88-224
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CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell! CA 95008
(408) 860-2150
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PUBLIC WORKS PERMIT
'Ior wor~1"9 1" ~ne
public r19ht_~-O~~w~ g' X-Ref. file
Isaued 01 I~ Application Date
PeI.i~ e~p. "~~ .os. expire.
APPLICATION - Application is hereby .ade for a Public Works Permit in accordance with campbell-
Municipal Code, Section 11.04.
Permit
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A. Work addres. or tract .
418 Industrial
Campbell
8.
Utility trench location S 0J;t4}(.,. rt>l ~ 63
Abandon service as indicated on the attached sketch.
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Nature of work:
Attach five (5) copies of a drawin9 showing the location, extent and di.ensions of the work
The drawing shall show the relation of the proposed work to existing surface and underground
improveaents. When approved by the City Engineer, said drawing becomes a part of this permit.
The General Conditions for all permits are listed on the reverse side. Special Provisions for
this permit are listed below. 'ailure to abide by these conditions and provisions may result
in jab Shut-down and/or forfeiture of Faithful Performance Bonds and cash deposits. (See
General Conditions 1 and 2).
E. An application fee must accompany this application. This is non-refundable.
Name of Applicant Pacific Gas and Electric Telephone: 973-8930
Address 10900 N. Blaney Ave., Cupertino 95014
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Is this work being done by the property owner at their own residence? ___yes no
Complete attached Workers' Compensation and Contractor for...
The Applicant/Permittee hereby agrees by affixing their signature to this per.it to hold the City of
Campbell, its officers, agents and e.ployees free, safe and haraless fro. any claim or de..nd for
damages resultin from the work covered by this permit.
The Applicant/ e aittee hereby acknow dges that they have read and understand both the front and
back of this e it, and tha th y 1 inform their contractor(s) of the infor.ation.
ACCEPTED W. Be 8/31/88
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NOTES: L WORK SHALL CONFORM WITH
STANDAR 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 BEPORE STARTING WORK.
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
E A ACHED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL
SPECIAL PROVISIONS
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1.
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
Ins_eetor.
rav .en~ ..y be cut for underground installations 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 sheets sent to the Public Work Dept. before starting work.
The hours of work are limited ~ outside the hours of 7-9 a.m. and 3-6 p.m. for any work
affecting a traffic lane.
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PERMIT APPLICATION FEB
PLAN CHECK DEPOSIT
BOND FOR PAITHPUL PERFORMANCE
F. P. (CASH) DEPOSIT
PERMIT PEE
(R-l)
($35.00)
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STANDARD
$50.00
$500.00
(100' OF ING. 1ST.)
AMOUNT
$ .5l).00
$
$
$
RECEIPT NO.
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($200 )
(4' OF BOND,$500 MIN)
(7' OF F.P. BOND
$35.00 HIN)
$..35". ()D
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APPROVED FOR ISSUANCE
~~
f: PWPERMIT
Revised 7/87
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CONSTRU~TI'6~~- ~__..
C~ampbel\' ., T4L f -'
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C.":,.,,:.,, '",;Of l<aY't'Jrhes\; 1lM~.-""." 7
on, the job site dUTtn,,f~e "rr.:W'JJ:L~ j/
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SUNNYSIDE
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$
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KENNEDY
100
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. . '\ ,;' #' .;. .PQVERAGE PART' NUMBER: .-/ COMMERcw.. GENEAAl LlABfLITY I
THIS ENDORSEMENT CHANGES THE POl.ICY. Pl.EASE READ IT CAREFUl.l.Y. .
ADDITIONAL INSURED-OWNERS, LESSEES OR CON-TRACTORS
(FORM B)
ThiS endorsement modifies insurance provided under the following:
COMMERCIAl. QENEAAlI.IABU.flY COVERAQE PART
WHO IS AN INSURED (Section II) is 8mended to include 85 8n insured tho person or organization shown in the
Schedule. but only with respect to liability .riling out of "your work" for thcst insured by or for yOU.
8CHEDUL.E
NAME OF PERSON Q8 pRGANlZATION:
It is hereby agreed that the
CITY OF CAMPBELL AND ITS RESPECTIVE OFFICERS, AGENTS AND EMPLOYEES
are named as Additional Insured from and against any claims, loss, liability, cost
or expense arising out of or in any way connected with the construction of the
project.
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JOB bESCRIPTION
PERMIT NO. 87-224
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JOB No.
COST
ADDITIONAL PROVISION:
AS reBpects the above owner. Lessee or Contractor, it i5 hereby agreed and
understood that this insurance is considered primary insur~ce for the project/permit
described.
PERMIT NO. 87-224
INSURED
COMP ANY
POLICY NUMBER
, END. EFFECTIVE:
E. A. HATHAWAY AND COMPANY
THE AETNA CASUALTY AND SURETY COMPANY
05 CO 5257630 CCS
10/01/88
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10/04/88 bs
CAT. 768200
PRINTED IN U,S,^. .