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That <br /> 1. his/her he/she <br /> has read all the provisions of tis ap Cat , d tat#t . ' k4 e <br /> knowledge,and :r <br /> 2. That hetshe is the owner the respective proper <br /> 3. That helshe will assume full responsUity for Obalftforto,ppop; <br /> described above,or whin may arise out of Ns&er f*re to=do Ifs ' <br /> 4. That in the event any claim of such amity ismade the< <br /> thereof,he shah defend,in � . joe <br /> dA:rnnify and holt ttierui <br /> each Athena t niles5 ems; <br /> or <br /> 5. That work shall be performed b the ardltx any r of-ft 'our <br /> Indicated site with a n= and x <br /> 6. That if penacission" ted as rec ueste(t,he agrees to do the work th aoocrc ae <br /> of this and sheet,included or spetal Ill proves. ' <br /> o#Appllc�rf Title <br /> »»»»»»»»> »»»»»»»»»»»»FIELDINSPECT COAi 3 k««< ««<4<< < « << <e< c <br /> Ext C� <br /> 1. DRIVEWAY: None ❑ Dirt ❑ Gravel ❑ Aggregate Base '❑ Phi pr) ❑ Padj ❑.r, <br /> 2. SLOPING: Away from Pavement E] Towards Pavernent L� Flat❑ <br /> 3. PIPES: Norse a-Exisfing-Type <br /> Other pipes in neighborhood: Yes qe5 Dain Size <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETE DIKE: Yes ❑ No [ <br /> 6. BARRIERS: along Right-of--Way 'v <br /> 7. DITCH: Yes ❑ No 5 IfYes. V Style ❑ 2 Pant ❑ Other ❑ W <br /> »»»»»»»»»»»»»»»»»»»»»»»»PEWITS REQ= S <br /> 1. DRIVEWAY: SFR R'�~Commercial ❑ Agriculture ❑ Industrial ❑ <br /> Paved with 14, "Min Depth A.C.over 'Milt Depth%AB over <br /> 2. PIPES: Length of Pipe Required + t FL and Diarneter ofPipe ) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes No <br /> Total Length: (with proposed) Total Numt"of Storm Dart Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No B-11� , <br /> 4. PAVED FRONTAGE: Paved with ` ' "Min Depth A.C.over ' <br /> Measuring Feet in length and Feetth <br /> »»»»»»»»>>>>> <br /> Driveway Encroachment Pemtit base fee $125.00 p0 <br /> Field lnsDecbon 0,3 <br /> Driveway w/or w/o pipe $110.00 Paved Frontage <br /> Drivewaywlbox Culvert $179:00 ❑ Curb,Gutter, J" <br /> 11SJPWGOV.OR SVCLERlCAIiPUBSV. PEMUORKWAY= (440.19) PW242 <br />