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HomeMy WebLinkAboutBLD2003-00542 0 • M LA03-00494 Review Type: I MANUFACTURED/ MOBILE HOME INSTALLATION APPLICATION Jefferson County Department of Community Development 621 Sheridan Street Port Townsend, WA 98368 PERMIT #: BLD03-00542 Received Date: 8/28/2003 SITE ADDRESS: ARDEN ST PORT HADLOCK, 98339 APPLICANT: MICHAEL P REGAN PHONE: (360) 385-7368 291 W HORTON PORT HADLOCK WA 98339 SUBDIVISION: IRONDALE Block: 64 Lot: 25-27 PARCEL NUMBER: 961806408 Section: 34 Township: 30 N Range: 01 W CONTRACTOR/ JAMIE KOZELISKYN CO PHONE: 765-3898 DEALER: 1280 LINGER LONGER RD QUILCENE WA 98376 Contractor's License MCCLACC174NA Expires 6/30/1998 REPRESENTATIVE: J PHONE: (—)/// PROJECT DESCRIPTIO4` MANUFACTURED HOME INSTALLATION TYPE OF WORK MOB MANUFACTURED HOME: SHORELINE: TYPE OF IMP NEW MAKE: PARKETTE SETBACK: VALUATION 600.00 YEAR: 1970 LABOR & INDUSTRIES APPROVAL? SIZE: 12 X 50 BANK HEIGHT: SEWAGE DISPOSAL: CON WATER SYSTEM: PUD BEDROOMS: BATHROOMS: PARCEL TAGS: YES NO Exist: 2 Exist: 1 STORMWATER: YES NO Prop: Prop: AREA Plat Conditions Total: 2 Total: 1 Wetland Erosion Seismic Streams Flood Way Floodplain Routing Date: l /o ?zF&W Landslide Shoreline Aquifer Type Amount Paid By: Date: Receipt: Approved/Date Permit $151.00 MJA 08/28/03 58342 Potable Water Application $51.00 MJA 08/28/03 58342 Total: $202.00 • • JEFFERSON COUNTY COMMUNITY DEVELOPMENT 621 SHERIDAN ST, PAP TOWNSEND WA 98368 MANUFACTURED HOME INSTALLATION PERMIT APPLICATION 0214 NEW BUILDING ❑ REPLACEMENT i .1 N V dO�3�JtJ- '" � " �O �cl�� x, I �llN(100 fIO"k�'�� 3f',� � SIZE YEAR (/ ? ° .k'•,kli�. � e' ee MAKE Q ' (—v" , iy L, COST `)A6, 0 3 L...L _ 1� -''.` BEDROOMS: BATHROOMS: . E, r r EXISTING EXISTING ir ' r._..___. — PROPOSED _ _ PROPOSED AUG I$ `, TOTAL _a_ TOTAL JEF''E'RSON) COUNTY TYPE OF SEWAGE DISPOSAL: WATER SUPPLY: , OF , ..,k r PEVELOPMEN1 , 0 SEWER 0 COMMUNITY SYSTEM 0 PRIVATE WELL 0 TWO PARY WELL 0 INDIVIDUAL SYSTEM Ca'Conventional EYPUBLIC /6/ 4PERMIT#SEP -f_'] Alternative / Name of water system: IF WATERFRONT PROPERTY, `- tiI /C1(5f 4 A ,.5 j)/( F s/7 // 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. cess and right of entry to the applicant's property or structure shall be requested and shall occur during regu us' ss ho?rs. SIGNATURE / 11 DATE D (r`NAME(PLEASE PRINT) J -A a'E.( 4 f- FOR OFFICE USE ONLY ` .; . CONSISTENCY REVIEW FEE 7 / ' a . RECE T# = � _4 BASE FEE (51,00 ADDITIONAL SECTIONS CAS k# C-, ' 19 OO SUBTOTAL 4 DA %'/ POTABLE WATER 8Z oD , 911/ROAD APPROACH t T(. i Y TOTAL Ij'Z! •f.C) H;WOME\PLNCNTR1INFOBLD\FORMSIMOBILEAP.11/26/01 0 • II i 1 a 0 i ' l z _ w 6 } 7 • • i "�` \ \'' ': �, 2 ` / a� t , to IAI % tili 5t# )111 _ "Cs t .it _.fin�A,' ( jZ x ''' i . f 1 ' f Qf((it { © . tI b 410 • PLEASE MAIL TO: FERSON 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 NAMEEA-06,1 / MAILING ADDRESS: THIS IS NOTA TAX STATEMENT NAME: The purpose of this questionnaire is to obtain information ADDRESS: r2 7/ Ili G7� 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 f17r� ( 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: 7 additional information. COY c 1 — 9 1) MOBILE HOME DATA: j i "7 ' AUGZ(A) MAKE - � (B) MODEL (C) YEAR (D) LENGTH (E) WIDTH ��r}�y (F)SERIAL NUMBER 9,7 ,f f (G) YOUR PURCHASE PRICE(DO NOT INCLUDE SALES TAX) (H) PURCHASE DATE 2) PREVIOUS OWNER/ LOCATION OF MOBILE HOME: (A) FROM WHOM DID YOU PURCHASE MOBILE P Z ("a�� ADDRESS d (B) WAS MOBILE HOME ASSESSED IN JEFFERSON COUNTY LAST YEAR? //%ES NO (IF NO,WHAT COUNTY? IF YES,WHAT WAS PREVIOUS ADDRESS OF MOBILE?)7 5/orkr 5-717seeY, 3) WHERE MOBILE HOME IS TO BE LOCATED: (A) WILL THE MOBILE HOME BE IN A MOBILE HOME PARK? YES "NO (B) IF LOCATED IN A MOBILE HOME PARK: NAME 8I ADDRESS OF PARK SPACE NO. (C) IF NOT LOCATED IN A MOBILE HOME PARK: NAME OF LAND OWNER: /` �f tee°- LOCATION (ADDRESS) • REAL PROPERTY PARCEL NUMBER/DESC PTION IgytA-' .2 3-26 2_7 THANK YOU FOR YOUR HELP! SIGNATURE mil/L.4-45 KELLI LARSON, roperty Technician THIS FORM CONFORMS TO THE STANDARDS OF THE STATE DEPARTMENT OF REVENUE AND IS SUBJECT TO AUDIT VERIFICATION. • Gw tiGC�! P/eAje fiZ po 3- 5itZ , G�hf edydkr, DN �� '��•• O � � mac- 20 c 5 20.06