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HomeMy WebLinkAboutBLA - BLA Plot / Site Plans - 3/20/1990 MASON COUNTY DEPARTMENT of GENERAL SERVICES Courthouse Annex J N. Fourth & W. Cedar P.O. Box 186 Shelton, Washington 98584 (206) 427 - 9670 APPLICATION FOR : BOUNDARY LINE ADJUSTMENT ❑ SHORT SUBDIVISION BLA No. S. S. USE BLACK INK ONLY 1. APPLICANT 'S NAME ❑"Owner of Parcel [:]Purchaser of Parcel ❑Representative 2. APPLICANT 'S ADDRESS Street City Zip 3. APPLICANT'S TELEPHONE (during Week) HOME ( ) WORK >�E. 4. OWNER ( if other than Applicant) SURVEYOR ( if applicable) Name Name Address Address Telephone ( ) Telephone ( ) 5. ASSESSOR 'S 12-DIGIT PARCEL NUMBER (of real property to be divided) .. /l ti �•�-• ASSESSOR 'S LEGAL DESCRIPTION Section Township Range 6. ADDRESS OF SITE ( if assigned) rt) ) 2,- / �Le,v a•%c��::� '�' 7. AREA OF PROJECT ( in acres , if possible) 8. IS PROJECT IN AN EXISTING SHORT PLAT? © No ❑Yes, Short Plat No. IS PROJECT IN AN EXISTING SURVEY? ❑ No ❑Yes, Volume Page 9. TYPE OF ON-SITE STRUCTURES (Give Lot Numbers) (Show location and label each structure on map) 10. WHAT USES ARE PROPOSED FOR VACANT LOTS? L ' Single-Family on Lots Duplex, on Lots Multifamily, on Lots Commercial on Lots Industrial , on Lots ( IF UNDECIDED, LOTS WILL BE REVIEWED FOR ONE SINGLE-FAMILY RESIDENCE PER LOT . ) 11. EXISTING SEWAGE DISPOSAL ❑None ❑ Sewer E Septic - Date Installed (Show on Map) 12. PROPOSED SEWAGE DISPOSAL ❑None ❑Sewer ❑Septic ❑ Other -1- 1/88 BLA # SS # 13. EXISTING WATER SUPPLY None Individual Well on Lot( s) No. (Show on Map) i Community Well - Name of System or Owner ❑ Municipal Water System - Name of Municipality 14. PROPOSED WATER SUPPLY None Individual Wells ❑ Community Well - Name of System or Owner ❑ Municipal Water System - Name of Municipality 15. ��SPPE�ECIAL AREAS ON YOUR PROJECT SITE (Show checked areas on map) l_—YN-one ❑ Creek/Stream ❑ Cliff ❑ Salt Water Name Name ❑ River ❑ Wetland Fresh Water Name Swamp/Bog ❑ Name. ❑ Lake/Pond ❑ Draw/Gully e 16. HAS A PORTION OF YOUR PROJECT SITE EVER FLOODED? ❑No--- Do Not Know ❑ Yes, when? ( if yes, show area on map) . 17. SHORELINE DESIGNATION ( if applicable) 18. LOT NO. t AREA IN SQUARE FEET LOT NO. AREA IN SQUARE FEET LOT NO. AREA IN SQUARE FEET LOT NO. AREA IN SQUARE FEET 19. DOES THE PROPERTY BEING SUBDIVIDED HAVE PUBLIC ROAD FRONTAGE? ❑ No es I f yes, name of road Right-of way width of road frontage 'qc) l If no, width and length of private road, easement or right-of-way from public road. ti � 0 feet wide by feet long. 20. IF PROPERTY TO BE DIVIDED IS ACCESSED BY PRIVATE ROAD, APPROXIMATELY HOW MANY PARCELS HAVE ACCESS BY THIS ROAD? j j1 ( include vacant parcels) . -2- 1/88 BLA # SS # SHORT SUBDIVISION APPLICATION SIGNATURE PAGE NOTE: The owner( s) whose signatures appear below certify that they are the legal owners of the property encompassed by this short subdivision and approve of the short subdivision of their property. k Signature of Applicant (Signature of,-Applicant) (Owner( s) (Owners) -TATE OF WASHINGTON) ) SS ;OUNTY OF MASON ) )n this day of 19 before me, the undersigned, a Notary Public in and for the State of Washington, duly commissioned and sworn, personally appeared to me known to be the individual described in and who executed the within and 'oregoing instrument, and acknowledged that signed the same is free and voluntary act and deed, for the uses and purposes :herein mentioned, and on oath stated that he was authorized to execute said instrument. (ITNESS MY HAND AND OFFICIAL SEAL THIS DAY OF 19 Notary Public