2014-05 ROW Permit 02062014 City of Velm 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
PThe dersigned
hereby makes application to: I, •"' .. "
-AXP
'114LOXII& Dr M, W-
cation orwork ..... » '1 -AA +- LaC�
1 agree to perform the work in strict compliance with Yelm Municipal Code, Chapter , ...,the special
conditions enumerated herein and the attached conditions l have read and will adhere to the general provisions
a licab to rcrinits contained on this form
The Public'Works Department(360-458-840b)tTi st be eoritaetc (_or ins ie tioii lio t before wwork
iwornmences or this germit will be v ` _
The Underground Utilities Coordinating Council (1-800-424-5555)must be contacted two (2)working day-
s
edrn ;with anyexcavation associated with this perrnrt
before roc.. ..,, .� ,. _._�. �...
e
Nai P
_ '"'"
Address. �. . dlione .
' � w w .
F'ro osed sttirtin date of installation i Duration 3 l
_,. ..
Date: 2lG Signatures
PERMIT RE U]REMENTS
oil
For Official Use Only
Fee Recerv...... _. __. _M.
Fee$ Issued
ed Application Approval
_ __ .
Receipt Number Si nature: -
.. ._ ..w... g P ._._ o Be om ►leted By C�tY ,ect tra-the encral _ov" " ns Data
Perm ission is hereby ranted to perform the above described work sii„ g contained
on t h_is form,and the followwiµnLL E ial conditions:
nd in the amount of is required to insure compliance with the above
conditions.refundable ri n satisfactory cons on 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:
C
First[ns ecti on Project t
Date: _o A Proyal .. m ..�
_.n .. ... ...
Revised 03/09/2011
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