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70 No~ Ptz.~ S~.
ca.pbell, Cl 11001
(40') .61-2150
(z:or varJUJl9 111 ale
pub1J..c riCJh~-of.....y)
%uued ,1 - -)" -- ~2 Applica~1on Dab
Pera1t expu.. 1D, 12 _. Application exp1na 1ft , _.
APPLICA'1'%OH - ApplicaUon 18 benby _d. for a l'ablic worD Puai~ 1D aocordaDae with CUpbell
MUnicipal COd., S.ction 11.04. (App1J..cation expiru 1ft , IIOIltU it pua1~ not: pulled)
A. Work addru. or t:ract . 1484 Capri Drive, Campbell, CA 95008
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Utility trench location
8. Katun ot varJu
Rp,p;d r of br6ken 4" sewer lateral in street
C. Attach tive (5) aop1.. of a draw1ftlJ &bow1ftlJ the locaUon, abn1: &Del d1Mn8ione at the vark
'!'he drav1n9 &ball &bow th. relaUon ot the prapo.. work to ex1RiDq .artaca aDd und.rqround
iaprov_enta. When approved by the City _in..., ..1d drawin9 beco.ea a par1: ot th18 perll1t.
D. '!'h. Gen.ral COndiUon. tor all perll1b are liated on the nvene aide. Special Proviaiona tor
this permit are liated below. Failure to abide by tbue condiUona &Del provi.ion. aay re.ult
in jOb .hut-dovn end/or to~a1ture at Faithful Pedoraanca Banda &Del caab dapoa1ta. (ae.
Gen.ral COnditlona 1 and 2).
s. An .pplication tee auat .~ thia .pplicaUcm.
H... at Applicant West Valley Sanitation District
Addre.. 100 East Sunnyoaks Avenue , Campbell, CA 95008
'ftlia 18 nan-retaDdable.
~~I 378-2407
Ia this vork bein; don. by the property owner at their own ruidanca? ---:/.. -DO
COllpl.t. and attach Worker.' eo.penaation and Con1:nC'tor Intoraation foraa.
'!'h. Applicant/Permittee hereby aqre.. by att1x1nq their .iqnature to thi. peralt to hold the City
Campbell, it. otticer., aqent. and .-ploye.. tr.., ..t. and haral..a tro. any claia or daaand tor
d...q.. r..ultin; tro. tha work cov.red by tbi. parait.
NOTES: ALL WORK SHALL CONFORM WI'l'H 'l'RI AT'l'ACImD, APPROVED PIMS AlII) ALL APPLICABLZ CUlPBBLL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MOST HAVE THIS PERMIT AND APPROVED PIoUa AND 110ft IID"l' 1rl'1'B '!'lIB P.W. IJISPZCTaR ON
THE SITE AT I.ZAST NO DAYS BU'ORB STARTING WOU.
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NOTICE MOST U GIVER TO PUBLIC 1fOItJt8 AT LD8'1' 24 IIOUJtS 8D'OD ItU'1'AIl'1'%If An 1IORJt.
SPECIAL PROVISIONS
_1.
Street &hall not be open cut tor undeqroaftd 1Datallatlona. JI1nt.ua CUb ..y be allowed
for coMactlona or exploratioD bol... auch cuta .uBi: be Ba.eifieallv lumravad bv tlta
In.nl)etor.
P.v..an~ aay be cut for und.r;round 1natall.Uone aDd _t be rutored 1ft accordance vith
the Utility Trench R..toratioD Standard oraw1nq.
Work to ba .takad by . Hcen.ad Land Surveyor or Civil Bn9inHr and t:vo (2) cop1.. of tha
cut .haet. .ent to th. PubHc Work DapUrtaant before abrtiftlJ work.
The houra ot work an l1a1tad to aataide the boara of 7-9 .... and 3-' p... tor Ally vork
attactin; . trattic lan..
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R!:Cl:IP'I' NO.
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PIM CIIBCK DUOSI':
BOND FOR FAImI'OL PBRI'ORIWfcz
CASII DUOSI':
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(4t or .-0, $100 1IDf)
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$100,000 - $500,00
APPROVED FOR ISSUANCE
t: PWPERMIT
Revised 4/91
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Applicant
INFORMATION SHEET FOR PUBLIC WORKS PERMITS
A separate form must be completed for the applicant and each contractor that will
work under this permit.
CONTRACTORS INFORMATION
Note that all contractors must have current City of Campbell Business License,
State Contractor's License and Workers' Compensation Insurance.
h"EST VALLEY SANITATION DrSTRIcr
Name of Contractor OF S~~A CL~ CO~1 Telephone
378-2407
Address
100 EAST SUNNYOAKS AVENUE, CAMPBEIJ.., CA. 95008
State Contractor License No.
City Business License No.
~ill do the following types of work:
_underground
x
P.C. concrete
x
A.C. paving
electrical
other (specify)
WORKERS' COt-1PENSATION INFORMATION
City Council policy requires the following information be submitted by the
applicant and any contractors prior to the issuance of a permit.
Name of (Applicant) or (Contractor)
'tNSD
One of the following must be on file with the Public Works or Building Department
(indicate one) :
~ Certificate of consent to self-insure issued by the Director of
Industrial Relations; or
Certificate of Workers' Compensation Insurance
Insurance Co. Policy No.
Expiration Date or
_ 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'
Co~pensation Laws of California.
Signed
Date
-NOTICE TO APPLICANT; If, after making this Certificate of Exemption, you should
become sUDJect to the WorKers' Compensation provision of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
I' f: Continfa
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\Y.\\ Rev. 4/87
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