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PUBLIC WORKS PERMIT Per.it No. M-1EfJ
(ror worKln9 In ~ne
public right-of-way) X-Ref. file
Iuued 7-11-8~ Application Date '+--J'2..--BA
Permi~ e~pl es In ~~ mos. expires ~.
APPLICATION - Application is hereby .ade for a PUblic Works Permit in accordance with Campbell-
Municipal Code, Section 11.04.
CITY OP CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell! CA 95008
(408) 8h-2150
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A.
Work address or tract , 921 Hazel Ave.
Utility trench location SDN1G67013, SOf.!6224TT'48
Nature of work: Abandon gas service as indicated on the attached sketch.
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.
The General Conditions for all permits are listed on the reverse side. Special ProviSions for
this permit are listed below. 'ailure to abide by these conditions and provisions may result
in job Shut-down andlor forfeiture of Paithful 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 Pacific Gas and Electric Company Telephone:
B.
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973-8930
Address 10900 N. Blaney Ave. Cupertino 95014
Is this work being done by the property owner at their own residence? ____yes no
Complete attached Workers' Compensation and Contractor for...
this permit to hold the City of
from any claim or deaand for
front and
ACCEPTED
ua'Ce
NOTES: ALL WORK SHALL CONPORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS 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 BEPORE STARTING WORK.
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEPORE 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.
~Avement 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 Bent to the Public Work Dept. before starting work.
The hours of work are limited ~ outside the hours of 7-9 a.m. and 3-6 p.m. for any work
affectin9 a traffic lane.
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PERMIT APPLICATION PEE
PLAN CHECK DEPOSIT
BOND POR PAITHPUL PERPORMANCE
P. P. (CASH) DEPOSIT
PERMIT PEE
(R-I)
($35.00)
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STANDARD AMOUNT RECEIPT NO.
$50.00 $ S-O.lCO Q
$500.00 $
(100' OF ENG. EST.) $
(U OF BOND,$500 MIN) $
APPROVED FOR ISSUANCE
(7' OP P.P. BOND
$35.00 MIN)
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royv ty r; (mt
$ .3S;-.DO Q
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f: PWPERMIT
Revised 7/87
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