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HomeMy WebLinkAboutBLD2006-00707 IUILDING PERMIT APPLICAAN MLA06-00673 Review Type: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD06-00707 Received Date: 12/19/2006 SITE ADDRESS: 1646 IRONDALE RD PORT HADLOCK, 98339 OWNER: HAROLD L TAYLOR PHONE: (360) 385-4718 DENISE G BAKER 1646 IRONDALE RD PORT HADLOCK WA 98339-9530 SHOLD'S ADDITION SUBDIVISION: Block: 5 Lot: 3 PARCEL NUMBER: 994800503 Section: 2 Township: 29 N Range: 01 W CONTRACTOR: BUY RITE HOMES PHONE: (360)479-0795 3543 W STATE HWY 16 PORT ORCHARD WA 98367 Contractor's License BUYRIH`0840B Expires 5/20/2008 REPRESENTATIVE: BUY-RITE HOMES PHONE: (360) 681-0777 259403 HWY 101 SEQUIM WA 98382 PROJECT DESCRIPTION REPLACEMENT MFH SERIAL NO. 28215/MODEL 56093 TYPE OF WORK MOB SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION 67,707.00 ADD'L: HEAT TYPE: EEE CODE EDITION: 2003 HEAT BASE: HEAT TYPE: OCCUPANCY: OCCUPANCY: UNHEATED: # OF STORIES: CONST TYPE: OTHER: SHORELINE: CONST TYPE: GARAGE: SETBACK: DECK: BANK HEIGHT: SEWAGE DISPOSAL: WATER SYSTEM: PUD BEDROOMS: BATHROOMS: Exist: Exist: Prop: 3 Prop: 2 Total: 3 Total: 2 Routing Date: L a I l ct 1 O(0 Type Amount Paid Bv: Date: Receipt: Approved/Date Manufactured Homes $163.00 KAS 12/19/06 86949 Total: $163.00 JAN 2007 • • 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#: BLD06-00707 Received Date: 12/19/2006 SITE ADDRESS: 1646 IRONDALE RD Issue Date: 1/17/2007 PORT HADLOCK, 98339 APPLICANT: HAROLD L TAYLOR DENISE G BAKER 1646 IRONDALE RD PORT HADLOCK WA 98339-9530 SUBDIVISION: SHOLD'S ADDITION Block: 5 Lot: 3 PARCEL#: 994800503 Section: 2 Township: 29 N Range: 01 W CONTRACTOR/ JH CONSTRUCTION PHONE: (360)681-0871 DEALER 670 PARRISH RD SEQUIM WA 98382 Contractor's License BUYRIH*0840B Expires 5/20/2008 INSTALLER: JH CONSTRUCTION WAINS0250 Expires: 7/31/200M 670 PARRISH RD SEQUIM WA 98382 PROJECT DESCRIPTION: REPLACEMENT MFH SERIAL NO. 28216/MODEL 66093 MAKE: KARSTEN YEAR: 2006 SIZE: 56 X 28 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 1/17/2008. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY TO YOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTING, SLAB or PADS USED): .,_ 6h,L-_Z/'_/b 7 Stormwater FINAL Approval: Blocking/Plumbing: ),/ -� Z,(;`) Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps: . 1 I\0\01 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 # BLD06-00707 1.) The application was reviewed by the Jefferson County Department of Community Development staff on December 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: SUSC aquifer recharge area; coastal SIPZ. 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.) Marine shorelines and islands are susceptible to a condition that is known as seawater intrusion. Seawater intrusion is a condition in which the saltwater/freshwater interface in an aquifer moves inland so that wells drilled on upland areas cannot obtain freshwater suitable for public consumption without significant additional treatment and cost. Maintaining a stable balance in the saltwater/freshwater interface is primarily a function of the rate of aquifer recharge (primarily through rainfall) and the rate of groundwater withdrawals (primarily through wells). The Washington Department of Ecology is the agency with statutory authority to regulate groundwater withdrawal for individual wells in Jefferson County. New development, redevelopment, and land use activities on islands and in close proximity to marine shorelines in particular should be developed in such a manner to maximize aquifer recharge and maintain the saltwater/freshwater balance to the maximum extent possible by infiltrating stormwater runoff so that it recharges the aquifer. 