RESIDENT NAME:_____________________________________________________________

CURRENT MAILING ADDRESS:________________________________________________

CITY, STATE, ZIP:_____________________________________________________________

DAYTIME PHONE:_____________________________________________________________

 

MUNICIPALITY OF NEW STRUCTURE:__________________________________________

 

TYPE OF STRUCTURE

NEW CONSTRUCTION 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:_______________________________________

 

WOOD FRAME HOUSE TOWNHOUSE/CONDOMINUM

MODULAR HOME OFFICE BUILDING

DOUBLE WIDE HOME OFFICE SUITE

MOBILE HOME/NOT IN PARK RETAIL TYPE BUILDING

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

DUPLEX HOUSE COMMERCIAL/ INDUSTRIAL FACILITY

APARTMENT CABIN/SEASONAL HOME

APARTMENT BUILDING 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: _______________________________