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COON ry OF -S "-QUiN <br />DEPARTMENT OF PULIC WORKS <br />DRIVEWAYS AND PAVED FRONTAGES <br />PERMIT APPLICATION <br />P5 -zeb <br />APPLICANT <br />_,. <br />Name: c��., k S✓L� C <br />Address: , _. O <br />City, State, Zip Code: <br />Area Code -Telephone Number: <br />SITE INFORMATION: <br />Parcel Owners Name: k <br />Site Address: I12cen 9eir4tp,4s ' <br />City, State, Zip Code: <br />3 <br />Area Code -Tele hone Number: <br />`5-7 –S-7 <br />CONTRACTOR <br />Name: <br />Address: <br />City, State Zip Code: <br />Area Code -Tele hone Number: <br />41 <br />Date: I1/la D2� <br />Received By: �— W <br />CR#: <br />The undersigned hereby app lie jos or permissio to excav e, construct andfor otherwise encroach on County Highw ight-of-W on the <br />side of o nnr� proximately 2 tee ile Say <br />of f Jl� \ vA a _ , by installing <br />commence on or <br />for approximately <br />days. <br />Work will <br />SKETCH (Separate sheet may be submitted) <br />JJJ3 �--� <br />9� <br />Will this project be self -installed? YES NO Contractor's License <br />MNCRNC TN15'W [W:NRA wVEMT mlN ykyY If % <br />OFFICE USE ONLY <br />J013 #: <br />11005 ISSUE DATE: <br />APN h 105130 11— FEE DUE: <br />EXP, DATE: <br />DRIVEWAYS: <br />STREET: N <br />LEM Nig <br />AREA: _ r <br />b e -Al A/ QUAD At 1v <br />TYPE: 2W <br />�4FP0444 <br />FORMS: S <br />NOTES: <br />DRIVEWAY <br />TYPE: <br />RYANTITY <br />WIDTHS <br />AGRICULTURE: <br />a FRONTAGE <br />COMMERCIAL: <br />_ <br />INDUSTRIAL: <br />RIW <br />RESIDENCE: <br />PAVED FRONTAGE <br />LENGTH: <br />FL X WIDTH: Ft. <br />The undersigned hereby app lie jos or permissio to excav e, construct andfor otherwise encroach on County Highw ight-of-W on the <br />side of o nnr� proximately 2 tee ile Say <br />of f Jl� \ vA a _ , by installing <br />commence on or <br />for approximately <br />days. <br />Work will <br />SKETCH (Separate sheet may be submitted) <br />JJJ3 �--� <br />9� <br />Will this project be self -installed? YES NO Contractor's License <br />MNCRNC TN15'W [W:NRA wVEMT mlN ykyY If % <br />