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I. That he site hes seed all tle provisions of this ad that the description included iethds <br /> knowlwdge;and applicatiws ane correct to the best ofhis/her <br /> 2. That he/she is the owner of the respective pmpedy,or is qualified to rapresart the owned and <br /> 3. That hdahe will assume hHWp=&W fir all fiability forpmmat kyr,ar&MW to swaty w kchmay arise out ofthe works described above, <br /> or which may arise out at;h'&4wc faihn to do the wodcprovided hemiu;and . <br /> 4. That is the event say claim ofsuch Habffity is made agsieat awceaoty of Sau A SOM or any deparinnut,officid or employee <br /> defend,indemnify and hold tl►arh andeach of than h0mufass fibs.such clam ashd ,be Shan <br /> 5. That work shall be performed by the 3Wlica*and/or any representative of the appticWt in the County Right-of--Way at the above indicated site <br /> w<ih a valid San Josgaia Couaty Factoadk,,d p�acrd <br /> 6. That ifpstmisgim is grauged as m4&m{ad,he agrees to do the wo&described in acoadmce with all tama,aftachad"K mcludod as oondrti(os aad t mtriclion afthis and anygemral III provisions <br /> Titter /Orcc� <br /> Data <br /> FIEF.D INSPECPOR C7OM1YiB1VTg <br /> >»»»»»»»»»»»»»>»»»»»»wSTINQC0NDM0NB««««««««««««««t«««««< <br /> L DRItTWAY: Now ❑ Dirt } Graved <br /> Z SLOPING: � ❑ ' A>�B�Base. ❑ ��(I+�) ❑ Paved(t3ood) <br /> Pavameot ❑ Towards Psvemeot ❑ <br /> 3. PIPES:. Nene ype " <br /> Otherlxl m Yes ❑ No Approaches [] Cross Drain ❑ Size C� <br /> Atfachma tto Yes ❑ No <br /> 4.HEADWALF- Yea .❑ No, <br /> 5-AMMI-T CONCUM B]IM , Yes ❑ Ne, <br /> C.BARREMS AmSij&,&Way <br /> 7. I)nxx Yee ❑ No IfYea:• V style ❑ 2 Pint <br /> ❑ Uther ❑ With Depth <br /> »»»»»»»»»»»»»»»»»»PERMT. <br /> REQUIRMAENTS<z�j ««««««««««««««««««« <br /> 1.DRIV&WAY: SFR E]. COh1AERCIAF, pJ'f <br /> AC1RtCEJLTETRA ❑ INDUSTRIAL ❑ <br /> PAVED with Wm Depth A G over "M,Depth 3/4"A.B. <br /> Irides <br /> 2. PIPES: EahgUhoPPipeRapes' FL sed Diamejwofpipe Inch <br /> To be comhected to any adjacent <br /> Yl Yea ❑ No <br /> DRAD(AOE INLET REQUIRED Yes O No <br /> Notes TOW LA0911L (gip ) Total Nre abw of stem Dr+da h" <br /> 3. HEADWALL Yes No <br /> 4 PAVED FRONTAGE: PAVED with "Msn Depth A G over <br /> "Min.Depth 3/4 ". <br /> M g Feet is width <br /> Driveway Fiha wwh eut Permit base fee. _.... . 1 $ <br /> �- ...S85.00 <br /> rnvewayw/or w/o pipe......__ -$95.40 SL y <br /> ❑Driveway w/box Qdvett,,,,,,,.,,,-_. ❑Paved frantaga_ _� __ __�S140 40+0.4G/ft ' <br /> ❑Curb,Out far,Sidewallc...:. .__.....5100.00+0.98/ft <br /> cauatalCompute,c:WcoeselApphmtion for Permii8Or veway and Paved Fruutage <br /> Page.2.cf2 Revised 8/2000 <br />