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HomeMy WebLinkAboutBLD2007-00341 MANUFACtRED/MOBILE HOME INSTA!ATION PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT #: BLD07-00341 Received Date: 6/25/2007 SITE ADDRESS: 13962 COYLE RD Issue Date: 11/2/2007 APPLICANT: KEITH S HOWARD PO BOX 823 KINGSTON WA 983460823 SUBDIVISION: Block: Lot: + PARCEL#: 601334031 Section: 33 Township: 26 N Range: 01 W CONTRACTOR/ OWNER/BUILDER PHONE: DEALER PROJECT DESCRIPTION: NEW MAN HOME - BENDIX SERIAL#SD2375A MAKE: KOZY YEAR: 1979 SIZE: 14x64 Directions To Site: THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 11/2/2008. CALL IN FOR THE REQUIRED INSPECTIONS THAT APPLY • YOUR PROJECT. / Setbacks/Footing (CONTINUOUS FOOTIN , LAB .r PADS US D): •/ ./,K /04 e7, Stormwater FINAL Approval: y Blocking/Plumbing: OK_ ID/w/O&Propane Tank/Lines NA, Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final kirting/Vents/Porches/Steps: Q /D 20 D ' , , / Z.//,g ,6' HEALTH DEPARTMENT AND PUBLIC WOR APPROVAL REQUIRED PRIOR TO/FIN L I PECTION 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 # BLD07-00341 1.) The application was reviewed by the Jefferson County Department of Community Development staff on July 19, 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: Type 3 stream, blue heron, commercial and rural forest lands adjacent. 2.) A Type 3 Stream (Fish and Wildlife Habitat Area) has been identified on the subject property. The stream will require a setback of 100-feet. The setback shall be measured horizontally from the Ordinary High Water Mark (OHWM). Fish and Wildlife Habitat Areas shall also have Buffers and Building Setbacks established. 3.) Stream buffers are areas that shall be maintained in their natural condition, however, minor pruning or alteration of vegetation may be permitted as long as the function and character of the buffer are not diminished. 4.) Among the native conifer species which may be used in buffers or for re-vegetation include, but are not limited to: Grand Fir(Aibes grandis), Sitka Spruce (Picea sitchensis), Shore Pine (Pinus contorta), Douglas Fir(Pseudotsuga menziesii), Western Red Cedar (Thuja plicata), and Western Hemlock (Tsuga heterophylla). Among native tree species which may be used includes: Vine Maple (Acer circinatum), Big-Leaf Maple (Acer macrophyllum), Red Alder(Alnus rubra), Pacific Madrone (Arbutus menziesii), Quaking Aspen (Populus tremula), Black Cottonwood (Populus trichocarpa), Bitter Cherry (Prunus emarginata), Oregon White Oak (Quercus garryana), Cascara (Rhamnus purshiana), Pacific Willow (Salix lasiandra), and Scouler's Willow(Salix scouleriana). Among the native shrub species which may be used are: Sevice-Berry (Amalanchier alnifolia), Red Osier Dogwood (Cornus stolonifera) Salal (Gaultheria shallon), Ocean Spray (Holodiscus discolor), Indian Plum (Oemlaria cerasiformis), Pacific Ninebark (Physocarpus capitus), Red Flowering Currant (Ribes sanguineum), Wild Rose (Rosa nutkana), Swamp Rose (Rosa pisocarpa), Willows (Salix ssp.), Red Elderberry (Sambucus racemosa), Snowberry(Symphoricarpos albus), Evergreen Huckleberry (Vaccinium ovatum), Red Huckleberry (Vaccinium parvifolium). 5.) The identified Fish and Wildlife Habitat Area (Type 3 Stream), shall maintain a vegetative buffer setback of 100-feet. The setback shall be measured horizontally from the Ordinary High Water Mark (OHWM) to the proposed manufactured home. 6.) An additional setback of five (5) feet is required from the edge of the stream buffer area to the proposed manufactured home. 7.) The applicant is proposing to create or add 840 square feet of impervious surface and 1590 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. 8.) 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. 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 installation application on June 25, 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 July 19, 2007 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 11.) This approval is for 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. 12.) The parcel has been designates RR 1:20 under the Jefferson County CoSehensive Land Use Map effective August 28, 1998. 13.