Lewis County Community Development
SITE ADDRESS APPLICATION
Applicant’s Name: ________________________________________
Mailing Address:__________________________________________ Email: _________________________
_________________________________________ Phone # (__
___)____________________________
City State Zip
Submit a complete application packet to the Permit Center at the address listed above. Incomplete applications will not be
processed. In some cases, location stakes may be needed to locate and identify the property, if needed stakes will be provided
at the Permit Center at the time of submittal. A sample site map is attached. The following is required for submittal:
Complete Site Address Application Form
Detailed Site Map (parcel/aerial map) showing:
The nearest County or State Roads
Neighboring properties and addresses
Location of the driveway/private road from the County or State road to the parcel
Access point to the parcel clear marked with an X
Site Information:
Tax Parcel Number: ____________________________________________________________________________
Road Name:
_________________________________________
Private Rd; County Rd; or State Hwy
Directions to the Property (From Nearest County Road Intersection):
Is there an existing driveway? No Yes
Address of nearest neighbor: ____________________________
Are there any structures on the site? No
Yes _____________________________________________________
Travel
ing from the intersection with __________________ Road, my property is on the
RIGHT LEFT
For Official Use Only:
Permit Tech: _____________ Date Received: ________________
Stakes issued Detailed site map received Stakes placed (date): ____________________am/pm
Road Approach Permit #: _________________; Type: ________________ Approved/Pending By: _________________.
Address Assigned: _____________________________________ (City):
__________________
Date Assigned: ______________TCA: ______________
Permit(s) Pending:
No Yes
□ City Verified by Permit Tech
Updated with new address (BY:
)
Address listing updated on: _________________________
Notice mailed to applicant on: _______________________
Adept Updated
County Road index cards or Private Road file updated
2025 NE Kresky Ave, Chehalis, WA 98532 ● Phone: (360) 740-1146 ● Fax: (360) 740-1245
S:\COMMUNITY DEVELOPMENT\Division, Permit Center\Forms - Handouts\2017 Forms
Is the access to this property gated? No Yes. If Yes, you must provide either the gate code, keys, or contact
A(phone) number to ensure gate is unlocked prior to inspecti
ons.
Application Number: ______________
