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CITY 0' CAMPBELL '
DEPT. or PUMLIC ~KS
70 North '&I.C 5C.
C..PbellL CA '~OO'
UOIl .. -laO
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I-a.,. file ~-,- -"L",-:l.-
AppUc:at 10n Dac. <) / (;., - J' cJ-"
.oa. ..plr.. .n _ .oa.
'eralt in accordance wlCh Caapbell
PUBLIC ~KS PERMIT
'tor worslng In ~n.
pub1ac rltht-ol...y,
...u.d s-~/ (:: 4/' d
..'.l~.. 1".. n '4
AP'LICATION - AppllCacion ia hereby ..4e lor a 'ubllC ~rk.
ltunac:1pa1 Code, Section 11.04. -7OJ 4 'Z:.:.>/
A. "orll addre.. or tract, .~ Do? AJ/F-
UtU&cy tuncll locuaon II MA/~ /AI.Ii'!'Id.Ar/~ c:' I etV1CF
I
WORK.
eM - 2..5"0 )
a.
"ture of work:
Attach five C~I copl.. of e drawing ellowing the locacaon. eatent end d1..n.aon. of tll. work
Yhe dr.vlng ehall .hOW che re1ataon of the propo..d vork to .xl.ting aurt.ce and und.lground
l.prov...nt.. Mhen apploved by Cb. Caey &ngln.er, eaad drawing beco... a pert ot clla. per.,t.
Yh. Cen.r.l Condition. for all per.lta ar. 1a.ted on the revere. ald.. SpeCial 'rovl.lona for
thl. per.'t .re 1i.ted below. 'ailur. co ebide by tile.. conditaon. and prova.ion. ..y r.ault
in job .hut-down and/or forf.ltur. of f.,thful '.rtolaanc. aond. end c..h depo.'ta. 15ee
General Condltlon. 1 and ll.
t. An applic.taon fee ~.C accoapany Cha. applacatlon. Yhi. a. non-r.fund.bl..
"a.. ot '-PpUcane JAN JoN /4IATFl (lOMPANY Telephone: 27'1-7947
Addr... 1.2..2. / .f' IlArcoM AVE
c.
o.
.a tlla. work be1ng done by tbe propercy owner at thelr own realdenc.l ____'ea -JCDo
Coap!ac. .eeaChed ~orkers' Coapen..tlon and Contractor foraa.
Yh. Appl,c.nt/Per.'ttee lIereby agr... by affixing their a19n.tur. to this per.it to hold the City ot
C..pbell. Its offlc.r.. egent. and e.ploy..s Ir... ..t. and b.ral..s froa any clai. or deaand for
d."gel r..ultang froe Che vork cov.r.d by ehla pee.at.
Yhe Applic.nc/Per.ieeae h.reby aCknowl.dges that th.y bav. reld and underatand botb tba
back of this perait, and Chat Ch.y wl11 lnfor. their contr.ctorlsl of the lnforaaeioo.
,.CCEPTED ~l~ S-:~;'it
front and
MOTES: ALL NO~K SHALL COH'ORM WITH THE ATTACHED, APPROVED PLANS ,..D ALL APPLICABLE CAMPBELL
.TANOA~D DRAWINCS AND CONDITIONS.
YIlE CONTRACTOR MUST RAVE ,.HIS PERMIT AND APPROVED 'LANS AMD MUST RUT MU'H TIlE '.M. llliPEC1'Oa ON
TilE &ITE A" LUST ,...0 DAYS aEFORE liToUTING NORIl.
aIOTICE lUlU at C;IV~ TO puaLIC WOIl" loT Lt.A.5T l. IIOUU "PORE RESToUTING "'Y ~K.
SPECIAL PROVISIONS
....
-
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5tr..t ah.ll not be open cut for underground an.t.llataons. Rlni.u. cuta aay be allow.d
for conneccions or exploration bo1... Such cuta .ust be SpeClflC.lly .pproved by the
Inlp.clor.
'aVeatRr aay be cut for underground tn.t.ll.caon. and ~at be re.torad an accordanc. vith
tha Utility Tr.nch Il..torlcion St.ndlrd Driving.
Work co be .tl..d by a licen.ed Lend Surveyor or Civil Engin.ee and two III copie. of the
cut .heets ..nt to the PubliC ~ork Dept. before .tarting WOlk.
The hour. ot work are 11.Ited to ouc.1d. the houl. of 7-t .... and l-' p... tor eny voek
attecc,n9 a traff1c lane.
-..
-~.
PE~IT APPLICATION PEE
PLAN CHECK DEPOSIT
.oMP FOR fAITHfUL P&a'ORNANCE
ca-1)
CU~.OOI
~
rtAllDUD
UO.OD
'~DD.DO
ClOD' or INC. 1ST.)
AItOUNT
, ~b.("D
I
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ucun liO.
P. ~. eCASHI DEPOSIT
'EaM'!' PIE
., "'PEIl"IT
an,nd 71.7
\',~. '
CI~OO' C4' or aoND.I~OO RIN'
(1\ OP P.P. aoND
~zJj "'....,.,
~Pl,'~~/
RECEIVED
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"'"1.
I~ S-. DC:)
s-
AP,aOVED POll ISSUANCE
MAY 13198,8
PUBLIC WORKS
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