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S� C . <br /> MOM flacific(T"rs irnrl <br /> l.lr:cfrict,'unr rrn Field Paving Farm Permit Number. <br /> l Y Permit Expiration Date: <br /> Date: S. Street Address: R b�L�`•v�-'r <br /> Foreman Name: .r r `� 4 rL <br /> Cross S et: \,JCA�.3 <br /> PM Number: _ 4' W <br /> Concrete W x L Depth <br /> Roadway _inches <br /> Sidewalk _inches Color:Y IN J Aggregate:YIN 1 Dec <br /> oratiyelStamped:Y/N <br /> Sidewalk _inches Color:Y I N 1 Aggregate:Y/N 1 Decoralive/Stamped:Y/N <br /> Drive' <br /> aY _inches Color:Y I N I Aggregale:Y IN 1 DecoralivelStamped:Y/N <br /> Driveway ____inches Color:YJ N I Aggregale:YIN 1 Decorative/Stamped:Y/N <br /> Curb Ramp Domes:Y/N <br /> Curb If Gutter:Y/N <br /> Valley Gutter If <br /> Doviels ea Size:#41 #5 <br /> Asphalt W x L Depth Adjust/keplace. <br /> Asphalt lC� inches Manhole Frame <br /> ea <br /> Mill&Fill —inches Sidewalk Gas Valve Box ea <br /> Asphalt!Concrete,Combo _'over Secondary Electrical Box ea 13'x-24'117"x 30'1 24'x 36' <br /> Grind —inches. Valve Frame ea 15' 1 23' <br /> Asphalt Fabric Valve Cover ea 30'x30'132'x 32'148'x 48' <br /> Asphalt Berm/Curb If <br /> Saw Cut Depth Other W x L i <br /> Asphalt t If inches: Place Paver/Stone/.Brick In Concrete:Y/N <br /> Concrete F9 _inches Traffic Marker Dots ea Re <br /> Ilective:Y/N <br /> Seat W x L Plug 1 W Gas Prospect.Hole ea Concrete 1 Asphalt <br /> Slurry/Fog/Sand <br /> Striping Width Notes <br /> Paint If _inches <br /> Thermoplastic If _inches <br /> Traffic Le.gend lea <br /> Double Center Lane If <br /> 3M'Scolch Lane' If 4'18'}12'.Crosswatk <br /> �r <br /> 1 � E <br /> �1 <br /> V I <br /> 4 i <br /> (t I i <br /> i <br />