HomeMy WebLinkAboutCAM2019-00255Begin Time:End Time:
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street, Port Townsend, WA 98358
Tel: 360.379.4450 | Fax: 360.379.4451
Web : www. co. ieff erso n.wa. u s/com m u n itvd eve I o pm e nt
E-mail: dcd @co.iefferson.wa.us
Customer Assistance lntake Form
Help us provide you the information you need by filling out this form.
This is a public information form, the contents of this form is available to view by the public.
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o The first l5 minutes of staff time is free.
o After the first 15 minutes, a minimum of one hour will be
charged at the rate of $ 100.00 a hour with additional time over
one hour billed in l5 minute increments.
o Please complete form and submit to the address or email
above and a staff member will contact you.
o Our goal is to respond within l4 calendar days of the request.
Office Use Only
Receipt #:
Check/CC #:
Date Paid:
Received By:
NAME:
EMAIL ADDRESS:
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MAILING ADDRESS:
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TELEPHONE: (HOME)(cELL)ta3. trsa.{6{/
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PLEASE NOTE: lnformation and guidance provided through Customer Asslsfance is advisory only and is based on
information provided by the customer. This is not intended to be an exhaustive review of all pofentlal lssues. Any dlscusslon or
information provided shall not bind or prohibit the County's future implenentation or enforcement of all applicable laws and
regulations. No sfalemenfs or assurances made by County representatives shall in any way relieve the applicant of his or her
duty to subnit an application conslsfenl with all relevant requirements of County, state and federal codes, laws, regulations,
land use plans, and other requirements.
Your Signature:
Monday, September 29, 2014
DATE:
Begin Time:{ ', /; End Time: q 3 S
Customer Assistance Intake Form Page 2 of 2
lnformation Requested - tist all questions and any information you need addressed. Attach
additional sheets of paper if necessary.
Property Description
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9.DIG!T PARCEL NUMBER
PROPERTY ADDRESS:
Tax Statement):
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