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�la�{Se'� c3cir �6�8� ������ ®�� Permit Number: <br /> (�.1•I I 4 per-_`,•@f`l��rv��' �iJ <br /> r / Permit Expiration Date: <br /> Date: `C Street Address: �f� /V 4 <br /> Foreman Name: Cross Street: - Af— "4A 7rliil <br /> PM Number: 2Cityl` 6Z/,�yp�, <br /> Concrete W x L Depth q ,31 O <br /> Pidewa@lk <br /> 'inches <br /> _inches Color:Y/N J Aggregate:Y!N J Decorative/Stamped:Y I N <br /> Sidewalk _inches Color:Y I N J Aggregate:Y I N J Decorative/Stamped;Y/N <br /> Driveway inches Color:Y/N J Aggregate:Y/N J Decorative/Stamped:Y I N <br /> Driveway _inches ColoF.Y/N J Aggregate:Y/N J Decorative/Stamped:Y/N <br /> Curb Ramp Domes:Y I N <br /> Curb If Gutter;Y/N <br /> Valley Gutter If <br /> Dowels ea Size:t:41 �5 <br /> Asphalt W x L Depth Adjust/Replace <br /> AsphaltI _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"J 17"x 30" 24"x 36" <br /> Grind _inches Valve Frame ea 15" 123" <br /> Asphah Fabric Valve Cover ea 30"x 30"J 32"x 32"J 48"x 48" <br /> Asphalt Berm I Curb Ir' <br /> Saw Cut Depth ®they W x L <br /> Asphalt<� if . inches Place Paver!Stone 1 Brick In Concrete:Y/N <br /> oncre If inches Traffic Marker Dots ea Reflective:Y/N <br /> Seal VII x L Plug 1%"Gas Prospect Hole ea Concrete J Asphalt <br /> SlurryI 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"112"Crosswalk <br /> S <br /> v <br /> ►�' <br /> 3 � <br />