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I. That he/a tebas reed all the p rdvisioffi of thisappy and that the description, <br /> ��8�$10d imscliaded-'this a��a+ed to the bast of b vlw <br /> 2. ThatI c/she is the owner of&e Mpoc&e F%etty,or is,I U"adto m tboownw,And <br /> 3. That ho/she will assume full rVma&ty ger ail <br /> orwbich may ansa out ofhis/her frilam to do the <br /> Y for Pmwal injury or dmnaga to propemty wbiohnuty arise out ofthe work described above, <br /> work prmded hetes M <br /> 4. That in the event arty claim ofmmh iability is made <br /> deft . and holdtbem and each of deem ba mgm far suds claim;�organ� any affidsi or employee t>xr04 he shau <br /> S. Tint work shall be <br /> Permed by the aPplicaut and/"any repreaeutstiye Oftbe a�piicxot in she <br /> wJ&jvalid San J Ewo&chmeut p and Bey Right-of-Way at the above.il&cd d site <br /> 6. That is as he to do dw attacas. fl I A`o�dascasbed amdaaroe with all tewls,000ditiom andrestrictiou afthis and any <br /> 4 <br /> &&fie ofApp Tmtie <br /> Dote <br /> F'�INSPECTOR CUp O&g,M <br /> »»»»»»»»»»»»»»»» »»>EMSTM IC[7N MONS««««««««««««««t«««««< <br /> L DNiTWAV. Nage Dht ❑ Oravnl [� <br /> 3.SLOPING: A St anBane ❑ paved+(poor) ❑ papood) ❑ <br /> ❑ Towand�Pavaemeort Fla A3:PIPES•. Now ❑ <br /> Existing-Type <br /> Odierpipm in nOOboifiood: Yes ❑ No <br /> meat too neW&oes pipe; Yes ED N, <br /> Apptoeclm� ❑ Ckoss Drawn ❑ sire <br /> 4.HEADWALL: Yea ❑ N. <br /> S ASPHALT CONCRETLe DIIOz Yui ❑ No <br /> 6�.BARREMS ak"RiBht &Way <br /> �. MCH Yes ❑ No <br /> Wyes:' V Style ❑ 2 Point ❑ Other �] W_ <br /> mft <br /> »»»»»»»»»»»»>>>>> »> <br /> Dapdl <br /> L DRIVEWAY, pTQUR+DVTs««««««««««<¢««««««««« <br /> 3FR � COMMERCF.AE, [] CULTEIk$ <br /> �� ❑ <br /> PAVED with. �! w�,Deplh A.C.over " <br /> Nates Min.Depth 3/4"AR <br /> 2. PUM& LeftthofPipe Re <br /> Pt.and Di+m"w cf pipe Inoh <br /> To be connected to any, y Yes ❑ Nrl <br /> DR AINAOEDUETREQQUBW Yea <br /> ❑ NoPL <br /> Nates Tow I msgth (wdhpropoemD Total Num &..:Dam b blela <br /> 3. HEADWALL Yes ® No e <br /> 4. PAVED FRONTACrE: PAVED with <br /> Dapth AC,over "hfm.Deplh3/4"AH <br /> Fad iia and Feet in width <br /> Drmveway Enaoau Pemmit base fee........................ 00 FEES <br /> vows an <br /> yw/or w/o pipe ..... $9S. <br /> ❑Ddveway w/box Cv1veR......__........ <br /> ❑Pavodfsootagn _ __. _ __ SIC1000+0.46M <br /> ❑Cutb,Ci*w,Sid.,&....._...:...........5100:00+0.9&a <br /> toantemlCa%%#w cAAcccaslAppliaahon <br /> for peamilslDriveway and Paved Pmm <br /> tge Page.2 of 2 Revised 812000 <br /> ,1 <br /> I <br />