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CITY or CAMPBELL '
DEPT. or PUbLIC NORIS
'0 North 'lr.t it.
camPb.llL CA .~O.
e.0', ... -~UO
PUBLIC WOUS PERMIT '.r.u .0. '8' 8'- I 8 '1
'tor war.lnv In ~n~
pubHc li,he-ol_a)'1 I-ld. file as -(3 '>
h.ud ~;} --j~ AppUQUon D.t. ~- J...(:) -8 ~
'.r.I~. I .a. ..ph.a I . .-aa.
APPLICATION - Applic.tion 1a h.r.b)' ..de for a 'ublic Morka '.r.it in accordanc. .ith CeapDell
lIunjdpel CocI.,-hcUon 11.'.. /'. ""
A. .... ...,... ., ,,0<:' 9A~""c.."':;:; A 0 F i0 <J f' \. J 38 "Z - LA ("n'8\j~ -
Utilitr trench loc.tjon 10 I ~ 01== eLl. t'""l Ot==....) A t..J1::=,!\.) l)_
a. Mature 01 _rkz \ ,..)'S-r A Li_ 1-4" t=- \ l'2F:. -:S &12, J ic:..t;
C. Attach tivI C~I copl.. 01 a dra.ing ahowing the location, .Itant and 'i..n.iona of the .ork
Yh. drawlng ahall ahow the r.lation of the propoa.d .ork to .xlat1ng aurt.c. .nd under,round
i~rov...nta. Mh.n approv.d b)' the Cjcy In,ln..r, .ajd dr..in, Deco... a part of chi. per.it.
D. Yhe Ceneral Conditjon. tor all per.ita .r. llat.d on the r.ver.e aide. Speci.l ProYi.lon. for
thi. per.it .re ll.t.d below. 'ailur. to .bld. b)' the.. conditlon. and provlalona "r r.ault
1n job ahur-down .nd/or forl.ityr. of r.lthful P.rtor..nce aOnd. and c..h d,po.lt.. i.e
General Condltlona 1 .nd 21.
c. An .ppljcatjon t.. .u.t accoapan)' tbla applic.tion. Ybi. ia non-r.fund.bl..
..... of AppHcanr SA"-J.J vSE WAI"e;rL G) "el.phon.:
r-3~ ~,...rv-i AI JE ~ c'.. A q 5 11.. g
la th1. .ork being don. b)' tae propertr own.r at tb.ir own r.ajd.ncel ___y.a ___.0
Aldr.a.
I 2. Z-t
'2.7 cr -784"7
s.
Co~l.t. .ttach.d ~ork.r.' Coapena.tion .nd Contr.cto~ for...
The Appllcant/Per.ltt.e ber.by .gr.e. b)' affixlng thelr ai,Ratur. to thi. per.it to hold the Cjty ot
C..Pbell. ite otf1c.re. ag.nt. and e.ploy... fr.., .afe .nd bar.l... tro. .ny clai. or 4e..n4 for
4."iea le.ulling fro. the vork Coy.r.d by thi. per.jt.
The Applic.nt/Peraitt.e hereby aCknowledgee thaI tb.y ha.. r.ad and under.t.nd both tbe front and
baCk of thia~per.it ~. d ~at the)' vall infor. thelr contractorCal of the ~nfor..tjon.
ACCEPTED . n~~ 7-1, err
' 7.~'.' uan
lecrus: ALL WORK SHALL CONrO." "1'1'11 TilE ATTACIlED, APPIlOVED P1.AIlS AIID ALL APPLICAALE cuP8ELL
STANDARD DRAWINCS AND CONDITIONS.
"IlE COH'I'RACTOR "UST !lAVE 'tiltS PER"I't AMD APPROVED P1.AIlS AIID RUST UET lun THE P.If. IUPECTOR ON
TilE SITE AT LUST TWO DAYS BErORE IiTARTINC WORk.
IIOTICE IIOST 8E CIVEII TO PU8LIC VOJtKS AT LEAST l. lIOUas urou: RESTARTI... AllY WIll.
SPECIAL PROVISIONS
L..l.
-~.
5tr..t ahall not be open cut for und.r,round inatallation.. "lni.u. cuta ..y be allow.d
for connectjona or .xplor.tion bole.. Such cut. auat be apeClfical1y .pproved by the
I na;~t't or .
Plve.ent ..y be cut for und.r9round 1nat.1I.tiona lAd ~at be r.ator.d ift accord.nce wath
the Utility Tr.nch a..loration Standard Draving.
Work to be ataked by · licen.ed Land SurY~yor or CiYil Engin..r and tvo (ZJ copj.a 01 th.
cut ah~~t. a.nt to th~ PubliC Work Dept. b~torc atartlng work.
Th. houra 01 work .rc la.lt.d to outalde th. hour. of '-t .... and l-' p... tor an)' vork
aft.ctln9 . tr.flic l.n..
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'E~IT APPLICATION PEE
'LAM CHECI DEPOSIT
aoHD PWt fAITH'UI. PO'OMPlAMCE
r. ~. CCAiHI DEPOSIT
.ERIUT 'EE
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ens.ool
HeEl" 110.
c:<.Ou)S'
STANDARD
no.oo
noo.oo
ClOD' or Dei. 1ST.)
IoIIOUNT
I 50. OD
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enool
e., or 8OND,iSDO MIM)
fl' 0' , .P. IlOND
U~.oo 'UNI
i 35: 00
Y';2~)
APPIIOVED 'OR
J55UANCE 'Cl) ]:l"t%: -
'-HI'
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f: I'WPERMIT
a..u.d 7'17
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TO: City C 1 e rk
PUBLIC WORKS FILE NO. 8~-1~?
$ LSD. 00
PHONE ;;<c:; t( - 52-( ;2. I
ZIP 9..!;)72.. '8>
Please collect & receipt
for the following monies:
(specify project)
PvunU eM:
R-] :
($'35)
($200)
(Cash) Depos i t
3372 Plan Check & Inspection Fee
3521 Other Cash Deposit (specify)
J373
3373
3372 Tentative Parcel Map Fil ing Fee ($350)
~~72 Final Parcel Hap Fil ing Fee ($300)
,2 Tentative Tract Map Fil ing Fee ($400)
3372 Final Tract Ma Fil in Fee ($350)
3372 Lot Line Ad'ustment Fee/Certificate of Compl iance
3372 Vacation of Publ ic Streets and Easements
3372 Assessment Segregation or Reapportionment
First Spl it ($500)
Each Additional Lot ($150)
3372 Env i ronmen ta 1 Assessmen t: .
Categorical Exemption
Ne ative Declaration
3370 Storm Drainage Area Fee per Acre Multi-Res.,
$2,060; all other, $2,250)
3395 Park Dedication In-lieu Fee per Unit ($1,132)
3380 Publ ic Works Special Projects
3510 Postage
TOTAL
NAME -rM t- M [)v;!~
ADDRESS ~ 3'"8 I (7 ~ P e -L...
<;:5
FOR
C I TV CLERK
Oil.Y
RECEIPT NO.
AMOll'n' PAID
RECE J VED BY
DATE
AMOUfn
$
50.00
July, 1987