88-134
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CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell1 CA 95008
(408) 860-2150
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Permit No. P j _ I
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PUBLIC WORKS PERMIT
IIor worK1ng 1n ~ne
public right-ot-WilY} .
Issued f", A? n' ~
Perm1~ e ~re ~n l~ mos.
APPLICATION - Application is hereby made for a Public Works Permit
MuniCipal COde, Section 11.04.
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Application Date 1f/I/J'i5
expires 1n~ ~oa.
accordance with Campbell~
A. Work address or tract .
Utility trench 1
B. Nature of work:
c. Attach five (5) copies of a drawing showing the location, extent and dimensions of the work
The drawing shall ahow the relation of the proposed work to eXisting surface and underground
improvementa. When approved by the City Engineer, said drawing become. a part of this permit.
D. The General Conditions for all permits are listed on the reverse side. Special PrOVisions for
this permit are listed below. 'ailure to abide by these conditions and prOVisions may result
in job shut-down and/or forfeiture of PaithfuI Performance Bonds and cash deposits. (See
General Conditions I and 2).
E. An apPlication~e my
Name of Plicant~
Address
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This is
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non-refundable~ .--8~ ~
. Telephone: l3 >-'3
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Is this work being done by ____yea no
Complete attached Workers' Compensation and Contractor for.s.
The Applicant/Permittee hereby agrees by affiXing their Signature to this permit to hold the City of
Campbell, its officers, agents and employees free, aafe and harmless from any claim or deaand for
damages resulting from ..~the work covered by this permit.
acknowle~ that they have read and understand both the front and
. y w >}Jd~~itheir contnctor(s) IJ~ I~~.
J \/. uate
NOTES: ALL WORK SHALL CONPORM WI
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.
APPROVED PLANS AND ALL APPLICABLE CAMPBELL
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
SPECIAL PROVISIONS
/1.
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2.
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.
~avemenc ..y be cut for underground installations and muat be restored 1n 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.m. for any work
affecting a traffic lane.
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PERMIT APPLICATION PEE
PLAN CHECK DEPOSIT
BOND FOR FAITHFUL PERFORMANCE
(R-l)
($35.00)
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STANDARD
$50.00
$500.00
(100' OF ENG. EST.)
AMOUNT
$ ~. (:.c.?
$
$
$
RECEIPT NO.
~
F. P. (CASH) DEPOSIT
PERMIT PEE
($200) (4' OP BOND,$500 MIN)
(7' OF P.P. BOND
~-:.- ~ $35.00 .,N]
l.Ofi{f~." r,
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APPROVED POR ISSUANCE
$ '~:;'. (X? Cf>
R E ~E~ljT':
,-wi-< G 1988
f: PWPERHIT
Revised 7/87
Public Works Administration
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