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HomeMy WebLinkAboutBLD1989-00122 AWING 'ERMIT APPLICATION 0 Jefferson County Building Departnsi,ent•� .0 . Box 1220.Port Townsend. WA 98368 r t , h LOCATION �\ Lck_L, L� SPECIFIC LOCATION SITE ADDRESS ,� ( POSTAL DISTRICT 1 /SUBDIVISION LEGAL DESCRIPTION LOT L✓ BLOC DIVISIA TAX NUMBER PARCEL NUMBS 1 / 4 SECTION / 1 PLANNING AREA !SECTION �LI TOWNSHIPS NORTH RANGE / ��J/ WM BUILDING INFORMATION BUILDING TYPE TYPE OF IMPROVEMENT SQUARE FOOTAGE ❑ SINGLE FAMILY 0 NEW BUILDING MAIN FLOOR F OBILE HOME 0 ADDITION 2ND FLOOR ❑ MODULAR HOME 0 ALTERATION BASEMENT / -- ❑ DETACHED/ATTACHED ❑ REPAIR CARPORT GARAGE ❑ REPLACEMENT GARAG ❑ WOODSTOVE 0 WRECKING/DEMOLITION COM. RCIAL ❑ MULTI - FAMILY 0 RELOCATION/MOVING DUSTRIAL NUMBER OF UNITS MOBILE HOMES ❑ COMMERCIAL SIZE -----0 @ $35 ❑ INDUSTRIAL YEAR 0 @ $ 16 ❑ HOTEL/MOTEL/DORMITORY MAKE 0 @ $6 NUMBER OF UNITS ❑ OTHER - SPECIFY ESTIMAT - D COST OF 0 a@ $8 IMPR. EMENTS TOTAL FAIR MARKET VALUE UBC OCCUPANCY GROUP $ $ .i SELECTED CHARACTERISTICS OF BUILDING PRINCIPLE TYPE OF FRAME P 1NCIPLE TYPE OF HEATING FUEL ❑ FOOD FRAME ELECTRICITY 0 COLLECTIVE SOLAR ;. MANUFACTURED W ODSTOVE 0 PASSIVE SOLAR TRUCTURAL STEEL AS 0 COAL ❑ REINFORCED CONCRETE 0 OIL 0 OTHER - SPECIFY ❑ MASONRY ( WALL BEARING ) DIMENSIONS ❑ OTHER - NUMBER OF STORIES TOTAL LAND AREA DEPARTMENTAL REVIEW HEALTH DEPARTMENT TYPE OF SEWAGE DISPOSAL NUMBER OF PROPOSED BEDROOMS ❑ PUBLIC OR PRIVATE NUMBER OF EXISTING BEDROOMS 0 INDIVIDUAL ( SEPTIC ) NUMBER OF PROPOSED BATHROOMP Q APPROVED DATE ❑ INDIVIDUAL WELL NUMBER OF EXISTING BATHROOM PUD TYPE OF WATER SUPPLY ❑ PUBLIC `( NAME OF WATER SUPPLY) _,---- APPROVED DATE ❑ PRIVATE ( NAME OF WATER SUPPLY/ - � PLANNING DEPT . WITHIN SHORELINE JURISDICTION/ ❑ YES NAME OF ADJACENT ,WATER BODY ❑ NO APPROVED DATE BANK HEIGHT SETBACK PUBLIC WORKS DEPT_ ROAD RIGHT-OF-WAY WIDTH ../- NAME OF PUBLIC ROAD �/- NAME OF PRIVATE ROAD APPROVED DATE ROAD ACCESS PERMIT REQUIRED 0 Y 0 NO - 14)Erli" caX1-9(44e-r- 30 (E'7) 4/12!'\ 4 9E3..ls --- MAILING ADDRESS ZIP TEL NO v NAME OWNER \ ` q.c . ,p0 _i_y_4),pcs., . F-i— '677 CONT STATE LICrRSE ND 1 ARCH f i THE OWNER' OF THIS BUILDING AND THE UNDERSIGNED AGREE TO CONFORM TO ALL APPLICABLE LAWS. IGNA/URE OF.���&L P ,L.ICANT �, API'LI ATIO�/��TE I ✓�P�T'�C(" ` R I C�ECK NUMBER OR CASH • //tj(V/�/!'Nf/� \\`�/ „\_c�lj 1. rt APPRO E BY P Ri4. T FEES A P `�e BASE FEE INSPECTIONL � �-4 l '� BLDG SURCHARGE PLAN CHECK R 2 see PLANJEFFER NING SO&N COUNTY ENERGY SURCHARGE •C.P � �� TOTAL BLDG DEPT 9 1 I NUMBER REFUND DATE DAT S , i • BUILDING OFFICIAL `. RETURN ADDRESS Walter C. Mead 1 5385 Rogue River Hwy #1 ! Gold Hill, OR 97525 El° °'mPnt%SHIN`TON MANUFACTURED HOME PLEASE CHECK ONE licEnSinG APPLICATION ®TITLE ELIMINATION ❑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) 0 MANUFACTURED HOME TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) @50709 1975 Hillc 24T X 52 0299J © LAND LEGAL DESCRIPTION ON PAGE REAL PROPERTY TAX PARCEL NUMBER MANUFACTURED HOME WILL BE 0 AFFIXED 0 REMOVED 901 342 023 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE QUARTER/QUARTER SECTION 2 Putas Short Plat NW, SW, 34-29-1W p GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGISTERED OWNERS NUMBER OF LEGAL OWNERS 1 1 NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER WALTER C. MEAD NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE NAME OF LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER WALTER C. MEAD 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 Walter C. Mead 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 Cettlfy that: t the 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. NAM (TYPED OR PRINTED) BLDG PERMIT OFFICE/PHONE# BLDG PERMIT# h��.TqN \Suc�r� C� �) 7q-�1�1rx7 Sri-0o1aa St N U�nR/�}E`J�/y`"AApP\O'�S`Il) I 'Ph/rYui{t n' - 6/0 05 TD-420-7 9MANUFHOMBAPPL(R/2 2)OR(W)Page1of2 MANUFACTURED HOME - FROM SECTION 1 TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) @50709 1975 Hillc 24T 52 0299J 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 County of Signed or attested before me on by WALTER C. MEAD PRINT NAME OF LEGAL OWNER Signature NOTARY OR AGENT by PRINT NAME OF LEGAL OWNER PRINTED NAME OF NOTARY Title County/Office No.OR DEALERSHIP POSITION/AGENT/NOTARY AND: Dealer No.ORNo ary ion 7 LAND DESCRIPTION (A legal description of the land can be obtained from the locals County tAssessor's Office) Lot 2 of Putas Short Plat recorded in Volume 2 of Short Plats, page 6, being a portion of the Northwest 1/2 of the Southwest 1/4 of Section 34, Township 29 North, Range 1 West, W.M. , Jefferson County, Washington. 8 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 DATE 10.....E»s FILING FEE APPLICATION MOBILE HOME FEE ELIMINATION FEE USE TAX SUBAGENT FEES MPORTANT: Once the application has been approved by the County Auditor/Vehicle TOTAL FEES&TAX 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 APPROVED 2 198 , (\,e C-„ ft MAI S ---- JEFFERSON COUNTY PLANNING&BLDG DEPT 3/(7( D CACL-41A/Z (g 17 0 ( / 41 . , 621,1 117 0 10 VX `4- 0111' fl air k ) 63/4 — AA- vt-ie lq-evnte Favi,f_r2-d _ 0,24 2r /Lead -13° " fly -/ 7/2-6 19' Leic 7-49