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Nur:ilir.Hns;turl Heid Paving Form Permit Number: <br /> IF . . I — - I lar-at ir,Cnurj�ruty � <br /> Permit Expiration Oate: <br /> Date: _—'5-- —/5— Street Address: _ 00 G'4d4laLJZ <br /> Forertian Naime: Cross Street: �. W,¢S 6TD,r.� <br /> PM NunUrer: �'Ze ?�y� Clly oust : _ STdC�TO� j <br /> Concroto W x L Depth <br /> i <br /> Roadvtay ____inches i <br /> Sidevralk —Inches Color:Y/N Aggregate:Y/N Decotalive/Stamped:Y I N <br /> Sidewalk —inches Coloi:Y/N Aggregate:Y/N DecorativelSlamped:Y/N <br /> Drivevmy ^Inches Color:Y/N Aggregate:Y/N Oecoralive/Slamped:Y/N <br /> Drive%vay inches Color:Y/N Aggregate:Y/N j DecorativelStamped:Y I N <br /> Curb Ramp Domes:Y 1 N <br /> Curb If Gullet:Y/N <br /> Valley Gut(er If <br /> Dovrels lea Size:#4 1115 <br /> Asphalt W x L Depth Adjust/Replace <br /> Asphalt yam" Inches Manhole Frame ea <br /> Mill&Fill Inches Sidevralk Gas Valve Box ea <br /> Asphalt/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 30'1 32'x 32'148'x 48' <br /> Asphalt eerm/Curb (( <br /> Saw Cut Depth Other W x L. <br /> Asphalt If --F—inches Place Paver/Stone/Brick In Concrete:Y I N <br /> Concrete it inches Traffic Market Dols ea Reflective:Y/N <br /> Seal W x L Plug 1%2'Gas Prospect Hole flea Concrete Asphalt <br /> Slurry I Fog/Sand �7 <br /> Strlplu0 Wldtlr Notes <br /> Paint If inches <br /> Thermoplastic If _Inches <br /> Traffic Legend ea <br /> Double Center Lane If <br /> 3M'Scolcir Lane' It 4'(8'112,Cross►valk <br /> V14 <br /> i <br /> I t <br />