92-168
CITY or CAMPBELL
DEPT. or PUBLIC WORKS
70 North First st.
<:aapbell, CA 95088
(408) 866-2150
1Ml!ROAl!RIIIMl' PKRlIrl'
(for working within the
public right-of-w.y)
Issued
Perllit expirea in 12 ao..
q?-lnH
Perait No.
X-Ref. file
Application Date 5/21/9 2
. Application expire. in 6 aos.
APPLICATION _ Application is hereby ..de for . Public WOrD Perait in .ccordance with CUpbell
Municipal Code, Section 11.04. (Application expire. in 6 aontba if perait not pulled)
e
A. Work address or tract. s/s #2 1 rolnP r.::lmpnpll Z'lut:> ,,fA ~"'nTQmvi .A1"i~g Rg
utility trench location ~M~~'-'C-:-(., '-i~~l
B. N.ture of work:
C. Attach five (5) copies of . dr.win; abowin; the location, extent and diaenaiona of the work
Tbe dr.wing sh.ll show the rel.tion of the proposed work to ex18tin; .urface and underground
improv...nts. When approved by the city En;ineer, .aid dr.wing becoaea . part of th18 perait.
D. The General Condition. for .11 permit. are listed on the reverse side. Special Provisiona for
this permit are listed below. r.ilure to abide by th_e conditione and proviaiona -y reault
in jOb shut-down and/or forfeiture of raithful Perforunce sureties and caab depodts. (See
General Condition. 1 and 2).
E. An .pplication f.. IIUIIt aaaoap.ny th18 .pplication. 'l'b18 f.. 18 non-refundable.
lIa.e of Applicant Pac i fie Be 11 Telepbone:
Address
Is this work being done by the property owner .t their own reaidence? ~es _no
Coaplete and .ttach Workers' eoapena.tion and Contractor Information forma.
The Applic.nt/Permittee hereby .qrees by .ffixing their signature to this permit to bold the City of
campbell, its officer., aqent. and ..ploye.. free, ..fe and harmle.. froa any claim or d...nd for
damage. resulting from the work covered by this permit.
The Applicant/permittee hereby acknowledge. that they have read and understand both the front and
back of this permit, and that they will inform their contractor(s) of the information.
ACCEPTED
Applicant (Permittee) print/sign
Date
NOTES: ALL WORK SHALL CONFORM WITH THE A'l"1'ACHED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS ON-SITE AND MUST MEET WITH THE P.W.
INSPEC'tOR ON THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK. APPLICANT MUST CONTACT THE INSPECTOR
TO ARRANGE FIELD MEETING.
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 BOORS BEFORE RESTARTING ANY WORK.
SPECIAL PROVISIONS
_1.
street shall not be open cut for underground in.tallations. llinillwl cuts ..y be .llowed
for connections or exploration hole.. Such cuts must be BDecificallv aDDreved bv the
InBDecter Drier te cuttina.
pav_ent aay be cut for underground in.tallationa and IIUIIt be reatored in accordance with
the utility Trench Restoration Stand.rd Drawing.
Work to be staked by a licensed Land surveyor or civil Engineer and two (2) copies of the
cut abeets .ent to the Public Work Dep.rtment before "!tarting work.
The hours of work are lillited to outside the h~ of 7-9 .... and 3-6 p... for any work
.ffecting a traffic lane.
_2.
_3.
_4.
_5.
STANDARD
AMOUNT
RECEIPT 110.
PBRHIT APPLICATXOII PEE
PIAN CHECK DEPOSIT
SURETY FOR rUTBl'tJL PERFORIIlUfCE
CASH DEPOSIT
$105.00
$500.00
(100' or BIlG. EST.)
(n or SURETY, $500 IIIH)
$
$
$
$
$
PIAN CHECK . XHSPEcrIOII FEE ($0-$100,000 10"
$100,000 - $500,000 9" $500,000 and above 7" $100 KIN)
APPROVED FOR ISSUANCE
Date
f: PW PERMIT
Revised 10/91
for City Engineer
(SEE OTHER Sl:DE)
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