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1 i ll�a�sPw� c�cirJf <br /> Field Paving Form Permit Number: <br /> —erk-Corrspa-juY Permit Expiration Date: <br /> Date: Y— Street Address: <' <br /> Forernan Naane: n ' Dross St eet: -� � 'ME�:ti <br /> PM Number: 3 I I_L47-7$Z os' <br /> Concrete W 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/N Decorative/Stamped:Y I N <br /> Driveway inches Color:YIN Aggregafe:Y/N Decorative/Stamped:Y I N <br /> Driveway inches Color:Y/N Aggregate:Y/N Decorative/Stamped:Y/N <br /> Curb Ramp Dorn es:Y I N <br /> Curb If Gutter:Y/N <br /> Valley Gutter If <br /> Dowels ea Size: ? ;r5 <br /> Asphalt W x L Depth Adjust[Replace <br /> Asphalt inches Manhole Frame . ea <br /> Mill&Fill _inches Sidewalk Gas Valve Box ea <br /> Asphalt I 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"1 32"x 32"1 48'x 48" <br /> Asphalt Berm I Curb If <br /> Sari Cut Depth other W x L <br /> Asphalt �If —inches Place Paver I Stone/Brick In Concrete:Y/N <br /> Concrete If —inches Traffic Marker Dots ea Reflective:Y/N <br /> Seal W x LPlug 1%"Gas Prospect Hole ]ea <br /> Concrete Asphalt <br /> Slurry/Fog/Sand <br /> Striping Width Notes <br /> Paint If _inches <br /> Thermoplastic If —inches <br /> Traiiic Legend ea <br /> Double Center Lane if <br /> 3M"Scotch Lane" If 4" 8"112"Crosswalk <br /> �, 5 4 <br />