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E DEPARTMENT OF PUBLIC WORKS Received by <br /> CR# <br /> DRIVEWAY AND PAVED FRONTAGES G S <br /> PERMIT APPLICATION <br /> APPLICANT OFFICE USE ONLY <br /> JOB#11005 ISSUE DATE <br /> Name. / APN (�3 - O(o0 - 'L'i— FEE DUE <br /> Lye e .DATE DRIVEWAYS: <br /> Address STREET NOWAMrJ E ' <br /> cl QUA <br /> S -Zip Code q TYPE <br /> 2i /J FORMS <br /> (Area )Telephone NOTE <br /> ��— .�: 2- Vic: <br /> SnT&INFORMATION <br /> Parcol Owns s Name <br /> / Site Add9yss Rr4EWAY <br /> City,State-�Z¢ip Code TYPE QUANTTII'_ WIDTHS <br /> AGRICULTURE @ FRONTAGE <br /> (Area Code)Telephone COMMERCIAL <br /> USTRIAL .@ RNV <br /> rESMENCS <br /> CONTRACTOR PAVED FRONTAGE <br /> LENGTIE Ft. X WIDTH: Ft <br /> Name <br /> AddressThe d es for pmxoisdm to encroach Cour",Hi way <br /> .of a fe <br /> City,State-Zip Code approximately feet/mile 5 0,y-TA of <br /> by installing <br /> (Area Code)Telephone <br /> Work <br /> will commence on or about for approximately days- <br /> SKETCH(Separate sheet may be submitted) <br /> Will this projoct be self-installed? NO YES Contractor's License <br /> AoomTer Ap TaanklkiwwayZaved&natap <br />