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PUBLIC WOflkS PERI'IIT .erait 110. cf j-J - / ) 9
lfOf VDrlln9 In 'tnr a~\ ~ ~~
pUblic 11,.ht-o'_ayl I-ad. tlle"-U4l"'te:-(b'~(.,""'o:. ~;::..
I..ue~ 'fi71..PP ~ppl1c.t1on D.te -:3 - i:.-c?if
.ela1rtr. r In u ~5. ..ph.a In . ~ .
APPLICATION - Applic.tion i. hereby ..d. (01 a Public Work. Pelait in accordance .ith eaapbell
Runicipel Code, Section 11.04.
CITY or CAMPBELL '
DEPT. or PUbLIC WORl5
70 North '11.1 61.
Ca~PbellL CA '~OOi
(tOll I .~ -:11 ~O
A. ~ork .ddr... or tract .
Ulility trenCh loc.tion
a. Kat UU. Gf ..,k: Q
C. Att.Ch tive (~I cople. of a dravin~ ahowln,. the loc.tlon, a.tent .n~ di..nllon. of the work
The dlawLn~ .hall .hOW the relation of the propo.e~ vork to ell.tin,. .urtace .n~ un~er,.roun~
l&prove..nll. ~hen .pprov.d by the City tn,.ine.r. aaid dravin,. Decoa.. a part of this peralt.
o. The ~eneral Condition. for .11 par.it. are 11.tad on the rever.e .ide. Spaci.l 'rGvl.1on. for
thl. per.lt .re 11.ted below. '.llure to .bide by thele condition. .nd plovi.ion. "r re.ult
in 10b enut-down and/or torfeltute of r.lthful Pertoraance Bond. .nd caah ~epoalt.. See
~neral Condlllon. I .nd 21.
E. An .pplication te. auat Icccapeny this .pplic.tion. Thi. 1. non-refundable.
Ma.. ot Appl1 cant Sq,.,:~.~ VV c. f4!! y ~ P Ii 1\ Y Telephone: :l- 7 t:j - 7 8 tf 7
~dreu [2..2-1 Soul-/') BU,<;CN>'\ AIk' 51>'" J6.<;~J Cel,! 1<512.6
I. this work bein9 don. by the property owner at their own r.eid.nce1 ___yea ~no
Coaplele attached ~ork.ra' Co.pen..tlon .nd Contr.ctor tor...
The Applicant/Per.lltee hereoy a9r.ea by .ttllin9 th.lr .Ignature to thla peralt to hold the City of
C..poell. lta otflcer.. .gent. and e~ployee. fr.e. a.te .n~ herale.. tro. any cl.l. or d...nd for
daaage. r..ulting tro. the vork covered by th1. perait.
The Applicant/Per.ltt.e hereby aCknowled~el th.t they have r.ad .n~ under.t.nd both the frGnt
baCk of thle peralt, .nd that they vlll Intora their contr.ctorlll of the lntor"'lon.
ACCEPTED ~d?'-'ti~ a-L-J>R
uata
and
MOTES: ALL WORK SHALL CONfOR" ~ITH THE ATTACHED, ~'ROVED PLANS ~D ALL APPLICABLE CAMPBELL
~TANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERI'IIT AND APPROVED 'LANS AND MUST kEET MITH THE ..~. INS'ECTOR ON
THE SITE AT LEAST TWO DAYS BEfORE STARTING WORK.
IIOTICE IIOST at GIVE:); TO PUBLIC WQIU.S AT UAST ;H IlOUIlS a~fORE IIESTAJlTING ANY WORK.
'PECIAL PROVISIONS
_1.
Slreet .hall not be open cut tor underground In.tallatlonl. Mlniau. cuta ..y be allowed
tor connection. or alplorat10n hole.. Such cut. aU'1 be 'paCifically approved by the
Inl~clOr.
~IVtmlnr aay De cut tor underground lnatall.tlonl and au.r be r..tor.d ln accordance With
the Ulllity TrenCh lIellOratlon Standerd Drawln~.
~Ork 10 be .llked by a llcen.ed Land Surveyol or Civ11 En9ine.r and tvo 121 Cople. ot the
CUI aneell aenl to thl PUbl,c Work Dept. betore atartinq work.
The hour. of vork.are ll.,ted to oUlalde the hourI of 7-' .... and 1-' p.a. tor any work
.freclln9 a tr.tfic l.n..
1.-\<"")( J\2-""=:::,. r-l(=- \..--'1 'JC12-\c- ~\->PL\. ~'\......;~ ""'---0
LDw.\lE- ~lc..'S:...~ C>UL"'I. T~~
~~TlaU PetL TtL-AL1'"' ~lC::>~
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( 11-1)
JlTANDAJlD
AMOONT
UCEIPT NO.
PCaI'IIT APPLICATION rEE
P~ C~ECl DEPOSIT
80HP rOR PAITHrU~ 'lAfORMAHCE
IU~.OOI no.oo
,~oO.OO
1100' or ENe. EST.1
5~.CL::J ep
5
5
5
P. ~. (CASHI DEPOSIT
.1. 4.Ll~
nltklT ru
f: PWP[III'1IT
Ilevlle~ 7/87
\'-"
($2001 (U or ~D,5~00 'UN)
(7, Of P.P. ~D
~bJ~
RECEIVED
5 \A.LCD cp
'~-\I-~~
IUIt"R
APPROVED 'OM ISSUANCE
E,r
/38--2/9
MAR 3 1988
PUBLIC WORKS
ENGINEERING
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