92-172
EMERGENCY PERMIT
CITY 01' CAMPBELL
DEPT. 0' PUBLIC WOIUtS
70 North Pint st.
CluIpbe11, CA 950&8
(408) 866-:2150
_l"Rnat!Rlllnl'l' PBRIII'l'
(for working within the
public rigbt-of-w.y)
~ - 97
I..ued - , '). c---
Perait expiru in 12 110..
Permit No. 92-172
X-Ref. file
Application Date 6 - 5 - 9 2
. Application expire. in 6 110..
APPLICATION - Application ia bereby _de for a Public Wora Perait in .ccordance with CluIpbe11
MUnicipal COde, Section 11.04. (Application expire. in 6 IIOntha if perait not pulled)
1420 Juanita 646'w of Burrows
A.
Work addre.. or tract .
utility trench location
B. N.ture of work:
ernerqencv repair water m~in
C. Attach five (5) copi.. of . drawin9 lIbowinq the location, extent and diaenaiona of the work
The drawin9 lIba11 .bow the relation of the propo.ed work to exi.ting .urface and underqround
iIIprovuenta. When approved by the City Engineer, .aid drawing beco... a part of thia perait.
D. The General COndition. for all permit. are li.ted on the revene aide. Special Proviaiona for
this permit are li.ted below. 'ailure to abide by th..e concUtiona and provi.ion. ..y reault
in job shut-down and/or forfeiture of F.ithful Perforunce sureti.. and ca.b depo.its. (See
General Condi tiona 1 and 2).
B. An application fee llUat aCCOJDpany this .pplication. 'l'bis f_ i. non-refundable.
Nue of Applicant ~~n .Tosp W;:lf-pr (G1enette) Telephone: 279-7825
Addre..
Ia this work bein9 done by the property owner at their own ruidence? --yea _no
Complete and attach Workers I eoapena.tion and COntractor InforJllltion foras.
The Applicant/Permittee herllby aqree. by affixing their a1qnature to this permit to bold the City of
campbell, its officer., agenta and employee. free, .afe and barmle.. froa any claill or demand for
d"'ge. re.ulting from the work covered by this permit.
The Applicant/Permittee hereby acknowledge. that they bave read and understand both the front and
back of this permit, and that they will inform their contraetor(.) of the information.
ACCEPTED
Date
Applicant (Permittee) print/siqn
NOTES: ALL WORK SHALL CONFORM WI'!'H '!'HE AT'l'ACHED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MUST HAVE '!'HIS PERMIT AND APPROVED PLANS ON-SITE AND MOST HlET WI'!'H THE P.W.
INSPEctOR ON THE SITE AT LEAST TWO DAYS BEPORE STARTING WORK. APPLICANT MOST CONTACT THE INSPECTOR
TO ARRANGE PIELD MEETING.
NOTICE MOST BE GIVEN TO PUBLIC WOIUtS AT LEAST 24 HOURS BBl"ORE RESTARTING ANY WORK.
SPECIAL PROVISIONS
_1.
street ah.ll not be open cut for underground in.tallation.. Kint.ua cut. may be allowed
for conneetion. or exploration bole.. Such cuts must be _D8cificallY aDDreyed bY the
In_Deeter Drier te cuttina.
Pavement ..y be cut for underqround inatallatiena and IlU8t be rutored in accordance with
the Utility Trench Re.teration Standard Drawing.
Work to be ataked by a licen.ed Land Surveyor or civil Engineer and two (2) copie. of the
cut lIbeeta aent to the Public Work Department before ..tarting work.
The houra of work are lillited to outside the bours of 7-9 .... and 3-6 p... for any work
affecting a traffic lane.
v;.
_3.
_4.
_5.
STANDARD
AMOUNT
$ \~. ~
$
RECEIPT NO.
PERIaT APPLICATION FEE
$105.00
$500.00
(100' 01' BIIG. BS'l'.)
(4' 01' SURITY, $500 KIN)
~
PlAH CBECJl: DBPOSXT
SURETY lOR I'AITIII'OL PBRPORllANCE
CASH DBPOSIT
$
$
$~'~
.-
q>
PlAH CBECJl: " nrSPBC'l'ION FEE
$100,000 - $500,00
APPROVED FOR ISSUANCE
f: PW PERMIT
Revised 10/91
(o-~-9-~
Date
SIDE)
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