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2013-017 ROW Permit 10142013 City of 1� � � 9� � Permit 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 Q....mmlfG/l 12' C TV The undersigned hereby makes application to: ��(���y�/nJ� mmm �7�iU„ w mmmmmMm �W ��m_ ....03°3��s 13�3s's__��r✓ J�a 47�4,r 7V�®n15 T✓ ® "JC: ocation of work / I agree to-perform the work in strict compliance with Yelm Municipal Code, Chapter,„ -- m�,the spe cial 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 ocec c1 � � lw w a w�tma -�- a• w .... ._._._..ww. iiig with any excavation associated with pen-nit. it Name _ .._ ..... � _... _ ..._ Phone: �Adress l � W � Proposed starting �to ..: .. .. of instalIiiion: 11 -N-13 Duration: � Date: o�y>:3 Signa.tun MIT R 2Ul EMEN'I''S For Official Use Only Fee $ Issued ._ �.. W ....V _- __ _ ............... Fee Received$ Application Approval Receipt Niirnbe Signature: � ........ To Be Coin ll " Permission is hereby granted to perform the above described work subject to the gengdKprovisions contained on this form,and the following special conditions: ._......._ ... ........................................... ... A bond in the amount of _ is required to insure compliance with the above conditions,refundable iipon �ggsfacGto!Xeoiii pleticin of work. No work shall be done under this permit until the p; _._ communicated with and received instructions from: �,�a,�, ""^�'� Kevin Ray Remarks Public works Field Supervisor .....W_ Cross Connection Control Specialist -....... _- __ - City of Yelm ImFirstInspectio� WWW� Inspector n Ins Final Pro- � " �'°� Office: (360) 458-8410 Date Coiiilcti.oii Apprci 901 Rhoton Road SE Fax: (360) 458-8417 105 Yelm Ave W www.ci.yelm.wa.us Revised 03/09/2011 Yelm,WA 98597 kevinr®ci.yelm.wa.us