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MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION
Jefferson County Department of Community Development
621 Sheridan Street Port Townsend, WA 98368
PERMIT #: BLD01-00292 Received Date: 5/22/2001
SITE ADDRESS: 53 W 3RD ST
PORT HADLOCK, 98339
APPLICANT: RICHARD L O'CONNOR PHONE: (360)379-8305
53 W 3RD ST
PORT HADLOCK WA 98339-0522
SUBDIVISION: HAYDEN'S SUP TO SOUTH PT Block: 4 Lot: 12-13
PARCEL NUMBER: 958800407 Section: 2 Township: 29 N Range: 01 W
CONTRACTOR/ OWNER PHONE:
DEALER:
PROJECT DESCRIPTION MANUFACTURED HOME INSTALLATION
TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE:
TYPE OF IMP NEW MAKE: RID6W SETBACK:
VALUATION 200.00 YEAR: 1979
LABOR & INDUSTRIES APPROVAL?
SIZE: 70 X 14 BANK HEIGHT:
SEWAGE DISPOSAL: OSS
WATER SYSTEM: PUBLIC
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
F&W Landslide
Routing Date:
•w3.0 , RA` Shoreline Aquifer
Forest: Commercial Rural
Type Amount Paid By: Date: Receipt: Approved/Date
Manufactured Homes $141.00 MAM 05/22/01 40094
Potable Water Application $30.00 MAM 05/22/01 40094
Total: $171.00
JEFFERSON COUNTY COMMUNITY DEVELOPMENT 621 SHERIDAN ST, PORT TOWNSEND WA 98368
MANUFACTURED HOME INSTALLATION PERMIT APPLICATION
❑ NEW BUILDING ElREPLACEMENT /'"•?
SIZE X \'
YEAR
i
MAKE �j/0Cvf.. -
,
COST c.4 UCJ I l7 C`s
BEDROOMS: BATHROOMS: ' �•/ <' <. r
EXISTING EXISTING
•
PROPOSED b PROPOSED 0
TOTAL TOTAL ILL
TYPE OF SEWAGE DISPOSAL: WATER SUPPLY:
❑ SEWER ❑ COMMUNITY SYSTEM ❑ PRIVATE WELL ❑ TWO PARY WELL
❑ INDIVIDUAL SYSTEM 0 Conventional ! PUBLIC
PERMIT # SEP 0 Alternative Name of water system:
IF WATERFRONT PROPERTY,
DISTANCE TO BANK OR HIGH WATER LINE 0 ft BANK HEIGHT 0 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 �.�G...�� ,-•�C_ X Oecr.. r-tru DATE
NAME (PLEASE PRINT) 4q i 6 L.1bi--j h , 01e c`) .f)•:_
FOR OFFICE USE ONLY `//'�,y
BASE FEE iyloo RECEIPT# `/'1tJl.1 lyi
ADDITIONAL SECTIONS //!� CASH/CK# I 7
SUBTOTAL 7 • 00 DATE 1��,l - r
/ / l�
POTABLE WATER ‘...30.00
911/ROAD APPROACH
TOTAL i
41117'.OO
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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: gi A--� )�Cr�.J. )OVL
' The purpose of this questionnaire is to obtain information
ADDRESS: :3 '�-� regarding either the current location of a mobile home or the
previous ownership and location of a mobile home. This will
help our office determine whether the mobile home is already
f96 it.r fu,O4 on the tax rolls in Jefferson County or if it has been moved to
this county from anoth- -rea.`Please see reverse side for
TELEPHONE NO: 3 75- 8, OS additional informatio .
410,
Arlo
1) MOBILE HOME DATA:
(A) MAKE Ra 0 c., (B) MODEL (C) YEAR J977
(D) LENGTH 7(5 (E) WIDTH J y (F) SERIAL NUMBER 0a1 I yet/
(G) YOUR PURCHASE PRICE(DO NOT INCLUDE SALES TAX) ,'��, CFI (H) PURCHASE DATE 6 -/%-O /
2) PREVIOUS OWNER / LOCATION OF MOBILE HOME:
(A) FROM WHOM DID YOU PURCHASE MOBILE Jt1-7cotey /I/I 5i? 44Ke, S
ADDRESS )?t� Box `�Sr
(B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? YA NO (IF NO, WHAT COUNTY?
IF YES, WHAT WAS PREVIOUS ADDRESS OF MOBILE? L, 4-1J f3F[.C,/n1,✓` i/ (,;,,) ,
3) WHERE MOBILE HOME IS TO BE LOCATED:
(A) WILL THE MOBILE HOME BE IN A MOBILE HOME PARK? YES
(B) IF LOCATED IN A MOBILE HOME PARK:
NAME 81 ADDRESS OF PARK SPACE NO.
(C) IF NOT LOCATED IN A MOBILE HOME PARK:
NAME OF LAND OWNER: I ,g-i4_14) }, , (; '
LOCATION (ADDRESS) i .3 it,-1
REAL PROPERTY PARCEL NUMBER/DESCRIPTION
THANK YOU FOR YOUR HELP!
SIGNATURE
KELLI LARSON, roperty Technician
THIS FORM CONFORMS TO THE STANDARDS OF THE STATE DEPARTMENT OF REVENUE AND IS SUBJECT TO AUDIT VERIFICATION.
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