HomeMy WebLinkAboutBLD2000-00223 MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT#: BLD00-00223 Received Date: 4/6/2000
SITE ADDRESS: 2205 CLEARWATER RD
FORKS, 98331
APPLICANT: MICHOR GENTEMANN
% ELIZABETH GENTEMANN PHONE: (360)413-9273
6531 63RD AVE NE
OLYMPIA WA 985169574
SUBDIVISION: Block:
Lot:
PARCEL NUMBER: 412192004 Section: 19 Township: 24 N Range: 12 W
CONTRACTOR/ OWNER
DEALER: PHONE:
PROJECT DESCRIPTION MOBILE HOME INSTALLATION
TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE:
TYPE OF IMP NEW
MAKE: REDMOND SETBACK:
VALUATION 1.00
YEAR: 1975
LABOR & INDUSTRIES APPROVAL? SIZE: 14X70 BANK HEIGHT:
SEWAGE DISPOSAL: OSS
WATER SYSTEM: PWELL
BEDROOMS: BATHROOMS: STORMWATER: YES NO AREA
Exi 3 �E!Si )t Wetland Erosion
rop: Seismic Streams
Total: 3 Total: I Flood
in9 Landslide
Plat Conditions
Shoreline Aquifer
Routing Date: Forest: Commercial Rural
Proximity
Type Amount Paid By: Date: Receipt: Approved/Date
I Permit $141.00 RAC 04/06/00 27147
Plan Check $29.00 RAC 04/06/00 27147
Total: $170.00
I
:\F_BLD_App_Mob.rpt
10/29/99
,
JEFFERSON COUNTY COMMUNITY DEVELOPMENT 621 SHERIDAN ST, PORT TOWNSEND WA 98368
MANUFACTURED HOME INSTALLATION PERMIT APPLICATION
0 NEW BUILDING ❑ REPLACEMENT
SIZE ,/y I ,. 9—
YEAR /q 17 5-
MAKE ,q_e(2,..y.),1,,,,_v red .
COST I. �a
BEDROOMS: BATHROOMS:
EXISTING ✓ EXISTING
PROPOSED
PROPOSED
TOTAL
TOTAL
TYPE OF SEWAGE DISPOSAL: WATER SUPPLY:
0 SEWER 0 COMMUNITY SYSTEM A PRIVATE WELL 0 TWO PARY WELL
1 INDIVIDUAL SYSTEM ❑ Conventional 0 PUBLIC
PERMIT # SEP 0 Alternative Name of water system:
IF WATERFRONT PROPERTY,
DISTANCE TO BANK OR HIGH WATER LINE ft
BANK HEIGHT ft
By signing the application form, the applicant/owner attests that the information provided herein is true and correct to the best of their
knowledge. Any material falsehood or any omission of a material fact made by the applicant/owner 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 it's employees, representatives or agents for the purpose of
application review and any required later inspections. Access and right of entry to the applicant's property or structure shall be requested and
shall occur during regular business hours.
/VJL
SIGNATURE � � p
DATE 2C) 4°Cl °
NAME (PLEASE PRINT) M LC t a 60 �rcf���C�
l
FOR OFFICE USE ONLY
BASE FEE i I - 'L RECEIPT# '' l Lf .
ADDITIONAL SECTIONS 1 1 . t � ;
CASH/CK#
SUBTOTAL I . "
TOTAL `.. DATE
POTABLE WATER
911/ROAD APPROACH
1 ,` "
H:\HOME\PLNCNTR\FORMS\MOBILEAP,10/99
}
fi PLEASE MAIL TO:
® �' u V FERSON COUNTY ASSESSOR
JACK WESTERMAN III EFFERSON COUNTY COURTHOUSE
ASSESSOR APR - X 1220,PORT TOWNSEND WA 98368
11 (360) 385-9105
MOBILE H f' •� ?r•;�F • FORM
DEPT.OF COMMUNITY DEVELOPMENT
OWNER'S NAME / MAILING ADDRESS: THIS IS NOTA TAX STATEMENT
NAME: JeA) yv��,it� The purpose of this questionnaire is to obtain information
regarding either the current location of a mobile home or the
ADDRESS: / 67 .. q- .3 testa /l) I previous ownership and location of a mobile home. This will
O` help our office determine whether the mobile home is already
4-710-6/ C�t-'-° 9 F--3.3 l on the tax rolls in Jefferson County or if it has been moved to
this county from another area. Please see reverse side for
TELEPHONE NO: .3(ec) - c9(p c/J additional information.
