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• ii <br /> (,irlfrr.(v',t s,�1lr!Inn Permit Number. <br /> i <br /> !lr�r frir,f'rurr Helot Paving Form <br /> 1,fl �l I j Permit Expiration Date: <br /> Date: 2 15� Street Address: <br /> Foreman Name: 12 ill Cross Street: <br /> PM Number: A?iW nI59(11 Cit Count 12MAen Auaf s 1 Concrete, W x L Depth <br /> I <br /> Roadway —inches <br /> Sidewalk —inches Color:Y I N Aggregate:Y I N Decorative/Stamped.-Y I N I <br /> Sider?alk inches Color:Y I N Aggregate:Y I N i Decorative/Stamped:Y I N <br /> .Driveway —inches Color:Y I N I Aggregate;Y I N Decorative/Stamped:Y I N <br /> Driveway _inches Color:Y I N I Aggregate:Y I N DecorativelStamped:Y/N <br /> Curb.Ramp Domes;Y I N <br /> Curb If Gutter:Y IN i <br /> I <br /> Valley Gutter If <br /> Dowels ea Size:#.41 115 <br /> Asphalt W x L Depth Adjirst/Replace <br /> fAsphallinches Manhole Frame ea <br /> &Fill _•inches Sidewalk Gas Valve Box ea 1 <br /> Asphalt I Concrete Combo. —over_" 'Secondary Electrical Box ea 13'x 24' 17"x 30"124'.x 36" <br /> Grind _inches Valve Frame ea 15" 123' I <br /> Asphalt Fabric Valve Cover ea 30'x 30'132'x 32'148'x 48' <br /> Asphalt Berm/Curb If <br /> Saw Cut Depth Other W x L I <br /> I <br /> C <br /> If inches Place Paver/Stone 1.8rick In Concrete:Y/Ne �If _inches Traffic.Marker Dots ea Reflective:YIPI <br /> Seal VII x L Plug 1%_'Gas Prospect Hole ea Concrete I Asphalt <br /> Slurry I Fog I Sand <br /> Striping Width Notes <br /> 1 <br /> Paint If _inches <br /> Thermoplastic If _,inches <br /> Traffic Legend ea <br /> Double Center Lane if j <br /> 3M"Scotch Lane' If 4"18'112'Crosswalk <br /> I � I <br /> i <br /> i <br /> ff--43 <br /> � I <br />