92-121
ern or c::&IIPUi.L
DDT. or PDBLJ:c WORD
70 1f0E1:ll nnc St.
c:apDe11, CI. '10"
(408) 811-Z~0 -
lW:ait Ho. 92-121
mR!RDAc:RIImI'P PmIIrl'J'
(for vorX1Dq v1t:b1.D die
public rilibt-ot.....y)
J:~. tUe
IanecI ? /? A. / q ? AppUc:aUon Dab
PenU.t apu.. in 12 _. . AppUc:aUon ap1zU in 6 _.
APPLXCAT%OIf - Applic:at:1Oft ia buUy ... tor a Public Worb Peaait in &acOZ'duu:e vitll c.a~M1l
lIWl1cipal Coda, Secn:ion 11.04. (Applicadon uptru in , -.1:ba if peaa1t not: PllUadJ
A. WOrk IIddnu or tract , 281 McGlincey ejo Cristich
utllity tnDcb locat:1Oft
B. Hature of varJt&
EMERGENCY
rpVrlir qrl~ lprik
c. Attacb five (5) copi.. of a dravinq DOVinq the locadoa, extent &lid cI1Muiona ot tIl. vau
'the draviDq IIball 8bov tIl. reladon ot tba pmpoaad VDrk to a1atinq nrtaca and 1UId~
!llprovaanta. When approved ~ th. CJ.ty Enqin.ar, aaid dzaviDrJ I:.Claes a PaR of tb.ia panit.
D. 'the GaIIaral ConditiOfta for all panaita an l.iaUd on the revezw. .ide. Special Praviai0ft8 tor
tIli. panait an luted b.lov. Failur. co abide ~ tbaaa c:ancU.t:10ft8 and proviai0ft8 uy rHUlt
in job abut-dovn and/or fOrfeiture ot l"aitbful PeJ:tonaaac:a SUnd.. and CUb dapoaib. (Ia.
GaII.ral Cond1doDa 1 and 2).
E. An appUcat10n f.. lIIUat '~any tIli. applicadon.
If_. ot Applicant P G & E Attn Sandra
~.. 10900 N. Blaney Ave Cupertino
1'h1a t.. 18 non-refundabl..
'l'elaphOftal7 2 5 - 2229
II tht. work beiDq clon. by tb. property ownar at tba1r own ra1danca? --yu --no
c:oapl.t:. and at:t:acb WorJtan. CoIIpanaat:ion and COntractor Intomadoa toz..
'l'b. Appl1cant,ll'eJ:m1tt_ baraby aqra.. ~ aftixinq their dqnat:are 1:0 thia panait to 11014 the CJ.ty of
CUlpb.ll, ita oftican, aqanta and saploy..s tn., ..t. and banI.l... fraa any claia or daund for
dallaq.. raultinq traa tb. work covared tly tbls panlit.
'l'b. Applicant/Paraitta. banoy acJcnovladq.. that tb.y bav. raad and undantand both tba front and
!:lack at t:hia pU1l1t, and tbat tb.y v111 inform tb.ir con1:ract:or(.) ~ the iDtormatiOft.
A(;~D
Applicant (Pam1tta.. pri.nt/s1qn
Dat.
1f0TES: ALL WORK SJIAL". CCHFORH WITH THE A'l"l'ACHZD, APPROVED PLUfS AHD ALL APPLICABLE CAMPBELL
STANDARD DRANIHGS AND CCHDlnDHS.
'l'HE CDHTRACOR HOST HAVE 'l'HIS PERHr1' AND APPROVED PLUfS QJI-SID AHD HUS'1' JIIE'1' WITH TIlE P.W.
INSPEctoR 011 'rBE Sn'!: AT t.ZUT TWO DAYS BEFORE STAR1'IIfG WOU. Al'PL%CUI'l HDST COIITAC1' TIlE DfSPEC1'CR
'fO AlUWfGE I'UI.D IlEftIHG.
HO'nCE HOST 8B GXVEH 'fO PDBLIc WORD AT LEAS'1' 2. HOURS BD'ORB U8'l'AJlTDG Aft WOlUt.
SPECYAL PROVYSYOHS
_1.
strut: aball not: J)a op.n cut: tor und.rqround 1natallat:10ft8. lIlniawa cut:a "I' ba allowed
tor c:annec:t:1Oft. or explontion bol... SUcb cuta IllUst h. lm.ci~ieal1v almrmr_d hv ~hlt
r"!I~.~or !!pior ~~ eu~fPlfl.
pavaant "I' tl. cut tor UDdarqround installations and _t be rutored in accordance vith
tb. utility 'l'nncb Rucontion Standard Dnvinq.
Work 1:0 tl. staked by a l1canaad Land Surv.yor or CJ.vil J:nqUlMr and two (2) c:op:i.. of the
cut lIba.ta sant to tba Putll1c Work O.part2lant tl.fon 1ftartinq work.
'l'h. boun of work an liaited 1:0 outa1d.. tb. boun at 1-9 a.a. and 3-6 p.a. for my work
attactinq a traftic Ian..
Vi'.
_3.
_4.
_5.
S'l'AHDARD
AMOtJHop
, \c...}~. C?Y~":>
RE~P'!' NO.
PERlIn" APPLXc:e%OIf I'D
PLUf c:BECI: DBPOSr.r
SDREft' POJl FAn'BPDL PDPoRlWla:
CUll DBPOSr.r
PIAH c:BECI: 6 DfSPEC1'%OH PEE
$100,000 - $500,000
APPROVED FOR ISSUANCE
!: PW PERMIT
Revised 10/91
$105.00
$500.00
(loot or ERG. 1ST.)
(4t or SIIUft, $500 JaJr)
'f
.
$
$
$~.~ ~
'"l... - ~4- - 9.~"L.--
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