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THE AYFLICANT HEREBY CERTIFIES: <br /> 1. That he/she has read all the provisions of this application,and that the description indoded inthis application are correct to the beat of his/her <br /> knowlwdge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owner;and <br /> 3. That he/she will assume full responsibility for all liability for personal injury or damage to property which may arise out of the work described above, <br /> or which may arise out of his/her failure to do the work provided herein;and <br /> 4. That in the event any claim of such liability is made against the County of San Jvagiva or any department,official or employee thereof he shall <br /> defend,indemnify and lroldthem and each of them lsanmleas for and <br /> 5. That work shall be performed by the applicant and/or any 71-d <br /> he applicant in the County ltigl�-of-Way at the above indicated site <br /> with a valid Sant J County End Pemri�and <br /> 6. That if pemvssi granted as requested,are agrees to do .in accordance with all turns,conditions and restriction of this and any <br /> attached rnciuded as general pro <br /> Siguatrm of Applicant Tithe Date <br /> FIELD LD INSPECTOR COA MENTS <br /> »»»»»»»»»»»»»»»»>>>>»»EMTINGCONDITIONS«««««««««««««««««««« <br /> L DRIVEWAY: None ❑ Dirt ❑ Graved ❑ Aggregate Base Paysd(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Away from Pavemcet ❑ Towards Pavement ❑ Flat <br /> 3. PIPES: Now A Existing-Type <br /> Other pipes in nei0borhood: Yes ❑ No Od Approaches ❑ Cross Ilam ❑ Size C] <br /> Atbuhment to neighbor': Yea El No <br /> El4. HEADWALL: Yea No' <br /> S.ASPHALT CONCRETE Dl%C . Yes ❑ No /t�1 <br /> 6. BARRIERS along ki&-ofWay <br /> 7. DITCH Yes ❑ No IfYes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PERMIT REQUIREMENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: SFR 0 COMMERCIAL ❑ AGRtCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "Mia Depth A.C.over Mia Depth 3/4"A.B. <br /> Notes <br /> 2. PIPM Length of Pare Rahairod: Ft and Diameter of Pipe -- Inch <br /> To be connected to any adjacent driveway pipe Yea ❑ — <br /> DRAINAGE INLET REQUIRED Yea ❑ No k <br /> Total Length: (with proposed) Total Number of Storm Dwain Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with "Msn.Depth A.C.over "Mia Depth 3/4-A.B. <br /> Measuring Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee............................$85.00 <br /> Fiel 'on <br /> Driveway w/or w/o pipe................................................$95.00 ❑Paved frontage.._....... ...__............$100.00+0.46/ft <br /> ❑ Drivewayw/box Culvert...............................................3155.00 ❑Curb,Gutter,Sidewalk.......................$100.00+0.98/ft <br /> Counter\Computer,c:\Access\Al0cati0n for Permits0riveway and Paved Frontage Page.2 of 2 Revised 8/2000 <br />