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PERM I IT FIELD CHECKLIST <br />44i�2SIsr I <br />PM# USAr{ EXPIRES , SUBMITTED BY: Tjyf36 DATE: ILl2`� I'J,o <br />PERMIT FOR: <br />NB:© or E: X EMERG: LK/GRADE: GPRF, CPRP: <br />OTHER <br />IF EMERGENCY, IS WORK COMPLETED ALREADY? YES. ❑ NO o(DATE)7 <br />Scheduled Dore <br />DATE PERMIT REQUIRED:_ _ <br />a AGENCY (CRY UN CALOTRANS, OTHER): S'• Co <br />a VERBAL AUTHORIZATION OBTAINED YES -o NO ❑ <br />(DATE/TIME/CONTACT)? <br />® LOCATION (INCLUDE DIMENSIONS FROM PROPERTY LINE, NEAREST CRgSS STREET, CURB OR OTHER LANDMARKS <br />e DIMENSIONS FOR EXCAVATION(Wx L x D) 4-', 1L b <br />® ASPHALT,®CONCRETCBOTHONO PAVING <br />® DIMENSIONS FOR RESTORATION (IF ASPHALT, INCLUDE ADDITIONAL FOOTAGE FOR' T"TRENCH OR OVERLAY; IF <br />CONCRETE SIDEWALK. INCLUDE FOOTAGE FOR ENTIRE FLAG OR NEAREST JOINT) N/A <br />® SIDEWALK CLOSURE REQUIRED? YES.❑ NO Lk <br />g BIKE LANE CLOSURE REQUIRED? YES ❑ NO q <br />® STREET CLOSURE REQUIRED? YES o NO o, <br />m LANE CLOSURE, PARKING STRIP OR OTHER TRAFFIC IMPACTS(Orclefi' <br />a _ ANY RE -STRIPING REQUIRED? YES ❑ NO T <br />® + TRAFFIC SIGNAL LOOP INVOLVED? YES ❑ NOS ' <br />® WILL "NO PARKING" SIGNS BE NEEDED? YES NO m, <br />a .OTHER COMMENTS TO FACILITATE PERMIT REQUEST? <br />J✓ \\CPI Cn Gam, <br />�E <br />b s <br />\ 4 <br />f <br />Ib <br />