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i.ThathdsNe has read&H the p misicos of this Wfinficni and that iha dm ip lion included M- Ois application are coffeetto the best of his/her <br /> knowlvdgr,nod <br /> 2. That hefshe is the owner ofthe respective property,or is qualified to resent the owner,and <br /> 3. That he/she will assume fall reVansikh'y fm all liehiirty faorperso A mjury or damage to property which may arise out ofthe work descn'bed above, <br /> or whichmay arise out ofl b&w failure to do the wok provided herek and <br /> 4. Tlhat m the oval any claim of such liability is made against ACCouuty of San tragi m or any department,ovist or byre twececc he shall <br /> defend,indemnify and holdgm and each of them harmless for such claim;and <br /> S. That wank shall be Performed by the aMHca*and/or any repreaentsfiw of the applicant in the County Right-ofWay at the above indicated site <br /> with a valid San 7oagnin County Encroachment Paunit;and <br /> 6. That if permission is granted as requested,he agrees to do the work desczrThed in accord w&all teens,coalitions and restriction of this and any, <br /> sheat,included as at special III provissars. <br /> l7 <br /> ofTitlls �O <br /> FIELD INSPECTOR COMMENTS <br /> L DRItIEWAY: Ncae ❑ Dat E] (k v.1 ❑ Aggregate Base ❑ Pav-vpoor) ❑ Pav*Good) <br /> FL SLOPING: Away flim Pavement ] Towards Pavamoat ❑ Flat ❑ <br /> 3. PIPES:. None EA1619-TY11 <br /> Other pipes in ochood: Yes ❑ No Apptosches ❑ Cross Drain ❑ Sin <br /> Aftadinenttoneigldhoes Yue ❑ No <br /> 4 HEADWALL: Yes ❑ No . <br /> S ASPSAI.T CONCRETE D>KE•: Yes ❑ No <br /> 6..BARRffitS at"M&-c&Way <br /> 1. D1TCS Yes ❑ No F7 IPYes:• V Style ❑ 2 Print ❑ Othw ❑ Widtlh Depth <br /> »»»»PERMIT REQUII2. MENTS««««««««««««««««z«««< <br /> L DRIVEWAY: SFR ❑. COMIAERCIAL [ AiC ICULMRE ❑ INDUMUAL ❑ <br /> PAVED with !i "hfm Depth A.C.over Mm Depth 3/4"AB <br /> Notes , <br /> 2. PIPE& Latgth of Pipe Required: FL and DimmAer of Pipe — -- Inch <br /> To be oanumW to any adjacent driveway pipe Yes ❑ No L�1 <br /> DRAINAGE INLET REQUIRED Yes 0 No <br /> TOW Length: (wigs p W oeed) Tot d Number of Shmm:Dradn Tdeft <br /> Notes <br /> 3. HEADWALL Yes no No <br /> ,A. PAVED FRONTAPE: PAVED with "hfiL Depth AC.over "bdnt Deptih 3/4"AS. <br /> Measuring Feet in length and Fed in width <br /> FEES <br /> Driveway Enauacimhent Permit base fix...........................SSS-00 <br /> Wolold[nopeefim <br /> veway w/or w/o pipe............... __ ❑Paved>3cantaga ___._ _..__ S100.00+0.46/& <br /> ElI]nivewayw/boxCnlvat._.._._ _......__.. . ... ._......S1SS.00 ElCwb,Guttar,Sidewalk..:...._.:...........$100:00+0.9878 <br /> CauntalComputer,c:Uccae\Application for Pmmits\Driyeway and Paved Frontage Page.2 of 2 Revised 8/2000 <br />