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Home My WebLink AboutBLD2008-00038 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 #: BLD08-00038 SITE ADDRESS: 1080 THORNDYKE RD Issue Date: 05/15/2008 PORT LUDLOW, 98365 Final Date: 6/1/2009 APPLICANT: WALTER HARDIN PHONE: 1080 THORNDYKE RD PORT LUDLOW WA 98365-9289 SUBDIVISION: TRAIL'S END 4TH ADD Block: 1 Lot: 2-3+ PARCEL NUMBER: 950200107 Section: 16 Township: 27 N Range: 01 E PROJECT DESCRIPTION: REPLACE OLD MFH W/NEW MFH MODEL - WOODMAISOR/SERIAL NO. 3491-1027-F (HUD # ORE239866) THE PROJECT LISTED ABOVE COMPLIES WITH THE REQUIREMENT OF THE BUILDING CODE 2006 EDITION. OCCUPANCY GROUP: TYPE OF CONSTRUCTION: SPRINKLER SYSTEM yes r.)� THE PROJECT PASSED ITS FINAL INSPECTION AND RECEIVED FINAL SIGN OFF ON 6/1/2009 I:\F_BLD_Occupancy.rpt 10/29/19 MANUFAG'TURED/MOBILE (HOME INSTA!LATION PERMIT Jefferson County Department of Community Development 621 Sheridan Street, Port Townsend, WA 98368 (360)379-4450 FAX (360)379-4451 PERMIT#: BLD08-00038 Received Date: 1/31/2008 SITE ADDRESS: 1080 THORNDYKE RD Issue Date: 5/15/2008 PORT LUDLOW, 98365 APPLICANT: WALTER HARDIN 1080 THORNDYKE RD PORT LUDLOW WA 98365-9289 SUBDIVISION: TRAIL'S END 4TH ADD Block: Lot: PARCEL#: 950200107 Section: 16 Township: 27 N Range: 01 E CONTRACTOR/ JAIME KOZELISKY PHONE: (360)385-3215 DEALER 1112 S JACOB MILLER RD PORT TOWNSEND WA 98368 Contractor's License KOZELHS027C3 Expires 1/6/2009 INSTALLER: JAIME KOZELISKY WAINS0626 Expires: 7/31/201( 1112 S JACOB MILLER RD PORT TOWNSEND WA 98368 PROJECT DESCRIPTION: REPLACE OLD MFH W/NEW MFH MODEL -WOODMAISOR/SERIAL NO. 3491-1027-F (HUD#ORE239866) MAKE: SKYLINE YEAR: 1993 SIZE: 48 X 28 Directions HWY 104 E TO SOUTH POINT RD- S ON SOUTH POINT TO THRONDYKE RD TO 1080 To Site: THIS PERMIT IS VALID FOR ONE YEAR. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 5/15/2009. CALL IN FOR THE REQUIRED INSPECTIONS THATAPPLXTOYOUR PROJECT. Setbacks/Footing ( ``ONTINUOUS FOOTING,'SLAB r PADS USED): --ADD ' .&P4 D (�r'�IV2WA-7 � �L��! Stormwater��FINAL Approval: Blocking/Plumbing: -A'(, t'C{) Propane Tank/Lines Zoning Final Approval: Septic System Final Approval (If not on sewer): Road Approach Final Approval: Final/Skirting/Vents/Porches/Steps: 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 • • MLA08-00036 Review Type: I MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD08-00038 Received Date: 1/31/2008 SITE ADDRESS: 1080 THORN DYKE RD PORT LUDLOW, 98365 APPLICANT: WALTER HARDIN PHONE: 1080 THORNDYKE RD PORT LUDLOW WA 98365-9289 SUBDIVISION: TRAIL'S END 4TH ADD Block: 1 Lot: 2-3+ PARCEL NUMBER: 950200107 Section: 16 Township: 27 N Range: 01 E CONTRACTOR/ JAIME KOZELISKY PHONE: (360)385-3215 DEALER: 1112 S JACOB MILLER RD PORT TOWNSEND WA 98368 Contractor's License KOZELHS027C3 Expires 1/6/2009 Contractor's License WAIN50626 Expires 1/17/2008 INSTALLER: JAIME KOZELISKY WAINS0626 1/17/2008 (360)385-3215 1112 S JACOB MILLER RD PORT TOWNSEND WA 98368 REPRESENTATIVE: PHONE: PROJECT DESCRIPTION: REPLACE OLD MFH W/NEW MFH MODEL -WOODMAISOR/SERIAL NO. 3491-1027-F (HUD # ORE239866) TYPE OF WORK MOB MANUFACTUF:E.D HOME: SHORELINE: TYPE OF IMP NEW MAKE: SKYLINE SETBACK: VALUATION YEAR: 1993 BANK HEIGHT: LABOR & INDUSTRIES APPROVAL? SIZE: 48 X 28 SEWAGE DISPOSAL: CON WATER SYSTEM: