97-140
(;fTY OF CAMPBELL
PUBLIC WORKS DEPT.
70 N. First St.
CampbelI, CA 95008
(408)866-2150
FAX (408)376-0958
OWNER OCCUPIED R-l
NO FEE ENCROACHMENT PERMIT
(for working within the
public right-of-way)..--
($5,000 maximum value of wotkr' ~
ISSUED 3J2B}q7~//
'-',.-.,,--.."'..
Permit No. q7- /';f)
X-Ref. File .
Application Date _31:).-~/tJl
I
APPLICATION - Application is hereby made for a Public Works Permit in accordance with CampbelI Municipal Code, Section
11.04. (Application expires in 6 months if the permit is not issued.)
A. Work Address ItectO L,'tl-\\\\:>,", ~\ ""~ (I~de \\A\-C~\l1:')
B. Nature of Work ~~~....:\~\C <U~\'-'1t- -,j';:'~~
C. Attach three (3) copies of a drawing showing the locatioh, extent and dimensions of the work. The drawing shall show
the relation of the proposed work to existing improvements. When approved by the City Engineer, said drawing becomes
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
securities.
NAME OF APPLICANT~\J It) --e9~RS TELEPHONE c.J.o(s- S/ ~~ 1?:;,~r.J
(Print Name)
ADDRESS /1.,'1 V L, \\~\\\Q~~~U
The Applicant hereby confirms that this work is being done by the property owner/applicant at their own residence.
The Applicant 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.
inform their contractor(s) of
'4'---
ACCEPTED
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE
CAMPBELL STANDARD DETAILS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AND MUST ARRANGE TO MEET WITH
THE PUBLIC WORKS INSPECTOR AT THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK.
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
PER SECTION 4215 OF THE GOVERNMENT CODE THIS PERMIT IS NOT VALID FOR EXCAVATIONS UNTIL
UNDERGROUND SERVICE ALERT (USA) HAS BEEN NOTIFIED AND THE INQUIRY IDENTIFICATION NUMBER
(TICKET NO.) HAS BEEN ENTERED HEREON. USA PHONE: 1-800-227-2600. TICKET NO.
SPECIAL PROVISIONS
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SECURITY FOR FAITHFUL PE
5T ANDARD
(100% OF ENG. EST.)
AMOUNT
$N/~
.
RECEIPT NO.
tV.! Jl
~<CJ'7/
Date
APPROVED FOR ISSUANCE
for City Engineer
Permit Expires 6 Months After the Date of Issuance
J: orms\r 1 permit/rev.
( SEE OTHER SIDE)
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