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HomeMy WebLinkAboutBLD2001-00191 t MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD01-00191 Received Date: 4/3/2001 SITE ADDRESS: 3835 THORNDYKE RD PORT LUDLOW, 98365 APPLICANT: DAVID FORAKER PHONE: (360)779-7074 261 NE MOE ST POULSBO WA 98370 SUBDIVISION: CEDARHOLM VILLA Block: Lot: T 10 PARCEL NUMBER: 942300059 Section: 19 Township: 27 N Range: 01 E CONTRACTOR/ OWNER PHONE: DEALER: PROJECT DESCRIPTION MANUFACTURED HOME INSTALLATION TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: GIBRALTER SETBACK: VALUATION 2,500.00 YEAR: 1975 LABOR & INDUSTRIES APPROVAL? SIZE: 14 X 60 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PWELL BEDROOMS: BATHROOMS: PARCEL TAGS: YES NO STORMWATER: YES NO Exist: Exist: AREA Plat Conditions Prop: 2 Prop: 1 Wetland Erosion Total: 2 Total: 1 Seismic Streams Flood Way Floodplain Routing Date: F&W Landslide x _ .-..r.., Shoreline Aquifer . . Forest: Commerc al , _ o ,;) ii gig sa Is or -' - Type Amount Paid By: Date: Receipt: Manufactured Homes $141.00 MAM 04/03/01 38240 APR 1 1 2001 Potable Water Application $30.00 MAM 04/03/01 38240 Total: $171.00 JEFFERSON COUNTY DEPT.OF COM NITY DEV�ELOPM T SIGNATURE: t MANUFACTURED/MOBILE HOME INSTALLATION PERMIT Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 (360) 379-4450 FAX (360) 379-4451 (800) 831-2678 PERMIT #: BLD01-00191 Received Date: 4/3/2001 SITE ADDRESS: 3835 THORNDYKE RD Issue Date: 4/17/2001 PORT LUDLOW, 98365 Expiration Date 4/17/2002 APPLICANT: DAVID FORAKER 261 NE MOE ST POULSBO WA 98370 SUBDIVISION: CEDARHOLM VILLA Block: Lot: T 10 PARCEL#: 942300059 Section: 19 Township: 27 N Range: 01 E CONTRACTOR/ OWNER PHONE: DEALER PROJECT DESCRIPTION MANUFACTURED HOME INSTALLATION MAKE: GIBRALTER YEAR: 1975 SIZE: 14 X 60 THIS PERMIT IS VALID FOR ONE YEAR AND IS NOT RENEWABLE. THE FINAL INSPECTION MUST BE SCHEDULED AND PASSED WITHIN THAT YEAR. THE EXPIRATION DATE IS 4/17/2002. REQUIRED INSPECTIONS: [y'-/ betbacks: 6 k [ Footing(If conti nous footings are used): 5L. 1{-.2 6- d f /� [ ] Blocking/Plumbing: e/4 - [ Final/Skirting/Vents/Porches/Steps: fe,f; . 9 HEALTH DEPARTMENT APPROVAL REQUIRED PRIOR TO FINAL INSPECTION BUILDING INSPECTION HOT-LINE 379-4455. CALL 24 HOURS IN ADVANCE TO SCHEDULE INSPECTIONS. Office Hours 9:00 a.m. -4:30 p.m. Inspector's Phone Hours 8:00 a.m. - 9:00 a.m. SPECIAL CONDITIONS APPLY -SEE REVERSE HOT-LINE AVAILABLE 24 HOURS A DAY SPECIAL CONDITIONS CASE # BLD01-00191 1.) The application was reviewed by the Jefferson County Department of Community Development for the presence of Environmentally Sensitive Areas (ESAs). The Department conducted a review and has concluded that the property DOES NOT contain Environmentally Sensitive Areas. However, future proposals will be subject to a new ESA review and conditions may be added if new ESAs are found on the property. 2.) The building height is not to exceed 35 feet. 3.) Thorndyke road setback shall be 20 feet minimum, side and rear setbacks shall be 5 feet minimum. 4.) Maximum lot coverage is not to exceed 25%. 5.) This approval is for a manufactured home installation only. Any future permits on this site are subject to review for consistency with applicable codes and ordinances and does does preclude review and conditions which may be placed on future permits. 6.) The site plan as submitted with the manufactured home installation permit has been reviewed for consistency under the UDC and approved by Jefferson County. Any modifications, changes, and/or additions to the stamped approved site plan dated 4-6-01 shall be resubmitted for review and approval by Jefferson County. 7.) Stormwater BMPs shall be employed to control erosion and sediment during construction. JEFFERSON COUNTY COMMUNITY DEVELOPMENT 621 SHERIDAN ST, PORT TOWNSEND WA 98368 MANUFACTURED HOME INSTALLATION PERMIT APPLICATION 0 NEW BUILDING Get-- REPLACEMENT , !" SIZE ( 4" i< Go. �K,`/ ,' ,, ,,, r �., YEAR ( q 7 „' n MAKE Gig km, lt2 /' e'Dt.t2.tN3 • 1 \C. t: a A • r�, COST t 3. C)O. o o :, 0O '" t N 1, BEDROOMS: BATHROOMS: ''^., ; .