95-246
CITY OF CAMPBE1.L
DEPT. OF PUBUC WORKS
10 North F'U5t St.
Campbell, CA ~
'8) 866-2150
blCROAOIMENT PERMIT
(for working within the
public ri&bt~-way)
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Permit expi1u in U IDCJ'..
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Application Date / () - d 7 - 9 '-~-
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APPUCA1l0N _ Application is hereby made for a Public Works Permit in acrordaDCe with CampbeU Municipal Code, Scctioa 11.04. (Application upUes
in 6 moaths if the permit is DOt jgucd).
Won: addrea or tnct # 81 b I
Utili., """" _tioo /lfe' C'Ot/ /! /G . @ , /.> &$ ~I?AJ . /J IL,
B. Natureofwon EirE-NO J01~T iKuJCJ-I163' W!~T AlONG ~oumSI/)t ~f MCCay AV$",
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C Attaeh four (4) copies of an engineered drIwin& showing the Joc:atioc, extent and ~~ of the work.. The dnwin& Ihal1 sbow the relation of the
propo&ed won to exi&ting 5Urface and underground improYCmentL When apptoYCd by the aty Engineer, Did c1rawinI becomC$ a put of ~ permit
D. Allwork Wll cooform to the ary" General Coadi~ Standard (;oostnictioIl1'rovisioo5 and Standard c:oomuctioo Detail5 for Public Worts
, Coostruction; the General Permit Cooditi0a5liitCd (l(\ the revetiC We; and the Special ProviAoo5 for this permit, listed below. Failure to abide by
the5e cooditi0a5 and provisioo5 may result in job Ulllt-dowD and/or forfeiture of Faithful Performance Suretie$ and c:a5h depoQtL (See General
Permit Cooditi0a5 1 and 2.)
E. A nonrefundable application fee mll$t accompany this application.
Name of Applicant rAc IFIC Be /...1... - SU)TT YOUN 6'
.3475 B N()~iH FIIlS1 Sr. SAfJ Jose,
15 thi& work being dooe by the property owner at their own reAdence?
Tclepbooe 4Q8-7/3Z
&::fS (.3<1-
OCE'VED
OCr a 71995
The ApplkantfPermittee hereby agrees by affixing their Iiptllre to ~ permit to bold the Ory of Campbell. its officen, ~t'It~ free, safe
and harmless from any claim. or demand for damages ~ting from the work CQYered by thi5 permit. 4DMINl ORii.5
STRA TlOl\;
e ApplicantfPermittee hereby acknowledges that they have read and undemand both the front and back of this permit, and they wil1 inform their
i1tractor(s) of the information.
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Complete and attach Workers' CompeD5ation and Contractor Informatioo for015.
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Accepted
(Applicant (permittee) print/5ign
Date
NOTES: ALL WORK SHAll CONFORM wrrn TIlE ATfAOiED, APPROVPD PLANS AND ALL APPUCABLE CAMPBElL STANDARD
DRAWINGS AND CONDIDONS.
TIlE CONI'RACTOR MUST HA VB TIllS PERMIT AND APPROVED PLANS AT 1HE srre AND MUST NOTIFY TIlE PUBUC WORKS
DEPARTMENf AT U'AST TWO DAYS BEFORE srAR11NG WORK.
NOTICE MUST BE GIVEN TO PUBUC WORKS AT U'AST 2.t HOURS BEFORE RESI'AR11NG ANY WORK.
spECIAL PROVISIONS
_1.
Street 6halI DOt be open cut for underground installat:i005. Minimum cuts may be allowed for coonectioo5 or apIoBtioa boles. Such cuts must
be soecifica1lv aool'OYCd bv the Insoector orior to cuttin2..
Pavement may be cut for underground in5tal1atioos and mllSt be restored in acrordanc:e with the Utility Trench Restotatioa StancSaro Drawing.
Work to be 5lakcd by a liceD5Cd Land Surveyor or Ovil Engineer and two (2) c:opies of the cut sheets sent to the Public Worts Department
~ore ~~ 0.1 :(1 r 4$ Jb!"., I~ f.. rcoIJ/~ .
_2.
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_4.
APPROVPD FOR ISSUANCE
srANDARD
$210.00
SSOO.OO
(1()()% OF ENG. EST.)
(4% OF SURETY, SSOO MIN)
(FIRSf ~$30,(0) 14%;
$80, $200 min)
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REl"'FJPT NO.
ex
.:.RMIT APPuo..nON FEE
PLAN CHECK DEPOSIT
SURElY FOR FAITIIFUL PERFORMANCE
CASH DEPOSIT
PLAN CHECK &. INSPECIlON FEE
!ext $30,000-$80,000 10%; Amo\int
(;)
/1 J 17,
Date
* *
h:PW PERMIT/Rev.4/94
USA phone (800) 642-2444
(see other side)
TICKET NO.
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