Please complete this form and return it to:

MERCER COUNTY REGIONAL PLANNING COMMISSION

2491 Highland Road

Hermitage, PA 16148

PHONE: (724) 981-2412       FAX: (724) 981-7677

e-mail: mail@mcrpc.com

Full Name ____________________________________________________________

Current Street Address __________________________________________________

City, State, Zip _____________________________________________________

Current Phone # Home: ______________ Work: ________________

Best Time to Contact _____________________________________________

Township, Borough, or City of new address: ______________________________

Was the structure to be addressed present in 1983? ________YES ________NO

Name the road the driveway connects with… ______________________________

Closest intersecting named road is… ______________________________

Previous property owner.. ______________________________

Tax parcel number ___ ___ ___ - ___ ___ ___

Distance between the closest intersecting named road and your driveway:

(in feet)________

As seen from the house facing the road:

Nearest residence on left:      (Name)_______________(House #)______________

Nearest residence on right:    (Name)_______________(House #)______________

Residence across road:           (Name)_______________(House #)______________

PLEASE SHOW THE FOLLOWING INFORMATION:

_____location of your home (or proposed home) and new or existing driveway

_____the closest intersection to your driveway and the distance between them

_____location of the nearest neighbors and their house numbers

_____distance, in feet, between nearest neighbors' driveways and your driveway

Remember to measure all distances in feet and try to draw the map as accurately as possible. Driveway distances are very important to the addressing process; we count on you to provide accurate measurements.

*Please print the application (only the selected frame), fill out all the 

necessary items and return to the above address.