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• C - I <br /> (�►rtirr(o,7s;rnrl <br /> larr:urr Curr urrr� field Paving FormPermit Number. <br /> I / } permit Expiration Date: <br /> Date: Street Address,: -/ b C��/J��?-e d t l I <br /> rorernan Name: , '� e, Cross Street: ^�f�K�/ �`)2�i �u l'4 <br /> PM Number: City ounty f� � <br /> Concrete WxL Depth <br /> Roadway _inches <br /> Sidewalk —inches Color:Y!N Aggregate:Y!N 1.Deeorative/Stamped:YJ N <br /> Side.w.alk _ n..ches Color.Y/N Aggregate:Y/N 1 DecoralivelStamped:Y/N <br /> Driveway _inches Color:Y/N 1 Aggregate'Y!N 1.Deeoralive/Stamped:Y/N <br /> Driveway I —inches Color:Y/N Aggregate:Y!N Decorative/Stamped:Y I N <br /> Curb Ramp Domes:Y/N <br /> Curb If Gutter:Y/N <br /> Valley Gutter If <br /> Dowels ea Size:#141 P5 <br /> Asphalt W x L Depth Adjust/Replace <br /> ri <br /> Asphalt �inches Manhole Frame ea <br /> VO+FNh— $ inches Sidevralk Gas Valve Box ea <br /> (Aspha ncrlttl TZombo 2- 7 $ 'over_' Secondary Electrical Box ea 13'x 24'117'x 30'(24'x 36" <br /> -Grind ° inches Valve Frame ea 15' 123' <br /> Asphalt Fabric Valve Coverea 30'x 3O I 32'x 32'14 8'x48' <br /> Asphalt Berm/Curb if <br /> SAW Cut Depth Other W x L <br /> Asphalt If inches. Place Paver/Stone 1 Brick In Concrete:Y/N <br /> Concrete If _inches Traffic.Marker Dots ea Reflective:Y/N <br /> Seal W x L Plug 1%'Gas Prospect Hole ea Concrete l Asphalt <br /> Slurry/Fog 1 Sand <br /> Striping Width Notes <br /> Paint If _inches <br /> Thermoplastic If _inches <br /> ' ` . -T—-- <br /> Traffic Legend ea A s� � }• I <br /> Double Center Lane If <br /> 3M`Scotch Lane If 4'1 8'(12'Crossvralk <br /> r <br /> El <br /> h <br /> i <br /> t <br /> u EJ <br /> �� ► , <br /> d� <br /> �3 <br />