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Pacific Gas and Heid Paving Form <br /> Ll� ide Cf ? a,�j/ PermNumber: <br /> it <br /> I, Permit Expiration Date: <br /> Date: 5 'Z 7-- S Street Address: 2 N c- <br /> Foreman Name: sx%✓ Cross Street: G- <br /> PM Number: _ qz �fgGl Ci County: c.� <br /> Concrete W x L Depth <br /> Roadway —inches, <br /> Sidewalk —inches Color:Y/N Aggregate:Y/N Decorative/Stamped:Y I N <br /> Sidewalk —inches Color:Y/N Aggregate:Y I N Decorative/Stamped:Y/N <br /> Driveway —inches Color:Y/N Aggregate:Y/N Decorative/Stamped:Y I N <br /> Driveway _inches Color:Y/N Aggregate:Y/N Decorative/Stamped:Y!N <br /> Curb Ramp Domes:Y 1 N <br /> Curb If Gutter:Y!N <br /> Valley Gutter If <br /> DoWels '' Nea Size:#41 #5 <br /> Asphalt W x L Depth Adjust/Replace <br /> Asphalt Wif <br /> Finches Manhole Frame <br /> ea <br /> Mill&Fill _inches Sidewalk Gas Valve Box ea <br /> Asphalt/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" 32"x 32" 48"x 48" <br /> Asphalt Berm/Curb <br /> Saw Cut Depth Other W x L <br /> Asphalt -78 Ilf . inches Place,Paver/Stone/Brick 1nConcrete:Y/N <br /> Concrete If —inches Traffic Marker Dots ea Reflective:Y/N <br /> Seal W x L Plug 1%Z"Gas Prospect Hole ea Concrete Asphalt <br /> Slurry/Fog/Sand <br /> Striping Width Notes <br /> Paint If _inches <br /> we( %S -Cir 6- <br /> 1herm0p123tic If inches g <br /> — � <br /> Traffic Legend ea <br /> Double Center Lane If <br /> 3M"Scotch Lane" If 4"18"112"Crosswalk <br /> S r,zie . <br /> r� . <br />