5.) The parcel is located within a coastal SIPZ (seawater intrusion protection zone) according to the County GIS map. There are voluntary and mandatory measures identified in the Jefferson County Seawater Intrusion Policy(Resolution 44-22, effective September 23, 2002) that apply to well drilling proposals and building permit applications on existing lots of record. A Coastal SIPZ is defined as: all islands and area within one-quarter mile of marine shoreline, but no history of chloride concentration above 100 mg/L in groundwater sources within 1000 feet. 6.) 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. 7.) To help prevent seawater from intruding landward into underground aquifers, all new development activity on Marrowstone Island, Indian Island and within 1/4 mile of any marine shoreline shall be required to infiltrate all stormwater runoff onsite. 8.) The property owner shall comply with Water Conservation Measures (per list maintained by the UDC Administrator). 9.) The applicant is proposing to create or add 896 square feet of impervious surface and 896 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. 10.) 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. 11.) 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). • • 12.) The revised site plan dated January 8, 2007 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 January 17, 2007 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 13.) This approval is for a replacement 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. 14.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 15.) 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. 16.) Minimum setback from Irondale Road right-of-way shall be 20 feet. Minimum side and rear yard setbacks shall be 5 feet. 17.) 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. 18.) 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. 19.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 20.) The building height is not to exceed 35 feet. 21.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. 22.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. 23.) An address of 1646 Irondale Road, Port Hadlock has been assigned to the parcel. Irondale Road is a county major collector(C933507). 24.) The lot was created through the Shold's Addition to Hadlock Subdivision on September 25, 1952 under AFN 134220. 25.) The parcel is served by PUD #1 water. 26.) REQUIRES JCPH INSPECTION OF PROTECTIVE BARRIERS PRIOR TO FINALING BUILDING PERMIT 27.) A septic permit (SEP94-0278)was finaled on August 3, 1994. A building permit (BLD94-0441) for a manufactured home was finaledon February 22, 2995. A building permit (BLD98-0289) for a detached garage was cancelled on May 20, 1998. A building permit (BLD01-0607) for a detached garage was finaled on November 8, 2002. An EES (OTH96-0038)was finaled on April 11, 1996. 01/08/2027 13: 53 13606810780 PAGE 02/02 01/04/2007 .t7:42 FAX 3603851111 HADLOCKBLEG5PLY-_UQ 40 4 001./001 01/04/2027 15:06 1360681E7E0 PAGE 01/01 tD06 - 70 VY\ UR 0(P—Ce73 .... ... ,. .... .._ .._ __ __ . .._ _ . . . _ . _.. -. _. _ _. _. ... JC, rri,)a:_ .._. ... _ —. Irorndalc Fond 1 I 59.72' RECEr! ' D \ Y � 1 I14 ' I I JAN 08 r 3 1 Jefferson C. ,,;.� ►b I I I S6.50 Environmental 1,r. Etng c ratlfwic� --N.79' q tt i 'l Lt I P� ! , ... ,..,��.........._.._._.I a�nFc�ld I rrom groposed homes I I tic:. l,a I*t carve xe+�a+» .. �, , ,wed„ dratnft 1 24' from ezl,stl,ng home I I k M+u+e u, V . W is a�, 1' .1P-18114.119 Id Ir.:!,..:- — 1— I ext a+t.ng 12 L. / `J S I a�dytw, home to be / I poor _ 17 removed 25.02' V" 47 I I proposed , I I home -�.,,' 33,6$' - .,r...I.. • 40,63' . --I� 2sx56 _.. __ . ..... 