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Dept. of Public Works <br />LIST OR PETITIONERS AND AUTHORIZATION (ATTACH ADDITIONAL SHEETS AS NEEDED) <br />Name: Cie Elum Pines West LLC, CO Chad Bala <br />Mailing Address: PO Box 808 <br />City/State/Zip: Cie Elum, WA 98922 <br />Day Time Phone: 509-607-0617 <br />Email Address: bala.ce@gmail.com <br />I certify that I am familiar with the information contained in this application, and that to the best of my knowledge <br />and beliefsuch information is true, complete, and accurate. 1 further certify that I possess the authority to undertake <br />the proposed activities. I hereby grant to the agencies to which this application is made, the right to enter the above- <br />described location to inspect the proposed and or completed work. <br />� r <br />Signature of Petitioner: / �,�- _ rte, I Date: 12 -13 -ZZ <br />Name: Pat Deneen <br />Mailing Address: PO Box 808 <br />City/State/Zip: Cle Elum WA 98922 <br />Day Time Phone: WO -260-0462 <br />Email Address: bela.cefgmail.com <br />I certify that I am familiar with the information contained in this application, and that to the best of my knowledge <br />and belief such information is true, complete, and accurate. I further certify that 1 possess the authority to undertake <br />the proposed activities. I hereby grant to the agencies to which this application is made, the right to enter the above- <br />described location to inspect the proposed and'or completed work. <br />Signature of Petitioner:y Date: <br />Name: <br />Mailing Address: <br />City/State/Zip: _ <br />Day Time Phone: <br />Email Address: <br />I cerin that I am familiar with the information contained in this application, and that to the best of my knowledge <br />and be/iefsuch information is true, complete, and accurate, i further certify that I possess the authority to undertake <br />the proposed activities. 1 hereby grant to the agencies to which this application is made, the right to enter the above- <br />described location to inspect the proposed and or completed work. <br />Signature of Petitioner: <br />411 North Ruby Street, Suite 1 <br />Ellensburg, WA 98926 <br />Page 3 of 4 <br />Date: <br />TEL (509)962-7523 <br />FAX (509)962-7663 <br />