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KIMBERLEY DRISCOLL MAYOR RICHARD RENNARD. DIRECTOR PUBLIC WORKS CITY OF SALEM, MASSACHUSETTS PUBLIC WORKS DEPARTMENT 5 JEFFERSON AVENUE SALEM, MASSACHUSETTS 01970 TEL. (978) 744-3302 FAX (978) 744-6820 REQUEST FOR SIDEWALK REPAIR BY PUBLIC WORKS DEPARTMENT DATE OF REQUEST: CONTACT NAME: ADDRESS: PHONE: FAX: PROJECT LOCATION (IF DIFFERENT THAN ABOVE ADDRESS): EXISTING SIDEWALK TYPE (check one): CONCRETE (white color) BITUMINUS (black color) BRICK CURB TYPE (check one): GRANITE (gray color) BITUMINUS (black color) NONE TREE ROOT PROBLEM (check one): Yes, No, DESCRIPTION OF SIDEWALK PROBLEM: FOR DEPARTMENT USE ONLY Date Inspected: Inspector: Length of Sidewalk: Width of Sidewalk: Confirm Information above: (Type of Sidewalk, Cubing Type, Tree Root Issues, Driveway Approach): Public Safety Issue (check one) Moderate High Extreme 4/5/2006