2015-21 ROW Permit 09292015 1'
" City of Yelm Permit No.Zo 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. 1,
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Location of work:
I a ree to erform 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 genet-at provisions
applicable to_permits 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
Name:--., associated with this permit.
t
before t o eedin with an e xca. ._____ ...�w..._.-._...�.w.
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Address: � ._ , �Z lcib ' Phone: „.~...
Proposed starting date of installation: 11 Ot f Duration: ,2
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U... Signature:
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Date: (S g
Pri,.R II IAL I.IIREME $T
For Off acial 1 °'e Dn
Issue
Fee .w
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Fee Received A pp li�atirt pp t ...w
Receipt Number ...
cccr t Num e Signature:
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To Be Coi .leted By CJ
Permission is hereby granted to perform the above described work subject to the general provisions contained
on this form,and the following special conditions;
A bond in the amount of is rewired to insure compliance with the above
conditions,refundable upon satisfactor completion of work,
No work shall be done under this permit until the party or parties to whom it is granted shall have
communicated with and received instructions fiom:
Remarks:
First Inspection -�� —1 Inspector Final Project---F Date:
Date Completion A roval:
Revised 03/09/2011
Job 3 0 1 ,5_2 -3 PRE-INSPECTION REPORT 9`1 MP_ OUNO 1:M:ku V
Date: f-23—/5- Address: 16 53
Jurisdiction; ye,144 City/Zip: V-e_1144
Right of Way Permit?' Fj YES ❑ NO Customer:
GV$f NX)NE NUMMiR
Est. Start Date: PM Insp: Af
g7
Est, Duration: PHONE NUMBER
WORK DESCRIPTION: V I pC— XN (4c, eo Construction Method
6— Ze
Open Trench ET
0 Trenchless ❑
PLAT MAP:
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2`1
_ew
Ab
Work Location Size of Cut Surface Type
.............7z-C— E W f o C L
IN S of CL I &_ 'E W of CL
--
....... .....
IN S of CL ...... 'E W of CL
FLAGGERS# 3 MPH ❑ TROLLY LINES ❑ BUS STOP# ❑ METER HOODS#
❑ OFFICERS# SPEED LUT ❑ TRAFFIC SIGNAL ❑ ARTERIAL ❑ NO PARKS#
Commercial F-1 Altered Commercial Leak Repair Service Information ❑ Template Bar
Residential F1 Altered Residential CP Work Diameter Meter EFV Bollards 2.5"#
❑ Multi-Family ❑ Replacement service F-1 Pothole ❑ 5/8" ❑ 250 ❑ 1800 E) Bollards 4"#
F] 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" ❑ 1000 Fuel Line Length:
Compete Sery F-1 Cut&Cap Mtr Loc. Fuel Line Diameter:
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Thurston County Map Out, Sage Page I of I
Thurston County Map
104,141 Alto ff...................................
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Disclaimer:Thurston County makes every effort to ensure that[his map is a true and
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'CAJoac refire sentat ion of the wo,l,orcounly,goverioneut.HoNwver,the Comity and all LEGEND
rclated persouncl make no warranty,expressed or implied,regarding The accuracy,
completeness sw convenica,ce of any iorounation diselosed on this matt.Nor does the C(umtY Major Roads
accept liability for arty(bruage or injury causvd by the use of thus map, :111bv Flood Zones
To the fullest extent pofaiissibh:pussumst to applicable low, rhuiston County disclaims A Roads
warranties,express or implied,including,but not limited to,implied warranties ofnierchruit 1)1116Vii, Water Bodies
ability,data fitness for a particular purpose,and non-infringements of proprietary rights.
Under no circumstances,including,but not limited to,negligence,shall Thurston County be Streams
liable for any direct,indirect,incidental,special or consequential damages that result from Zoning
the use of,or the inability to use,Thurston County materials. Contours
'11111i's(MV,0 2013-Thmston Courgy GcoData Center Wetlands ........... cities
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C'eme ( Wetland Buffers Parcels
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