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t 50 " 'as Permit Number. <br /> '-.� �"�-� a;�� Field Paving Form <br /> Permit Expiration Date: <br /> Date: l ©� `�� � ��� Street Address: IPA 0t`-U <br /> c3 c, <br /> Foreman Name: :\,J Cross Street: C o L�e— <br /> PM Number. `� �d 1 S City/County: <br /> Concrete W x L Depth <br /> Roadway _inches <br /> Sidewalk inches Color,Y 1 N j Aggregate:Y I N j DeoorativelStamped:Y!N <br /> Sidewalk —___,inches Color,Y I N Aggregate:Y/N ] Decorative/Stamped:Y I N <br /> Driveway —inches Color.Y I N Aggregate:Y/N j Decorative/Stamped:Y I N <br /> Driveway _inches Color Y/N j Aggregate:Y/N ] Decorative/Stamped:Y/N <br /> Curb Ramp Domes:Y I N <br /> Curb If Gutter.Y/N <br /> Valley Gutter If <br /> Dowels ea Size:441 #5 <br /> Asphalt W x L Depth Adjust/Replace <br /> Asphalt 3 inches Manhole Frame ea <br /> Mill&Fill __inches Sidewalk Gas Valve Box ea <br /> Asphalt/Concrete Combo over _" Secondary Electrical Box ea 13"x 24" 17"x 30" 24"x 36" <br /> Grind _inches Valve Frame ea 15" 1 23" <br /> Asphalt Fabric Valve Cover ea 30'x 30"1 32"x 32"148"x 48" <br /> Asphalt Berm/Curb If <br /> Saw Cut Depth Other W x L <br /> Asphalt If inches Place Paver I Stone/Brick In Concrete:Y/N <br /> Concrete �If inches Traffic Marker Dots ea Reflective:Y 1 N <br /> Seal W x L Plug 1 Y2 Gas Prospect Hole ea Concrete j Asphalt <br /> Slurry/Fog/Sand W <br /> Striping Width Notes <br /> Paint If inches <br /> Thermoplastic If —inches <br /> Traffic Legend ea <br /> Double Center Lane If <br /> 3M"Scotch Lane" If 4"18"112"Crosswalk <br /> j 7 <br /> 1 <br /> D c) a. Cl ct Y0 I <br /> I <br />