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1. That be/afthes mod all the provisions of this application,and that the description inchmded inthis spplxxheu am oeuect to the best of his/her <br /> lmowtv4M and <br /> 2. Thal he/she is the owner of the respedivo property,or is qualified to rqrcsmt the owns,and <br /> 3. That he/she will assume fall cneponaffi ity liar all liability Ear personal rnjuryordamage to property,whichmay wise cut of the,work d=ibed above, <br /> or wbwh may arise out of his/her fattane to do the sock provided haviq and <br /> 4. That is the event any claim of such liability a made against the Coocdy of San kagiun or any depipctnmeat,official or employee thereof;he shall <br /> defend,indemnify and hold*=end each of them WnAees for such dorm;sad <br /> S. That work shall be pe famed by the appliaaut and/or any representative of the applicant in the County Right-of--Way at the above indicated site <br /> with a valid Sam and <br /> 6. Tientnf pemniseim is a ed,be a es to o the work described in acocrdauoe w othan fume,conditions and rrahutiaa of this and any <br /> attached dheet; p <br /> �p <br /> Sigosime of Appliwat-Title <br /> FIELD INSPECTOR COMAtt)r M <br /> »»»»»»»»»»»»»»»»»»»»EXISTU40 CCR4=ONS«««««««««««««««««««« <br /> t <br /> L DRIt%WAY: Now ❑ Dat Brave/ ❑ Aggregate Base ❑ Pived(poor) ❑ Paved(Good) ❑ <br /> L SLOPING Away fi.Pavement ❑ Towards Pavam of Flat ❑ <br /> 3. PIPE& New )4 Snetieg-Type <br /> Other pipes ian*0kchood: Yes ❑ No �} Approaches ❑ Croes Dram ❑ Size <br /> AtfachmedtoneiaM"%pipe: Yes ❑ No <br /> 4. HEADWAUd Ya ❑ No jo <br /> S.ASMALT CONCRETE DIICEe Yee ❑ No <br /> 6..BARREMS slang ki*W&Way <br /> 1. DITCH Yee ❑ No IfYes: V`81* ❑ 2 Point ❑ Other ❑ W-dlh Depth <br /> »»»»»»»»»»»»»»»»»»PBRMTTREQUildE1MTS«««««««««««««««««««« <br /> 1.D)<RVEWAY: SFR COMMP3tCM ❑ AQRkMTUJtk ❑ IIdDUSTRW. ❑ <br /> PAVED with Q "EIa Depth AG over < Ian.Depth 3/4"A.B. <br /> Nates <br /> 2. PEMSc Lento of Pipe Reg kV& Ft and Diameter of Pipe inch <br /> To be 000neded to say a4somt driveway pipe Yea ❑ No <br /> DRAINAM IMI"REQUIRED Yes ❑ No (� <br /> T OW LaROL (with proposal) Teal Number of Atom Drab Metz <br /> Natm <br /> 3. HEADWALL Yea Q No <br /> A PAVED FRONTAGE: PAVED with "Ma Depth AG over "Lisa.Depth 3/4"A.B. <br /> Measuring Feet is lmgx and Feet in width <br /> ESDriveway Ena+oschmeot Pamir base fee .._.......(;�FieldInspectoni � <br /> �Driveway w/orw/o pips.........._ ___._.......�_ 59300 ❑Pavedfi=Uge._....__..._.._.__,5100.00+0.46/8 <br /> Ddvewayw/box cutvert.r..___.....__ _ „ _5153.00 ❑cud,,(utter,Siciewallc...:.._......._....SIoo.00+0.98/8 <br /> CoudaCanputm;c:\AcoeiiisVff1icahon for PamfdDripeway and Paved Frontage Pege.2 of 2 RAvieed 812000 <br /> . ' i <br />