Loading...
HomeMy WebLinkAboutBLD2006-00516 MLA06-00501 Review Type: I MANUFACTURED/ MOBILE HOME. INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00516 Received Date: 9/7/2006 SITE ADDRESS: 2290 ANDERSON LAKE RD CHIMACUM, 98325 APPLICANT: RAE ANN VAN TROJEN PHONE: 360-732-5051 2290 ANDERSON LAKE RD CHIMACUM WA 983258765 SUBDIVISION: RUSSELL SHORT PLAT Block: Lot: 2 PARCEL NUMBER: 901104021 Section: 10 Township: 29 N Range: 01 W CONTRACTOR/ BISHOP ENTERPRISES PHONE: (360) 417-0861 DEALER: 982 LEWIS RD PORT ANGELES WA 98362 Contractor's License BISHOE*999MT Expires 7/24/2008 REPRESENTATIVE: BISHOP ENTERPRISES PHONE: (360) 417-0861 982 LEWIS RD PORT ANGELES WA 98362 PROJECT DESCRIPTION: M/H REPLACEMENT (PACIFIC:A) SER#25406 TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: MARLETTE SETBACK: VALUATION YEAR: 2006 LABOR & INDUSTRIES APPROVAL? SIZE: 70 X 40 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PUD — BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 3 Prop: 2 Total: 3 Total: 2 Rot? Datte: ( 1Rooreb �O( C.i �cup CZ- Type Amount Paid Bv: Date: Receipt: A -Approved/Date Manufactured Homes $163.00 LYK 09/07/06 84786 Add. Manufactured Home $34.00 LYK 09/07/06 84786 R , ,7 Total: $197.00 Jefferson County Planning & 6ui101a 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#: BLD06-00516 Received Date: 9/7/2006 SITE ADDRESS: 2290 ANDERSON LAKE RD Issue Date: 10/7/2006 CHIMACUM, 98325 APPLICANT: RAE ANN VAN TROJEN 2290 ANDERSON LAKE RD CHIMACUM WA 983258765 SUBDIVISION: RUSSELL SHORT PLAT Block: Lot: 2 PARCEL#: 901104021 Section: 10 Township: 29 N Range: 01 W CONTRACTOR/ BISHOP ENTERPRISES PHONE: (360) 417-0861 DEALER 982 LEWIS RD PORT ANGELES WA 98362 Contractor's License BISHOE*999MT Expires 7/24/2008 PROJECT DESCRIPTION: M/H REPLACEMENT (PACIFICA) SER#25406 MAKE: MARLETTE YEAR: 2006 SIZE: 70 X 40 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 10/7/2007. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): Stormwater FINAL Approval: 6LerrEes, Aa pspzgds 4 116E{rug.)-6 DK //D�/G7 Blocking/Plumbing: &pel(MNC I G �bi,UIVS C 1 r1 4,,,t70/j- Propane Tank/Lines WA 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 • SPECIAL CONDITIONS CASE # BLD06-00516 1.) The application was reviewed by the Jefferson County Department of Community Development staff on October 6, 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: landslide 1; eagle; SARPA& 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 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.) 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. 6.) Geologically Hazardous Areas in Jefferson County are characterized by slope, soil type, geologic material, and groundwater that may combine to create problems with slope stability, erosion, and water quality during and after construction or during natural events such as earthquakes or severe rainstorms. 7.) The applicant is proposing to create or add 1960 square feet of impervious surface and 1000 square feet of land disturbing activities. 8.) 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. 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 manufactured home replacement permit application on September 7, 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 October 6, 2006 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 11.) This approval is for a manufactured home replacement 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 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. 411 411 14.) Minimum setback from Anderson Lake Road 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.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. 19.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. 