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CITY OF CAMPBELL
DEPT. or PUBLIC WORKS
70 North First St.
campbell! CA 95008
(408) 86b-2150
Permit No.
PUBLIC WORKS PERMIT
(ror worrIng 1n tne
public right-of-way) X-Ref. file
Issued (p /{ bacf' Application Date ~.../~ ~BB
Permit ex~ s ~ l mos. expires n 6 os.
APPLICATION - Application is hereby ~ade for a Public Works Per~it in accordance with Campbeli~
Municipal Code, Section 11.04. ~ /
W~S.I SlOt: 1Ji:LL live '1-:;.; N 0- ~ SUI\JNY 61lj.".~ Ave
A. Work address or tract' ~ JC/'UJN r () r- q de; iJ&LL Avt {ri!.f:1v(..H /I'f2!j
Utility trench location S.t. C;;CfJ --;;AI' JldJ
B. Nature of work: #1J1'~f1i,J .-rlf'-f-Ad H VD {L. (' A At f ~LA(/:. ml-w-r
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C. Attach five (5) copies of a drawing showing the location, extent and dimensions of the work
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.
D. The General Conditions for all permits are listed on the reverse side. Special Provisions for
this permit are listed below. Failure to abide by these conditions and provisions may result
in jOb shut-down and/or forfeiture of Faithful Performance Bonds and cash deposits. (See
General Conditions I and 2).
E. An application fee must accompany this application. This is non-refundable.
Name of Applicant PALl rJL 13~LL Telephone: I/q/ &Vq
Address /5'3 J /'/I/'l....l-/rLtJ fJP-> Ave.5::r
Is this work being done by the property owner At their own residence? ___yes ~no
Complete attached Workers' Compensation and Contractor forms.
The Applicant/Per~ittee hereby agrees by affixing their signature to this permit to hold the City of
Campbell, its officers, agents and employees free, safe and harmless from any claim or demand for
damages resulting from the work covered by this permit.
The Applicant/Permittee hereby acknowledges that they have read and understand both the front and
back of this permit, and tqat they will inform their contractor(s) of the information.
ACCEPTED lAJ ,,.jj! /j.JJ t:, .- /11 -i f
Applicant (~ermltteel uate
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NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MUST HAVE TillS 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 cuts may be allowed
for connections or exploration holes. Such cuts must be specifically approved by the
Inspector.
~~rrr-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 to outside the hours of 7-9 a.m. and 3-6 p.m. for any work
affecting a traffic lane. ..
.5cE ArrACH~ UTil-~'J /fl..{;:NUi ~~"fTl o^-.l b~AlA.IliLJ<=r
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4.
.......... 5.
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PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
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($35.00)
AMOUNT
$ 50.00
$
$
$
$ 11' ..80
RECEIPT NO.
STANDARD
$50.00
$500.00
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BOND FOR FAITHFUL PER~ORHANCE (100\ OF ENG. EST.)
F. P. (CASH) DEPOSIT ($200) (4\ OF 80ND,$500 MIN)
PERMIT FEE -Il42.1..F.(5"OO /....{'.e .2-0\.P\ OF F.P. BOND
"-4~ t..F,1it .tU ... $35.00 MIN)
APPROVED FOR ISSUANCE :;~~ 'I{I/!<----
lor ~lpy n r-
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f: PWPERMIT
Revised 7/B7
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