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HomeMy WebLinkAboutBLD2007-00103 0 • 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 #: BLD07-00103 Received Date: 3/16/2007 SITE ADDRESS: 61 CASCADE AVE Issue Date: 4/6/2007 PORT TOWNSEND, 98368 APPLICANT: KELLI E HEDIN 2022 QUEEN ANNE PL PORT TOWNSEND WA 983687305 SUBDIVISION: IRONDALE Block: 128 Lot: 1-6 PARCEL#: 962112809 Section: 34 Township: 30 N Range: 01 W CONTRACTOR/ OWNER/BUILDER PHONE: DEALER PROJECT DESCRIPTION: REPLACEMENT MAN HOME W/120 GAL A/G PROPANE TANK (GARAGE READY) SKLYLINE/GREENBIAR 6303 (BLD07 00103) MAKE: SKYLINE YEAR: 2007 SIZE: 66x27 THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 4/6/2008. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY AD. YOUR PROJECT. Setbacks/Footing (CONTINUOUS FOOTING or PADS USED): (...l14-i°el* y e_ ( 7 Stormwater FINAL Approval: t Blocking/Plumbing: _ i/( ,e' / Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps: �i(.. 1 i lOn 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 ILDING PERMIT APPLICATA ML Revviewiew Type: 130 I Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD07-00103 Received Date: 3/16/2007 SITE ADDRESS: CASCADE AVE PORT TOWNSEND, 98368 OWNER: KELLI E HEDIN PHONE: 360-385-7153 2022 QUEEN ANNE PL PORT TOWNSEND WA 983687305 IRON DALE SUBDIVISION: Block: 128 Lot: 1-6 PARCEL NUMBER: 962112809 Section: 34 Township: 30 N Range: 01 W CONTRACTOR: OWNER/BUILDER PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOl REPLACEMENT MAN HOME W/120 GAL A/G PROPANE TANK (GARAGE READY) SKLYLINE / GREENBIAR 6303 TYPE OF WORK MOB SQUARE FOOTAGE: TYPE OF IMP NEW VALUATION MAIN: CODE EDITION: 2003 ADD'L: HEAT TYPE: EEE OCCUPANCY: HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: CONST TYPE: OTHER: GARAGE: SHORELINE: CONST TYPE: SETBACK DECK: BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PWELL BEDROOMS: BATHROOMS: Exist: Exist: Prop: 3 Prop: 2 Total: 3 Total: 2 Routing Date: f / o ) Ol c Type Amount Paid By: Date: Receipt: Approved/Date Manufactured Homes $163.00 CJZ 03/15/07 89583 APPROVED Permit $102.00 CJZ 03/15/07 89583 Total: $265.00 APR 6 2007 Jefferson County Planning & Building Department • SPECIAL CONDITIONS CASE # BLD07-00103 1.) A MINIMUM OF 5' MUST BE MAINTAINED BETWEEN BUILDING FOUNDATION AND SEPTIC TANK. 2.) The application was reviewed by the Jefferson County Department of Community Development staff on March 27, 2007 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: Coastal Seawater Intrusion Protection Zones (SIPZ). 3.) 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. 4.) 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. 5.) 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. 6.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ: Water conservation measures: 1. Roof and other intercepted precipitation shall be routed to on-site detention ponds and/or other approved means and allowed to be released to the soil slowly. 2. Water collected from Storm water and roof catchments may be used for watering lawns and gardens. Unless catchment water has been treated to meet drinking water standards, there shall be no cross connections allowed between the potable supply and impounded water. 3. Water withdrawn from wells on each property shall not be used for watering of lawns and/or gardens. 4. Ground water withdrawn from each property shall be restricted to a rate of three (3) gallons per minute. 