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Dept. of Public Works <br />Authorized agent, If different from petitioner(s): <br />Agent Name: <br />Mailing Address: <br />City/State/ZIP: _ <br />Day Time Phone: <br />Email Address: <br />I certify that 7 am familiar with the information contained in this application, and that to the best of my knowledge <br />and beliefsueh information is true, complete, and accurate. l further certify that l possetr 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 Authorized Agent: <br />411 North Ruby Street, Suhe 1 <br />Ellensburg, WA 98926 <br />Page 4 of 4 <br />Date: <br />TEL (509) 962.7523 <br />FAX (509)962-7663 <br />