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DEPARTMENT OF PUBLIC WORKS Received by <br /> CR# <br /> DRIVEWAY AND PAVED FRONTAGES <br /> PERMIT APPLICATION <br /> OFFICE USE ONLY <br /> JOB#11005 ISSUE DATE, <br /> N N A0V -�/�-_aL FEE DUE Zz9, 76 <br /> tx� �� .DATE DRIVEWAYS: <br /> p Address _ STREET V. ' <br /> QUAD /( <br /> 7Q City,State-Zip Code TYPE PW <br /> FORMS s5T.✓uJ Guy-�Z <br /> (Area Code)Telephone NOTE <br /> ozo5,,,��/- 98 <br /> SITE rFORMAITON <br /> 11191 e <br /> arc el 7wK <br /> ame <br /> Ca <br /> ^ySiteA s Gp5�� <br /> / DRIVEWAY <br /> City, tate-Zip Code TYPE QUANTITY WIDTHS <br /> de ._ GRICULTURE @ FRONTAGE <br /> (Area Code)Telephone COMMERCIAL <br /> INDUSTRIAL @ R/W <br /> IDENCE <br /> CONTRACTOR PAVED FRONTAGE <br /> LENGTH. Ft. X WIDTH: Ft. <br /> Name <br /> Address The undersigned hereby applies for permission to encroach on County Highway <br /> Right-of-Way on the S/W Cir. of Ptta/i Br Jww,x <br /> City,State-Zip Code approximately feet/mile 'of <br /> by installing <br /> (Area Code)Telephone <br /> Work <br /> will commence on or about for approximately days- <br /> SKETCH(Separate sheet may be submitted) <br /> �e /77 ou e ��f"t -�f `�S �f 0 fr�2 <br /> G-"A`� <br /> l ` <br /> Will this project be self-installed? —NO YES Contractor's License <br /> Acces0er ApplFomr\Drive vayPavad frontage <br /> 0 <br />