11.._ . shop ....... , 24z26 ,6,16' s1"_'2�11 c . sac zi of rol.I ' 12/12/06 i%Li- Ka es Hofnc$ fail or, Harold and V enL5e 2940 idw4 101 5e WIC 9882 1646 I rondal e Ind Port i-ladlock 60- 681- 0777 r � 8005 Con �1 C3�a� rd, RE 14+ ko-al-07 •tad Has been APPROVED by JEFFERSON Stormwater B DEPT.OF Co EL EN Required SIGNATURE: CK WVESTEIRMAN ]� .leiferson •ity- Courthouse "I''" ASSESSOR PO Ilox 1220. Port Tort yen l' n (360) 385.9105 R j '( 1\ ' � MOBILE HOME INFORMATION FORM i r f ?9rr° OWNER'S NAME/MAILING ADDRESS: L din, ` NAME: �Ay. Dif , /��a.� id „ 6.-i//S s� l � �, 111V�� 1��� ADDRESS: / , �6 z eo cJd,QL ,Pd ,,-�Ad/ace' �,� 9�939 PHONE NO. 360 -28s-Sz-77d 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 hone is already on the tax rolls in Jefferson County or if it has been moved to this county from another area. I)MOBILE HOME DATA: (A) MAKE 44°LS7 (B) MODEL �ZQ 93 (C) YEAR o20O e, (D) LENGTH 5Z ' (E) WIDTH .Gc91 (F) SERIAL # a8�/6 (G) YOUR PURCHASE PRICE (Do not include sales tax).7, 707. PURCHASE DATE /1//7/06 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3) (A) FROM WHOM DID YOU PURCHASE MOBILE &I?/-,(.i rE liewEs ADDRESS 259 SL03 1169/ /D i `koziri? ie)/7 9,? 382, (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 HOME PARK? Yes No (B) IF LOCATED IN MOBILE HOME PARK: NAME dr. ADDRESS OF PARK Lot/Space # (C) IF NOT LOCATED IN MOBILE HOME PA K: NAME OF LAND OWNER: 7Af/LOk ,. /f1,&OLd LOCATION ADDRESS /6'�4 ieDrtJdAi-E- ,& ,&r ,a/./zr1 �,f 9:9339 REAL PROPERTY PARCEL #/DESCRIPTION Q9.45OO53 . ) \' ignature f applican THANK YOU FOR YOUR HELP! Lfs e50 n JO COSSELL, Property Technician F('EN1F1,, IWO '11 A A 4 • 1 I. _______ ... 26'-8" f '‘ , _i,_-- MittiSllh 1;11111\010 ,_..,..., 14x39V \,,L! 1------1-1 ' t i LWallEr 1 1 r- 5 n — ) , , 3 _ Q v) 1? / 1.•,*: r() ___ ( \ cr 167 nal L CC 7 Lk) ------- -, C.) 2 CM lt, (11 itt 3 r 0 ...„?I ro (...7\ •-•< , -3 • )- e--) -....... (-') (1) -, ,----^ 1,.....--...:....: ---'-t_ -a 111 . Refer- 0 E.12 ,-1- CO 7 , 0 ''''r44 ri,.4 r r `1-14 1 C, al: x i CT CO iii I CAD t, bl 1 O < 0 s 0 0 CJ1 i---, I Raised Snack Bar CT -1: ., tr, i•.•- --- [ i I- 0 LO 4=:. -41 I\ t= , V) cn - C r-, S..._ O > "--C0-3- X ''.1411-P . 77) 0° 70 . - - , ) < M 0:5,..,,,-., I t M ; ,'''' ' '''t" ' ...L n 'i 1 ''' .-olelom4,r (----1■11MINIIMI MINIft, rri , ' 0 -...,• , N. I a" V.,..I -71 S..:D ,--r, (T) c2 .—,.: — 70 CD CD ex Ss - 7- I. ''4,-•!, \_CD (-_-.. C.) 0 = ' rr . ..,„ ....'4 ( ) r\..) co CS..t. / I 1 A L ___ 78x58H `,....... ,.... )‘-, rA, (.> k.....:, �.¢g° c�& JEFFERSC OUNTY R �•JVTRT�) ti1� A DEPARTMENT OF COMMUNITY DEVELOPMENT `d 621 Sheridan Street • Port Townsend Washington 98368 360/379-4450 • 360/379-4451 Fax �` '' ) .qs Oi www.co.jefferson.wa.us/commdevelopment Master Permit Application jt!q.HN �'��i iu'' 'I�,. f �� MLA: ��- tU-1_. Pro'ect Description(include separate sheets as necessary): filet- ;/,i9 R h2/9,i/u-4e7/l42Ed 741 E. d<J EA'/S7i l9 Si 7 Property Tax Parcel Number: 99960 i5 Size: 1/3 (acres/ quare feet) Site Address and/or Directions to Property: /414 �,�p,c;dr2/6-* xf/ i, er,1/,1/a" #7 9�.?39 Property Owner(s)of Record: 7 /// e, i 9 &Lc ,Telephone:,' _,4/k5-- 4z77,8 Fax:�j email: Mailing Address: // Lip OAVAILE 4/ )�,eTy/Q, q/ / /A /0 '1, 3q Applicant/Agent(if different from owner): l(1'- ,eiTE t/n&S Telephone: AO-lag/-D 7 2 7 Fax: ,_60-/�/-6780 email: Mailing Address: ,?S9 V-63 fuijy i / tce9a/� /')� 99�z Wh t kind of Permit?