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. <.V6.lLY1 1 Vl' 1.7L'11Y JVrl�vu� Recaived Uy <br /> DEPARTMENT OF PUBLIC WORKS CR# - d3 <br /> DRIVEWAY AND PAVED FRONTAGES <br /> PERMIT APPLICATION <br /> APPLICANT OFFICE USE ONLY <br /> JOB 011005 ISSUE DATE <br /> Name N�5 -22 -�_ FEE DUE <br /> y; DATE DRIVEWAYS- <br /> p STREET -Ike <br /> QUAD ✓ <br /> City,State- 'g TYPE <br /> ORMS <br /> (Area Codd)Tel OTE <br /> 2 <br /> SITE INFORMATION <br /> Parcel Name, <br /> •fib - <br /> DRIVEWAY <br /> 101 <br /> TYPE QUANHTY- WIDTHS <br /> S Zip O RICULTURE FRONTAGE <br /> (Aran Code)Telephone CONIlviERCIAL <br /> USTRIAL � �R/W <br /> ZD� - 917,,. cf )' IDErICE . <br /> CONTRACTOR PAVED FRONTAGE <br /> C}TIi Ft. X WIDTH Ft <br /> Name <br /> Address The un&m*tcd hereby applies for p=dsdm to encroach eukCaunty N*way <br /> Right-of-'Wayonthe 6AST side of ?uJ2NPlRD. <br /> City,State-Zip Code apply<r �� G�77.1 of E N� or' <br /> T?rP�llolkE .by• �t <br /> (Area Code)Telephone <br /> Work <br /> wilt commence on or about for approximately <br /> SKETCH(Separate sheet may be submitted) <br /> i <br /> Will this project be self-installed? NO YES Contrmt&s License <br /> AcoeaslPer A 1.FormUMvewayPaved fcaatage <br />