87-196
Permit No.
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Applicant
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INFORMATION SHEET FOR PUBLIC WORKS PERMITS
A se~rate form must be completed for the applicant and each contractor that will
work under this permit.
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CONTRACTORS INFORMATION
Note that all contractors must have current City of Campbell Business License,
State Contractor's License and Workers' Compensation Insurance.
State Contractor License No. ~:S6~ 7
TelePhon(?tOf ) ~?7- 76:51
c;. 96//0
Name of Contractor
Address 59 :5.
City Business License No. ()~IJOJ' / 7 .~
Will do the following types of work:
_____underground
P.C. concrete _____A.C. paving
electrical
other (specify)
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WORKERS' COMPENSATION INFORMATION
City Council policy requires the following
applicant and any contractors prior to the
(1)4{'1- .J
Name of (Applicant) or IContr~or)
information be submitted by the
issuance of a permit.
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Building Department
One of the following
(indicate one) :
Certificate of consent to self-insure issued by the Director of
Industrial Relations; or
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Certificate of Work~rs' ~ompensation
Insurance co.~
Expiration Date I 0 ~7 ; or
Insurance ~OO/
Policy No. 'I1We.50tft,RJ ;
Certificate of Exemption from the workers' compensation laws
(sign certificate below).
CERTIFICATE OF EXEMPTION
I certify that in the performance of the work for which this permit is issued, I
shall not employ any person in any manner so as to become subject to the Workers'
Compensation Laws of California.
Signed
Date
~OTICE TO APPLICANT; If, after making this Certificate of Exemption, you should
become subject to the Workers' Compensation provision of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
~/ f: Continfo
1~~ Rev. 4/87
Page _of
PUBLIC WORKS INSPECTION REPORT
..ate . //f"i~. . Perait or Project No.
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Address ~S- . uJ. Z.. ",.;'-0".)
B7-/'~,
Street Storm v"" Sanitary Electrical
Other (describe) ;::?C.c. wo.bC-
o PRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached)
Type of work:
o FINAL INSPECTION WITH DEFICIENCY LIST (attached)
~AL INSPECTION - ACCEPTANCE
Signed plans? Y ~ (If signed, Council acceptance.)
Charges against deposit? Y
Overtime: hrs. @ $
Date , realion:
~
.
$
Barricade rental (attach invoice)? Y
Date , reason:
cD
$
Other?
$
$
$
· Refund $
ck. req.)
Total charges deducted from deposit:
(Cash Depoliit $ less charges $
o ONE YEAR MAINTENANCE WITH DEFICIENCY LIST (attachad)
o ONE YEAR MAINTENANCE - ACCEPTANCE
(Rele.8e'aAinten~nce bond. Check Requelit if cash.)
er
Engineer
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