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� I <br /> 19eld� Paving Fomiro PermifNumber.� I �,� ,':!l:r,•iric.f:urnjuulj/ PermilExpirafionDate: <br /> i <br /> Date: _ I Street Address: - -2D H S - S r da l e <br /> Foreman Name: S a ky\ SPX S Cross Street: <br /> city(S) <br /> Concrete W x L Depth <br /> Roadvray _.inches <br /> Sidewalk _inches Color:Y/N Aggregate:Y I N Decorative/Stamped:Y/N <br /> Sidewalk _inches Color:Y/N Aggregate:Y I N Decorative/Stamped:Y/N <br /> i <br /> Drivevlay ^inches Color:Y/N I Aggregate:Y I N Decorative/Stamped;Y/N <br /> Driveway _inches Color:Y I N Aggregate:Y I N Decorative/Stamped:Y/N <br /> Curb Ramp Domes:Y/N <br /> Curb If Gutter:Y/N <br /> Valley Gutter If <br /> DoNels ea Size;#41 P5 <br /> Asphalt W x L Depth Adjust/Replace <br /> i <br /> �anil <br /> -7 inches Manhole Frame. ea <br /> —inches Sidewalk Gas Valve Box ea <br /> i <br /> Asphalt/Concrete Combo _'over Secondary Electrical Box ea 13'x 24" 117"x 30'124"x 36" I <br /> Grind I _inches Valve Frame ea 15' 1 23' i <br /> Asphalt Fabric Valve Cover ea 30'x 30'132',4 32'148'x 48' <br /> Asphalt Berm/Curb If <br /> Saw Cut Depth Other W x L <br /> �oncrete <br /> If inches Place.Paver/Stone/Brick In Concrete:Y/N <br /> If _inches Traffic Marker Dots ea Reflective:Y/N ' <br /> i <br /> Seal W x L Plug 1 Y2,Gas Prospect Hole Ilea Concrete I Asphalt <br /> Slurry/Fog/Sand k <br /> Striping Width Notes J <br /> Paint If _inches 77 0 ' s Q �• W Q S rl <br /> Thermoplastic If —Inches ri <br /> Tra is Legend ea <br /> Double Center Lane If <br /> 3M'Scotch Lane' If 4° 8' 12'Crosswalk <br /> i <br /> . WashrVA) Fort I <br /> i <br /> 0 , <br /> o i <br /> J �.p <br /> I <br />