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Home My WebLink AboutBLA Cancelled - BLA Application - 10/6/2023 MASON COUNTY COMMUNITY SERVICES Budding Plami o%Environmental Health Community Health APPLICATION FOR BOUNDARY LINE ADJUSTMENT APPLICANT flJ Owner of Parcel ❑ Purchaser of Parcel ❑ Representative Name: G- lJTbcTW(4&-K Address: 2.,\ ` ) MO/A I W k 9 65"'� Phone: Alternative: Email: OWNER(if other than applicant) SURVEYOR --<< Name: Name: OLAAA) t4,5 O (�I .5 Address: Ad ess: ?a ;o) 23-79 Phone: Phone: 3 E 0 — L1 Z6 -Zq J 0 Email: Email:�Ql✓mA (` h ac , CAW) 12-DIGIT PARCEL Area of Original Lot Area of Resulting Lot (excluding tidelands) (excluding tidelands) acre/a ft p,jc� acre/.&R-4 U 0a5 acre/.Ft 0,1 acre/sq'T- 1'L"1Lh5�,fi3Y�t 1 acre/sq ft acre/sq ft acre/sq ft acre/sq ft TY OF ON-SITE STRUCTURES(provide lot numbers)(Show location and label each structure on map.) Lot number Structure Type Additional Details 0 50 2A koQS15- , S£prl C - G3)2)0 Nk�� S£ PT1L ALL INFORMATION PERTAINING TO THE APPLICATION ARE DUE AT THE TIME OF SUBMITTAL. INCOMPLETE APPLICATIONS WILL BE RETURNED TO THE RESPONSIBLE PARTY. SPECIAL AREAS OF YOUR PROJECT SITE(Show checked areas on map) Miff/Steep Slope ❑ Draw/Gully ❑ Wetland/Swamp/Bog ❑ Salt Water (name of waterbody) ❑ Creek/Stream/Ditch (name of creek/stream) ❑ Fresh Water (name of fresh waterbody) ❑ River (name of river) ❑ Lake/Pond (name of lake/pond) IS ANY PORTION OF THE PROPERTY SHOWN IN FEMA MAPPED FLOODZONE? ❑ No ❑ Do not know <4es: �A, ❑ AE, ❑ AE, Floodway ❑ AO ❑ VE, ALL INFORMATION PERTAINING TO THE APPLICATION ARE DUE AT THE TIME OF SUBMITTAL. INCOMPLETE APPLICATIONS WILL BE RETURNED TO THE RESPONSIBLE PARTY. Return to: Mason County Community Services 615 W Alder St Shelton,WA 98584 Please print neatly or type information DOCUMENT TITLE(S) ,� REFERENCE NUMBER(S)OF RELATED DOCUMENTS (ADDITIONAL REFERENCE#'S ON PAGE_) GRANTOR(S)(Last,first,and middle initial) t21fWt :A— K LEtik Ow� GRANTEE(S)(Last,first,and middle initial) — r(ADDITIONAL REFERENCE#'S ON PAGE_) LEGAL DESCRIPTION(Abbr.form: quarter/quarter,section,township&range,plat,lot&block) w(' `ZZ A) (ADDITIONAL REFERENCE#'S ON PAGE_) PARCEL NUMBER(S) oZ�, (ADDITIONAL REFERENCE#'S ON PAGE_) The Auditor/Recorder will rely on the information provided on this form.The staff will not read the document to verify the accuracy or completeness of the indexing information provided herein. DECLARATION OF BOUNDARY LINE ADJUSTMENT PLEASE NOTE!THIS.DOCUMENT DOES NOT CONVEY TITLE KNOW ALL BY THESE PRESENTS: That the undersigned parties,have a real interest in the tracts of land described by this declaration,do hereby declare the herein described resulting tracts of land approved as Boundary Line Adjustment# on the day of 20 ,by the Planning Department,subject to the following condition: This action is made only for the purpose of adjusting boundary lines,which does not create any additional lots,tracts,parcels,sites,or divisions nor create any lots,tracts,parcels,sites,or divisions,which contains insufficient area,and/or dimensions to create a parcel non-conforming to current Mason County Code requirements,or in cases of legal non-conforming lots,does not increase the non-conformity beyond what is allowed by code. Declarants acknowledge: That there are I Wor are not ❑ lienholders who may need to be notified for partial release/modifications that may be required for boundary line changes. That this Boundary Line Adjustment approval does not convey title. That this Boundary Line Adjustment will become void if not recorded with the Mason County Auditor within one year of the date of approval. That conveyance documents must be conveyed within year of the date of approval,or this approval is void. A survey has been reviewed by Mason County showing the resulting parcels of BLA# and has been recorded under Auditor's File Number BLA# Date Approved