92-143
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CITY OF CAHPBELL
DEPT. OF PUBLIC WORKS
70 North Pir8~ S~.
ea.pbell, Cl '5001
(408) '''-2150
C12.-/t-f3
ENCROAcmmH'l" PERIII'l' Penlit Ho.
(tor working In the .,., I
public r{q f:_l_ay) X-a.!. til. I U () 0
1.111I s:: ~ Application Date---4..L!13 'Z
hralt .xp Application axplru 1iI . m..
APPLICATXOH - Application i. bereby ..de for a Publio .orb hrai~ 1D accordance with ca.pbell
Municipal Code, Section 11.04. (Application expir.. in 1 .,ntba if perai~ not pulled)
A. Work addre.. or Uact' H I ~ W Ai t11'- IJwTtP~ V 1~1Dc;..r;, VG '-I "MJ 6 Z' ~ff;/;2U.. ,MJ cr. -
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Utility tranch location ~T c,(~e j;t/tJIN,A."" l?T I 0
B. Hature of workl.J:Ql.JXDlIG 0EMJ€-tl- U.T€-~ 2J.-' &Jh l4A1tJ FvfZ- ~"Gre- ~
c. A~tacb five (5) oopie. of a dr8winq abovinq the location, axtan~ and d1Junaione of the work ni
'!'be drawing .ball abow ~ relation of the propo.ed work ~ ax18~inq .urface and underground
baprov_anta. Whan approved by the City Engineer, .aid drawlnq becoae. a part of thla peralt. ttl
D. '!'be Canerd concUtion. for all peraita an lla~ on the ravene dde. Special Providone for &;
thia permit are liated belovo ..ailure to abide by the.e conditione and provldon. ..y re.ult to3
in job .bUt-dOVD and/or forfeiture of Faithful hrforaance IIonda and caab depo.ita. (S.. tt.2
General COnditione 1 and 2). ~
B. An application fee aut accoapany thla application.
H..e of Applicant 0/dJ .} t)l;E WArE;- je- C.(J.
Addre.s_i 'Z '2- t '7. ~~ CO t-1 J'x1} C5 . \ 0 A ~
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'!'bia ia non-refundable.
--t:/Vl - 7 ~4&
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Telephone I
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I. thla work being done by the property owner at their own reddance? --ye.
co.plete and attach Worker.' eoapen.atlon and Contr8ctor Inforaation foraa.
The Applicant/Permittee bereby agr.e. by affixing their e1qnature to th1e pe~it to bold the city of
Ca.pbell, it. otficer., agent. and eaploye.. free, .ate and baral... frea any claia or deaand for
da_g.. re.ulting frea the work covered by thi. perait.
The Applicant/Peraittee hereby acknowledge. that they have read and under.tand both the front and
back of this per1li~.nd that they will inf thei ntr.ctor(.) of the inforaaUon.
ACCEPTED bEN \~A "-.\A.e..G..5;> ~ A- / ~ /'11-
Applicant (Peraittee) print e1qn Data /
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NOTES: ALL WOU SHALL CONFORM WITH THE A'l"1'ACllBD, APPROVED PLUS AND ALL APPLICA,IJ.B CAllPBBLL
STANDARD DRAWINGS AND CONDITIONS. II' II (;
THE CONTRACTOR MOST HAVE THIS PERMIT AND APPROVED PLUS AND MOST IIDT WI'l'B THB P.!. lHSA~~ A"ilo
THE SITE AT LEAST TWO DAYS BEFORE STARTIHG NOH. "'PI?'"
HOTICE MOST BE GIVD '1'0 POBLIC WORKS AT LD8T 24 HOURS DFORB RBSTARTDfG _~'_ 9 1992
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SPECIAL PROVISIONS .~/E~;~
_1. strut aball not be open cut for underground inatallaUone. lliniaua cut. ..y be .llov~
for cOMectione or exploration bol... Such cuta mist be .oecificallv aDDroved bv the
~ InsDector.
~2. pav...nt .ay be cut for underqround inatall.Uone and aut be ~red in .ccordance with
the UUlity Trench Re.toration Standard Drawing.
_3. Work to be .taked by . licen.ed Land Surveyor or Civil Bnqineer and two (2) copi.. of the
cut .heet. .ent to the Public Work Deptart.aent before .tartinq work.
_4. The bours of work .re li.ited ~ outaide the boura of 7-' .... and 3-1 p... for any work
affecting . traffic lane.
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nH65.
fiT fiLL
STANDARD
AMOUHT
RECEIP'!' NO.
PERIII'1' APPLICAUOH FD
$100.00
. 105'".00
rp
PIAN CIDCIl: DEPOSIT
BOND FOR FAI'l'BI'UL PBRlORIIAlICE
CASH DEPOSIT
$500.00
(lOOt 0.. BIIG. EST.)
(el OF 1DfD, $500 lID)
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5/5-l; 2-
Date
PIAN CBBCK , IHSPBCTIOR FEE ($0-$100,000 10',
$100,000 - $500,000 9'~0,0~aboVe 7', $100 KXR)
APPROVED FOR ISSUANCE /}7;u ~ '1M
for City Engineer
t: PWPERMIT
Revised 4/91