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L <br />E� '! <br />xlrrrr"MVM <br />KZTTZTAB COUNTY <br />DEPARTMENT OF PUBLIC WORKS <br />FRANCHISE APPLICATION (� CC�I <br />Facility in County Road Right of WAY Rr-* d del' <br />Fee (Non -Refundable): $1,615.00 <br />Owner Name <br />Mailing Addc <br />Phone Number C�f19 - CL2n I Lio-S Q <br />Applicant Name <br />Mailing Address <br />Phone Number <br />Payment Method: IY Check ;N 95 Cash <br />Permit # <br />JAN a B 2020 <br />DATE STAMP <br />If re_guest is for agricultural or residential use, continue with this application. If not, <br />applicant shall use the Franchise Complex application. <br />Pursuant to KCC 15A.03.040, upon receipt of the application, Kittitas County Public Works will <br />contact the applicant to schedule a meeting with the Director of Public Works and/or the County <br />Engineer to discuss terms and conditions of franchise agreement and schedule a Public Hearing for <br />consideration of the franchise agreement by the Board of County Commissioner's. <br />Supporting Documents Required for complete application: <br />• Detailed Project Plans <br />• Detailed Vicinity Map <br />• Schedule for Work to be performed <br />CALL BEFORE YOU DIG 1-800-424-5555 or 811 <br />Applicant is responsible for calling for underground utility locates 48 hours prior to construction. <br />Warning: The County does not mark any of the County infrastructures; the Applicant is responsible for any damage <br />to the County infrastructure. <br />PJ/ Ali required supporting documents have been attached. <br />Applicant agrees to obtain a work in Right -of -Way permit upon approval of the franchise agreement. <br />Applicant/Agent Signature & r/ ' `lG�s% Date Q'• V (J 12b2 <br />411 N. Ruby St. Suite 1 - TEL (509) 962-7523 <br />Ellensburg, WA 98926 FAX (509)962-7663 <br />