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S. ZYc, <br /> Pay ifi,-Ga, G�.�` <br /> Field Paving Form Permit Number: <br /> (� L-Iar do Cora anY tt Permit Expiration Date: <br /> Date: 4-0 Street Address: I« .M oro <br /> Foreman Name: Cross Street: Urh,:!c7PM Number: 4Z2✓U 7011O ✓�JG <br /> Concrete W x L Depth <br /> Roadway _inches <br /> Sidewalk _inches Color:Y/N Aggregate:Y/N I Decorative/Stamped:Y/N <br /> Sidewalk _inches Color:Y/N Aggregate:Y/N I DecorativelStamped:Y/N <br /> Driveway _inches Color:Y/N Aggregate:Y/N Decorative/Stamped:Y/N <br /> Driveway _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 /> AsDhalt W x L Depth Adjust/Replace <br /> Asphalt 2 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 /> Asphalt If 14 inches Place Paver/Stone/Brick In Concrete:Y/N <br /> Asphalt <br /> �If _inches Traffic Marker Dots ea Reflective:Y/N <br /> Seal W x L Plug 1 W Gas Prospect Hole ea Concrete Asphalt <br /> Slurry/Fog 1 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 /> r4c <br /> h - <br /> S4,,PVnh,-� ale aS& �� ------- <br />