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r i � PalForm Permit Number: - • <br /> / Permit Expiration Date: <br /> Date: Street Address:ZlS6 1�0u1'!4 �'""7 <br /> Foreman Name: <br /> PM Number: Cross Street: <br /> - 3//Q9��� � Ci County: <br /> Concrete W x L Depth <br /> Roadway —inches <br /> Sidewalk _inches Color:Y/N Aggregate:Y/N Decorative/Stamped:Y/N <br /> Sidewalk —inches Color:Y/N Aggregate:Y/N Decorative/Stamped:Y/N. <br /> Driveway — <br /> Drivewainches Color:Y/N Aggregafe:Y/N Decorative/Stamped:Y/N <br /> y —inches Color:Y/N Aggregate:Y/N Decorative/Stamped:Y/N <br /> Curb Ramp Domes:Y/N <br /> Curb If Gutter:Y/N <br /> Valley Gutter If <br /> Dowels ea Size:#4 1 #5 <br /> Asphalt W x L Depth Adjust[Replace <br /> �Fii <br /> inches Manhole Frame <br /> I inches S <br /> idewalk Gas Valve Box ea <br /> Asphalt/Concrete Comboea <br /> Grind inches Valve Frame <br /> over_' Secondary Electrical Box ea 13"x 24"�17"x 30"124"x 36" <br /> — <br /> Asphalt Fabric ea 15" 23" <br /> Valve Cover ea 30"x 30"132"x 32"148"x 48" <br /> Asphalt Berm/Curb If <br /> Saw Cut Depth <br /> Other W x L <br /> Asp alt If Q.inches Place Paver/Stone/Brick <br /> oncrete In Concrete:Y/N <br /> If inches Traffic Marker Dots <br /> FP41 <br /> Seal ea Reflective:Y/N <br /> W x L <br /> Slurry/Fog/Sand Plug 1%"Gas Prospect Hole <br /> P ea Concrete Asphalt <br /> Striping Width <br /> Notes <br /> Paint If _inches <br /> Thermoplastic If _inches <br /> Traffic Legend ea <br /> Double Center Lane If <br /> 3M"Scotch Lane" If 4" 8" 12"Crosswalk <br /> i <br /> 5' <br />