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`` KITTZTAS COUNTY <br /> DEPARTMENT OF PUBLIC WORKS <br /> ROAD STANDARDS VARIANCE APPLICATION <br /> Application for: Road Variance$1,075.00 Payment Method:X Check2 Cash❑Credit Card <br /> Owner Name �U`�� t ` W�`��SG� y� Permit#K"J4`C4^ <br /> Mailing Address <br /> z Phone Number RECEI Eta <br /> S7�`� `�'2 `z-�'�o O <br /> Email Address e* <br /> ,��, JUN 11 16 <br /> Applicant Name <br /> Mailing Address <br /> AlItUMS C UNTY <br /> Phone Number IEPT OF PUBLIC WORKS <br /> Email Address <br /> Variance Request Information <br /> Applicant to provide support' g td�cuments and an area map. <br /> 1.Property Tax Parcel numbers: �_I 1 <br /> 2.Narrative project description: l b� <br /> "1 D12aceh cn <br /> 2� t°a✓� <br /> 3. Provision of road standards for which this variance is requested and the way in which you wish <br /> to v 1aryr from the s ndards` n <br /> Cvv�Sfv <br /> Reason for the variance request: <br /> 4. Proposed Mitigation for requested variance: <br /> 5.Are there aq'y 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 , 1. <br /> above-described location to inspect t r, osedap,4 or completAwork. <br /> / CL c iU c <br /> Signature of Authorized Agent: � Date: /( <br /> Signature of Land Owner of Record: v� �2? Date: /l <br /> 411 N.Ruby St.Suite 1 TEL (509)962-7523 <br /> Ellensburg,WA 98926 FAX (509)962-7663 <br />