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x3 d- <br />,•.,• ,,,,•,,"e, <br />KITT'ITA6 4C4DXYz41X V <br />DEPARTMENT OF PUBLIC WORKS <br />RL [�,13 <br />ACCESS AND ADDRESS APPLICATION <br />l. <br />s $270.00 Payment Method: Check Ul41� ash <br />Application for: 0 Address 5100.00 XAccesqp <br />0 Access and Address $330.00 <br />Owner Name <br />A �y <br />I mit Per0 L ( co — I r�l <br />QA <br />Mailing Address 4 &,X <br />101). '(It �/ <br />� <br />'r <br />Phone Number�-n) <br />RECEIVE <br />Email Address�i1s 'T(07-irmf4ffit <br />No, <br />Pili'• <br />Applicant Name SILI=I-& <br />iaA}(L04 <br />Mailing Address <br />v <br />DEPT OF PI IRI IC WORW <br />Phone Number <br />Email Address <br />DATE STAMP <br />Request Access and/or Address for: <br />0 Approved Subdivision 0 Pending Subdivision JX Agricultural Access <br />0 Single Family Dwelling 0 Commercial Access 0 Temporary Access <br />0 Other <br />Number of Lots to be served by the Access: 1 <br />Assessor's Map No.: n I q- 33 D — J <br />Plat Name Lot JJ <br />Road Name of Access Location: �t W4 <br />Distance and Direction to Nearest Intersection or Adjacent Address: <br />Desired Width of Driveway: (Minimum Width Requirement is based on <br />length of driveway) <br />CALL BEFORE YOU DIG 1-800424-5555 OR 811 <br />Applicant is responsible for calling for underground utility locates 48 hours prior to construction. <br />0( 1 have attached a site map with details on the seems, driveway and any buildings (existing or <br />proposed). <br />2( Applicant will stake along right-of-way to mark desired location of access. <br />0 Applicant agrees to perform the work in compliance with the Kittilas County Road Standards and <br />the requirements an the Access Permit. <br />Applicant certifies that the access applied for is only for the purpose indicated. <br />Applicant declares he/she is the ci a agent of the real property whose acegss is/ und�J/ton. <br />Applicant SignDate <br />411 N. Ruby St. Suite 1 TEL (509) 962-7523 <br />Ellensburg, WA 98926 FAX (509) 962-7663 <br />