. 25.) A septic permit (SEP99-0112)was cancelled on August 25, 1999. A septic permit (SEP03-0099) was finaled on November 15, 2005. A building permit (BLD06-0506) for a self supporting garage will be issued with the SFR permit. A road approach permit (RAP06-0178) will be issued with the buidling permits. 4 • • N MI L f6 L U O a a m CD O U O ., CD en , , ,...?„ u c)i i w IN_ o re, I ' I I C 15 o }_ 3 ~ ...1va O Alo0 -ccn Op in o • C CI o Vr oI CM 0 yEx cCI ,., CI w t \ tO WWI 03 :I: ' tl31N33'1N tlH'l. WO a c9 o ` O 0 ■ d `t cc IL 05 q C� O[ {` • c Z I, fn Z • 5. Cr =O y _ o [1 ' tr-: J y. r- il S' , 1 7i) N Ie044l Off`'' O S% d U � ■ Miw • 0 11 ■■ ■ _ El k E co 0 to ...5. ■ \` III I: N I ce. El 4 CUI •"'a!Iss ■ I 9 :0 i7li .a.1 fo'l nib.of=oy :"►� _ 13 m a CD cu °P 1■ ■I ¢ ■ _ ,,o _ CO c O a' I1• ~ • wcc III ¢_- _ t co o ao el • • mi C he V En .s-,st „9-4t1 .s-,sG t N ` con IN r co0 x N m '�1 w �+ !O N N � i~ a E m O '.4 visa ti O O U iimilii c,..., a, O 7 0 Z> N • G R A- (Ft-- Iz (Po ^' " GOLDEN WEST HOMES MANUFACTURER'S CERTIFICATE OF ORIGIN TO A MANUFACTURED HOME The undersigned MANUFACTURER hereby certifies that the new MANUFACTURED HOME described below, is the property of said MANUFACTURER,and is transferred this day of _20 on Invoice No. to DIISTRI•UTOR.DEALER,ETC. whose address is STREET CITY STATE Trade Name Other Series or Model Name Serial No. Width in Inches(less eaves) «RUX. Shipping Weight _Length it inches(less eaves) The MANUFACTURER certifies the above statements are true and correct and that this was the first transfer of such new MANUFACTURED HOME in ordinary trade and commerce. Executed on at Albany OR DATE CITY Name of Manufacturer GO(_ WEST HOMES Signature of 4, „,)• ‘ ,;/JJJJJJ ENERA� MANAGER Company Official SIGNATURE I TITLE OR POSITION V Manufacturer's Address(Street) 2445 S.W. Pacific Blvd. City Albany Oregon State SL-32 HBOS MANUFACTURING, LP JACK WESTERMAN • ASSESSOR Jefferson lOtty Courthouse PO Box 1220, Port Townsend, WA 98368 (360):I85-9105 MOBILE HOME INFORMATION FORM OWNER'S NAME/MAILING ADDRESS: NAME: dAg A- t(025- L L-SIC`). ADDRESS: ) I 1 Z C • c LA 7 PHONE NO. .3(c a- �� � - 3 7 � 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 G-oLbtO, C,�:-'j Ore (B) MODEL__&E 5 2. I F �D o) 2\XS e 13010 (C)YEAR 14E4, (D) LENGTH (E) WIDTH .A SER ALI # CSTp1_ZQ1- / r7/bq (G)YOUR PURCHASE PRICE (Do not include sales tax �C7J OOa f PURCHASE DATE gip' 2) PREVIOUS OWNER/LOCATION OF MOBILE H i E: (IF NEW MOVE TO QUESTION 3) (A) FROM WHOM DID YOU PURCHAS . IOBILE ADDRESS (H) WAS MOBILE HOME ASSES D IN JEFFERSON COUNTY LAST YEAR? Yes No If Yes, Previous add s of mobile. If No, What Coun as Mobile assessed in last year. 3)WHERE MOBILE HOME IS TO BE LOCATED: (A) WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes UNTO) (B)IF LOCATED IN MOBILE HOME PARK: NAME & ADDRESS OF PARK Lot/Space# (C) I NOT LOCATED IN MOBILE OME PARK: NAME—OF LAND OWNER: < S( .HA- / 2 C L`S r"-` - LOCATION ADDRESS �!� (,..)A-Pc? REAL PROPERTY PARCEL #/DESCRIPTION 7&Z - / 1 2 ( a THANK YOU FOR YOUR HELP! Signature of applicant 4JO COSSELL, Properly Technician • • A4 ° cOr, JEFFERSON COUNTY al \� a NG' , DEPARTMENT OF COMMUNITY DEVELOPMENT ''4 621 Sheridan Street• Port Townsend •Washington 98368 iti 3j' $ 360/379-4450 . 360/379-4451 Fax q O www.co.jefferson.wa.us/commdevelopment $ S Master Permit Application MLA: 0(0_1.3r7 Project Description(include separate sheets as necessary): \O(...0 071 J Dom " Tax Parcel Property Number: 9t Z I I Z C-.70 Size: f 2 S (acres/ quare fe Site Address and/or Directions to Property: c p cS Pc LT ___.pi foo 6A wQY of.) /Z p L Property Owner(s)of Record: c IA SCN,4 2e L.-S r ;Q �-' Telephone: "L-70- $S� 3 2,/ i Fax: i= Z1 C OAP 67512.Ft) I�l 2 S:�{'r"{ email: MailingAddress: S . JAI-r R ik.1 L.(_Ee_ pm pi,(2 . 'Te)1_,=^=.c,-e r f) , cow Applicant/Agent(if different from owner): ` IA i yAt t- 2 - L.L Sri Telephone: 3(v0-3&S- _Z 1 1 Fax: S A- 4'`'�4, email: Mailing Address: What kind of Permit?