96-101
Permit No.
X-R.cf. file
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Utility treDeh Iocatioa
B. Natuft of wort W~TE:9
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,
/h~toy{ ~UL;ldz.
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A. Wort eddrca or tnct #
Tr2.ACT 57(0\
I'
C. Attadl four (4) CIOfIieI of III aaiDceJed clrniaa IbowiD& tbe Ioc:adoa, alcDt IIId cNalclFil* of tbe work. ne cIIniDa IbaIlIIDr die reIatioa of tbe
popoICd wort to cziltiJlllUlfaa: ad UDdcIp'OUDd ~tL Wbea -wa~ by tbe CtJ BqiDccr. aid ~ "- a put of tbiI permiL
D. AD wort IbID CODform to tile Oty'1 GeaenI CCDditioal, Studard ea.trucdoII PIOViIioaIIIId Studard ea.trucdoII DaaillIar Public Worb
CoaItnIctioD; tile GeDeraI Permit CCDditioallilted CID tile rcvet'Ie Iidc; IDd tile SpeciM ..--.. rex ... permit, lilted below. PailIIR to IIbidc by
dlae CIOIIditioallDd prcMaioaI may rauIt ill job lbut4JwD lIId/or forfeiture of PmtbfuI PafonDlDCle Sureties IIId c:MIl depoIitL (See GeaenI
Permit Coaditioall ad 2.)
E. A DOIU'efuDdable appIicatioa fee anlA ~ ... ..,picatioa.
Name of Applicant ~ ,,\oSE.. W~'Tf-O CD.
Addras l~ 5, eASCoM A.'JE.. ~ J::s€.. .
I (
II tbiI wort beiDa doae by tile property oner at tbeir 0Ml raidcDce?
TcIepboDe 'L1Q ~ ie4L
~c;,?~
Yea VNo
CoN<ST. c..csr. 1$ SZ-/7'rJ
.
Complete ud attach Workers' CompelllatiOD aDd Coatnctor lDformatiOD forms.
Tbc AppIic:ant/perminee bereby apea by affixiJII their lipature to tbiI permit to bold tbe CtJ of r..,,-..u. ia ofticcJs, ....tllDd empkl}"lC5 flee, aafe
IDd barmless from aDY claim or demaDd for damap reaultiq from tbe wort COYeJed by tbiI permiL
Tbc AppIicant/permittee bereby ackIlowledges that they ~ read IDd UDderstaDd both tile froGt aDd bact of tbiI permit, aDd they wiD iJlform tbeir
lXlGtnctor(s) of tbe iJlformatioo. .-/'
Aa:epted E'DWlt.! L. tJ\8.LO) ~.E.. ~ u< ~ J~ 4 I \qq0
(ApplicaDt (pemuttee) / print/lip Date I
NOTES: AU.. WORK. SHAll.. CONFORM wrrn llIE ATIAaIP.D, APPROVFJ> PLANS AND AU.. APPUCABLE CAMPBELL STANDARD
DRAWINGS AND CONDmONS.
llIE CONrRAcroR MUST HAVE nns PERMIT AND APPROVFJ> PLANS AT llIE SITE AND MUST N01lFY llIE PUBUC WORKS
DEPARTMENT AT LFASr twO DAYS BEPORE STAR'llNG WORK.
NOTICE MUST BE GIVEN TO PUBUC WORKS AT LFASr 24 HOURS BEPORE REsrAR'llNG ANY WORK.
SPECIAL PROVISIONS
_2.
i:
Street IbID DOt be opeD cut for UDderJroWId iDIta1IatioaL NiDiJDum cutl may be aIloRcl for CIOIUIeCtioDI or CIpIoratiOIl boIeI. Such cutl must
be soecificallv a1)Dr'O'\I'Cd bv the 1Dsoector mor to cuttiD2.
hvemeDt may be cut for UDdcqrowId iDIta1IatioalaDd must be ratored ill aa:ordIIIc:c with tile Utility TreDdI ReItoratioa StuIdard ~
Work to be staked by a IiceJIIed Laad Surveyor or aw EqiDeer IDd two (2) CIOfIieI of tile cut Ibeets leat to tile Public Worb Departmeat
before &tartin& work.
Lt- "" . c.J ~ ~ C Ie.. A/ t
S;Q !.N
STANDARD
AMOUNT
$.2,,) 5'. c) 0
$ -
S
S -
S;!/Id'. ~ C)
RErF.I1"T NO.
($(
_1.
PERMIT APPUCATION FEE
PLAN OIECK DEPOSIT
SURElY FOR FAITHFUL PERFORMANCE
CASH DEPOSIT
PLAN OIECK & INSPECIlON
Next S30,OOO-$80,OOO 10%;
(J.
/-')'C;-9
Date
* *
b:PW PERMIT/Rev.4j94
USA phone (800) 642-2444
(lee other side)
TICKET NO.
CITY OF CAMPBELL
FIELD ENGINEER'S DAILY REPORT
PROJECT NO.
~ /J -
o /
REPORT NO:
;
1'''1(j ( cy!' 5e/.'" n1l1.i"tF,I;GD
DATE:3 i z- '17
WEATHER:
C C h fi/2
CONTRACTOR:
INSPECTOR:
(/)/(- ----=:> .
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DESCRIPTION
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PAGE: I OF I