Page 1/2 Director of Community Services Declarant(s)/Owners of original parcel: NAME MAILING ADDRESS CITY/ZIP CODE IN WITNESS WHEREOF,the parties hereto have executed this instrument as of the date first above written. DECLAIZAN (signatures) C�Y-2 i� STATE OF � p S ) :SS COUNTY OF MkS017 ON THIS DAY personally appeared before me h v tL�l as AI/e4q 14,1y'1 to me known to be the individual(s)described in and who executed the within and foregoing Declaration and acknowledge that signed the same as S free and voluntary act. ;Z 0 �2 3. Nn(arr Seal: �•�---- OFFICIAL STAMP PATRICIA A STANLu11NQ NOTARY PUBLIC IN AND FOR THE State of NOTARY PUBLIC-OREGON Wae�g�ea;residing at COMMISSION NO.MY COMMISSION EXPIRES EBRUARY 1979 Q 2026 ��"' Gf BLA# Page 2/2 Date Approved Director of Community Services BOUNDARY LINE ADJUSTMENT APPLICATION SIGNATURE PAGE Note: The applicant(s)whose signatures appear below certify that the information provided on —this application is true and correct. (signature) (signature) STATE OF O/'e y&vim) 110.5 . :SS COUNTY OF*ASBN ) kos 11)O-Sk rgf ON THIS DAY personally appeared before m 0 kA-5 CA✓"rLI1 ►rig �t �('S• to me known to be the individual described in and who executed the within and foregoing instrument acknowledge that A e, signed the same as A.! free and 1 voluntary act. S 1 a.H.�``� `' { Cr'vim►-. L�•r•d¢r ► h a vv d &r_9 L,�a.�seal __ �-- Mary Seal: NOTARY PUBLIC IN AND FOR THE State of OFFICIAL STAMP t,1/ ��C�/� '111" residing at PATRICIA A STANDRING (JCL / 7 fl� NOTARY PUBLIC-OREGON COMMISSION NO.1021979 MY COMMISSION EXPIRES FEBRUARY 17,2026 STATE OF WASHINGTON ) :SS COUNTY OF MASON ) ON THIS DAY personally appeared before me to me known to be the individual described in and who executed the within and foregoing instrument acknowledge that signed the same as free and voluntary act. GIVEN under my hand and official seal this day of 920 Nolary Seal: NOTARY PUBLIC IN AND FOR THE State of Washington,residing at Declarant(s)/Owners of original parcel: NAME MAILING ADDRESS CITY/ZIP CODE K1Lr {((J L WN. IN WITNESS WHEREOF,the parties hereto have executed this instrument as of the date first above written. DECLARANTS(signatures) STATE OF WASHINGTON ) :SS COUNTY OF MASON ) `' ON THIS DAY personally appeared before me tome known to be the individual(s)described in and who executed the within and foregoing Declaration and acknowledge that f 1&aX3 cuxs signed the same as free and voluntary act. S�nre_m Vera in G c�x1C_ SHERA JEAN CLARK Notary Public NOTARY PUBLIC IN AND FOR THE State of State of Washington Washington,residing at License Number 22032149 My Commission Expires January 24, 2026 BLA# Page 2/2 Date Approved Director of Community Services BOUNDARY LINE ADJUSTMENT APPLICATION SIGNATURE PAGE Note: The applicant(s)whose signatures appear below certify that the information provided on this application is true and correct. (signature) (signature) STATE OF WASBINGTON ) :SS COUNTY OF MASON ) ON THIS DAY personally appeared before me O-Ji1 me known to be the individual described�iin``and who executed the within and foregoing instrument T acknowledge that i 1 CY)WC A ozU nS signed the same as free and voluntary act. rLicense RA JEAN CL 'To(l�Xl C�1Q, Notary Public NOTARY PUBLIC IN AND FOR THE State of te of Washington Washington,residing at Number 22032149 ommission Expires �n uv4� anuary 24,2026 STATE OF WASHINGTON ) :SS COUNTY OF MASON ) ON THIS DAY personally appeared before me_��AM aALto me known to be the in . 'dual descn ed in and who executed the within and foregoing instrument acknowledge that I QhCk rd C ()LjjS signed the same as free and voluntary act. GIVEN under my hand and official seal this__(� day of ne _b e' ,20 a'�') . SHERA JEAN CLARK Notary Public NOTARY PUBLIC IN AND FOR THE State of State of Washington Washington,residing at License Number 22032149 My Commission Expires January 24,2026 �AWW bwy*