Fill and Sign the Request for Address Assignmentverification the City of San Form

Building Address Application -- Change of Address, Additional Address Assignment, or Address Verification City of _________________ (Name of City), _________________ (Name of State) - Bureau of Development Services (BDS)____________________________________________________________________Staff Use Only: Confirmation of AddressBDS Staff Member: _______________________________________________ Date _____________________ [ ]Changed Building Address _____________________________________ [ ]Additional Building Address _____________________________________[ ]Verification of Building Address_____________________________________Comments: ___________________________________________________________Internal Records: Copies to:[ ] Maps [ ] Building Owner ____________________[ ] TRACS Set-up [ ] Sign-off [ ] Fire Marshal ______________________ [ ] Excel [ ] Verification of Address Requestor: ________________________________ [ ] Other: _____________ [ ] BDS Inspections: _____________________________________________________________________________________Directions: This form is to be completed by the building/property owner or a member of the City Staff from BDS and/or Fire Dept. Inspector when an existing building address is to be changed, an additional building address is to be assigned, or when additional information is needed to verify a building address. If you have a building permit under review this form is NOT necessary.Fee and Contact Information: There is a $_________ fee for a change of building address and for each additional building address from a building/property owner. An additional building address will only be assigned to a new or previously notaddressed building entrance. There is no fee for a change of building address or additional building address based on Fire requirements. There is no fee for verification of a building address.If you need additional information, please leave a detailed message on the BDS Addressing Hotline at _________________ (Phone Number). Applicant Information:Name ________________________________________ Date _________________Mailing Address _______________________________Zip Code ________________Phone_______________ FAX ________ e-mail ___________________________Property Information:[ ] One and Two Family Residential [ ] Commercial & Multifamily ResidentialExisting Address _______________________________________________________Quarter Section Maps(s) _____________ Lot __________ Block ____________Tax ID # ______________________ Addition _________________________Requestor is:[ ] Building Owner _________________________________________[ ] Fire Marshal ____________________________ Fire Requirement, _______________ (Name of City) Code Number __________[ ] Agency Requiring Address Verification ________________________________Request:[ ] Change Building Address (include site plan below) [ ] Verification of Building Address[ ] Assignment of Additional Building Addresses (include site plan below)Reason: __________________________________________________________Site PlanPlease draw a site plan and include:North arrow;Building for which a changed or additional address is being requested. Indicate the current building address; Streets with street names indicated;Adjacent building(s) and address of adjacent building(s); andFloor plan divisions for commercial buildings indicating location of door(s) which need an address._______________________________________________________________ (Drawing of Site Plan) You are responsible for providing address information to service providers. BDS does provide address information to the parties listed below; however there can be a delay in addressing data being updated and recognized.BDS provides information on changed and additional building addresses to:USPS Address Management SystemsQwest Address Management Center NW Natural Gas _________________ (Name of City) General ElectricComcast_________________ (Name of County) County Assessment and Taxation_________________ (Name of County) County Cartography and Records DivisionBureau of Emergency Communications _________________ (Name of City) Water BureauBureau of Environmental Services