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CITY OP CA~BEIL
DEPT. OF P BLI~ WORKS
70 North F rst~St.
Campbell! A ,~5008
(40B) 86D-215Oi
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PUBLIC WORKS PERMIT
lIor wor~lng 1n ~ne
public righ~-of-way) X-Ref. file
Issued '//"'i'-; If' Application Date
Permi~ explI s 1n l~ mos. expires
APPLICATION - AP~lication is hereby lIade for a Public Works Permit in accordance with Campbeli~
:~ni:::'.::::. ::t:::c:':O~~~~ ' ~
B. :::~::Yo:r:::::~ ~:- . -. n ~.- \'J~~;.
C. Attach five (5) copies of a drawing showing the location, extent and dillensions of the work i
The drawing shall show the relation of the proposed work to eXisting surface and underground ~
improvements. When approved by the City Engineer, said drawing become. a part of this permit.
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D.
The General Conditions for all permits are listed on the reverse side. Special Provisions for
this permit are listed below. Pailure to abide by these conditions and provisions may result
in job shut-down and/or forfeiture of Paithful Performance Bonds and cash deposits. (See
General Conditions 1 and 2).
E.
Address
no
non-refundable.
TelePhone:-3]'S -~9 ~()
Name of
Is this work being
Complete attached Workers' Compensation and Contractor forlls.
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of
Campbell, its officers, agents and ellployees free, safe and harlll.ss from any clai. or demand for
damages resulting from the work covered by this permit.
The Applicant/Permittee hereby aCknOWledges 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.
I-tu:~?~
_yes
ACCEPTED DA'\lI'~ &~~~~Y-
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NOTES: ALL WORK SHALL CONPORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AND MUST MEET WITH THE P.W. INSPECTOR ON
THE SITE AT LEAST TWO.DAYS BEPORE STARTING WORK.
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
SPECIAL PROVISIONS
>-3
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1.
Street shall not be open cut for underground installations. Minimum cuts may be allowed
for connections or exploration holes. Such cuts must be specifically approved by the
Inspector.
~avement may be cut for underground installations and must be restored in accordance with
the Utility Trench Restoration Standard Drawing.
Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the
cut sheets sent to the Public Work Dept. before starting work.
The hours of work are limited ~ outside the hours of 7-9 a.m. and 3-6 p.ll. for any work
affecting a traffic lane.
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PERMIT APPLICATION PEE
PLAN CHECK DEPOSIT
(R-l)
($35.00)
RECEIPT NO.
q;
STANDARD
AMOUNT
$ ~-....LJ. C:CJ
$
$
$
PERMIT PEE
$50.00
$500.00
(100' OP ING. EST.)
($200) (4' OP BOND,$500 MIN)
(7' OP P.P. BOND
~5'.O MIN]
$~S.cL..; ~
\ .~ l "2... ~ -e:. ~
ua~e
BOND POR PAITHPUL PERPORMANCE
P. P. (CASH) DEPOSIT
APPROVED POR ISSUANCE
f: PWPERMIT
Revised 7/87