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I. That he/she has read an the provisions oftbis apphfio,4 and that the description iucip4ed i' tics <br /> � q application ars conedto the bast ofhis/hea <br /> 2. That he/she is the owner ofthe respective property,or is qualified toepresent the ownw,and <br /> 3...That he/she wilt assumo full respaasp&iy fair an liability hrpmmll injury or dantage&h pqperty whichmay arise out ofthe wcdc described above, <br /> or which may arise oat of Ws&tr faihm a to do fire work provided hetero;and <br /> 4. That is the event any claim ofsuchtiabi&y is nhade against theComty of San magi<m or any a�Ciat ar empbyee thereat;hs shall <br /> defmd,iodenmify and holdthem mrd each ofthem hmmlew fm sm h cam;and <br /> S. That wads shall be performed by the appliead and/or any reprove of the applicant in the Com ty Rigbt-of-Way at the above indicated arta <br /> with a valid San Jowpk Cw dy Enamchmed pemit;and <br /> S. That if pam ission is granted as rnquest4 he agrees tD do the wo&described in accordance with all <br /> attached te�he,conditions sad restriction ofthis and any. <br /> Date <br /> FIELD INSPECTOR COl1dhII+M <br /> �'>>>>>"""""""""'>>">>>>> >>>>EXISTMJOCONDMONS««««««««««««««z«««««< <br /> L nRrt►EwAY: Now - } - <br /> ❑ Gravel ❑ Aggre8m Base ❑ PaveW(Ihocr) ❑ Paved(Good) ❑ <br /> L SXOPINC- Amy P��e�at <br /> ❑ Towards Pavaameot •[] Fiat <br /> 3. PIPE&. Nana -Typ& , <br /> Othorprpes m Yes No ED] A, l!(�J Cmes Dayur ❑ sizeAftachmed toneiglib«'a : Yea ❑ No <br /> 4.HEADWALL: Yes ❑ No +++111/1 JJJJJ <br /> s:ASPHALT CO NCS DIICL►: Yes ❑ Na <br /> Ad <br /> 6►.BARRIlEI2S akwgtti*.4Way <br /> 4. DT!'CS Y, ❑, Ifyes:• v Style ❑ 2 FEhiat ❑ Otlher <br /> ❑ Width Depth <br /> >>�-""""""""""J'yam">>�">>>>>�>P�bRT'REQUIRE),/ENT S««««««««««««««««z«««< <br /> 1.DR[VEVAY: ggg p7( <br /> C0MMEgCFAF, ❑ AMkVLTUU ❑ INDUgTJAL ❑ <br /> PAVED with "I&L Depth AC.over. "Mm Dep1h "A <br /> Wates 3/4 R <br /> 2. PUM& IA"6cfp�PeR"*O& Ft.and Dim icer of pipe pooh <br /> To be cconeded to aayadjacw*iypipo Yas <br /> ❑.NO <br /> DRAWAGE BUZZ REQUMED Yes C1 No <br /> Total ( Tatar Nuu&w orStw m Drama L1. <br /> Nates <br /> 3. HFADWALLYes Q No <br /> A PAVED FROWfAfW_ PAVED with "Min Dem AC over <br /> "Mm Dapth3/4"Ali <br /> Mem Feet in length whd Feet is width <br /> Driveway Pama ?EKES <br /> base fee_....... 00 <br /> e1dImpection <br /> Drivowayw/or w/o _S9s_00 <br /> Drivewayw/boxCttive�t,__ _ ❑Pavedfh ga_ _ _ __---$100.00+0.461ft <br /> ❑Curb,Gultey Sidewalk.. .....:...........5100.00+0.98/8 <br /> cO +c:1AcoeealA�n for PamWDdvmmv and Paved Frontage <br /> Page.2.af2 RavisDd 8/2000 <br /> •t <br />