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