HomeMy WebLinkAboutADR2009-00168.
ADDRESS REQUEST
JEFFERSON COUNTY PERMIT CENTER
621 Sheridan,Port Townsend, WA 98368 (360) 379-4450
APPLICANT: Please fill out item 1 through 8. Fee as per Jefferson County Fee Schedule
l.4 New Address Li Correction ❑ Change El Review DINT' LEFT M.P. RIGHT DIFF
2. Applicant Name: b41 6tr-
3. Mailing Address: T R I it x E
Town/State/Zip ,,e,citr, 1 WA 12)02,
,
4. Telephone: Wort?°'' 9'1 4u Hoii e ' $(o '9 '
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 ? 200 1E 6
Plat Name Block Lot
6. Road Name: 13C, kilt c 4 J
Is this a PRIVATE o OUN ad? CIRCLE ONE
Nearest Cross Road:
7. Neighbors' Address if Known:
Name/Address:
Name/Address:
8. Do You N To Construct a Driveway?
YES or NO CIRCLE ONE
FIELD NOTES
9. Was This S Itted With A Building Permit?
YES or 'O CIRCLE ONE
SHADED AREAS OFFICE USE ONLY
New Address: `0pOZ I ° .#1 4- IP .
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Postal District: -Po r+ (OW KISed ,V
Real Milepost: 1 t v Road #: � "" I
Left Right Fire District I Building Permit# Plate Sent (0 /(6i ',/
Or
Odd Even Date Paid O8/r /O Check# (0837 Receipt# ( l ( 0(4-Date in Computer ((y(ci 09
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