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Held Pacing Form Permit Number: <br /> ft�rr I ` ''' Permit Expiration Date: <br /> Date: Street Address: 7 Wphb ~ <br /> Foreman Name: 66 Gross Street: eb, <br /> PM Number: City oun_ <br /> Concrete W x L Depth <br /> Roadway _inches <br /> Sidewalk _inches Color:Y I N J Aggregate:Y/N J Decorative/Stamped:Y l N <br /> Sidewalk _inches Color:Y/N J Aggregate:Y/N J Decorative/Stamped:Y/N <br /> Driveway _inches Color:Y I N J Aggregafe:Y I N J DecorativelStamped:Y/N <br /> Driveway _inches Color:Y/N J Aggregate:Y/N J DecorativelStamped:Y/N <br /> Curb Ramp Domes:Y/N <br /> Curb If Gutter:Y/N <br /> Valley Gutter If <br /> Dowels L iea Size:3�4 J #5 <br /> Asphalt W x L Depth AdjusflReplace <br /> Asphalt inches Manhole Frame , ea <br /> Fill inches Sidewalk Gas Valve Box ea <br /> Asphalt I Concrete Combo _"over_" Secondary Electrical Box ea 13"x 24"117"x 30"124"x 36" <br /> Grind _inches Valve Frame ea 15" 123" <br /> Asphalf 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 /> f�sp>halt Ir' . inches Place Paver/Stone/Brick InConcrete:Y/N <br /> ncrete �If _inches Traffic Marker Dots ea Reflective:Y I N <br /> Seal W x L Plug 1 YY Gas Prospect Hole ea Concrete J Asphalt <br /> Slurry/Fog/Sand W <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 /> y, <br /> t' <br />