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an Of (".AMl"BELL Fer-"No. 't & .- II Lj
DEtT. or PUBLIC WORKS X file
'70 North P'1t5t St. )
~r::2~ 9S(D AppIicatioll Dele " ;) (1 I q to
AppIicatioll apiza ill 6 IDOl.
. APPUCAll0N - AppIicatioll iI bcrcby made for. Public Worb Permit iIlllCCOl'daDcle wItb r.~-u NuaicipeI Code, SocdoIlll.cM.~~....-.
~ ia 6 moaths If the permit II DOt iIIucd~ I __ 7 I) '. ,4 ~ '~--.r-c"JV e 0
.l! A Wo.t......",UOd# / It". '- a 1);'::> ~ 14N"10~
Utility treGCh Ioca~ I PU8L/r l'
B. Na~ ohork 7 /lJ // ,1l--f2-- tl ~; -' 1:- XI 577 /I) 6' CA-t?j ~/ r.c=-~JNIS"'R'i;~6~
C Attach four (4) copies oC 1UI ~ ~ Ibowiac tbc IocatioB, ClteDt _ clime..... oC the wort. The dnwiD& md Ibow tbc ftlatioa oC tbc
prOJlO"d wort to cxistiDJ 1U1'f.oe aDd UDdcrpouDd Iu.p.~ Wbca ~.o.cld by tbc ClJ EqiDcer, uicS dnwiIIc bc:cames . part 01 thII permit.
D. ALl '110m dIaII coaCorm to the aty's GcDcnl CoDditioGs, SWIdard CoastructioIl PnMsioas _ StlUIdard CoaItnIctioIl Dctaik for Public Worts
~ the GeDCral Permit CoDditioa& ..ecs OIl the revase lick; _ the SpcciaI ~ for thII permit, lilted below. Pailv:rc 10 abide by
these CODditioa& _ pt'OYiIioaImay RIUIt ia job sbut~ _lor forfcitllft oC Paithlul PafOl1lllUlCt Sureties _ c:adl dcpoIitL (See GcDcn1
Permit Cooditioa& 1 and 2.)
_ E. A IIOIU'CfuDdablc appIicatioll f"UIt IlCCIOIIIJ"llJ'thiI ~tioa,. J
. Name of Applicant r /\ ~ /'\. __ \ ' ,< L L_
Mdras '7 l - S' s'- tu t V~ :J--c::t)
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The AppIicantfPermittee hereby agrea by aII'ixiDa their Ilpa~ 10 tbiI permit to bold tbc Oty 01 CIImpbd1, lis ofticers, apts aDd cmpIorce5 free, safe
aDd harmless from any claim or demand for cIamap re5UltiD& from the wort covered by tbi5 permit.
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The ApplicantfPermittee hereby ac::Jthat they ~ read SDd UDdeJ'itlUld both the froot GDd bact of this permit, and they will' arm their
COl1tractOr(S) of the W;zb' '. IH~ ~ I .
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Accepted , L/L... / ~ V"",' C / '/ ! :> d I
,/ (APPlicant (permittee) print/lip Dele
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Is this 'IIOrt being doae by the property oncr at their 0WIl raicIeDcc?
Yes
No
NOTES: AU. WORK SHAlL CONFORM WIllI 'IHB ATrAOIED, APPROVED PLANS AND AU. APPUCABlli CAMPBElL STANDARD
DRAWINGS AND CONDmONs.
t' 'IHB CONI'RAcroR MUST HA VB THIS PER.MlT AND APPROVED PLANS AT 'IHB srre AND MUST N011PY 'IHB PUBUC WORKS
'3 DEPARTMENI' AT LEAS!' lWO DAYS BEFORE srAR.11NG WORK.
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;l NOTICE MUST BE GIVEN TO PUBUC WORKS AT LEASI' 24 HOURS BEPORE RESTAR.11NG ANY WORK.
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SPECIAL PROVISIONS
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PERMIT APPUCATION PEE $110.00
: PLAN OIECK DEPOSIT SSOO.oo
.c: SURETY POR FArrnPUL PERPORMANCB (10091i OF ENG. I!Sl'.)
- CASH DEPOSIT (4* OP SURElY, SSOO NIN)
~ PLAN OIECK &: INSPECIlON PEE (FIRSI' $(}.$30,OOO 14%;
~ :R::::::::'^:"ZJf:l?"'-oUal
1Il for Ci ,Eqineer
~< u
h:PW PERMIT/Rcv.4/94 '
* USA phone (800) 642-2444
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Street dIaII DOt be opeD cut for UDderpouDd iDmlIatioaL NiDimum cuts may be allowed for CIClCIJICCtioGs or upIoratioIl boles. SudI cuts must I
be SDCcifica1lv anol'OYed bv the lnsDeCtor mar to cuttiD2. I
Pavement may be cut for UDderground iDstal1atioas and mUlt be restored ill acoordaDcc with the Utility Tl'CIICb ReGoratioll SClUIdard ~ ~
Work to be staked by a liceued Land SulYC)'Ol' or aw EagiDCer _ two (2) copies oC the cut lbeets IeDt 10 ,the Public Worts DepartmeDt c:
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