HomeMy WebLinkAboutADR2009-00120 ADDRESS REQUEST
JEFFERSON COUNTY PERMIT CENTER
621 Sheridan, Port Townsend,WA 98368 (360) 379-4450
APPLICAN : Please fill out item 1 through 8. Fee as per Jefferson County Fee Schedule
1. • New Address 1: Correction • Change •Review DIFF LEFT M.P. RIGHT DIFF
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Mai ntName: �0.1''►�'� ■
2. Applicant -■
3. Mailing Address: (9.-i r • --
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Town/State/Zip 0• • " Ai
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4. Tel ep hone: Work Home: ■-
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5. Location: Attach a Detailed Drawing or Map.
Additional ■-
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Fees May Be Required if More Than One -.
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Site****Is Necessary
*******PLEASE -■
PLEASE FLAG YOUR DRIVEWAY.******* --
Date Flagged: / / Flagging Color -■
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Nine Name p it Tax Parcel N umber n
Plat Nam -■
� �� i�� Block Lot SR --
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6. Road Name: _ %JG01111► If --
Is this a PRIVATE or OUNTY •d? CIRCLE ONE ■
Nearest Cross Road: = di-
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7. Neighbors' Add ress if Known: ■
Name/Address: -■
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Name/Address: -■
8. 'Po iu Need To Construct a Driveway? �� --
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ES or NO CIRCL E ONE — FIELD NOTES
9. Was This Ai". • itted With A Building Permit?
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YES or CIRCLE ONE I nCOrre resS -
SHADED AREAS OFFICE USE ONLY C1DSS p
New Address: e. •SS
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Postal District: 1)o r-t- 0 W 5�� p/ _ /
Real Milepost: DI Road#: \/
Left 'igh Fire District
Building Permit# — Plate Sent / /
o Recei t# Date in Computer k /Z2 /c)(3 Odd Eve' Date Paid / / Check# p
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