Addressing Assignments Electronically Submitted




 Phone Bill Name:

Current Mailing Address:

Address line 2:

Phone Number - Include separate lines for data:

 Landlord's Address:

Structure Information: Check one New Building  Existing Building Replacement Building Other

Tax Map Number: Building Permit #:

Road Name:   New or Old

Driveway Entrance Uses Existing Yes  or No

 Latitude (N)

  Longitude (W)

Structure Front Door

Latitude (N)

 Longitude (W)

Sketch - make sure to include landmarks and adjacent addresses.

























New Address:

Security Measure