96-123
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~O~fCZ~~~ ::=thePERNIT
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OuDpbdI, CA 9S008y- ~D r::/~V: /:"\, ., / 'It:
(408) 866-2150 \C WORKS 1aIued" -'lI'1 App6catioll Date 01-/ I ~ 1 (c
pU \) \. ,,:nO N Pamit' iD IDOL - I Applicatioll upircs ia 6 IDOL
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APPUCATION - Apil6catioll ill hereby made for. Public Worts Permit ill 8CCOr'CIaDce widl Campbell NuaicipaI Code, Soc:tioG lLCM. (Applic:atioll apUa
ill 6 IIlOIltbs if the permit ill DOC iAued).
Fermit No.
X-Ilef. file
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A. Wort addrca or 1nd #
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Utility tftDCh Iocatioll (" ,
B. NatuIc of wort ~~ /l f ^ J' (/) (j,h f If /r /' 0 /7 -^ ~. ~ J./ ..-1 /
,
C Attacb four (..) copies of an ea&iJ.teercd dra'tria& Ibowlq the Iocatioa, atcat aDd dim rD~~ of the wort. ne dra'tria& IballIboIr the rdatioa of the
pcopored wort to emtiD& lUlfacc aDd UDdeq:roulld improvaDaltL Wbea approved by the Oty &peer, laid 4rniDc bccomc& . put of tIIiI permit.
D. AD wort Iba1J coaform to the Oty'I GcDeral CoDditioGl, SWIdard CoastNctioIl PIOViIioaI aDd ScaDdard CoastNctioIl Details (or Public Worts
CoaItnIctioa; the GeDenI Permit CoaditioIIIIiIted oa the rewne Iide; aDd the Special PIOViIioaI for tbiI pcnDit, Jilted below. PdaIe to abide by
tbeIe coaditioal and provisioas may result iD job lhut-dowD aDd/or forfeitule of PaitbfuJ PafonaaDCC SumieI aDd CMh cIcpoIitL (See GeDera1
Permit Coaditioos 1 and 2.)
E. A IIOIll'CfuDdable appIic:atioa fee must acoompatI)' thiI appIicatioa.
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Address
NameoCApplicant SAN JOSE WATER COMPANY
1221 S. BASCOM AVENUE
Tdepbooe 279-7R10
Is this wort being cSooe by the property owner at their own rcGdcDce'!
Yes
X No
Complete and attach Worlters' Compensatioa and Contractor Informatioa f~
ne AppIic:aat/perminee bereby agrees by atfixiDJ their lipamre to tIIiI permit to bold the Oty of r..."...,u. its ofticers, aptl aDd empklJ"$ free, ale
and harmless from any claim or dellWld for damages resulting from the wort COYercd by this permit.
The AppIicanttpermittee bereby actDowtedgcs that they ~ read aDd UDderstaDd both the froat aDd bact oC this permit, aDd they wiD worm their
COOtractOr(5) of the wormation. ..---- .
Accepted SAN JOSE WATER COMPANY / (~) ",,," / ;{ ~'/L/.',,-(. ..'
(Applicant (perminee) print/5ign 'I I
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NOTES: A1l.. WORK SHAlL CONPORM wrrn TIlE ATIAOIED, APPROVED PlANS AND A1l.. APPUCABLE CAMPBEll. STANDARD
DRAWINGS AND CONDmONS.
TIlE CONrRAcroR MUST HAVE TInS PERMIT AND APPROVED PLANS AT 11m SITE AND MUST NO'llPY 11m PUBUC WORKS
DEPARTMENT AT lEAsT lWO DAYS BEfIORE STARTING WORK.
NOTICE MUST BE GIVEN TO PUBUC WORKS AT LEASf 24 HOURS BEfIORE RESfARTING ANY WORK.
SPEaAL PROVISIONS
_1.
_2.
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Street Iba1I DOt be open cut for UDdergrou.od iIIStal1atioal. Ninimum cull may be ~ for c:oancctioaI or upIoratiOll boIeL Such cull ~
be IDCCificallv aool'OYed by the Instlector llrior to cuttin2.
Pnement may be cut for UDderpouDd iDItalIatioal aDd mUll be restored iD 8CCOr'CIaDce with the Utility Tr=ch Ratoratioa Staodard Drawing.
Wort to be Raked by. 1ioc1lled Lud SutYeyor or QYiI F.oaiDeer aDd two (2) copies of the cut sbeell seDt to the Public Worb Dept.rtmeIIt
before starting ~ ,A ' 1 .
uS€: MerfffJd f1 AA.a-HtL 1'" IU/~16NtfJw f..,tf Au fJrT:!> ~ I/)JAc~ J,J 5'1~P':r
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APPROVED FOR ISSUANCE
SfANDARD
$210.00
SSOO.OO
(100% Of ENG. EST.)
(4% Of SURElY, SSOO NIN)
(FIRST $0-$30,000 14%;
7% min)
AMOUNl'
S;J.S .Vc.>
s
$
$ -
$7'35. l)Cl
RE.l'Fll'T NO.
0-
PERMIT APPUCA110N PEE
PIAN OffiCI( DEPOSIT
SURElY FOR PAITIIFUL PERFORMANCE
CASH DEPOSIT
PIAN CHECK &. INSPECIlON
Next $30,000-$80,000 10%; AmouIIt
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h:PW PERMITfRev.4f94
USA phone (800J 642~2444
(see other side)
TICKET NO.
CITY OF CAMPBELL
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CONTRACTOR: ((yJ ff'tlMd.-
PROJECT NO. q (" ~ J lJ
REPORT NO: I
DATE: If rl9C
WEATHER: t:Q;,.
INSPECTOR: K. ~~51fALL
FIELD ENGINEER'S DAILY REPORT
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ITEM
DESCRIPTION
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