88-146
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CITY OF CAMPBELL R E eEl 'tJJ~ WORKS PERMIT
DEPT. OF PUBLIC WORKS IIor worK1ng 1n tne
70 North First St. A 111t01O.ic right-ol-w.ay) X-Rel. lile
Campbell CA 95008 U fry LJ: \~O(} r
(408) 866-2150 I'fIH Iuued :) -/(,,J--,Y Application Date S-/V~-:p
C WOR~mit e:lpues ~n J.'" 1I0S. expires in 11 .
APPLICATION - APPlicati~~LlQ'eSY~de lor a Public Works Permit in accordance with Campbell~
Municipal Code, Section l!~~LL~1
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PerMit No.
j/ cV -/Y6
A.
Work address or tract .
121 South Third Street
SD#41G66910, SO#6150R'66
B.
Utility trench location
Nature of work: Abandon gas service as indicated on the attached sketch.
C.
Attach five (5) copies of a drawing showing the location, extent and diaensiona of the work
The drawing shall show the relation of the proposed work to Existing surface and underground
improvements. When approved by the City Engineer, said drawing becomes a part of this permit.
The General Conditions for all permits are listed on the reverse side. Special Provisions for
this permit are listed below. Pailure to abide by these conditions and provisions may result
in jOb shut-down and/or forfeiture of Paithful Performance Bonds and cash deposits. (See
General Conditions 1 and 2).
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An application fee must accompany this application. This is non-refundable.
Pacific Gas and Electric Company
973-8930
Name of Applicant
Address 10900 N. Blaney Ave. Cupertino
Telephone:
95014
Is this work being done by the property owner at their own reaidence? ___yes no
Complete attached Workers' Compensation and Contractor lora..
The Applicant/Permittee hereby agrees by affiXing their .ignature to thia perait to hold the City of
Campbell, its officers, agents and employees free, aafe and harMleaa from any claim or demand lor
damages resulting from the work covered by this permit.
The APPl..~~' ant ermitte eby acknowled hat they have read and understand both the front and
back of/t:hia p rmit, d hat twill rm t,eir contractor(s) of the information.
ACCEPTalL . d C 0 oot _ May 2, 1988
uate
NOTES: ALL WORK SHAtL CONFORM WITH
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AND MUST MEET WITH THE P.W. INSPECTOR ON
THE SITE AT LEAST TWO.DAYS BEFORE STARTING WORK.
AND ALL APPLICABLE CAMPBELL
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
SPECIAL PROVISIONS
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Street shall not be open cut for underground installations. Minimum cuts may be allowed
for connections or exploration holes. Such cuts must be specifically approved by the
Inspector.
ravement may be cut for underground installations and must be restored in accordance with
the Utility Trench Restoration Standard DraWing.
Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2)
cut sheets sent to the Public Work Dept. before starting work.
The hours of work are limited ~ outside the hours of 7-9 a.m. and 3-6 p.m.
affecting a traffic lane.
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copies of the
for any work
4.
5.
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
BOND FOR FAITHFUL PERFORMANCE
(R-l)
($35.00)
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STANDARD
$50.00
$500.00
(100\ OP ENG. EST.)
AMOUNT
$ ~. c::c.::~
$
$
$
RECEIPT NO.
Cf
F. P. (CASH) DEPOSIT
PERMIT FEE
($200) (4\ OP BOND,$500 MIN)
(7\ OP P.P. BOND
~ $35.00 MIN)
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APPROVED FOR ISSUANCE
f: PWPERMIT
Revised 7/87
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