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rcmvau Uy <br /> DEPARTMENT OF PUBLIC WORKS CR# O Q q a el q <br /> DRIVEWAY AND PAVED FRONTAGES <br /> PERMIT APPLICATION <br /> APPLICANT OFFICE USE ONLY <br /> JOS#11005 ISSUE DATE <br /> Name - _ FEE DUE <br /> O J DATE DRIVEWAYS: <br /> Address $IREET fit' <br /> QUAD <br /> lZ : <br /> City,State-Zip Coda <br /> TYPE LYS <br /> irn©� CS ZSO. ORMS 7 / <br /> (Area Coda)Telephone OTS <br /> SITE INFORMATION <br /> Parcel Owncts Name <br /> T Site Address <br /> DRIVEWAY <br /> TYPE QUANTITY_ WIDTHS <br /> City,State-Zip Coda AGRICULTURE @ FRONTAGE <br /> - <br /> R c- 0( Sl> COMMERCIAL <br /> (Area Coda)Talepbmw USTRIAL @ R/W <br /> ENCB . <br /> CONTRACTOR PAVED FRONTAQE <br /> QTH Ft. X WID1Ti Ft <br /> �✓ .Nsmo <br /> Addrasa The tmdarsignad bareby applies for permission to encroach as County IMIighvmy <br /> Ri&-of-Way on the side of STA <br /> fly r; /mile Sr Of <br /> City,State-Zip Code -by instaming <br /> (Area Code)Telephone <br /> Work <br /> will commence on or about for approximately days- <br /> SKETCH(Separate sheet may be submitted) <br /> Will this project be self-installed? NO YES Contractor's Licenpa <br /> Accew\Per App\FormTdvewayEaved fnntage _ <br /> \S.1/ <br />