HomeMy WebLinkAboutADR2019-00109aw00rofi
DEPARTMENT OF COMMUNITY DEVELO
621 Sheridan Street, Port Townsend, lfA 98368
T el: 360.37 9.4450 | Fax: 360.379.4451
Web : www.co.iefferson.wa.us /communiwdevelooment
E-mail: dcd@co.iefferson.wa.us
PMENT
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NEW ADDRESS APPLICATION -
Steps in the Permit Process:
-Review required submittal items to ensure all information is completed prior to submitting application.
-Fees will be collected at intake. Additional fees may apply after review and payment is required before permit is issued.
o New Address
{ NewD must be fl ed with ta received from DCD
For Department Use Only Receipt #: I
Related lication #s:P #:+ aql
FOR OFFICE USE ONIY
Date: I
DIFF LEFT M.P. RIGHT DIFF
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Tidemark entry,\ ?'1ft)Road database entry:lltl/otr' Post office \l r< / ?ezc)
New Address:I Date plates mailed:
# Plates:
Property lnformation ;02 17/ r)04
10n
Assessor Tax Parcel Number:
Parcel Address (if applicable)
Di ons to perty:
if known
Yes
Street
I tk
O O*oror
Cou or State Permit #:
Na reet(s)from which access wmofest
Do you need to construct a driveway from road onto
Neighbor's Name & Addre
I be gain
e*ols this a private road? QV"t
Name/Address:
Name/Address:
ROAD APPROACH OR STATE HWY ACCESS PERMITS ARE REQUIRED IF YOUR DRIVEWAY IS OFF A COUNTY OR STATE
ROAD lN ORDER TO PROCESS ADDRESS REQUEST. Please contact Public Works at (360) 385-9L60 with questions.r State: WSDOT http://www.wsdot.wa.gov/Northwest/DevelopmentServices/AccessServices.htm or (360) 757-596L
W 385-9160Permits-Vacations or 3civilus.com/r Cou ncou
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Address Apphcation I
Name:
Address
Phone #
Please contact Authorized Agent/Represe with proj nfo.
Applicant / Contractor: Authorized Agent/Representative
Name:
Phone #:
License #
E-mailAddress:
Expiration Date:
Submittal ms - use ms included
Current copy of parcel map from Jefferson County Assessor's Office, showing
http ://www.co,jeffe rson.wa. us/id ms/m a pserver.shtml
North Arrow --..i11J, iJ. $4
Road names in the area i, ,
Existing access easements
Parceldriveway location, label any driveways as new or existing/t"'7 ta 'U
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Addresses of neighboring properties " "" "'
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Travel path from main named county road to the driveway, theM
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Copy of a site plan, showing:
a. lf there are multiple structures, the addresses of all existing structures
b. For commercial permits, identify suite numbers for all existing and proposed busihesses and identify
the business names.
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 its 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 making any issued permit null and void.
I further agree to that all activities I intend to undertake or complete associated with this permit will be performed in
compliance with all applicable and I agree to provide access and right of
entry to Jefferson County and e sole purpose of application review and
any required later inspections ntent to enter upon the property for visits
related to this application and
Signature Print Name Date /s-i6 -t2
Jefferson County(vitl notify appropriate postmaster, fire district, and rgency sefvices of your new
address. We wil! provide you with a new fire plate and you will be required to install itlon your property
once the address is assigned.
Address Application 2
Tech Fee
*Additional fees may apply
E-mail ress:
state
OFFICE USE ONLV
Permit Fees
New Address Permit Fee s282.00*
s14.10
TOTAL s296.10
911r
, Audttor
Iiltr#hcn rccorded return to:
Gary Roundy
920 Marion St
Ccntra)ia, WA 98531
Nicole Black
A
SS:
satisfactory evidencc that Nicholas M. Illacka*dffiilacle.
before me, and said persons acknowledgcd that
and acknowledgc it to be tlpir and voluntary the
in this instrurnent
,i
05s /B
?op
Filcd for Record at llequest of
Jcffcrson f itle Company, Inc.
