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r 5.3. C, <br /> 1� V <br /> 1 <br /> d ?,sg� �Hedy` Field Paving Form <br /> Permit Number: <br /> Permit Expiration Date: <br /> GG C� r <br /> Date: "" l L Street Address: / O / 7> 61A c/- 56 <br /> Foreman Name: Potl 6 C 00 U140 Cross Street: M (- <br /> PM Number: I13$l3,3 Ci County 1 j:d d e e 5�C <br /> Concrete W x L Depth <br /> Roadway _inches <br /> Sidewalk _inches Color:Y I N Aggregate:Y/N Decorative/Stamped:Y I N <br /> Sidewalk _inches Color:Y I N Aggregate:Y/N Decorative/Stamped:Y/N <br /> Driveway _inches Color:Y I N Aggregafe:Y/N Decorative/Stamped:Y I N <br /> Driveway _inches Color:Y/N Aggregate:Y/N Decorative/Stamped:Y I N <br /> Curb Ramp Domes:Y/N <br /> Curb If Gutter:Y/N <br /> Valley Gutter If <br /> Dowels ea Size:#41 #5 <br /> As halt W x L Depth Adjust/Replace <br /> Asphalt / inches Manhole Frame ea <br /> Fill _inches Sidewalk Gas Valve Box ea <br /> Asphalt 1 Concrete Combo _"over_" Secondary Electrical Box ea 13"x 24" 17"x 30"124"x 36" <br /> Grind _inches Valve Frame ea 15" 123" <br /> Asphalt Fabric Valve Cover ea 30"x 30"132"x 32"148"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 I N <br /> oncrete �if _inches Traffic Marker Dots ea Reflective:Y/N <br /> Seal W x L Plug 1%"Gas Prospect Hole ea Concrete Asphalt <br /> Slurry/Fog/Sand L� <br /> Striping Width Notes <br /> Paint If _inches <br /> Thermoplastic If _inches <br /> Traffic Legend ea <br /> Double Center Lane If <br /> 3M"Scotch Lane" If 4"18"112"Crosswalk <br /> 5 <br />