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THE APPLICANT HEREBY CERTIFIES: <br /> 1. That he/ahte lbs read all the provisions of ibis application,and that the description included inthis application are cmect to the best of his/her <br /> hmowhvdge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent Sue owme,and <br /> 3. Thai he/she will assume full responsibility for all liability for personal injury or damage to property which may arise out of the wok 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 suck liability is made against the Comity of San Jbagiva or any deparweent,official or employee thereof be shall <br /> defend,indemnify and holdthem and each of thean harmless for such claim and <br /> 5. That wait shall be performed by the applicx:it and/or any represe"ve of the applicant in the County RiglA-of-way at the above indicated site <br /> with a valid Sam doagWm County Encroachment Permit;and <br /> 6. That if permission is granted as requested,he agrees to do the work described in aooardmce with all terns,conditions and restriction of this and any <br /> sttaclmed inducted as 7t7aid III provisions. <br /> I /<Nb L <br /> Sige of -Title tate <br /> FIELD INSPECTOR COMMNTS <br /> »»»»»»»»»»»»»»»»»»»» <br /> METING CONDITIONS««««<<<<< «««««««««« <br /> 1. DRIVEWAY: None ❑ Out Gravel ❑ Agg ague Base ❑ Pavod(Pcwr') ❑ Paved(Good) ❑ <br /> 2. SLOPING: Awry fi+onu Pavement ❑ Towards Pavement ❑ Flat <br /> I PIPES: Name � Existing-Type <br /> Other pipes in mighborhoock Yes ❑ No Approaches ❑ Cass Drain ❑ Sim <br /> Attachment to neighbor's pipe. Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No W <br /> S ASPBALT CONCRETE DIKE: Yea ❑ No , <br /> 6. BARRIERS along Rigid-cf Way <br /> 1. DITCH Yes ❑ No & IfYes: V Style ❑ 2 Point: ❑ Other ❑ Width Depth <br /> »»»»»»»»»»»»»»»»»»»»PF.RMTT REQUIR.EMEN S<z««««««««««««««««««« <br /> 1.DRIVEWAY: SFR COMMERCIAL ❑ AGRtCULTIJRE ❑ INDUSTRIAL ❑ <br /> PAVED with "Mims Depth A.C.over "Mia Depth 3/4"Ali <br /> Notes <br /> 2. PIPE& Legh of Pipe Repaired: Ft.and Diameter of Pipe Indra <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No kr- <br /> TOW <br /> Toth (with Proposed) Total Number of Storer Draft Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No . <br /> 4. PAVED FRONTAGE: PAVED with "Wm Depth A.C.over "Ma Depth 3/4"A.B. <br /> Mpg Feet in length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base free......................... . 85.00 <br /> Fiel on <br /> Driveway w/or w/o pipe..... .. ... ..._ <br /> ❑Paved <br /> ❑Driveway w/box Cuhvart..............._............__------.........5155.00 ❑Curb,Gutter,Sidewalk..........._..........$100.00+0.98/ft <br /> Counter\Computer,c:\Access\Application for PermitstDriveway and Paved Frontage Page.2 of 2 Revised 8/2000 <br />