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HomeMy WebLinkAboutBLD2001-00086 MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD01-00086 Received Date: 2/8/2001 SITE ADDRESS: MOORE ST PORT HADLOCK, 98339 APPLICANT: FAWNDA WHITE PHONE: (360)732-4087 523 WHISPERING CEDAR LN CHIMACUM WA 98325 SUBDIVISION: IRONDALE Block: 54 Lot: 44 PARCEL NUMBER: 961805409 Section: 34 Township: 30 N Range: 01 W CONTRACTOR/ DEALER: INSTALLER: JAIME KOZELISKI WAINS0626 7/22/2001 (360)385-3215 1112 JACOB MILLER RD PORT TOWNSED WA 98368 PROJECT DESCRIPTION MANUFACTURED HOME INSTALLATION TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: CITAN SETBACK: VALUATION 1,000.00 YEAR: 1983 LABOR & INDUSTRIES APPROVAL? SIZE: 66 X 14 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PUBLIC BEDROOMS: BATHROOMS: PARCEL TAGS: YES NO STORMWATER: YES NO Exist: Exist: AREA Plat Conditions Prop: 3 Prop: 1 Wetland Erosion Total: 3 Total: 1 Seismic Streams Flood Way Floodplain Routing Date: 1, r ?Q-- Shoreline Aquifer l Forest: Commercial Rural Type Amount Paid By: Date: Receipt: Approved/Date Manufactured Homes $141.00 MAM 02/08/01 38113 Potable Water Application $30.00 MAM 02/08/01 38113 Total: $171.00 1 ruw .- d 1 --47 JEFFERSON COUNTY COMMUNITY DEVELOPMENT 621 SHERIDAN ST, PORT TOWNS_END WA 98368 MANUFACTURED HOME INSTALLATION PERMIT APPLICATION lid NEW BUILDING /' 0 REPLACEMENT (�' (� �/] SIZE ' 6 x /? D V� Lam, V YEAR I1�3 , MAKE (, I k _ FEB - 8 2001 COST a i 3zo>1 JEFFERSON COUNTY DEPT. OF COMMUNITY DEVELOPMENT BEDROOMS: , BATHROOMS: EXISTING S EXISTING I PROPOSED 3 PROPOSED 1 TOTAL 3 TOTAL l TYPE OF SEWAGE DISPOSAL: WATER SUPPLY: 0 SEWER ❑ COMMUNITY SYSTEM 0 PRIVATE WELL 0 TWO PARY WELL ( INDIVIDUAL SYSTEM [Conventional rA PUBLIC PERMIT # SEP 0 Alternative Name of water system: Port TOA//'!Se,0/ 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. SIGNATURE C7 ai,v-14-4J 0. Cj/ .✓ DATE Z///b NAME (PLEASE PRINT) i-ywh de, 6 . lit) je // FOR OFFICE USE ONLY 2 BASE FEE G � OBI RECEIPT# tt ADDITIONAL SECTIONS Ltz- CASH/CK# (efo SUBTOTAL DATE 0 ( POTABLE WATER O ©y/ 911/ROAD APPROACH S ©------- CO TOTAL H:\HOME\PLN C N T R\F O R M S1 M O B I L E A P.10/99 _ . t --- . R !e. .. 14 5/ "`y. 1ioRT • d fr9ooc eWJ_ 14OMe --__ —. A UE21 F-N THIS P .O R L.[u E PR.I 02 r� :/10STfhCL/ 17oN Y !lo' s/ 3 z DRAI0F/Eo1) STAKED /•l i / 1 pRL7'6S�D 1 / / /�S/� y D eel.uEwn4 8S' / Z / tEii l00.9 / //th /1 �/ R ESLfZU Cr: LSJ loos' i % I sLAPE I SA O/ I A I 5, / .LU 100.0. ^ I M.) > 5 i C.o73o i C_oT3t i Lww32.- C.0T33I! LOT 3 Li /1\ -WO : `_ T- M jE C E. W 1 E n N SCA LE t\1\ FEB - s 2001 \LUJPA -� iA f-SUS- 'QS L��-�,>z JEFFERSON COUNTY � 9G DEPT. OF COMMUNITY DEVELOPMENT DES7Cn0EO /I s 'Prz G SEAJSE Jefferson County Department of Community Development /� cO-)N Cow 621 Sheridan Street, Port Townsend WA 98368 (360) 379-4450 Universal Plot Plan l--C--gE _ F E B - 8 2001 JEFFERSON COUNTY Fill in the following blanks as completely DEPT. OF LOPMENT Project Description: ��,[[ // leanuGtC�u�'C� / a�ne 1 i?Slal��7 4, 9 Digit Parcel Identification Number (from your tax statement): Site Address 911#: Road Name: S , , Zip Code: <.1 Legal Description Subdivision Name: 1"r Block: 6 4/ Lot(s): , -3I/ Section: Township: Range: Parcel Size (acres or square footage): / 3 7 c } r r (iv, 42 s. Property Owner: // Phone: fabono/� �- r1,,Le- (3c ) .73.2 -40S 7 Mailing Address: / /rjGL. 1.