92-148
EMERGENCY
Blf~AcmmII'I' PmIIIrl"
(for worJc1ncJ w1~ tha
public r19ht-ot_.yJ X-Rat. fUe
Iaaued ~Sr~ tj 2.--- Application Date 4 - 22 - 9 2
PenI1t 12 _. . Application axpire8 in 6 110..
APPLICA'l'ION - ApplicaUon i. hereby ude tor a Public Worb PHait: in accordance with CUlpbell
MUnicipal COde, Section 11.04. (ApplicaUon upiru in 6 1IOIlt:ha U parai.t: not: pulled)
A. Work addre.. or tract , 1360 Juni ta A ven ue, Campbe 11
CITY 01' CAJIPBEI.L
DEP'1'. 01' PDBLIC WORD
70 North F~ St.
CUlpbell, CA 950liNl
(408) 866-2150 .
Puait NO.9 2 -14 8
B.
Utility trench location
Nature of wark: Water Main Repair
C. Attach tive (5) copie. of a dnwinq abowinq tha location, extant and dJ..aanaiona of the work
'!'be drawinq shall ahow the relation of the propo.ed wan to aiatinq aurface and undeZ'lJZ'OUDd
iJIIprov..anta. Whan approved by the City Enqinur, .aid dra"1DCJ becoaaa a part of thia panit.
D. The General COnditiona tor all permit. are liatecl on tha ravene .ide. Spacial Proviaiona tor
this permit are liated below. railure to abide by thaae conditione and provisions IDaY reault
in job ahut-down and/or torfeiture of Faithful Pertonaanae Surati.. and caah deposits. (See
General COnditiona 1 and 2).
E. An application t.. IllUat accollpany thia application. '1'211a f.. 18 non-refundable.
Name of Applicant Glennette, San Jose Water Company Telephone: 279-7825
Addre..
I. this work beinq done by the property owner at their own residence? -Ye. _no
COllplete and attach Workers' eompenaation and COntractor IDronaaUon fonaa.
The Applicant/Permittee hereay aqree. by affixinq their aiqnatura to this permit to hold the City of
Campbell, it. officer., aqent. and employ.e. tree, sate and harmle.. from any alaiJII or demand for
damaqe. re.ultinq troll the work covered by thi. pena1t.
The Applicant/Permittee hereby acJcnowledqe. that they have re.d and understand both the tront and
back of thia permit, and that they "ill inform their contractor(a) of the information.
ACCEPTED
Applicant (Permittee) print/aiqn
Date
NOTES: ALL WORX SHAL", CONFOR!( WITH THE A'1"l'ACHED, APPROVED PIANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR HOST HAVE THIS PERMIT AND APPROVED PIANS ON-SID AND HOST MEET WITH '1'HE P.W.
INSPEctOR ON 'l'BE SITE AT LEAST TWO DAYS BEFORE STARTING WORX. APPLIC&HT HOST CONTACT '1'HE INSPECTOR
'1'0 ARRANGE FIELD HEETIHG.
NOTICE HOST BE GIVEN '1'0 PDBLIC WORD AT LEAST 24 BOORS BD'ORJ: RESTARTING ANY WOlUt.
SP~CIAL PROvrSIONS
_1.
Street ahall not be open cut for undeZ'lJZ'OUDd inatallationa. MiniJllum cut. may be allowed
tor connectiona or exploration hole.. SUch cuts mua~ be aaecificallv aaa~ed bv the
InB~.e~~r ~rior ~o eut~in~.
pav..ant may be cut tor underqround inatallationa and IIIWJt be re.toncl in accordance with
the Utility Trench Reatoration Standard ors"inq.
Work to be .taked by a lican.ed ~d Surveyor or CivU Enqinaar and two (2) copi.. of the
cut abeeta .ent to the Public Work Department betore -.tart:inq work.
'!'be hours of work are liJllited to outside the boura o~ 7-9 .... and 3-6 p.lI. tor any wark
affectinq . traffic lane.
v-;.
_3.
_4.
_!S.
STANDARD
AMOUlM'
RECl':IP'I' NO.
PERKIT APPLIceIOH PEE
$ \c>~.ec
$
$
$
$ \.(!)~ . c.o
$10!S.00
$500.00
(100' 01' BlfG. EST.)
(4' 01'~, $500 M%H)
q>
PLaH CBEClt DEI'OSXT
SD'RE'1'Y FOR FAITBFOL PERFORllANCE
CASH DEPOSXT
PIAN CBEClt , DlSPEC'l'ION PEE
$100,000 - $500,000
APPROVED FOR ISSUANCE
CD
4--&..~ -q,--
Date
t: PW PERMIT
Revised 10/91
OTHER SIDE)
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