5. Installation of water conserving fixtures such as low flow toilets, faucets and shower restrictors and other water saving plumbing fixtures. 6. Landscaping plan (xeriscaping, native vegetation with minimal amounts of irrigation). Please NOTE that the above listed measures are not intended to be exhaustive, but rather is intended to be illustrative of the types of water conservation measures. 7.) VOLUNTARY MEASURES OF COASTAL &AT RISK SIPZ: 1. Installation of a flow meter. 2. On-going well monitoring for chloride concentration. 3. Submittal of monitoring data to County. 8.) MANDATORY MEASURES FOR COASTAL SIPZ: • 1. For proof of potable water on a building permit application, applicant must utilize DOH-approved public water system if available. 2. If public water is unavailable, a qualifying alternative system may be used as proof of potable water or an individual well may be used as proof of potable water subject to the following requirement: a. Chloride concentration of a laboratory-certified well water sample submitted with building permit application. 3. If public water is unavailable, a qualifying alternative system may be used as proof of potable water. 9.) The applicant is proposing to create or add 2848 square feet of impervious surface and 4408 square feet of land disturbing activities. JCC 18.30.060 and 18.30.070 require the project applicant submit a stormwater plan meeting Minimum Requirements#1 through #5 of the Department of Ecology Stormwater Management Manual for Western Washington. The stormwater plan shall address measures to control stormwater, erosion and sediment during construction and shall address permanent measures to stabilize soil exposed during construction, and in the design and operation of stormwater and drainage control systems. 10.) A Stormwater Site Plan for a medium project 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. 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 site plan as submitted with the building permit application on March 15, 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 March 28, 2007 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 13.) This approval is for a manufactured home installation and a garage attached to the 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 setbacks from the edge of Cascade Ave right-of-way and Gary Ave right-of-way are 20 ft. Minimum side and rear setbacks are 5 ft. 17.) 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. 18.) 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. 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.) This parcel has been designated as Rural Residential 1:5 under the Jefferson County Comprehensive Plan Land Use Map effective August 28, 1998. 22.) A septic permit (SEP96-00114)was finaled on May 2, 1997 for a 3 bedroom system. • 23.) Cascade Ave (C678409) is a county local access road. A road approach was reviewed under RAP07-00031, and an address of 61 Cascade Ave has been assigned to the parcel. 24.) The proposal is to develop across separate parcels. Setback requirements will not allow for the development to span over lot lines. For the purpose of meeting bulk and dimensional requirements and minimum land area, a Declaration of Restrictive Covenant has been recorded under AFN 521391. 25.) This parcel was created through the Irondale Division No. 5 under AFN 29795, filed of record April 2, 1910 in Plat Book 2, page 135 with Jefferson County Auditor's office. 