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THE APPLICANT HEREBY CERTIFIES:andthat the description inchrded in this application are correct to the bast of hislher <br /> 1. That he/she has read all the provisions of this applhxtian, <br /> Imowh dge;and <br /> 2. That helshe is the owner of the respective property'-is quaim$edto r r theowneq and <br /> 3. That he/she will assume full rh' <br /> atl lnal�lity f�personal>aJm9 or to ply which may arise out of time work descrbed above, <br /> or which may arise out of his/her Mute to do the work provided herein,and <br /> 4. That in the suet any claim of such liability is made against the County of Sao k&*m or any�officrat or employee thereoi,he shall <br /> defend,indemnify and holdthem and each of them harmless for such claim;and &"-Way at the above indicated site <br /> 5. That work shall be pelf ted by the applkaivt and/or any re�presetative of the apphcaut in the County Ri ght Y <br /> with a valid San Joagaia COWRY Enn'ond-nd Peunk and <br /> 6. That if permission is granted as <br /> re¢med4 he agrees to do the work.described in accordance with all teems,conditions and restriction of this and any <br /> 9tacbed seet, gQo— <br /> hincluded as eneral or sp,c44III pro ora <br /> a <br /> Dare <br /> Siguatme of Appficamt-Title <br /> FIELD INSPECTOR COAd14 MS <br /> COMMONS <br /> »»»»»»»»»»»»»»»»»>`»»g���} «««««««««««««««««««« <br /> Dirt ❑ Gravel ❑ Awe Base Paved(po-) ❑ Paved(Good) El <br /> L DgIVEWAY: None ❑ FlElZ. MOPING: Away$+om Pavement El Towards Pavement at <br /> 3. PIPES: None k Existing-Type EJOtherpipes m °rbOOd: Yes El N�Appro Coosa Drain ❑ Size <br /> Attachment to neWaboes ' : Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> S. ASPSALT CONCRETE DACE: Yes ❑ No <br /> 6. BARRIERS along Rmghr-0f--Way <br /> 7. DITCH <br /> Yes El No IfYes: V Style E] 2 Point El Other ❑ Widfh Depth <br /> »»»»»»»»»»»»»»»»»»»PERMIT <br /> <Z««««««««««««««««««« <br /> 1.DRIVEWAY: SFR tK COMMERCIAL ❑ <br /> AGRICULTURE ❑ INDUSTRIAL El <br /> PAVED with ?j "IYTm Depth AC.over "Mm Depth 3/4"AB. <br /> Notes <br /> 2. PIPES: Lang*of pipe Requirod: Ft and Diam.ew of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yes ❑ No — <br /> DRAINAGE INLET REQUIRED Yes ❑ No <br /> Tots(Length: (with proposed) Totd Number of Storm Drat"IBleta <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth A.C.over "Mia Depth 3/4"A.B. <br /> Measuring Feet in leg&and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................585.00 <br /> Feld Inspection <br /> El Paved $1()000+0.46/t <br /> Driveway w/or w/o pipe............................._...... ._. $95.00 <br /> .$100.00+0.98/ft <br /> ElDriveway w/box Cu(vert..............................................$155.00 ❑Curb,(m�xttea;Sidevvailc..:.................. <br /> 2 Revised 8/2000 <br /> Couuter\Computer,c:AAccess\Applieation for Permits\Driveway and Paved Frontage <br /> Page.2 of <br />