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b�SC of,' ... T<1TfIF <br />DEPARTMENT OF PUBLIC WORKS <br />KiTMTAS (Y)(R.T' <br />ACCESS AND ADDRESS APPLICATION <br />Application for: ❑Address $183.00 . L1 Access $437.00 Payment Method: L']'Check <br />%)J Cash <br />❑ Access and Address $620.00 ❑ Credit Card 7�� �' <br />Owner Name Il 4 N nt (- C V� L Y L"t. Permit 0 c Y 1..�- i <br />Mailing Address _2[ Gd AJ ^'r <br />Phone Number 15awi_ C E I VE r <br />Email Address d <br />Applicant Name Mailing Address A.--k J 2025 <br />Phone Number <br />Email Address_ <br />Request Access and/or Address for: <br />J4 Ki ITIIA6 WUN TY <br />STAMP'= -PT OF PJBI IC WORK <br />❑ Approved Subdivision ❑ Pending Subdivision ❑ Agricultural Access <br />❑ Single Family Dwelling XCommercial Access ❑ Temporary Access <br />❑ Other <br />Number of Lots to be served by the Access: p <br />Assessor's Parcel No.: f.' �? l .t <br />Plat Name Lot <br />Road Name of Access Location: X �Z�/ <br />Distance and Direction to Nearest Intersection or Adjacent Address: <br />Desired Width of Driveway: (Minimum Width Requirement is based on <br />length of driveway) <br />Quantity of material that will be filled, excavated, or relocated for access development or <br />other site preparation (e.g., grading to level building site): cubic yards. <br />• <br />CALL BEFORE YOU DIG 1-800424-5555 OR 811 C <br />A1-1 <br />- FOR 1NSPEGTtOt <br />Applicant is responsible for calling for underground utility locates 48 hours prior to construction. 962 7 523 <br />5ag- <br />f1.1 1 have attached a site map with details on the access, driveway, and any buildings (existing or <br />/ proposed). <br />Applicant will stake along right-of-way to mark desired location of access. <br />Applicant agrees to perform the work in compliance with the Kittitas County Road Standards and <br />the requirements on the Access Permit. <br />Applicant certifies that the access applied for is only for the purpose indicated. <br />Applicant declares he/she is the ow er owner's agent of the real property whose access is under construction. <br />f <br />Applicant Signature <br />Date � <br />411 N. Ruby St. Suite 1 TEL (509) 962-7523 <br />Ellensburg, WA 98926 FAX (509) 962-7663 <br />