2014-09A ROW Permit 06022014 01/11./2013 FRI 9- 06 FAX 360458841 1 C.i,tYoffVehn Pr.bl°lkc Work, (1o4)4/P.o4
' o t City of YOM Permit loo.
PUBLIC WORKS -
901 Rhotan Rd MV Application to Perform Work on
Yel►n,WA 98597 Public Tight of Way and/or Connect
Phone: 360-458-8406 to Utilities
.; -.. FAX: 360-458-8417
APPLICATION
3 tries a alication to:
flt�:uc�lcit~1 si mmPlcd lrerelay°ul.. _
Location of`work:
e I agree to aerforril the work in_strict.-compliance with Yelai Municipal Code,.�C ha ter __. the special
conditions enumerated herein and the attached conditions I have read and will adhere to the general provisions
a plicable to jLi%i contained on this farm. _
The Public Works Department(360 453-8406)must be contacted far insnectiort 24.hnurs before work
con,file or this p+e rn.� it r i1,1 be yule/.
The Underground Utilities Coordinating Council(1-800-124-5555)must 6e contacted two(2)working days
befor eedin with any excavation associated with this permit.
Address,
Pro p ose g _ l ..1tlratPOn: �
d startin date ofirast<lll��tra�lt: I'
Date; Signature:
a, I i'l lt.h;awl L'l S _..
For Official Use Onl
Issued
Fee Received$ Application Approval
Itecei at'�uni t Signature:
1 _._�m__ .. ............ .
___ To Be
Permission is hereby granted to perform the above described work subject to the general prow isions contained
on his form,and the conditions:
..�., ..._._.----- _..
n"a— required with the above
A bond in the amount ol'w m__........� Ps re uPna�l to�rl�albr�com.. ..���-.���..�
conditir,')ns,1 1t1ndabic upon satis at t��ry� �t'o�tlal�ti�wn� ,......
.� ..
tvo work shall be clone under this ermit until the p m& t €�1 parties to vrl�lor��lt...�...ranted s._._._._w m_.......... .....�_.� �.
p p y l I g hall have
communicated with and received instructions from:
l�ers7ilrl�9
w
t 1r sP Yoasg�c rdon /nape for Final nloyect ��r
Pate cm letlon� lrovai .�...�
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