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�` A -7 p �j P E]E�14�IT FIELD CHECKLIST <br />PMttTJ Q1''( / FJ d'l1SAq SUBMITTED BY: �x DATE: 5 Z-/ <br />PERMIT FOR: <br />NB 0 G O (or) E 0 EMERG 0_ LK 0 (GRADE): GPRP 0 CPRP 0 <br />IF EMERGENCY, 15 WORK COMPLETED ALREADY? YES 0 NO 0 (DATE)? <br />SCHEDULED DATE: <br />DATE PERMIT REQUIRED: <br />• AGENCY (CITY, COUNTY, CALTRANS, OTHER): <br />• VERBAL AUTHORIZATION OBTAINED: YES 0 NO [r— <br />• (DATE/TIME/CONTACT)? <br />• LOCATION (INCLUDE DIMENSIONS FROM PROPERTY LINE, NEAREST CROSS STREET, CURB OR LANDMARKS) <br />• DIMENSIONS FOR EXCAVATION (W x L x D): �' P X <br />• ASPHALT,%� CONCRETE 0 BOTH 0 NO PAVING 0 <br />• DIMENSIONS FOR RESTORATION (IF ASPHALT, INCLUDE ADDITIONAL FOOTAGE FOR "T TRENCH OR OVERLAY. <br />IF CONCRETE SIDEWALK, INCLUDE FOOTAGE FOR ENTIRE FLAG OR NEAREST101NT) N/A <br />• SIDEWALK CLOSURE REQUIRED? YES 0 NO Q <br />• BIKE LANE CLOSURE REQUIRED? YES 0 NO CSI <br />• STREET CLOSURE REQUIRED? YES 0 NO C�r/ <br />• LANE CLOSURE REQUIRED? YES)(NO 0 <br />• PARKING CLOSURE REQUIRED? YES 0 NO Cel <br />• OTHER TRAFFIC IMPACTS? <br />• ANY RESTRIPING REQUIRED? YES 0 NO E;T / <br />• TRAFFIC SIGNAL LOOP INVOLVED? YES 0 NO ❑ <br />• WILL "NO PARKING" SIGNS BE NEEDED? YES 0 NO J <br />• OTHER COMMENTS TO FACILITATE PERMIT REQUEST? Fi <br />m <br />F07 <br />4 <br />la <br />11 �/Uisr RD - <br />vi <br />