HomeMy WebLinkAboutBLA Application APPLICATION FOR
BOUNDARY LINE ADJUSTMENT
USE BLACK IHK ONLY
1. APPLICANT'S NAME: ) A
Owner of Parcel Purchaser of Parcel Representative
2. APPLICANT ' S ADDRESS : o']o �� ll��-n9� 17 ��S 30
Street City State Zip
3. APPLICANT 'S TELEPHONE : Home: A�)7.za�7�� Work:
4. OWNER ( if other than Applicant ) : Surveyor :
Name : Name: - -( -F UAw1 V uE2
Address: Address: {9 1 1
V �`� L,.)A r
Telephone: ( > Telephone : ( )
S. ASSESSOR'S 12-DIGIT PARCEL NUMBER
(of real property divided) :
3�1 a 37. O p O $O
Sc,fk 1/1-6444 s45- � 0 V" Nw y4 Ota.. SLOW 0-f sec.32
ASSESSOR'S RIPTION :
ction Township -Range
6. ADDRESS OF SITE ( if assigned ) :
7. AREA OF PROJECT ( in acres, if possible) :
8. IS PROJECT IN AN EXISTING SHORT PLAT? :
No _Yes, Large Lot No. VUc, 11t)( a� 1HIeU��
IS PROJECT IN AN EXISTING PLAT? :
No Yes, Volume Page
IS PROJECT IN AN EXISTING LARGE LOT PLAT? :
No Yes, Volume Page
IS PROJECT IN AN EXISTING SURVEY? :
No Yes, Volume Page
9. TYPE OF ON-SITE STRUCTURES ( Give Lot Numbers )
�� 10 '/h
( Show lJoation and label each structure on map )
10. SPECIAL AREAS OF YOUR PROJECT SITE (Show checked areas on map )
None Cliff/SteepSlope Wetland/Swamp/Bo-g[ I Draw/Gully
Salt Water Creek/Stream JO LL/ ,2
Name Name
Fresh Water River
Name Name
Lake/Pond
Name
11. HAS A PORTION OF YOUR PROJECT SITE EVER FLOODED? :
No Do Not Know Yes, when?
( If yes, show area on map. )
12. SHORELINE DESIGNATION ( if applicable)
( 1 ) 5/91
BLA 7
BOUNDARY LINE ADJUSTMENT SIGNATURE PAGE
NOTE: The owner( s) whose signatures appear below certify that they are the legal owners of the
property encompassed by this Boundary Line Adjustment and approve of the Boundary Line
Adjustment of their property.
Signature o f App I scant ig ure of App is
(owner( s) (Owners)
STATE OF WASHINGTON)
) SS
COUNTY OF MASON )
On 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
foregoing instrument, and acknowledged that signed the same
as free and voluntary act and deed , for the uses and purposes
therein mentioned , and on oath stated that he was authorized to execute said instrument.
WITNESS MY HAND AND OFFICIAL SEAL THIS DAY OF , 19
Notary Public in and for the State of
Washington, residing at
WITNESS MY HAND AND OFFICIAL SEAL THIS DAY OF 19
(Signature of Applicant)
Contract Purchaser( s)
STATE OF WASHINGTON)
) SS
COUNTY OF MASON )
On this dayof 19 before me the undersigned , Notary g a No a y 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
foregoing instrument, and acknowledged that signed the same
as free and voluntary act and deed , for the uses and purposes
therein mentioned , and on oath stated that he was authorized to execute said instrument.
WITNESS MY HAND AND OFFICIAL SEAL THIS DAY OF , 19
Notary Public in and for the State o
Washington, residing at
(2) 5/91