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-1. That helsbe has read all the provisioro of this appfi-fio%and to do desdxip m iochided Inthis application are coffect to the best of his/her <br /> Ymowlwdm and <br /> .2. That he/she is The owner of die respective pcopedy,or is qualified to represent do owner;and <br /> 3. That he/she will assume fall responsiidity for all oddity for personal injury or damage to propedy which may arise out ofthe wodc described above, <br /> or which m y arise out of iiwlw Mm to do the wo&provided herein;and <br /> 4. That in tho eve d any claim of such tiabift is made against%&C,oudty of San 7 m*m or any depaftswt;o field or employee hawt he shall <br /> defend,iodemdify and holditm and cacti cf dtm ham for saes ckim;and <br /> 5. That work shall be performed by the applionot and/or any reprosmisfive of fm appticaot in the County Ri*-of-Way at dhe above indicated site <br /> vft a valid San oagaid Cagily F.nwmbwmd Permit;and <br /> b. That if peamiWan is granted as regnested,he agrees to do die wodc described in acaordaaoe mi&all temps,oonditiods and test i(fin of this and any <br /> attached sheet,inducted as general6r special It1 ptovii OM <br /> Signature ofApplicami4itte Daft <br /> FIELD INSPECTOR COMMMS <br /> »»»»»»»»»»»»»»»»»»» <br /> EMTMOCONDMONS««««««««««««««l«««««< <br /> 1. DRIFEWAY: Now ❑ Ilett .� Qw,,d ❑ AggdrgabeBase ❑ Pavokpoor) ❑ Paved(Good) ❑ <br /> 2. SLOPING. Awaylrom Pay..A ❑ Tow"&Pavoament ❑ Flat <br /> 3: PIPM. Now E3&ft-Type <br /> Olierpipes inndobodoodk Yes ❑ No ��, Approaches 0 Cross Drain ❑ 3iu <br /> Attubma t to oedibarls pipe: Yes ❑ No <br /> 4 BF.ADWALF, Yea .❑ NO <br /> S. ASPEMM CONCRETE DI7C6: Yes ❑ No <br /> &.BARREMS alooFRight-cMay <br /> 1. MICK Yes ❑ No IfYes:• V Style ❑ 2 Pont ❑ ofher ❑ W-W& Depth <br /> »»»»»»»»»»»»»»»»»>>PERMTREQL1iREllENTS<z««««««««««««««««««« <br /> 1.DRIVEWAY: SFR ❑. COMMEI2C2IAL ❑ AGRfCUI.TE= INDUSTRIAL ❑ <br /> PAVED wilt .2 "I fuL Depths A.Q 0VW 4' "Min.Depth 3/4"A.B. <br /> Nates <br /> .2. VHS& Length of Yips Respired ' I?k sod Diaodater of Pipe In& <br /> To be oonnwW to say adjaoeot driveway pipe Yes ❑ No <br /> DRRINAM INLET REQUIRED Yea ❑ No <br /> Total Lengti: (w!h proposed} Total Na ber of Storm Drab Mob <br /> Notes <br /> 3. HFADWALL Yes Q No <br /> A. ?AVID FRONTAGE: PAVED with "hfiL Depth AQ over "bIm.Depth 3/4"A.B. <br /> Measuring Fed io 1mg&and Feet in width <br /> FERS <br /> Driveway F.adroacbsned Pamit base fee..........._........... <br /> .585.00 <br /> Field Inspection <br /> &znVewayw/a•w/.pipe.......... ___ _:_ 595.00 ❑PavedSromtaga __ _ ...._—$100.00+0.4618 <br /> ❑Ddvewayw/box culvert_--.._---....._................__..$155.00 ❑ ct*Clutter,Sidewalk..........:...._.....$100.00+0.98/ft <br /> Ci <br /> Cmd it�CmVuta,c.-VWcesslApplication for ParmbMgyeway and Paved Frontage Page.2.42 Revised 8/2000. <br />