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2015-25 ROW Permit 11162015 City of Yelm Permit No. �U 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 m lies ap alicati�on to: I A f 1 — rN., 15 Cl k" Location, W 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}?plic,abipmits contained on this form. _.._. The Public Works Department(360-458-8406)must be contacted for inspection 24 hours before worilz c M1 r^t is 11grinit will,be void, ac The Underground Utllities Coordinating Council(1-800-424-5555)must be contacted two (2)working days before proceeding with aily excavation associated with this permit, Addresl S1%r%0 Phone:,s- fProposc:dstarEin1g_, dale of i�r'tallat�io r' Duration: tiorr: _ �...._. (J Signature: PERMIT REQUIII.Il:«I'EN'TS Fee For Official Use Only " „'� � - lssucd Fee i'ved l bC� Application Alpruw � Receipt Number ratstu��c: ._ er_ To Be Completed B Ci P t r�rissiota is hereby granted to perform'the alcove described work subject to the general provisions contained on this fora, and the following,special conditions: * . r d" t of a • A, 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: u Remarks— First Inspection Inspector Final Project Date: Date: Com letion Ap rovaL n t Revised 03/09/2011 C N l City of Yelm Permit No PUBLIC WORKS 901 Rhoton Rd NW Application to Perform Work on Yehn,WA 98597 Public Right of Way and/or Connect Phone: 360-458-8406 to Utilities FAX: 360-458-8417 i i APPLICATION 7undersigned hereby m l.es ��i�tion to- �1,S 1. 1 — e. l5 Location of work: �� 1'Y1 .,. -- 1 53 53 1 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 Pu to n its contained on this foam The bli c a Publi Works Department(360-458-8406) h.m s� ...w.., . ..'...__�_.� u...,nust 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 �� associated with this permit. before proceeding excavation associ - Name: with a Addrass: 5150, pltO11e: Pro p osed start n g date of installation: ... I tKt�ation: Date: j Signature: I'I It1 I ItitQUIRLMl N"TS ; For Official Use Only Fee$ Issued /1,1)4 Y Fee R._eceived$ Application Apprt�....... N Receipt Number Signature -- To Be Com leted Ci .. .._.._ .. . Permission is hereby granted to perform the above described work subject to the general provisions contained on this form, and the following special conditions: i 6 A bond in the amount of is required to insure compliance with the above conditions,, refundable a LI, 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 A rovaL Revised 03/09/2011 r r t I' GENERAL PROVISIONS APPLICABLE TO ALL PERMITS In accepting this permit, the petitioner,his successor and assigns, agree to protect the CITY OF YELM, WASHINGTON, and save it harmless from all claims, actions or damages of every kind and description which may accrue to or be suffered by any person, or persons, corporation or property by reason of the performance of any such work, character of materials used or manner of installation,maintenance and operation or by the improper occupancy or rights of way or public structure and in case of any suit or action is brought against said City for damages arising out of or by reason of any commencement of such action, defend the same at his or their sole cost and expense and will satisfy any judgment after the said suit or action shall have finally been determined if adverse to the said City. k If the work done under this permit interferes in any way with the drainage of the area,the grantee shall wholly ` and at his own expense make such provisions as the City may direct to correct said drainage problems. Upon completion of said work herein contemplated, all rubbish and debris shall be immediately removed and from the roadway and roadside shall be left in a neat and presentable condition that is satisfactory to the City. The party or parties to whom this permit is issued shall maintain at his or their sole expense the structure or object for which this permit is granted in a condition satisfactory to the CITY OF YELM. The CITY OF YELM may revoke, annul, change, amend, amplify,or terminate this permit or any of the conditions herein enumerated if grantee fai is to comply with any or all of its provisions, requirements or regulations as herein set forth or thru willful or unreasonable neglect, fails to heed or comply with notices given or if the utility herein granted is not installed, operated, and maintained in conformity herewith or at all or for any cause or reason whatsoever. All work areas shall be adequately barricaded according to MUTCD Standards. Barriers steal I be properly F lighted at night. All trenches shall be backfilled with selected backfill materials unless otherwise directed by the Engineer. D PAVEMENT REPLACEMENT: Asphalt pavement shall be replaced to a minimum depth of four(4) inches thick or match to the existing pavement whichever depth is greater and to the dimensions specified by the I Engineer. In gravel alleys the permittee shall replace base and surface rock. All work shall be conducted using current WISHA/OSHA regulations. Particular attention shall be paid to the requirements as they pertain to work in trenches, electrical work,work in high places and to safety apparel such as,hard hats and safety vests. All work shall be completed to City Standards as set forth in the City ofYelm Development Guidelines, and policies. C The PUBLIC WORDS DEPARTMENT office (360-458-8406) must be contacted for inspections 24 hours before work commences. i G v a, Revised 03/09/2011 f PRE-INSPECTION REPORT Job#: Date: Address: 33 S`tA-r S-07 51F_ Jurisdiction: ,e, wt,, City/Zip: 9 y - ,cc � c Z - 2-8 f P w Right of Way Permit? YES ❑ No Customer: .a� y'. Est. Start Date: PM/Ins Est. Duration: _ .._____. _...._... _ r11 V rrW NuMeera _. yVORI(,UESCRImPiI,ON; Construction ethod G G S� rr 5✓c -to tie S I7✓u� S�� Open Trench wtA�N Trenchless A-r . ❑ n PLAT MAP: ZQj 1/0 114 V b / �G l� /C) I I 4 I i Work Location Size of Cut SUgace T �e �. . . _ m ofCl CL + @ 'E W of CL � ® FLAGG of CL W Of CL MPH ❑ TROLLY I_INE_S 4 [f BUS STOP, ry ❑ METER tIOODS# nmeIT ® TRAFFIC SIGNAL Fj ARTERIAL ❑ NO PARKS# O Commecsal Altered Cor-. ......�..._. .,--�.��.. _ _-� SPEED LIMIT ❑ ❑ Leak Repair _ Service Infarmatl rI n Template Bar _ Residential Altered Residential CP Work Diameter Meter EFV ❑ ❑ ❑ Bollards 2.5"# ❑ Multi-Famlly ❑ Replacement Service ❑ Pothole [lg 5/8" ❑ 250 ❑ 1800 Bollards 4"4 New Constr. ❑ Main Maintenance ❑ Extension ❑ 11/8°" ❑ 425 ❑ 2600 ❑ ❑ Stub ❑ service Maintenance ❑ 11/4" ❑ 630 ❑ 10,000 ❑ FUEL LINE PERMIT NEEDED ❑ Extension valve Maintenance ❑ 2" [j 1000 Fuel Line Length: _ Compete Sery E] p [ , Cut&Cap Mtr Loc: Fuel Line Diameter i I T h r pp `Al �# io ✓ ,.' p cs m u p� 0 t2 Y N CA ?78'E Ul r b l% fi r w c m 3t:0 tl' r OD p �! 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