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HomeMy WebLinkAboutBLD2007-00094 • I CERTIFICATE OF OCCUPANCY Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 (800) 831-2678 PERMIT #: BLD07-00094 SITE ADDRESS: 13938 CENTER RD Issue Date: 06/20/2007 QUILCENE, 98376 Final Date: 12/19/2007 APPLICANT: JIMMIE G ACKERMAN PHONE: 360-301-4238 PO BOX 544 QUILCENE WA 983760544 SUBDIVISION: Block: Lot: PARCEL NUMBER: 702131037 Section: 13 Township: 27 N Range: 02 W PROJECT DESCRIPTION: NEW M/H W/ U/G 500 GAL PROP TANK - SER# 9152 THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2003 EDITION. OCCUPANCY GROUP: ' max time_ i me b,30_4 p t-S Pe LsT TYPE OF CONSTRUCTION. SPRINKLER SYSTEM yes o THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 12/19/2007 I:\F_BLD_Occupancy.rpt 10/29/19.c • • 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 #: BLDO7-00094 Received Date: 3/12/2007 SITE ADDRESS: 13938 CENTER RD Issue Date: 6/20/2007 QUILCENE, 98376 APPLICANT: JIMMIE G ACKERMAN PO BOX 544 QUILCENE WA 983760544 SUBDIVISION: Block: Lot: PARCEL#: 702131037 Section: 13 Township: 27 N Range: 02 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 1/6/2009 PROJECT DESCRIPTION: NEW M/H W/ U/G 500 GAL PROP TANK -SER#9152 MAKE: STATLER YEAR: 1980 SIZE: 49 X 24 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 6/20/2008. CALL IN FOR THE REQUIRED INSPECTIONS THAT APP 0 YOUR PROJECT. Setbacks/Footing ( TINUOUS FOOTING SLA: or PADS USED): ae4/2$/O7 A Adijgec'n Jr owNLE- Stormwater FINAL Approval: Blocking/Plumbing: I`L"l t-vL V1 Propane Tank/Lines 1Z`l4'D1. (4713 Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps: 12'''{71./1 i. 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 BUILDING PERMIT APPLICA•N MLA07-00117 Review Type: I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD07-00094 Received Date: 3/12/2007 SITE ADDRESS: 13938 CENTER RD QUILCENE, 98376 OWNER: JIMMIE G ACKERMAN PHONE: 360-301-4238 PO BOX 544 QUILCENE WA 983760544 SUBDIVISION: Block: Lot: T 165 PARCEL NUMBER: 702131037 Section: 13 Township: 27 N Range: 02 W CONTRACTOR: KOZELISKY'S HOME SERVICE INC PHONE: (360)385-3215 1112 S JACOB MILLER RD PORT TOWNSEND WA 98368 Contractor's License KOZELHS027C3 Expires 1/6/2009 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION NEW M/H W/ U/G 500 GAL PROP TANK - SER# 9152 TYPE OF WORK MOB SQUARE FOOTAGE: TYPE OF IMP NEW VALUATION MAIN: CODE EDITION: 2003 ADD'L: HEAT TYPE: WOD OCCUPANCY: HEAT BASE: HEAT TYPE: PRO OCCUPANCY: UNHEATED: # OF STORIES: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PWELL BEDROOMS: BATHROOMS: Exist: 0 Exist: 0 Prop: 2 Prop: 2 Total: 2 Total: 2 Routing Date: 0r 1 Type Amount Paid By: Date: Receipt: Approved/Date Manufactured Homes $163.00 LYK 03/12/07 89567 APPROVED" State Building Code $4.50 LYK 03/12/07 89567 Propane Tanks/Stoves $102.00 LYK 03/12/07 89567 JUN ao 2007 Potable Water Application $58.00 LYK 03/12/07 89567 Jefferson CountyPI arglMc Total: $327.50 &Building Boomtown n 11110 SPECIAL CONDITIONS CASE # BLD07-00094 • 1.) The application was reviewed by the Jefferson County Department of Community Development for the presence of Environmentally Sensitive Areas (ESAs). The Department conducted a review and has concluded that the property DOES NOT contain Environmentally Sensitive Areas. However, future proposals will be subject to a new ESA review and conditions may be added if new ESAs are found on the property. 2.) The applicant is proposing to create or add 1200 square feet of impervious surface and 1200 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. 3.) 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. 4.) 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). 5.) The site plan as submitted with the building permit application on March 12, 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 April 16, 2007 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 6.) This approval is for installation of 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. 