97-106
CITY OF CAMPBELL ~ 0 ENCROACHMENT PERMIT
DEPT. OF PUBUC WO~S \" ~ (for working within the ---....
70 North First St. e ~ public right-of-way) /)
Campbell, CA"A)<'I. ~1 / A /r;, 7 / ~)J /iLL /.
(408) 866-215~ ""\ \. ~,':).., Issued' t-rr1 ~ Application Date I ./ I tJ 7
Fax (408) 376-0958 ~~~ . _.'. Permit expiies in 12 mos. Application expires ffi. 6 mos.
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APPUCATION - Appli~tion iS~~~de for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application
expires in 6 months if the;penni't is not issued Application Fee is non-refundable).
J it No.
X-~ef. File
2?-LDh
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A. Work address or tract #
Utility trench location
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B. Nature of work
4' ')(4' &LU-IOLC 10 cur-orr 5E:;ev1i..e... f'12aI {;pf5 rlAIIJ
C. Attach four (4) copies of engineered plans showing the location and extent of the work, and four (4) copies of the preliminary Engineer's
Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by
the City Engineer, said plans become a part of this permit.
D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions
listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result in
job shut-down and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2.)
E. THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AT THE SITE AND MUST NOTIFY THE PUBUC WORKS
DEPARTMENT AT LEAST TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GWEN TO PYBUC WORKS AyLEAST ~!IOURS
BEFORE RESTARTING ANY WORK. 6 akin' AC~j.J.I?E.rzi.-/'( ~fL U /.J
fJ-.J ~('- <1) w' c!i:-' - /nc ..of.'M"l' A- r/dJrlK"71- .f;#q.<.-
Name of Applicant/Permittee n-'i. C t f",l L ) ( 7 f' C -' (J .-' teiepho~e
Address / (] 9 (; C 'iJ f.. :-;; f ar )( 0 :'1__ It'll c'; 0CJ 15J I if
Is this work being done by the property owner eir own residence? Yes No
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers, agents and employees free,
safe and hannless from any claim or demand for damages resulting from the work covered by this permit.
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JOB NO. 0.5"4 IC-84 <:03
S.O. NO. 0/77yr FOOTAGE
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