20.) The lot was created through the Russell Short Plat on August 19, 1991 under AFN 342869. 21.) A septic permit (SEP90-0343) was fnaled on April 10, 1991. An EES was completed on March 27, 2006. 22.) An address of 2290 Anderson Lake Road, Chimacum has been assigned to the parcel. Anderson Lake Road is a county minor collector(C523408). 23.) The proposal was not sent to WDFW for potential impacts to Eagle's as this is a replacement of an existing manufactured home in approximately the same location. 24.) The site is served by PUD#1 water. 25.) The parcel is relatively flat. It appears the county GIS mapping that shows the landslide hazard area 1 is in the neighborhood of the intersection of Old Anderson Lake Road and Anderson Lake Road. 09/06/2006 16: 24 3603794451 JEFF CO PERMITCENTER PAGE 01/02 • i JACK WESTERMAN III Jareirodm, Connly(;o.xrthouv, ASSESSOR PO Rex 1220. Port Tora-nN41 d. WA 1'10360 (790) 305.9105 MOBILE HOME INFORMATION O C ''iVE 11) OWNER'S NAME/MAILING ADDRESS: N ►�tE:_ 4 n n o(fl rcben S � 0 7 ADDRESS_ n , -n is ke Rcl PHONE NO. .7 3 s o51 The purpose of this questionnaire is to obtain information regarding either the qmtrrrent location of a mobile home or the previous ownership and location of a mobile home. lids will help onr office determine whether the mobile home is already on the tax rolls in 'Jefferson Comity or if it has hem moved to this county from another area. II.)MOWILE ROME DATA: (A) MAKE M ac (III) MODEL PO.0 �1 C.c\ (C) YEAR�OO6 (B) LENGTH r o / (E) WIDTH I 0 (F)SERIAL # c 5 L1 C-) (G) YOUR PURCHASE PRICE(Do not include Pnlc,a tax) 1,71ayI _PUBCIIIASE DATES-2Z-O 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3) (A) FROM WHOM DID YOU PURCHASE MOBILE (col ci.e 0_-(o tr_e 5 ADDRESS /65 it). Aaci 74'c I/W y 1 /vo' c/ o en (H) WAS MOBILE HOME ASSESSED IN JEFFEHSON COUNTY LAST YEAR?Yes (Ni') If Yes, Previenq address of mobile. If No. What Comity was Mobile assessed hi last year. 3)WHEIE MOBILE HOME IS TO BE LOCATED: (A) WILL THE MOBILE HOME HE IN MOBILE HOME PARK? Yes Na (B) IF LOCATED IN MOBILE HOME PARK: NAME &ADDRESS OF PARK Lot/Space# (C) IF NOT LOCATED IN MOBILE HOME PARK: NAME OF LAND OWNER: ka.).A(lam VantADDRESS LOCATION ADDRESS a a a 9 o ! I Po1 c� HEAL PROPERTY PARCEL #/DESCRIPTION {©( lay( a ( �" !`Nis e-,d1 Si nattn of applie THANK YOU FOB YOUR HELP! a0_50A JO. COSSELL. Prol»erty Technician • • • to F alrr=7-..== LJ L i n o at i a N — r' 41 Pr �7 it n i 11 III 11 11,, o _ Ii I__` I-3' / — — ;; •� f I 1,SS,aS; Vim" II �� maw 1 IlLi6YMI i,tt rq : .- .so f`x — iI ii F_y 1 ,:, u_______I 1i_ 0t _r $J f �lJ O ,........, ......, �C y I � Co -.1 O II CZ>--Q ' —�---- - , O O os gt i as • J `V -- \ ( I 25- cit 0-4-1 n1 r1 rl 77n.'7„." ,..zr".71,3 72::\ 1 (a) : 0 Zg.:-"3 .1•0.4 t rn� d,t., o „ c.,2 ._,....3 co- 1 !A-,o h / 0 0 --------=====q (i--:, ¢, °N cOG JEFFERS•COUNTY • 4-.� DEPARTMENT OF COMMUNITY DEVELOPMENT A, ," `'' 621 Sheridan Street• Port Townsend•Washington 98368 &, $ 360/379 4450• 360/379-4451 Fax 'gS, NGp www.co.jefferson.wa.us/commdevelopment Master Permit Application MLA: ao-50I Project Description(indude separate sheets as necessary): Piep(G_r' 'C. MO() je hom.c (,.Ji'+h Y\Nw man tl-F4Cfur d h0n-, e Tax Parcel Number 9 Q i (Q Q a [ Property Size: 5 O.< r e,; (acres/square feet) Site Address and/or Directions to Pr d, o O An4,o(-.SCE:- �c�. c.t Rd , Property Owners)of Record: 1�(A o f nY\ VA rcf r o j en Telephone: 360- 7 a— S OS I Fax: email: Mailing Address: Applicant/Agent(if different from owner): 13 i 5h,;p Ent . Telephone: 360- L (-7 O €'_6 j Fax: 3(O- //7-I 1 oC email: Mailing Address: el L a. Lew l‘5 Rc a Pi .A rxi e k"t i tE What kind of Permit?