(Check each box that applies) (Building ❑Variance(Minor,Major or Reasonable Economic Use) ci Demolition Permit ❑Conditional Use[C(a),C(d),or C]** Fa °Discretionary"D"or Unnamed Use Classification Garage Attached Detached ❑Special Use(Essential Public Facilities)** iSingle Manufacture ome °Boundary Line Adjustment d Modular °Short Plat** QCommercial* °Binding Site Plan** Change of Use °Long Plat** L i Address 1 Road Approach °Planned Rural Residential Development(PRRD)/Amendments** Propane ❑Plat Vacation/Alteration** DAllowed"Yes"Use Consistency Analysis ❑Shoreline Master Program Exemption/Permit Revisions** OStormwater 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 Pre-Application Conference Please identify any other local,state or federal permits required for this proposal, if known: I hereby designat (� Qs-2DESIGNATION OF AGENT v- to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE Date: -2 Z`c% � 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 application t t or wants prior notice.Signature: Date: 0 G - 2 2 -V 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 the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transfer ble respo s' ility for adhering to and complying with the ESA. The Applicant has read this disci imer ansigns a d dates it below. Signature: f Date: - C/ D:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05-2.doc 0 • 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: roZ c L_S(�.--?._ .•._..k Sc SZ.),c{ ( /— L . (3& 3 g-S -3 Z‘S— ( ) ,---c MAILING ADDRESS: I I f-t S `‘ LL7(1D L'Lz(((y7 IZ/j EMAIL: CONTRACTOR'S LICENSE Rcri-T --row Y'P-- -0 WAINS NUMBER: NUMBER lP ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: ❑ New 0 Wood Existing: 0 Sewer ❑ Addition 0 Steel Proposed: Z Bank ❑Community System ❑ Alteration/Remodel 0 Concrete Total: 2 Height: Rkgdividual System , ❑ Repair 0 Masonry SEP Permit# 0 3 -9 q/ ❑ Demolition 0 Other: Bedrooms: �_ Water Supply: Existing: Setback: ❑ Private well 0 Two Party Type of Heat: Proposed: i Public C C c= ,� � V-C Total: 3 Name of System: 0 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: 0 Underground Tank 0 Above ground Tank Size of Propane Tank: O Heat Stove ❑Cook Stove 0 Woodstove ❑Fireplace Insert 0 Hot Water Tank 0 Pellet Stove p 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: 2n°Floor Heated Consistency Review 6 15 3 Other Heated Base fee: 1 G3 Mezzanine Additional Section: _ Heated Basement Plan Check fee: ____ _--. Unheated Basement State Surcharge fee: ...-- .o---. Other Unheated Pot Water Review fee: a Garage/Carport SUBTOTAL . --\ \ Decks 911/Rd Approach fee: i t Other TOTAL: $ Vl (03 Receipt Number: a}.—1/„q Cash/Check Number: 1 ,tOv� ESTIMATED COST(REQUIRED) Date: �"f .Fair market value of all labor and materials foundation to finish 3 Initials: D:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05-2.doc RETURN ADDRESS �IAI✓I'1E IGoZGu.. cstc.c77 S � � . CAszy AVE 10,-t3 the L(77crArroFwASH,NGTON MANUFACTURED HOME AS CH CKONE L/J l�rparlu�rnt q� lICEnSInG APPLICATION ['TITLE ELIMINATION ❑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) Zoo3 GW sZ 2- LAND LEGAL DESCRIPTIONAA ON PAGE MANUFACTURED HOME WILL BE ❑ AFFIXED ❑ REMOVED I RE PgOPRTY T�xIEL NIjMBEg I LO I BLOQK PLAT NAME 0RSECTION/TOWNSHIP/RANGE `/(��� L (P TE 1 2 10 NA-L G QUARTER/OUARTER SECTION 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 NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 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 Title County/Office No.OR DEALERSHIP POSITION/AGENT/NOTARY AND: DealerNo.OR 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. ❑ 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# Ash I eL Sc.h e n K J-e-c"2,YS�3n Courri-Li,DC D C3cco)31q-44550 t3LD OCR'-50 SIGNATURE/POSIITION� VC � rY1DATE C( TOchn, -7/ 10 6TD-420-729MANUFHOM PL(R/2/02)OR(W)Pagelo12 MANUFACTURED HOME - FROM SECTION 1 TPO/PLATE NUMBER YEAR rMAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) a00 G-LA) sa a 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 NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE State of Washington Signed or attested County of before me on by Signature • PRINT NAME OF LEGAL OWNER NOTARY OR AGENT by PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTARY Title County/Office No.OR DEALERSHIP POSITION/AGENT/NOTARY AND: DealerNo.OR Notary Expiration Date D LAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office) Sff- C74 We- 'Ai --1-co 3o N e. J W p_0IJ t� c E Lo C ( I Z ( L-6T S T{-t-fL LA I '3 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) I certify that the above application appears to have been completed correctly,and the applicant has sufficient documentation to proceed with the recording of this form. NAME(TYPED OR PRINTED) COUNTY OFFICE/VFS OPERATOR NUMBER SIGNATURE DATE 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. TD-420-729 MANUF HOME APPL(R/2/02)OR(W)Page 2 of 2