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HomeMy WebLinkAboutBLD2015-00123 - CANCEL THIS BUILDING IS NOT FINALED . THIS IS AN INCOMPLETE BUILDING APPLICATION . THE PERMIT WAS NEVER ISSUED . BUILDING PERMIT APPLIAION BLD15-00123 Review Type: Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD15-00123 Received Date: 4/13/2015 SITE ADDRESS: 981 FOUR CORNERS RD PORT TOWNSEND, 98368 OWNER: BARBARAJ HARROLD PHONE: 360-895-8647 8162 SW LOOP DR PORT ORCHARD WA 98367-9221 SUBDIVISION: Block: Lot: PARCEL NUMBER: 001343026 Section: 34 Township: 30 N Range: 1'v CONTRACTOR: PHONE: PHONE: REPRESENTATIVE: PHONE: PROJECT DESCRIPTIOI THIS IS NOT A PERMIT !!! THIS IS A TITLE ELIMINATION!!!! TYPE OF WORK T.E SQUARE FOOTAGE: TYPE OF IMP NEW MAIN: VALUATION ADD'L: HEAT TYPE: CODE EDITION: 1985 HEAT BASE: HEAT TYPE: OCCUPANCY: UNHEATED: #OF STORIES: OCCUPANCY: OTHER: CONST TYPE: GARAGE: SHORELINE: CONST TYPE: DECK: SETBACK: BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: BEDROOMS: BATHROOMS: Exist: Exist: Prop: Prop: Total: Total: Routing Date: Type Amount Paid By: Date: Receipt: Approved/Date Permit $78.00 SRE 04/07/15 154280 Permit $0.00 SRE 04/13/15 Total: $78.00 / \\tidemark\data\forms\F_BLD_App_Bld.rpt 4/13/2015 JEFFERSON COUNTY ,DC) NO. 154280 DATE 4/7/X / S t 1 RECEIVED FROM 1AJ_ DESCRIPTION BARS# AMOUNT CURRENCY ark �d �J s-6, , Ct) COIN / /�'b�,/ CHECKS n C l � rL �✓�/YI �cjCF1 o 00 %r 3 (:), b m 9gl ' r (4,0-aei-.c 33o h. o4 0. � 4ii- ,tel erb RECEIVED BY flit, ` 14 TOTAL / . 1 • , i RETURN RECORDED DOCUMENTTO: s��°LpprrO iVi „br$16 � ®1 1 (,v . po qg 67 CILWASHINGTON STATE DEPARTMENT OF Manufactured Home Please check one: LICENSING Application VTitle Elimination For full instructions on completing this form,see Manufactured Home Application ❑Transfer in Location Instructions,form TD-420-730. ❑Removal from Real Property El Manufactured Home TPO/Plate number Year Make Length/Width(feet) Vehicle identification number(VIN) 15x30 /`r7 AMEST Laxzv D19jDc( I wAv is Land Manufactured home will be Real property Awl ' 71913 Affixed ❑Removed Tax parcel no. OD 13'7 3 oaf, Legal description on page Lot Blodc lat`` me.Q$eectio %o i Wige Quarter/Quarter sectionS5I N,W` © Grantor(s)Registered/Legal Owner(s)—Additional names on page County number No.registered owners No.legal owners Grantee name(if applicable) Name of registered owner Washington driver license or UBI number Ga.r r4._ J - 14Ocrt—Ok HAARD(3J'y878G Name of additional registered owner Washington driver license or UBI number Address(Address,City,State,ZIP code) S"1 . . S.O. Loy Dr§V2 PDr4 D��L€— 1 1aa. q8.34,7 Name of legal owner Washington driver license or UBI number Name of additional legal owner Washington driver license or 1.181 number Address(Address,City State,ZIP code) I declare under penalty of perjury under the laws of the state of Washington that I am/we are the registered owner(s)of this manufactured home and the foregoing informaa n is true and correct. Signature of registered owner title,if applicable Signature of additional registered owner and title,if applicable Notarization/Certification State of County of Signed or attested before me on (Seal or stamp) by by Print registered owner name Print registered owner name Notary printed or stamped name Notary signature and Title Dealer/county office number or notary expiration TD-420-729(R/4/12)WA Page 1 eta Continued on next page • • Manufactured home TPO/Plate number(from Section 1) a Title Company Certification PRINT orTYPE Name of person signing Title company name Position (Area code)Telephone number 1 certify that the legal description of the land and ownership is true and correct according to the real property records. X Signature Date Okluilding Permit Office Certification I certify that Lithe 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. PRINT or TYPE Name of person signing Building permit office Building permit number Position (Area code)Telephone number X Signature Date 0 Signature of Legal Owners) Signature of legal owner indicates consent for Elimination of Title or Removal from real property. X Signature of legal owner and title,if applicable X Signature of additional legal owner and title,if applicable Notarization/Certification State of ,County of Signed or attested before me on (Seal or stamp) by by Print registered owner name Print registered owner name Notary printed or stamped name Notary signature and X Title Dealer/county office number or notary expiration Land Description Y Legal description of land paV—e—e_ 42s1A-N/'� vt.,�p, tea-- p9 r .4 (9 .44„e_ l v.- + (Q0.21- 4,0‘. I, SeC4f '-- 3 �/ otov . p “;i Noy- 1, 12oz,-fie 1 1-t)65-I. WM c1) a'2-4 3%4_ 1 ta- I I I 9 E(7) 4u d' 40rs -F;1e_ i�jo . 3z.z Rte2-� ��lu. e �n 0P s u� �es� ,pa fie. 11 L ) re r✓OK•cis P T L Q C-6"- 114)'1" • TD-420-729(R/4/12)WA Page 2 of 3 Continued on next page Manufactured homeTPO/Plate number(from Section 1) 0 Dealer Report of Sale-Selling dealer complete this section PRINT or TYPE Dealer name Washington dealer number Date of sale Purchase price Tax jurisckction/Tax rate ❑Sales Tax Exempt t-Sale to a Certified Tribal member on the reservation (attach notarized statement of delivery). I certify that this information is correct.The manufactured home is clear of encumbrances except as shown. Any required sales tax has been collected. X Dealer authorized signature Q County Auditor/Agent Licensing Office Approval (not for use by subagents) PRINT orTYPE Name County office/VFS operator number 1 certify that the above application appears to be completed correctly,and the applicant has sufficient documentation to proceed with the recording of this form. X Signature Date 10 Title Fees Filing fee Application Mobile home lee Elimination fee Use tax Subagent fees Total fees and tax 0 Anyone who knowingly makes a false statement of a material fact is guilty of a felony,and upon conviction may be punished by a fine, imprisonment, or both. RCW 46.12.750 We are committed to providing equal access to our services. TD-420-729(w4/12)WA Page 3 of 3 If you need accommodation,please call(360)902-3600 or TTY(360)664-0116. • • Sally Ellis From: Jodi Adams Sent: Tuesday, May 05, 2015 2:28 PM To: sharrold@wavecable.com Cc: Sally Ellis Subject: RE: elimination of title for 15-00123/15-00122 Hi Barbara, I'm just following upon your e-mail below. Did Carl reply back to you? We did have building permits issued previously but both were cancelled. There were inspection previously done on both the mobile homes. When we issue the new permit we will not be looking for you to bring the existing homes up to code, but to finalize the inspections that were not previously performed. The inspector will review that the porch issue has been corrected and that the homes are affixed to the property. If you have