2015-12 ROW Permit 04062015 City of Yelm xmit No.
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:
Location of work: m Q
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
applicable to germits contained on this form.
The Public Works Department(360-458-8406) must be contacted for iris eetion 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 proceedin with any excavation associated with this permit.
_Name:
Address: Phone:
Proposed starting date of installation: Duration:
Date: 3,1�115 Signature:
ERMIT REQUIREMENTS
For Official Usq Oilly
Fee $ Issued
Fee Received $ Application A r'
Receipt Number Signature:
To Be Complete, By 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:
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N w Am�e
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A bond in the amount of is required 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 from:
Remarks:
First Inspection Inspector Final Project Date:
Date: Completion Appro yal:
Revised 03/09/2011