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Pacific Gas and Field Paving Form Permit Number: <br /> I4'CtTl CUtlijl2tijr' Permit Expiration Date: _ <br /> Date: _ _ Street Address: <br /> Foreman Name: _ L i°',r Street: to y f <br /> 7 — <br /> PM Number: ci _3t Ci ounty: i} uc-„ t) <br /> Concrete W x L Depth <br /> Roadway `inches <br /> Sidewalk _inches Color:Y/N Aggregate:Y/N Decora`ive!slarrped:Y/N <br /> Sidewalk inches Color:Y I N Aggregate:Y I N Decorative/Stamped:Y/N <br /> Driveway inches Calor:Y/N Aggregate:Y/N Decorative/Stamped:Y/N <br /> Driveway inches Color:Y/N Aggregate:Y/N Decorative!Stamped:Y/N <br /> Curb Ramp Domes:Y!tV <br /> Curb If Gutter:Y/N <br /> Valley Gutter If <br /> Dowels ea Sive:#-4,1 #5 <br /> Asphalt W x L Depth Adjust/Replace <br /> Asphalt inches Manhole Frame ea <br /> I'All&Fill inches Sidewalk Gas Valve Box ea <br /> Asphalt 1 Concrete Combo _ over Secondary Electrical Box ea 13'x 24' 17"x 30"J 24°x 36" <br /> Grind inches Valve Frame ea 15" 1 23" <br /> Asphalt Fabric Valve Cover — ea 30"x 30"132'x 32"1 48'x 48' <br /> Asphalt Berm/Curb if - <br /> Saw Cut Depth Other W x L <br /> Asphalt if inches Place Paver/Stone/Brick In Concrete:Y/N <br /> Concrete If inches Traffic Marker Dots ea RefleCive:Y/1`1 <br /> Seal W x L Plug 1 %'Gas Prospect Hole ea Concrete Asphalt <br /> Slurry/Fog/Sand <br /> Striping Width Notes <br /> Paht If --inches <br /> Thermoplastic If __inches <br /> Traffic Legend ea <br /> Double Center Lane if <br /> 31`0"Scotch Lane' If 4'18'112"Crosswalk <br /> Ir <br /> _t I <br /> I <br />