2014-11A ROW Permit 07142014 ql'. 2013 r R 1 9.ol' FA,( 360a538417 i'ityof%rel:n public Forks oil)pa'n;7
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o Cite ol• VC1111 Peruut No.
tJtF014-11
PC!BLIC'WORKS -�• ��-
901 Rholon Rd N«' Application to Perform Work on
Ychn,R'A 98597 Public Right of Way and/or Connect
Phone: 360-458-8406 to Utilities
FAX: 360-458-8417
APPLICATION
The undersignccl hereby makes application to
till IrDe
w
r �
Locatton oC
wot°1f:
i agree to perform the work in strict compliance with Yelm Municipal W-�_ mm... •
p a1 Code,Chh apter ,the speck
conditions enumerated herein and the attached conditions l have read and will adhere to the general provisions '.
a pplicable to crtnits contained on this form.
The Public Works Department(360-458-8406)ntttst he contacted
�_-
for inspection
24 tartars 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
Name _ crated with this hermit.
before roc edinh a exavatioas -µ�
1 � Phone. _.........
Address: c1 tom , .. .
Proposed starring data of tnsudIMiow, t t�urtttlon
�� ��
Duty. Signature: Mcc"
PERM RE UIRENMENTS -
For O ficta
Use( n l'�
Fee$ t issued
l ee Received$ Application Approval Kevin Ray
Receipt Number ..._.- .�.... ... _. Si natutre�
To 13e Coin R eted
Perrntsston is hereby granted to perform �.- -•�� � ....-•-••-_� ��•�.�• ••• �.
the above described work subject to the general provisions contained
on this lttt°tvtw and the followirtt+
-A bond in tttz atrtaunt of w_ is required to insure compliance with the:tbov m- mm
.............. . e
table npt�tt ,atisfactoty completion of work
�ondttton5.,.rc.fune a......
Cotta nunicaled with and t cei\,cd insttuetion-, from: parties nt +vneYu it is granted shad hair
Nu Work.
I�ema�t k tiiaali bc,tl�...� l� or na
unc unau this auimt unto Ihe ,at �,�� . _...®. ..
p rk�
Fu St 1n, ��duti Inspector find Ptn�W Datc.
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