HomeMy WebLinkAboutADR2008-00073 (61A-1)
ADDRESS RE I VEST
JEFFERSON COUNTY PERMIT CENTER
lfi 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: 61 GAc(.- Plq1/1A1-, l )( c tel:
3. Mailing Address: P O JV X 117 0
Town/State/Zip 0-4)1— 1 ���
4. Telephone: Work Home: it 39- 2t 7
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 '62 Ork, 0
Plat Name Block Lot
6. Road Name:
Is this a PRIVATE or COUNTY road? CIRCLE ONE
Nearest Cross Road: nn
7. Neighbors'Address if Known: -L/ 10 6A(L-F2h' Ve6A'c
Name/Address: 6I-( A1 I u 7 tifii S Al\)M6 e
Name/Address:
8. Do You N-- : o Construct a Driveway?
YES o NO CIRCLE ONE
FIELD NOTES
9. Was i ub 'tted With A Building Permit?
YES I NO CIRCLE ONE
SHADED AREAS OFFICE USE ONLY
■
New Address:
Postal District: i •
Real Milepost: Road#:
Left Right Fire District Building Permit# Plate Sent / /
Or
Odd Even Date Paid / / Check# Receipt# Date in Computer /
2Z. locili3
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