1) MOBILE HOME DATA: n
(A) MAKEC�,��Lzg-yLc�L (B) MODELAT24-j-ef (C) YEAR /975
(D) LENGTH '7Q / (E) WIDTH /7 1 (F)SERIAL NUMBER 42 8,33
(G) YOUR PURCHASE PRICE(DO NOT INCLUDE SALES TAX) (H) PURCHASE DATE
2) PREVIOUS OWNER / LOCATION OF MOBILE HOME: oy
(A) FROM WHOM DID YOU PURCHASE MOBILE
ADDRESS I 5 / ` } iIL (, / ,/ I / z//%t ` (1.1. I
(B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? YES CP(IF NO,WHAT COUNTY?
IF YES,WHAT WAS PREVIOUS ADDRESS OF MOBILE?
3) WHERE MOBILE HOME IS TO BE LOCATED:
(A) WILL THE MOBILE HOME BE IN A MOBILE HOME PARK? NO
(B) IF LOCATED IN A MOBILE HOME PARK:
NAME ez ADDRESS OF PARKM.,(v�J� M� SPACE NO. 4/
C1YJ
(C) IF NOT LOCATED IN A MOBILE HOME PARK: U ./1 9,ce-3J/
NAME OF LAND OWNER:.
LOCATION (ADDRESS)
REAL PROPERTY PARCEL NUMBER/DESCRIPTION
THANK YOU FOR YOUR HELP!
S fG NATURE
KELLI LARSON, roperty Technician
THIS FORM CONFORMS TO THE STANDARDS OF THE STATE DEPARTMENT OF REVENUE AND IS SUBJECT TO AUDIT VERIFICATION.
_ I
1' • Department of Labor&Industries ,ti. " ,,,. ALTERATION PER MIT
Factory Assembled Structures Section � : Donott complete shaded areas
l
'' 'fi Permit#
INSTRUCTIONS: yt,.��° 1
134183
1. Complete all spaces,including the signature box(marked with an X). Invoice#
2. Draw a map on ieverse side of WHITE copy only.
3. Forward completed permit and fees to the nearest L&I office. See list on reverse. _________
4. Contact and schedule the inspection with the same L&I office within 15 days. Insignia#
Owner last name first name Daytime phone Date
,/ /; � / � a
L !sw a4Te-1' Q .e."-. -.. s ................_._..._............_(' z ......f.. 'ot..'....._�cri....q .3 I Q-.i -/iG -067
Address City State ZIP
,f.5`J/ S l 16/66)-C-r°/G / 0!0740..,) w.Uw,/9 9e'-3-3/
Installer/Contractor/Dealer Phone I Contractor's registration number
i It
Address City _ State Z1P+4
Check the appropriate boxes in section A and section B. FEES
A Commercial Coach B j Alteration Inspection(check appropriate boxes below). $ _
Serial No. Air Conditioning/Heat Pump
Electrical
'Alectrical Appliances
Mobile Home r rz :,
,Fire Safety 4':t1 I Y _D ,,lh00', 4r. a
Serial No. 3 Gas Furnace AF F'iC't L .1.3g1 3
.: .. Trig I _ ,.t�16i0i?
Gas Piping 0 j- /20 t, 14 it
HUD No. t�sf+
Plumbing Glik" lz_! _ $84.25
Structural Serial No
VehicleRecreational or I y� Park Trailer
"� ❑ R i l ❑ Wood/Pellet Shove — —�
Serial No. Plan Review $
RV Inspection $
Model No.or Plan Approval No. Original Permit
Reinspection No. $
Technical Inspection $
Note: This permit expires one year a teR eo purc�haaseD(Non-refundable) 4 - ;c co ac""'
/Signature of applicant or authorized representative Makecheck payable to: Dept.of Labor&Industries
\X ( :- �e... (1'2 /6,J - ye.r-z� MAR 17 20� ) FEES DUE $ Z -
,I.:PT. Of L 9 I
Department use only PORT ANGELES
ell Request approved or ❑ Request denied because of specific violations ofWashington rules and regulations. Violations must
se corrected and reinspection requested within 10 days for recreational vehicles and 20 days for mobile homes and commercial coaches
of the notice of violation date. (This does not apply to technical inspections). It is unlawful to offer for sale, rent, or lease any
non-complying mobile home,commercial coach or recreational vehicle.
