20160223 ROW Permit 02232016o taaZ
City of YOM
Permit No. 03
No as halt cutfltio taencl5iti ob# 101097213
PUBLIC WORKS
Location of work 203 lst St. S,
901 Rhoton Rd NW
Application to Perform Worlc on
The Public Works Department (360- 458 -8406) must be contacted for inspection 24 hours before work
commences or this permit will be void.
The Underground Utilities Coordinating Council (1- 800 -424 -5555) must be contacted two (2) working days
before noceedin with any excavation associated with this perinil,
Yehn, WA 98597
Public Right of Way and/or Connect
Proposed starting date of installation: 3111116 1 Duration: 1 day
Date: Z2
Phone: 360- 458 -8406
to Utilities
For Official Use Only
Fee $
FAX: 360 - 458 -8417
Fee Received $
APPLICATION
The undcesigned hereby makes application to: Work in ROW to relocate a ote to assist with Cit of Yelm's
Sidewallz Irn rovement Pro'eet.
No as halt cutfltio taencl5iti ob# 101097213
Location of work 203 lst St. S,
I agree to perform the work in strict compliance with Yelm Municipal Code, Chapter the special
conditions enumerated herein and the attached conditions I have read and will adhere to the general provisions
a licable to crmits contained on this form.
The Public Works Department (360- 458 -8406) must be contacted for inspection 24 hours before work
commences or this permit will be void.
The Underground Utilities Coordinating Council (1- 800 -424 -5555) must be contacted two (2) working days
before noceedin with any excavation associated with this perinil,
Name:
Address: 2711 Pacific Ave. S.E., 01,m ia, WA 98506 Phone: (425) 324 -5341
Proposed starting date of installation: 3111116 1 Duration: 1 day
Date: Z2
Signature:
PERMIT RE 1JIRENIENTS
For Official Use Only
Fee $
Issned s„
Fee Received $
Application Approval {
Signature: �-
Receipt Number
To Be Com leted By C
Permission is hereby granted to perform the above described work subject to the general provisions contained
on this form, and the followin s ecial conditions:
tic
A bond in the amount of is required to insure compliance with the above
conditions, refundable a on actor , completion of work.
No work shall be done under this permit until the party or parties to whom it is granted shall have
communicated with and received instructions from:
Remarks:
First Inspection
Date:
Inspector Final Project
Corn letion A roval:
Date:
Revised 03/09/2011
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