92-174
CITY OF CAllPBELL
DEPT. OF PUBLIC WORKS
70 North First st.
caapbell, CA 95088
(408) 866-2150
KIICROAcmmII'l' PBRIIrl'
(for working within the
public right-of-way)
Issued <f d 2/'1 'J-/
Penlit exp rea n 12 aos.
92-174
Per1Iit No.
X-Ref. file
ApplicaUon Date 6/11/9 2
, Application expires in 6 aos.
APPLICATION - ApplicaUon is hereby ..de for a Public WorD Pena1t in accordance with CUpbell
llUDicipal COde, Section 11.04. (Application expires in 6 aontha if perait not pulled)
A. Work address or tract. Oppos i te 1357 De 11 A ven ue
Utility trench location
B. Nature of work:
"Rprompt=Jr+1nn of nln ~--:-~nrh t-h~t- n;::lC C:lln'k-
C. Attach five (5) copies of a drawing shOW1nq the location, extent and diaanllions of the work
'1'he drawing shall show the relaUon of the proposed work to exisUng surface and underground
iIIproveaentll. When approved by the City EnCJineer, said drawing becoae8 a part of this penlit.
D. '1'he General COnditions for all penlits are listed on the reveree side. Special Provisions for
this permit are listed below. Failure to abide by th..e condiUons and provisions ..y result
in jOb shut-clown and/or forfeiture of Faithful Perfonaance Sureti.. and cash deposits. (See
General Conditions 1 and 2).
E. An applicaUon f.. aust accoapany this applicaUon.
Name of Applicant Pacif ic Bell
'1'his f.. is non-refundable.
'1'elephone: 491- 2050
San Jose CA 95110
Address
145 South Montoomerv.
Is this work being done by the property owner at their own reaidence? ---3es _no
COJIplete and attach Workere' COIIpeJuIation and COntractor Inforution fOr1l8.
'1'he Applicant/Permittee hereby .grees by attixing their signature to this permit to hold the City ot
campbell, its otticers, agents and .-ployee. tree, sate and harmless trom any claill or demand for
damages resulting trom the work covered by this permit.
The Applicant/Permittee hereby acJtnowledg.. that they have read and undenUnd both the front and
back of this permit, and th.t they will intorm their contractor(s) ot the intormation.
Howard Lewis (EMERGENCY) 6/11/92
Applicant (Permittee) print/sign Date
ACCEPTED
NOTES: ALL WORK SHALL CONFORM WI'l'H 'l'HE A'l"l'ACHED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
'l'HE CONTRAC'l'OR MUST HAVE 'l'HIS PERMIT AND APPROVED PLANS ON-SI'l'E AND MUST MEE'l' WI'l'H '1'HE P.W.
INSPEctoR ON '1'HE SI'l'E AT LEAST TWO DAYS BEFORE STAR'l'ING WORlC. APPLICAN'l' MUST CON'l'ACT '1'HE INSPEC'l'OR
'1'0 ARRANGE FIELD MEE'l'ING.
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 BOURS BEFORE RESTAR'l'ING ANY WORK.
SPECIAL PROVISIONS
_1.
street sball not be open cut tor underground installation.. llinimwa cuts may be allowed
tor connections or exploration holes. Such cuts must be sDecifieally aDDrOyed by the
InSDeetor Drior to cuttina.
pav_ent may be cut tor underground installations and IlU8t be r..tored in accordance with
the Utility Trench Restoration standard Drawing.
Work to be staked by a licensed Land Surveyor or Civil En9in..r and two (2) copies of the
cut sheets sent to the Publie Work Department betore ",tarting work.
'1'he bours ot work are limited to outside the bours ot 7-9 .... and 3-6 p... tor any work
a5t1,ina a tratfic l~ ~ '
If, 71NJU "5 ~.' 7J.,u()- I;JA I7ZAFRC J4T ilL{ 77MGS
_2.
_3.
_4.
$..5.
Ol<-
-Z;b ~1r:,.,1V oFF
I -1f1-9~
STANDARD
AMOUNT
RECEIPT NO.
o
PERKIT APPLICA'l'ION FEE
PLAN CHECK DBPOSI'l'
$105.00
$500.00
(100' or ERG. BS'l'.)
(4' or SURETY, $500 NZH)
J C5". (J()
$
$
$
$
$ /05.UO
-
SURETY lOR FAI'l'BFUL PBRPOIUlANCE
CASB DEPOSI'l'
Q
r;/Zi9L
te
PLAN CHECK . IRSPBcrION FEE ($0-$100,000 10"
$100,000 - $500,00~?9'~500,OOO and~e 7', $100 NZH)
APPROVED FOR ISSUANCE ~1./2 <; ~
tor citY~ineer
t: PW PERMIT
Revised 10/91 (SEE OTHER SIDE)
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