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a ., <br />t"z srr <br />Date: <br />Foreman Name: <br />PM Number: <br />Concrete <br />W x L <br />Depth <br />Roadway <br />_ inches <br />Sidewalk <br />_ inches <br />Sidewalk <br />—inches <br />Driveway <br />—inches <br />Driveway <br />_ inches <br />Curb Ramp <br />Domes: Y I N <br />Curb <br />If <br />Gutter: Y I N <br />Valley Gutter <br />If <br />Dowels <br />ea <br />Size: #41 #5 <br />Asphalt <br />W x L <br />Depth <br />Asphalt = J <br />if�j` <br />10 inches <br />Fill <br />inches <br />Asphalt I Concrete Combo <br />_" over _" <br />Grind <br />_ inches <br />Asphalt Fabric <br />Asphalt Berm I Curb <br />If <br />� <br />Permit Number: <br />Permit Expiration Date: <br />Street Address: -?,& i c') <br />k­,era <br />Cross Street: i_�Jv ' S7 <br />Color: Y I N Aggregate: Y/ N Decorative/Stamped: Y/ N <br />Color: Y/ N Aggregate: Y I N Decorative/Stamped: Y/ N <br />Color: Y/ N Aggregate: Y/ N Decorative/Stamped: Y I N <br />Color: Y/ N Aggregate: Y I N Decorative/Stamped: Y I N <br />Adjust/Replace <br />Manhole Frame ea <br />Sidewalk Gas Valve Box ea <br />Secondary Electrical Box ea 13" x 24" J 17" x 30" J 24" x 36" <br />Valve Frame ea 15" 23" <br />Valve Cover as 30" x 30" 132" x 32" 148" x 48" <br />ut <br />Depth Other W x L <br />Asphalt 2 If � inches Place Paver I Stone I Brick In Concrete: Y / N <br />Crete �if inches Traffic Marker Dots ea Reflective: Y / N <br />Seal W x L Plug 1 %' Gas Prospect Hole ea Concrete I Asphalt <br />Slurry / Fog / Sand m <br />Striping Width Notes <br />Paint If _inches <br />Thermoplastic If —inches <br />Traffic Legend ea <br />Double Center Lane If <br />3M "Scotch Lane" If 4" 8" 112' Crosswalk <br />�L''f <br />I ' <br />LA! <br />i <br />L <br />CJ_ - 11 foto <br />