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�. C, <br /> t . <br /> l��v{Q5Pv CG:S E.—nn <br /> Field Pa19pp g Fc)rm Permit Number: <br /> Permit Expiration Date: <br /> Date: r <br /> --�' J f r Street Address � ,� _ <br /> Foreman Name: �/ s — i � <br /> Cross Street: — <br /> 4�(' y 1,� <br /> PM Number: _ Lj�, �� ��! -- <br /> Cit Couni <br /> Concrete W x L Depth —� <br /> Roadway —inches <br /> Sidewalk _inches Color:Y I N <br /> Sidewalk Aggregate:Y/N Decorative/Stamped:Y I N <br /> _inches Color:Y/N I Aggregate:Y I N Decorative/Stamped:Y/N <br /> Driveway —inches Color:Y/N I Aggregate:Y/N Decorative/Stamped:Y/N <br /> Driveway _inches Color:Y/N Aggregate:Y/N Decorative/Stamped:Y/N <br /> Curb Ramp Domes:Y/N <br /> Curb If Gutter:Y/N <br /> Valley Gutter Dowels Ljelfa Size:#45 <br /> Asphait W x L Depth Adjust/Replace <br /> Asphalt <br /> inches Manhole Frame . <br /> Mill&Fill ea <br /> inches Sidewalk Gas Valve Box <br /> Asphalt/Concrete Combo ea <br /> —'over—" Secondary Electrical BoxHca <br /> ea 13"x 2d" <br /> Grind _inches j 1T'x 30" 24"x 36" <br /> ____---------------_- — Valve Frame ---- ea 15" 23" <br /> Asphalt Fabric — ----- —---- -- --- ----- --- -- --- <br /> Valve Cover — -- -- ------ -- -- <br /> Asphalt Berm/Curb If 30"x 30"j 32"x 32".j 48"x 48" <br /> Saw Cut Depth <br /> Other W x L <br /> Asphalt If —inches Place Paver/Stone/Brick <br /> Concrete If _inchesIn Concrete:Y/N <br /> Seal W x L <br /> Tra nc Marker Dots ea Reflective:Y/N <br /> Slurry/Fog/Sand <br /> Plug 1%"Gas Prospect Hole ea Concrete I Asphalt <br /> Striping Width <br /> Notes <br /> Paint ' If —inches <br /> Thermoplastic If —inches <br /> I raffic Legend ea <br /> Double Center Lane If <br /> 3M"Scotch Lane" If 4" 8" 12"Crosswalk <br /> -------------- <br /> _ y <br />