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E:16—oe c Company <br /> Field Paving Form Permit Number: <br /> Permit Expiration Date: <br /> Date: 57 Street Address: <br /> Foreman Name: _ ESL' ,i �y� Cro -, j �7 <br /> PM Number: 3 1 150/ 3 C' /county: C, i— ,�V <br /> Concrete W x L Depth <br /> Roadwayinches_, , <br /> _inches Color:Y I N Aggregate:Y/N Decorative/Stamped:Y IN <br /> Sidewalk —inches Color:Y I N Aggregate:Y I N Decorative/Stamped:Y I N <br /> Driveway _inches Color:Y I N Aggregate:Y I N Decorative/Stamped:Y I N <br /> Driveway _inches Color:Y I N Aggregate:YIN Decorative/Stamped:Y IN <br /> Curb Ramp Domes:Y IN <br /> Curb If Gutter Y I N <br /> Valley Gutter If <br /> Dowels ea Size:#41 #5 <br /> Asphait W x L Depth AdjustlReplace <br /> Asphalt —inches Manhole Frame <br /> Mill&Fill _inches Sidewalk Gas Valve BoxIle <br /> Asphalt I Concrete Combo _"over_" Secondary Electrical Box13"x 24" 17"x 30" 24"x 36" <br /> Grind —inches Valve Frame 15" 23" <br /> Asphalt Fabric Valve Cover 30"x 30" 32"x 32". 48"x 48" <br /> Asphalt Berm/Curb If <br /> Saw Cut Depth Other W x L <br /> Asphalt �If inches Place,Paver/Stone/Brick In Concrete:Y/N <br /> �021If inches Traffic Marker Dots ea Reflective:Y 1 N <br /> W x L Plu 1%'Gas Prospect , <br /> 9 p t Hole ea Concrete Asphalt <br /> Slurry/Fog/Sand C� <br /> Striping Width Notes <br /> Paint If _inches !�/yyi <br /> Thermoplastic If —inches <br /> Traffic Legend ea <br /> Double Center LaneHilf <br /> f <br /> 3M"Scotch Lane" 4"18"112"Crosswalk <br />