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f 00.3 and Field Paving Form PermitNumlier: <br /> Ir c 9'antpany, Permit Expiration Date.. <br /> Date: Zb r I Street Address: 3 t7 I eb o It A q � <br /> Foreman Name: .�, �-a f l� -�v'•t� Cross Street: <br /> PM Number: 3f*l 7 Clty/ un 1b C.GT-O e7 <br /> Concrete W x L Depth <br /> Roadway _inches <br /> Sidewalk _Inches Color.Y/N I Aggregate:Y I N I Decorative/Stamped:Y I N <br /> Sidewalk —inches Color:Y/N j Aggregate:Y/N I Decorative/Stamped:Y I N <br /> Driveway _inches Color.Y I N I Aggregate:Y/N I Decorative/Stamped:Y/N <br /> Driveway inches Color.Y I N j Aggregate:Y I N j Decorative/Stamped:Y/N <br /> Curb Ramp Domes:Y/N <br /> Curb If Gutter.Y/N <br /> Valley Gutter if <br /> Dowels ea Size:#41 #5 <br /> Asphalt W x L Depth AdjustlReplace <br /> Asphalt A inches Manhole Frame ea <br /> Mill it Fill _inches Sidewalk Gas Valve Box ea <br /> Asphalt/Concrete Combo _'over= Secondary Electrical Box ea 13'x 24'j 17'x 30'124*x 36" <br /> Grind —inches Valve Frame - ea 15' 123' <br /> Asphalt Fabric Valve Cover ea 30'x 30'1 3Tx 32'148'x 48' <br /> Asphalt Berm I Curb If <br /> Saw Cut Depth Other W x L <br /> Asphalt If _Inches Place Paver I Stone 1 Brick in Concrete:Y/N <br /> Concrete �If _inches Traffic Marker Dots ea Reflective:Y I N <br /> Seal's W x L Plug 1 Y2'Gas Prospect Hole ea Concrete j Asphalt <br /> Slurry I l=og/Sand <br /> Striping Width Notes <br /> Paint If _inches <br /> Thermoplastic if —inches <br /> Traffic Legend ea <br /> Double Cenler Lane if <br /> 3M'Scotch Lane' If 4'18'I f2'Crosswalk <br /> L <br />