- -Sf., 'i/n L �G�i fi7 t- r7�:c:ur?2 :�.ii 3S Applicant/Occupant: Phone: (if different from owner) Mailing Address: Authorized Rep: Phone: Mailing Address: General Contractor: Or Manufactured Home Installer: Phone: Mailing Address: Contractor's State License Number: Expiration Date: Septic Designer: - /j / ' Phone: 3 of c' $ ensc i Sc.rre11 «.t/ r/X) Mailing Address: Architect:/Engineer: Phone: Mailing Address: Loan Lender/General Phone: Contractor's Bond Holder: Mailing Address: FOR OFFICE USE ONLY Fire District: Planning Area: School District: Zone: 1/00 H:\home\pincntr\forms\universal plot plan PLEASE MAIL TO: S JEFFERSON COUNTY ASSESSOR JACK WESTERMAN III JEFFERSON COUNTY COURTHOUSE ASSESSOR PO BOX 1220,PORT TOWNSEND WA 98368 (360) 385-9105 MOBILE HOME INFORMATION FORM OWNER'S NAME / MAILING ADDRESS: THIS /S NOTA TAX STATEMENT NAME: rat 4f)A, e The purpose of this questionnaire is to obtain information regarding either the current location of a mobile home or the ADDRESS: 5a2 3 1.ti1, S� e� fr��,,, h previous ownership and location of a mobile home. This will help our office determine whether the mobile home is already c h 1 m a C , rn h'. ,,t 5 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: (.? c,1) 732 -y r(a.7 additional information. 1) MOBILE HOME DATA: (A) MAKE C / c,r; (B) MODEL (C) YEAR /9�3 (D) LENGTHLoj (E) WIDTH / (F)SERIAL NUMBER SG Lf 7? /4 (G) YOUR PURCHASE PRICE(DO NOT INCLUDE SALES TAX) /, O (H) PURCHASE DATE 1c71'.z 9 cselJ 2) PREVIOUS OWNER / LOCATION OF MOBILE HOME: / (A) FROM WHOM DID YOU PURCHASE MOBILE /9l.-s A, leiyi Ih/c it �y ADDRESS P• o- box / 337, S47,4407, (B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? YES (NC�(IF NO,WHAT COUNTY? k,'f S- p IF YES, WHAT WAS PREVIOUS ADDRESS OF MOBILE? 3EVEl�JEII .--,3) WHERE MOBILE HOME IS TO BE LOCATED: FEB - 8 2001(A) WILL THE MOBILE HOME BE IN A MOBILE HOME PARK? YES (B) IF LOCATED IN A MOBILE HOME PARK: JEFFERSON COUNTY DEPT. OF COMMUNITY DEVELOPMENT NAME Si ADDRESS OF PARK SPACE NO. (C) IF NOT LOCATED IN A MOBILE HOME PARK: v' NAME OF LAND OWNER: f o wfcrt of c r, (-0 7e e LOCATION (ADDRESS) S.:2 3 AJAR' (P t.-,4q Plop- Ln .� C`i,rb Ca In j,//11 REAL PROPERTY PARCEL NUMBER/DESCRIPTION // _Trona4 / ,2 15'/ c k P/J 'Lois 30-3z), 1USIA' I1S 1 9-1- pR-ce THANK YOU FOR YOUR HELP! nu SIGNATURE KELLI LARSON, roperty Technician THIS FORM CONFORMS TO THE STANDARDS OF THE STATE DEPARTMENT OF REVENUE AND IS SUBJECT TO AUDIT VERIFICATION. r, t ii . cidill • „. > .,. �-�, � �rs'r� fib/,/ y f d rp 111110‘' Sy