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 14.) 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. 15.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. 16.) The building height is not to exceed 35 feet. 17.) Maximum lot coverage is not to exceed 25%. Lot coverage is defined as amount of impervious surface which includes roof tops, driveways, concrete, etc. 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.) 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. 20.) Minimum setback from Coyle Road right-of-way shall be 20 feet. Minimum setback from the north (commercial forest lands) property line shall be 250 feet. Minimum setback from the west(rural forest lands) propety line shall be 100 feet. Minimum setback from the Type 3 stream shall be 105 feet. 21.) An address of 13962 Coyle Road, Quilcene has been assigned to the parcel. Coyle Road is a county minor collector(C403908). 22.) A road approach permit(RAP07-0016)was cancelled on February 15, 2007. A septic permit(SEP07-0080) was issued on November 1, 2007. 23.) Jefferson County has determined that the use of real property for agriculture and forestry operations is a high priority and favored use in the county. The county will not consider to be a nuisance those inconveniences or discomforts arising from such operations, if such operations are consistent with commonly accepted best management practices in compliance with local, state, and federal laws. If your real property includes or is within five hundred (500) feet of real property designated as Rural Residential 1:10 or 1:20, Rural Industrial, Rural Commercial, Agriculture, or Forestry, you may be subject to inconveniences or discomforts arising from such farming and forestry operations, including but not limited to noise, tree removal, odors, flies, fumes, dust, smoke, the operation of farm and forestry machinery during any 24-hour period, the storage and disposal or manure, and the application of permitted fertilizers and permitted pesticides. One or more of these inconveniences may occur as a result of agricultural and forestry operations which are in conformance with existing laws and regulations. 24.) The parcel is served by an individual on-site well. 25.) The proposed 840 square foot manufactured home is located greater than 150 feet east from the GIS mapped Type 3 stream. JACK WESTERMAN. Jefferson its Courthouse ASSESSOR PO tIox 1'l2if, Port Tow-nsend, fl'.t 90368 (360)385-91OS MOBILE HOME INFORMATION FORM OWNER'S NAME/MAILING ADDRESS: NAME: / , t /* $t /47C9 ct? A ZO ADDRESS: A O , 8 2,..3 X/,j G$ ra ry cti I'd_, (1.::51 3 (-1 6 PHONE NO. 3 C S o`i Co 2 -?' 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: l (A) MAKE 62'ti 4 t k /i O 'Z. Y (B) MODEL 1' /"/ X. ( 1 tl (C)YEAR - 7 9 ! / !/ (D) LENGTH Co / (E► WIDTH / 3 !0 (F)SERIAL # S 0 rZ 3 7 -CA (G) YOUR PURCHASE PRICE (Do not include sales tax /$0.c' PURCHASE DATED//C '7 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3) fPh41 r� 1qc/<e2szr4iv (A) FROM WHOM DID YOU PURCHASE MOBILE )3 i Le.- / , /,a c/<".e,2 fn 4/U ADDRESS A.?5 `1 Co 3 N&'Y lO / Oct i C,Cen.9 Lt2 4 , 9 & 3 76 (B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAIPTO No If Yes, Previous address of mobile. S,i ek'-e P y 4 13 CJ v `e- 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 'o! (B)IF LOCATED IN MOBILE HOME PARK: NAME A.ADDRESS OF PARK ✓U Lot/Space # (C) IF NOT LOCATED IN MOBILE HOME PARK: �( NAME OF LAND OWNER: /(Q (7/4S c /� 0 CO A IZ/3 LOCATION ADDRESS / 3 `4 Cs 2— e,c Vc___C-e ( . c Cs2 c _ ,CC.•eN Q- REAL PROPERTY PARCEL #/DESCRIPTION `3 C) ( 3 3 Li C' 3 / ----2/- 7-,/ ignature of applitinnt THANK YOU FOR YOUR HELP! 1111 el)SIR I , JO I 1 COSSELL, Property Technician • 44,41 V JEFFERSON COUNTY JUN z5 fDEPARTMENT OF COMMUNITY DEVELOPMENT ' 2007 4 621 Sheridan Street • Port Townsend • Washington 98368 L JKiy"J (Oc° 360/379-4450 • 360/379-4451 Fax i>EV i, http://www.cojefferson.wa.us/commdevelopment/ STORMWATER SITE PLAN SUBMITTAL TEMPLATE MLA# C \ PROJECT/APPLICANT NAME: /�-0_,i 27 S (/ p CC, A vZ t7 Please answer all of the following questions to the best of your ability. Where the question calls for depiction on a site map, the applicant may choose to either incorporate