BRIDGEHVN -- BEDROOMS: BATHROOMS: Exist: Exist: Prop: 2 Prop: 2 Total: 2 Total: 2 Routing Date: al/ �os V Type Amount Paid 13v: Date: Receipt: /t, pprplexiED Manufactured Homes $168.00 KAS 01/31/08 95822 Total: $168.00 MAY 5 2008 Jefferson County Planning gt! Ruiiriinq Deaartment -- • • SPECIAL CONDITIONS CASE # BLD08-00038 1.) SPLASHBLOCK DESIGN CRITERIA: A VEGETATED FLOWPATH OF AT LEAST 50 FEET SHOULD BE MAINTAINED BETWEEN THE DISCHARGE POINT AND ANY PROPERTY LINE, STRUCTURE, STEEP SLOPE, STREAM, WETLAND, LAKE, OR OTHER IMPERVIOUS SURFACE. SENSITIVE AREA BUFFERS MAY COUNT TOWARD FLOWPATH LENGHTS. A MAXIMUM OF 700 SQUARE FEET OF ROOF AREA MAY DRAIN TO EACH SPLASH BLOCK. A SPLASHBLOCK OR A PAD OF CRUSHED ROCK(2 FEET WIDE BY 3 FEET LONG BY 6 INCHES DEEP) SHOULD BE PLACED AT EACH DOWNSPOUT DISCHARGE POINT. NO EROSION OR FLOODING OF DOWNSTREAM PROPERTIES MAY RESULT. FOR SITES WITH SEPTIC SYSTEMS, THE DISCHARGE POINT MUST BE DOWNSLOPE OF THE PRIMARY AND RESERVE DRAINFIELD AREAS. 2.) The application was reviewed by the Jefferson County Department of Community Development staff on April 27, 2008 for the potential presence of Environmentally Sensitive Areas (ESAs) under the provisions of the Unified Development Code (UDC). After an initial Geographic Information Systems mapping review and an investigative site inspection, the following ESAs were confirmed to be present on the subject property: SUSC aquifer recharge area; high risk SIPZ. 3.) Aquifer Recharge Areas in Jefferson County are characterized by porous geological formations that allow percolation of the surface water into the soils and the underlying zone of saturation. Aquifers are geologic formations that contain sufficient saturated permeable material to yield significant quantities of water to wells and springs. Aquifers serve as the source of drinking water within most of the rural portions of Jefferson County. 4.) Susceptible Aquifer Recharge Areas are those with geologic and hydrologic conditions that promote rapid infiltration of recharge waters to groundwater aquifers. 5.) 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. 6.) The parcel is located within a High Risk SIPZ (seawater intrusion protection zone) according to the County GIS map. There are 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 High Risk SIPZ is defined as: areas within 1,000 feet of a groundwater source with a history of chloride analyses above 200 milligrams per liter(mg/L). 7.) To help prevent seawater from intruding landward into underground aquifers, all new development activity on Marrowstone Island, Indian Island and within 1/4 mile of any marine shoreline shall be required to infiltrate all stormwater runoff onsite. 8.) The property owner shall comply with Water Conservation Measures (per list maintained by the UDC Administrator). 9.) Critical Aquifer Recharge Are nay require special protection measures tltigate water quality degradation. The submitted proposal does not require additional aquifer protection measures. However, during construction the project shall follow the Best Management Practices (BMPs) and facility design standards as identified and defined in the Stormwater Management Manual for the Puget Sound Basin. 10.) The applicant is proposing to create or add 192 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. 