2015-11 ROW Permit 03162015 City of Yelm Permit No. 2015-11
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 LIMIC Sigued,hereby makes application 0114.
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I agree to perform the work m strict com loanc with Yelm Code Chapter _ tl
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 for tns o 4 hours Ibefo a!Xor
conilloences or th' rmit will void. _
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The Underground Utilities Coordinating Council (1-800-424-5555) must be contacted two (2)working days
before proceedm�with any excavation associated with this permit. . .....w�aw
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Proposed starting date of installat%on',T „� Duration; , '.
Date:3z1 gnature:
PERMIT RE UIREMENTS
For Official Use Only
I Fee $ �..�' Issued '_031T672T5_..'..,
Fee Received$ Application Approval
Receipt Number Signature: > hVift, RAq
To Be Completed B� City
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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 following special conditions:
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A bond in the amount of _ is required to insure compliance with the ave
on
conditions,refundable u on satisfactor co
of work.
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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 Ins ection ... _._.. �.. �.Ins�ector•FnapP � � . _.... .. ...... . . .. .........p ro�ect Date.
Date: Com letion A r�ovalmm
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Revised 03/09/2011
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