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PERMIT FMLD CHECKLIST <br />PM# ggq'Lsu 9V USA# EKPIRES SUBMITI ED BY:IR,A�& <br />PERMIT FOR: <br />NB: G: or E: X EMERG• UCJGRAE: PRP; CPRP: , <br />OTHER <br />IF EMERGENCY, IS WORK COMPLETED ALREADY? YES, o NO o (DATE)? <br />Schedaaled Date <br />DATE PERMIT REQU _ CC <br />m AGENCY (CITY, OUN CALTRANS, OTHER): J J C-0 <br />® VERBAL AUTHORIZAOON OBTAINED YES ❑ NO ❑ <br />( DATE%TIME/CONTACT)? <br />DATE: <br />m LOCATION (INCLUDE DIMENSIONS FROM PROPERTY LINt, NEAREST CROSS STREET, CURB OR OTHER LANDMARKS <br />b DIMENSIONS FOR EXCAVATION (W x EX D) 4')c 4' <br />m ASPHALT�CONCRFTE�BOTHQNO PAVING <br />® DIMENSIONS FOR RESTORATION (IF ASPHALT, INCLUDE ADDITIONAL FOOTAGE FOR "F" TRENCH OR OVERLAY; IF <br />CONCRETE SIDEWALK. INCLUDE FOOTAGE FOR ENTIRE FLAG OR NEAREST JOINT) NIA <br />m . SIDEWAIKCLOSURF REQUIRED? YES,❑ NO\q <br />m BIKE,LANE CLOSURE REQUIRED? YES o NO <br />® STREET CLOSURE REQUIRED? YES o' NO'' <br />m LANE CLOSURE, PARKING STRIP OR OTHER TRAFFIC IMPACTS(Orcleff , <br />m _ ANY RE -STRIPING REQUIRED? YES ❑ NO'd�q , <br />® mTRAFFIC SIGNAL LOO P INVOLVED? YES -o NO <br />WILL "NO PARKING' SIGNS BE NEEDED? YES NO r\ <br />m .OTHER COMMENTS TO FACILITATE PERMIT REQUEST? - <br />N <br />