97-132
CITY 01; CAMPBELL
DEPT. OF PUBLIC WORK$
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
ENCROACIIMENT PERMIT
. working within the
,blic right1-way)
Issued 3{14 {q 7
Permit expires in 12 mos.
Permit No.
X -Rr - r;ile
j.~.L.
{17.//32-
Application Date 3, I 0 "' i q '11
Application expires in 6 mos.
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). R
A. Wo,kadd,= 0' '"'" U I Z <;1 CAt:: I DR. "TO 13"3 c,A Pltl Oil.. E C 15 I "15 "',
Utility trench location CPt r ~ , ----8, I V ~ u
( -11
B. Nature of work j,NAf E;f?- MAl tJ I tJ S fA f...L... A ,10 t-J r; 7 .- 011 ) _ ._ 199}'
fJUL I.. 1(:. '
c. Attach four (4) copies of engineered plans showing the location and extent of the work, and four (4) copies of the ~M~~ltreer's
Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. Wh~~r~~ed 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 HA YE 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/Permittee
7AtJ fo~E:
L-JAfE-~
Go M fA fJ Y
Telephone (4oe) z7ct -1 ~4/P
Address 12.2.1 , S. BASU7lV1 Ave..,. SAiJ rcs~ I c..,.. 4~12-6
Is this work being do'ne by the property owner at their o~n residence? Yes)(..... No
,
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers, agenls and employees free,
safe and hannless from any claim or demand for damages resulting from the work covered by this permit.
The Applicanr/Permittee hereby acknowledges, at they have read anunderSland both the front and back of this permit, and they will inform their
contractor(s) of the information: ._
M, I(~ CA V~ I . E-, l{ 3/10-1/ PL- '
(Applicant/Permittee) Date
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P-us
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DAILY REPORT
PROJECT
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REPORT NO.
CONT, NO.
DATE Lf_ 30-97
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CANARV. SUPERVISOR
P'NK.OESIGN
GOL.OENROO'L.ABORCOM~
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