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aconed to the bast of his/her <br /> 1. That hds&Las read all the provisiom of this� that the deseaiptia►iachrded iathss ,pi err te <br /> lmowlwdge;and <br /> or is quali$edto r theowne�and <br /> 2. TLathelshe ism owner offfia raspadive ProP�Y. arise out ofthe work described above, <br /> liar alt h4iht'y for personal injwy+or damage to PrOPCOy ki hmay <br /> 3. Thathe/she will assume fall rarity . <br /> or which may stisa oat ofhialLa taiiure to do iLe worYpravided hack and officiat he shall <br /> 4. Mat in the event any Claim of auh liabildy is made gPnV t 1hCrCaooty of Sam htiacom or sw�' <br /> defend,indemnify and holdthem and each ddwn Lamalws for sods cls and <br /> S. Tbat work shall be permmed by the apphc"mor any f° e of"e��in the Coemty Right-of-Wsy at the above indicated site <br /> with avalid Sea Joaquin Coudy Fwoachn a t Pemut,and <br /> as requested,he agrees to do the wodt desaibed inswordanoe wiihali turns,oonditioos sad t estitiction ofthis and any. <br /> 6. That if permson is ll � <br /> aaacbed sheet,included as gwa''l or spepal III Provastow. <br /> Date <br /> gofAppl&xn!-Title <br /> FIELD INSPECTOR CO11MWM <br /> L DRI+vLwAY: <br /> Now ❑ vitt (travel ❑ Agee Base ❑ PavONPOar) Paved(Good) <br /> ❑ ❑ <br /> 2. SCOOPING: fmm <br /> AvmyPavanwd ❑ TowardsPavemat ❑ Flat <br /> 3. rem. Nene E -Type <br /> Opes Yes El No Approaches 0 Cross Thain Elze <br /> SiL� <br /> AZtsdxna tto ndgVmft pipe: Yes ❑ No <br /> 4.RUDwALiu: Yee ❑ .No" <br /> S AWNALT C014CRM DIIi3re Yes ❑ Na <br /> 6..B,ARREW along Right-c&Way AMA <br /> 9. I)rMR Yes ❑ No IfYea:• V Style tj 2 Point ❑ Other Dep1h <br /> »»»»»»»»»»»»»»»»»»PSRMITREQLJtItENB <br /> <z««««««««««««««««««« <br /> L DpRiVEwAY: SFR C ID&BROAL ❑ AIE,,#//RtCEII nl" ElINDUSTRIAL ❑ <br /> PAVED with "Mm-Depth A.C.over Y "Wm Dep*314"A.B. <br /> NOW <br /> 2. PIPS& Lma}h of PipeRegaired:' Pt,and D-Adw cf Pipe Inch <br /> TobecomededtoanyadyaeentdrivewayiaiPO Yes ❑.No <br /> DRAINAM INLET RUQ UIRED Yes ❑ No <br /> Tot41 (with proposed) ToW 1%nbef of Stamm Drain hate" <br /> Nates <br /> 3. HEADA'ALL Ya ® No . <br /> 4. PAVED FRONTACTE: PAVED with Depth A G over "Mia Depth 314"AB. <br /> Meaming Feet is tmgth and Fed in width <br /> PEW <br /> Driveway Faauaehmeat Permit base fee..............._.........$&5.00 <br /> Field Iaepecti(m + <br /> Driveway w/orw/o _595.00 ❑Paved finutiga - _ _ __$100.00 0.46/8 <br /> Pipe......... <br /> Els Drivewayw/boCulvert......................_......—........_.—$155.00 ❑Curt►,Guaar,Sidewallr..:.. .. .._5100.00+0.9&2 <br /> counwWomp►rte,o:\Accm\Appfoafm fur Pem�Di"y am Paved Fhmtaga Page.z c�2 RaalBed a/2oo0 <br />