11.) 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. 12.) 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). 13.) The site plan as submitted with the mobile home installation permit application on January 31, 2008 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 18, 2008 shall be resubmitted for review and approval by Jefferson County Department of Community Development. 14.) This approval is for a manufacture home replacement 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. 15.) The parcel has been designated as RR 1:5 under the Jefferson County Comprehensive Land Use Map effective August 28, 1998. 16.) Outdoor residential storage shall be maintained in an orderly manner and shall create no fire, safety, health or sanitary hazard. 17.) 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. 18.) A minimum of two (2) on-site parking spaces shall be provided for the single family residence. 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.) Minimum setback from Thorndyke Road right-of-way shall be 20 feet. Minimum side and rear yard setbacks shall be 5 feet. 21.) Exterior lighting for commercial and industrial uses shall not exceed thirty feet(30') in height from the finished grade. 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. 22.) 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. 23.) The building height is not to exceed 35 feet. 24.) An address of 1080 THorndyke Road, Port Ludlow has been assigned to the parcel. Thorndyke Road is a county minor collector(C418708). 25.) The lot was created through the Trails End 4th Edition Subdivision on April 7, 1958 under AFN 157199. 26.) The parcel is served by the Bridgehaven Community Club water system. ilk27.) A building permit (BLD98-02•or a mobile home installation was finaled arch 29, 1999. A septic permit(SEP77-0078)was finaled on March 15, 1977 and an EES on April 16, 2007. A building permit(BLD02-0076) for a detached garage was finaled on April 24, 2002. A road approach permit (RAP02-0031)was finaled on january 14, 2005. 28.) A MINIMUM OF 10' MUST BE MAINTAINED BETWEEN BUILDING FOUNDATION AND EDGE OF DISPOSAL COMPONENT. A MINIMUM OF 5' MUST BE MAINTAINED BETWEEN BUILDING FOUNDATION AND EDGE OF SEPTIC TANK. 29.) ALL COMPONENTS OF THE SEPTIC SYSTEM ARE TO BE COMPLETELY PROTECTED FROM VEHICULAR TRAFFIC OR MECHANICAL DISTURBANCE. 30.) MUST COLLECT AND DIVERT ALL SOURCES OF DRAINAGE AWAY FROM SEPTIC TANK, RESERVE & DRAINFIELD. MUST COMPLY WITH ALL PERMIT CONDITIONS, STATE AND LOCAL CODE. 31.) 10' SEPARATION REQUIRED BETWEEN A WATER LINE AND ALL PORTIONS OF THE ONSITE SEWAGE SYSTEM; EFFLUENT TRANSPORT LINE, TANKS, TREATMENT AND DISPOSAL COMPONENTS. JACK WESTERMAN. Jefferson nth Courthouse ASSESSORDDT:k 1'O Box 1220. Port Townsend, W.% 983611 •:is ' r� (360)385-9105 MOBILE HOME INFORMATION FORM OWNER'S NAME/MAILING ADDRESS: NAME: �.� ,L, Gt ADDRESS: /DOc ;r,braR-AJcly/GZ f2c,' {fQe/7".A-vci 2-4104 4Ix. 9R,3C� PHONE NO. ?fi 2�yg c ar � rrA �6a b jt 3o7g 47.'i's1 'f3',a /s/086 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)MOHILE HOME DATA: JAN 3 1. L U / ? (A) MAKE ) MODEL C 7 D 3 yEA :- S (C) (D) LENGTH �G Z 0 ,�r� G t Z ti F r (E) WIDTH (F)SERIAL #3 ,2/ -1 -r (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 f .4'L- r-4/.J44 SAL/27 S ADDRESS -266//GJJ/2D f 7 Oa (5 Jd/ ML . 