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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
1. ❑ New Address ❑ Correction Change ❑Review DIFF LEFT M.P. RIGHT DIFF
2. Applicant Name: 0 ' G,('
3. Mailing Address: 44 S X 411 .as CAS A-V-s1 `mil
Town/State/Zip ( & Cis--,-e 1 q X3'7(p
4. Telephone: Work Home:
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 +.: r
Nine Digit Tax Parcel Number '0 p`1 a-? O.EA - _
• Plat Name i i lB lock n Lot •
1.1 ii,..
6. Road Name: (`A S e u
Is this a PRIVATE or COUNTY road? C CLE ONE
Nearest Cross Road:
7. Neighbors'Address if Known:
Name/Address:
Name/Address:
8. Do You Need To Construct a Driveway?
YES or NO CIRCLE ONE -tA
FIELD NOTES
9. Was This Submitted With A Building Permit?
YES or NO CIRCLE ONE e\ 110\
SHADED AREAS OFFICE USE ONLY
New Address: x.-\53,0 LC4C.\ \- W .Q Lco9
Postal District: <\ CQ
Real Milepost: Road#:
•eft Right Fire District LIB 3 Building Permit# Plate Sent / /
Or
Odd Even Date Paid / / Check# >a(/ Receipt# Date in Computer / /
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JEFFERSON COUNTY DEPARTMENT OF COMMUNITY DEVELOPMENT
ADDRESS REQUEST INSTRUCTIONS •
o Complete the address request form in as much detail as possible. The most important
information to include is the complete name of the road where your property is located,
whether or not the property is in a plat, the nine digit parcel identification number and
the block/lot number. The fee is $ 1,-
o You must also attach a vicinity map or drawing.
o Use the survey ribbons provided to flag both sides of your driveway. If your driveway is
not in yet, mark the location where the driveway will be. You must apply for a road
approach permit if your driveway will connect with a county road.
o The address technician from the Permit Center will assign your address within 5 working
days. The technician will visit the site and determine the address according to the
nearest milepost distance from the start of the road.
o The red address plate will be sent to your current mailing address, as indicated by you on
the address request form, within one week to ten days. The plate is to be posted at the
end of your driveway and is to be clearly visible from both directions.
o The Permit Center will notify the appropriate postmaster, fire district and emergency •
services of your new address.
ROAD APPROACH INSTRUCTIONS
o you are constructing a driveway that will connect with a county road, you must - •sly for
a r.`: f approach permit. The fee is $ (cam -
o To complete ' : application for the permit, you will need to i •' .te the nature of work
and to include a si .. e sketch of the proposed work. Yt, will also receive a survey
ribbon to mark the site.
o Once the permit inspector has visite. -, a permit will be drawn up and will include
the general conditions as well as a ° .ecific :8uirements concerning your site.
o The permit will be sen ou for you to read and sign. •u are then asked to return the
permit to the Permit enter for the permit inspector to sign. feu will receive a copy of the
signed permit. T permit is valid for a period of one year.
IF BOTH THE RE REQUEST AND THE ROAD APPROACH PERMIT IS : •PLIED FOR
AT THE S TIME, THE TOTAL FEE $ fJ-- •
If yo ave additional questions, call the Department of Community Development at(360)379-4450.
Homelpincntrlinfodpw\instruct.doc 1/1/05
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