�` EXISTING 2. EXISTING _ _ °, PROPOSED PROPOSED TOTAL 2. TOTAL I TYPE OF SEWAGE DISPOSAL: WATER SUPPLY: 0 SEWER 0 COMMUNITY SYSTEM af...PRIVATE WELL 0 TWO PARY WELL el-INDIVIDUAL SYSTEM Conventional 0 PUBLIC PERMIT # SEPbb-boOZb 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 s. SIGNATURE____cl, J� DATE ` Z` d f NAME (PLEASE PRINT) .LJA.Je, /4L}- /4... FOR OFFICE USE ONLY BASE FEE l _0 0 RECEIPT# (,1(� 4 ADDITIONAL SECTIONS CASH/CK# 1UUY SUBTOTAL t(4, �0 0 DATE 14 /3 /01 POTABLE WATER 0 " 91 1/ROAD APPROACH TOTAL 1;L O O H:\HOME\PLNCNTR\FORMS\MOBILEAP.10/99 PLEASE MAIL TO: ' 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 IS NOTA TAX STATEMENT NAME: virVft f'oRAkE'R, The purpose of this questionnaire is to obtain information Moe, either the current location of a mobile home or the ADDRESS: 2.Co I A/i J' lOf Sr previous ownership and location of a mobile home. This will help our office determine whether the mobile home is already I-!,c/L S e O L.) 4 , 4 e 3 70 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(,C)) (/= 'a..`? 7' 7O 7 qI additional information. 1 ) MOBILE HOME DATA: (A) MAKE Pl o 6 r4 y,,1j*J (B) MODEL 6-t siz f}LTE (C) YEAR t5 7S' (D) LENGTH 6,0r (E) WIDTH l4/ ` (F) SERIAL NUMBER q- f$-36. (G) YOUR PURCHASE PRICE(DO NOT INCLUDE SALES TAX) ‘72,4o O (H) PURCHASE DATE t 2S=O / 2) PREVIOUS OWNER / LOCATION OF MOBILE HOME: (A) FROM WHOM DID YOU PURCHASE MOBILE TDM TL,9,'vl /� ADDRESS 6, ! SU cL,e rcH5K 8y (t D /» 1)()RAt c4Q Is, Lr14_ gBiic (B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? YES NO F NO, WHAT COUNTY? K(7541" IF YES, WHAT WAS PREVIOUS ADDRESS OF MOBILE? 3) WHERE MOBILE HOME IS TO BE LOCATED: a �n (A) WILL THE MOBILE HOME BE IN A MOBILE HOME PARK? YES OA r `J D (B) IF LOCATED IN A MOBILE HOME PARK: NAME 81 ADDRESS OF PARK ' E NO (C) IF NOT LOCATED IN A MOBILE HOME PARK: JEFFERSON OOUNTY MMUNITY pEVE�OPMENT NAME OF LAND OWNER: p t p i DEPT Of CO LOCATION (ADDRESS) 3 8 3 S 7 4,2N'D yge A. REAL PROPERTY PARCEL NUMBER/ DESCRIPTION (_J p 4-g- /4o L, r.. V 1 L.L. A T r}X jQ P'KCAL #- 9 30o oS? o0 THANK YOU FOR YOUR HELP! l" SIGNATURE KELLI LARSON, roperty Technician THIS FORM CONFORMS TO THE STANDARDS OF THE STATE DEPARTMENT OF REVENUE AND IS SUBJECT TO AUDIT VERIFICATION. JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT rk • UNIFIED DEVELOPMENT CODE TYPE I LAND USE PERMIT • APPLICANT: DAVID FORAKER 261 NE MOE ST POULSBO WA 98370 DATE ISSUED: April 17, 2001 DATE EXPIRES: April 17, 2002 MLA NUMBER: MLA01-00149 PROJECT PLANNER: M POKORNY PROJECT DESCRIPTION: MANUFACTURED HOME INSTALLATION PROJECT LOCATION: Parcel number 942 300 059, Cedarholm Villa, T10, in Section 19, Township 27, Range 01 East, WM located at 3835 Thorndyke Rd, Port Ludlow, WA. FINDINGS: 1.) The Administrator finds that this application complies with applicable provisions of the Unified Developmen Code, all other applicable ordinances and regulations, and is consistent with the Jefferson County Comprehensive Plan and Land Use map. 2.) The application was reviewed by the Jefferson County Department of Community Development for the presence of Environmentally Sensitive Areas (ESAs). The Department conducted a review and has concluded that the property DOES NOT contain Environmentally Sensitive Areas. However, future proposals will be subject to a new ESA review and conditions may be added if new ESAs are found on the property. CONDITIONS: 1.) The building height is not to exceed 35 feet. 2.) Thorndyke road setback shall be 20 feet minimum, side and rear setbacks shall be 5 feet minimum. 3.) Maximum lot coverage is not to exceed 25%. 4.) This approval is for a manufactured home installation only. Any future permits on this site are subject to review for consistency with applicable codes and ordinances and does does preclude review and conditions which may be placed on future permits. 