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• Vo �QO-4-1-qv <br /> Pacific Gas and Field Paving Form Permit Number: <br /> Electric Cotnpany Permit Expiration Date: <br /> Dater /,:, lP" Street Address: <br /> G s� P� Cross Street: <br /> Foreman Name: i <br /> PM Number: ✓ l d ��' City/County: �J� <br /> Concrete VV is L Depth <br /> Roadway _inches <br /> Sidewalk _inches Color:Y I N j Aggregate:Y I N ( DecoralivelStemped:Y I N <br /> Sidewalk _inches Color:Y I N (Aggregate:Y I N ! DecoraUve/Stamped:Y I N <br /> Driveway —inches Color:Y I N ( Aggregate:Y I N ! DecorativelSiamped:Y I N <br /> Driveway —inches Color:Y-i N j Aggregate:Y I N ( Decorative/S#amped:Y I N <br /> Curb Ramp Domes:Y I N <br /> Curb If Gutter:Y I N <br /> Valley Gutter If <br /> Dowels ea Size:#41 #5 <br /> Asphalt W x L Depth Adjust/Replace <br /> Alpha (p 7 *inches Manhole Frame ea <br /> Mill&Fill —inches Sidewalk Gas Valve Box ea <br /> Asphalt I Concrete Combo ,_'over_` Secondary Electrical Box ea 13'x 24'1 17'z 30'124'x 36' <br /> Grind . _inches Valve Frame- ea 15' 123' <br /> Asphalt Fabric Valve Cover lea 30'x 30'132'x 32'148'x 48' <br /> Asphalt Berm I Curb If <br /> Saw Cut Depth Other W x L <br /> AsphalIf inches Place Paver I Stone I Brick In Concrete:Y I N <br /> Concrete � _.if —inches Traffic Marker bots ea Reflective:Y 1 N <br /> Seal W x L Plug 1 Y2 Gas Prospect Hole ea Concrete I Asphalt <br /> Slurry/Fog l Sand CT <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 iff 4'18'112'Crosswalk <br /> . rLLI�0 <br />