in and for the State of Washington, residing at 'ITNESS MY HAND AND OFFICIAL SEAL THIS DAY OF , 19 Signature of Applicant Contract Purchaser( s) TATE OF WASHINGTON) ) SS OUNTY OF MASON ) n this day of 19 before me, the undersigned, a Notary Public n and for the State of Washington, duly commissioned and sworn, personally appeared to me known to be the individual described in and who executed the within and oregoing instrument, and acknowledged that signed the same s free and voluntary act and deed, for the uses and purposes ierein mentioned, and on oath stated that he was authorized to execute said instrument. ITNESS MY HAND AND OFFICIAL SEAL THIS DAY OF 19 Notary Public in and for the State o Washington, residing at -3- 1/Hp ,A #36 DECLARATION OF SINGLE LOT UPON PROPERTY LINE ADJUSTMENT A DIVISION MADE FOR THE PURPOSE OF ADJUSTING BOUNDARY LINES WHICH )ES NOT CREATE ANY ADDITIONAL LOTS, TRACTS, PARCELS, SITES OR DIVISIONS )R CREATE ANY LOTS, TRACTS, PARCELS, SITES, OR DIVISIONS WHICH CONTAINS [SUFFICIENT AREA AND DIMENSIONS TO MEET MINIMUM REQUIREMENTS FOR WIDTH [D AREA. PLEASE NOTE ! ! THIS DOCUMENT DOES NOT CONVEY TITLE THIS DECLARATION MADE THIS 20 DAY OF MARCH , 1990 BY JERRY AND KYLE HAYNES, HUSBAND AND WIFE , "DECLARANT AS OWNERS OF THE REAL PROPERTY ;GALLY DESCRIBED HEREINAFTER AS "PARCEL 1 " AND BY JERRY AND GAYLE HAYNES, HUSBAND AND WIFE "DECLARANT" AS OWNERS THE REAL PROPERTY LEGALLY DESCRIBED HEREINAFTER AS "PARCEL 2" WHO WISH ADJUST THE COMMON PROPERTY LINE BETWEEN SAID "PARCEL 1" AND "PARCEL 2" CTHOUT CREATING ANY ADDITIONAL LOTS, TRACTS OR SITES . THE LAND DESCRIBED i "PARCEL 3" SHALL BECOME A PERMANENT PART OF AND APPURTENANT TO LAND ;SCRIBED AS "PARCEL 2" AND TOGETHER SHALL NOT BE FURTHER SUBDIVIDED [TROUT THE PRIOR WRITTEN PERMISSION OF THE DIRECTOR OF GENERAL SERVICES ? MASON COUNTY. ► "PARCEL 1 : " (ASSESSORS PARCEL NO: 42216-50-00014 ) IS LEGALLY ;SCRIBED AS : LOT 14 LAKE CUSHMAN DIVISION #9 , VOLUME 7 OF PLATS PAGE 1,RECORDS OF MASON COUNTY WASHINGTON. "PARCEL 2 : " (ASSESSORS PARCEL NO: 42216-50-00015 ) IS LEGALLY 3SCRIBED AS: LOT 15 LAKE CUSHMAN DIVISION #9 , VOLUME 7 OF PLATS PAGE 84, ECORDS OF MASON COUNTY, WASHINGTON. "PARCEL 3 : " TO BE TRANSFERRED FROM "PARCEL 1" TO "PARCEL 2" AND IS LEGALLY DESCRIBED AS :LOT 15 LAKE CUSHMAN DIVISION #9, FLUME 7 OF PLATS, PAGE 84, RECORDS OF MASON COUNTY, WASHINGTON. kTE APPROVED: IRECTOR OF GENERAL SERVICES MASON ��*T �y ��/ �^ AUTHORIZED D QF1VU'L O V COL V 1 l llVt--. AGENT i W.RAILROAD AVE.•P.O.BOX Z•SHELTON,WA 98564 SHELTON(206)426-1626•BREMERTON(206)377.5017 reg FAX(206)426-9493 TICOR TITLE INSURANCE BLA# DECLARANTS/OWNERS OF ORIGINAL PARCEL: NAME MAILING ADDRESS CITY & ZIP JERRY AND GAYLE HAYNES P.O. BOX 344 HOODSPORT, WA 98548 IN WITNESS WHEREOF, THE PARTIES HERETO HAVE EXECUTED THIS INSTRUMENT AS OF THE DATE FIRST ABOVE WRITTEN: DECLARANTS f i I STATE OF WASHINGTON, County of Mason , On this day personally appeared before me JERRY ANS GAYLE HAYNES to me known to be the individual (s) described in and who executed the within and foregoing instrument, and acknowledged that THEY signed the same as THEIR free and voluntary act and deed for the uses and purposes therein mentioned. GIVEN under my hand and offical seal this Notary Public in and for the State of Washington, residing at My commission expires DATE APPROVED: DIRECTOR OF GENERAL SERVICES 1 O �,�• AUTHORIZED OFJt,��y�T �-y� AGENT �/MASON COL V l 1 M. FOR yy 215 W.RAILROAD AVE.•P.O.BOX Z•SHELTON,WA 98584 SHELTON(206)426.1626•BREMERTON(206)377.5017 FAX(206)426-9493 TICOR TITLE INSURANCE