(Check each box that applies) 7 Building 0 Variance(Minor, Major or Reasonable Economic Use) ❑ Demolition Permit 0 Conditional Use[C(a),C(d),or Cj** ❑ Single Family ❑ Discretionary"D"or Unnamed Use Classification ❑ Garage Attached/Detached ❑ Special Use(Essential Public Facilities)** ['Manufactured Home ❑ Boundary Line Adjustment ❑ Modular ❑ Short Plat** ❑ Commercial* ❑ Binding Site Plan** ❑ Change of Use ❑ Long Plat** ❑Address ❑ Road Approach 0 Planned Rural Residential Development(PRRD)/Amendments** ❑ Propane ❑ Plat Vacation/Alteration** ❑Allowed"Yes"Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** ❑ Stormwater Management ❑ Shoreline Management Substantial Development** ❑ Site Plan Approval Advance Determination (SPAAD)* ❑ Shoreline Management Variance ❑ Temporary Use ❑ Comprehensive Plan/UDC/Land Use District Map Amendment 0 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: T DESIGNATION OF AGENT I hereby des' na e �/�` to act as my agent in matters relating to this application for permit(s). OWNER SIGNATURE L� /" �-/ Date: /f'/1'ECP By signing this application form,the owner/agent at sts 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 gee to pr de access i I right of entry to Jefferson County and its employees, representatives or agents for the sole purpose of application rev' na\any re fired later irj tions.Access d right of entry to this property shall be requested and shall occur only during regular business ho rs. Sign ...ire: /,/7/ Date: The action or actions Applicar4will unde e 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 of 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 p/ pliance with tfi Jefferson Count development code.The Applicant acknowledges that he,she or it holds individual and non- tranerab res sibility or adtier' g t and comply' g with the ESA. The Applicant has read this disclaimer and signs and gates it below. Signa ure: �Q (/ Date: Ia,74 (s G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc • BUILDER STATEMENT • The signer of this statement does hereby certify that they are the Owners of the parcel referenced herein,that they are not licensed contractors and that they will be assuming the responsibility of the General Contractor for the proposed project. Signature: Date: GENERAL CONT CTOR,,OOR MANUFACTURED HOME INSTALLER: PHONE: FAX: - • �a s (366 )1081-0777 (34D ) 4,8/-0780 MAILING ADDRESS: q V-03 Z j 1 / 2.0 .38L EMAIL: CONTRACTOR'S LICENSE WAINS NUMBER: Buy la Nit L D9 NUMBER C()/7/��`SD,5Q ARCHITECT/ENGINEER: PHONE ( ) FAX: ( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: V New Wood Existing: _ _ ❑ Sewer L] Addition 0 Steel Proposed: 02 _ Bank Height: ❑ Community System H Alteration/Remodel ❑ Concrete Total: o. 19 - -individual System $4'-Z1P 0 Repair ❑ Masonry SEP Permit# EX151:4(/y ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: ❑ Private well ❑ Two Party Type of yeat: Proposed: .3 f LYPublic F1FL-re IC-. Total: 3 Name of System: -?Gl D If this is a Commercial Protect 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 ❑ Above ground Tank Size of Propane Tank: H Heat Stove ❑ Cook Stove LI Woodstove ❑ Fireplace Insert U t Water Tank Li Pellet Stove I] Other Is this appliance being installed in a Manufactured/Mobile Home? es / 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 150D.3 EH Bld App Review: I K• orti 2nd Floor Heated Consistency Review: t55 .(9 `J (� cam` f cc Other Heated � ,,} '; -:,j-i;`` \)% It'"'f4 J CO `E `'�, 4 7 lL J Mezzanine Additional Section: , Heated Basement ' ',", Plan Check fee: Unheated Basement urchar a fee: .y�1 i Ub g Other Unheated Pot Water Review fee: Garage/Carport SUBTOTAL — O t_LC: Decks 02. 