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(rasrurrl <br /> I, l:lnrarir.(:rrajurlp Field Paving Form Permit Number: <br /> Perm*Expiration Date: <br /> Date: 5 Street Address: zYs^ 6-e - <br /> rorornan Natno: sx c/ Cross Street: �V,1 SH;N�}/�,t <br /> PM Ntimber: ' `)'�' i!r `�'' - ?j E, ($to $ Clly/ ttni : G� / <br /> Cottcroto W x L Depth <br /> Roadway ._Inches <br /> Sidewalk —Inches Color:Y I N Aggregate:Y I N Decoraltve/Slamped:Y I N <br /> Sidewalk —Inches; ColorY/N Aggregate:Y/N Decorative/Stamped:Y I N <br /> Drnreway _,Inches Color:Y I N Aggregate:Y I N Deooralive/Stamped:Y I N <br /> Driveway `inches Color:Y/N Aggregate:Y/N DecoraNvelSiamped:Y/N <br /> Curb Ramp Domes:Y I N <br /> Curb If Gullet:Y/N <br /> Valley Gutter it <br /> Dowels ea Size:941#5 <br /> Asphalt W x L Depth Acljust/Roplaco <br /> Asphalt inches Manhole Frame ea <br /> Mill&Fill _Inches <br /> Asphalt/Concrete Combo Sidevralk Gas Valve Box a <br /> over Secondary Electrical Box ea 13'x 24'11 'x 30. 24'x 36' <br /> Grind Inches Valve Frame ea 15' 123' <br /> Asphalt Fabric Valve Cover ea 30'x 30'132'x 321148'x 48' <br /> Asphalt BermICurb If <br /> Saw Cut Depth Other W x L <br /> Asphalt If Inches PlacePaver 1 Slone 1 Brick In Concrete.Y/N <br /> Concrete if —Inches Traffic Marker Dols as Reflective:Y i N <br /> Seat W x L Plug I%'Gas Prospect Hole ea Concrete Asphalt <br /> Slurry/Fog i Sand L_= <br /> Strlpinn Width Notes <br /> Paint I! Inches <br /> Thermoplastic if ^inches <br /> Traffic Legend ea <br /> Double Center Lane if <br /> 3M'Scotch Lane If 4'(8' t2'Crosswalk <br /> i Fri <br /> { E I Cit <br /> ; i rr <br />