97-147
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) .
4 15 q7
Permit No.
'X-Ref. file
97,-147
Issued
Permit expires in 12 months
Application Date 4/14/9 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 or tract #
1300 Dell Avenue (x-street Hacienda)
Utility trench lOcation
B. Nature of work
EMERGENCY Main Repair - 3'x3'x4' cut ln street
C. AWlCh 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 work. 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 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 I 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.
Pacific Gas & Electric T I h 725-2176
Name of Applicant e ep one
Address 10900 N. Blaney, ~-&fffic:rtino 95014
24 HOUR EMERGENCY TELEPHONE NO.
Is this work 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, safc and harmless from
any claim or demand for damages resulting from the work covered by this permit.
The Applicant/Permiuce hereby acknowledges that they have read and understand both the front and back of this permit. and they will inform their contractor(s) of the
information.
Accepted
Gwynn Holst (EMERGENCY VERBAL)
(Applicant/Permittee) (sign)
4/14/97
Date
_3.
_4.
SPECIAL PROVISIONS
_1. Street shall not be open cut for underground installations. Minimum cutsm:u;be allowed for connections orcxploration hoIcs.Suchctitsmav be soccificallv
approved bv the Inspector prior to cutting.
Pavement may be cut for underground installations arid must be restored in accordance with the Utility Trench Restoration Standani Details, Method 'A'Backfill,
unless otherwise approved by Inspector.
Work to be staked by a licensed Land Surveyor or Civil Engineer and cwo (2) copies of the cut sheets scnt to the Public WorksDcpartilllmt before starting work.
Per Section 4215 of the Govcrnment Codethispcrmit is not valid for excavations until Underground Service Alert (USA) has bccnnotified and lhc inquiry
identification number has been entered hereon. USA Phone 1-800-227-Z600. USA TICKET NO.
_2.
_5.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
. :n:ffi
t.crIL.
AMOUNT
Sj).s'-
S ~
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s
0J7t;'~
RECEIPT NO.
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR&: MATERIALS
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & INSPECTION F"D~~
APPROVEDFORISSUANCE U-- _
fo ity Engineer
6Z
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Q
CITY OF CAMPBELL
FIELD ENGINEER'S DAILY REPORT
/3dO ()d,/.
PROJECT NO. 17~) 1;
REPORT NO: I
DATE: q //4--/'1
WEATHER: F'AI R.
INSPECTOR: K. ~G:-51fALL
CONTRACTOR: (J b ~ 6
ITEM
DESCRIPTION
CC:
PAGE: /
OF I