(Check each box that applies) I Building I Variance(Minor,Major or Reasonable Economic Use) I Demolition Permit 1 Conditional Use[C(a),C(d),or CI** cif Single Family I Discretionary'D"or Unnamed Use Classification I Garage Attached/Detached I Special Use(Essential Public Facilities)** 41*Manufacured Home I Boundary Line Adjustment Modular I Short Plat** I Commercial* I Binding Site Plan** I Change of Use I Long Plat** I Address I Road Approach I Planned Rural Residential Development(PRRD)/Amendments** I Propane I Plat Vacation/Alteration** I Allowed'Yes"Use Consistency Analysis I Shoreline Master Program Exemption/Pemiit Revisions** I Stormwater Management I Shoreline Management Substantial Development** I Site Plan Approval Advance Determination(SPAAD)* 1 Shoreline Management Variance I Temporary Use I Comprehensive Plan/UDC/Land Use District Map Amendment I Wireless Telecommunication* I Jefferson County Shoreline Master Program Amendment I 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 ' 1IJ i i!\ to act as my agent in matters relating to this application for perm' s. ONMER SIGNATURE Date: / - e "0 Ce 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 attorneys 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 inspe/���ons.Acce and.right of entry to this property shall be requested and shall occur onlyduring hours. �� r�r l / n9 regular business Signature: 6) ' LP , GW Date: The action or actions Applicant will undertake as a ult of the issuance of this permit may negatively impact upon one or more threatened or endangered species and could lead to a potential lake"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 in 'dual,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 fferson unty development code.The Applicant acknowledges that he,she or it holds individual and non- transferable re ibility r ad " gto and plying with the ESA. The Applicant has read this disclaimer ands anc6atesMow. Signature: LJ Date: ' /1 C:\Documents and Settings\canal\Local Settings\Temporary Internet Files\OI.K86\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 as khJ ty of the General Contractor for the proposed project. r+, , /Q ���s7 Signature: / (L'YLi 'C1 _ Date: '�/T GENERAL CONTRACTOR OR MANUFACTURED HO STALLER: PHONE: FAx: (i5k0p Enie -pr,is s (30) 9/7-0i%I (36e) rfi7"i?3 . MAILING ADDRESS: 1 ga l e,w;s Rd , P1) _ (,1)11 rag e_EMAIL: CONTRACTOR'S LICENSE WAINS _ NUMBER: 1j`( 5 HOB p l�t(Tr NUMBER .3 7 q PHONE ( ) FM:( ) ARCHITECT/ENGINEER: MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: 1LI Wood Existing: ❑ Sewer A, New i i Steel Proposed: jc Bank Height: ❑ Community System ❑ Addition Total: I R Individual System ❑ Alteration/Remodel a Concrete SEP Permit# 9c-0(3513 ❑ Repair I_I Masonry l i Other. Bedrooms: Water Supply: ❑ Demolition Existing: Setback: ❑ Private well [1 Two Party Proposed: ! Public � _1 Type of Heat: Total: j — Name_of System:r(r re 4 rs C 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 Underground Tank I Above ground Tank Size of Propane Tank: I Heat Stove i Cook Stove i Woodstove i Fireplace Insert I Hot Water Tank I Pellet Stove i Other Is this appliance being installed in a Manufactured/Mobile Home? Yes / No property applying for a permit to install a propane tank you must also submit a site plan showing all of the buildings,all p lines,tank location and size,distances from the propane tank to all properly lines,buildings and septic system components, including the reserve area. — Square Footage Current Proposed For Office Use Only — Amount Revision l Main Floor Heated — EH Bid App Review: (, 2nd Floor Heated Consistency Review —_I 53 — — Other Heated Base fee: 1 Cr?,-3 1 Mezzanine Additional Section: _ 31 Heated Basement Plan Check fee: Unheated Basement State Surcharge fee: Other Unheated Pot Water Review fee: Garage/Carport