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DEPARnvffiNT OF PUBLIC WORKS CR# f)aR()R D <br /> DRIVEWAY AND PAVED FRONTAGES <br /> PERMIT APPLICATION <br /> APPLICANT OFFICE USE ONLY <br /> JOB#11 5 ISSUE DATE <br /> _2zv _ 39 FEE DUE OXO <br /> Name <br /> `�A. Q l�+ 1"\G (Z C-c A- DATE - DRIVEWAYS: <br /> STREET <br /> A&tmss t(;-I <br /> c L C- <br /> C? ����y QUAD <br /> TYP <br /> City,state- P Coda L-( <br /> S�S I oRMS v - <br /> OTE <br /> (Area )Telephone <br /> -3 370.3 <br /> SHEEN <br /> Parcxl Name <br /> �� A 4,2C-"A+� <br /> n 1 Site Address RIVEWAY <br /> I Y 3 1 L7 L( n Nl-C- "A TYPE QUANTITY. WIDTHS <br /> City,State-Zi 3 Coda GRICULTURE @ FRONTAQfi <br /> R;SrRCTAL R/W(Area Code)Telephone RIAL <br /> IDENCE <br /> CONTRACTOR ' PAVED FRONTAGE <br /> QTIi Ft. X WIDTH <br /> The undersigned bmby applies for.peamission to encroach on County Highway <br /> Address Rigbl-0f-Way oa tha of l✓MIYE AM <br /> usge- <br /> We of CH(ZlSwtw� <br /> �y - - <br /> city,State-Zip Code �D by installing <br /> (Area Code)Telephone . <br /> Work <br /> will commence on or about for approximately days- <br /> SKETGH(Separate sheet may be submitted) <br /> Will this project be self-installed? NO YES Contractor's License <br /> AccrosTcr ApplFormUkivmaypAv ed&notar <br />