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1. That he/she lees read all the provisionsof this fflfficafim and that the deseription included iatlais application are coned to the best of his/her <br /> knowhrdge;and <br /> 2. That he/she is the owner of the respective propedy,oris qualified to rpt Sae ownw,and - <br /> 3. That helshe will assume fall caponsihOity fm all Lability for personal injury or damage to property which may arise out ofthe work described above, <br /> or wbichmsy arise out ofhislher failureto do the workpeovidedh ,;and <br /> 4. That in the event any claim of such Habd ty is made against tleConnty of San 3osgi m or any department,official or emplsoym there4le shall <br /> defend,indemnify and holdthwn and each of them harmleas for such dagq and <br /> S. That worse shall be peribm ed by the applicant and/or any representative ofthe applicant in the County Right-cf-Way at the above indicated site <br /> with a valid Sea Joaquin Comely Encroachment Pen nit;and <br /> 6. That if pemlMan is granted as req vested,he amma to do the mark described in acoerdaace with all tams,oaodotims and ne*icdm ofthis and any <br /> attacbed <br /> 3ignaera aftlpphicant-Fide Date <br /> FIXED INSPECTOR COMMOUM <br /> »»»»»»»»»»»»»»»»»»»ENISTMO CONDMONg««<«««««««««««<<«««««< <br /> L DRT%MWAY: Nae ❑ pat [] awvd ❑ Amegme lase ❑ Pav-d(P w) ❑ Psved(Oood) <br /> 2. SLOPING: Asmyfi+an Pavmhmt ❑ Towards Panum a t -❑ Flat <br /> 3 PIPES:. Nave l rating-Type <br /> Othwpipeskno bbadooK Yes ❑ No Approaches 0 Cross Drain ❑ Sim <br /> Attachment to mw&oes pipe: Yes ❑ No <br /> 4.HEADWALL: Yes ❑ No' <br /> S.AsnuLT CoNcRETL Dm. Yes ❑ No, <br /> C.BARRED alangRigbt-oWay <br /> 4. DTPCH Yes ❑ No IfYes:• V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> ?»»»»»»»»»»»»»»»»»»>PERMiTRBQUMEMMM««««««««««««««««e«««< <br /> 1.DRIVEWAY: SFR COMMER JAL ❑ AGRiCULTUM ❑ INDUSTRIAL .❑ <br /> PAVED with Z "Mm.Depth AC.over ¢ "If .Depth 3/4"AB <br /> Nates <br /> Z. PIPE& Leogtlr of Pita Ralajrpd ' a and Diarlww of Pipe Inch <br /> To be connected to any ajacent may*0 Yes ❑ No <br /> DRAINAt3ED=REQUIRED Yea ❑ No 1�-- <br /> Troad 1- : (With proposed? Total Nmuber of Shum:Drak bbb <br /> Nates <br /> 3. HFADWALL Yea Q No <br /> . 4. PAVED FRONTAgM PAVED with "Wm Depth AC.over "Mm.Depth 3/4-AB <br /> meas ming Feet is length and Feet in width <br /> FEES <br /> Driveway Encroachment Permit base fee.......... ...... ..S$S. <br /> Feld Inspection <br /> WrDrivewayw/or w/o pipe.......... .__. _r ❑P,.dfcoataga—___...N_-_....5100.00+0.46/S <br /> ❑Driveway w/box CalverL—............_....._._____...._�}SS.Op. ❑ Curb,Gutta;Sidewalk..:.. ... . S100.00+0.9vft <br /> CounfeCo ,,,.c:V=essVVq ioation for PwmWDriyaway and Paved Frontage Page.2 of 2 Revised 8/2000 <br />