HomeMy WebLinkAboutADR2009-00166 ADDRESS REQUEST
JEFFERSON COUNTY PERMIT CENTER
621 Sheridan, Port Townsend, WA 98368 (360) 379-4450
APPLICANT: Please till out item 1 through 8. Fee as per Jefferson County Fee Schedule
1. ❑ New Address ❑ Correction g Change ❑Review DIFF LEFT M.P. RIGHT DIFF
2. Applicant Name: ,--1 ,(a,rl,+o. Fa; rL.
3. Mailing Address: 4,5447 J 1 Iver 1C levi Lin N1AI
Town/ State/Zip 33r 'yier+on, WA 6/8,311
4. Telephone: Work Home:3(oO-6f8-343
5. Location: Attach a Detailed Drawing or Map.
Additional Fees May Be Required if More Than One
Site Visit Is Necessary
*******PLEASE FLAG YOUR DRIVEWAY.*******
Date Flagged: / / Flagging Color
Nine Digit Tax Parcel Number 701 39.1 0 (( 3.qlo 38
Plat Name Block Lot
4 new oeaen
AM 6. Road Name: Li h IL Pd. 3 � '
qq-Is this a PRIVATE or road? CIRCLE ONE �// l fp
Nearest Cross Road: 38 3,9t) 3O(� fiair-Ailed
O
7. Neighbors' Address if Known: 3,5260 ,�q 33830
Name/Address:
Name/Address: 3 gcos
8. Do ou Need To Construct a Driveway?
ii ll1 e r NO CIRCLE ONE
FIELD NOTES
9. Was This Sul e fitted With A Building Permit? � �m � �Q W�
YES or 0 CIRCLE ONE ChQ
SHADED AREAS OFFICE USE ONLY P (ease_13e. .sure hole_
New Address: ?j b Lir a(,( 4- J I L Rd . oto1'-J ne_6 0 3 in address
Postal District: au ; f 60.4 1e J r "^ ^"'e
Real Milepost: 3. cp.! Road #: -
fo - �!5qi
'( Left ( R(gh \t Fire District Building Permit# (✓ Plate Sent Ci/ (9/61
Odd rEven Date Paid / / Check# Receipt# Date in Computer q/ ( /
17212C-t2
0:7°1 13