2015-06 ROW Permit 02192015 City of Yelm P, At 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 applicatio A a' X V A) 7\ V
DILIJi W, c 1 �# E C mm a r C °:!a L Dom' IlG 1M., ex a ,ce: 'r LL CLON-i
w" � V add° 4 �z tAN U UN-1 L to s
Location of work: 433 i LL' Li a-1 S \/C an
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 permits contained on this form.
The Public Works Department(360-458-8406) must be contacted for inspection 24 hours before work
commences or this Rermit will be void.
The Underground Utilities Coordinating Council (1-800-424-5555) must be contacted two (2)working days
before proceeding with any excavation associated with this perm.it.
Name: A j7v 4.,o R1Vc:rU'a an 1v nip r"'ve-r0� Ca h corms
Address: P' .° , I�` W� " .S t; `�C-'L ► Phone: Z + 3`t*`� --qq 1
Proposed starting date of installation: Duration: -1 pp�.y
Date: /r� �5 Signature
PERMIT REQUIREMENTS
For Official Use Only
Fee $ Issued — -°
Fee Received$ Application Approval
Receipt Number Signature:
To Be Completed Py,Ci
Permission is hereby granted to perform the above described work subject to a =eneral provisions contained
on this form, and the followin special conditions:
A bond in the amount of is required to insure compliance with the above
conditions, refundable u on satisfactory 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: Com letion Appro yal:
Revised 03/09/2011 FEB 8 2015