95-272
aI'Y OF CAMPBELL
DEPT. OP PUBUC WORKS
10 Nmt F"mt St.
CamPt>cu.CA9SOCIl
(G) 866-2150
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;CR.OAaINENT PI!RNIT
\,or wortiac witbiD the
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APPUCATION - AppIkatioa II beftby ID8de for. Public Worb Permit ia accorducc wItIa r...."... NlIIIicipaI Code, Soctioa IUN. (Applicatioa apireI
ill 6 moaths if the permit " DOt iIIucd).
A Wort Iddrea or tncI # PO '^ /.J) Ii' [J R 0 fl /J F !? (J;VI j-J B So TT r 0
Utility treDcb Ioc:atioa ~; E f }) I tlic /:": /.:: rt
B. Nature ohork ' /... Ii -':: C \v \/ i / . Iv
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C. Attach four (4) copies 01 u cqiDccrcd cSrniac IbowiII& the Ioc:atioa, ateDt aad cfimclllioal of the wort. nc dnwiq IbaIlIbow the...tioa of the
propoICd work to c.xiltiJlllUffacc aad lIDdcfJl'OUDd improvemcIltl. WbeG appmvecl by the cty &peer, aid dnwia& bcc:amcI a put 01 tIliI permiL
D. AU 'W!t I!WI coaCorm to the Cty'1 GcDeral CoOdidoal, SCudard Coastructioc PrcMsioaI aad StIDdud Coastnx:tioa Details for Public Worb
Coastnictioa; the GcDcral Pcnnit CoOditioas Uaed 011 the mteIIe &ide; aad the Special PrcMsioaI for tIliI permit, lilted beIow-. failure to Ibide by
tbe&e coaditioas aad pnMsioa& may result ill job mut<<Jn aad/or fodeituR of PaithfuI Pcrformaace Sumie& aad cash depodtl. (See GcDeraI
Pcnnit Coaditioas I aad 2.)
_ E. A DOIl1'efuDdable appIicatioa fee must ~tIai& 8ppIicatioa.
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Is this work beiq doae by the property oner at their 0IrIl rcsicScDce?
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Complete aDd attach Workers' CompellAtioa aad Coatnctor lDformatioa forms.
NOV 3 (1 1995
The AppIicant/permittee bereby agrees by atI'illiq their IipatuR to tbiI permit to bold the Cty 01 r..~u. its ol6ccrs, qea_ u4 ~, ~ safe
aDd harmless from uy claim or demand for cSamap R5UltiD& from the work CillIYCred by this permiL, i) /,,11 N 15 r 1< A f' ,),
~rt::~~~... --;;: _...~~..;... ~wm ~-~.
(ApplicaDt (permittee) priIlt/. n.te
NOTES: ALL WORK SHAll. CONFORM wrIlIllIE AlTAOfED, APPROVED PlANS AND ALL APPUCABLE CAMPBELL STANDARD
DRAWINGS AND CONDmONs.
e- llIE CONfRACI'OR MUST HA VB 1HIS PERMIT AND APPROVED PLANS AT llIE srm AND MUST NO'IlFY llIE PUBUC WORKS
-g DEPARTMENT AT LEASI' lWO DAYS BEPORE STAR11NG WORK.
C"
~ NOTICE MUST BE GIVEN TO PUBUC WORKS AT LEASI' 24 HOURS BEPORE RESTAR11NG ANY WORK.
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'5 SPEaAL PROVISIONS
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Street IhaI1 DOt be opeD cut for lIDdcfJl'OUDd ialtaUatioa&. Niaimum cuts may be allowed for c:oaac:ctioa& or expIoratioa boles. Such cuts must
be &DecificaUv aDDI'OYed bv the Iasoedor Drior to cuttia2..
PavemeDt may be cut for uaderpou.ad ialtaUatioas aad must be Jatored ia accordaDce with the Utility T~ Rcstoratioa StaDdard Dnrwiag.
Work to be staked by a IiceIllCd Laad ~ or aw Eqiaeer &ad two (2) copies of the cut IhcetllCDt to the Public Worts DeputmeDt
before Itartiag wort.
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PERMIT APPUCAnON PEE
PLAN OIECK DEPOSIT
SURElY FOR fArIHPUL PERFORMANCE
- CASH DEPOSIT
~ PLAN CHECK &: INSPECI10N PEE
e Next $30,000-$80,000 10%; Amovnt
$210.00
SSOO.oo
(100% Of ENG. EST.)
(4% OP SURETY, SSOO NIN)
RSI' $0-$30,000 14%;
, S200 Mia)
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Date
t: APPROVED FOR ISSUANCE
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* USA phone (800) 642-2444 TICKET NO.
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