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t/) paoiiL-Gas arwil, Field Paving Form Permit Number: <br /> 1 c t3aa'ifrio riaarnpan <br /> Permit Expiration Date: <br /> Date: '��"�✓� Street Address: / -16V - <br /> Foreman Name: _ Cross Street: 1700, Ss�' <br /> PM Number: '452-1-TS City oun �►�� <br /> Concrete W x L Depth <br /> Roadway _inches <br /> Sidewalk _inches Color:Y/N I Aggregate:Y I N I Decorative/Stamped:Y I N <br /> Sidewalk _inches Color:Y/N I Aggregate:Y I N I Decorative/Stamped:Y/N <br /> Driveway _inches Color:Y/N I Aggregate:Y I N I Decorative/Stamped:Y/N <br /> Driveway _inches Color:Y/N I Aggregate:Y I N I DecorativelStamped:Y/N <br /> Curb Ramp Domes:Y I N <br /> Curb If Gutter:Y I N <br /> Valley Gutter If <br /> Dowels ea Size:#41 #5 <br /> Asphalt W x L Depth AdjustlReplace <br /> Asphalt `t inches Manhole Frame ea <br /> Mill&Fill _inches Sidewalk Gas Valve Box ea <br /> Asphalt/Concrete Combo _"over_" Secondary Electrical Box ea 13"x 24"117"x 30"124"x 36" <br /> Grind _inches Valve Frame ea 15" 1 23" <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 /> i <br /> Asphalt Blf —1 inches Place Paver I Stone I Brick In Concrete:Y I N <br /> Concrete If inches Traffic Marker Dots ea Reflective:Y/N <br /> Seal W x L Plug 1 W Gas Prospect Hole ea Concrete I Asphalt <br /> Slurry I Fog I Sand <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 /> V <br />