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CAPES:.TO„fPC <br /> Pam �`� KIT"rZTSiS CbTTNTY <br /> DEPARTMENT OF PUBLIC WORKS <br /> KrrnTns crourry <br /> ROAD STANDARDS VARIANCE APPLICAnON <br /> Application for:Road Variance$1,075 00 Payment Method: ©Check ©Cash <br /> 0 Credit w Card^ <br /> Owner Name z Permit## t v r oo(A <br /> Mailing Address 1 Se 2 , <br /> Phone Number <br /> Email Address _ r c t oVi G �`l0 IYIGte C( <br /> MAR 19 . "�4 t <br /> Applicant Name V !l <br /> Mailing Address + i <br /> PhoneNumbcr 6 �� +.�. 11 +VV—i8Ka <br /> Email Address M'n fion et",(1& 1LY'�t c:Y Y C <br /> Variance Request Information <br /> Applicant to provide supporting documents and an area map. <br /> 1.Property Tax Parcel numbers. t'-o <br /> 2 Narrative project description: se'e- a:+f C�'/.�-,.y <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 pending applications or issues associated with this property? <br /> _Yes No If yes,describe: <br /> Application is hereby made for permit(s)to authorize the activities described herein.I certify that 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.I further certify that I possess the authority to undertake the <br /> proposed activities.I hereby grant to the agencies to which this application is made,the right to enter the <br /> above-described location to ms the proposed and or completed work. �j n <br /> Signature of Authorized Agent: Date:J L <br /> Signature of Land Owner of Iiee r;d���- <br /> : Date: 12 241 <br /> 411 N.Ruby St Suite I TEL (509)962-7523 <br /> Ellensburg,WA 98926 FAX (509)962-7663 <br />