Escrow Number: 86l47DF
Statutory Warranty Dced
I'I{E GRANTOIfS Nicholas M. Black, as his scparatc estate and
joint tenants with rights of survivorship for and in consideration of 'l'EN
AND VALUAIILE CONSIDERATION in hand paid, conveys and
the following described real estate, situated in the Counfy of J,
Abbreviated Lcgal: Ptr NE NE l7-25-ZW Lying Westerly Of
Tax Parcel Number(s): 502 771 002
The Northeast% ot the Northeast % of
Jefferson County, Washington;
EXCEPT Duckabush Road;
cstatc, as
GOOI)
dy, a single pcrson
7, Township 25 North, Range 2 W.M.,
and madc a part hcrcof
ALSO EXCEPT that portion lying Easterly
Situate in the County of
Subjcct to: As fully describcd on Exhibit "A
Dated October 2019
.-r+L
Nicholas Illack
STATE OF
COLINTY OF
I certify
the
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EXHIBIT A
Any claim to (a) ownership of or rights to minerals and similar substances, including but not
Iimited to ores, metals, coal, lignite, oil, gas, uranium, clay, rock, sand, and gravel located in, on, or
under the Land or produced from the Land, whether such ownership or rights arise by lease, grant,
exception, conveyance, reservation, or otherwise; and (b) any rights, privileges, immunities, rights
of way, and easements associated therewith or appurtenant thereto,
or rights excepted in (a) or (b) appear in the Public Records.
whether or interests
d
I
described
d in deed
a
ent
ip 25 North, Range 2 West
2. A reservation of one-half of all mineral, gas and oil rights, which are reserved
grantors, as contained in the deed from Wade B. McCoy, Donald B. McCoy,
Elizabeth M. Guider (formerly Elizabeth M. Arnold), grantors, to Robert R
Workman, his wife, grantee, dated May 17, 1946, recorded in Volume 11
Auditor's File No. 107601, records of Jefferson County.
3. A reservation of the remaining one-half of all mineral, gas and oil rights
property, which are reserved forever to the grantor, their heirs and
from Robert R. Workman and Marie G. Workman, his wife, to
Washington Corporation, dated July 10, 1946, recorded in Vol
Auditor's File No. 107629, records of Jefferson County, Wash
4. Easement, including terms and provisions contained
Recorded: February 10, 1948
40S,
112807
United States of
Transmission line easement and
Portion of Sections 4, 8, I
said premises and other property
5. Easement, including terms and provisions
Recorded:
Recording No.:
ln favor of:
For:
Affects:
premises and other property
6. Easement, including terms and
Recording No.
ln favor of:
For:
Affects:
Recorded:
Recording No.:
ln favor of:For: E
Affects:
June 30, 1948
114392 in , pages 358 through 362
United States
Transmission line road easement
Porti hip 25 North, Range 2 West said
therein
Aug
rh Road, Fulton Creek Road and Duckabush County Road
ing terms and provisions contained therein:
March 6, 1997
39871 5
State of Washington
Roads
Portion of said premises and other property
7. A record of
matters:
1
U
n structures and appurtenant stgnal lines
and other property
nd ng no. 237621, said survey discloses the following
the Northeasl Ta of lhe Northeast % of Section 1 7
r recording no.252520, said survey dlscloses the following
oining properties or the public and Jefferson County of the following
County Road No
A record of su
matters:
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Possi
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roads:
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11. Easement, including terms and provisions contained therein:Recorded: March'6, 1997
Recording No.: 398716
ln favor of: State of WashingtonFor: RoadsAffects: Portion of said premises and other property
12. License To cut and Remove Trees imposed by instrument recorded on November
Recording No. 462192.
13. Easement, including terms and provisions contained therein:Recorded: April24,2015
Recording No.: 590858
ln favor of: Public Utility District No. 1 of Mason County
For:Construct, reconstruct, repair, operate and
facilities
14. The terms and provisions contained in the document entitledRecorded: August 14,2017
Recording No.: 609948
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