the elements into the general plot plan for the Master Land Use Application or to submit a separate stormwater site plan map. Project Overview 1. Describe the proposed developed conditions of the site. Indicate position and relative size of proposed improvements on the site map. "d- )e- Cam 02 x Ll0 G" 26-e Existing Conditions Summary 2. Describe the existing topography. Indicate contours on the site map. 3. Describe the existing vegetation. Indicate native vegetation areas on the site map. rt9 I c cue e cT c o ti S �C ra✓L o c< vz-�,� c ( L. e m jo e e Cc /1 w cc- 2-e 4. Describe the existing soils. Indicate soil type on the site map. ACC_ socL ex."c9--e e 5 c:L S ,4 •Vd To e. a 'sr est.i-t S ©( L 3zJ` Tci <1 •4/ ., 5. Describe the existing site hydrology(i.e.,drainage;behavior of water on the site—above,below, and on the ground). Indicate existing stormwater drainage to and from the site on the site map. Depict separate drainage basins on the site map, if applicable,and indicate acreage of each. Cu-a f•en ©n-c.-c ix., s 2o .vo 12 U ra S iL(2.0-e_sj N cz'sn rc) -e x e,s d (ia,6- 194, 1 6.k..9-e /J/7 c . 6. Describe any excess levels of noise generated by the proposed use or activity: APPROVED roCr - s 1 5 C.� 1�c� �-� �j �.,�5 csd :�Rc�1 TER PLAN Stormwat r s JUL 1 9 2001 Require JEFFERSO C U Y Dstormwater site plan template—rev.10/1/2003 SIGEIvP TUORFt�T E .L PM NT 5 • • 7. Describe significant geographic features and critical areas (i.e., environmentally sensitive areas such as wetlands, streams, steep slopes,etc.)on the site. Indicate location on the site map. fO t.�c_ 711 0 3)-Ct--,/Z- 141-0 �y 8. Describe the general vicinity of the site, including adjacent land uses and structures, utilities, roads,and sensitive/critical areas (streams,wetlands,lakes,steep slopes,etc.). S Lag-- In(4 s Permanent Stormwater Control Plan This portion of the Stormwater Site Plan consists of the selection and installation.of the appropriate stormwater control BMPs and facilities to remain in place after construction of the project is completed. "Medium" size projects are required to have the totals calculated of all impervious surfaces, pollution-generating impervious surfaces, and pollution-generating pervious surfaces to verify that the thresholds for treatment facilities and flow control facilities are not exceeded. g_ Describe the developed site hydrology, as proposed. Indicate whether stormwater will be fully dispersed(i.e., per BMP T5.30 in the Manual)or, if not,what types of stormwater flow control will be utilized for the site or specific threshold discharge areas within the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. S a9- (-RA,eg.tc( 0,1 u 0-Lot- 10. If the project requires the use of stormwater treatment facilities, describe the types of stormwater treatment facilities proposed for use on the site. Locate these facilities on the site plan and differentiate proposed facilities from existing facilities. [This is normally for large"projects or projects that involve the potential for dispersion of contaminants.] 11. Describe the performance goals and standards applicable to the project. /UCIlt re, C( u Not_1744 cc 2 c - I- " t 12_, Describe the flow control system.-� --•-; L .- ,.,. Y I • 1 stormwater site plan template—rev.10/1/201/3 t+ 6 • • ij l • 13. Describe the water quality system. 1 i 1 s A)0 —s N �W2�ri Cvi J�N 2 5 2007 !v NTv DEVEL©PPEN1 14. Describe the conveyance system analysis and design. / A- 15. Describe the source of fill material,physical characteristics of fill material,and deposition of excess material. N A- 16. Proposed methods of placement and compaction consistent with the applicable standards on Appendix Chapter 33 of the Uniform Building Code. A- 17. Describe the proposed surfacing material. Nit > ' 3 S 18. Describe methods for restoration of the site. AC. A "- r ss s s 19. An Operation and Maintenance Manual is required for each flow control and treatment facility. [This is normally required for "large"projects only and only those for which facilities are required to control flow or treat runoff.] If included,list the Manuals here. Av/A 20. List here and include any special reports or studies