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4.45'*f-'5-11 PERMIT FIELD CHICKLIST <br />PM#44W� USA# SUBMITTED BY: 40�11 DATE: 62A /2 / <br />PERMIT FOR: <br />NB O G ❑ (or) E ❑ EMERG ❑ LK>e(GRADE): -a- GPRP ❑ CPRP ❑ <br />IF EMERGENCY, IS WORK COMPLETED ALREADY? YES ❑ NO ❑ (DATE)? <br />SCHEDULED DATE: <br />DATE PERMIT REQUIRED: L <br />• AGENCY Q COUNTY, CALTRANS, OTHER): <br />• VERBAL AUTHORIZATION OBTAINED: YES ❑ NO © — <br />• (DATE/TIME/CONTACT)? <br />• LOCATION (INCLUDE DIMENSIONS FROM PROPERT LINE, AREST CROSS STREET, CURB OR LANDMARKS) <br />• DIMENSIONS FOR EXCAVATION (W x L x D): 4 X T <br />• ASPHALTXCONCRETE O BOTH ❑ NO PAVING ❑ <br />• DIMENSIONS FOR RESTORATION (IF ASPHALT, INCLUDE ADDITIONAL FOOTAGE FOR "T" TRENCH OR OVERLAY. <br />IF CONCRETE SIDEWALK, INCLUDE FOOTAGE FOR ENTIRE FLAG OR NEARESTJOINT) N/A <br />• SIDEWALK CLOSURE REQUIRED? YES ❑ NO Lt- <br />-. <br />BIKE LANE CLOSURE REQUIRED? YES ❑ NO Q� <br />• STREET CLOSURE REQUIRED? YES Cl NO LEr" <br />• LANE CLOSURE REQUIRED? YES.XNO ❑/ <br />• PARKING CLOSURE REQUIRED? YES El NO ff <br />• OTHER TRAFFIC IMPACTS? <br />• ANY RESTRIPING REQUIRED? YES ❑ NO 01-- <br />• TRAFFIC SIGNAL LOOP INVOLVED? YES ❑ NO l <br />• WILL "NO PARKING" SIGNS BE NEEDED? YES ❑ NO Ef <br />• OTHER COMMENTS TO FACILITATE PERMIT REQUEST? <br />3ph1 <br />V, .oi%aI0c-io <br />