1991, 04-03 Permit App: 91001557 MH Spokane County
DEPARTMENT OF BUILDING & SAFETY
West 1303 Broadway Avenue Spokane, WA 99260 (509) 456-3675
INFORMATION WORKSHEET
PARCEL NUMBER: . f Z_ /51>
STREET ADDRESS: //2// 1Z _ - -
CITY/STATE/ZIP: pi , �if.L 91Z-'Ljr
SUBDIVISION: i. /4 /lil/ //,,t -d /L J�iY/. /Ll�/ .T
BLOCK: 7 LOT: ZONE: DISTRICT:
LOT AREA: F/A: WIDTH: DEPTH: R/W:
# OF BUILDINGS: # OF DWELLINGS: WATER DISTRICT:
OWNER: ( /474:.G`c.2'G' 1404, ; G � � PHONE: - - 3 I f
MAILING ADDRESS: -17-4W -Z/7/ %' 4t 264/e, S 3/c /4211 :f
CITY/STATE/ZIP: �
L C/' 4 ,eeG.7 J
(.7;;A/;44
CONTACT: l"` G;L-/t_'1/ PHONE: -3Z7 - Sd6
SETBACKS: - FRONT: LEFT: RIGHT: REAR:
PERMIT USE:
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BUILDING INFORMATION
CONTRACTOR LICENSE NUMBER:
CONTRACTOR: PHONE: - -
MAILING ADDRESS:
ARCHITECT/ENGINEER: PHONE: - -
MAILING ADDRESS:
NEW: REMODEL: ADDITION: CHANGE OF USE:
DWELL UNITS: OCCUPANT LOAD: BUILDING HGT: STORIES:
BUILDING DIMENSIONS: % (WIDTH X DEPTH) SQ. FT. :
REQUIRED PARKING: # HANDICAP: SPRINKLERED: CRITICAL MATERIAL:
P.03
Manufactured Home:
Year /9 > Make A i )1-:-J---Lie _._Width V Length w(/ _
Vehi/,le Identification Number L L /10 i / x 0
Regi:;^tired Owners:
Names. rZ® ' ,v •JP-Ott Signat,res' .1 __/ .Z
Lega► Owners: `-';•`,
di.
Names'�� � _ Signa re �Qv,i"Le44,7.)94)
`SIGNATURI`.S O''OWNERS INDICATE TERMINATION OF INTEREST IN THE MANUFACTURED HOME T OUGH TITLE PROVIDED BY C8.12 RCW ANO
INDICATE INTFN r TO PERFECT INTEREST IN THE MANUFACTURED HOME AS REAL PROPERTY WITH HE LAND HE/SHE/THEY OWN AND TO WHICH IT(8/1S
BEING A:1IX(i0:
Land to Which Manufactured Home Is Being Affixed:
Property Tax Parcel Number ,.1.5/9.•�, ASO ,
f!�1! A ,"74-
Legal De;cription i . A M.7 i / J 9I fiwners' Name+ !��
/ ' �1/_� . /
-1-�'� .Egnatures2
'
{ 'SIGNATURES OP 0 8 IN011 TE CONSENT TO HAVE THE MANUPACT RED HOME ADDED TO THE REAL PROPERTY LISTED ABOVE.
I .,
Building Pemit Office Certification:
I certify that the manufactured home has been affixed to the real property as described above and/or buildingpermit
number?f i 5 S 7has been issued for the purpose of affixing the anufact d home to the land anwill be
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inspected upon completion. 6 pogk L=_-es.,2_, . --/,,c2_443 ,O;u. 6 -' ��zx
NAME SIGNATURE
BLDG.PERMIT DFFICE DATE
PHONE NUMBER
County Auditor/Agent Licensing Office Approval: (Not for use by subagents)
•
I certify that the above application appears to have been Completed correctly, and that the applicant has sufficient
documentation to proceed with the recording of this form.
NAME • SIGNATURE
- OFFICE/CRAP OPERATOR NUMBER DATE
Recording Office;
•
.1 certify that this form has been recorded in the county records.
•
NAME
SIGNATURE
COUNTY DATE
RECORDING NUMBER
Note: Every person who falsifies or intentionally omits material information required in an affidavit is uilt
misdemeanor punishable in accordance with RCW 9A.20.021. 9 Y of a gross
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TD-420.750 MFG HOME TITLE EUM IN/1!901 Page 2 of 2 i
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