' ,G %� _. f4 r . l�X - J -dam- , .;;h-!."°t— :G y, _ :
. :ll`.'.. . . . .' .ert Gt<C46C 1./1GC:� . . . . . 7:t . r-"' rfC';' 14_
. .. . . . . . Ci""i.e / .e:t:K�t.s : `-:-.- . . . . . . . . . . .11.. - - . . , . .
V %',\e'er .
. . . . . . . . . . . . . . . . . . . . . .,..,. .,..,.„.. . . .,,,.. .„_,_,,,,,,_.,.... . .... .,.,, I. '.'.(:"-.,,,. ./..'. f.-.-. . . . . . .. . . . . . . . . . . . .
. . . . . . _ . . . . . . - . .
❑ Included.are forms required whicemat be completed and fees submitted bef6re rein ection. _
Date—, .Afea.' e Inspector _ /' ,' ,` ' Total pages
F622-012-000 alteration permit 8-99 White-Olympia Canary-Inpector Green-Contractor Pink-Purchaser`Goldenrod-Purchaser
i
i
,
I
...
,....
1
)
kJ I
. 4
. .
Ag.
CA
. . ; 1.4•15' i
)
0 1.
)
12);:4E 4
.i;
)
. 4
i
. __. _.4 ,..... __ ..... ....., , ;
2 c-N
1/4.1
F)-14$ 4 1 ()4OG V a 3....
. f k'
r ....0
................,-,.... ., ....'-',....,,--,..,__ ,,,..---... . e."4, 'N
. ,
r
_--
cr: 11
e"'")
,1 ....
, ................,‘_—, \ 1
i
1 1)
.71D 1
1 , 40
/
1 '„ i
[ e)n°41)W'CV
11.11) )--• 1 ;Ttrj p oj ' ;
Cv
;1
g:74 f
i 2 1
....i
1 1
1
! ,
. . .......... . ... - i
,....
. *.....-_----........--.,
1
.,.
cl.„ . ...0 0?j r-al-.. ...a 4 c 4 1 zt-(cp a 1 v
.......
1 -..
11
+r o
ada ri_. ---(-).
g g pr) ,
n
• a
o v AO 0_' tMn " �o w �?
i IS n 1 o
c� a a 3 � (r .4 a j a. �a a
cm Et Ci �� 1~ ' •N
.24
c�. :6
r
iM Z=, 4-. V ' 1 ,/ N. (2 2 )1`P g li
Mco C-_ 1 - •4 C r.jd 'r &j. ' ,
pu,f ,,.,,,
3T, �p . . ,
q cr, ,,
2
Vx H
c , 1 T\
9 A e ,5___.
2 o u g lu
2 g o M o faaa
CZ!
o� TY^`� c 5 Ii
o —1p ul
iNC) (1 y N q Wvo C - O 'h ›+ iG, P •d ° 0 N •eN '' N -b 1, N ,.., t v
L, 8 v o N v n vV vp v 7: v q ° v
.._,..1-45o � : o a am ° a ao o op �v ti ) a.o Avbo.oE t ° i a-6r _, io i pu1 aoo 04 ,
6. a ON � o v o nn c' ► o � a ..!C `-� 6 L7 CD V ,.Q V . W -
A
Y
W � z Z SN�VHI;S
a !
n w
z
o
n o w
IA o 4 Z
}
F cr ~ ,� >. O a 3
m C.)
W o
d J
0
m ) A
m >- A. W
Q - J
3 ,^ CI
W V,
H •^ — U
m `` d
A LP v a
H f- LI H w Z
'b1 auWi Z 7 w
y`�l a a W
,S, ot_ Zcc o
v> o J o Q La 0 a
,ex. 0 W i .
Pi,o W
d, N
OJ
`Yo Y
,,)4,b
2
,Q
Z Y '� - a z ro
a V1
J
D. a 0
r
a 0
O c a
aZ W
O V1 C
d
p J C d
a a l0 ,L
... V.
O a o E
—J V)
2205 0....terkruiri,