7.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 8.) 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. 9.) Minimum front setback from the southern parcel boundary is 20 feet. Minimum side and rear setbacks are 5 feet. The BPA and utility easements on the property further impact setbacks. 10.) 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. 11.) Exterior lighting for residential uses shall not exceed twenty feet(20') in height from the finished grade, excepting when such lighting is an integral part of a building or structure. Ground level lighting is encouraged. 12.) 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.) The building height is not to exceed 35 feet. 14.) A minimum of two (2) onsite parking spaces are required for a single family residence. 15.) This parcel has been designated as Rural Residential 1:5 under the Jefferson County Comprehensive Plan Land Use Map effective August 28, 1998. 16.) This parcel was created through a survey recorded under AFN 254969 on January 3, 1979. 17.) Center Rd is a major collector(C931507). The road approach is via an easement for ingress, egress and utilities recorded under AFN 466746. An address of 13938 Center Rd has been assigned to the parcel. i 18.) A septic permit (SEP07-000twas approved on May 22, 2007 for a system of 360 gallons per day. JACK WVESTERMAN Jefferson (lily 'on rill on'VC ASSESSOR 1'0 1140‘ 1220. Port Tom nsend, 98368 (360)3115-9105 MOBILE HOME INFORMATION FORM OWNER'S NAME./MAILING ADDRESS: NAME: , 1 rY\ 1 G l . ka-t-inw-N ADDRESS: PO c. 51" ' R- 1%31 L' PHONE NO. 1- 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. 1)MOBILE HOME DATA: (A) MAKE w (B) MODEL (CO YEAR F180 (D) LENGTH q 1 (E) WIDTH (F) SERIAL # Gi 1 S. (G) YOUR PURCHASE PRICE (Do not include sales tax) 4- PURCHASE DATE DOD/ 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IFj NEW MOVEO TO QUESTION 3) (A) FROM WHOM DID YOU PURCHASE MOBILE Sar J A I►-e -l ADDRESS 10510 1 '4"-ra' Ne-Gl/ Si I r ' att. G 153a3 (B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR?Yes ( '-o) If Yes, Previous address of mobile. If No, What County was Mobile assessed in last year. 3)WHERE MOBILE HOME IS TO BE LOCATEI/: (A) WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes e (B)IF LOCATED IN MOBILE HOME PARK: NAME &ADDRESS OF PARK Lot/Space # (C) IF NOT LOCATED IN MOBILEOME PAR NAME OF LAND OWNER: �/ VYt�'V1LQ '.-1 LOCATION ADDRESS 13613 Cr,4-C.r 12.A. (� �ti-Q VVa— 03� REAL PROPERTY PARCEL #/DESCRIPTION 1 0 D- 131 03.1 Si ature of applicant THANK YOU FOR YOUR HELP! 0_,I)S. -e JO COSSELL, Property Technician • mot- • CV Cabinets mE E O > o -,t, / _Li eZ Hem 4IeN E 4) U 2 O E oCZ t 7 co -� D IZ Es E / m I I E q.asor.,- o n � Sm 00 cz in 16 IZ lasoll • -, risky& . So.N C � JEFFERSO�OUNTY ; f W ,4 DEPARTMENT OF COMMUNITY DEVELOPMENT '" `4 621 Sheridan Street • Port Townsend • Washington 98368 360/379-4450 • 360/379-4451 Fax 'nry. 1 4qs p�pti www.co.jefferson.wa.us/commdevelopment 11TN 1 i Master Permit Application MLA: 0'7- i 1 Project Description(include separate sheets as necessary): �nsl-u-Itcd-COv- c -� N1a-rwc6,c -tcL rk 0=- Tax Parcel Property Number: -1 0- \-61 ID3 1--1 g Size: 5 . 3� aC_ (acres/square feet) Site Address and/or Directions to Property: t 59 3%� tU I� 1c 0-2 . CS_ bv,Car1 1c- 1. i rvb 4i ) Property Owner(s)of Record: ,j-1 rNl r 1 e Telephone: 30 2 3$ Fax: email: Mailing Address: k0 54t-t CZLA..k 62.r- IA.Dw cl%3-7 Le Applicant/Agent(if different from owner): tf\\ (;,__ Telephone: ax: email: Mailing Address: What kind of Permit?