conducted to prepare the Stormwater Site Plan. 21. List other necessary permits and approvals as required by other regulatory agencies. If those permits or approvals include conditions that affect the drainage plan or contain more restrictive drainage-related requirements,describe those conditions or restrictions here. stonnwater site plan template—rev.10V1/2003 7 • • CONSTRUCTION STORMWATER POLLUTION PREVENTION PLAN(SWPPP) The Construction SWPPP addresses sediment and erosion control during construction. The BMPs indicated by the applicant in the template that follows must be installed on the ground during all construction phases of the project. The proponent is responsible for preventing sediment and erosion impacts to environmentally sensitive areas and off-site areas. Consult the Construction Stormwater Pollution Prevention (SWPP) Best Management Practices (BMPs) Packet for guidance, particularly with rural residential development. SECTION I—CONSTRUCTION SWPPP NARRATIVE 1. Construction Stormwater Pollution Plan Elements. Describe how each of the Construction SWPPP elements has been or will be addressed. Identify the type and location of BMPs used to satisfy the required element. If an element is not applicable to the proposal,justify in writing. Descriptions of the 12 Elements are found at section 2.5.2 of the Manual (beginning on page 2-15). 12 Required Elements—Construction SWPPP 1. Mark Clearing Limits. d l3 `f N0 e ,nJ Cc�F.i 6 i mod-, Cr; CPc>P�� 2. Establish Construction Access. is i0(Lr 0 e cui4j -1 C,L0L 3. Control Flow Rates. / C. /J--t c,c � -C (.4-) c C L f lac-) eo L(a2r9 S fU ' 7 l -cs P 9L!S a"/ 7� 4. Install Sediment Controls. c 8 /0 Ay 7)(-1 rid cA,-A--) w U c., Nor' � - 6,2.KA(r o ,-, • 5. Stabilize Soils. r p /L3 A, t.0/'�c-A. V C, C'U cC N C4 ,,` 6. Protect Slopes. /VcrGt Wt /LdcC �wC C) � � ��ct-�c� .J 7. Protect Drain Inlets. /v/A ACC, c_,C eG6 cf co LC eve‹. vt /3 e e t.itAr'f' stormwater site plan template-rev.10/1/2003 8 • 12 Required Elements—Construction SWPPP(continued) I fZ [u (0 C, ! CV; 8. Stabilize Channels and Outlets. ' +i L11 JUN 2 5 2GQ i _,r1TY 9. Control Pollutants. %c!/ELOPh1 /1-9 C9-rr- -& r cc d -e-c c+x3 C Y�� 10. Control De-Watering(the act of pumping groundwater or stormwater away from an active construction site). • nifri 11. Maintain Best Management Practices(BMPs). e r-c tXz cr^-} T i2-- c 12. Manage the Project. e,tis s ce..T i u--e 0 'e5c t r t—Q-'e 2. Adjacent Areass. a. Description of the adjacent areas that may be affected by site disturbance (e.g., streams, lakes, wetlands, residential areas, road ). b. Description of the downstream drainage path leading from the site to the receiving body of water(minimum distance of 400 yards). N 0 3. Environmentally Sensitive Areas. a. Description of environmentally sensitive areas that are on or adjacent to the site. Jo- stormwater site plan template—rev.10r12003 9 • • b. Description of special requirements for working in or near environmentally sensitive areas. Now 4. Erosion Problem Areas. Description of potential erosion problems on site in the context of the characteristics of the on-site soils(e.g.,erodibility,settleab ity,permeability,depth,texture,soil structure). 5. Construction Phasing. a. Construction sequence C_ Ce�2 r U s c e / rt) m `< i cic9 / �. 6 i C e t ru s r`cc. C 3-02 p Cc, ,t1E- A. c9G S e ©mob" b. Construction phasing(if proposed) io/ !�l,2- 6. Construction Schedule. Wet season is October 1 through April 30(page 2-21 of the Manual). I. Provide a proposed construction schedule. c5 S #S II. Wet Season Construction Activities. a. Proposed wet season construction activities. e£-.¢ LX cL ti y 0.e 5 cx Pr o.v r2 - qP c f vz e 10 b. Proposed wet season construction activities for environmentally sensitive areas. (ti c) 7. Financial/Ownership Responsibilities. a. Identify the property owner responsible for the initiation of bonds and/or other financial securities. / irl 5e C(0,c4_9 if4i rZ,0 b. Describe bonds and/or other evidence of financial responsibility for liability associated with erosion and sedimentation impacts. 8. Engineering Calculations. Provide Design Calculations on a separate sheet for the following,if applicable. a. Sediment Ponds/Traps. 