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CITY OF CAMPBELL t. ~ 11..0 PUBLIC WORKS PERMIT
DEPT. OF PUBLIC WORKS ~worK1n9 1n ~ne
70 North First St. Uf\'( 4. ~w.lc right-of~W y) X-Ref. file ~..& - \04-
Campbell t CA 95008 111 C~{ / I 0 0 t.-
(408) 86b-2150 dAlcted -::"-7. O~ Application Date ./ -'f-PJ-"
PUBUC W ~i~ u'P 'V n J." .os. expires 1n .11 mos.
APPLICATION - Application t~\~~~~G. for a Public Works Permit in accordance with Campbell-
Municipal Code, Section ll~~
Per.it No.
y,f -/'77
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Work address or tract .
153 Shelley Ave.
Sn#41G66878,SO#6028k'37
B.
Utility trench location
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Nature of work: Abandon gas service at street as>indicated on the attached sketch. ><
Attach five (S) copies of a drawing showing the location, extent and di.ensions of the work t-3
The drawing shall show the relation of the proposed work to existing surface and underground ~
improvements. When approved by the City Engineer, said drawing becomes a part of this permit. t'1
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The General Conditions for all permits are listed on the reverse side. Special Provisions for '1j
this permit are listed below. Pailure to abid.e by these conditions and provisions may result '1j
in job shut-down and/or forfeiture of Faithful Performance Bonds and cash deposits. (See t"'
General Conditions I and 2). H
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D.
E. An application fee must accompany this application. This is non-refundable.
Name of Applicant Pacific Gas and Electric Company Telephone: 973-8930
Address 10900 N. Blaney Ave. Cupertino 95014
Is this work being done by the property owner at their own residence? ___yea no
Complete attached Workers' CompensAtion and ContrActor for.a.
The Applicant/Permittee hereby agrees by affixing their aignature to this permit to hold the City of
Campbell, its officers, agents and employees free, aafe and har.less from any clai. or demand for
damages resulting from the work covered by this permit.
The Ap 'i~~. /Permit acknowled that they have read and understand both the front and
back thi'a}permit, ey will of the information.
Haba;. 1988
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 BEFORE STARTING WORK.
APPROVED PLANS AND ALL APPLICABLE CAMPBELL
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEPORE RESTARTING ANY WORK.
SPECIAL PROVISIONS
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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.m. for any work
affecting a traffic lane.
V 2.
3.
4.
5.
PERMIT APPLICATION PEE
PLAN CHECK DEPOSIT
BOND FOR FAITHFUL PERPORMANCE
(R-l)
($35.00)
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STANDARD
$SO.OO
$500.00
(100' OF ENG. EST.)
AMOUNT
RECEIPT NO.
$ -:S-..C:>. C?l?
$
$
$
F. P. (CASH) DEPOSIT
PERMIT PEE
($200) (4' OP BOND,$500 MIN)
~(7' OF F.P. BOND
~~ J ~ ~ $35.00 MIN)
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$ ~~, 0(',..;> Cf
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APPROVED POR ISSUANCE
f: PWPERMIT
Revised 7/87
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