(Check each box that applies) i Building i Variance(Minor, Major or Reasonable Economic Use) I Demolition Permit i Conditional Use[C(a), C(d), or C]** i Single Family i Discretionary"D"or Unnamed Use Classification I Garage Attached/Detached i Special Use(Essential Public Facilities)** ✓Manufactured Home i Boundary Line Adjustment I Modular i Short Plat** I Commercial* I Binding Site Plan** Change of Use i Long Plat** I Address i Road Approach i Planned Rural Residential Development(PRRD)/Amendments** Propane i Plat Vacation/Alteration** I Allowed"Yes"Use Consistency Analysis i Shoreline Master Program Exemption/Permit Revisions** i Stormwater Management i Shoreline Management Substantial Development** I Site Plan Approval Advance Determination(SPAAD)* I 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 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 of entry to Jefferson County and its employees, representatives or agents for the sole purpose of application review and any required ater'nspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the ap. 'cation :/or she wants prior notice. f�7 Signature: I . aLa. Date: ����v The action o fictions Applicant will undertake as a result of the issuance of this permit may negatively impact upon one or more threatened or endangered •-cies 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 iityou are i •m• iance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transfe•aWe res,• Y/'y for adhering to and complying with the ESA The Applicant has read this disclaimer and s,9kns and dates it below. Signature: r Date: 2'ZZ 'v 7 G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 07-14-2000.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 CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: Y-07-- iA'ql ( ) ( ) MAILING ADDRESS: EMAIL: CONTRACTOR'S LICENSE WAINS NUMBER: NUMBER ARCHITECT/ENGINEER: PHONE ( ) FAX:( ) MAILING ADDRESS: EMAIL Project Type: Frame Type: Bathrooms: Shoreline: Type of Sewage Disposal: New Wood Existing: a Ll Sewer ❑ Addition ❑ Steel Proposed: Bank Li Community System ❑ Alteration/Remodel ❑ Concrete Total: Height: t�(Individual System ❑ Repair ❑ Masonry SEP Permit# ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: a Setback: ❑ Private well h7/1-wo Party Taffeat: Proposed: I I Public �Q,� Total: 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: i Underground Tank i Above ground Tank Size of Propane Tank: i Heat Stove •Cook Stove ✓rWoodstove i Fireplace Insert Hot Water Tank i Pellet Stove I Other Is this appliance being installed in a Manufactured/Mobile Home?a' 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 2na Floor Heated Consistency Review: lU Other Heated Base fee: Mezzanine Additional Section: -___, Heated Basement Plan Check fee: Unheated Basement State Surcharge fee: r r:. Other Unheated Pot Water Review fee: -2 Garage/Carport SUBTOTAL Zt F j Decks 9�. 1 lOc Other TOTAL: $ r� ' � �-' f Receipt Number: SCI�r rl Cash/Check Number: 35-��0� ESTIMATED COST(REQUIRED) Date: ��, ^�,'I •Fair market value of all labor and materials foundation to finish (� Initials: G:\PermitCenter\FORMS\DRD FORMS\Master Permit Application 07-14-2006.doc • • RETURN ADDRESS Timberland Bank PO Box 697 120 Lincoln St Hoquiam,WA 98550 LSTATE OF WASHINGTON 4 o��mm, MANUFACTURED HOME licEnsinc APPLICATION LE❑TRANSFERITLEI II AT O LOTIONN ❑REMOVAL FROM REAL PROPERTY Anyone who knowingly makes a false statement of a material fact is guilty of a felony,and upon conviction may be punished by a fine,imprisonment,or both. (RCW 46.12.210) D MANUFACTURED HOME T O/ I 'IMBER 71, YEAR MAKE -H WGC,T DTH(FEET) VEICLDENTIFICATION NUMBER(VIN) LAND 1(�1 O yCjJL(J,l ' ��L/EGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE El AFFIXEDREAL PROPERTY TAX PARCEL NUMBER 0 REMOVED 702 131(49- . '` LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION 13-27-2W NE © GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS 1 1 NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER Jimmie G.Ackerman NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE 13938 Center Rd Quilcene WA 98376 NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER Timberland Bank NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE PO Box 697, 120 Lincoln St Hoquiam WA 98550 GRANTEE NAME Jimmie G. Ackerman I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT f AM/ r�E REGISTERED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title,IF APPLICABLE I/ Signatu8WiddlitiOppOzevgistered Owner and Title,IF APPLICABLE N(>LIZ"���j NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE . x-,..,.