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�, Field Pavinompxjy, g Form Permit Number: <br /> Permit Expiration Date: <br /> Date: q b Street Addlress.�T�2�0�f�� l'� (,l�� ►r �^y . <br /> Foreman Name: 1 J' Cross Street: xrvti�� <br /> PM Number: _ 1�4 <br /> Cay(5 c5 1 r � <br /> GoncreteW 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 I N Decorative/Stamped:Y/N <br /> Driveway —inches Color:Y/N Aggregafe:Y I N Decorative/Stamped:Y/N <br /> Driveway _inches Color:Y/N Aggregate:Y/N Decorative/Stamped:Y I N <br /> Curb Ramp Domes:Y/N <br /> Curb mc <br /> f Gutter:Y/N <br /> Valley Gutter f <br /> Dowels a Size:9 1 +5' <br /> Asphalt W x L Depth Adjust(Replace <br /> Asphalt G Gi inches Manhole Frame <br /> ea <br /> Mill&Fill —inches Sidewalk Gas Valve Boxea <br /> Asphalt/Concrete Combo _"over—" Secondary Electrical Box ea 13"x 24" 17"x 30" 24"x 36" <br /> Grind —inches Valve Frame ea 15" 23' <br /> Asphalt Fabric Valve Cover ea 30"x 30" 32"x 32".148 x 48' <br /> Asphalt Berm/Curb If <br /> Saw CW Depth Other W x L. <br /> Asphalt F <br /> If -inches Place Paver/Stone l Brick In Concrete:Y/N <br /> Concrete If inches I rafnc Marker Dots ea Reflective:Y/N <br /> Seal W x L Plug 1 %2'Gas Prospect Hole <br /> Ilea Concrete Asphalt <br /> Slurry/Fog/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" 12"Crosswalk <br /> L <br /> � • i <br />