26.) A minimum of two (2) on-site parking spaces are required for the single family residence. 27.) No plumbing has been reviewed or approved for building permit(BLD07-00104) by Jefferson County Public Health. Additional requirements may apply if plumbing is proposed. 0 • fl� �\ 1 - ' a I tv. - ! 4 , p.m, -.r in CM el a Mlf.s ii aR r ^.1e.r. .n...r :wuf.ssu.. a kal BziG iasas i , 11 ..wrrilia SW it se 41.11 it v� Ile s irssrsr • ls •Usss.f ' ti isss •' b iiil.ii. C rrr rs �ii�r e oi saetralk weak _ • (j 1 .4____ r, 0�i:t.2.ssr.il if II 1 sr wrsa.f+mmom . . iarrr.r.'aafl SSW i .. H JACK WVESTERMAN I40 Jefferson ('oOp Courthouse ASSESSOR PO Ilex I221. fort Townsend. WA 983611 (360)385-910 i MOBILE HOME INFORMATION FORM OWNER'S NAME/MAILING ADDRESS: NAME: Kel i e , { ed ADDRESS: 1D e1'� e,el. P. T: 1.3a 0183608 PHONE NO. 386•lv�5"3 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 `>{_,i41 (II) MODEL Clreey-Z i(ir 4Q3 8(C)YEAR CO-7 ` � (D) LENGTH (p(0i --7(E) WIDTH o� ( (F) SERIAL # (G) YOUR PURCHASE PRICE (Do not include sales tax) PURCHASE DATE 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3) (A) FROM WHOM DID YOU PURCHASE MOBILE r1 ) c ADDRESS ►� (B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR?Yes Co If Yes, Previous address of mobile. )1A• If No, What County was Mobile assessed in last year. N I A 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 diADDRESS OF PARK N n I Pt Lot/Space # (C) IF NOT LOCATED IN MOBILE HOME PARK: NAME OF LAND OWNER: se,I4-- LOCATION ADDRESS o CQ.f ,t Po T. ,L a. REAL PROPERTY PARCEL #/DESCRIPTION C*_ q /), ±< i,, 13 ©c L2 Signs re of applicant THANK YOU FOR YOUR HELP! JO COSSELL, Property Technician ill III moll It 4- --)r:F -,") r-• 1 ' I-. 11 W r--) CASCADE AVE. coo 11 11- I — — " 1 ' O u 2 i 5 Ii t, co cv A PiZof7c5-67- y, I 1 ,r4 hi gravel drive • 410., 1 o 1 DEVrOPMENT al ' 0 'Power line -1-.. • *I' ..1,isc io Curtain drain for downspout .2.ii I,Proposed GARY AVE. , garage r0 ‘ nil `ti .2.0' 0 \/ meow IN I i( Proposed sed manufactured home It 1 Curtain drain for downspout 5:2 419...). 7 i gl ' 'ia,1 V Co01 Man•RireaciLl KEMaleb I nc- 16-' :)1- ..1 ri (N 1 ____ th • f, 4b i 4* I .............._4 sewer line - Id _______ _ o < ›. / I."- ( `.) . 74 if . :,/ Old driveway to be abandoned • and planted in grass _ --- * 6 7 1 .L--,-, • <-----> Water line f , ............10 1 0 _67' 4, PPROVED SITE PLAN drain field f to 0 51 II" co 2 8 2007 rt ri I r4 ti) JEFFERSON COUNTY crl Reserve Area DEPT.OF 1, L NIT • Eymp 1 SIGNATURE: ....../1 1 1 (..) ti, We l I 01/4 g •. --——100' Scale I to .1 7 kV' a_ Parcel# 962112801 - - - DROJECT NAME: KELLI HEDIN NEW RESIDANCE NAME: KELLI HEDIN TAX PARCEL# 96211A sem ADDRESS: 2022 QUEEN ANNE PL. PORT TOWNSEND, WA. ;ITE ADDRESS: 41311611004WistrUL 6 1 C 1.5 c6ote e4t46.. 98368 DWG TITLE: SITE PLAN FOR NEW actigage PHONE: (360) 385-7153 (-;Het._ ON odJEFFERSO UNTY �g DEPARTMENT COMMUNITY DEVELOPMENT • "' Q i-C 621 Sheridan Street • Port Townsend •Washington 98368 360/379-4450 • 360/379-4451 Fax qs'IN www.co.jefferson.wa.us/commdevelopment Master Permit Applicatio - MLA: 0 1. -- I' ec rpeription(include separat s as`nessary): �Q m il try. .orwe- (Rec1/4-1 P,Pe.- - w1 Atro.al.e1 cici guy ',a0 C4cd.C-cp. Tax Parcel Property Number: 9 Cp 1 ' p, ?0 I Size: 15-OcY-s f.ee- (acres/square feet) Site Address and/or Directions to Property: Property Owner(s)of Record: K.,i t i E E . Ke-a.wi Telephone: 1 3 Fax: - email:t biie,SO.GS Ec t.iir .n2t Mailing Address: 2C � j j'l 1i�E P1 , c .T, ) Lal. .cit3(as J Applicant/Agent(if different fro owner): '"'r2 LJ `or Telephone: 3€6.11 s 3 .