Name: Your Name Here Current Date: Organization/Department: Contact Info: Your Phone # Emergency Contact Name: Emergency Contact Number: Campus Box Number: Select one: Permanent Site Temporary Site When will construction begin and end approximately? Start date: End date: Not applicable Name of Permanent Structure: Attach Site Map to This Document (Required) Site map must be attached for address to be issued. Site plan must include all and reference to any neighboring “when known” temporary support structures structures. List any fire department connections, hydrants, loading docks, main entrance(s), street access, hazmat storage & fire alarm panel location if applicable. Other Information Note: This address is only for emergency services use. No mail or packages will be delivered to this address by UW departments, UPS, FedEx, USPS, etc. You must use your assigned UW box number for those services. print name signature date
Name: Your Name Here Current Date: Organization/Department: Contact Info: Your Phone # Emergency Contact Name: Emergency Contact Number: Campus Box Number: Select one: Permanent Site Temporary Site When will construction begin and end approximately? Start date: End date: Not applicable Name of Permanent Structure: Attach Site Map to This Document (Required) Site map must be attached for address to be issued. Site plan must include all “when known” temporary support structures and reference to any neighboring structures. List any fire department connections, hydrants, loading docks, main entrance(s), street access, hazmat storage & fire alarm panel location if applicable. Other Information Note: This address is only for emergency services use. No mail or packages will be delivered to this address by UW departments, UPS, FedEx, USPS, etc. You must use your assigned UW box number for those services. print name signature date
603-Physical-Address-Form.docx