HomeMy WebLinkAboutCAM2019-00247Begin Time:End Time:
DEPARTMENT OF COMMUNITY DEVELOPMENT
521 Sheridan Street, Port Townsend, WA 98368
Tel: 360.379.4450 | Fax: 360.379.4451
Web: www.co.iefferson.wa.us/communitvdevelopment
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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.
Olfice Use Only
Receipt #:
Check ICC #:
Date Paid
Received By:
NAME:()
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EMAIL ADDRESS:
MAILING ADDRESS:
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TELEPHONE: (HOME)t Nano (cELL)5eo^ e L{q -7r t z
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PLEASE NOTE: lnformation and guidance provided through Customer Assrsfance is advisory only and rs based on
information provided by the customer. This is not intended to be an exhaustive review of all potentr,a/ issues. Any discussion or
information provided shall not bind or prohibit the County's future implementation or enforcement of all applicable laws and
regulations. No slalemenls or assurances made by County representatives shall in any way relieve the applicant of his or her
duty to submit an application conslsfenl with all relevant requirements of County, state and federal codes, laws, regulations,
land use plans, and other requirements.
Your Signature:r'
Monday, September 29, 2014
Begin Time:End Time:
Customer Assistance lntake Form Page 2 of 2
lnformation Requested - List att questions and any information you need addressed. Attach
additional sheets of paper if necessary.
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Property Description
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PROPERTY ADDRESS:7C 0
Offtce Use Only
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