� 01 o Dg3 ax: - ` email: 6o 1 Mailing Address: .50.AY\t„:1 What kind of Permit?(Check each box that applies) )(Building 1 Variance(Minor, Major or Reasonable Economic Use) 1 Demolition Permit 1 Conditional Use[C(a),C(d),or C]** Al Single Family 1 Discretionary"D"or Unnamed Use Classification X1 Garage cttached)Detached 1 Special Use(Essential Public Facilities)** ,C 1 Manufactured-Home 1 Boundary Line Adjustment 1 Modular 1 Short Plat** 1 Commercial* 1 Binding Site Plan** I Change of Use 1 Long Plat** ?4:1 Address /Q S 1 Road Approach `/C',, 1 Planned Rural Residential Development(PRRD)/Amendments** X1 Propane 1 Plat Vacation/Alteration** 1 Allowed"Yes"Use Consistency Analysis 1 Shoreline Master Program Exemption/Permit Revisions** 1 Stormwater Management I Shoreline Management Substantial Development** I Site Plan Approval Advance Determination (SPAAD)* 1 Shoreline Management Variance 1 Temporary Use 1 Comprehensive Plan/UDC/Land Use District Map Amendment 1 Wireless Telecommunication* I Jefferson County Shoreline Master Program Amendment 1 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 later insppc:tions. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the application thgt 1p or she wants prior notice. Signature: L Date: oZ l 13 l 01 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 compl' nce with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transferable respnonAibili y for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: = Q X IL LQa_i�L Date: cal 13 01 G:\PermitCenter\FORMS\DRD FORMS\.Master Permit Application 07-14-2006.doc • BUILDER STATEMENT • The signer of this statement d s 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 resp sibilit of theGeperal Contractor for the proposed project. Signature: ' k � -ITC A-V l Date: c -i i�—j/ 07 GENERAL CONTRACTOR OR MANUFACTURED HOME INSTALLER: PHONE: FAX: ( ) ( ) 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 a Wood Existing: C1 Sewer ❑ Addition ❑ Steel Proposed: . Bank ❑ Community System ❑ Alteration/Remodel ❑ Concrete Total: ,;, Hei ht: I Individual System I k ❑ Repair ❑ Masonry 1`l�A SEP Permit# — Bedrooms: Water Supply: ❑ Demolition CI Other: Pp Y: Existing: X Setback: ❑ Private well Two Party Type of Heat: Proposed: Public _ - j `1; ,{- Total: - _' Name of System: 1;j IA-_If this is a Commercial Project you must answer the following: Number of Parking Spaces: Current: Ni 1 1N Proposed: l ( ) Number of ADA Parking Spaces: N jA Number of occupants(includes owners,tenants,employees,etc) Current —CO— Proposed N I A IBC Occupancy: t i 1(-A- IBC Type of construction: NI I IN 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 Above ground Tank, Size of Propane Tank: 13C- (qv-L. i Heat Stove i Cook Stove i Woodstove CrTireplace Insert 1 Hot Water Tank i Pellet Stove I Other Is this appliance being installed in a Manufactured/Mobile Home?GP 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: (03 2nd Floor Heated Consistency Review: 153 Other Heated Base fee: I CO 3 Mezzanine Additional Section: ___' Heated Basement Plan Check fee: • Unheated Basement State Surcharge fee: - --- Other Unheated Pot Water Review fee: 9a.ptacvrr.o„ ' —' No ire Cktsl,rb Garage/Carport SUBTOTAL Pc-►-tom t AyJC°t1 I O a Decks 911/Rd Approach fee: 1 ,D` Other _ TOTAL: $ ? Receipt Number: 861 5?' Cash/Check Number: d ESTIMATED COST(REQUIRED) Date: �j-��S��� f 'Fair market value of all labor and materials foundation to finish f,�c/ COC 00 Initials: Cy, G:\PennitCenter\FORMS\DRD FORMS\Master Permit Application 07-14-2006.doc • • RETURN ADDRESS -l?ou n p Z, Cvmm. C.C. O. P.D, Bo/. 