•• •••••.. 4' , State of Washington Signed or attested ,�' �� ,•••O�•A R•y'. County of Jefferson me on ` S �' 13 1 7�0�0 1 3py Jimmie G.Ackerman Signa a _so 0$I o 0 ` PRINTED NAME OF REGISTERED OWNER IA ARY OR A ._ U'>,':. P U 8\-` ..1 .0 ;.y IAC l.,✓lL.J►M t" .A .9 � .*'�: PRINTED NAME OF REGISTERED OWNER RINTED NAME OF NOTARY T•'•'•....... .. k' ••c-0 \�� County/Office No.OR '/-%,-Oft,11711r:0�`\\ Title —PA,61,(� AN": Dealer No.OR Z -3 /� \ HIPPPO /NOTARY NotaryEx nation Date / 1o ® 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 Jefferson Title Company (360)385-2000 SIGNATURE/POSITION DATE Finalize this application with a Licensing Agent within 10 calendar days of the date Title Company Representative signs. CI BUILDING PERMIT OFFICE CERTIFICATION I certify that: ® the manufactured home has been affixed to the real property as described. ❑ a building permit hasbeen issued for this purpose and the attachment will be inspected u on completion N7(TYPED OR PRINTED BLDG PE �I.YS..t `,..�Q�)t C. (PoM`�iGI;IT I nO BLDGPERMIT# D <�u 0*\� SI N TURE/P �; tit \ '1 31 WI TD-420-729 NUF HO PL(R/2 2)EXT(W)Page of 2 • • MANUFACTURED HOME-FROM SECTION 1 TP I PLATE NUMBER YEAR MAKE L T IDTH(FEET) VEH CLE IDENTIFICATION NUMBER(VIN) SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR ELIMINATION OF TITLE/REMOVAL FROM REAL PROPERTY. Signature of Legal Owner and Title MIINA,IF APPLICABLE -, (L,A (4 Signature of Additional Legal Owner and Title,IF APPLICABLE NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE State of Washington Signed or attested Countyof `7ni�'j ��(��b��. before me on y-n sis b • Signature r' REBECCAA. L rkt n;� . (� brcc/a A. ( 1.�t- NOTAR1f Pt�B PRINTED N OF REGIS ERED OWNER ARY OR AGENT r �t STATE OF WAS Sal h�� � rG� 1 RSLLI'EA OF REGI TERED OWNER V PRINT NAME OF NOTAR My commission Apr'3 it • County/Office No,OYR «ililb AND: Dealer No.OR DEALERSHIP POSITION/AGENTMOTARY Notary Expiration Date DLAND DESCRIPTION(A legal description of the land can be obtained from the local County Assessor's Office.) Parcel 1 of survey recorded January 3,1979 in Volume 3 of Surveys,page 2,under Auditor's File No. 254969,being a portion of the Northwest Quarter of Section 13,Township 27 North,Range 2 West,W.M., records of Jefferson County,Washington; TOGETHER WITH easements of ingress,egress,roads and underground utilities as shown on the face of said survey. Situate in the County of Jefferson,State of Washington. © DEALER'S REPORT OF SALE I CERTIFY THAT THIS INFORMATION IS CORRECT,THE VEHICLES 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 0 USE TAX EXEMPT Sale to a Certified Tribal member on the reservation(attach notarized statement of delivery). mi 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 ® 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 call(360)902-3600 or TTY(360)664-8885. TD-420-729 MANUF HOME APPL(R/2/02)EXT(W)Page 2 of 2 tcli itet CD +/- 369' 6" ''+'' 4 a)l a , . ± .. , ,. . N T 0 i. TI A am: O rri :a7 C V M I o — en CCD • Z CC CI 1l 1: • r-0 ro 0 0 r N DK X C Z D f�l r= m 0 r : r- o r- r� o yo t hKt�G- � � -3 • I. it t:t: : cc`OG cn + ri 4 : Z rn iv i C IV ..0)/,5i..‘ 3 " (.0 o 0 —I 7 /1(‘‘s°\ '(/ t: : • / i I• Cpaa / 2 O 00 as 3 rY3 c/o "° Stormwater B 1 s Required ro' _ APPROVED * ro , �-., : SITE PLAN =� <' APR 1 6 2001 tt !/ --. j : ..e. + ' `� JEFFERSON COUNTY _^ �s �''�� •, ;' t�► Z: DEI'T.OF C ERSO p = ^V y { ' SIGNATURE:��� co co TRANSFORNtER v N ' -- - - - - j 60' EASEMENT Cur)U-ry, 100' Well Radius c re Ackerman Site Plan -g - ,) , ,. , a ai• _ L ___. _ 'o l,,M ,, f , enter Rd• O > . s „ > � v m "S �� O < •a tli,i Chimlcum Wa �, 0 N � yttiv Parcel # 702131037 a P o m0 a .CO L - —