HomeMy WebLinkAboutCAM2019-00254Begin Time:End Time:
DEPARTMENT OF COMMI]NITY DEVELOPMENT
621 Sheridan Street, Port Townsend, WA 98368
Tel: 360.379.4450 | Fax: 360.379.4451
Web: www.co.iefferson.wa.us/communiWdevelopment
E-mail: dcd@co.iefferson.wa.us
Customer Assistance lntake Form
Help us provide you the information you need by fitting 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 nqils-nt_nutes 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 !4 calendar days of the request.
Office Use Only
Receipt #:
Check/CC #;
Date Paid:
Received By:
NAME:Vi,l 54{^^)}rBs DArE: 5-/- n
EMAIL ADDRESS:fishnd oT1 z @broadsfri ?e,n*
MAILING ADDRESS:Tos b5oz5, F L. wA- qKAoS -oozs
TELEPHONE: (HOME)
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PLEASE NOTE: lnformation and guidance provided through Customer Assisfance is advisory only and is based on
information provided by the customer. This is not intended to be an exhaustive review of atl potentra/ rsst6. Any discusslon or
information provided shall not bind or prohibit the County's future implenentation or enforcement of alt appticable laws and
regulations. No slatemenfs or assurances made by County representatives shall in any way relieve the applicant of his or her
duty to submit an application consr.stent with all relevant requirements of County, state and federal codes, laws, regulations,
land use plans, and other requirements.
Your Signature:t)*t1-1.W
Monday, September 29, 2014
Begin Time:End Time: \3-
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Customer Assistance lntake Form Page 2 of 2
lnformation Requested - List all questions and any information you need addressed. Attach
additional sheets of paper if necessary.
Property Description
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g-DlGlT PARCEL NUMBER (from Tax
PROPERTY ADDRESS:
Office Use Only
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