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CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North Pir.t It.
Campbelll CA '5008
(408) 860-21$0
88 ;/C,4-
PUBLIC WORKS PERMIT
(tar worKlnw In ~n.
public rivht-of-way) X-Ref. file
I..ued .fi ~2 ~ZcP ,j-7 Application Date .r./~ 8
Per.it.ll .. 14 .0.. expire. i... .
APPLICATION - Application i. hereby ..de for a 'ublic Work. 'erait 1n accordance with Ca.pbell-
MuniCipal Code, Section 11.04.
153
A. Work addu.. or tract .~rUk.-;1' t6~ <;'C~-1f
Utility trench location
B. Nature of work: If. -M't:t..u...,. V;; :t.~, (.;' S'b.0~ ~
C. Attach five (5) copies of a drawing showing the location, extent and di.en.ions of the work
The drawing shall show the relation of the propoled work to existing .urface and underground
improvements. When approved by the City Engineer, .aid drawing becomes a part of this perait.
D. The General Condition. for all permits are listed on the reverie side. Special Provisions for
this permit are listed below. Failure to abide by these conditions and prOVisions aay result
in jOb shut-down and/or forfeiture of 'aithful Performance Bonds and cash deposits. (See
General Conditions I and 2).
'er.it 110.
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E. An app1i~..tion fee Ilust.~co.tllpany this application. This 18 non-refundable.
Name of TelePhone:~~'~~
Addreas
Is thia work being done by the property owner at their own residence? ____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 e.ployees free, safe and harmless from any claim or demand for
damages resulting from the work covered by thia permit.
The Applicant/Perll'ttee h reby acknowledges that they have read and understand both the front and
back of thi perm , and hat they will inform their contractor(s) of he nformation.
ACCEP
NOTES}^! EjIL\ ~~y s~~t'tT!~bW;bR~!~Hif\.,Q[ i~lIc1g0~~;~~~~;' PLANS AND ALL APPLICABLE CAMPBELL
STANDARD D~ INGS 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.
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
SPECIAL PROVISIONS
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Street shall not be open cut for underground installations. Minimum cuta aay be allowed
for connections or exploration holea. Such cuts must be specifically approved by the
Inspector.
yavement aay be cut for underground installations and must be restored in accordance with
the Utility Trench Reatoration 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 to outside the hours of 7-9 a.m. and 3-6 p.a. for any work
affecting a traffic lane.
L2.
_3.
4.
5.
PERMIT APPLICATION PEl
(R-l)
($35.00 )
$
. ;'t,i' ~ot,~tl~'" ti'v..,.-
$
$
STANDARD
$50.00/
AIIOONT
50. 00
RECEIPT NO.
20(.,70
PLAN CHECK DEPOSIT
BOND FOR FAITHFUL PERFORMANCE
P. P. (CASH) DEPOSIT
PERMIT PEE
$500.00
(100\ OF ENG. 1ST.)
.,/
($200) (4' OP 8OND,$500 MIN)
(7\ OP P.P. BOND
. ./":/ ?/~ MIN) V'
~ (~~~~ln.er
20(.,. 70 r&9
~/~~/tie ';jj6f6
JlI-t,.-L./
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500. DO
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$
35.00
APPROVED FOR ISSUANCE
f: PWPERMIT
Revhed 7/87
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