Please use this form to apply for a New 911 Address with the Wayne County, PA, Planning Commission

Who is requesting the new 911 address?

Property Owner Builder

Other

If Other List Here:

Owner First and Last Name:*

Requester's First and Last Name*

Requester's Email*

Requester's Phone Number*

Address where the tax bill for the property is sent. (Street, City, State, & Zip)*

Control # or Tax Map # :*

Reason for New Address:

New Residential Construction New Commercial Structure or Address

Address for Utilities Other

If Other, list here:

Do you have your state Highway Occupancy Permit (HOP) or township street encroachment notice for your driveway? *

Yes

No

Do you have your municipal Building Permits? *

Yes

No

Please upload a document such as a plot plan that shows where the driveway will enter your property and where the house will be located.
THIS IS REQUIRED FOR AN ADDRESS TO BE ISSUED!*

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