9,9-Y (B) WAS MOBILE HOME ASSESSED IV JEFFERSON COUNTY LAST YEAR? No If Yes, Previous address of mobile. � ale 7'5'01- 09, 'r2 If No, What County was Mobile assessed in last year. 3)WIIERE MOBILE HOME IS TO BE LOCATED: (A) WILL THE MOBILE HOME BE IN MOBILE HOME PARK? Yes Cly3 (B)IF LOCATED IN MOBILE HOME PARK: NAME &ADDRESS OF PARK Lot/Space# (C) IF NOT LOCATED IN MOBILE OME X r , 0 NAME OF LAND OWNERTT.;[�i QQ��,,�✓.•/.• u oo�E�x�� LOCATION ADDRESS Jo e /j de..Jd ycccK asRCr �•,c�'��riZe-a1 aA ?Q3 g 6C - REAL PROPERTY PARCEL #/DESCRIPTION ! , T OZd0 IO7 6d,jjeltvL- ;— Signature of applicant THANK YOU FOR YOUR HELP! 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II k i',t" I ,7,.t A ' •��. { • . �� L �� I.- 11 ,-- sil,in I - 3r. • - -- - ME . ■ ina<-.{ k4igONN 00i.6. JEFFE , N COUNTY • DEPARTMENT OF COMMUNITY DEVELOPMENT '}n k _ c JAty <e 621 Sheridan Street • Port Townsend • Washington 98368 360/379-4450 • 360/379-4451 Fax /S4rINO CI www.co.jefferson.wa.us/commdevelopment Master Permit Application MLA: O? -3jL Project Description (include separate sheets as necessary): KCivi e_o t/e_ c L.d 9 el_ z`i le y 6 eud 4 2.</7(r,.,P.gvtgst<4.a.76 f 9 P 34 e2 8 X zit 8 eti er aI e--' M 0 Tax Parcel C� Property Number: _!tfO 2, a C9 f e0 7 Size: z t F/..2 .3 3 (aarea/square feet) Site Address and/or Directions to Property:"a 3d o/()`dyPc'��D1‘24::3,P(74.roC1-4r.1v6-119-7.g '' �6,- /esy 7---b So.--fiffPei..rr-)24-5,a-,r. jrye••e7-7-677--/ceerdd,Ke-�2o,gd Ta /DA.d . Pro[erty Owner(s)of Record: G(fi9 -,tite_ , eLie c A./4' pfar Telephon 6 if,47—z3 e Fax: email: Mailing Address: /ego 7—/-2/,5-,Q,tJ-a(yfc R-a/hnJ.Feto2Y c17 nr✓C(TA, 78 36S Applicant/Agent(if different from owner): Telephone: Fax: email: Mailing Address: What kind of Permit? (Check each box that applies 08uildiny 0 Variance(Minor, Major or Reasonable Economic Use) ❑ Demolition Permit 0 Conditional Use[C(a),C(d),or CI** ❑ Single Family 0 Garage Attached/Detached 0 Discretionary"D"or Unnamed Use Classification 'g Manufactured Home 0 Modular 0 Special Use(Essential Public Facilities)** ❑ Commercial* 0 Boundary Line Adjustment ❑ Change of Use 0 Short Plat** ❑ Address ❑ Road Approach ❑ Binding Site Plan** ❑ Home Business 0 Cottagelndustry 0 Long Plat** ❑ Propane 0 Planned Rural Residential Development(PRRD)/Amendments** ❑ Sign - 0 Plat Vacation/Alteration** ❑Allowed"Yes" Use Consistency Analysis ❑ Shoreline Master Program Exemption/Permit Revisions** ❑ Stormwater Management 0 Shoreline Management Substantial Development** ❑ Site Plan Approval Advance Determination(SPAAD)* 0 Shoreline Management Variance ❑ Temporary Use 0 Comprehensive Plan/UDC/Land Use District Map Amendment ❑Wireless Telecommunication* 0 Jefferson County Shoreline Master Program Amendment ❑ Forest Practices Act/Release of Six-Year Moratorium ❑ 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: I hereby designate/LI Sr ft,I M ��< DESIGNATION OF AGENT Y to act as my agent in matters relating to this application for permit(s). OWNER SIGNATUREajtfa Q• yrsL:_ Date: 1'-- Y^O 7 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 application that he or she� wants prior notice. Signature6i6a .