92-157
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70 North F1ra~ St.
ca.pbell, Cl .1001
(40') '''-2150
(EOr varJUnq UI use /? -) /5 "7
public dpt-of-way) X-bf. fUe 7,;-
Iuued lj - 2 9 ~ f~ Applicat1cm Dab '/- .7/ <} - ;7 V
Puait expu.. iD,12 _. Application ap1rU iD I _.
APPLICATION - Application 18 benby ..de fOl" . l'ablia WOrb Pualt 1D acccmIaDoa vith CUpbell
MUnicipal COde, Section 11.04. (Application expine iD I IIOIltba lf pen!t DOt pallad)
A. Work addna. or tract . 180 Kennedy Road
Utllity trench location under curb, gutter, and sidewalk
B. Matura of varJu Repair (EMERGENCY) of sani tarv sewer lateral
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C. Attach five (I) copt.. of a dnvtftlJ &boviftlJ the location, axtent and dJ.aeuiona of the work
'!'he dravin; aball &bov tba nlation of the propoaad work to axiatiDCJ nrface and uncserqround
iaprov_enta. Ifban approvad by tIl. City _inaer, Aid dnvin9 beco.e. a part of tIlia per1l1t.
D. '!'ha Ganuel Condition. for all pentb an U.tad on the ravene .ide. Spacial Provi8ione for
tilt. permit are Uatad belovo Failure to abide by thue conditione and providona ..y reaUlt
in job abu~-down and/or forfeiture of FaithfUl PertOZ'UDCa Bonda and caab dapeaib. (See
Ganaral Condi tiona 1 and 2).
E. An appU.ca~ion fee aat acco.pany tbia application. 'ftl1a 18 nan-ntaDdable.
N..a of Appl1can~ WEST VALLEY SANITATION DISTRICT '1'e1apbonal 378-2407
Mdreaa 100 E. Surmvoaks Avenue, Campbell. CA. gS008
Ia tilt. work bain; done by tha property ownar at their own naidanca? -Y" X-J'O
COlaplata and attach Workera' co.panaation and Contnct:or IDfonatlon fona.
The Applicant/Parmittee bereby aqraaa by affixinq tIleir aiqnatun to till. penit to bold tile City ot
campbell, it. otticara, aqanta end employae. fne, .ata and ~..a froa any claia or d~ for
da..qa. reaultinq fro. the work covared by thi. penit.
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undantand both tIla front and
of tba intonation.
4-28-92
Data
NOTES: ALL WORK SHALL CONFORM IfITB 'l'HB A'1"1'ACDD, APPROVED PLUS UD ALL APPLICABLI CAIIPBBLL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MOST HAVE '!'BIS PEIUaT AND APPROVED PLUS UD 110ft IIDT 1I1'1'B 'ftm P.W. DnIPZCTaJl ON
THE SITE AT LEAST 'l'If0 DAYS BDORB STARTING WOU.
NOTICZ MUST U GIVD '1'0 PUBLIC 1fORD AT LIA8'1' 24 IIOOlt8 IUOU JtU'DR'1'IRG All! 1ID1Ut.
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SPECIAL PRovysrCHS
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Streat &ball not ba open cut for unclar;round inata1lati'Ona. II1naIm cuta ..y ba allovad
for coMactiona or exploration hol... Such cuta au.~ M .a.ei~ieal1v atmraved bv the
In.!).~or.
P.v"en~ ..y be cut for undarqround tnaullaUone and -.1: be ~ in accordance witll
tha Utility Trench ReatoraUon Standard DravinCJ.
Work to ba atakad by a licanaad Land Surveyor or Civil Bnq1naer and two (2) copt.. of tile
cut .beat. aant to tha Public Work DaptartaaDt bafon 8tart1DlJ work.
The boura of work an l1a1tad to oataida tIla boun of 7-1 .... and 3-1 p... for any work
affectinq a traffic lana.
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_5.
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AIIOtJH'II
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~TPl' NO.
~ APPLtCU'IOII PO
110'00
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PLAIf C8BCI: DIJIOSI'l'
BOND POll PAI'l'IIPUL PBRI'ORIIUcz
CUll DBPOSI'l'
poo.oo
(loot or aG. BII'l'.)
(4t or ..u, flOO II1II)
(to-$100,000 lot,
7t, flOO II1II)
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PLAN CHBClt , IHSPBC'1'l:OR PO
$100,000 - $500,000 .
APPROVED FOR ISSUANCE
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Revis.d 4/91
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Date
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 DISTRICT
Name of Contractor OF S~~A CL~ CO~1 Telephone
378-2407
100 EAST SUNNYOAKS AVElJUE, CAMPBELL, CA. 95008
Address
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' COHPENSATION 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)
TtNSD
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'
Compensation Laws of California.
Signed
Date
.NOTICE TO APPLICANT; If, after making this Certificate of Exemption, you should
become subJect to the Workers' Compensation provision of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
,
1%7
f:Continfo
Rev. 4/87
Page
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