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DEPARTMENT OF PUBLIC WORKS cR - nzg0 <br /> DRIVEWAY AND PAVED FRONTAGF-S <br /> PERMIT APPLICATION <br /> APPLICANT OFFICE USE ONLY <br /> JOB#11005 ISSUE DATE <br /> N FEE DUE ?Wt) <br /> e 7�Gt� DATE DRIVEWAYS: <br /> l as STREET SSFCM 0►J ►� <br /> � <br /> i�,Stat p !�� <br /> _ TYPE <br /> Ata Tel hone OTE <br /> 7 -qq <br /> SITE DNFORMATION <br /> P "f? N UZ�i <br /> to ( EWAY WIDTHS <br /> , TYPE QUANTITY �FRONTAGE <br /> - <br /> (Area <br /> State- Code r— . GRICULTI)RE <br /> COMMERCIAL R/OV <br /> (�Code)Telephone ���, <br /> roENCEy <br /> CONTRACTOR PAVED FRONTACIE <br /> (}TH: Ft. X WIDTH: Ft <br /> Name . <br /> The imdersigmmed hereby applies for pmrm non to encroach on County Ilighaay <br /> Address Right-of-Way on the So�r.�/ side of / ' <br /> approximate)Y �LN)e,!5 :r of a A?yy <br /> City,State-Zip Code ,by' 7Ju- <br /> (Area Code)Telephone <br /> Work <br /> will commence on or about for approximately days' <br /> SKETCH(Separate sheet maybe submitted) <br /> Will this project be self-installed? NO YES _Contractor's License <br /> Aeom\Per AppTorm\DdvmayPaved fmatage <br />