any additional questions please let me know. Jodi Adams Office Coordinator- DCD Phone 360-379-4494 All e-mail sent to this address has been received by the Jefferson County e-mail system and is therefore subject to the Public Records Act, a state law found at RCW 42.56. Under the Public Records law the County must release this e-mail and its contents to any person who asks to obtain a copy (or for inspection) of this e-mail unless it is also exempt from production to the requester according to state law, including RCW 42.56 and other state laws. Original Message From: Barb &Steve Harrold [mailto:sharrold@wavecable.com] Sent: Tuesday,April 21, 2015 2:18 PM To: Carl Smith Cc: Steve Harrold;Jodi Adams Subject: elimination of title for 15-00123/15-00122 Mr. Smith, I am the owner of this property. I am trying to eliminate title on the mobiles at 981/983 Four Corners Road prior to selling. I spoke with Jodi Adams at length this morning and I just need clarification. Were there no building permits issued and final for either of the mobiles? I initially understood that the building permits were canceled on the decks due to a dispute about handrails between Jack Tice and the building inspector at time. If there were no permits issued will we need to go with current standards or since these homes have been in place since 1989 and 1993 will some things be grandfathered/allowed. I am currently going thru files and have found most of the information needed, and will be working to get them in order. 1 • • Any information you can share will be most helpful. Thank you, Barbara Harrold 2 • • Sally Ellis From: Sally Ellis Sent: Tuesday, April 14, 2015 4:24 PM To: 'sharrold@wavecable.com' Subject: Inspection fees for title elimantions Attachments: title elmination -barbara harrold.pdf Dear Barbara Attached are the invoices we discussed on the phone yesterday- You can pay these invoices online-you would go to the following website- http://www.co.jefferson.wa.us/ Then click on Departments- Then select Community Development You should be lead to the below page- / '" Jefferson County Home County Info Departments Search tC.lpiiranentrrt ter Wed corn+e to CRCL tebowweileuumweint Isz.ae L.inits nx rzwtc _ #tannin ct GoMVAizxsan 2-12-15r Marljua ns Maratorium pue}ty CPP 3'+lanni.^.Yi � Patirsl (ePP1 rdrfta rt cac t?XI.-t?2(7'..#-ti.ra It Gon,p ret,ensive P#an 4e,-or d_and Liss Tn#�.rmation about uxxakipnstir>nz A-so a AND MART31 AANA unifi cel C3avarbPmert* IT! .)ff JSOtl CO, iltty costa (ut.�t) Ata/A, eta 0icatieae,�Forinsn S. stzsg- it txetNtamse sca rct, Public. R®ecl tc. Reg2 cats iNP rupia related to T-582 On�raa ct.e t car et as �.a „s 'A ,. eclierCk Pavn4ants. It farmer Pubt c NotiCe - NEwt eat tin...tea..n ns.m..rle(Y:'i so,. County Community[]rvctc,pment Aw+.t V.WAPP0.1.0 9x5ara, 100.1.0lari WJ. rawKFea'tT Planning Manager eLnplc.yment 1'Me£MMb:360..379.4130 tazo 3150.379.{1.41 __. F i ..:, .+.a..�.. r ir.l.einrz•.