2015-16 ROW Permit 07272015 City of e 10errsrmmt:No.
� piJBhIC WORKS
901 Aston 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
APPLICA.TIO
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Th es
The undersi" �� os� to
g�s�cl'Bsa�s�ley makes�sl. "1 sic sr�. ....
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Location of work°
I agree to perform the work in strict compliance with Yelrn Municipal Code Chapter the special!
conditions enumerated herein and the attached conditions I have read and will adhere to the general provisions
applicable to permits contained on this form
The Public,Works Department('360-458-8406)must be contacted ___ _ �_..befo
'' far inst;rectios� 24 hours before work
So ences ®r t is er it will be void,.. .�,.. ... �... .._. ...
The Underground Utilities Coordinating Council (1-800-424-5555)must be contacted two (2)working days
before)proceeding
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tioI n�a°sso.ciated..wi1t..h this permit.
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Signature:
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PERMIT REQUIREMENTS
For Official
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Fee�
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Permission is hereby granted to perform the above described work subject to the general provisions contained
on this form,and the follow' special conditions:
A bond in the amount of is required to insure compliance with the above
conditions,refundable upon satisfactory copletion of work,
1�o work shall be _..._ ._.. M...
done under this permit until e or parties to whom it is granted shall have
communicated with and received instructions fro
Remarks:
First Corn lets®n A
.�__.�.— Project � Bate
i Inspepcfor I'maipproval: _
Date Inspection......�
Revised 03/09/2011
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