5.) The site plan as submitted with the manufactured home installation permit has been reviewed for consistency under the UDC and approved by Jefferson County. Any modifications, changes, and/or additions to the stamped approved site plan dated 4-6-01 shall be resubmitted for review and approval by Jefferson County. 6.) Stormwater BMPs shall be employed to control erosion and sediment during construction. NOTICE: This permit does not excuse the proponent from complying with other local, state, and federal ordinances, regulations, or statutes applicable to the proposed development. Development pursuant to this permit shall be undertaken subject to the applicable development and performance standards of the Jefferson County Unified Development Code. If during excavation or development of the site an area of potential archaeological significance is uncovered, all activity in the immediate area shall be halted, and the Administrator shall be notified at once. The Federal Endangered Species Act rules to protect threatened Chinook and Summer-run Chum salmon became effective on January 8, 2001. Bull trout have been listed as threatened since early 2000. Under the ESA, any person may bring lawsuit against any individual or agency that"takes"listed species (defined as causing harm, harassing, or damaging habitat for the listed species). In addition, the National Marine Fisheries Service can levy penalties. All areas in Jefferson County are induded as"critical habitat"for a listed species. Development of property along any marine shoreline, freshwater shoreline, or floodplains could harm habitat if protective measures are not taken. To minimize the potential to damage habitat, all property owners developing adjacent to marine shoreline, freshwater shoreline, or floodplains are advised to do the following: -Set back buildings, utilities and roads as far as possible from surface waters(streams, rivers, lakes, marine waters),or at least 150 feet from the edge of the water -All development activities should avoid unstable slopes, wetlands, and forested areas near surface waters - Remove minimal vegetation for site development, especially large trees -Allow trees that have fallen into surface waters to remain there - Infiltrate stormwater from buildings and driveways onsite through drywells rather than discharging directly into surface waters or roadside ditches Any individual, group, or agency can bring suit for a listed species "taking", even if you are in compliance with Jefferson County development codes. The risk of a lawsuit against you can be reduced by consulting with a professional fisheries habitat biologist, and following the recommendations for site development provided by the biologist. For more information, contact the National Marine Fisheries Service in Seattle at (206)526-6613, or the U.S. Fish and Wildlife Service at(503) 231-6121. Pursuant to RCW 36.70C, the applicant or any aggrieved party may appeal this final decision to Jefferson County Superior Court within twenty-one (21) calendar days of the date of issuance of this land use decision. For more information related to judical appeals see UDC Section 8.5.2. UDC Administrator • JEFFERSON COUNTY STORMWATER MANAGEMENT ORDINANCE SMALL PARCEL EROSION AND SEDIMENT CONTROL PLAN EROSION AND SEDIMENT CONTROL WORKSHEET Property Owner: D"i V E 6 2./f g- Telephone: 3 ( 0 7 7 at 70 74/ Address: Z (Q f ME /lob 5-77 POUL 5-e C.A.)4. ?637o Assessor's Parcel Number: Q 4113 000 6-er Building Permit or Septic Permit Application Number(if applicable): St? 0 0 ^ 0 ©0 2(S t � Brief. Project Description: INS T tic/ lot, A- /L{ X 40 Aloe 1 LF gotty 4A/.6 ftPTIG_-PQ/4-► , Site Location: 3 1?