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. Ay,"CANT HERESY CERTIFTE,= andthat the descrigtios <br /> ;,ychded intbis application are correct to the best of his/her <br /> 1. That hetdiehas read all the provisiom of this app}ic 81io4 <br /> k.owlwdga;and ""ed to r theowDM and <br /> 2. That hc/she is*0 ow <br /> of the respective prop�3 0��y which may s�od°f the wodc described above, <br /> ner <br /> for sll fiabiliiY�P <br /> 3. That 110**will assume fall r�do the wo&Provided herein'and <br /> or whichmom'sties out ofhis/her ihaccvnly of Son JoaQeun of MY ,°fbcial a employoe thaea&he shall <br /> 4. That intho event any claim of suchbability is made agar <br /> defend,indemnify and holdthem and each of them harmless such Of the applicant in the Coady RiO-f Way at ft above indicated site <br /> S. 'I-ag work shall be performed and/or any ropreautalir"e <br /> Pew and in&OO Unm with all tams,o� m o°s and N&Icb of tbia and any <br /> with avalid Sam J4agaim he agrees to do the wo&desert <br /> er <br /> 6. That if pemusston is (� <br /> wd R1 provisions <br /> admc}rd sheep �, a i1/ <br /> Signer Title <br /> HUM INSPECTOR COBS <br /> r�7NDIITONS«««««««««««««««««««« <br /> »»»»»»»»»»>>>>1 »>f»»F.XiS ilriQ Pao Po") ❑ Pa good) <br /> 1. DRTVEWAY: Nape ❑ <br /> (k.,.1 ❑ A Base ❑ Flat <br /> 2. SLOPING: <br /> Awayfran paveu>ed ❑ Towa�Pavemad El <br /> Name � Esisft-TYPO ❑ Caws Dram ❑ Sim E= <br /> 3. PIPES:. Yes ❑ No ❑ Approaches <br /> Other pipes inu ❑ <br /> Af O tis�: Yes E] No <br /> 4 HEADWALL: Yea ❑ No' <br /> S. ASMAL,T MNCRETE DIICE° Yea ❑ No <br /> Depth <br /> 6..BARRIERS °lan�)2i -of a'ay atl�er ❑ � ----__ <br /> Yes P No ❑ ifyes: V Style g 2 pbiaot ❑ <br /> 7. DTPCH NTS«««««««««««««««««««« <br /> »»»»»»»»»»»»»»»»»PERMIT RE iJLTEJitE ❑ INDUSTRIAL C1SFR ® COMMERCJAL ❑ <br /> 1. DRIVEWAY: Isfim Dapth3/4"A.B. <br /> PAVED with �_"Ifin' th A.C.over <br /> Notes <br /> Ft.and Dianufirr of PaP° �imoh <br /> 2 PIPE& Lmgth-f Pipe,RaN+� <br /> __---- Ya ❑ No <br /> To be comected to any adyaced driveway PiPeDRA ❑ <br /> INLET REQUIRED Yes No <br /> 15 <br /> Totgj L gth Totem Naa�a e!Stares DrI t Imleb <br /> Toted LmgW� (withpropoe�) <br /> Notes <br /> 3. HEADWALL Yea ® No ® "Mm Depth 3/4"AB. <br /> PAVED with "Mm-i)apth AC.over __4. PAVED FRONTAGE: Fed in im8 and Fed in width <br /> Measuring <br /> FEES <br /> Pamitbasefe ............................585.00 <br /> Driveway Fns S100.00+0.461& <br /> Field Inspection ❑Paved fix+atsga••-._-._. _ .._- <br /> S100.00+0.98/ft <br /> y w/or w/o ❑Cutb,Gutter,Sidowatk..:....._...._.... <br /> Drtvewa prpe......................_........... .Si55.00 <br /> ❑Dnvoway w/box Calvat.._._....._.............._--.. <br /> --_ Revised=000 <br /> Couute�ComPuter,c:�AocesBWpPl►oonfor P �!!" Y <br /> and Paved Fri Para of 2 <br /> • i <br />