ENC2004-00097
CITY OF CAMPBELL
DEFT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
ENCROACHMENT PERMIT
(for working within the public ,I' 'i-1J;;:::...:'
right-Of-:~y) " ,'~J"-
Issued ..::>/} '0 104 v
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Pennit Expiration Date ~S
!ermit No (,\.le., 2.004- - OCiCfj '1
X-Ref. File
Application Date sl s ) Dtt i
Application Expiration'Date i 5 /lJV
APN 4-14 - Lf-'D - 030
APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in
12 months if the permit is not issued. Application Fee is non-refundable.)
A. Work address or tract #
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B. Nature of work
Utility trench location
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C. Attach four (4) copies of an engineered plan showing the location and extent of the work, and four (4) copies of the preliminary Engineer's Estimate of
work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer,
said plan becomes a pan of this permit.
D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions listed on
the reverse side; and the Special Provisions for this permit, listed below, Failure to abide by these conditions and provisions may result in job shutdown
and/or forfeiture of Faithful Performance Sureties and cash deposits, (See General Pennit Conditions 1 and 2.)
E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before starting work,
Notice must be given to Public Works at least 24 hours before restarting any work.
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Name of Applicant \...... c:::. \ '\- ~ C J
Address t Cl q 00 ([, blQV'-( 'j
E-Mail Address J Ow 5" Q {) c; \:... ..
t- E. \ e. c\ c', '-- Telephone '-\0 ~ .1::>--') - ~ d..- \""'7
(print name)
A v <- ~f' 24-HOUR EMERGENCY TELEPHONE NO.
COM..
Is this work being done by the property owners at their own residence?
Yes
"'(--
No
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers, agents and employees free, safe and
harmless from any claim or demand for damages resulting from the work covered by this permit.
The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their
contractor(s) of the information. Applicant is advised that upon issuance of this permit, propeny owner, or propeny owner's successors, shall be responsible
for any and all damages arising out of the condition of 'vate improvements in the public right-of-way,
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Accepted ~ ~ -( 'I f \ \.}...J (. ~ ../
(Applicant Permittee) (sign)
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Date
Contractor
(Print Name)
Date
SPECIAL PROVISIONS
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Street shall not be open cut for underground installations, Minimum cuts !lli!.Y be allowed for connections or exploration holes. Such cuts!lli!.Y
be specifically approved bv the Insnector prior to curting.
Pavement may be cut for underground installations and must be restored in accordance with the Utility Restoration Standard Details Method
"A" Backfill, unless otherwise approved by Inspector.
Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public Works Department
before starting work.
Per Section 4215 of the Government Code this permit is not valid for excavations until Underground Service Alert (USA) has been, notified and
the inquiry identification number has been entered hereon. USA Phone 1-800-227-2600. USA TICKET NO.
Prior to any work, the propeny owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be
recorded.
_1.
"/2,
_4.
_5,
_6,
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
APPROVED FOR ISSUANCE
~
'. 'Par" , Engineer
Pennit Expires 12 Months After Date of Issuance
AMOUNT
$ 275
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$
$ 'Be)
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, Date
RECEIPT NO.
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & INSPEcrl0N FEE
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Revised 1.20.04
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