ENC2003-00154
.
Application Date ~ 16 ) 0.3
Application expires in 6 months
RECEIVED
APPLICATION - Application is hereby made for a Public Works Pennil in accordance with Campbell Municipal Code. Section 11.04. (Application expires in 6 molllhs
if the permit is not issued. Application Fee is non-refundable.) , [) E C 0 5 2003
A. Wort address or uaa ,~ \ t-(0lJ A" E ·
Ulility trend1IOC3ljon~L"1'CII..) ~ve
t.1TY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
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ENCROACHMENT PERMIT
(for working within the
public right-of-way)
P~rmit No.fNG2 uD~'. u 0 \5~
X-Ref. file
IZ
B. NaIUre of wort
I :UIiIMI& wOAKS
AOMINIITFtATlON
C. AlIal:h four (4) copies of an engineered plans showing the location and extenl of the wort. four (4) copies of the preliminary Engineer's Estimalc of wort. The
plans shall show the rela1ion of the proposed work to existing surface and underground improvemenlS. When approved by the City Engineer, said plan becomes a pan of
this permit.
D. All woric shall confonn 10 the City of Campbell Standard Spec:i'fications and Details for Public Works Construction; the General Permil Conditions listed on the reverse
,ide; and the Special Provisions for this pennil, listed below. Failure to abide by these conditions and provisions may resull in job shul-down and/or forfciblrc of Faithful
Pcrlonnance Sureties and cash deposits. (See General Pcnnil Conditions 1 and 2.)
E. THE CONTRACTOR MUST HAVE THlS PERMIT AND APPROVED PLANS AT THE SITE AND MUST NOTIFY THE PUBLIC WORKS DEPARTMENT AT
LEAST TWO DAYS EFORE ST. TING WORK.. NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
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24/ EMERGENCY TELEPHONE NO.
Yes ../ No
Address
Is this woric being done by the propeny owner aI their own residence?
The ApplicantfPerrnince hereby agrees by affIXing their sigllllblre 10 this pennilto bold the City of Campbell, its officers. agcnlS and employees free, safe and harmJess from
any claim or demand for damages resulting from the: wort covered by this permit.
The ApplicanllPcrmiuc:c hereby acknowledges thai they have read and understand both the from and back of this pennil. and they will infonn their COIlll'llClOr(s) of the
information.
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Work lGPc: .stalced by a licensed Land Surveyor or Civil.EngineeraJli:J lWo(2) coplcs ofthecutsbccissenl tOiliel'ubrICWtirU1>cpartJiieiir~o~ 5Imini'work:.
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. SEE PUBtlCWORKS FEE SCHEDULE FOR CtJ'iuiENT FEEs
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