RESIDENT NAME:_____________________________________________________________

CURRENT MAILING ADDRESS:________________________________________________

CITY, STATE, ZIP:_____________________________________________________________

DAYTIME PHONE:_____________________________________________________________

MUNICIPALITY OF NEW STRUCTURE:__________________________________________

TYPE OF STRUCTURE

ð NEW CONSTRUCTION ð EXISTING STRUCTURE

IS THE LOCATION OF THE STRUCTURE MARKED ? _______NOTE: WE MUST BE ABLE TO SEE THE LOCATION IN ORDER TO ADDRESS IT.

EXPECTED CONSTRUCTION START DATE:_______________________________________

ð WOOD FRAME HOUSE ð TOWNHOUSE/CONDOMINUM

ð MODULAR HOME ð OFFICE BUILDING

ð DOUBLE WIDE HOME ð OFFICE SUITE

ð MOBILE HOME/NOT IN PARK ð RETAIL TYPE BUILDING

ð MOBILE HOME- IN PARK LOT#________ ð WAREHOUSE/STORAGE FACILITY

ð DUPLEX HOUSE ð COMMERCIAL/ INDUSTRIAL FACILITY

ð APARTMENT ð CABIN/SEASONAL HOME

ð APARTMENT BUILDING ð OTHER ADDRESSABLE STRUCTURE

IF EXISTS, BRIEFLY DESCRIBE THE STRUCTURE (COLOR,SPECIAL FEATURES, LANDMARKS NEARBY):________________________________________________________________________________________________

DIRECTION TO THE SITE( INCLUDE NEIGHBORS NAMES AND ADDRESSES, IF POSSIBLE):____________________

IF POSSIBLE INCLUDE A COPY OF PLAN OF LOTS

LOT PLAN NAME:_________________________________________________ LOT#____________________

DO NOT WRITE BELOW THIS LINE- OFFICE USE ONLY

NEW ADDRESS:_________________________________________________________________________ FILE # ADAP- ___________________

AID #__________________________ DB ENTRY:__________________________________ FIELDWORK:_______________________________

GPS FILE NAME:_______________

ADAP RECEIVED:______________ COMPLETED: _______________________________ COMMENTS: _______________________________