1"-2 /i - b. Diversions. �— c. Waterways. to /f' d. Runoff/Stormwater Detention Calculations 7kil ' stormwater site plan template—rev.10/1/2003 10 mow • • • Stormwater Site Plan Changes If the designer wishes to make changes or revisions to the originally approved Stormwater Site Plan,the proposed revisions shall be submitted to DCD prior to construction. The submittal shall include substitute pages that include all proposed changes, revised drawings showing any structural changes,and any other supporting information that explains and supports the reason for the change. Final Corrected Plan Submittal If the project included construction of conveyance systems,treatment facilities,flow control facilities, or structural source control BMPs (not standard on-site stormwater management BMPs),the applicant shall submit a final corrected plan ("as-builts")when the project is completed. These should be engineering drawings (stamped by a licensed civil engineer) that accurately represent the project as constructed. APPLICANT SIGNATURE By signing the Construction SWPPP worksheet, I as the applicant/owner attest that the information provided herein is true and correct to the best of my knowledge. I also certify that this application is being made with the full knowledge and consent of all owners of the affected property. C n�(4t�� ( DOW R OR HORIZED REPr; ENTATIVE SIGNATURE) (DATE) THIS SPACE MAY BE USED FOR ADDITIONAL NOTES, IF NEEDED: r:61 - ' , M L. , i . iF;1�Nl i ' stormwater site plan template—rev.10/1/2003 12 RETURN ADDRESS L1SCATCUl v,rS„11 (:T-n MANUFACTURED HOM PLEASE CHECK ONE licEni.,,_�.r.,,nr`' APPLICATION TITLE ELIMINATION sinG 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 il.:AgMBF„S YEAR MAKE xi, LE(GOTH/WIDTH(F�ET) VEHICLEIDENTIONNUMBER(VIN) LAND /V�((�J� (//yl 4 X LEGAL DESCRIPTION ONfJ PAGE MANUFACTURED HOME WILL BE AFFIXED ❑ REMOVED REAL PROPERTY TAX 3 e N0B3 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE `/l•C• 7]QUARTER/QUARTER SECTION 5e. cc.,, 33 ,41. tV /2i i S"aiAl El GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS / / NAME OF GISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE /3 9 !a 2- C Gy L...€_ ,L'•,' O c,2 c le .c.,,, .c (2..)A rfs .3 / 6 NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER /</ie_ i l-1{ S S. /Wp u--) /Vie G9 NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE /3 `. (C) C___L:5 e_r c L#P}? (" 4„, e e c_r,t 60,2 + 9,93/a -NAME NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGISTERED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title, IF APPLICABLE_ Signature of Additional Registered Owner and Title, IF APPLICABLE NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR REGISTERED OWNERS)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 I Certify that: Y.the manufactured home has been affixed to the real property as described. 0 a building permit has been issued for this purpose and the attachment will be inspected upon completion. NAME(TYPED OR PRINTED) BLDG PERMIT OFFICE/PHONE# BLDG PERMIT# ifNaAA.,Q.-- 6 r IIMQ S,,.ic. A- C 3Co0) 3.1 t- 4450 3c_a67- obi 1 SI URE/POSITION DATE ja sil,. Pan( ry,,6-- Told\ TD-420-729 MANUF HO PPL(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) X 6 SIGNATURE OF LEGAL OWNER SIGNATURE OF LEGAL OWNER INDICATES CONSENT FOR ELIMINATION OF TITLE/REMOVAL FROM REAL PROPERTY. Signature of Legal Owner and Title, IF APPLICABLE Signature of Additional Legal Owner and Title, IF APPLICABLE NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR LEGAL OWNER(S)SIGNATURE State of Washington Signed or attested County of before me on by Signature PRINT NAME OF LEGAL OWNER NOTARY OR AGENT by PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTARY County/Office No.OR Title AND: Dealer No.OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date D LAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office) EI 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). Q 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 providing equal access to its services. If you need special accommodation, please cal(360) 902-3600 or TTY(360) 664-8885. 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