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DEPARTMENT OF PUBLIC WORKS recc.ved`v <br /> DRIVEWAY AND PAVED FRONTAGES a <br /> PERMIT APPLICATION <br /> �-APPLICANT OFFICE USE ONLY <br /> JOB#11005 ISSUE DAT1, / / <br /> Name APN41 - 910 - /o2 FEE DUE_ <br /> Z 2 Z l�)• S66/, /J (/� .DATE DRrvEWA3'S: <br /> Address STREET , r* <br /> PO �Z7i� QUAD_� <br /> „ <br /> City,State-Zip Code TYPE <br /> ORMsUJw, —/7 <br /> (Area Code)Telephone NOTE <br /> SIM INFORMATION <br /> Parcel Owmes Name <br /> 00-7- 3 - 2 <br /> 2 3 tc ss DRIVEWAY <br /> City,State-Zip Code TYPE QUANTITY- WIDTHS <br /> &4f'Aof F?:�, 0'Z Za AGRICULTURE @ FRONTAGE <br /> (Aron Code)Telephone COM MIRCIAL <br /> USTRML _ @ g/w <br /> CONTRACTOR PAVED FRONTAGE <br /> LENGTI1- Ft. X WIDTH: It <br /> Name <br /> Address Thie undersigned hereby applies for permission to encroach on Coi w ni&"y <br /> Right-of-Way on the side of <br /> City,State-Zip Code r Z o SdtETf/ of T, *1,j AW <br /> (Area Co&)Telephone <br /> Work <br /> will commence on 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 /> ADcm\Per AW\FocmMdvewayFAvad fimftge <br /> m <br />