1630 Po R:r TLCr3nr O toik cr )(A 11° Sr=r`aT� F`�`STON MANUFACTURED HOME PLEASE CHECK ONE h���n" WA "'v0 ®TITLE ELIMINATION licEnsinG APPLICATION ❑TRANSFL dN-LOCATION Anyone who knowingly makes a false statement of a material fact is guilty ❑REMOVAI )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) Q007 SK4IJ-INE (o(o LT/•�s © LAND LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE 1g AFFIXEDREAL PROPERTY TAX PARCEL NU BER 0 REMOVED LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUA- UARaTol ECTION -40 IQ SroMal-e.DiViSic^ * - fcm►nlacw to etnt2 © GRANTOR(S)REGISTERED/LEGAL OWNER(S) I ADDITIONA , AMES ONVIttark1330401M COUNTY NUMBER NUMBER OF REGISTERED OWNERS 01'ArinA6t Rf<IF LIBriaolvtereer!trltwttlA •,A! NAME A OF REGISTERED OWNER .. r DOL GUSTO ER AC '•U I +M: R ME K e...t I, e . ea i- NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER N oVle- ADDRESS CITY STATE ZIP CODE logy £. C&S J 4)€ Pe. . C-i(-1---1-ek)Nr\se d vJo. q8 366 NAME OF LEGAL OWNER - DOL CUSTOMER ACCOUNT NUMBER KeA\.; . 2.d.tIn NAME OF ADDITIONAL,, LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER 1 \r,^ e ADDRESS CITY STATE ZIP CODE [o I -6 . CEtSCa4-e Pre. . , 9ov A-'�it>o_N sey\c( t,,\a, a 8 3(08 GRANTEE �1 N(WE of i' p - . ComenoN1�� r ram I - C. 0. 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 County/Office No.OR Title AND: Dealer No.OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date 4 TITLE COMPANY CERTIFICATION I certify that the legal description of the land and ownership is true and correct per the real property records. 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 certify that: pa 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 (TYPED OR PRINTED) LDG PERMIT OFFICE/PHONE# BLDG PERMIT# A41V 4Q.. at + 1^ 4450 poi-Doi SIGN URE PO ITI N f- - DATE, I PIA/ ir l P r1, i 1I ia0g TD-420-7 9MANUFHOMEAPP (R/2/02)OR(W)Page 1 of 2 • • MANUFACTURED HOME - FROM SECTION 1 TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) attoT1 SK9lihe 647X 27Yz 6 SIGNATURE OF LEGALLIOWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR ELIMINATION 0 TITLE/REMOVAL FROM REAL PROPERTY. Signature of Legal Owner and Title, IF APPLICABLE 11 Signature of Additional Legal Owner and Title, IF APPLICABLE N f P NOTARY SEAL OR STAMP I NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE at�of y/ hi gton Signed or attested v ��ou y of err—c5=z r-L for e on l l ( NOtOry PNltillp gale d Wa Signature mama IARENINT NAME LEGAL OWNER TAR OR A NT My Appoirditiord Empkal.tul 31, 2010 ' /"hU Ec-E ',Li,,.fo iR I y PRINT N LEGAL OWNER PRINTED NAME OF NOTARY rwirgpqrairsie T�-Nor County/Office No.OR Qi /0 Title I"C r AND: Dealer No.OR D DEALERSHIP POSITION/A ENT/NOTARY Notary Expiration Date D LAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office) L r� w ) NCL �e-- i g BLoCK caSC F (RO OHS€. Div iisIDN No, €i s PER_ PLAT- IDP a3 fv v Fr >s � j efr,= )N Cc o Nsrn�i u-�14��Nf,tic;��N- Pic (3�, R a 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 OFFICENFS 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 proviq'ing 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