92-136
crrY 01' CAIIPBBLL
DBPl'. OF PDBLIC: WORD
70 North F!r.t S~.
CUlPbeU. C& 950"
(coa) 866-l150 .
92-136
mH!ROAcmmII'P PmIIIrl'
(for worJc1Dq withiD t:Ila
public dljJ!at-of_y) X-Ref. fUe
I..ed 3/ l?:J 9 Z- Appl1c:at1Clft Data 3/18/9 2
Penlit upirU in 12 _. . Applic:atiClft upina in 6 _.
APPLICA'l'IOM - Application i. hereby ..de for a AJblic Worb Pen1t in aCCOrdance with CQpbell
JIWlicipal COde, Section 11.04. (Applic:at:ion upiru in 6 1IDIlt:ba if pen&it not: pulled)
A. Work addre.. or tract . sje corner Sam Cava & Railway
PeaU.t Mo.
Utility t.nncb location
B. Mature at work:
hlTnrMnt- rppri i r
76-100
C. Attach five (5) copiea of a drawinq abowinq the location, extent UId d1Mnaiona of the work
The drawinq abal! abow the nlation of the propoaed work to exiatinq aurtace and under;round
JJaprovaent:a. When approved by the City Engineer, aaid dravinq becoau a part: of thia peait.
D. me General CondiUone for all permit. are lUted on t:Ila r8Yerae .ide. Special Proviaiona for
thi. permit are U.tad below. Failure to abide by th..e condit:iona UId proviaione III&Y nml~
in joD abut-down and/or forfeiture at Faithtul. Pertormance Bureti_ and caah depoaita. (See
General Conditione 1 and 2).
E. An application f.. IllUat ac:c:ompany thia applicat:ion.
NUle of Applicant GlennettejSan Jose Water
EMERGENCY PERMIT
'ftl1a fee 1.11 non-ntUlldable.
279-7825
Telephone:
Addre..
I. this work beinq done by the prop.rty owner at thair own ruiclenc:e? --ye. _no
COJaplete UId attach Worken' COIDpenaation and Contractor ZDformaUon torma.
'!'he Applicant/Permittee hereby agr... by affixing their 81qnatun to this permit to hold the City of
campbell, ita officera, aqents and employe.. tree, aate UId harml_. from any claim or daaand tor
damaq.. ruult1nq trom the work covered by this peait.
The Applicant/Permittee hereby acknowledqe. that th.y bave nad and understand both the front and
back at thi. permit, and that they will intorm their contractor(.) of the information.
ACCEPTED
Applicant (Per:ittee) print/siqn
Date
NOTES: ALL WORK SHAL", CONFORM WITH THE A'l"l'ACHED, APPROVED PLAHB AND ALL APPLZCA8LE CAMPBELL
STANDARD DRAWINGS AND CONDITIOHS.
THE CCHTRACTOR MUST HAVE mIS PERMIT AHD APPROVED PLAHS OM-SITE AND MUST MEET WITH 'l'BE P.W.
IHSPEctOR OM 'l'BE SITE AT LEAST TWO DAYS BEFORE STAR'l'IHG WORK. APPLZCAHT HOST COHTACT 'l'BE INSPECTOR
TO ARRANGE FIELD KEE'l'IHG.
HarICE MUST BE GIVEN TO PDBLIc WORKS AT LEAST 24 HOURS BEFORE RESTAR'l'IHG ANY WORK.
SP~CIAL PROVTSYORS
_1.
Street ahall not be open cut for underground installation.. lUnimua cut:a may be allowed
for connection. or exploration hole.. Such cuts mu.~ be saeeit1eallv aa~rov~d by the
rns~e~or ~rfor ~o eut~in~.
pav_ent may be cut tor underqround installatione and must be rutored 1D accordance with
the Utility Trench Re.toration Standard Draving.
WorJe to be ataked by a licenaed Land Surv.yor or Civil Enqineer and two (2) copt.. ot the
cut abe.t. aent to the Public Work Department betore -.tartinq work.
'l'he hours of work are limited to outside the hours ot 7-9 .... and 3-6 p... tor any work
affectinq a traffic lan..
~
_2.
_3.
_4.
_5.
S'l'Al(DARD
AMotm'I'
$ \ ~ , cs>c::.
$
$
$
$ \~. cPO
REeEYPT HO.
PZRIIIT APPLXClnOH FEE
$105.00
$500.00
(loot 01' BIIG. EST.)
(4' 01' SDRErr, $500 NXH)
C1?
PL&If CBEClt DBI'OSrr
SURETY POll FA:rrBl'DL PERFCRHAHa:
CASH DBPOSrl'
PIAN CBEClt , DlSPECTIOH FEE
$100,000 - $500,000 t,
APPROVED FOR ISSUAHCE
!: PH PERMIT
Revised 10/91
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