ENC2009-00070Jun-09-2004 08:07 AM Comcc-~t Cable 9254240420
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CITY OF CAMPI3EI.L I?NCTtC)AC:HMENT' PERMIT' Pcrtnit No . ~ V ~ + ~ "~~ ~~ O
ll!?p'I'. ()t~ IaU13LIC:1~'OkkS (for working willun the public X-Ref. Pile
70 Nurlh First Sl. rigfib of way)
C:aml]bell, C:A 95008 6 Applictltion )date
(4D$} 866-2150 Issued (~ `/ ~ ~ Ap(]lication EaTiiratton ate
Fax (408} 376-0958 ~ ~ / [/~~ ~r~„~
Pc°tmil Expiration Dale <O ~L 0 APN ~~r' ~-v
APPLICATION -- Application is 1]crctry mxdc for a Public Wcnks Permit in ac:wrdance with Crunpbell Municipal Code. Section 11.04. {Applicatiar expires iu six {6)
mouths if the pcrnllt 15 ]lot issnc~d.~/Applicatirm >~ce is non-rcfunduhlc.)
A. W nrk address or trur:C Ir t ~"~' ~ ~'~'"'~~ ~C1 ~ ~~
Utility trend] focauon 1 ~ ~TfLr".~I"-~'~
33- Nvfirc of work ~'7[ ~..~ ...'l, ~!Y A 1-~ ~ T (--/~ d ~~i !rt r ~.CJ~~ ~ 1 ~ `V ~~~ ~t~/1'(1-tC,V~
C. Attach four (4) copies of au eugu]eered plan shooing rite location and extent of the. work, and four (4) copies of the preliminary ingineer'.v Estimate of work. '1'~ ~ Z
plans shall show flee relaiiou of Che proposed work to existing surface and underground imprnvemcnts. When approved by thn City Enl.,rineer, said plan bccutnc~a~ ~ p~ ~[ O
part cC this pea'rtliL LLI QO ~ F
cv O Q
D. All work shall conform m the Cary of Campbell Slatrdarrl 5peeificatious and Details for Public Works l~onsmtetion; the General Permit C:nnditions lismd ern ~tL~~~ O
t'eveasc side; and the Special Provisitrevs Cor fitis pea~r]if, listed below, Pailarc to abidr.. by these conditirnts and pmviaions may result in.iob shutdown andlor furhit~G ~ O (~ N
(rf Faithful 1'rsfatmancc Sureties' and cash deposits. (Src (icrtora! Permit C,onditinns t and 2.} Z ,J Z
)r. 'Chc Contractor must have this permit and approved plans at the site and must notify tl~e Public R'orks Deptunnent at least two days bct'orr-starting work. Noit~ ~ 0=.
111t1St Ue g1VC]] ID Pu~b7li~c. ~W~orks at 3casi 24~ boon before rlestartin~e any work,' y ~ Q
Name of Applicant t--•EJ~ 1/ I r~'~=.. 1 t_..~~t~l.~ ~'1.~~.1~ \I '1'clcphpnc C.~ ~~i - 217 - Q~~ 7
--..... .
(print name) /~,~
Al+dress S `CYLI~~ ~-'~-, t~_ - ~.~~ rs~t~Z~~I-oJ K N.~ft:kc>•rNrv'rl,LfIFFIONENO.. ., ~..T.~/~.~..(P.~~J ° !t j h
H-Mail Address---~. t~~ _... ____
Is thi; work hcinri dune by the proper[y owners at their own residence'? _____..-_,-YaS , _ Na
Tlcr ApplicanUPert]]ittce 11e1•cby ag-tees by affixing their si~~uature tU lltis pet'slll[ io hold file City ot. Campbrll, its nff~ccrs, xgenCS and employees free, safe and harmless
from any claim or dc]nand frn- damages rc-aultin; Crum the work covered by this pernzit.
'I'hc ApplicandFermitfee hereby acknowledges that they have read and understand both the front and Uack of [iris permit, and they will inform their contractor(s) of the
iuforara(iou, Applicant is advised that upon issuance of this penult, property owner, or property owner's succes:nrs, 'shall he reaprrnsiblc fcn• any and all daarages
arising out of the contljtion of-any ri tic imprnvnm(c~n s iu Qte public rigl]t~of way. C~
Accepted -- f,e1 ,GY.V~ - .. .._ ~ ~~~ A
(Applicant Pcr]~]~,ttce) (sign) Date
C:oRRACLOr (Print Name) Date
SPF CIAL FROVISIO_NS
_l, Street shall clot be open cut fcrr under;,*rtrund installations, Miuilnatn cu[5 L~k'1i! be allowed for ennnceticsns or cxplaratian holes. Such cuts u~~
- / he spocificully avnruved by the iuspe~cim' prior to cutting.
y 2. Paverncnf utay be cot for uttdcrgmund installations and must be restot'ed iu accordance with the Standard 1]ctails 'IYcnch Kesioration Merhtxl
"A", unless otkterwisc approved by inspector.
Work to he staked try a licensed i.,autl Surveyor or Civjl Engineer and two (2) copies of the col slu'ets seat Co the Public Works Dcpartntcnt
bcfcm starling work.
_.-_4. Per Section 4215 of tk]o C=ovcrnment Coda this permit is not valid for excavatimis nntiJ Llndcrgraund Service Alen (IJSA) has been uuGfied ar,d
the inquiry idendficatien rrurnber 1]as been elltct'cd hereon. LISA Phrme I-&00-'.:'L"/-2600. USA TiCI{ET NO~
_5. Prior ut any work, lltu property Owner shall execute an AgreemcnC fur Private lutpr'oven]eu[S in [I]e Public Right-ot=Way, which shall he
reccurled.
_G. Public Notifacatiott Rcquircmen~s: _; ,... __
SH'N Pi18LIC WORKS FEE SCHEDiILP. FT)K C'tJkkli'NT FG1rS
PBRMIT APPI.IC.a'rIUN FE1:
PLAN C=HECK UI:YbSIi'
SECURITY FOR FAPI'I~IPUL PERFORMANC:ElLAliOk & MA`I'CiRIALS
CONSTRUCTION CASH T]AYt}tiI'I'
P1..AN CHECK dl 1NSPl;C°i'ION IEE
APPROVED FOR
AMOUNT RECEIPT N0.
$ 3l5 6~
~~3~
Pot City Et>niueer
PCt7111t 1?xpiros I2 Months After 1]atc uC Iasuancc
I]ate
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Jun-04-200Q 12:56 PM Cc~mcc Cable 925424b420
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Jur-09-2009 08:06 AM Comcr--t Cable 9254240420
Jun-04-2009 12:55 PM Camcasc: Cable 9254240420
C;omr.~et
3055 Triad Dr
Livarrnoi~, Ca 34581
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JUN 0 9 2009
PUBLIC WORKS
~4MINIgTRATION