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P<f-/77
CITY or CA"P8ELL "" 0 6 1 PUBLIC WORKS PERMIT
DtPT. or PUIILIC IIbII'H 988 'tor WOrKln'll In l"ne
70 ~orth ',r.c 'to pUblic ritht-o ..ay) l-a.I. fil.
C,,,pbelIL CA .SJrOf)LIC -1 '<2'118'" 7:t~ 'n
UOII .. .21~0 ruD WORKS ".ued . /, J CJ AppHcaUon D'te / i.o
ENGIN 'er..I a. .Ipir.. an .
APPLICATION - APPlicat~'~JV~rebY ..de for a 'ublic Mor_a 'er.it in accordance with C.apbell
Runicipal Code,lection 11.0..
"or_ addre.. or tract'. ~cr ~o73 (Jif~ ~('1G'Alj)AAv~1 1ir5'-2.7b
UtUlty trench loc:.tton ~~;::: Av..G -."'"": .
..ture 01 wor_: A/1,AJAI____. A.T~_-;; (' lekllJ~ W"gk
Attach liv. C~I copi.. ot . dr.wlng ehowlng tbe loc.tion, .Itant and di..n.lon. 01 tbe wor_
The drawlng lball IhOW tb. relation 01 tb~ propo..d work to e'llcing aurt.c. .nd und~rground
laprove..nt.. Wben approv.d by the City &ngine.r, ..id dr.wing beco... a pert ot tbl. perait.
The ~neral Condition. for .11 per.it. ere li.ted on the rever.. .id~. Special 'rova.ion. for
tbi. peraic .re ll.t~d below. t.llur~ to .bida by th~.~ condition. and provl.ion. ..y re.ult
In job IhUr-down .nd/or torl.ltur~ 01 ralthful 'artoraance aond. .nd c..h depo'lt.. 15ee
~ner.1 CondlClon. 1 .nd 2).
E. An appllc.tion fe. au.t accoapeny tbl. application. Thl. I. non-r.tund.bl~.
.... ot Telephone: 277-7847
A.
a.
C.
D.
Addu.. I 2.
I. thl. work being don. by tb. property own.r at tb.lr own re.idencel ___,e.
Coapl.c. .tt,chad Wor_.r.' Coapenl.tion and Contr.ctor lor...
Th~ Appllcant/Per.ltC~a her'by a9re~. Dy .tllllng their .I,nature to tbi. per.lt to hold tbe City of
C'.pb.ll, It. otticerl, .gant. .nd e.ploy.e. tr~.. .',~ and bar.l... Iroa .ny cl... or de..nd lor
daaagel l""ulting froa the vork cov.red by thil pee.lt.
eo
---
Th~ Appllcant/Peraittee hareu1 aCknowledge. th.t tbey b..e ra.d and under.tand botb tbe
b.ck of thl. per.lt, .nd th.t they vll1 iolor. th.lr contr.ctorl.) 01 lhe iolor..tion.
ACCEP'tt~ ~t:~l 1 ~ t!t
front and
IIOTES: ALL WORK SHALL COtltOR" '111'11 Tilt An-ACHED, APPROVED .1.Ul5 UJl ALL APPLICABLE CAJlPaELL
.TAHOARD DRAWINCS AND CONDITIONS.
Tilt CONTRACTOR "UST RlVE THIS 'ER"IT AND A'PROVED ,LAMS UD RUST UET WIn TIlE '.W. lUPEC'l'OR 0tI
TtlE SITE A" LUST nlO DAYS BErORE &TAJlTINC WRIl.
tIOTJCE RUST BE CIVDI 1'0 PUBLIC WORkS AT LEAST l4 IIOURS Hrou: RtSTAJlTINlii AllY MOItI.
SPECIAL PROVISIONS
_1.
&tr~et .h.II not be Qpcn cut ter underground In.call.t10n.. "lnl.u. Cute ..y be .llowed
tor conn~ctlon. or aaplor.tlon bole.. Such cuta au.r be .peCllically Approved by the
I n"~ct or .
..vemenr-aay be cut tor underground In.t.ll.tiona aad au.[ be r.ator.d in accord.nc. with
the Utlllty TrenCh a"Lor'tion Standard Dr.wlng.
Work l"0 De .taked by . lic~n.ed Land Surveyor or Civil En9in..r and two lZ) copie. of the
Cut .he~t. .ent tc the PubliC Work ~pt. before at.rting vork.
The hour. of vork .re 11alted to out'lde the hourI of 7.' .... and J-' p... tor any work
allacLlng . [rattlc l.ne. _.
~.o:;~ A7TAc.HE:7-" ~ i!9JC.H Z1E,77'YtA 77 0....1 .ae:779" L
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.laNIT APPLICATION PEE
PLAN CIIECI DEPOSIT
~D POJt rAITllrUI. PDPOilIlANCE
P. ~. CCA5HI DEPOSIT
'EJl"IT Plf
(.-1)
(US.OO)
Hell" 110.
Q
nUDAIID
no.oo
'~OD.DO
(100' or &Ne. 1ST.)
($200) C4' or .oND,5~00 "1M)
n, or P.P. .oN!)
'\ . . U!l.OO 'UII)
Jriiit.e~-'-'-"
AROUNT
5 _-5"0.00
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.
5.35: 00
ii' ..~
7.' / /,1
I j UAt.
APPROVED POR ISSUANCE
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