92-152
ern OP ClJIPDLL
DEP'l'. OF PUBLIC waDS
70 North Fint St.
CUlpbell, CA 910~
(408) 866-2150 -
EMERGENCY PERMIT
KIICROAcmmtrr PERIIl'l'
(for workinCJ within the
public dCJbt-of-vay)
Penait Na.
X-Ref. fUe
92-152
I..ued Application Date 4 /2 3 /9 2
Permit expiru in 12 _. . Application expire. in 6 ma..
APPLICA'l'ION - Application ia hereby _de tar a Public WarJal Permit in accordance with Capbell
JlUnicipal COde, Section 11.04. (Application expirea in 6 mant:ha if permit not pulled)
A. Work addre.. or tract f 1583 Keith
tJtilUy trench location 4~ X 4~ foot sidewalk
B. Nature ot work:
C. Attach five (I) copie. ot a drawinCJ lIbowinCJ the location, extent and diJaeneiona at the work
The drawinCJ ahall sbow the relation of the propo.ed work to exi.tinCJ surface and underqraund
iIIprov..enta. When approved by the City EnCJineer, .aid drawinCJ beCOJle8 a part of this permit.
D. '1'I1e General COndition. tor all permit. are li.ted on the reveree .ide. Special Provi.iona tor
this permit are li.ted below. Failure to abide by th..e condition. and provisions uy ruult
in jOb .hut-down and/or torfeiture of Faithful Performance Sureti.. and caah depo.ita. (See
General COndition. 1 and 2).
E. An application t.. lIUSt accollpany this application.
Name ot Applicant Pacif ic Bell
T.hi. tee ia nan-retundable.
Telephone: 491-2050
Addre..
14S ~ Montaomerv SJ
I. this work beinCJ done by the property owner at their own ruidence? -ye. _no
COllplete and attach Workers' campensation and COntractor Information forma.
'1'I1e Applicant/Permittee hereby agree. by affixinCJ their aiqnature to this permit to hold the City of
callpbell, its otficer., aCJents and employees tree, .ate and barmle.. troll any claill or demand tor
damaCJes re.ultinCJ troll the work covered by this permit.
The Applicant/Permittee hereby acJcnowledqe. that they have read and understand both the tront and
back of thi. permit, and that they will inform their contractor(.) of the information.
ACCEPTED
Applicant (Permittee) print/.ign
Date
NOTES: ALL WORK SHAL", CONFORM WITH THE A'l'TACHED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR HOST HAVE THIS PERMIT AND APPROVED PLANS ON-SITE AND HOST MEET WITH THE P.W.
INSPEctOR ON THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK. APPLICANT HOST CONTACT '1'BJ: INSPECTOR
'1'0 ARRANGE FIELD MEETING.
NOTICE HOST BE GIVEN '1'0 PUBLIC WORD AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
SPECIAL PROVTSIONS
_1.
Street ahall not be apen cut tor underqraund in.tallation.. Minimum cut. may be allowed
tor connection. or exploration hole.. Such cut. IlUSt be _Deciticallv aDDraved bv the
In_Dectar Driar ta cuttina.
pav..ent may be cut for underqraund in.tallations and IlU8t be re.tored in accordance with
the Utility Trench Re.toration Standard OrawinCJ.
Work to be staked by a licensed Land Surveyor or Civil EnCJin..r and two (2) capi.. ot the
cut abeets .ent to the Public Work Department betore -.tartinq work.
The hours at work are lillited to outside the hours ot 7-9 a.lI. and 3-6 p.lI. for any work
atfectinCJ a traffic lane.
_2.
_3.
_4.
_5.
STANDARD
AMOUNT
RECEIPT NO.
PERMIT APPLICAnOH FEE $105.00 $
PLM CBECJ: DEI'OSrl' $500.00 $
SURETY FOR FAr1"Bl'tJL PERPORllAHCE (loot or ERG. EST.) $
CASH DEPOSrl' (n or StJRB'.l'r, $500 KIH) $
PLAN CBECJ: , INSPECTIOH FEE ($0-$100,000 lot, $
$100,000 - $500,000 9t, $500,000 and above 7t, $100 KIH)
APPROVED FOR ISSUANCE:
f: PW PERMIT
Revised 10/91
for City Enqineer
(SEE OTHER SIDE)
Date
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