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To be completed by applicant <br />Name: lvtiL64,j <br />P ;*^-kIALc Date of Apphcation:_Anz t 2c-,ic <br />Address: _Z2 i f 1T vkj 1- 4, Av, <br />L d ''2V,4: Daytime Phone: <br />Name of road to be considered:. <br />Approximate limits of request (Nearest cross streets/intersections or other identifiable londmorks) <br />Reason for request:_....zL4r-- V, C- <br />I'V Tc- j? e&t C"rE S O'Al zj--� " S C I - I, � r <br />1,71 `-,� � 1 40 �4�7 I -C It e- I - <br />I— I <br />Proposed solution(s):_-t" C5 4— i—Hog tlq T T -v :'t: <br />0.1&40* - .0 .... OUM"Ok . . ^No ...... 11 ..... 09.0.4**, <br />incomplete 0;;ITC;j;n; OPPlicant WNbe within 4 weeks from receipt <br />Of complete 000fatiOnS UNLE55 the OpphCOm IS notified of need for extension OY Deportment of Public Works. (Weather Or <br />other seasonal conditions may influence timing of Wed studies).Applicant will be notified in writina of rpc,,tft of A: _� <br />study and the recommended oction <br />I have read and understand the statement above: <br />Signature of applicant: <br />Date: 4,LK 14, <br />--G7E—ng79—oa—d[-CgTS <br />