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ZfL1'It�t'fL L t.Ji'/f`y�'iL'+y� <br /> I. That he/she hes reed all the provisiow Of this M*mtjom,end that the <br /> kaowlwdg�and descriptioaa mchrded iatiia RM 00fred to the beat Ofhis/her <br /> 2. That he/she is the owner ofthe dye y or is qualifiedto represet theownw,and <br /> 3. That he/she will assume fall raponsibitay r r all sabirly far <br /> or which mty atise oat of his/her failan to do the work pmvidedded lsaruo;and Pgpdy whtohmay arise at oftha work deacn'bed above, <br /> 4. That in the event any claim ofsadt liabgfty is made <br /> �. 'and hold them and each of them harmless for suds c hdnr amd mormydepwhme4 Officisl ar amPlOyee gxceog he shall <br /> Tint <br /> slaff be <br /> S. wHh a v�atrd nt meEa =P itre of the applicant in the Cosmiy Right-0P-way at to above.Mca t ed site <br /> b. That if pamisaion is <br /> Brasted as requested,he agrees to do the we&dascrIW ifl accordance wtlh all temts,conditions and or <br /> aItnstricxian ofthis and any, <br /> ttadud ,mduded as Borax{ II <br /> s*wft eafAFPHCsld.TMl A,—. <br /> Date <br /> »»»»»»»»»»»»» FIELD INSFATOR COpgWU n <br /> »»»»»» <br /> gC? <br /> t=ONDI1iD1VS«««««««««««««««««««« <br /> L DRIt'EWAY: None ❑ Dirt ❑ aravel <br /> AgBcqga6e Base <br /> s.SLOPING: AwayfiamPavement ❑ Pavad(Foa) ❑ Paved(Oood) ❑ <br /> Tavands Pav�ssaet '❑ Flat Ap9 . <br /> Now Eaiet;eg-Typs <br /> OdW OPes in ueig kodwod: Yes ❑ T{ <br /> Approaches ❑ . does Drain 0 Size <br /> acLmeot to ncW6oee Pipe; Yee ❑ No <br /> 4 HEADWALd,: � Yes ❑ No" <br /> 3.ASPI!<ALT CGf4CRETZ DIICL►:' Ya ❑ No <br /> • 6�.BARRIERS <br /> '1. DrKH Yea ❑ No <br /> Ifyes: V Style ❑ 2 Fbk t ❑ Other ❑ mria <br /> »»»»»»»»»»»>> >>>>>>>>>>>>>pERtliT �' <br /> L DRIOEWAYa REQUIREMENTS«««««««««««««««««««« <br /> SFR <br /> PAVED with 1ERCIAI. ❑ A,O[RtCUI 1'fIR ❑ INDUSTRIAL ❑ <br /> Notes lfiL Depth A.C.over T "116e.Dmplh 3/4"A.B. <br /> 2. PIPE& L0386Qfp <br /> Ft.and DiaeAe6er of pipe inch <br /> To be oaooeded to any adjaoerd ❑ No <br /> * ypipe. <br /> Yes <br /> D�'DAMIN ETREQUIRED Yes O No <br /> Toted Length <br /> Nacos ( Proposed) <br /> TeW Namticr est :Drslrt Y e& <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONT <br /> . ACtE: PAVED with "I&M Dom,AG over " <br /> lfm Depth 3/4"AB. <br /> Feet is and <br /> Fad in width <br /> ------------ <br /> Drsveway Faaoachn3ent Permit hese flee......:...:..».»...:� <br /> FEES <br /> kM lnel:ection <br /> plkm <br /> away w/o'w/o pips................._.........._......... <br /> ❑Driveway. <br /> ..._.._»_51ss_oo ❑pa�ds�on�e,,,,�.___.__.._..__....slaaoo+o.a�/s <br /> - ❑Curb,(Sutter gidewalL...:.. . ...__. 5190:00+0.98/8 <br /> CamftlComPu 'c:lAoceas on for Ply and Paved Mvetage <br /> Page.2 of 2 Revised M000 <br /> K <br />