HomeMy WebLinkAboutCAM2019-00252Begin Time:End Time:
DEPARTMENT OF COMMI]NITY DEVELOPMENT
621 Sheridan Street, Port Townsend, WA 98368
Tel: 360.379.4450 | Fax: 360.379.4457
Web: www.co.iefferson.wa.us/communitvdevelopment
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:filA* Soap;ss^
EMAIL ADDRESS:eL 5 o(e^ s-r( @ h-+W*l . * ^
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PLEASE NOTE: lnformation and guidance provided through Customer Assisfance is advisory only and ls based on
information provided by the customer. This is not intended to be an exhaustive review of all potenflal rssues. Any drscussion or
information provided shall not bind or prohibit the Coung's future implementation or enforcement of alt applicabte laws and
regulations. No statemenfs or assurances made by County representatives shall in any way relieve the applicant of his or her
duty to subnit an application conslstenl
land use plans, and other requirements.
with all requirements of County, state and federal codes, laws, regulations,
Your Signature:
Monday, September 29, 2014
Begin Time:End Time:
Customer Assistance lntake Form Page 2 of 2
Information Requested - List all questions and any information you need addressed. Attach
additional sheets of paper if necessary.
Property Description
9-DIGIT PARCEL NUMBER (from Property Tax Statement), f I ? /O O O2Z
PRoPERTYADDRESS: z5<g F/an, /r- e-J
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