ENC2009-00120
~
` Print Form
CITY OF CAMPBELL ENCROACHMENT PERM17 Permit No~ C- ZC~G - ~.
DEPT. OF Pt18LIC WORKS (for working within the public X-Ref. File _
70 North First Street right-of-way) Application Date ~ ~ l 2 O
Campbell, CA 95008 Issued ~ ~ ~ ~ ~J I ~ ~ Appl' tion Ex iration Date ~,~
Ph. (408) 866-2150 A ~_
Fx. (408) 376-0958
Permit Expiration Date ~ ~
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APPLICATION -Application is hereby made for a Public Works Permit in accordance with Cam pbelE M
unicipal Code, Section 1 t.04. (Application expires in six
(6) months if the permit is not issued. Application Fee isnon-refundable.)
A. Work AddressorTractNo.: I !J~/L~ ~~•~~ ~~~~~~ j `~~ /
Utility Trench location: I ~ 2-
1~~~ X-2i ~~i1 ~~ LC.iI ~~---Z ~~ G~ T'-
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3. Nature of Work: ( ~ G(v~re~ ,~.`5~ ~ - /jIZGI.f~. ~. ~ // ~'.(~'7" ,~ ~J~ Gf/1. /V
C. Attach four (4) copies of an engineered plan showing the location and extent of the work, and four (4) copies of the preliminary Engineer's i~1-ST%/~%1/L~
Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved /
by the City Engineer, said plan becomes a part of this permit
D. All work shall conform to the Clty of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions
listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result
in job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2.)
E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before
starting work. Notice must be given to Public Works at least 24 hours before restarting any work
Name of Applicant: 1 ~ /f ev
n~iVui.___.
~~~ Telephone: //U~' ~ /
Address: ~ ~S~I C•U'yyyGw"'~ /~ J ~~ ~1~'!1'1~~ ! vl 7 ~~~~J
E-Mail Address: ~~~~~~ ~ (~~ ~~ L'!c/~~ , Cb~EV,~, G:G~•r~4-HOUR EMERGENCY PHONE NUMBER:
f
Is this work being done by the property owners at their own residence? r- YES ~ NO
The ApplicantlPermittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers, agents, and emptoyees free, safe
and harmless from any claim or demand for damages resulting from the work covered by this permit.
The ApplicantlPermittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their
contractor(s) of the information. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be
responsible for any and ages arising out of the condition of any private improvements in the public right-of-way.
/.
Accepted: ~'L~.-e~--'~ `~~ ~~~
L/ (Applicant Permittee) (sign) Date -1
(Contractor) ~ intt3ame) Oate
SPECIAL PROVISIONS:
_1. Street shall not be open cut for underground installations. Minimum cuts m~,y be allowed for connections or exploration holes. Such cuts maybe
SDeCifically approved by the InsRector prior to cutting.
2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method
"A",unless otherwise approved by the Engineer.
_3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2} copies of the cut sheets sentto the Public Works Department
before starting work
_4. Per Section 4215 of the Government Code this permit is not valid for excavations until Underground Service Alert (USA} has been notified and
the inquiry identification number has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET N0.
_S. Prior to any work the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be
recorded.
~6. Public Notification Requirements:
7
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS
CONSTRUCTION CASH DEPOSff
PLAN CHECK & INSPECTION FEE
AMOUNT ~~j RECEIPT (~Ito1,
$ G D
APPROVED FOR ISSUANCE
For City Engineer
Permit Expires 12 Months After Date of Issuance
ll ~3
Date
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