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HomeMy WebLinkAboutBLD2007-00605r A. JACK WVESTERMAN• Jeffersonibty Courthouse ASSESSOR Po Box 1220, Port Townsend,'WA 98368 (360)385.9105 MOBILE HOME INFORMATION FORM OWNER'S NAME/MAILING ADDRESS:nn NAME: C�i-ZO 374) ADDRESS: W 5, C.©.$ MI LL4g,e 41).. PHONE NO. I--300-vs:--2.q lti 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. 'MOBILE HOME DATA: (A) MAKE l Y.bD (B) MODEL C6"eYelf/l (C) YEAR 714 (D) LENGTH SZX�1- (E) WIDTH 2-4- (F)SERIAL # 5 .9-333 (G)YOUR PURCHASE PRICE (Do not include sales tax)6/J(— PURCHASE DATE7. 2 7 2) PREVIOUS OWNER/LOCATION OF MOBILE HOME: (IF NEW MOVE TO QUESTION 3) (A) FROM WHOM DID YOU PURCHASE MOBILE/11024 &/75-- OZ/ ' ADDRESS 4L7 e/D ./1.J, GV� 3�� (B) WAS MOBILE HOME ASSESSED IN JEF ERSON COUNTY LAST YEAI6 No If Yes, Previous address of mobile. 77/►1i / �i�l�S 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 S (B)IF LOCATED IN MOBILE HOME PARK: NAME &ADDRESS OF PARK Lot/Space # (C) IF NOT LOCATED IN MOBILE HOME PARK: NAME OF LAND OWNER: ('1 mtyx) ti.WC9463—D4061 LOCATION ADDRESS 2 cf leaxo- Di? REAL PROPERTY PARCEL #/DESCRIPTION Itaie4/ 1.1%..cii ' . ''' If/.' - ,t) 42 Signature I \:pp cant - b '—7- THANK YOU FOR YOUR HELP! 4 „a cL DEC 4 2�"7 JO COSSELL, Property Technician JEEEEA u'�.a Li�J , :% • I �,�E �T�,�DEPARTMENCOMMUNITY DEVELOPMENT I• . a ,i. I,_ ' 621 Sheridan Street •• Port Townsend ••Washington 98368 360/379-4450 •• 360/379-4451 Fax . ._. ._q i. ywww.co.jefferson.wa.us/commdevelopment DEC ; L. �?SING Master Permit Application MLA:''' .4Lai' BCD Project Description (include separate sheets as necessary): T/7 .c///d/f'lff- —/ f Tax Parcel �i Property n Number: `i 2 S�084 Size: `76 X/ (acres/square feet) Site Address and/or Directions to Property: 2s-/ ,-/9 Ae, /A77 al/9 . g3 Property Owner(s)of Record: C(6e) / viid Telephone: / -jb &c$- 2q4/ Fax: 414? email: /0,eif.)-5 {%i8 j Mailing Address: 'e1--/ S. Qe i'Yf/(zt4e) Applicant/Agent(if different from owner): peet,o Telephone: /" 366- 3ks` - 2614( Fax: 104 email: /____7T Mailing Address: 'T ( S -,MC 03 /k/L&Ge 2. ,,-f ail 9Yg•LE What kind of Permit?(Check each box that applies ❑Building 0 Variance(Minor, Major or Reasonable Economic Use) O Demolition Permit 0 Conditional Use[C(a),C(d),or C]** ❑ Single Family 0 Garage Attached/Detached 0 Discretionary"D"or Unnamed Use Classification ❑ Manufactured Home 0 Modular 0 Special Use(Essential Public Facilities)** O Commercial* 0 Boundary Line Adjustment O Change of Use 0 Short Plat** O Address 0 Road Approach 0 Binding Site Plan** ❑ Home Business 0 Cottagelndustry 0 Long Plat** ❑ Propane 0 Planned Rural Residential Development(PRRD)/Amendments** ❑ Sign 0 Plat Vacation/Alteration** 0 Allowed"Yes"Use Consistency Analysis 0 Shoreline Master Program Exemption/Permit Revisions** 0 Stormwater Management 0 Shoreline Management Substantial Development** O Site Plan Approval Advance Determination (SPAAD)* 0 Shoreline Management Variance ❑ Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment 0 Wireless Telecommunication* 0 Jefferson County Shoreline Master Program Amendment O Forest Practices Act/Release of Six-Year Moratorium 0 Tree Vegetaion Request *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 inspections. Staffs access and right of entry will be assumed unless the applicant informs the County in writing at the time of the a li/licat��ion that he or shesh7 wants prior nj Signature: t i✓C-[/ �J/��lJ �jy PT: /I6* Date: /z--7g 7/7 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 compliance with the Jefferson County development code.The Applicant acknowledges that he,she or it holds individual and non-transferablebl responsibility for adhering t and comp yang with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature: t� s/�� '/L1 l{�� �i/�� !7L/. /�1 l�//`GT Date: //-/1 7 G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.