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PacificGasarref Field Paving Form Permit Number:ti <br />P �t E t' D te <br />Pfecfnc Gompaay <br />Date: 190 //2 <br />Foreman Name: t�g2 i" iAS r 0/0 <br />PM Number: l.iV 5 i r4F3 1' <br />Concrete W x L ''` 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 / N <br />Curb <br />Gutter: Y / N <br />Valley Gutter <br />If <br />rIll <br />Dowels <br />ea Size: #41 #5 <br />Asphalt <br />W x L `: Depth <br />Asphalt <br />�' (orinches <br />.Milf-&-ml <br />6 inches <br />Asphalt I Concrete Combo_" <br />over _" <br />Grind <br />_ inches <br />IF <br />Asphalt Fabric <br />Asphalt Berm / Curb <br />Saw Cut <br />Depth <br />Asphalt ��` If Cinches <br />Concrete If inches <br />Seal Wx L';. <br />Slurry / Fog / Sand m <br />Striping Width <br />Paint <br />Thermoplastic <br />Traffic Legend <br />Double Center LaneHff <br />3M "Scotch Lane" <br />If _ inches <br />If _ inches <br />ea <br />If <br />4" 8" 112" Crosswalk <br />ermi xpua ti <br />a <br />Street Address: 510 � k'" °e <br />Cross Street: Iv. 1 wrk,d g J9!Z <br />Color: Y/ N Aggregate: Y/ N Decorative/Stamped: Y I N <br />Color: Y/ N Aggregate: Y/ N Decorative/Stamped: Y/ N <br />Color: Y/ N Aggregate: Y I N DecorativelStamped: Y/ N <br />Color: Y I N Aggregate: Y/ N Decorative/Stamped: Y I N <br />Adjust/Replace <br />Manhole Frame ea <br />Sidewalk Gas Valve Boxea <br />Secondary Electrical BoxHea <br />ea 13" x 24" 17" x 30" 124" x 36" <br />Valve Frame ea 15" 1 23" <br />Valve Cover 30" x 30" j 32" x 32" j 48" x 48" <br />Other <br />WxL <br />Place Paver I Stone I Brick In Concrete: Y I N <br />Traffic Marker Dots <br />as Reflective: Y / N <br />Plug 1 Yz" Gas Prospect Hole ea Concrete I Asphalt <br />Notes <br />Cl.- 15 <br />