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DEPARTMEW OF PUBLIC WORKS <br /> DRIVEWAY AND PAVED FRONTAGES <br /> PERMIT APPLICATION <br /> X , ` - /J OFFICE USE ONLY <br /> l� JOB# 11005 ISSUE DATE <br /> f� <br /> N ARN. Id . �fi - FEE DUE - <br /> !/ DDRIVE'W YS: <br /> Address .�O -- TREET n/SET- Ax% -- " <br /> �7bc�+ctyxl QUAD' /VS <br /> City, -Zi Code TYPE <br /> 0 ORMS e-17 <br /> (Area Code)Tolepbpne NOTE —�—� <br /> Ald <br /> IlQFORMATION <br /> x <br /> Parcel ' Name <br /> to Address-, <br /> DRIVEWAY <br /> City,State-Zip Code TYPE QUANTITY. WIDTHS <br /> 0RICULTURE @ FRONTAGE <br /> (Area Code)Telephme COMvh?RCIAL <br /> USTRIAL (03 R/W <br /> ENCE •_ t�— <br /> O Q <br /> CONTRACTOR PAVED FRONTAGE <br /> (}TIi Ft. <br /> X. WIDTH: Ft <br /> Name <br /> Address The undersigned hareby applies for pamissioa to encroach cm Cotmt}+Highway <br /> Rigbt-Of--Way on the_f d&Of 1.U5ET /�lE. <br /> City,State-Zip Code �y J So mile_ Noa27 N of 70779.t! <br /> by installing 0 w <br /> (Area Code)Tdephi e <br /> Work <br /> will commence an or about for approximately days. <br /> SKETCH(Separate sheet may be submitted) <br /> Will this project be self-installed? NO YES Contractor's License <br /> ���npp�ormm�i�yEa�d li�� <br /> to <br />