-e.ae#.,,. Next on the left hand side of the page-you will see DCD Quick Links- You should select-Online Credit Card & Echeck payments. Then you will simply follow the directions and or steps for paying online. The two attached invoices DCD15-BLD15-00122 This is for the 1994 mobile home and the invoice is for$156.00 $78.00 for inspection fee $78.00 to record a new notice to title saying stair rails is now corrected. The Second Invoice DCD15BLD15-00123 is for the 1987 mobile home- and the invoice is for$78.00 $78.00 for inspection fee 1 • • Once these invoices have been paid-we will then issue you a new permit-and mail those permits to you-you will then be able to call in for inspection on these two new permit. Once those permits have been signed off and final- we can then do the Title Eliminations for both mobiles. Please note you will have to be onsite when the inspections have been schedule-someone has to be present for all final inspections. If you have any questions and or need more information please do not hesitate to contact me. Thank you A' V Sally L,Ellis Jefferson County Community Development Permit Tectmician 621 Sheridan St., Port Townsend,WA 98368 Mon-Thurs 9am-4:30pm, closed from 12-1 Ph: 360-379-4452 Fax: 360-379-4451 sellis@co.jefferson.wa.us http://www.co.iefferson.wa.us 2 VOICE Dat � 2015 4/13/ In ID: DC/2015 15 00123 �gON cp JEFFERSON COUNTY � (` DEPARTMENT OF COMMUNITY DEVELOPMENT -`; 621 Sheridan Street I Port Townsend, WA 98368 360-379-4450 I email: dcd@co.jefferson.wa.us . . oy www.co.jefferson.wa.us/commdevelopment .SK I NC-3.'C-- Date O� Date Due: BILLING ADDRESS: 5/13/2015 BARBARA J HARROLD 8162 SW LOOP DR PORT ORCHARD WA 98367-9221 Permit 78.00 Total Amount Due: $78.00 REMIT TO: Jefferson County DCD 621 Sheridan St. Port Townsend, WA 98368 Please return the above portion with your payment Permit Number: BLD15-00123 Permit 78.00 Total Amount Due: $78.00 Payment is accepted by cash, check, debit or credit card (Visa, Mastercard, Discover, American Express) To pay by credit card, go to www.co.jefferson.wa.us/commdeveloPment, and click on the "Online Credit Card & echeck Payments" link on the left side of the page. (questions: call 360-379-4450) 0 0 cbze view Add Lielele ray bee nlzmry rent MCWnd View Case Fee -- - i Fee TYp e Permit Iran Code —. m Fee Aount $78 00 Amount Clue 1 $78 00 Edit srocc 'Revenue/GL Acct 222 10 00 ..s ' s,.Info, Heel Created.423!2015 By SPF —..�....., Cancel x r sire 'WE WE DID FIND APERMIT IN ARCHIVES HOWEVER THIS PERMIT WAS FROM 1967AI D WAS Hel `-' NOT ENTERED INTO TIDEMARK-TIIF PERMIT WAS NOT FINAL-THEREFORE NEW I ,__� PROPERTY OWNER MUST PAY FOR INSPECTION VB 00 BEFORE WE WILL DO TITLE 11 Amount Due Updated EUMINATIONS t.00 � 5000 0411372015162927 SI Primary Parcel poi34 :'t 1 e =31 ill 1111 RETURN RECORDED DOCUMENT TO: Y- ‘00._._4(..._ A�rY`0 t�5 I E2 4J 1 t i p r pier)- © rte' - 7 8.3 4,7 cdWASHINGTON STATE DEPARTMENT OF Manufactured Home Please check one: . LICENSING Application VTitle Elimination For full instructions on completing this form,see Manufactured Home Application ❑Transfer in Location Instructions,form TD-420-730. ❑Removal from Real Property DManufactured Home 1 TPO/Plate number Year Make Length/Width(feet) Vehicle identification number(VIN) l 15.130 fTsr7 AMEsr iaxZss D(9 tict, i wh115 © Land lT Manufactured� home will be Real property / 7 Ig,3 !ti Affixed ❑Removed Tax parcel no. OO )3 ? Oat, Legal description on page Lot Block $ PIgn�m e-pr_ cpo , ovaship/Range Quarter/Guartersection `h i iutvv KK I WW NO © Grantor(s) Registered!Legal Owner(s)—Additional names on page County number No.registered owners No.legal owners Grantee name(if applicable) Name of registered owner Washington driver license or UBI number `3ar‘rDa.