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OES-. TUTgPc'�l <br />.P"��`. / °M9 KZTTZTAS COUNTY <br />DEPARTMENT OF PUBLIC WORKS <br />KITTITAS eDIMT1' <br />ROAD STANDARDS VARIANCE APPIACA'rim <br />Application for: Road Variance <br />/$1,075.00 Payment Method: ❑ Check <br />Owner Name.'J__rl I/io '�7"��6°t'r" <br />Mailin° ddress <br />ClL tYt <br />Z Z 5, riMA) 4AIMOZ <br />i! <br />Phone Number <br />Email Address <br />m�i.0 2 <br />Applicant Name <br />Mailing Address <br />Phone Number <br />Email Address_ <br />0 Crash it (Credit Card <br />'�t y�j-- 5 -000 10 <br />Permit 73`AA s <br />i4♦�1t5 C V 2U' <br />OEPT OF PUBLIC WORM: <br />!� ��p JJ-Ac Variance Request Information <br />/r1�t'i� Applicant to provide supporting documents and an area map. <br />1. Property Tax Parcel numbers:�� <br />2. Narrative project description: <br />3. Provision of road standards for which this variance is requested and the way in which you wish <br />to vary from the standards: <br />Reason for the variance request: <br />4. Proposed Mitigation for requested variance: <br />5. Are there any other <br />pending applat' issi e�s associateA wf )perty? <br />bi <br />XYes_No Ifyes,de! <br />DY <br />Application is hereby made for permit(s) to authorize the activities described herein. I certify teat I am <br />familiar with the information contained in this application, and that to the best of my knowledge and belief <br />such information is true, complete, and accurate. 1 further ccrtifv that.! possess the authority to undertake the <br />proposed activities. 1 hereby grant to the agencies to which this application is made, the right to enter the <br />above -described location to inspect the proposed and or completed work. <br />Signature of Authorized Agent: Date: <br />Signature of Land Owner of Recor r � tug— Av 2 <br />411 N. Ruby St. Suite 1 TEL (509) 962-7523 <br />Ellensburg, WA 98926 FAX (509) 962-7663 <br />