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CITY OF CAMPBELL
D~I ~. OF PUBLIC WORKS
70 North First St.
Campbell! CA 95008
(408) 860-2150
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PUBLIC WORKS PERMIT
,xor worK1n9 1" ~ne
public right-ot-way
Issued f. t7 6" gr
Permi m08.
Permit No.
X-Ret. tile
Application Date ?(.:./~/ 8'&-
expires ln' s.
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Nature of work: in~rrl1 1 utilities as indicated on the attched sketch. wall 42130D >-<
Attach five (5) copies of a draWing showing the location, extent and di.ensions of the work t-3
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. trl
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The General Conditions for all permits are listed on the reverse side. Special PrOViSions for '\:J
this permit are listed below. 'ailure to abide by these conditions and provisions may result ~
in job shut-down and/or forfeiture of Faithful Performance Bonds and cash depoSits. (See r-<
General Conditions I and 2). H
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APPLICATION - Application is hereby made tor a PUblic Works Permit in accordance with Campbell~
MuniCipal Code, Section 11.04. ~t1~~
660 w. ~
Work address or tract .
Utility trench location
B.
C.
D.
E. An application fee must accompany this application.
Pacific Gas and Electric
Name of Applicant
Address 10900 N. Blaney
This is non-refundable.
973-8930
Telephone:
Is this work being done by the property owner at their own residence? ___yea no
Complete attached Workers' Compensation and Contractor tor...
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of
Campbell, its officers, agents and employees free, safe and harmleaa from any claim or demand for
damages resulting m the work covered by this permit.
The Applicant/Pe s that they have read and understand both the front and
back of thia pe oBf:!'~/~~ormation.
ACCEPTED
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NOTES: AL iWORK SHALL CONFORM WITH THE
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 BEFORE STARTING WORK.
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
ED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL
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.
~Avemen~ may be cut for underground installationa 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 aheets sent to the Public Work Dept. before starting work.
The hours of work are limited ~ outside the houra of 7-9 a.m. and 3-6 p.m. for any work
affecting a traffic lane.
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4.
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PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
(R-I)
($35.00)
$ SO.oo
$
$
$
STANDARD
$50.00
$500.00
(100' OP ENG. EST.)
AMOUNT
RECEIPT NO.
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BOND FOR PAITHPUL PERFORMANCE
F. P. (CASH) DEPOSIT
PERMIT FEE
($200) (4' OF BOND,$500 MIN)
~ (" OP F .P. BOND
IC~35.00 MIN)
RECEIVED
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$ 35: OD
APPROVED FOR ISSUANCE
f: PWPERMIT
Revised 7/87
AUG 231988
PUBLIC WORKS
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