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fJLCC'ASi- f< IA:;!-I fI <LLU
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71) North Jl'&m St. public ri&ht4-w1)')
~~2~ ~ NOV 3 1995 ~, J- (;, -9 ~ AppIicatioc Date \ \ - 2-<7 S"
PUBliC Wm~l(~) Permit cxpirca iD U IDOl- f11vJ AppIicatioc expires iD 6 IDOl-
APPUCATION _~~~I~~~lfora P\ab\icWortI PermIt In ecrordmcc with CampbeD N~ Code, Sectioa 11.04. (AppUcatioa expires
in 6 mooths if the permit is DOt igued).
\t=2A~l ~ ~2 2J':)
1L.\l""1> L::)UleJ'E:.- 'biZ. ~o
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mutNo. C7\
_.-Rd. file
Utili ty trench Jocatioc
B. Nature of won lrz.f)...l.C H ~
IL-I H\ La LJ I -:J't::.. {:)TZ. .
L~A t"?t (-?f?,F LL -A vF::.. . \"'2)
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A Wort address or tract #
C. AttaCh four (4) copies of an engineered dnwin& &bowing the Ioeatioa, extent and dim(~ of the wort. The dnwin& Iha1I Ibow the Jdation of the
proposed wort to eD.sting surface and u.nderground improvementL When ~ by the Oty Engineer, aid drwwin& becomeS a put of this permit
D. All won shall conform to the Oty's General Cociditioos, StaDcSard CoostructioIl J'royidoos and StaDc1ard Coostnactioo Dctaik for Public Wcnb
. Coostroctioo.; the General Permit Coaditioos 1istCd oa the reverse Iide; and the Special PrcNisioas for this permit, listed below. Pailure to abide by
these cooditioos and providoos may re5Ult in job shut-dowD and/or forfeiture of fait.hflll Performance Sureties and cash depoliitL (See General
Permit Cooditioos 1 and 2.)
E. A nonrefundable application fee must ac:compID)' this applicatiOc.
- YA-t l ~'l C -g~L..L-
.~4'?S 13 t-j, I ~ c:::;-r. i2-Gr.oM 20.0
Name of Applicant
Tdcpbooe 4 ~3 - 7 l'7 3
t
to
Address
~
Is this wort: being done by the property owner at their own ~?
Yes
'I- No
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Complete and attach Workers' Compensatioc and Contractor Informatioc f0rm5.
The ApplicantfPermittce hereby agrees by affixing their dgnat\lre to this permit to bo&d the Oty of Campbell, its olficen, agents and ~ free, we
and harmless from any cJ.aim or demand for damages resulting from the wort coYCred by this permit.
have read and un<krstand both the froot and back of this pe1i' and flley will inform their
/ " /1 -
Accepted
133 Date
NOTES: ALL WORK SHAll CONFORM wrrn TIlE ATIAOIED. APPROVED PLANS AND ALL APPUCABLE CAMPBPLL STANDARD
DRAWINGS AND CONDmONS.
..
TIlE CONTRAcroR MUST HAVE TIllS PERMIT AND APPROVED PlANS AT TIlE SITE AND MUST NOTIPY TIlE PUBUC WORKS
DEPARTMENT AT LEAST lWO DAYS BEFORE STARTING WORK.
NOTICE MUST BE GIVEN TO PUBUC WORKS AT LEAST Z4 HOURS BEFORE RFSfARTING ANY WORK.
SPECIAL PROVISIONS
_1. Street shal1 not be open cut for un<krgroun<! installatioaL Minimum cuts may be allowed for c:onnec:tioos or expIoratioa boles. Such cuts must
be ~calJy aooJOYed by the InsoeCtor tlrior to cuttin2.
_2. Pavement may be cut for underground installatioos and must be restored in ecrordmcc with the Utility Trenc:b Restoratioa Standan! Dnwi.ng.
_3. Won to be staked by a licensed 1.aDd Surveyor or CiYi1 Engineer and two (2) copies of the cut sheets scnt to the Public Worb Department
before starting wort:.
_4. 'At t'5
Jt..
llPrFJPT NO.
APPROVED fOR ISSUANCE
$210.00
$SOO.oo
(100% OF ENG. ESI'.)
(04% Of SURETY, $SOO MIN)
(PIRST $O-S30,OOO 104%;
,000 , $200 min)
S dol ;: (J ()
S --
$
$
S7c)7. .,l.0
a
PERMIT APPUCA110N FEE
PlAN QIECK DEPOSIT
SURETY fOR fAIDIFUL PERFORMANCE
CASH DEPOSIT
PlAN CHECK &. INSPECIlON PEE
Next S30,()()()"$80,OOO 10%; Amount
.....
6(
II 6 S-
Date
h:PW PERMIT/Rev.4/94
USA phone (800) 642-2444
(see other side)
TICKET NO.
44t I }I, ~ II ~ 70 7Jc
;- CITY OF CAMPBELL
.,.
.
PA-~UJ--
PROJECT NO. 9>,:.2 (~
REPORT NO:
FIELD ENGINEER' S DAILY REPORT
e,J,t1 (.,041St OT. ~O6(,
?
CONTRACTOR: [BvJlj S;-rJ 6~/ff>-.
)J-
WEATHER: ;:;/r,
INSPECTOR: K. ~~.srfALL
ITEM
DESCRIPTION
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