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2011, 05-11 Title EliminationMANUFACTURED HOME PLEAS CH CK ONE t1STfiTCOFW,SSHINGTON ���A.rit�f icEnsinc APPLICATION ■TITLE ELIMINATION ■TRANSFER IN LOCATION , Anyone who knowingly makes a false statement of a material fact is guilty of a felony, and upon conviction may be punished by a fine, imprisonment, or REMOVAL FROM REAL PROPERTY both. (RCW 46.12.210) D MANUFACTURED HOME TPO / PLATE NUMBER Y l 9 KE CiY U lav (A✓ a LENGTH/WIDTH(FEET) x VEHICLE IDENTIFICATION NUMBER (VIN) D1-1611y6-6HsE416isX 2 LAND LEGAL DESCRIPTION ON PAGE MANUFACTURED HOME WILL BE 0 AFFIXED • REMOVED REAL PROPERTY TAX PARCEL NUMBER LOT 3 BLOCK P T NAME OR SECTION/TOWNSHIP/RANGE Plate_ Vc y Es,, s QUARTER/QUARTER SECTION 3 GRANTOR(S) REGISTERED/LEGAL OWNER(S) • ADDITIONAL NAMES ON PAGE COUNTY NUMBER NUMBER OF REGIST RED OWNERS 1 NUMBER NUMBER OF LEGAL OWNERS NA E OF REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER r f9 r�0 NAME OF ADDITIONA REGISTERED OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESSCITY STATE ZIP CODE (J� c Sr -NA p ©(Cc ) A - LEGAL OWNERF DOL CUSTOMER ACCOUNT NUMBER NAME OF ADDITIONAL LEGAL OWNER DOL CUSTOMER ACCOUNT NUMBER ADDRESS CITY STATE ZIP CODE GRANTEE NAME I DO SOLEMNLY ATTEST UNDER PENALTY OF PERJURY THAT I / WE AM/ARE THE REGISTERED OWNER(S) OF THIS VEHICLE AND THIS INFORMATION IS ACCURATE: Signature of Registered Owner and Title, IF APPLICABLE r Signature of Additional Registered Owner and Title, IF APPLICABLE-L.,_yl NOTARY SEAL OR STAMP NOTARIZATION/CERTIFICATION FOR REGISTERED OWNER(S) SIGNATURE State of Washington Signed or attested County of before me on by Signature PRINT NAME OF REGISTERED OWNER NOTARY OR AGENT by PRINT NAME OF REGISTERED OWNER PRINTED NAME OF NOTARY County/Office No. OR Title AND: Dealer No. OR DEALERSHIP POSITION/AGENT/NOTARY Notary Expiration Date TITLE COMPANY CERTIFICATION certify that the legal de§cription 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: 433 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. NAM (TYPED OR PRINTED) i BLDG PERMIT OFFICE/PHONE # �' "�`r�, ADc i� �� S� � BLDG PERMIT # 110CC-,\y7 C) SIG 1 • TURE / POSITION DATE P -12)C ` I -C t c-11 S'A- 11 -4R,-age 1 0