2015-10 ROW Permit 03062015 City of Yelm Permit No.
'UBLIC 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 f y makes application to ..� -�._.•�_�,. � . �... �
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Location of work: " ti. d�a ..._ ...• � ;..
I agree to perform the work in strict compliance ._...t ._ ..... Code, ..... • the special
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with Yelm Municipal Code, Chapter , p ' :1
conditions enumerated herein and the attached conditions i have read and will adhere to the general provisions
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cable to �orr�tits contained on t�tsor �� ...•.m. -_
The Public Works Department (360-458-8406) must be' contacted'ho-r--in"
or inspection 24 hours before work
cr�ntnuence �,�r tltis �°�°nit will lie voitll
The Underground Utilities Coordinating Council 1-800-424-5555 must be contacted two( ) o (2) working days
before roceedm with an excavation associated with this hermit.
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ame:
Address:
i � Duration: F lute.
Proposed tartit�m date �t:�Ilat o � L:. �..W._...�...-.
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Date: ( Signatu : y
PERMIT REQUIREMENTS
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For Offic 1
Fee $ Issued `- C
Fee Received $ mmmmnIT ,.,m .. .Application Aproval
Receipt Numbet S� nature
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To Be C
Permission is hereby granted to perform the above described work subject to the general provisions contained
on this form and the following special condo ns m
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f .is required to insure compliance ���
A bond in the amount o
• ce with the above
conditions, refundable upon satisfactory completion of work._
i4o work be done under this permit until the party or partiesv.whom it is granted shall have
ave
communicated with and received instructions from:
Remarks:
T ._.n_-s.pection W... .... _ . iFinii Pio J-e.ct ... .� w� Date
Com Pleti on Approval:
Datea
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Revised 03/09/2011
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