2015-26 ROW Permit 12082015 City of Yelm Permit No. l
PUBLIC WORKS
901 Rhoton Rd NW Application to Perform Work on
Yelm,WA 98597 Public Right of Way and/or Connect
Phone: 360-458-8406 to Utilities
FAX: 360-458-8417
APPLICATION
The undersigned hereby makes application to:
't
Location of work:
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 pplicable to permits contained on this form.
"1.1lie public Works 1` eptu-tment(360-458-8406)must be contacted for inspection 24 hours before work
commences or this germit will be void.
The Underground Utilities Coordinating Council(1-800-424-5555)must be contacted two (2)working days
before proreeding with any excavation associated with this permit.
Name: l
Address: 3130 15-0 Vie: - _
Proposed starting date of installation: 1241 1 Duration:
Date: �, Signature:
PE REQUIREMENTS
For Official Use Only
Fee $ Zvi:_00 Issued I'2 1 IF 14;--
Fee Received $ O Application Approv l
Receipt Number I Signature:
To Be Com feted Py City'
Permission is hereby granted to perform the above described work subject to the general provisions contained
on this form, and the following special conditions:
A bond in the amount of is required to insure compliance with the above
conditions,refundable upon satisfactory 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 Inspector Final Project Date:
Date: Completion Approval:
Revised 03/09/2011
Job#: 108589168 PRE-INSPECTION REPORT
Date: 11/2/15 Address: 15624 COATES RD SE
Jurisdiction: YELM City/Zip: YELM
Right of Way Permit? I] YES ❑ NO Customer: JODY 360-878-1602
Est. Start Date: 11/20/15 PM/Insp: AMBER UHLS
Est. Duration: 4 HOURS PHONENUMMR '
WORK DESCRIPTION:
Construction Method
Open Trench p
PERM RETIRE 5/8"PESVCATMAIN Trenchless ❑
PLAT MAP: 282 044
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Work Location Siz�of Surface Type
N
of CL,�..._ O,ATES I��.SE E of CL....._.LpN.CI�I1��.T._ E w 4X3Cut ASPSPHALT LT
'N S of CL, �..
'N S of CL ........... & 'E W of CL.
El FLAGGERS# 2 35 MPH ❑ TROLLY LINES ❑ BUS STOP# ❑ METER HOODS#
❑ OFFICERS# SPEED LIMIT ❑ TRAFFIC SIGNAL ❑ ARTERIAL ❑ NO PARKS#
[I Commercial ❑ Altered Commercial ❑ Leak Repair Service Information ❑ Template Bar
p Residential ❑ Altered Residential ❑ CP Work Diameter Meter EFV
L Replacement Service Pothole —5/8 ❑ Bollards 2.5"#
�:::i 250 i❑ 1800
10 New Constr. E] Main Maintenance L1 Extension ❑ 11/8" [1 425 [1 2600 E] Bollards 4"#
❑ Stub [1-Service.Maintenance,, ❑ 11/4" ['1 630 ❑ 10,000 ❑ FUEL LINE PERMIT NEEDED
❑ Extension ❑ Valve Maintenance ❑ 2" ❑ 1000 Fuel Line Length:
❑ Compete Sery EI Cut&Cap Mtr Loc: Fuel Line Diameter:
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