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1 <br /> f;rrifia Gas wid �;�� Paving l FormPermit Number: <br /> F j <br /> l. lYucrrrr;I;nJJJIi;aJJy Permit Expiration Date: <br /> Date: ®`�� Street Address: _J d Ce✓rf'lld— <br /> Foreman Name: Gros�Str t: <br /> PM Number: - tS �_ /County: <br /> Concrete W x L Depth <br /> Roadway _inches <br /> Sidewalk _inches Color:Y/N Aggregate:Y/N I Decora.livelSlamped:Y/N <br /> Sidewalk _inches Color:Y/N Aggregate:Y/N Decorative/Stamped:Y I N <br /> Driveway —inches Color:Y/N I Aggregate:Y/N Decorative/Stamped:Y/N <br /> Driveway _inches Color:Y/N l Aggregate:Y/N I DecorativelStamped:Y/N <br /> Curb Ramp Domes:Y/N <br /> Curb If Gutter:Y/N <br /> Valley Gutter It <br /> Dowels ea Size:#4 45 <br /> "It W x L Depth Adjust/Replace <br /> (� <br /> Asphalt inches Manhole Frame ea <br /> Fill _inches Sidewalk Gas Valve Box ea <br /> Asphalt/Concrete Combo _'over_" Secondary Electrical Box ea 13'x 24'(17'x 30'124'x 36" <br /> Grind —inches Valve Frame ea 15' 123' I <br /> Asphalt Fabric Valve Cover lea 30'x 30'132'x32'148'x48' <br /> Asphalt Berm J Curb If <br /> Saw Cut Depth Other W x L <br /> Asphalt If inches Place Paver/Slone!Brick In Concrete:Y I N <br /> Concrete �If _inches Traffic Marker Dots ea Reflective:Y/N <br /> Seat W x L Plug i %2 Gas Prospect Hole ea Concrete Asphalt <br /> Slurry/Fog/Sand <br /> Striping Width Notes 1 <br /> i <br /> Paint If _inches j <br /> Thermoplastic If inches <br /> Traffic Legend ea <br /> Double Center Lane If <br /> 3M'Scotch Lail e" If 4' 8'112'Crosswalk <br /> I <br /> �10 0 <br /> G0 e <br /> 5/ <br /> w <br /> 3 <br /> �-ry �l3►f�� <br />