„rtt__ a. 14 &.meta 1.1 A ARO e a tis?eG Name of additional registered owner Washington driver license or UBI number Address(Address,City,State,ZIP code) t P S.0, Lciel p4ricuica /-h--', 'oJd `1Fs31P7 Name of legal owner G/ driver license or UBI number Name of additional legal owner 5/t O� Oq� D (l 7 I driver license or UBI number Address(Address,City State,ZIP code) vyj'A Vh KKKJ%% !!! I declare under penalty of perjury ire the registered owner(s)of this manufactured hor able ckle,if applicable Notarization/Certification '1-1' (Seal or stamp) /Y /1.4"Ij' f(� .c�owner name pgf, eye -- nature ,unty office number or notary expiration TD-420-729(R/4112)WA Page 1 of 3 ,R^\l'l \ )�j, Os_ 0'\ ✓ Continued on next page v V /L�/ L r` •_,iv FT G • yVrma °; � r v '_._..- ` EEE1lli ,ham t rc? a�. sk...,.„..:.:,...j: ,A.,0-4;4. ..:., t ,�s+yr -,-3',,t kY`_ a . lik V Foy. x, a,.. '2�a �r-, 'e. „,•,,,,,,, „ a .i..e. p ``.•: x:# � ata .R,` ' ..'. .r...., amt - . ,„1..n-Z-4-0:4'. .- 't x,. .e vyR _P+ y,a " n "4 ; a a i•— `h ` �. ,. Y '''Zw. '. ."r ---.-'2-'4e. J Pm i.q � ' y:,`' t +. an. . y6� � � .7,.. ,,...,.,..-;.?om; '� ; .p :'.. •T iiw ' 5, 4 µ y .. fi„.} F y. 7! � �� r-,.. t '-',:-.1. *j.' fi _� '-',.• t k W -'. :-.4.-1. •:•:- a a (,q 1 1 Corners Rd • REPORT OF SALE If you are the seller: You must releaseest in the vehicle by signing below on the Vehicle ate of Ownership (Title)and • give it to the buyer. The report of sale is considered properly filed if it is received by the department or a local vehicle licensing office within five (5) business days after the sale of the vehicle and includes all information requested in the following boxes: NAME.01 SELLER/TRANSFEROR(CURRENT REGISTERED OWNER) NAME OF PURCHASER/TRANSFEREE COMP'ETI"ADDRESS OF SELI ERTRANSFEROR COMPLETE ADDRESS OF PURCHASEREFRANSFEREE CITY STATE ZIP CODE CITY STATE ZIP CODE DATE VEHICLE SOLD TODAY'S DATE SAI F PRICE PURCHASER/TRANSFEREE S DRIVER LICENSE NUMBER(IF AVAILABLE) I ICENSE NUMBER VEHICLE IDENTIFICATION NUMBER MN) YEAR MAKE MODEL CERTIFICATE NUMBER &15230 01910561 WAB 1987 AMEST 48128 0731010208 For additional information regarding Reports of Sale visit the DOL Website at: I IIIIN 1111 11 II 1111 1111 1 111111 www.dol.wa.gov You may complete your Report of Sale online at www.InternetTabs.wa.gov OR at your local vehicle licensing office (there is a fee for this option). A person who files a vehicle report of sale without the knowledge of the transferee is guilty of fraudulent filing and may be punished under state law 9.45 RCW. 05/06 The Department of Licensing has a policy of providing equal access to its services. If you need special accommodation,please call(360)902-3600 or TTY(3601 664-8885 l L "r:V' ,IA ,;,oisVksV,?n ., b Nfr V6'.!CSLl'6, ISh ''' ?r tis 'v rA,.11h��! 'AN 11 :. I A � - (�R',d Ili'n'„';11��, i h� Y,✓ S 5 `h , pl L �i} Y IA H OF ��/�.5f�tN��7 WASHINGTON .-=,..,VEHICLE CERTIFICATE OF Mc- OWNERSHIP(TITLE) `- CERTIFICATE NUMBER .A sz ' 0731010208Vit, r-, LICENSE VEHICLE IDENTIFICATION SERIES 'A < NUMBER NUMBER(VIN) YEAR MAKE MODEL STYLE BODYit &15230 01910561WAB 1987 AMEST 48/28 -•4 x F�' ODOMETER FLEET EQUIP FUEL 4 pLt DATE ISSUED MILES ODOMETER STATUS NUMBER NUMBER TYPE .t _< 11/06/2007 0000000 EXEMPT UNPOWERED = ' USE SCALE GROSS FrNIJN iITU' PRIOR TITLE -St- CLASS 'CLASS WEIGHT WEIGH I VEHICLE COLOR STATE NUMBER ' MOB 00000 000000 WA 9607110901 1 '.-..'I' .> ,2z .g ' COMMENTS y 36000-1987 ;�,f l I ft- ( BRANDS G ° SALE PRICE $ ?` l s ,. 