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
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The undersigned hereby makes application to: ��(���y�/nJ� mmm �7�iU„ w mmmmmMm �W ��m_
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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 ..:
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of instalIiiion: 11 -N-13 Duration: �
Date: o�y>:3 Signa.tun
MIT R 2Ul EMEN'I''S
For Official Use Only
Fee $ Issued
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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
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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