SUBTOTAL A Decks 911/Rd Approach fee: Other TOTAL: $-Lk (k' 1 Receipt Number: C t-t'' 3( io Cash/Check Number: - 3 gut ESTIMATED COST(REQUIRED) Date: (�CIS--I O�p .Fair market value of all labor and materials foundation to finish Initials: '"� C:\Documents and Settings\caral\Local Settings\Temporary Internet Files\OLK86\Master Permit Application 12-30-05.doc • • RETURN ADDRESS FIRST AMERICAN TITLE COMPANY 2037 EAST SIMS WAY PORT TOWNSEND, WA 98368 ST=TEOF f SHINGT N MANUFACTURED HOME PLEASE CHECK ONE IICEflSIflG 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) Oo255.5 3°MC06 I NIA(le,1 e 7L)o'x ti(?bi LAND LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE Z3 AFFIXED 0 REMOVED I REQ�P�ioPRzY/rAx� 1�EL NUMBER LOT BLOCK PLAT NAME yy 1 (UJ4 U LL 1 SECTION/TOWNSHIP/RANGE © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER 1 NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS NAME OF REGISTERED OWNER RAE ANN M. VAN TROJEN NAME OF ADDITIONAL REGISTERED OWNER ADDRESS CITY STATE ZIP CODE 2290 ANDERSON LAKE RD CHIMACUM WASHINGTON 98325 NAME OF LEGAL OWNER FIRST FEDERAL SAVINGS AND LOAN NAME OF ADDITIONAL LEGAL OWNER ADDRESS CITY STATE ZIP CODE P.O. BOX 351 PORT ANGELES WASHINGTON 98362 GRANTEE NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT AM/ T E GIST RED WNER(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 I NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER( NATURE \00%11W ll//11,', `\ k_ ID A I State of Washington Si nedorattested �<(` �' County of F�� r Sch;� �— .• •. 9 �` bef re me on ,` • • 2008by RAE ANN M VAN ' 20JEN l��/�---- itma 15. Z PRINT NAME OF REGISTERED OWN Signature NO RY O AGENT PRINT NAME OF REGISTERED OWNER r Y� PRINTED NAME OF NOTARY Y W c�?�\`\ I Title�c County/Office No.OR /."//lit 114“' DEALERSHIP POSITIO AGENT/NOTARY AND: Dealer No.OR )\.A.,t__15� �^4 TITLE COMPANY CERTIFICATION Notary Expiration Date 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 me ffed to prort ❑ a buildinganufac pa it hasho beenhas issuedbeen fora this ix purposethereal and thepe attyachasdescribed.ment will be inspected upon completion. NAME(TYPED OR PRINTED) BLDG PERMIT OFFICE/PHONE# K0,kti,Q n� C��� - a90 `�1 q-L LII(BLDGy�� PERMIT�" M�/�G SI N URE/POSITI9N `� /1 I C 71�b1p—(ATE J TD-420-729 MANUF HOME APPL(R/8/98)OR Page 1 of 2 `�IY�V 1_ k. • • 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 PRINTED NAME OF NOTARY PRINT NAME OF LEGAL OWNER County/Office No.OR Title AND: Dealer No.OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date DLAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office LOT 2 OF THE RUSSELL SHORT PLAT, AS PER PLAT RECORDED IN 0 VOLUME 2 OF SHORT PLATS , PAGE 187 , RECORDS OF JEFFERSON COUNTY, WASHINGTON. DEALERS 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. —WA DEALER NUMBER DATE OF SALE DEALER NAME(TYPED OR PRINTED) PURCHASE PRICE TAX JURISDICTION/TAX RATE DEALER'S AUTHORIZED SIGNATURE 0 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 thatthe 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) 1 COUNTY OFFICENFS OPERATOR NUMBER DATE SIGNATURE 10 TITLE FEES SUBAGENT FEES FILING FEE APPLICATION MOBILE HOME FEE ELIMINATION FEE USE TAX .} l 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 11110•1111,11"--- L r- ' . ..+ 0\3 . c3 ....vt ..?\ -,- Pt) qi ?`• \ Y \ • 93 liu 2 -k---co , ..,-------iT \ A-- \ \C?? : C.--. • ' >c . C 2:7 0 k . ti) \ (P' ( --' --1 \, ' .*.,'. (0 . • /4) 1 .s•Y ' , N.." I '§--, .).) P _ca re,tj or. 0 3 = g E 71 ww 0 t=6.- 3. • ,., , i. . • tc„ r___. 11 ••••+" ' '..! 7i) 94 az CZ 0 co ri r; :4%. trl iP r • ,,... , i7'';• P:i ici 0 ti i`;:-.:'-',:I t=i - -. IIIPt C4 Xi Ca• . 57' 0111:49 .111La-° o r..1 --..- r - ______ _- CI • , rZi ti- • - — J ' , _, 1...:3 _