1,s- ;i DATE OF SALE 111 I rl- LEGAL OWNER: When lien is satisfied. release interest by signing belov and transmit this document to County Auditor or _�� 1 ' Agent with proper fee. Failure to properly release and transmit the document within 10 days after lien is satisfied may result • in monetary penalty to the debtor, pursuant to RCW 46.12.170.TRANSFEREE/BUYER MUST APPLY FOR TRANSFER 1 OF OWNERSHIP WITHIN 15 DAYS FROM DATE OF DELIVERY TO AVOID PENALTY. LEGAL OWNER REGISTERED OWNER k .:- Lt HARROLD,BARBARA JEAN SAME AS LEGAL OWNER . x !: 8162 SW LOOP DR PORT ORCHARD WA 98367-9221 31 "1\ ) ...„.4 ,,......, i ' SIGNATURE OF LEGAL OWNER HEREBY DATE SIGNATURE OF REGISTERED OWNER DATE � ` / fi RELEASES ALL INTEREST IN VEHICLE AS HEREBY RELEASES ALL INTEREST IN ��, - DESCRIBED ABOVE VEHICLE DESCRIBED ABOVE A� 1 . II- ':.'''f'. SIGNATURE OF LEGAL OWNER HEREBY DATE SIGNATURE OF REGISTERED OWNER DATE ,�J RELEASES ALL INTEREST IN VEHICLE AS HEREBY RELEASES ALL INTEREST IN I DESCRIBED ABOVE VEHICLE DLSCH(I3ED ABOVE ` . - I CERTIFY THAI'THE RECORDS OF THE DEPARTMENT OF LICENSING J'y,_✓deg a/ 00171'30(11 AV � )C- SHOW PERSONS NAMED HEREON AS REOI$TERED OWNERS AND • VAC ' �� iILEGAL OWNERS OF THE VEHICLE LSC,RIBtD RECTOR DEPAR'rMEN70F LICENSING 0017130 Ol AV • /certify to the best&my knowledge,that the ODOMETER READING as shown below/(CHECK ONE) .__ _ _- -___._.,-__ _.___„_,. ` NO ❑1 is the ACTUAL MILEAGE of the vehicle - `tJre I O` TENTHS2 isinEXCESS OFITSMECHANICAL LIMITS,a-WI 3 isNOT THE ACTUAL MILEAGE '<m ODOMETER READING(In miles) DateorTrensfer4. lU O TRANSFEREE/BUYER:unless llceneed dealer rgest transfertitle wl(hln t days of sale w o I/we WerraM thio TUIe and oartiTytial Nieehiclet�ea«iheddiierein hes-linen sold dT UtefosFaTie q: Ir zit !SIGNATURE OF TRANSFEREE/BUYER SIGNATURE OF TRANSFEROR/SELLER /x,r W ; __T - —.—. w e (//ANDPRINTF/T NAME OF TRANSFEREE/BUYER �J-(�('IpPRWTFQ NAME OF TRANSFEROR/SELLER s, / Lit l y I:- !ADDRESS OF TRANSFEREE I BUYER jADDRESS OF TRANSFEROR/SELLER ':'?..;"4 }, L /''t �. ......r-n , n.-n... .,,,....,,.nom....-. ..u.., ..,....,.,,. ....,,......... „n..,.,... ................._...... 41.1f V' Oepartmnentue of teve V.ec+rRta'1 Stall REAL ESTATE EXCISE TAX AFFIDAVIT This form is your receipt PLEASE TYPE OR PRINT when stamped by cashier. CHAPTER 82.45 RCW-CHAPTER 458-6IA WAC THIS AFFIDAVIT WILL NOT BE ACCEPTED UNLESS ALL AREAS ARE FULLY COMPLETED (See back of last page for instructions) File No. 57353RW 0 Check box if partial sale of property If multiple owners, list percentage of ownership next to name I. Name Barbara J. Harrold, a married woman as her Name Justin Rankin. an unmarried individual and separate estate Chasina McGee, an unmarried individual OMailing Address 8162 SW Loop Dr LLI Mailing Address PO Box 329 > z g City/State/Zip Port Orchard, WA 98367 g City/State/Zip Port Hadlock,WA 98339 Phone No. (including area code) (360)895-8647 Phone No.(including area code) (360)385-3312 3. Send all property tax correspondence to: ® Same as Buyer/Grantee List all real and personal tax parcel account Listed assessed value(s) numbers-check box if personal property Name Justin Rankin 001 343 026 0 192,857.00 Mailing Address PO Box 329 0 City/State/Zip Port Hadlock, WA 98339 0 Phone No. (including area code) (360) 385-3312 0 ® Street address of property: 981 & 983 Four Corners Rd,Port Townsend,WA 98368 This Property is located in ® unincorporated Jefferson County