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I.ELG <br /> 1. That Wshc has read all the psovisicns of this�eats that the description imchdad i'athis applicatia�h are to the best of hi8/her <br /> Imowh IM and <br /> 2. That he(she is the owner of the respective prnpedy,ar is qualified to rem the ownwI and <br /> 3. That he/she will awww full oily fshr'U!>dxTdy farpascoai inMy or damage to properly whuhmay arise out oft o wodc desca4bed above, <br /> or which may arise out of hill w faihme to do tlhe wa&pcovidedlher k and <br /> 4. That is the evart any claim of such liability is made against theCowrty of Sam aoscliva or any*uWwgk omciat or employee&=4 he shall <br /> defmd,indemnify and holdgm and each cfd m ha aces for amch claims aad <br /> 5. That wmkaW be padmud by the applicW and/or any reprove of the applicasit in the Courtly Right-of-Way at the above indicated site <br /> with a valid San JosT=Coudy Enwasdhma t Permit;and <br /> 6. That if pemhission is as requested,he agrees to do the woak dear as in acacrdaace wi&an teams,oonditims and ro&ic ham of ibis and any <br /> attached sheat;' as geoe eche!III <br /> Signetehre ofApplicaul-Title Daft <br /> FIELD IKSPECFOR CObgdFX TS <br /> »»»»»»»»»»»»»»»»»>}»»WMT114G ONDMOIN8«««««««««G««««««««G«« <br /> L DRASMAY: Ncae ❑ pat ❑ (travel Aggregate Base Q PaV*d(P-w) ❑ Pav(Good) ❑ <br /> 2. SLOFINC- Awayfinin Pavamed Toanrds P—meet ❑ Flat ❑ <br /> 3. PIPES:. Now ❑ Ehci ft-Type N e M,'P <br /> Other Pipes iand*bcdwod: Yes R No ❑ App vwhca E Crow Drain . Size <br /> Atladmoeet to the&Kes pipe: Yes ❑ No <br /> 4.HEADWAfJ- Yea ❑ NO <br /> S.ASMULT CON CRETE BUM Yes ❑ Na [� <br /> 6..BARRUM alder$Right-away <br /> 4. Dnl(x Yee No ❑ IfYec. V&* ;R 2 F--t: ❑ O&w ❑ Width Depth <br /> »»»»»»»»»»»»»»»»» <br /> PERMIT REQUMEMENTS<z««««««««««««««««««« <br /> 1.DRIVEWAY: SM ❑. COMIrrIERr`JAL ❑ AGRRttCULTUR$ INDUSTRIAL ❑ <br /> PAVED with "Mm.Depth A.C.over �- "Mho Dept 3/4"A.B. <br /> Moto <br /> 2. PUT& Laoglh of Pkw ReRaired+' FL and Diandetw of Pipe <br /> To be coomcted to any adjacent driveway pipe Yes ❑.No <br /> DRAINAGE INLET REQUIRED Yea No <br /> Todd Length: (with proposed) Total Number of S hwm:Drak Itaieb <br /> Notae <br /> 3. HEADWALL Yes Mn No . <br /> 4. PAVED FRONTAgE: PAVED witch "hfiL Depth AG over "Mia Depth 3/4"A.B. <br /> Meaauing Feet is and Feet in wilt <br /> FEES <br /> Driveway Fnawwb ment Permit bole fee..........:....._..........585.00 <br /> Field Inspection <br /> ❑Driveway w/or w/o pipe.......... _--S95.00 ❑Paved f mtaga _._........Y..__....S100A0+0.46/ft <br /> ❑Driveway w/bos C tdvarL..._............... _._$155.00 ❑Cmth,Otter,Sidewalk..::.. ..:...........5100.00+0.98/ft <br /> CounteAComputer,c.V=ess\Appliaation for Pem itsMViyeway and Paved Frontage Page.2.of 2 Reviabd 8!2000. <br /> � i <br />