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crrY OF CAMP&::LL
m:P'l' . (jF POBLXC WORltS
~O North Firat st.
ca.pbell, CA 95008
(408) 866-2150
haUt No.
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ENCROACHKl':N'I' PJI:RIIrM'
(for worJt1Dq withiD t:ha
public rir;bt-ot-vay) -Rat. tUe .
Iasued / - / 7 - 91, L' ~l1cat1on Date J.- I 1.0- '1 Jo
. Permit expirea ill 12 -IJ7// Application apirU ill 6 _.
APPLICATION - Appl1cation ia hereby _de for a Public W~' t 1D accordance w1t:h Caapbell
Municipal COde, Se~ion 11.04. (Application expu.. in 6 -=tha U the pera!t 18 not 1a.ued)
A. Workadclreuortract, IN Fr20lfT OF /115 W. Pflt212. AilE:
Utility trench location SeE' iJ TI fl C 116: /) . D (? IJ W ( AI!2 S
B. Nature ot work: 1)[~LfJC'L EXtsT7JJC-- SuiJ MY:;:' SilL Ph.D -1- {lLSe/
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c. Attach .even (7) cop!.. of an engineered drawing movinq t:ha locaUon, extent and cU.IIenllions of
the work. The drawinq mall mov the nlation ot the propoaacl WOrk to ax1at1nq aurtace and
underqround 1mprovaents. When approved by the City Enqinaer, Aid drawiDq ............. a part ot
this permit. .
D. All work ahall conform. to the City'. General Conditiana, 8taDdard CCnatruction Prov18iona and
Standard Con.tru~ion Detail. for Public Works Constructionl the CanU'lll Parait ConcU.t1ona
listed on the revers. dde, and the Special Proviaiana, far this panU.t, liatacl belov. Failure
to abide by the.e conditions and provisions uy rault 1D job mut-dovn and/or fOrfeiture of
Faithtul Performance Sureties and cam deposita. (8_ General Pu:a1t Candit10na 1 and 2).
E. A nonrefundable apPli~t1on fe. IIWIt aCCmlpany this,~lica~on.WE15J3,
HllJIIe of Applicant P 1ft I r / L g E ~ A IT N. - 1// tic '! hJ.ephcmaz 1af - 49'3 - 7 I 33
Address ?, 175 g N!:'it ST t'f1 ' 2tY) Sf! AI Jc~ I (' /'I LI ~ ;J f.! ~,11 V, _\
Is this work being' done by the property owner at their own J:aIIidanca? ~\; '<i~O' ,d~l.
COmplete and attach Workers' CoIIpanaation and ContractClr Inforaation forJla. Jp't-.; 1.6 >j9Sf
Th. Applicant/Permittee hereby aqraa. by au1x1ng their 8iqnatura to th1a P8Dl1t to hold the City of
Campbell, its otficers, aqenta and employ.es tne, ute and harmJ.... frail any clata oJ:t,daaand.tor
dlUllages re.ultinq frtl1ll th. work covered by this parm.1t. ,,5 i i> '_, ~)
The Applicant/Pe tte. h.reby a~OWledq s t th.y have read and UDdaratand both the front and
back of this , t thy v 1 f their contractor(.) of the intonlation.
ACCEPTED
Date
HOTES: ALL WORK SHALL CONl'OlU! WITH THE A'rl'ACHED, APPROVED PUHS AHD ALL APPLICABLE CAIIPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MOST RAVE THIS PERMIT AND APPROVED PLANS AT THE Sm: AND MOST MEET WI'1'B THE P.W.
INSPEC'l'OR AT THE SITE AT L!:AST TWO DAYS BEFORE STARTING WORK. APPLICANT MOST CONTACT TIlE DlSPECTOR
TO ARRANGE A FttLD KEE'l'ING.
NOTICE MOST BE GIVEN TO POBLIC WORKS AT LEAST 24 Botms BEFORE RESTAR'.I:DIG ANY WORlC.
SPECIAL PROViSIONS
_1.
Stre.t mall not be open cut for underqround installations. Ilinimm cuta uy be allowed
for connections or exploration holes. Such cuts JllUst be lmAl!ificallv IlMlrov@d bv the
Insnector nrior to cu~tina.
PaY_ant -y be cut for und.arqround installatiana and ~ be raatoracl in accordance with
the Utility Trench Restoration standard Dravinq.
Work to be staked by a licensed Land Surveyor ar Civil Enqineer and two (2) copies ot the
cut sheets sent to the Public Work Deparblant betore 8tartinq WOrk.
The hours of work are limited to outside the hours of 7-9 a.a. aDd 3-6 p.a. for any work
attectinq a traffic lane. _,
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S'l'ANDARn
AHm1N'r
R!:crrPT NO.
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PERKr1' APPLICATION l"EE
PLAN CHECX DEPOSIT
stJRE'1'Y FOR l'AI'l'BFOL PERl'ORKAHCE
CASH DEPOSIT
PLAN CHECX " mSPECTION
Hext $30,000-$80,000 1 "
APPROVED FOR ISSUANCE
$210.00 $ ,)..2<<5, 0 c
$500.00 ,~
(loot 01' ERC. EST.) $ -'
(4' 01' SDRITr, $500 KXK) ,
(First $0-$30,000 14', $ j.lC. () ~
than $80,000 7', $200 aiD.)
---'
t: PW PERMIT
Revised. 6/92
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