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t~'l1[ 01' CUPBELL
fDE . 01' PUBLIC WORD
70 o~th I'i~st st.
C b.ll, CA '5008
I (408) 8"-2150
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3
p.rait No.
ENCROACHMENT PBRMI'l
(for workinq in the
pUblic right-of-w.y)
Xs.ued
Perait expi~.s in 12 ao..
x-a.f. fU.
Application D.te Y -.:3 0 -~
Application expire. in , ao..
APPLICATION - Applic.tion is b.reby ..de for a PUblic Wo~k. P.rait in .ccordanc. witb C..pb.ll
Municipal Code, Section 11.04. (Application expire. in , aonth. if perait not pulled)
A. Work .ddress or tract. / /s- -5:, TH'//2LJ JT/2~r
utility t~encb location
B. .ature of workl era G"XlfT flu..;
c. Attacb five (5) oopi.s of a drawinq sbowinq tb. location, .xt.nt and di..nsions of tb. work
'lbe d~awinq sb.ll show tbe r.lation of the p~opo..d wo~k to existinq su~face and underq~ound
1aprov..ents. Wben app~oved by the City Bngineer, said d~.wing becoa.. a part of this perait.
D. The Oeneral Condition. for all perait. are listed on the ~.ver.e .ide. Special provi.ions for
this perait .re listed below. Failure to abide by the.e condition. and provi.ion. aay re.ult
in job .but-down and/or forf.iture of I'.itbful P.rforaance Bond. and cash depo.it.. (See
Oener.l Condition. 1 and 2).
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application.
'lhi. i. non-refundable.
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B. AD .pplication f.. au.t .ccoapany tbi.
.... of Applicant 8' LI..//(./C//\/5 ON
Addre.. //,5-.s-. r/f.//2p 5r.
(
Telephone I
378 -/.3C/8
V;e.
_no
I. this work being done by the property owner at their own re.idence?
Coaplete and att.ob Work.rs' Coap.ns.tion and Contractor Infora.tion foras.
'lb. Applicant/P.raitt.. b.r.by .qr.es by .ffixinq th.ir sign.tur. to this p.rait to bold the City
of
c..pbell, it. officer., aqent. and ..ployee. free, .afe and harale.. froa any claia or d..and for
d..ag.s r.sultinq froa the work cov.r.d by this p.rait.
acknowledqe. that they have read and under.tand both the front and
aoca"'D t"lt oo.tt..totl') of t.. l'fO~~
D.t.
HO'lBS. ALL WOU SOLL CODORM nTH 'lBB AftACllBD, APPROVBD PLUlS AHD ALL APPLICABLE CUPBBLL
S'lANDAItD DRAWINOS AHD CONDITIO.S.
HB COIl'1'RAC'l'OR MUST BAVB HIS PBItKJ:'l AHD APPROVBD PLUlS AND IIVS'l KBB'l WIH 'lBB P.W. I.SPBCTOR O.
'l1lB SI'lB AT LBAS'l HO DAYS BBI'ORB S'lARTI.O WOU.
HO'l'ICB IIVS'l' BB GJ:VB. TO PUBLIC WORD AT LBAS'l 24 HOURS .BI'ORB aBS'lAR'lI.O ANY WOU.
SPBCIAL PROVISIOHS
_1.
.Str..t shall not be op.n out for und.rground in.tallation.. Hin1aua outs ..y b. allow.d
for oODD.otions or explor.tion bol.s. Suoh outs aust b. sp.oifioallY .pprov.d by the
In.peotor.
pav..ent ..y be out for underground in.t.llations and au.t b. r..tor.d in aooordano. with
the Utility 'lrenoh R..tor.tion Standard Drawing.
Work to be staked by & lio.nsed Land Surveyor or civil Bngin.er and two (2) oopi.s of the
out sh..ts s.nt to the PUblic Work D.ptarta.nt before starting work.
'lh. hours of work are liaited to outside the hours of 7-' .... and 3-' p... for any work
affeoting a tr.ffio lan..
_2.
_3.
_4.
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aBCBIft NO. ::;
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':2-.0 '7~c?
_5.
PEItKJ:T APPLICATIOH I'BB
PLUI CHECK DBPOSI'l
(R-1)
(t35.00)
STAHDARD AHOUH'l
$50.00 $ 35"-
$500.00 $
(10n 01' DO. BST. ) $
(4' 01' BOND, $500 MI.) ,
(n 01' I'.P. BOND, '35 HIN) $
BOHD FOR I'AI'lBI'UL PBUORKAHCB
~
ttj7/86
CASH DBPOSIT
PLUI CIIBCK i I.SPBCTIOH FEB
($200.00)
APPROVBD Foa ISSUANCE
for City Bngineer
Date
f I "PERMIT
R.vised 8/88
PUBLIC ~JORKS FILE NO. &,g- 2/ b
TO: City Clerk
ACCT.
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35-]396
3372
3521
3521
3372
3521
Please collect & receipt
for the following monies:
ITEM
Project Revenues (specify project)
PubUc. ('Jo:dl..6 Exc.a\.Ja.-Uon PeJlmLt fee.4:
App I i ca t i on Fee
Plan Check Deposit
Faithful Performance (Cash) Deposit
AMOUtn
$
OthVL:
($ 50)
'( $500)
(4% of FPB)
($500 min.)
(]'I.. of FPB)
($ 35 min.)
R-1 :
($'35)
($200)
35"'-
Plan Check & Inspection Fee
Other Cash Deposit (specify)
l373
3373 &
3372 Tentative Parcel Map Fil ing Fee ($350)
3372 Final Parcel Hap Filing Fee ($300)
3372 Tentative Tract Map Fil ing Fee ($400)
)372 Final Tract Ma Fil in Fee ($350)
3372 Lot Line Ad'ustment Fee/Certificate of Compl iance
3372 Vacation of Publ ic Streets and Easements
3372 Assessment Segregation or Reapportionment
First Spl it ($500)
Each Additional Lot ($150)
3372 Envi ronmental Assessment: '
Categorical Exemption cost
Ne ative Declaration
3370 Storm Drainage Area Fee per Acre Multi-Res.,
$2,060; all other, $2,250)
3395 Park Dedication l",-lieu Fee per Unit ($1,132)
3380 Public Works Special Projects
3510 Postage
NAME
13 . VV i L 1< /17/ SO It/'
TOTAL
$ 35'--
3 7....p~ /3 ~J3
ZIP 7s-0 0 cf
PH:lNE
3~
ADDRESS
/I!!" S.
C'~/~t
RECE IPT NO.
d,..<:9/ b 8
3 S-03
~
~1.3"~
July, 1987
FOR
C I TV CLERK
OiLY
AMOlNr PAID
RECE I VED BY
DATE' '1 ~