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1996, 06-07 Permit: 96004059 MHSPOKANE COUNTY DIVISI OF BUILDING AND PLANNING 1026 W. BROADWAY • KANE, WA 99260-0050 (509) 456-3675 SITE INFORMATION PROJECT INFORMATION 5 C R S R T SITE ADDRESS: 19011 E BLOOM CIR GREENACRES WA 99016 PARCEL NUMBER: 55173.2103 SUBDIVISION: LABERRY MOBILE PARK ADD LOT: 2 BLOCK: 3 ZONE: UR -7 INSPECTOR: LEONARD FLUNO WATER DIST: OWNER: FARNE, DELBERT 8 WILMA PHONE: ADDRESS: 19011 E BLOOM CIR GREENACRES WA 99016 PROJECT NUMBER: 96004059 ISSUE DATE: 06/07/96 PERMIT USE: DOUBLE WIDE MOBILE HOME (EXISTING 1985) W/DECK APPLICANT: FARNE, DELBERT 8 WIL PHONE: ADDRESS: 19011 E BLOOM CIR GREENACRES WA 99016 CONTACT: HERMAN HERMAN PHONE: 509 928 8310 SETBACKS -> FRONT: 36 LEFT: UNK RIGHT: UNK REAR: UNK LENDER NAME: PHONE: ADDRESS: BUYLDINO'PERM CONTRACTOR OWNER LICENSE #: MOBILEHOME PERMIT CONTRACTOR OWNER LICENSE #: NEW BUILDING INSPECTION FEE 2 DIM.= 10 X 27 1 STORIES Q FT = 270 STATE SURCHARGE 4.50 COUNTY SURCHARGE 22.00 OV DECK R•3 VN 270 TOTAL PERMIT FEE S126.50 TOTAL VALUE: 22,430.00 ESIDENTIAL VALUATION 64.75 TATE SURCHARGE 4.50 ESIDENTIAL SURCHARGE 14.25 OTAL PERMIT FEE S83.50 PAYMENT SUMMARY NOTES PAYMENT DATE RECEIPT PAYMENT AMOUNT 06/07/96 00005104 TOTAL FEES 5210.00 S210.00 AMOUNT PAID AMOUNT OWING S210.00 S.00 ISSUED PERMIT BY: CAROL FRAZIER ALE 0 ADDRESS: I °I o� E-151-001,4 G R- � ZONE: ROAD WIDTH: FRONT FLANKING: COMMENTS. REVIEWED BY D-Z/ • • r 1q®Dep.rtm nrl o%SInNGTON MANUFACTURED HOME ICEfS/fG APPLICATION RECORDER'S CLOCK FILED AT THE REOUEBT OF: NAME ADDRESS Please check one X TITLE ELIMINATION (Complete all but section 3. below) TRANSFER IN LOCATION (Complete ALL sections below) REMOVAL FROM REAL PROPERTY (Complete all but section 4, below) dli: MANUFACTURED HOME TPO/PLATE +53890 NUMBER YEAR 1985 MAKE SOMER WIDTHILENGTH 52/24 VEHICLE IDENTIFICATION NUMBER (VIN) SM5734 $'$$2. LAND Attach a copy of the legal description of your land. It can be obtained from Coun Assessor's Manufactured office or it may be typed or home will be printed on an Additional AFFIXED your y Attachment Form (TD -420-732). REMOVED PROPERTY TAX PARCEL NUMBER S57 73 j �cx 7/0 x 31 TITLE COMPANY CERTIFICATION I certify that the legal description of the land and ownership is true and correct per the real property records. NAME TITLE COMPANY/PHONE NUMBER SIGNATURE X 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 perm't that the manufactured home has been affixed to the real property as described, or a building has been 'ssued for this purpose and the attachment will be inspected upon completion. BLD PERMIT #� / �60C)AinC/ � � / ' r' -(,(,C)U�lLi(.�-�J^ SIGNATURETITLE (, SPOKANE COUNTY ptvtstON OF BUILDING AND PLANNING BLDG PERMIT OFFICE/PHONE # (sv ) ' Syn 74_v!c DATE ((HI's'Sf 19 le °5 OWNE INFORMATION COUNTY INC UNINC ❑ ❑ s REGISTER° OWNERS # LEGAL OWNERS Provide the Washington Driver's License or I -D. card number (PIC) for each owner: FILING FEE @ie2 IO NAME OF FIRST OWNER DELBERT S. FORNEY FORh)Eh4- 9aom i APPLICATION -,'t NAME OF SECOND OWNER ISWILMA L. FORNEYnRfilll—WL 722(5,2„. MOBILE HOME FEES 1 EJIS ADDRESS OF OWNER 'E•y E. 19 011 BLOOM CIRCLE --OR-- if the owner is a business, ELIMINATION � iT 0'I CITY '•u'j:. Ilf S POKANE , STATE WA ZIP CODE 99016 provide the Unified Business Identifier (UBI), found on the business Registration & Licenses USE TAX 1 I'" NAME OF FIRST LEGAL OWNER' }q'y L;: w IMS EVERGREEN MONEY SOURCE MORTGAGE CO. liz Document. SUB -AGENT FEES 'E . MAILING ADDRESS OF FIRST LEGAL OWNER `N 6553 CALIFORNIA AVENUE } More than two owners or one lienholder? Please use attachment TOTAL FEES & TAX nO"': CITY .401/4, STATE ZIP CODE form(s) #TD -420-732. �— SEATTLE W • 98136 DEALER'S REPORT OF SALE e+ tr 'SIGNATURE OF LEGAL OWNER IND AAT/E�SC/OJ!ENT FOR MINA oN oFFFTTi LEEE/REEMMOVAL FROM REAL PROPERTY _ I certify that this information is correct. The vehicle is clear OI encumbrances except as shown Anyone who knowingly makes a lalse statement of : aerial fact . g upon conviciton may be punished by a fine of up 1. . -.000 and/ 10 (RCW 46.12 210). I DO SOLEMNLY ATTEST UNDER PEN • TV pity of a felony, and ears imprisonment WA DLR NO DATE OF SALE PURCHASE PRICE $ OF PERJURY LAW TFIAT I/WE ARE THE REGISTERED OWNERS OF THIS VEHIC ND THIS INFORMA- TION IS ACCURATE: Owner Signetuure(s) 8 Thief 9): DEALER NAME TA%JURISDICTIONRAX RATE X . / /'�A / ` 4 G% v `�–e DEALER'S AUTHORIZED SIGNATURE l'‘ .As x C ,c '� ♦,•�YA%,/ X ••• USE TAX EXEMPT Sale to a Certified Tribal member on the reservation (attach notarized statement of delivery) s• M. AGECwT I- ._/� / -ju. t• ` TA•'► rv�+((rrv. I `' SUBSCRIBED TO AND SWORN .�7U DAY OF Ink, BEFORE ME THIS 19 CI (0 Residing in (County) }• ' + i .. 7 .� T !CEWSING OFFICE APPROVAL: (Not fo se by Sub -Agents) at '.ove y ' ,h th •tt, aton appears to have been completed correctly, and the applicant has sufficient documentation to re Q :' .-t . is form. NA , ••.• .Q' ' ;'s## ♦♦ ...... ,�.M�t• /*mi t�?0♦♦• SIGNATURE x OFFICENFS OPERATOR NUMBER DATE