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Pacific Gas and Field Paving Form Permit Number: <br /> l; Electric Company Permit E=xpiration Date: <br /> Date: t — � <br /> Street Address: C" <br /> Foreman Name: _ C--Ar 1 S,i Cross S t-` Ot <br /> PM Number: Z01 IN Ci County: <br /> Concrete W x L Depth <br /> Roadway _,inches <br /> Sidewalk —inches Color:Y I iJ Aggregate:Y I N l Decorative/Stamped:Y I N <br /> Sidewalk _._,inches Color:Y I N Aggregate:Y I N Decorative/Stamped:Y I N <br /> Driveway _inches Color:Y I N Agg regale:Y/N j Decorative/Stamped:Y/N <br /> Driveway _inches Color:Y I N Aggregate:Y I N DecoragvelStamped:Y I N <br /> Curb Ramp Domes:Y I N <br /> Curb If Gutter:Y 1 N <br /> Valley Gutter if <br /> Dowels ea Size:#41 #5 <br /> Asphalt W x L Depth Adjust/Replace <br /> Asphalt 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' 1 Tx 30'124'x 36° <br /> Grind _inches Valve Frame ea 15" 123' <br /> Asphalt Fabric Valve Cover ea 30°x 30'132'x 32'148'x 48" <br /> Asphalt Berm 1 Curb If <br /> Saw Cut Depth Other W x L <br /> p a ;, If . inches Place Paver/Stone I Brick In Concrete:Y I N <br /> Concrete =If _inches Traffic Marker Dots ea Reflective:Y/N <br /> Seal W x L. .` Plug t Yz Gas Prospect Hole ea Concrete l Asphalt <br /> Slurry/Fog I Sand <br /> Striping :Width Notes <br /> Paint 7 If inches <br /> Thermoplastic If _inches <br /> Traffic Legend ea <br /> Double Center Lane If <br /> 3M'Scotch Lane° If 4'18' 12'Crosswalk <br />