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DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street, Port Townsend, WA 98368
Tel: 360.379.4450 | Fax: 360.379.4451
Web : www.co. i effe rson.wa. us/com m u n iUd eve lo om e nt
E-mail: dcd @co.iefferson.wa.us
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Customer Assistance lntake Fo
Help us provide you the information you need by filling out
This is a public information form, the contents of this form is available ro view
o The first I5 minutes of staff time is free.
o After the first 15 minutes, a minimum of one hour wi!! 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.
Ofi.ce Use Only
Receipt #:
Check/CC #:
Date Paid:
Received By:
MAY
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NAME:Sotr R. Larne-r DATE:t^tayl
EMAIL ADDRESS:lJa n *r^
MAILING ADDRESS:?G C f<4kpri,te B"|nnot4 U ft
TELEPHONE: (HOME)(cELL)36t-"v70*goe?
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PLEASE NOTE: lnformation and guidance provided through Customer Asslsfance is advisory onty and is based on
information provided by the customer. This is not intended to be an exhaustive review of att potenfiallssues. Any drscussron or
information provided shall not bind or prohibit the County's future implementation or enforcement of atl applicable laws and
regulations. No
duty to submit
land use plans,
staternents or assurances made by County representatives shall in any way relieve the applicant of his or her
an application conslsfenl with all relevant requirements of County, state and federat codes, laws, regulations,
requirements.
Your Signatu
L
Monday, September 29, 2014
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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.
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Property Description goo VoB
9-DlGlT PARCEL NUMBER (from Property Tax Statement):
?6 Cr-a-qkDC Bri"t4oq Llft.97g69PROPERTY ADDRESS:
Ofice Use Only
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