�1 = Date: 7_,/-0 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-trans rable responsibility for adhering to and complying with the ESA. The Applicant has read this disclaimer and signs and dates it below. Signature:Lcat-a. ,.,tom Dater-- c(.. T 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� � Hof the General Contractor for the proposed project. Signature:C a_fit .__._1,L Date: c( 2 V - e 7 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 0 Wood Existing: ❑ Sewer ❑ Addition ❑ Steel Proposed: Bank ❑ Community System 0 Alteration/Remodel ❑ Concrete Total: -a_ Height: ,individual System ❑ Repair 0 Masonry SEP Permit# ❑ Demolition 0 Other: Bedrooms: Water Supply: Mn c,,-/4„,e Existing: Setback: ❑ Private well ❑ Two Party Type of Heat: Proposed: Z i$ Public ELbEc r� Total: Zr Jo_ Name of System4ec4-a .vc,t) 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: 1 Heat Stove i Cook Stove i Woodstove l Fireplace Insert l Hot Water Tank i Pellet Stove l 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 septi^ .,, tam component srm including the reserve area. - Square Footage Current Proposed For Office Use.Only Amount . Revision: Main Floor Heated EH Bld App Review: /` ^^ 2na Floor Heated Consistency Review: j { ?7 Other Heated Base fee: f i Q ./, ,t 2 rrtr�. f!4 V` 0 Mezzanine Additional Section: Heated Basement Plan Check fee: Unheated Basement State Surcharge fee: -- Other Unheated Pot Water Review fee: Garage/Carport SUBTOTAL G DO Decks 911/Rd Approach fee: •1 Other TOTAL: $ 3 CI CO Receipt Number: 5 C-3D Cash/Check Number: 14 1 ESTIMATED COST(REQUIRED) Date: •Fair market value of all labor and materials foundation to finish I (Ci Initials: J G:\PermitCenter\###FORMS###\DRD FORMS\Master Permit Application 12-19-2006.doc 0 • RETURN ADDRESS L/1sr-rrOFWASHINGTON MANUFACTURED HOME PLEASE CHECK ONE LyII Urra l�nent o/ IICEflSIflG APPLICATION N['TITLE U?) TRANSFER IN LOCATION v 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) 0 MANUFACTURED HOME TP /PLATE NU BER YE MA LEN THWIDTH(FEET) VEHICLE ID NTIFICATION NUMBER(VIN) DLit/ ) �u 141Q. �x 7- 311[i 1 7 2-0 2- LAND LEGAL DESCRIPTION ON AGE MANUFACTURED HOME WILL BE AFFIXED ❑ REMOVED REAL PROP TYTAXPARCELNUMB R LOT % BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION 0 GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER j NUMBER OF REGISTERED OWNERS NUMBER OF L OWNERS 0Z NAME OF R GI TERED 0 NER DOL CUSTOMER ACCOUNT NUMBER NAME OF ADDfTION L REGISTEREDOWNER DOL CUSTOMER ACCOUNT NUMBER bLir ADDRESS d (n ( �i �� '�� I Y STATE ZIP CODE iv o UrrVJ(,j/� lad j� UulibliJ ())A 43 S-- NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE GRANTEE 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 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. 0 BUILDING PERMIT OFFICE CERTIFICATION I certify that: Elthe manufactured home has been affixed to the real property as described. Ixa building permit has been issued for this purpose and the attachment will be inspected upon completion. NAME TYPED OR PRINTED) BLDG PERMIT OFFICE/PHONE a BLDG PERMIT a S SIGNA URE/POSITION P 6 3i t D `O TD-42200--77229\fJrANUFHOME PL(R/2/ 2)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) 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 1Q 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. TD-420-729 MANUF HOME APPL(R/2/02)OR(W)Page 2 of 2