88-215
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CITY OF =aMPBBLL
DBft. OF POBLIC woau
70 Korth Firat It.
Caapbell, CA .5008
(408) 8"-2150
C)C' -
perait Ho. U () -.-;J- / ':,
X-Ref. fUe
Application Date S /:Ju/,s:f?
Application expire. in 6 .0..
BHCROACHMEN'l' PBRMIT
(for workinq in the
public ri~ht-of-way)
I..ue4 S'3 0 ~g>J
Perai t exp re.' n 12 .oa.
APPLICATIOK - Applic.tion ia hereby ..de for. Public Worka Perait in .ooordanoe with C..pbell
Municip.l Code, lection 11.04. (Applic.tion aspirea in 6 .ontha if perait not pulled)
fl5~ \VJt (p~(f-L{ 1\G e~~l\~??$ f ~ L_
utility trench location ~ \
NtruJ J;yc(c!t~ LUftLf Cf' {1,Kff
ahowinq the locati~n, extent .Dd di.enaiona Of the work
of the propo.ed work to exiatinq aurface and underqround
City Bnqineer, .aid drawinq baco.e. a part of tbi. perait.
A.
Work .ddrea. or tr.ct .
B.
Kature of workl
C.
Attach five (5) oopiea of . dr.winq
Tbe drawinq ahall ahow the relation
iaprov..ent.. Wben approved by the
D. Tbe General Condition. for all perait. are li.ted on the rever.e .ide. Special provi.ion. for
tbi. perait are li.ted below. Failure to abide by tbe.e oondition. and provi.ion. .ay re.ult
in job abut-doVll and/or forfeiture of Faithful Perforaance Bond. and ca.b depo.it.. (See
General Conditiona 1 and 2).
B.
Thia i. non-refundable.
37?-7~37
K_e of
Addre.a
Ia thie
_yea _no
Co.plete and att.ch Workera' Co.pen..tion and Contractor Inforaation foraa.
The Applicant/Peraittee hereby aqree. by affixinq tbeir
of
C..pbell, it. offioera, aqent. and ..ployee. free, .afe
d_aqe. re.ultinq froa the work covered by thi. perait.
.iqnature to tbi. perait to bold the City
and harale.. fro. any clai. or d..and for
Tbe Applioant/Peraittee hereby aoknowledqe.
back of tbi. pera1t, and tbat they will
Lt\.\LR t2l:\-rTT
Appl can
and under.tand both the frcnt and
.) of the inforaation. .. V c?
i -1j(j - t? ()
Date
ACCEftBD
MeWBSI ALL WOIUt SBALL CODORM WIH HE AftACBBD, APPROVBD PLUlS UD ALL APPLICABLE CUPBBLL
ITANDAItD DIlAWIHGS UD COWITIOIIIS.
HIl COIl'l'IlACTOR HOST UVB 'l'BIS PBRKIT AND APPROVBD PLUlS AND MUST NEET WI'l'B 'l'BB P.W. IIISPEOTOR 06
TUB SITE AT LBAlT TWO DAYS BBFORB STUTIKG WORlt.
IIOTICB MUST BB GIftIl m 'UBLIC woau AT LBAlT 24 BOURS BBFORB RBSTUTIIIIG ANY WORlt.
SPECIAL 'ROV%SIOHS
_1.
. street .h.ll Dot be open cut for underqround in.t.ll.tion.. Mini.ua outa ..y be .llowed
for oODDeotiona or asploration hole.. Suoh out. .u.t be .pecifioallY approved by the
Inapector.
'.v..ent ..y be out for underqround in.tallation. and .u.t be re.tored in accordance with
tbe Utility Trenoh ..ator.tion Standard Drawinq.
Work to be .tated by a licen.ed Land Surveyor or Civil Bnqineer and two (2) copie. of the
cut .heet. .ent to the Publio Work oeptartaent before atartinq work.
The hour. of work are liaited to out. ide the hour. of 7-' .... and 3-6 p... for any work
affectinq . traffic lane.
_2.
_3.
_4.
_5.
'BRMIT A..LICATIOII FBB
.LUI CHECK DBPOSIT
(R-1)
($35.00)
$50.00
$500.00
(100\ OF BIIIG. BST.)
(4\ OF BOW, $500 MIIII)
STANDARD
AHomrr
. :;s-:- DO
$ --------
RBCEIft HO.
207</9
BOW FOR FAITBJ'UL 'BRI'ORKUlCB
------
$ ---
$
$
.f /JO / P-r
( Date
2. tiC) . 0 ct'
J-07VC)
CASH DBPOSIT
($200.00)
'LAN CHECK' IIIS..OTIOII FBIl (]~/) (7~ F.'. BOIm, $35 KIll)
APPROVBD FOR ISSOANCE ~~ l- (! ['-----
for C ty Bnq neer
,-- -------
fl PWPBRMIT
Revieed 8/88
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CITY OF CAMPBELL
Permit No.
Applicant
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INFORMATION SHEET FOR ENCROACHMENT PERMITS
A separate form must be completed for the applicant and each contractor
that will work under this permit.
