92-113
CI'1'Y or CAIIPUU.
DEP'1'. or PUBLIC WORD
70 North F~ st.
ca.pbell, Cl 950"
(408) 866-Z1~0 .
92-113
ElICROACIDID'l' PERlIn'
(for worJt1nCJ wi.th1D the
public riq.llt-of-vay) X-Rat. fUe
I..ued") /.:.3 (q z....-... Application Date 2 - 3 - 9 2
Penait expire. in 12 _. . Application expirea in 6 11I08.
APPLXCAT%ON - Application i. hereby ade for a PlIblic WOrD Pen1t in ac:corclaDca with CUpball
MUnicipal COde, Section 11.04. (Application upirea in 6 ~ if panit not pulled)
A. Work addre.. or tract. 151 Jane Ann Way (west/side)
Pen1t No.
UUlUy trencb location
cis Bucknall Road
B. Natura of work:
Rm~raen~y 9~~ leak renair
c. Attach tive (~) copies of a dravinCJ ahovinCJ the location, aftant: and d1unaiona of the work
The drawinq shall .bov the nlation of the propo.ed work to exi.t:inq 8Ul:'face and underqround
1mprov_entr. When approved by the City EnCJineu, .aid draviDCJ ~. a part: of thia panit.
D. The General Condition. for all penait. are liated OD the nYeI:'IIe .ide. Speaial Provisiona for
this permit are li.ted belov. Failure to abide by th_e conditiona and proviaiona ..y ruult
in jOb ahut-down and/or forfeiture of Faithful Pertormance Sureti_ and caab deposita. (See
Ganeral COnditione 1 and 2).
E. An application f.. lIIUat accompany thia application. 1'Ilia f.. ia non-refundable.
Nue of Applicant PG&E Julie Coffland '!'alephone: 725-2176
Addr...
I. this work bainq done by the property owner at thair own re.tdance? --Y- _no
complete and attacb Worken' Companaation and COntractor IDfozmation fonlS.
The Applicant/Permi.ttee hereby aqr.e. by atf1xi.nq their aiCJftat:ure to thia permit to hold the City of
campbell, it. officer., aCJenta and amploye.. free, ..fe and haral_. from any claim or dallland for
dUlaCJe. re.ultinCJ from the work covered by this panit.
The Applicant/Permittee hereby aclcnovladCJe. that they have nad and understand both the front and
back of this permit, and that they will inform their contractor(.) ot the inforution.
ACCEPTED
Applicant (Per:ittee, print/.iqn
Date
NOTES: ALL WORX SHALT, CONFORM WITH THE A'l"1"ACHED, APPROVED PLANS AND ALL APPLIClBLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR HOST HAVE 'l'HIS PERMIT AND APPROVED PLANS ON-Srrz AND HOST KEE1' WITH THE P.W.
INSPEctOR ON THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK. APPLICAIIT MOST CONTACT TD INSPECTOR
TO ARRANGE FIELD MEETING.
NarlCE HOST BE GIVEN TO PDBLIC WORKS AT LEAST 24 HOURS BEFORE RZSTAIrlDfG ANY WOU.
SPECYAL PRQVYSYONS
_1.
Str.et aball not be open cut for underqround inatallatione. llinilDwl cuts may be allowed
for connection. or exploration hol... sucb cuts must he s~eci~icallv a~~roved hv the
Ins~eetor nrfor ~o cu~~in~.
Pay_ant ay be cut for underqround installatione and 1IU8t be re.tored in accorcSance with
the Utility Trench Re.toration Standard Dravinq.
Work to be staked by a licenaed Land surveyor or Civil EnCJineu and two (2) copi.. of the
cut abeeta sant to the Public Work Departaent betore ~ta1"t1nq work.
The hours of work are limited to outside the hours ot 7-9 a... and 3-6 p... for any work
affectinq a traffic lane.
_2.
_3.
_4.
_5.
S'l'AHDARD
AMOmrI'
$ Lex;. ~ c...~
$
$
$
$ lC:1S. e.o
RECEYPT NO.
PZRMr1' Al'PLXClftON PD
PIAN c:m:a DBl'OSrr
SDRETY 1"Oll FAITBPOL PERFORlWfCE
CASB DEPOSrr
PIAN ama , DfSPEC'l"ION FEE
$100,000 - $500,000
$105.00
$500.00
(loot or ERG. EST.)
(n OF SD1Iftr, $500 KIH)
cp
--
APPROVED FOR ISSUANCE
! : PW PERMIT
Revised 10/91
Date
Cf'
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