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Received by <br /> DEPARTMENT OF PUBLIC.WORKS CRN O a'4 a'�5:j <br /> i DRIVEWAY AND PAVED FRONTAGES <br /> PERMIT APPLICATION <br /> APPLiC OFFICE USE ONLY <br /> JOB#11005 ISSUE DATE <br /> n_Name 1 $ - -_� FEE DUEYZ <br /> O <br /> L DATE DRIVEWAYS: <br /> Address STREET lWe--,VixXw Ak <br /> AMA Sloe-,er0A/- QUAD- WS <br /> City,State-Zip Code TYPE <br /> FORMS S5 ,,yys X-1-7., <br /> (Area Codd)TeFeghone NOTE <br /> SITE RlF0RMATQN <br /> Ize- <br /> Parcel Ownds Nam ' <br /> J . <br /> Site Address R1VEwAY <br /> Ci ,State-Zip Code TYPE QUANTITY- WIDTHS <br /> a-L a a7 AGRICULTURE (d FRONTAGE <br /> ( Code)Telephone COMMERCIAL <br /> JINDUSTRIAL R/W <br /> IDENCE <br /> NTRACTO PAVED FRONTAGE <br /> < GTIL Ft. X WIDTH Ft <br /> ame <br /> Address The undersigned hereby applies for pmmiasion to encroach an County Highway <br /> Z o Rigbt-of-Way an the 1A--*c.3F side of Q lAY--, AX., <br /> State-Zip Code qvroximAwylld /mile O of Sczvm <br /> d Z o� Atm• •by installing —ZW <br /> Code)Telephone <br /> Work <br /> will oommence on or about for approximately days- <br /> SKETCH(Separate al cet may be submitted) <br /> �oA f— <br /> Will this project be self-installed? NO YES Contmotoes License <br /> Ac c—'Per AWTFormWriva"yPaved f m taga <br />