ENC2005-00001
CITY OF CAMPBELL
DEPT. OF PUBUC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
ENCROACHMENT PERMIT
(fOT working within the public
right-of-way)
Issued -LJ 3 lV5 ~
,
Permit Expiration Date \ 1.3) 0 to
.
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.mnt Not::I'J ~
X-Ref. File
Application Date I I 31 c> 5. I .
Application Expiration Date '7 1:3 /0':::>
APN 305 -35 -DJL!
Utility trench location
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D. All work shall conform to the City of mpbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions listed on
the reverse side; and the Special Provisi s for this permit, listed below. Failure to abide by these conditions and provisions may result in job shutdown
and/or forfeiture of Faithful Performance eties and cash deposits. (See General Permit Conditions I and 2.)
Name of Applicant
~Go\ c
~GC
Telephone '-\.0 ~ ~ .J..':>" ). ~~ 7
/
24-HOUR EMERGENCY TELEPHONE N()/
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E. The Contractor must have this permit and appro d plans at the site and must notify the Public Works Department at least two days before starting work.
Notice must be given to Public Works at least 24 Ii rs before restarting any work.
Address \ OC\OQ f\,
E-Mail Address ,OW" ~
Is this work being done by the property owners at their own residence?
Yes
x
No
The Applicant/Permittee hereby agrees by affixing their signature to this peron to hold the City of Campbell, its officers, agents and employees free, safe and
harmless from any claim or demand for damages resulting from the work covere by this permit
The Applicant/Permittee hereby acknowledges that they have read and understand bo the front and back of this permit, and they will inform their
contractor(s) of the information. Applicant is advised that upon issuance of this permit; property owner, or property owner's successors, shall be responsible
for any and all damage,f_llJ,iSing out of t~e C~d~'ti n.~any private improvements in the p lic right-of-way.
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Accepted
(Applicant Permittee) (sign) Date
Contractor
(Print Name)
r
~L~SV~ as
(,
OOler
ooo~q
SPECIAL PROVISIONS
_1.
Street shall not be open cut for undergroun(j installations. Minimum cuts ImY be allowed for conn
be specificallv approved bv the Inspector nrior to cutting.
Pavement may be cut for undergroundinstallations and must be restored in accordance with the Utility
"An Backfill, unless otherwise appr ved by Inspector.
Work to be staked by a licensed nd Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to e Public Works Department
before starting work.
Per Section 4215 of the Gov ment Code this permit is not valid for excavations until Underground Service Alert
the inquiry identification mber has been entered hereon. USA Phone 1-800-227-2600. USA TICKET NO.
Prior to any work, the p. perty owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be
recorded.
A) has been notified and
/2.
_3
_4.
_5.
_6.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
AMOUNT
RECEIPT NO.
C9
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PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & INSPECTION FEE
--A:-
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,
For City Engineer
Permit Ex ires 12 Months After Date of Issuance
$ ~l~
~=t=
$
$ I f')()
APPROVED FOR ISSUANCE
Date
J:\forms\pwperm
Revised 1.20.04
CITY OF CAMPBELL PERMIT SKETCH
TYPICAL
SERVICE TRENCH
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