ENC2011-00010CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408)376-0958
ENCROACHMENT PERMIT
(for working within the public
right-of--way)
Issued -~~ 1~
Permit Expiration Date ~ 2 ~ 2
30~ Zxg~o
Petmit No IaV ~. 2a ~ ~" GUC I ~
X-Ref. File
Application Date (~ 2 `i ~ I
Application Expiration Date
APN
APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 1 l .04.
months if the permit is not issued. Application Fee is non-refundable.)
A. Work address or tract # Y Uy1 G 2`~ ~r Ch µ ~l~C~ ~~/~`
Utility trench
B. Nature of work
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(Appiicati sin six (6)
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C. Attach four (4) copies of an engineered plan showing the location and extent of the work, and four (4) copies of the preliminary Enginetr's Estimate of worfC.~'~
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 City of Campbell Standard Specifications and Details for Public Works Conswction; 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 andlor 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 least 24 hours before restarting Zany work.
Name of Applicant ~'~~~- ~~G~ ryN~ ~ Telephone ~ [v ~ ~ ~ zs Zdd Z
/ Q~ ~,,/~ f ~D t name)
Address l y l ~V ~^"a~"1r' r ~~ ~ LU~GL7~V Z4-HOUR EMERGENCY TELEPHONE NO.
E-Mail Address ~Yr 1' ~ ~~C ' ~M
is this work being done by the property owners at their own residence? Yes ~ No
The ApplicanUPermittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers, agent<e and employees free, safe and harmless
from any claim or demand for damages resulting from the work covered by this permit.
The ApplicanUPermittee hereby acknowledges that they have read and
information. Applicant is advised that upon issuance of this pe ~ ,
arising out of the condition of any private improvements in the lie ri
the front and back of this permit, and they will inform their contractor(s) of the
or property owner's successors, shall be respons'ble for any and all damages
~~~/~
(sign) Date
Contractor (Print Name) Date
1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts maY
be~pecifically approved by the Inspector orior 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 Inspector.
- 3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to 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 NO.
_5. Prior to any work, the property owner shat) execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be
recorded.
_G. Public Notification Requirements:
7.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT N0.
PF.RMTT' APPLICAT[ON FEE $ ?2~C~
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $
CONSTRUCTION CASH DEPOSIT $
PLAN CHECK 8r. INSPECTION FEE $ ~ ~ S
APPROVED FOR ISSUANCE `--~-. ~ Z5 ( I
For City Engineer Date
Permit Expires 12 Months After Date of Issuance
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