3X3 u''L ` 911/Rd Approach fee: /' Other _���� ! TOTAL: $ .,, ,'`c Jt" Receipt Number: (9 Li 9 Cash/Check Number: 1,t ;I as ESTIMATED COST(REQUIRED) Date: I��l h nt .Fair market value of all labor and materials foundation to finish i "t. UXJ Initials: C G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 12-30-05.doc ti JOr RETURN ADDRESS FIRST FEDERAL SAVINGS & LOAN ASSN P.O. BOX 351 PORT ANGELES, WA. 98362-0055 ATT: TINA 1,4USTATroFWASHINGTON MANUFACTURED HOME F *m4R.Ix�_r'�`'f� 1JefrarM�enl of APPLICATION WITITLE ELIMINATION 1......._ICE175111G ®TRANSFER II 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 006 MAKE LENGTH/WIDTt{(F ET) VEHICLE IDENTIFICATION NUMBER(VIN) ,1A,' KARSTEN ��ttJ� �( LL STA0282150R © LAND LEGAL DESCRIPTION ON PAGE REAL PROPERTY TAX PARCEL NUMBER MANUFACTURED HOME WILL BE ®AFFIXED ® REMOVED 994 800 503 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION 3 5 SHOLDS ADD'N TO HADLOCK © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS 16 2 1 NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER HAROLD L. TAYLOR NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER DENISE G. TAYLOR ADDRESS CITY STATE ZIP CODE 1646 IRONDALE ROAD PORT HADLOCK WA 98339-9530 NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER FIRST FEDERAL SAVINGS&LOAN ASSOCIATION NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE PO BOX 351 PORT ANGELES WA 98362-0055 GRANTEE NAME DEPARTMENT OF LICENSING I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE A ARE THE REGISTERS OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title, IF APPLICABLE a' f Signature of Additional Registered Owner and Title, IF APPLICABLE J r� NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR REGISTERED OWNERS IGNATURE i1/40HIElipo //�� State of Washington Signed or attested Q. 0,9 County of CLALLAM before me on 01 05 07 Q`�'�pN EXPIR .410 m R r 4� HAROLD L. TAYIAR ��4' 0• '�P Z -...S. by Signature 's `,.* �-,� CO .V= # O S 0PRINT NAME OF REGISTERED OWNER NOT RY OR E (` n W • p ~ by 1 1! ID. 0 0\' g,: _ � DENISB G. TAYIAR �' •.��'.••4,oA.�O1���\ PRINT NAME OF REGISTERED OWNER NTED NAME OF NOTARY 3 i i 5 County/Office No.OR ,4 7's OF 14Q'\\��1� Title DEALERSHIP POIYTION/AGENT/NOTARY AND: Notary ExpiraDealetion Date` . 1 4 TITLE 88tANY 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 JEFFERSON TITLE COMPANY 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. NAM (TYP D OR PRINTED) BLDG PERMIT OFFICE/PH NE# BLDG PERMIT# A �� �tk�,�� c (00) . fl��-ICU titAl Ad hliPnA,1 icy - U)C) } ., SIG T RE/P;SITIO DAT TD420-729 ANUFHOM .PPL(R/ OR(W)Page 1 of 2 • • • MANUFACTURED HOME - FROM SECTION 1 TPO/PLATE NUMBER YEAR 2006 MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) KARSTEN 56 X 27 STA028215OR a 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 \ t ,, � ..1- r, Signature of Additional Legal Owner and Title,IF APPLICABLE `���NtAUttli MP KEt ���' NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE � � AM 0. ARCy 9 ,'','� State of Washington CLAI'L Signed e or forettmeted3t. -7 i Countyof / �: Q OZ \ FIRST FEDERAL SAVINGS �!. ? �yI2.001 '4 0 by Signature , :�'7,'`1 ��-'J- /GC��(s 01 I 4 �, /„ = PRINT NAME OF LEGAL LN CLOSER 9T, .clad t• PUs ` .. C? .. by"" 5`•~ �'••......••...... .$� 9 PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTARY " OF Ivi IxS����`\\ Title NOTARY County/Office No.OR 1-5-10 AND: Dealer No.OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date © LAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office LOT 3,BLOCK 5 OF SHOLDS ADDITION TO HADLOCK,AS PER PLAT RECORDED IN VOLUME 4 OF PLATS ON PAGE 2,RECORDS OF JEFFERSON COUNTY,WASHINGTON. SITUATE IN THE COUNTY OF JEFFERSON,STATE OF WASHINGTON 8 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 BUY RITE HOMES tp 1 2-`� 3/y 3 /c ..7 P R HASE PRICE . TAX JURISDICTION/TAX RATE DEALER'S r�T'HORIZED GNATURE / _! "l v 7 �% ll�orl �.�i��; c ❑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 TITLE FEES FILING FEE APPLICATION MOBILE HOME FEE ELIMINATION FEE USE TAX SUBAGENT FEES TOTAL FEES&TAX MPORTANT: 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