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APPUCAll0N . ~~.~ for. Public Warb PamIt ill KCiOIduoc wIda r..~-U NlIIIicipaJ Code, Scc:doa 11.04. (Application apira
ia 6 moatbs if' the permit is DOt iIIucd).
A Wort addrca or tract '- 80 3~ J ~DI (\J~ ~.
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Utility treDCh location S a f\-rme.t~-(==:'i) CotJ'CiJ \ 'T 1::> l,.lJ \,,::;0
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B. Nature ohm I?U! MJft'fB ~P~)( - 40 ~A ':
'2- OF- fa '
RAc-.~ S~.. BoX
C. Attach four (4) copicI of 811 ~ dnwia& IbowiDc the Iocatioa, CltCDt aad 6iDKDI'bII of the wort. nc dnwia& IballIbow the rcIatioa of the
propo5Cd wort to cmtiD& lWface aad UIlcScrp'ouDcS bupao.c-zatL WbcG approvocd by the at)' EqiDccr, aid dnwiD& bccoIDcs . part of this pcrmiL
D. All wort IhaII coaform to the Otyl Gelleral CoGdidoal, StaDcSud Coastructioa ProviIioclI UId StaDcSud CoaItnIcdoIl DetaiI5 for Public WOIb
CoastnM:tioa; the GeDeral Permit CoDditioallilte.t OIl the I'CYmIe IicSe; UId the Spec:UJ PJOYiIioaI for this pcrmit, tilted bdow. Pailure to abide by
these coaditiool UId proviIioaI may result ill job sbut-dowD aad/or forfeiture of PaithfuI Pcrfor'llWlCC Sureties aad cash ckpoIitL (See GeIIeraI
Permit Cooditiooll UId 2.)
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II this wort being cSooe by the property OWIlCf at their 0IrIl raideace?
Yes ~_No
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Complete and attach Workers' CompeDll.ltion aad Cootnlc:tor bformatioD fClnDS.
The Applicant/permittee hereby qreca by aftixiq their Ifpature to this permit to bold the at)' of r..~-U. its ofticcrs, aptl aad cmpIoyca ~ aCe
and harmlea from U1y claim or demand for cSama&es rcsuItia& from the wort CXM:red by this permiL
The AppIicant/permittee hereby ackJIowIcdp that they hm: read UId UDderstaDd both the Croat and bact of this permit, and they will worm their
cootractor(s) of the wormatioa.
Accepted S:oK
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NOTES: ALLWORK SHAlL CONFORM WIllI
DRAWINGS AND CONDmONS.
ATrAOIED, APPROVFD PlANS AND ALL APPUCABLE CAMPBELL STANDARD
t' 1lIE CONfRAcroR MUST HA VB nus PERMIT AND APPROVFD.PLANS AT 1HB SlTB AND MUST N01lPY 1HB PUBUC WORKS
:l DEPARTMENT AT LEAST lWO DAYS BEFORE STAR11NG won
0-
~ NOTICE MUsr BE GIVEN TO PUBUC WORKS AT LEAST 24 HOURS BEFORE RESI'AR11NG ANY won
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"5 SPECIAL PROVISIONS
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PERMIT APPUCAll0N PEE $210.00
: ~ PlAN 0iECK DEPOSIT ssoo.oo
..c:: SURElY POR FAIllIFUL PERFORMANCE (100% OF BNG. EST.)
; - CASH DEPOSIT (4% OP SURElY, SSOO NIN)
,~ PlAN 0iECK cllNSPECI10N PEE (FIRSI' $()..$3(),OOO 14%;
. ~ :R:=:::~~~~i?e~, f $80, ~' $200 miD)
, ~ for Qty . r
< h:PW PERMIT/Rcv.4/94 (see other side)
* USA phone (800) 642-2444 TICKET NO.
Street shall DOt be opeD cut for UIldergrowld iDltaUatioal. Minimum cuts miy be ~ for CXlCIDCCtioaI or ciporatioa boles. Such cutl must
be soecificaUv anolOY'Cd bv the lnsDc:dor mor to cuttin2.
Pavement may be cut for UDdergrouDd iMta11atioal and must be restored ill KCiOIduoc with the Utility Trench Restoration StaDdard Dnwia&-
Wort to be staked by a IiccIlSCd LaDd SwYcyor or CviI Eqineer and two (2) copicI of the cut meetlscDt to the Public Worts DepartmeDt
before IWtiDg work.
STANDARD
AMOUNT
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