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1. That helke has road"the provisions of this applicafion,and that the <br /> inc»lesded iatibs aro conror#to the t+en as maionr <br /> kmwlwdge;and <br /> 2: That he/she is the owner oftha respective property,or is gwtifiat to reprmnt the awl send <br /> 3. That hdalto will assau:o fall respomdbrhly for ati tiabiMy farpersouai injury or damage to propaiy'whid►may arise out of9w work described above, <br /> or which may arise out of his&tr Siiare to do the wank provided and <br /> 4. That in the event any claim of sada tiabibty is made agemat gwC UUty of&w joa*MorsMY.dRwhMIA OMCW on GOVICAYMgmteot b a shall <br /> dderA mdemnif r and hold dmm and each of them hamdess for sach dairq and <br /> S. That work shall be perfaaned by the applica*and/or any represesWw of The applicant in the Com ty R4Aof-Way at the above.iadicaW site <br /> w1h a valid San loagain Coanty Enaroadmient pemat;and <br /> b. That if permission is he agrees to do the work desca'bed in acaardanae with an turns,aoodati(os and restddian of tins and any <br /> attached sheet,included Ill Pr' s, <br /> D ;-0J�_- Ol <br /> 8ignetsata ofAFp}icaeb Tine Date <br /> FIELD INSPECTOR GO]l agt B <br /> EXMIMqOCONDrrjOM«««««««««««««««««««« <br /> L DRIFEWAY: Now ❑ Mt ❑ (MV4 AmgpteBase ❑ Paved(poer) ❑ Pav*Good) ❑ <br /> 2_SLOPINCe Away fivm Pavamem ❑ Towaads Pavaoaaot ❑ b7at <br /> 3:YIPEB:. Now Eaisft-TYPO <br /> OdwP Yes ❑ No Approaches Crow Drain ❑ Size 1 <br /> PAW <br /> Yes ❑ No <br /> 4.HFADWALL: Yes ❑ No' <br /> 3. <br /> ASPHALT CONCRETE DEKZ-: Yea ❑ No <br /> . l�.BARRIBRS aktagRight•afNWay <br /> ').DtrICH Yea ❑ No IPYas:• V styk El2 Fbint E] Odw E] width <br /> «««««««««««««««««««« <br /> L DR[OEVIrAY: <br /> OR ❑. COMMERCFAL A dCULTUMk ❑ EMUSTRIAL ❑ <br /> PAVED with,7_�14&DepBa A.Q over t Mm,Da:Ih 3/4"A.B. <br /> NQea <br /> E7 <br /> 2..PIlcR& of °tLe9riia�' Pk and Disn"err of Pipe Inch <br /> To be connected to my adjaoent driveway AM Yes ❑.No <br /> DRAINAM DMET REQUIRED Yes ❑ No , <br /> row I MWL- (With proposed) Trial Number of S6m=.Draiia Inlets <br /> NCIes <br /> 3. BWADWALL Yes © No <br /> 4. PAVED FRONTAgE: PAVED with "Wk Depth A.C.over "WL Depda 3/4"AB. <br /> M�rrhrg �_Foot in leaA and Feet in width <br /> FEES <br /> Driveway Faetnachwa t Permit base fee__.:...:. .. ...: _.S&5.00 <br /> �dEospectidn <br /> L'�Dtavaway W or w/a pip&......._ _ _ <br /> ❑ Drivewa w/boa ❑Paved finoadagn +0.46/R <br /> ❑Curb,Gutter,Sidowaik....:_._......._.._$lo0:00+09818 <br /> Collwar ,Campvter,c:lE►ocaslApplioation for FamWDripeway and Pawed Frontage Page.2 of 2 <br /> Rovised gMW. <br /> v" <br />