HomeMy WebLinkAboutADR2019-00020\ --r!
DEPARTMENT OF COMMUNITY DEVELOPMENT
621 Sheridan Street, Port Townsend, W.{, 98368
TeI 360.379.4450 | Fax: 360.379.4451
Web: www.co.iefferson.wn.us /communitydevelopment
E -mail: dcd(@co. j e fferson.r'g'a.us
NEW ADDRESS APPLICATION
Steps in the Permit Process:
-Review required submittal items to ensure all information is completed prior to submitting application.
-Fees will be collected at intake. Additional fees may apply after review and payment is required before permit is issued
New Address \..'u/Correction Change
For Department Use Only Receipt #:Date:
Related ication #s:#:,/ New Dri must be fla with fla tape received from DCD
t,a
-s)A(J
ao
FOR OFFICE USE ONIY
7 ioL f
1 LfL ? ZlL
DIFF
Tidemark Entry:Road database ent Post Office:
NotesLEFT M.P. R]GHT DIFF
New Address:D?*Date mailed:
# Plates:
lnformation
Assessor Tax Parcel Number:
Parcel Address (if applicable)
Directions to Property:
oozts I qL7
C<:a-!26
City
OFY .
Name of street(s) from which access will be gained
ls this a private road? yes
Neighbor's Name & Address, if known:
Name/Address: €
Do you need to construct a driveway from road onto your property?
Cross Street
Yes No
No
Coun or State Permit #
Name/Address:
TE HWY ACCESS PERMITS ARE REQUIRED IF YOUR DRIVEWAY IS OFF A COUNTY OR STATE
ROAD lN ORDER TO PROCESS ADDRESS REeUEST. please contact public Works at (360) 385_9j.60 with questions.o State: WSDOT http://www.wsdot.wa.gov/Northwest/DevelopmentServices/AccessServices.htm or (360) 757-5961
ROAD APPROACH OR STA
o Cou htt :llwa ncou civicplus.com/rmits-Vacations or 60 38s-9160t-of-
tr -t J
Property Owner
Name:
Address:
Phone #:
AUAA
zgo Lo€F
E-mailAddress
W.z'ptease contact Autho rized Agent/Rep resentative with p roj ect i nfo
lcant Contractor: Authorized Agent/Representative
Name:
Phone #:
License #
l(.\a 6 C[E€?ss
ryaJ r-3'E-mail Address:fg a/pilS 0 cz>.1
c^t1,.8'i42c Expiration Date
Required Submittal ltems - use column on left to check off items included with your submittal
Current copy of parcel map from Jefferson County Assessor's Office, showing:
htt p ://www. co. j e ffe rso n. wa . u s/i d m s/m a pse rve r. s h t m I
a. North Arrows
b. Road names in the area
c. Existing access easements
d. Parcel driveway location, label any driveways as new or existing
e. Addresses of neighboring properties
t. Travelpath from main named county road to the driveway, then the structure
Copy of a site plan, showing:
a. lf there are multiple structures, the addresses of all existing structures
b. For commercial permits, identify suite numbers for all existing and proposed businesses and identify
the business names.
By signing this application form, the owner/agent attests that the information provided herein, and in any attachments, is
true and correct to the best of his, her or its knowledge. Any material falsehood or any omission of a material fact made
by the owner/agent with respect to this application packet may result in making any idsued permit null and void.
I further agree to that all activities I intend to
compliance with all applicable federal state
entry to Jefferson Cou and its em
any req
related
uired later ins
unde,'.ake or complete associated with this permit will be performed in
and c:unty laws and regulations and I agree to provide access and right of
,, representatives or agents for the sole purpose of application review and
may request notice of the Cou nty's tntent to enter upon the property for visits
to this a n and uent permit issuance.
Signature a-r*print Name . (g Dr^le,.ls Date: lr{r I
Jefferson County wi!! notify the appropriate postmaster, fire district, and emergency services of your new
address. We will provide you with a new fire plate and you will be required to install it on your property
once the address is assigned.
\ciltss \pplrcrtrorr
OFFICE USE ONIY
Permit Fees
New Address Permit Fee s282.00 *
Tech Fee 74.LO
TOTAL 296.10
.Additional fees may apply
a
E
E
z
q
ctr{I&lr.Irl
I
"d
U
c
Jl,
3}-
N
A]
?o
B
+-N
!4
tN
\
S+\N
p
?\r
o
F
op!s
t4s
/vg\8
T
3
tl)
cJ
A
a\,
Ll
\F
t!
E\t
lg.l
a-
oJI-
cJ
v\
J
d
3Y
I'
P
q- \1
$- r\t$ '-
$
,tr.\r_ y
8r
DJ vL)
,$a
SBNS
-0lrN<.:
[\l-Nl-o
=Q€r
V
t\)!
I
{
[,
{Yv
{
)<-.|,
?
gboog'b\('16
e.t
4.6<toe-<r-_ to-\
4- e\
{tv
u$$$
0,
\I)
\I)\
\+-
xt{
v
D*u{dgJ
€(>B5L
JJy 2 B5fj\-d p &
3 fl:ii e
ov
$'\
-a a5
I
*\?
O/
Y
3
a
f--f..-
a*
ES
{
?aN4
3A
I
a
F
E:
I
(
I
I
I
I
1
l
l
)
II
t
I
(
I
t
t"
sxo
c.)
v.4rl/t\
o
ergq z
urri' 'ce-
lF
>4t
I
-:b I
at.
&3
osl
ssArl
r)''-
eJ
\c\
I
IJ,
I,
]
\
I
j
I
p
,ry,
E,
CL<
uu
I
I
x-
I
N
\
Critical Areas
1:4,514 Date:4D412019
are on
an "AS-lS" basis, without
warranty of any type,
expressed or implied, includin
but not limited to any warranty
as to their performance,
merchantability, or fitness for
anv particular ourDose.fti. m- i mt i crA.iltncftr r.rEta fidd c,.wa,. d f^. h.rin^ 2dr .d rv a{*.d leh.c.
'e40
t
F:
002131 00E
J;#far.<qn]
L,ser
6gE:iIdpirL":, ?li'LEB,i:rlru:r.'e. lr.$, i!.L3!r\ llsqEr.\tregFi-fl €t I arij iir:
oraftf ftd
00313 r008