97-124
CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
ENCROACHMENT PERMIT
(for working within the
public right-of-way)
Permit No.
X-Ref. file
97-124
Issued
Permit expires in 12 mo
Application Date 2/2 5/9 7
Application expires in 6 months
APPLICATION _ Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in 6 months
if the permit is not issued. Application Fee is non-refundable.)
A. Work address ortraet# North side of Rincon, 64 I west of San Tomas Aquino Road
lclosest address: 4300 Buckna11 Road)
Utility trench location
B. Nawre of worlc
EMERGENCY Service Repair - 2'x3' cut in concrete
C. Attach four (4) copies of an engineered plans showing the location and extent of the work. and four (4) copies of the preliminary Engineer's Estimate of worlc. The
plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer, said plan becomes a pan of
this permit.
D. All worlc shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions listed on the reverse
,ide; and the Special Provisions for this pennit. 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 PUBLIC WORKS DEPARTMENT AT
LEAST TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
Name of Applicant San Jose Water Company Telephone 279-7979
(print lIlIAIe)
Address1221 S. Bascom Av-e, ~an Jose 95128 24 HOUR EMERGENCY TELEPHONE NO.
Is this worlc being done by the property owner at their own residence?
Yes
No
The ApplicantlPermittee hereby agrees by affixing their signature to this permit to hold the City of Campbell. its officers, agents and employees free. safe and harmless from
any claim or demand for damages resulting from the work covered by this permit.
The ApplicantlPenninee hereby acknowledges that they have read and understand both the front and back of this permit. and they will inform their contractar(s) of the
information.
Accepted
Jane Leinberqer (EMERGENCY VERBAL)
(ApplicantlPerminee) (sign)
2/25/97
Date
SPECIAL PROVISIONS
Street shall not be open cut for underground installations. Minimum cuts.J!!!Y be alJowed for connections or exploration holes. .Sucb cIIts mav be sllCcificallv
approved bv the Insllectorprior to cuttinl1:.
Pavement may be cut for underground installations and must be restored in accordance with the Utility Trench Restoration standard Details. Method' A' Backfin,
unless otherwise approved by Inspector.
Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public WorksDepanment before starting work.
Per Section 4215 of the Government Code this permit is not valid for excavations until Underground. Service Alen. (USA)basbecnnotified and the inquiry
identification number has been entered hereon. USA Phone 1-800-227-2600. USA TICKET NO.
1AwC-1dl' .1l..fAc~lE. A..J/j b;,4/At'Y. co'llr ~J<T"t' .,... .,J~~;T l"c.o~'
.
_1.
_2.
_3.
4.
A.
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCElLABOR& MATERIALS
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & ,"SPEenON FEE I?~./ /1 /
APPROVEDFORISSUANCE ~_~
for City Engineer
~
u./I'-- '
AMOUNT
S1.i$'....
s -"
$
S
s /.:J. ~
RECEIPT NO.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
Q
Q
;l-~6197
, Date