96-117
arYOPc.J\! C E IVE ~
DEPT. OP PUBUC WORKS 1
10 North P"ust St. FEB 1996
Campbell. CA 9S(Ql
(a) 866-2150 PUBLIC WORKS
ADMINISTRATION
ENCR.OAOINENT PERMIT
(for wortiDc withiD the
public ri&bt-of-way)
~~-m~~~
Permit No.
X-Ilcf. 6Ie
qltr 1/1
AppIicatioa Date /? -t.. 9 ~
AppIicatioa expirc& m 6 IDOL
APPUCA110N _ AppIicatioa iI hereby made for. Public Worb Permit m accordaDct with CampbcII NwUdpal Code, Sectioa 11AM. (Applicatioa apira
ill 6 moatbs if the permit iI DO( iIIucd).
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A. wort addrc& or traCt #
. 'c.- -=:>> ~ ~e:..~ '( 1"fP' \..oE:.
Utility trcoeb Iocatioa
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B. Nature of work l2.Jiaa - ---r'"'IE. ~ e:Te::e... """'- K..~ '"Tb F":. -, , ''--J:::::t ~... ~L-IL..
C. Attach four (4) copies of all cqiDeercd c1rniD& IbowiD& the Ioc:atioG, alcDt and ctiIIJ.. ~ of the wort. nc dnwiD& IbaIl .. the Jdatioa of die
JlI'OPO'Cd work to emtiDc surfaoe and UDdcrpouad imptovt:meDlL Wbea ~ by die Oty F..apcer. aid cJnwiIII bccaIDc5 . put of this permit.
D. AD wort shill conform to the Oty'1 GcDcraI CoGdidoal, StaDdud CoamuctioII ProviIioaI and S&aDdard CoD5tnIctioG DctaiI5 for Public Worb
Coaarudioa; the GeDeral Permit CoIIdi~ lilted OIl the ~ lick; aDd the Spec:ial ProYiIioaI for tb.iI permit, lilted below. Failure to abide by
~ CODdi~ and provisioas may result ill job lhut-4owD aDd/or forfeiture of Paithful PerformaDClC Sureties aDd c:-aIh cSepoGlL (See Geocral
Permit Coo4i~ 1 and 2.)
E. A DODrefwldable applicatioo fee muA aocompaDy tbiI appIDtioo.
Addl'C$5
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Name 0( Applicant
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II this work being dooe by the property 0WDer at their own raideDce1 Y C$
Complete and attach Worke~' Compensatioa and Cootractor Informatioa f~
The Applicant/permittee hereby agrees by affixiq their lipature to this permit to bold die Oty of C-~ iu ofticers, qcuts aDd ~ free, afe
and ha.rmlC5li from any claim or demand for damap JUUlting from the work COYered by this permit.
NOTES: ALL WORK SHAlL CONfORM wrrn TIlE AlTAOIED. APPROVED PlANS AND ALL APPUCABLB CAMPBElL STANDARD
DRAWINGS AND CONDmONS.
and UDderstaDd both the front and bact 0( this permit, aDd they will worm their
The AppIicant/permittee hereby actnowledges that they
cootractor(s) or the wormatioo.
Aa:epted~~ F"-...-..ej~'--'/'
(Applicant (permittee) print/ .
z-y~
Date
TIlE CONTRAcroR MUS!' HAVE TInS PERMIT AND APPROVFD PlANS AT TIlE SITE AND MUST N01lFY TIlE PUBUC WORKS
DEPARTMENT AT LEAST lWO DAYS BEFORE STARTING WORK.
NOTICE MUS!' BE GIVEN TO'PUBUC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
SPEOAL PROVISIONS
_1. Street IhalI DOt be opeD cut for UDdergrouad in5taUatioDL NiDimum cuts may be allowed for CXlIUleCtioas or upIoratioa boIC5. Sucb cuts mU5t
be SDeCificallv aoof'()Y'ed by the 1Dsoector Drior to cuttiD2.
_2. P~meDt may be cut for UDdergrouad iIIstalla~ and mUlt be restored ill acamSaDce with the Utility TreDCh Restontioa StaDdan1 Drawing.
_3. Wort to be staked by . licensed Land SurYeyor or QyjJ EqiDeer aDd two (2) copies of the cut IheetsleDt to the Public Worb DepartmeDt
before starting WOrL
_4.
STANDARD
AMOUNT
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S /2.1:>.(1 4
RECEJl'T NO.
(l.
APPROVED fOR ISSUANCE
PERMIT APPUCATION FEE
PlAN CHECK DEPOSIT
SURElY fOR PArrnPUL PERfORMANCE
CASH DEPOSIT
PlAN CHECK & INSPECI10N PEE
Next $30,000-$80,000 10%; Amount
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J-j./ 9 b
Date
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h:PW PERMIT/Rev.4/94
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