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20160334 ROW Permit 09212016City of Yelm PUBLIC WORKS 901 Rhoton Rd NW Yelm, WA 98597 Phone: 360- 458 -8406 FAX: 360 - 458 -8417 Permit No. Zoi V 0 33 y Application to Perform Work on Public Right of Way and /or Connect to Utilities APPLICATION The undersigned hereby makes application to: Emer gency Work - Completed 9/1/16 Car Pole Accident - replace 45' Pole No asphalt cut or Trenching job #186574526 Location of work: 16125 Railway Rd. SE, Yelm I agree to perform the work in strict compliance with Yelm Municipal Code, Chapter , the special 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 permit will be void. The Underground Utilities Coordinating Council (1- 800 - 424 -5555) must be contacted two (2) working days before proceeding with any excavation associated with this permit. Name: Puget Sound Energy Potelco, INC Address: 2711 Pacific Ave SE, Olympia, WA 98506 Phone: 253- 306 -2255 Proposed starting date of installation Duration: Date:q Signature: it'/\ PE UIREMENTS For Official Use Only Fee $ C, _ Issued Fee Received $ Z Application Approval Signature: Receipt Number To Be Completed By Ci Permission is hereby granted to perform the above described work subject to the general provisions 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 upon satisfactory completion 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: First Inspection Date:, - Inspector Final Project Completion Approval: Date: Revised 03/09/2011 } 4mot < =.c= z x <( 2 $ }%! o) j }$ | ƒ x y W !!)j §! \ )k \ ) ( / 2 :am \) \ \ b LL /�) \ \E k } $ �� } t� C) » \ \ { )( q i § ( ƒ a 7 `! m ) k( @ § / 4mot < =.c= E ®�� 2 $ }%! o) z | § y W !!)j §! \ ) ( \ \ \ \ |! , ! $ \ \ \ \ \ u \)\ \)^ /§� p! «& y/ / ( m � � «! . ] I� �! y a� ��. � . } /\ ƒ2 3p 4mot < =.c= E ®�� 2 o) -11 | § !!)j §! / ( m � � «! . ] I� �! y a� ��. � . } /\ ƒ2 3p i w, n Railway Road Southeast, N Th ehformationon the aft ached map is subject tochange Pm pert yof Puget So Lind Energy A without notice. Puget Sound Energy makes no re presentati Maps, Records and Technology Pt,'GE7 SOUND ENERGY PSE Web Map or warranty of suitability of this information for any purpose. 355 110th NE, BELLEVUE, WA, 98004 � This map is not to be used for determining the actual location NAD_1983 St ate Plan e_Washington North FIPS_4601_Ft o o.00�so.ms 0.03 of any PSE facilities. Copyright ©2012.All rights reserved Date: 9172016 Reference Scale: l:0 Miles City of Yelm Community Development Department Building Division Phone: (360) 458 -8407 Fax: (360) 458 -3144 Applicant: Name: PSE POTELCO, OLYMPIA Address: 2711 PACIFIC AVE SE OLYMPIA WA 98506 Property Information: Site Address: 11n17r% RA11 WAV On CG Assessor Parcel No.: 64303601200 Subdivision: Contractor Information: Name: PSE POTELCO, OLYMPIA Address: 2711 PACIFIC AVE SE OLYMPIA WA 98506 Contractor License No.: Permit No.: 20160334 Issue Date: 9/21/2016 (Work must be completed within 180 days) Phone: 253 - 306 -2255 Owner: Phone: Expires: 0 /00 /0000 Lot: Project Information: Project: UTILITY Description of Work: EMERGENCY WORK - COMPLETED SEPT 1, 2016. CAR POLE ACCIDENT, REPAIRED 45 FT POLE. NO ASPHALT CUT OR TRENCHING. JOB #186574526 Sq. Ft. per floor: First Heat Type (Electric, Gas, Other): Second Third Garage Basement Fees: Item RIGHT OF WAY Contractor PSE POTELCO, OLYMPIA TOTAL FEES: Applicant's Affidavit: I certify that I have read and examined the information contained within the application and know the same to be tru@ a ec . a certify that the proposed structure is in conformity with all applicable City of Yelm regulations including th se governing zoning and land subdivision, and in addition, all covenants, easements an estriction f record. If applying as a contractor, I further certify that I am currently registered in t e State qtWashington. 1 Signatur Date l' lz� - Firm 67— Fees $ 125.00 $ 125.00 OFFICIAL USE ONLY # Sets of Prints: Final Inspection: Date: By: Cite of Yelm (36 0 458 -3244 RES : 00244622 9/21/2016 9:08 AM OPER: CO TERM: 001 REFV 832524 PAID BY: TRAM: 33.0000 BUILDING PERMIT'S 20160334 125.0(CR PSE POTELCO, OLYMPIF 16125 RAILWAY RD SE ROW 125.0(CR TENDERED: 125.00 (HECK. APPLIED: 125.00- CHANGE: 0.00