WORKERS' COMPENSATION INSURANCE INFORMATION
Name of Contractor/Applicant
One of the following must be on file with the Public Works Department:
A Certificate of Consent to Self-insure issued by
the Director of Industrial Relations; OR
A Certificate of Workers' Compensation Insurance
Insurance Co.
Policy No. Expiration date
; OR
.............................................................. ................ ...................................... .. .. ............................ ..
/
This Certificate of Exemption from the Workers' Compensation
laws printed below (certificate must be signed).
CERTIFICATE OF EXEMPTION
I certify
shall not
to the Wo
that in the performance of the work for this permit, I
employ any person in any manner so as to become subject
".rs' Ct"ft::;"ws of California ~ate f ~ :; d.1f ~
Signed
NOTICE TO CONTRACTOR/APPLICANT: If, after signing this Certificate
of Exemption, you should become subject to the Workers' Compensation
provision of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked.
. .
............ ................................ .......................................................... .. .. ........ .. .. .... ............ .. .. .. ........ ..
CONTRACTORS INFORMATION
Note that all contractors must have current City of Campbell Business
License, State Contractor's License and Workers' Compensation Insurance.
Name of Contractor
Address
Telephone
State Contractor License No.
City Business License No.
Expiration Date
Will do the following types of work:
__underground __P.C. concrete __A.C. paving __electrical
other (specify)
f:PERMINFO
REV. 8/88
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l,~()r~ CO~ISTRUCTION.
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RECEIPT
CITY OF CAMPBELL
CAMPBELL. CALIFORNIA
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ADORES'"
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For/'l,fi.?/;''--,/!I f" a.1; h-?u-
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(a..~'-'-A.. l ( ><- ~.~~
<68-;) IS
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REVENUE ACCOUNT NO.
'3 37.;) 'Ii 3 .s 02-
~
FUND NUMBER
~K
o MONEY ORDER
o CASH
DATE
AMOUNT
THIS RECEIPT
MUST BE MACHINE
VAUDATED AND
SIGNED BELOW.
3~7"L-
3$70 C
.30 .!~
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00
00
BY
tZ/rI
CITY CLERK
20149
Thank You
CITY OF CAMPBELL
CITY TREASURER
eM
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REFUNDABLE DEPOSIT
CHECK REQUEST
TO: FINANCE DIRECTOR
CITY OF CAMPBELL
Please issue check payable to:
Address:
Line 1:
1136 Ridqeley Dr.
(30 spaces)
(30 spaces)
(30 spaces)
State: CA Zip: 95008
(2) (10 spaces)
(24 spaces)
Larry Rhett
Line 2:
City :
Campbell
(20 spaces)
Description:
Cash Deposit Refund
Exact Am~unt Payable:
Account Number:
$200.00
001.00.905.0000.4662
PURPOSE: '
Release of cash deposit for Excavation Permit No. 88-215.
See receipt #20749 dated 8/30/88.
Requested by: P.w. Inspector Date: 11/22/88
.
. Approved by: Date: 11/22/88
P.w. Director
. Verified !:>y: Receivable Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as is
xx
Mail in attached envelope
Return to:
(Department)
(Name)
Other:
j
08/24/88
PUBLIC WORKS INSPECTION REPORT
Date 'o4k6.
Address / B c. ~
Permit or Project No.
.ee 2/5
1'ype of work:
R/~G--Y.
../
Street Storm
Other (describe)
Sanitary Electrical
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[JPRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached)
[]FINAL INSPECTION WITH DEFICIENCY LIST (attached)
taHrfNAL INSPECTION - ACCEPTANCE
Signed plans'? Y 0 (If signed, Council acceptance.)
Charges against deposit? y
Overtime I brs. @ $
Date" reason:
Q
/hr.
.
$
Barricade rental (attach invoice)?
Date " reason:
y
(t)
$
Other?
$
$
Total charges deducted from depositl
(Cash Deposit $ less charges $
$
· Refund $
ck. req.)
DONE YEAR MAINTENANCE WITH DEFICIENCY LIST (attached)
o ONE YEAR MAINTENANCE - ACCEPTANCE
(Release'maintenance bond. Check Request if cash.)
Engineer
~or
r
CITY OF CAMPBELL
70 NORTH FIRST
CAMPBELL, CALIFORNIA
(408) 866-2100
STREET
95008
Department:
Public Works
October 10-, 1988
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D!.A,Z I J,CiLE
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M.h,NLEY I il'
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Mr. Larry Rhett
1136 Ridge1ey Dr.
Campbell, CA 95008
RE: Final Inspection and Acceptance
Permit No.: 88-215
Location: 1136 Ridgeley Dr.
r-
We have made a Final Inspection of subject public works construction and
find it acceptable and in conformance with City standards. Accordingly,
the work is hereby accepted subject to the one-year maintenance
requirement indicated below.
You are responsible for the maintenance, repair and/or replacement of all
work done should any failures occur within one (1) year of this date.
We will inspect the work in one year and advise you whether or not
maintenance is needed.
Please feel free to call the undersigned if you have any questions.
Sincerely,
Gregg Eaton
Public Works Inspector
GE:sd
cc: Suspense - 1 year