Date

    Applicant Name

    Current Address

    Email Address

    Applicant Phone No

    HomeWorkCell

    New Structure Information

    Proposed Building:

    HouseMobile HomeBusinessOther

    Township

    Road Name

    Property Owner

    Adjacent neighbor's addresses and mailbox locations (same side as property or across the road)

    • The address will be assigned based upon the location of the approved access point.

    • All driveways will be evaluated for the appropriate permit requirements.

    • Applicant will indicate the approximate location of the structure being addressed.

    • The address will not be assigned until access has been approved.