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CITY 0' CAMPBELL '
DCPT. 0' PUbLIC ~KS
70 NOlth '1,.1 Sl.
CAmpb.JJ, CA .~OO.
e.O', '..-~ao
PUBLIC ..oJlKS .ER..U' 'e,ait .0. ex g - ;Z 0-0
'tor wor.ln9 In ~n.
PllbUc rltht-ol-vart I-ad. fUe 'i\ R- ')91
hilled ~ - ii- ~? Application Date 1\-::;- >5~
'eran .pi I In I~ _a. ..phea t . 1101.
APPLICATION - Appllcation ia he,ebr ..de lor a '~blic Moc., '.r.lt ift accocdenee with Caapbel1
Runlclpal Code,~"ction 11.0..
A. 1I0lk addu.. or tract'. --r-iZ",""",c:_::;-- ~> I ~ z /'/38/ - ~;g)(/~T
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Uc il it r t renell locat ion ~~;:""l2"~ IZ-J e=:::-T~ ~ "/ ~ ;_"'-'--= 2.---.,~~;~ I c::::_~ c:::;-=r~
"tuu of lfOrk: f'/l..o.....,....... l"v~.~~~,..~,="'-' (~-z...":::".:>1 + K'1....L 'sMI/"'-E::S
ACtach five (~t copie. of e drawing .howing the location, e.cent and 'i..n.ion. of the lfOrk
Yh. d'lwlng .~ll Illow the relation 01 the Plopo.ed WOlk co .lllcing IlIrface end undelglound
lAplo.e..nc.. When epproved br tile Clty Engineel, .Iid drawing becoae. a part of thil pelait.
Yhe General Conditionl for all pelaic. ere lilted on the rever.e .ide. 'pecial 'rovi.lon. for
thi. perait are 11'ted below. 'allule to abid. by the.e condition. Ind Plovilionl "r reault
in 10b Ihut-down and/or lorleitllre of ralthflll 'erfor..nce Bond. and ca.h depollla. 5ee
General Condlllon. 1 and 2).
o.
E. An application fee auat accoapany tbia application. Yhia il non-refllndable.
Ma.. of Applicanc ~-~~~-~~ "'-./.c...---r~c=....e:_ .::"~ !'depbone: ...z..7~-7":?'::"c'"'::"7
Addre.. 12.2._, ~ ......+-J ~~i-1 ~ \,,6-.
Ja thl. lfOlk belng done by tbe property owner at th.ir own reaidencel ___,.a ___ao
Coaplece aCcach.d Work.rl' Coapen.ation and Contractor foraa.
The APfliclnt/P.raittee hereby a9reel by atfixlng thelr 8ignacure to thil peralt to hold the City ot
C..pbe 1. Ita otficer., agent. and eaployael tree, .afe and balalea. froa any claia or deaand 101
d."ie. relulting froe the work Covered br thla perait.
The App!icant/Peraittee hereby aCknow1edlea that they bave read and underatend both tbe
baCk of thia r'lt, an~ t ac tber Will afor. tbeil contractOlllt of the lnfolaalion.
ACCEPTED ~/ .:.2./~e:.
uate
front and
~~~
IIOTtS: ALL WORK SHALL CON'ORM WIt'1l TIlE AftACIlED. APPROVED PLANS AIID ALL APPLICABLE CAllP8ELL
STANDARD DRAWINCS AND CONDITIONS.
,.ilE C'OHTRACTOR "UST IlAVE THIS PER"n AND APPROVED ,l.AJCS AIID IlUST UEt III!'II TIlE '.If. JIliPEC'I'OR ON
TilE SITt AT LEAST TWO DAYS BErORE STARTING WORK.
IIOTICE RUST BE CIVDi TO PUBLIC WOIlKS A'I' lLU'I' l. lIOUa5 UFQRE RESTAR'I'ING AllY ..oJl1.
SPECIAL PROVISIONS
_1.
SCleet ahall not be open cut tOI IIndertround tnltallaciona. Mlniall. cllta aay be ellowed
lor connecliona or e.plolacion boles. 5uch cut, aull be apeClflcally .pproved by th.
Ina;Pf'ctor.
Pavement ..y be CIIC tor ~nder9lound lnacall.tioAl aAd ault be reatored in accordance With
the Utllicy TrenCh .elloralion SI.ndard Dr.wing.
Work to be ataked by a llcenled Lend Surveyor or Civil Engina.r aDd two (~J COpiea of the
Cut In..t. lent co the PubJIC Work Dept. before .taltin~ Walk.
The nourl or work are llalted to OIItalde the hOllr. ot 7-t .... end J-' p.a. tor enr work
attecllng a traffic lane.
~2.
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.ERMIT APPLICAT10N PIE
rLAM CHECK DEPOSIT
~D I'OR PAITH'UL .U...OR.....CE
ca-1)
.ns.OOt
UCII" 110.
0.
ITANDAIlD
no.OO
noo.oo
ClOO. 0. aIG. 1ST. t
AIIOUNT
ISO.OcJ
5
I
5
--
r. ~. (CASH) DEPOSIT CI200t C4. or aOND,I~OO MINt
rUMIT 'IE S{.DL.P/ S$OL.F,lE 0.2,.0 e~. .,. 01' P.P. aoND
,"0 t../t:: e. 0.1 S. e~, US.OO "IN)
APPROVED POll ISSUANCE ~ ~~,tL~~ ~~.
lur ~
f /tJ'j, 00
g/.~
I I NPCIl."IT
.avu.a 7/17
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