2009, 07-21 MH ApplicationRETURN ADDRESS
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MANUFACTURED HOME
APPLICATION
a false statement of a material tact is guilty
may be punished by a fine, imprisonment,
alITLE
REMOVAL
(RCW
-PLEASE'CHECK•oNEs
ELIMINATION
IN LOCATION
FROM REAL PROPERTY
46.12.210)
■TRANSFER
or both.
Anyone who knowingly makes
of a felony, and upon conviction
1. MANUFACTURED HOME
TP / PLATE NUMBER
0 3 2 S (
YEAR
1TF
MAKE
PAc A
LENGTH/WIDTH(FEET)
L10X2'1
VEHICLE IDENTIFICATION NUMBER (VIN)
ma0LCcS-A /A
Q LAND LEGAL DESCRIPTION ON PAGE
MANUFACTURED HOME WILL BE
AFFIXED
REAL PROPERTY �,?' TAX PARCELNUMBER
/
•
• REMOVED
LOT
BLOCK
PLAT NAME OR SECTION/TOWNSHIP/RANGE
DUARTER/OUARTER SECTION
iU GRANTOR(S) REGISTERED/LEGAL OWNER(S) ADDITIONAL NAMES ON PAGE
COUNTY NUMBER
NUMBER OF REGISTERED OWNERS
NUMBER OF LEGAL OWNERS
NAME OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER
671/1gx107Tr_ V k4 /I //fitS
NAME OF ADDITIONAL REGISTEREDGIIOWNER /�'�J // '1 '/n // OMACCOUNT NUMBER
��JJ� DOL CUSTOMER?7,-
»/i iV, .]JR- / ,E 5 s / (C 0/{ Na {' ;A4: y FUS% / / OS O!O
[
ADDRESSCITY STATE ZIP CODE
/
NAMEDOL CUSTOMER ACCOUNT NUMBER
NAME OF LEGAL OWNER
NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER
ADDRESS CITY STATE ZIPCODE
GRANTEE
NAME
I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY
VEHICLE AND THIS INFORMATION IS ACCURATE:
Signature of Registered Owner and Title, IF
Signature of Additional Registered Owner and Title, IF
THAT I / WE AM/ARE THE REGISTERED OWNER(S) OF THIS
APPLICABLE
APPLICABLE
NOTARY SEAL OR STAMP
State
by
by
Title
NOTARIZATION/CERTIFICATION
of Washington
County of
FOR REGISTERED
Signed or attested
before
OWNER(S) SIGNATURE
me on
Signature
PRINT NAME OF REGISTERED OWNER NOTARY OR AGENT
PRINT NAME OF REGISTERED OWNER PRINTED
NAME OF NOTARY
County/Office No. OR
AND: Dealer No OR
Notary Expiration Date
DEALERSHIP POSITION/AGENT/NOTARY
4° TITLE COMPANY CERTIFICATION
1 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.
'5 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 4
G `a�� (i4 j(p
UrYGU
BLDG PERMIT ft
t.-144 1
s TURE
A
�,1 POSITION nL} \`
/ {Tit
n
-
TD.420{(29 A)ANUF HOME APPL (Fi/2/02)OR (W)Page 1 al2