ENC2009-00015k~, ~ ~lJfly ?;Z,jPM r ~f; Guy n~:~ E' ~-itiC Co. No. ~19G P. 1
Cf'1 ~ OF CAIvfYHEL,1. -dC12pACI1MENT PERMIT fermi ~ ~ ~~, ~ "'~ ~'.,
DEPT, OF PUI~LIC WORKS (for working within the public X-Ref. 1"ile
7l1 North first 5t. tight-Uf-way)
Campbell, CA y5008 ~ ~ / Li Application Tate
(408) 36fi-2150 Issued ~ C~ 1 Application Expiration 17ate
1~ax (4U8) 37(i-11958 ( C
Permit Expiration llate ~t J E'% APN ~~„~~j ~' J
APPLTCA'T'tON -Application is hereby made for a Public 1Vorks Permit in accordance with Campbell Municipal Code, Section tri .~04. (Application expires itt six (ci)
monihs if the permit is nor issued. Application F~eIe/. its npn- fundable. ~ ~~-
A, 11tod_ address or tract # W • t,;r •jt','~~-/-11 ~~ / ~,' ~~
Utility trench location
13. Nature. of ivork ~`'~' -]
C. At[ech four (4) copies of an engineered p]an showing the location and extent of the work, and fp t Ocopies of die preliminary~Engineer's )3slimatc of work. ~TYte
plans shall show the relation of the proposed work to exis[ing surfitce and underground improvem ts. When approved by [he City l=.ng;neer, said plan becomes a
par[ of lids perrtrit,
G- All work shall conform to the City of Campbell Standard Specifica[ions end De[ails for Public 'Works Construction; the General Permit Conditions listca un the
reverse side; and the- Special Previsions fpr this permit, listed below, Failure [o abide by [here. condi[ians and provisions may rusutt in job slmtdowti andlor forfeiture
of 1=ai[hful Performance Sure[ies and cssh fleposits. (See Genersl Permit Conditions I and 2.)
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E. The Caniracdur must have this permit and approved plans a[ the site and must notify the [ uhlic Worla Gcpartment at (east iwo days before srbrting work. N6~e~
must he given to P is Vyarkg at Icast 24 hours bef c res rung any work W
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Addressr ~~~_. 24-HOUR EMERGENCY TELE];HUNE I~lA.
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The ApplicanUPer;ninee hereby+agrees by afFxing their signature [u [leis permit to hold the City pf Campbell, its officers, agents and employees fret,, safe and hann~css
from any claim or demand for damages resulting fram the work covered by this permit.
'1`hc ApplicanUPcrmittte hereby act:nowlCdgF, that they have- read and underswnd both the. fram and beck of this permit, and they wit] inform their conu•aaar(s) of the
infortna[ion. Applicant is advised tha[ u n suss ~ ..of ibis permit, property owner, pr property o er's successors, shalt 6e respo sthtc fpr any and all damages
arising ou[ of t~te'cbCidi[iuu of any pr~a~t~iy~ive nts in the public right-Rf-yva~. /~ !
(Applicant Fermit[ee) (sign} r/ Dalc
Conlraclor (Prin[ Name) T pate
_l. So-ee[ shall na[ be open cut for underground installations. Minimum cutslYl$y be allowrd forconnections or explora[ion holes. Such cu[s t~
'mss 1S~1fkCall>' sort ved by~te Insnectoi ariar to cut[ine.
_2. pavement tray be cut for underground installations and must be. restated in accordance with the Standard Details Trench Restoration MelYtad
"A", milcss otherwise approved by Ingptctpr.
_3. Work to be staked by a licensed Land Surveyor or Civil Tsnginccr and two (2j cppics pf the cu[ sheets sent to [he public Works Departmcm
before staring work"
a. Pcr Scotian 4215 Of the Government Code this permit is not valid for excava[ians until Underground Service Alert (U5A) has been no[ified aad
the inquiry identitieation number hss been entcrCd hereon. USA Phont 1-500-227-2b00. USA TICICE,T NU.
_,___5. prior to any work, the pmpeny owner shalt c:ccutc an Agreement for private Improvements in the Public Right-of-Way, whleh shall be
recorded.
_(i. Public: Nolifica[iau R~uire.men[s:
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i~HRhiCT APPLICATION Fe}? w S 8 rj (j„'
FLAN CH13Ck DflPOS1T ~
SECURITY FOR FAITHFUL FERFORMANCE/LABOR d± MA'TPRIALS ~
CONSTRUCTION CASH ABPdSIT $
PLAN CHL+C'IC & fNSP6CCtpN I'f?$ S d
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APFROVEL7 FOR ISSUANCE_ --"--" """ "~ [-/ cs
_.".~~ Pear CityBngin.ecr ~17are
Permit Expires 12 Months Af[er Date of Issuance (`.
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