92-158
EII(!ROACIIImlI'P PBIIIIl'r
(for worJd.DcJ wiUl1D tba
public riCJht_f-vay)
I.lIUed 4.-{ - '2- q /1 .~
Perai.t expira in 12 _. , Application expirui in 6 _.
APPLICA'l'IOlf - Application ill beraby _de tor a Public WorJta Puait in ac:ccmIuIce with Capbell
JIWlicipal. Code, Section 11.04. (Application expi.na in 6 .m:ba U peni.t not: pu.lled)
South side of Campbell Ave., 16' west of Kim
A. WOrk addre.. or t:ract ,
ern or CAIIPBELL
DZP1'. or PUBl.%c WOU8
70 North rint St.
cupbell, CA 950"
(408) .66-2150 .
l'end.t Ho. 9 2 - 15 8
X....f. fUe
Application Date 4/2 9/9 2
Louise
utility tnncb location _.~.~
8. Nature of work: R2iJcii}: daI.1aqecl. hJdrant and sidewalk (EMERGENCY)
~j\J Jon No. IbJ. U
C. Attach five (5) copies of . drawinCJ aIlovinCJ tba location, at:ent and diJlanaiona of the work
'ft1e dr.winCJ aIlall aIlov the relation of the propaaed varJc to aiat1Dq nrtace and under;roaDd
iaprovaenu. When approved by the City Enqineer, .aid dJ:awinq 1>>~. . part: of thia puait.
D. me General Conditiona tor all penait. are l1ated on tba revez.e .ide. Special Praviaiona tor
thi. permit are li.ted belovo F.ilure to abide by th_e cancU.tiona and provilliona ..y renlt
in job aIlut-dovn and/or torfeiture ot F.ithtul ~or.ance sureti_ and caab depo.ita. (See
General COndi t:iona 1 and 2).
B. An application t.. IlUat .CCOIIpany this application. 'ftlia t.. 18 lIOIl-retanclable.
Nue at Applicant San Jose Water Company 'l'e1ephone: 279-7825
1221 South Bascom Avenue, San Jose CA 9512H
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I. this work beinCJ done by the property owner .t their own raidenaa? --Ye. --RO
eomplete and .ttach Workers' COIIpena.tion and Contractor IDtormation forma.
The Applicant/Permittee bereby .qne. by .ff1xinCJ their dqnat:ure to this permit to bold the City of
campbell, ita officer., .CJent. and employe.. tre., ..te and bar.a1_. tro. any claim or deJDand tor
duaCJ.. raultinCJ frena the work covered by this permit.
The Applicant/Permittee bereby acJcnovledCJe. that they bave read and understand both the tront and
back of this permit, and that they will inform their contractor(.) of tba information.
ACCEPTED CrQnnat-t-,:> T,rlWH'nr.p (EMERGENCY VERBAL) 4/29/92
App icant (Permittee, print/aiqn Date
NOTES: ALL WORX SHAL". CONFORM WI'l'H THE A'1"1'ACHED, APPROVED PlANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
'1'HE CDHTRAC'rOR HOST HAVE THIS PERMIT AND APPROVED PlANS ON-SI'l'Z AND HOST MEET WITH 'l'HE P.W.
INSPEctoR ON 'l'HE SITE AT LEAST TWO DAYS BEFORE STARTING WORK. APPLIc:urr HOST COH'l'AC'l' 'l'HE IHSPEC'OR
'1'0 ARRANGE FIELD IlEETIHG.
NOTICE HOST 8B GIVEN '1'0 PUBLIC WORD AT LEAST 24 BOORS BD'ORB RBSTAR'1'IHG AllY WORX.
Str..t all.ll not be open cut for underqround inata11ation.. lUni.lDwa cute may be .llowed
for connectiona or exploration bole.. sucb cuts must be saeeitleallv BDDrftVed bv the
r~S~8~or ~rior ~o eu~~intt.
Pav_ent may be cut for underqround inatallationa and 1IU8t be ratored in .cCOrdance with
the Utility 'l'rancb ".tor.tion standard DrawinCJ.
Work to be staked by a licen.ed Land Suneyor or Civil Enqineer and two (2) copi.. of the
cut aIleet. sent to the Public Work Department befon -.tart:inCJ work.
The bours of work are limited to outside the boura of 7-9 .... and 3-6 p... for any work
affect:inCJ a traffic lane.
SPECIAL PROVTSiOHS
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STANDARD
H~tPl' HO.
PDKI'1' Al'l'LXCU'IOlf FEE
PLaIf CllECE DDOSI'1'
SURE'1'r l"OJl rAr1'BPOL PERPoRlWfCE
c:&SJI DEPOSIT
$105.00
$500.00
(loot or ERG. BS'l'.)
C4' or SURErr, $500 KDI)
PLAN CllECE . DfSPEC'f'ION FEE
$100,000 - $500,00
APPROVED FOR ISSUANCE
! : PW PERMIT
Revised 10/91
(SEE OTHER SIDE)
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