›3C THoKN DYKE i). Person Responsible for BMP Installation and Maintenance: Address: Telephone: 1. Describe/check the Best Management Practices (BMPs) that you will implement during land disturbing activities or construction to control erosion and prevent sediment from entering water bodies (marine waters, streams, rivers, lakes, or wetlands) or impacting adjacent property or roads. Please check the measures you plan to implement and show their approximate location on the site plan. You may also propose measures other than those listed. Attach additional sheets, if more space is required. [] Stabilize construction access route. Limit construction vehicles to one route, if feasible. Provide a stabilized construction access by applying quarry spalls, ballast, or crushed rock to minimize tracking sediment onto roads. (See attached illustration from Stormwater Management Manual.) If sediment is transported onto roads, they will be cleaned thoroughly. [^ / Minimize the extent of land disturbing activity and preserve existing vegetation. Preserve buffers of well-established vegetation between disturbed areas and property boundaries, roads, water bodies, and designated critical areas (wetlands, fish and wildlife habitat areas, landslide or erosion hazard area, etc.). SPESC Instructions—Short Form Revised June 3, 1999 3 • EROSION AND SEDIMENT CONTROL WORKSHEET Phase clearing so that only areas that are actively being worked are uncovered. Start and complete land disturbing activities and stabilize the site between April 1 and September 30. Stabilization means that disturbed areas will have well-established plant cover or be landscaped to minimize erosion. [] Stabilize exposed soil Exposed and unworked soil will be covered within 2 days between October 1 and March 31 and within 7 days between April 1 and September 30. [ ] Cover exposed soil with a minimum of 2 inches of straw or hay or other material approved for this purpose. [ ] Cover soil stockpiles with plastic sheeting and locate away from water bodies, roads, and property lines. [] Place gravel base on roads, driveways, and parking areas after clearing and subgrade preparation. [] Protect adjacent properties and water bodies from sediment deposition: [] Place straw or hay bales in ditches and drainage ways down slope from areas of land disturbing activity to filter runoff before it leaves the project site or enters water bodies. (See attached illustrations from Stormwater Management Manual.) [ ] Install a filter fence down slope from areas of land disturbing activity to filter runoff before it leaves the project site or enters water bodies. (See attached illustration from Stormwater Management Manual.) Regularly inspect and maintain all BMPs especially after storms events. Describe other erosion and sediment control Best Management Practices. Be specific as to design and specifications. 7H44..) Tp 5 -c-0 LiST('i * 4/2. 1-5 C�3r / 'c-•9-T' C54- 0 6/111i✓ .) SPESC Instructions—Short Form Revised June 3, 1999 4 EROSION AND SEDIMENT CONTROL WORKSHEET 2. Describe how disturbed areas will be permanently stabilized (seeded, landscaped, apply gravel base to roadways, etc.) Lg�. 7o c c-6 Y41LO ik t4 o 6€ 2.� 3. Describe how runoff from impervious surfaces will be controlled (disperse to vegetated areas to infiltrate, dry well,infiltration trench,route runoff to existing drainage facilities,etc.). fr<.•r,a, -‘0 iv /047-o.2.4 If' 4i,47704.) wi)S Gb-c,66 -4 ) C AtPI- r CAA 74! 2v i i l&. 4‘0 LA.) ' 7 tf u or2 T .h Lv q 1 /L. SPESC Instructions—Short Form Revised June 3, 1999 5 EROSION AND SEDIMENT CONTROL WORKSHEET 4. Specify your construction sequence. Describe the timing of all land disturbing activities (clearing and grading, construction, installation of drainage facilities, landscaping, etc.) and Best Management Practices.Describe proposed maintenance of BMPs. A,e-4_, £ 4ri/2 4-t_ ,4i 4.1 me. 6d c1X-4.- 1)/21✓ -,...34-y, C Q , '6 4A.