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' Heid Paving Form Pe mit Number: <br />���h�.�l .__..... Permit Expiration Date: <br />Date: rf -Z <br />�a7 Street Address: <br />Foreman Name fes,,Zs� � )1., Cross Sir t: <br />PM Number: ; ,' ` ' ,�l3 d citc un't • <br />Concrete W x L Depth <br />Roadway inches <br />Sidewalk _ inches Color: Y/ N Aggregate: Y I N Decorative/Stamped: Y I N <br />Sidewalk T inches Color: Y/ N Aggregate: Y/ N Decorative/Stamped: Y/ N <br />Driveway _ inches Color: Y / N Aggregate: Y / N Decorative/Stamped: Y / N <br />Driveway _ inches Color: Y/ N Aggregate: Y I N DecorativelStamped: Y/ N <br />Curb Ramp Domes: Y / N <br />Curb If Gutter: Y / N <br />Valley Gutter If <br />Dowels ea Size: #41 #5 <br />As W x L Depth Adjust/Replace <br />Asphalt �Qinches Manhole Frame ea <br />Fill _ inches Sidewalk Gas Valve Boxea <br />Asphalt I Concrete Combo _" over _" Secondary Electrical BoxHas <br />ea 13" x 24" 117" x 30" 24" x 36" <br />Grind _ inches Valve Frame as 15" 23" <br />Asphalt Fabric Valve Cover 30'x 30" 132" x 32" 148" x 48" <br />Asphalt Berm / Curb If <br />Saw Cut Depth Other W x L <br />Asphalt If (0 inches. Place Paver / Stone / Brick In Concrete: Y / N <br />ete �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. <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" 18" 12" Crosswalk <br />r1 <br />M <br />-�— <br />Row -46` <br />Fp- 3)' <br />CIL- 6A <br />