Resident Name:
Current Mailing Address:
City, State, Zip:
Email:
	*The Email field must be filled out in order for you to receive an email confirmation of your address submission. You will be notified by email that your application has been received*
Daytime Phone:
Municipality of New Structure:
Type of Structure:	New Construction		Existing Structure
Is The Location of the Structure Marked? Select One... Yes No Note: we must be able to see the location in order to address it.
Expected Construction State Date:
Please Choose the One that Most Applies:
Wood Frame House		Townhouse/Condominium
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#
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