-.E15c0c) YA11-0 4/ A O,0O.0 a-di.BtOc- Tto*0, The Best Management Practices proposed above will be implemented to control erosion, sediment, and sto .. ter f. I will notify the Permit Center for inspections as required. Signature of Owner/Agent Date SPESC Instructions—Short Form Revised June 3, 1999 6 • • RETURN ADDRESS AWASHINGTON STATE DEPARTMENT OF Manufactured Home LICENSING Application ❑TITLE ELIMINATION Anyone who knowingly makes a false statement of a material fact is guilty ORMVALTRANSFER IN LOCATION of a felony, and upon conviction may be punished by a fine,imprisonment, or bbotthE ROW 46 ROMF2 210 REAL PROPERTY MANUFACTURED HOME ) TPO/PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) @391671975 Gibra 60 X 14 91536 LAND LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE ❑AFFIXED ❑ REMOVED REAL PROPERTY TA iPARCELNUMBER 943300059 LOT BLOCK PLAT NAME OR SECTION/TOWNSHIP/RANGE 71,72 and 73 Cedarholm Villa Tracts QUARTER/QUARTER SECTION GRANTOR(S)REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE _ COUNTY NUMBER NUMBER OF REGISTERED OWNERS I NUMBER OF LEGAL OWNERS NAME OF REGISTERED OWNER I Michael L. Bronk DOL CUSTOMER ACCOUNT NUMBER NAME OF ADDITIONAL REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS 3835 Thomdyke Rd. CITY STATE ZIP CODE Port Ludlow WA 98365 NAME OF LEGAL OWNER Kitsap Community Federal Credit Union DOL CUSTOMER ACCOUNT NUMBER NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS 9481 Silverdale Way CITY STATE ZIP CODE Silverdale WA 98383 GRANTEE NAME 1 DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I/WE AM/ARE THE REGISTERED OWNER(S)OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: ��//ff Signature of Registered Owner and Title, IF APPLICABLE AL(.. - Signature of Additional Registered Owner and Title, IF APPLICABLE NoT..kk �9 L /F P ��\\\\y SM I Ty //�i�� NOTARIZATIO CE TIFICATION FOR REGISTERED OWNER(S)SIGNATURE \- PtJ••,••,..••..•••• � State of Washington Signed or attested . A Y. • • 2 County of . fore me on • = w .• oP z°1°••• 0 k CO `' 21,,b\ G r aySit atu re-t '',' ° �` Z I— PRI T NAME OF REGISTERED OWNER ��-�`.LI _� 446 '..�(ci-QPv6 ��ab r' i..YOR / �Tq••..........-w,Q---, 1 y PR NAME OF REGIST D OWNER •- ' TED NAME OF NOTA•V �b/I County/Office No.OR /////�E f O F,����\\\\� i TitieoCA P POSITI /A ENT/NOT AND: Dealer No.OR ENT/NOTARY Notary Expiration Date--1�' / � 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 certify that: the manufactured home has been affixed to the real property as described. 0 a building permit has been issued for this purpose and the attachment will be inspected upon completion, NAME TYPED OR PRINTED) BLDG PERMIT OFFICE/PHONE • # BLDG PERMIT# SIGNA RE/P $ITION •f i. �)(. l" C k .- gg `I, ,• -ATE ,.....:111 TD 420J�2�(R/6l06)W Pageof 2 ), I a E/1)1 • MANUFACTURED HOME-FROM SECTION 1 TPO I PLATE NUMBER YEAR MAKE LENGTH/WIDTH(FEET) VEHICLE IDENTIFICATION NUMBER(VIN) @39167 1975 Gibra 60 14 91536 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 Signature PRINT NAME OF LEGAL OWNER 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,OR Notary Expiration Date LAND DESCRIPTION (A legal description of the land can be obtained from the local County Assessor's Office) Lots 71, 72 and 73 of Cedarholm Villa Tracts,as per plat recorded in Volume 2 of Plats,page 119,records of Jefferson County, Washington in Section 19,Township 27 North,Range 1 East,W.M.,Jefferson County, Washington. Except that portion conveyed to Jefferson County for County Road No. 9 by deed recorded under Auditors File No. 195652,records of Jefferson County,Washington 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 SIGNATURE DATE 10 TITLE FEES FILING FEE APPLICATION 'MOBILE HOME FEE ELIMINATION FEE USE TAX SUBAGENT FEES IMPORTANT: Once the application has been approvedyTOTAL FEES&TAX r/Vehicle Licensing Office,take your application form tothe County Record ng 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. TO.420-729 (R/6/06)W Page 2 of 2 ,moo b i �o Q O rco � ,, 'yCn / v r,,o0 4a p-'..,---i ,) azi Z...---* .. G' CA J Olt Vs\ {f ,-, • 4. 'Jl y j, 0 /.\ pr cN ' +\" i .- L .. y 0. cib -,fir- t 4 Olt -Vh' J1 p h P ` 70 a.7 wa --Y mr co ov. ;% si o Z v h in 710 a- iv