OR within 0 city of Port Townsend ❑ Check box if any of the listed parcels are being segregated from a larger parcel,are part of boundary line adjustment or parcels being merged. Legal description of property(if more space is needed,you may attach a separate sheet to each page of the affidavit) SEE EXHIBIT "A" ATTACHED HERETO AND MADE A PART HEREOF FOR COMPLETE LEGAL DESCRIPTION • 5. Select Land Use Code(s): 11 7. List all personal property(tangible and intangible)included in selling price. Enter any additional codes: (See back of last page for instructions) Is this property exempt from property tax per YES NO chapter 84.36 RCW(nonprofit organization)? 0 6. YES NO Is this property designated as forest land per chapter 84.33 If claiming an exemption,list WAC number reason for exemption: RCW? 0 Is this property classified as current use(open space,farm and agricultural,or timber)land per chapter 84.34? ❑ WAC No. (Section/Subsection) Is this property receiving special valuation as historical property per chapter 84.26 RCW? ❑ ® Reason for exemption If any answers are yes,complete as instructed below. Type of Document Statutory Warranty Deed (1)NOTICE OF CONTINUANCE(FOREST LAND OR CURRENT USE) NEW OWNER(S): To continue the current designation as forest land or Date of Document August 28,2015 classification as current use (open space, farm and agriculture, or timber) land, you must sign on(3) below. The county assessor must then determine if the land transferred continues to qualify and will indicate by signing below. Gross Selling Price $ 200,000.00 If the land no longer qualifies or you do not wish to continue the designation *personal Property(deduct) $ or classification, it will be removed and the compensating or additional taxes will be due and payable by the seller or transferor at the time of sale. (RCW Exemption Claimed (deduct) $ No 84.33.140 or RCW 84.34.108). Prior to signing (3) below, you may contact your local county assessor for more information. Taxable Selling Price $ 200,000.00 Excise Tax: State $ 2,560.00 This land 0 does 0 does not qualify for continuance Local $ 1,000.00 *Delinquent Interest: State $ Local $ DEPUTY ASSESSOR DATE *Delinquent Penalty $ (2)NOTICE OF COMPLIANCE(HISTORIC PROPERTY) Subtotal $ 3,560.00 NEW OWNER(S): To continue special valuation as historic property, sign(3)below. If the new owner(s)do not wish to continue,all *State Technology Fee $ 5.00 additional tax calculated pursuant to chapter 84.26 RCW, shall be due and payable by the seller or transferor at the time of sale. *Affidavit Processing Fee $ (3) OWNER(S)SIGNATURE Total Due $ 3,565.00 PRINT NAME A MINIMUM OF$10.00 IS DUE IN FEE(S)AND/OR TAX *SEE INSTRUCTIONS I CERTIFY UNDER PENALTY OF PERJURY THAT THE FOR GOING IS TRU AND CORRECT Signature of Signature of • Grantor or Grantor's Agent ' Grantee or Grantee's Agent Name(print) Barbara J.Harrold /� Name(print) Justin Rankin Date&city of signing: -3/-/}' 1)117/747iw t�td/ Date&city of signing 9 J j / ( ;0/e j- 71, Perjury: Perjury is a class C felony which is punishable by imprisonment in the state correctional institution for a makimum term of not more than five years,or by a fine in an amount fixed by the court of not more than five thousand dollars($5,000.00),or by both imprisonment and fine(RCW 9A.20.020(1C). REV 84 0001a(04/30/09) THIS SPACE-TREASURER'S USE ONLY COUNTY TREASURER 703n) 3 :i _ .1201 565