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CITY or CA"PBELL '
DEPT. 0' PUbLIC WORk'
70 ~orth 'lr.t 6t.
caspbellL CA '~OOI
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'er.it "0.
88 -175"
PUBLIC ~KS PER"IT
"or vorrln9 In rn~
publIc ri9ht-ot..ayl X-kef. tl1e
luurd 7 /7/<38 ApP!1caUon Date "'/~c/~R
'er.lt e.'II~'ln I~ ~a. ..pirea In'~~w.
APPLICATION - Application 1. hereby ..de for a 'ubllc Morka 'er.it In eccordance with C..pbell
Runlcipel Code, Sectlon 11.04.
&.
liIork addre.. or tract t 117S Dqr# 8lfKOM
UtUlty trench loc:aUon ~ ~Jt"~ ~II,F
Mature of work: C"II!YORAlJr A/./'rtll. T/(,Iv AV/)
RffIIlGM~Nr
$9-.2..7
AVE
I.
C. Att.Ch live 1~1 copie. of a drawing .~owing the location, e.tent .nd di..nalon. of the work
Th. dravlng .halJ .~ow the relation of thr propo.ed work to eXl.ting aurf.ce .and undrrground
laprove..nCI. When .pproved by the City 1ngineer, .aid drawing Deco.ea a part of thia peralt.
O. The General Condition. lor all per.lt. are ll.ted on the reverae .1de. SpeCial Provi.ion. lor
thi. per.lt .rr li.ted below. tailure to .bide by theae conditiona .nd plovl.lonl "r re.ult
In job ahut-down .nd/or lorfeiturr ot ralthful "erforaance Bondi .nd calh drpo.lta. See
~nel.l Condltlon5 1 and ~I.
E. An appllc.tion I e
..... 01 Appl}cant
~duu 122/ .J:' &ucOA/1
Thi. 1. non-refundable.
Telephone: 27 7-7~7
AVE
CfS/2C
I. thl. work Delng done by the property owner at their own re.idence} _____yea _____no
Coaplete attached Workerl' Coapen5atlon .nd Contr.ctor loraa.
The Applicant/Per.lttre hereby .gree. by affi.1ng thelr .ign.ture to thl. per.it to hold the City ot
Ca.pbell, itl otflcrr5. .genta and e~ployee. lree. ..fe .nd harale.5 froa any cla1a or de..nd for
da..qe5 reaulllnQ tro. the vork coveled by thla per.ll.
Th. Applicant/Peratttee hrreby aCknowledgel that they have read .nd underatand both the
baCk of th1a perait, .nd th.t they VIII infor. their contractorta) of the lnloraallon.
~- tI;~ ~/..zfl4'P
p J ~
front and
ACCEPTED
.oTES: ALL WORK SHALL CONfOR" WITH THE ATTACHED, APPROVED PLAHS'AMD ALL APPLICABLE CAKPBELL
5TAHOAR~ DRAWINGS AND CONDITIONS.
THE CONTRACTOR "UST HAVE THIS PER"IT AND APPROVED PLANS AMD "UST ~tT WITH THE '.W. lKiPECTOR ON
THE SITE AT LfAST TWO DAYS BEfORE STARTING WORK.
ItOTICE "OS7 BE GIVtH TO PUBLIC WOilllS AT UAST ~. HOURS !l&POJU: RESTARTING UY WORK.
'PECIAL PROVISIONS
_1.
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6tre., .hall not be open cut tor underground inatallationa. "iniau. CUt. aay De allow.d
lor connectlona or exploration hOlel. SUCh CUtl aU.1 be .paClflcally approved by the
J n"p<"cI or .
~.Vfmfnr-aay De cut lor underground inatallatlona .nd .wac De reatored 1n accord.nce With
the Utility Tlench ileatoratlon Standard Dravlnq.
Work to be .taked by a lieen.ed Land Surveyor 01 CIV11 En9ineer and two '~I Cop1e. 01 the
cut Inert5 aent to the PubliC Work ~pt. before atarting vork.
Tne hour. of vork are llllced to outalde the houta ot 7-9 .... and J-' p... for any vork
aft.Ctlng . tr."lc l.ne. .
.i?tE/v1tPv€ .~"AEIA/ALk' FXOM Sc..OK.~ ,.,;;4.t!.JtI Tb SC-L)/e.t! N14-CJt:. Mu.s-r o~""./
95% UJ~1'4GT7'oJ tL ,vDDe c..ultl!J { 6uTT€~,
PERMIT APPLICATION tEE
'LAM CHECk DEPOSJT
IlOHD '011 'UTH'UL POrORIlAHCE
P. ~. I CASH I DEPOSIT
.tkIUT FEE
<<.-1)
U]~.OOI
AIIOUNT UCE! P't ~o.
5 SD.oo ~
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5.3 s: 00 Q
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7/6;~
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aTANDAIlD
i~O.OO
'~DO.OO
(l00, or UG. 1ST.1
C., 0' 8OHD,i~OO MINI
0' 0' r.p. ~D
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APPROVED 'OR ISSUANCE
'4~l11tt4"I
': I'WPEIl"IT
'Iued 7/17
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