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 Gen al Contractor for the proposed project. Signature: C Date: `2 67 7J;�9 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 ❑ Wood Existing: ❑ Sewer ❑ Addition ❑ Steel Proposed: Bank El Community System ❑ Alteration/Remodel ❑ Concrete Total: Height: ❑ Individual System • Repair ❑ Masonry SEP Permit# ❑ Demolition ❑ Other: Bedrooms: Water Supply: Existing: Setback: ❑ Private well ❑ Two Party Type of Heat: Proposed: ❑ Public 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 i Cook Stove I Woodstove I Fireplace Insert i Hot Water Tank I Pellet Stove i Other Is this appliance being installed in a Manufactured/Mobile Home? Yes / No 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: 2nd Floor Heated Consistency Review: Other Heated Base fee: r —CS IR- L OuI , 1Da. oD Mezzanine K � A J Additional Section: Heated Basement Plan Check fee: DEC 1 4 2007 Unheated Basement State Surcharge fee: Other Unheated :r rF{B S N COUNTY BCD Pot Water Review fee: Garage/Carport SUBTOTAL IDa.DD Decks 911/Rd Approach fee: Other TOTAL: $ L Da ,DO Receipt Number: 9 5(05S Cash/Check Number: LA Ct ESTIMATED COST(REQUIRED) Date: rr51%-i •Fair market value of all labor and materials foundation to finish Initials: G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc F • II RETURN ADDRESS L41 STpastmrnt oATE OF Wf MANUFACTURED HOME ASHlNGTON PLEASE CHECK ONE De TITLE ELIMINATION liCEnSinG APPLICATION ['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 TP /PLATE NU BFi Y E a MAKE gLENC�TH/WIDTH(F� T) V AT ICLE I NT I ION NUMBER(VIN) LAND LEGAL DESCRI TION ON PAGE AFFIXED REAL PROPERTY TAX PARCEL NUMBER MANUFACTURED HOME WILL BE El 1..10 5000 81 LOT , BLOCK PLAT NAME SECTION/TOWNSHIP/RANGE 0 GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS NAF OWJNER J�® 1k l 4,A. NAME O`ADDITIONAL.REGISTERED OWNER A R ESS CITY STATE ZIP CODE \ cCo \�ov F -Pdr�`" -oct o. cecs-cob NAME OF LEGAL OWNER NAME OF ADDITIONAL LEGAL OWNER ADDRESS CITY STATE ZIP CODE GRANTEE j NAME C-4.4J ."- . CM1 I DO SOLEMNLY UNDER PENALT�PERJURY THAT I/WE AM/ARE THE REGISTERED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: 1 Signature of Registered Owner and Title,IF APPLICABLE cie.t.e....)-A Ck, ,l, - 4'1"1- Signature of Additional Registered Owner and Title,IF APPLICABLE NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S)SIGNATURE State of WashingtoncA,..\..(fay-1 Signed or attested County of before me on '21 V.A.) O'-4- Alli AL; by -C'kj)n \kO>CUf\O PV \Y\ Signatur-W�f c)-6 lk PRINT NAME OF REGISTERED OWNER NOTARY e' AGENT by PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY County/Office No.OR Title AND: Dealer No.OR ��Q` DEALERSHIP P ITION/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. 0 BUILDING PERMITOFFICE CERTIFICATION certify that 1,6 the manufactured home has been affixed to the real property as described. I ❑ a building permit has been issued for this purpose and the attachment will be inspected upon completion. NAME PED OR PRINTED) BLDG PERMIT OFFICE/PHONE# BLDG PERMIT# (T--14\i t Anne - (a0)37q--4 q`) o-7 -oc 65 SIGNATyRE/POSITION' DATE `�4 -e-e �l ) l rm a e—c it L 21171 D i TD-420-7 MANUF HOME'APPL(R/ 8)0 Page 1 of 2 111 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 LD/ gS . C Wf t c/' Q/Ulj/d7'1 ,il&, 5 /6/2 /e OIeDS 1 t{F �i-r'. Sue jt j ;-0 'le I r f701,3 , /i9e`Sr�i/117 d4,5 EL-co 4.0. 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). 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 providing equal access to its services. 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