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CITY 0' CAMPBELL
~EPT. 0' PUBLIC WORXS
70 ~orth ,irlt st.
Campbell, CA '5008
(408) .66-2150
9/-/0/
Permit 110.
ENCROACHMENT PERMIT
(tor working in th.
public fiqht-ot-way)
I..ued /;/:7~~/
'erait expire. in 1~ .0..
A. Work addre.. or tract .
J;-RI!. tile
Application ~ate / /3/f/
Application expire. in 6 mos.
APPLICATION - Application il hereby .ade tor a Public Workl Permit in accordance with Caapbell
Municipal Code, Section 11.04. (Application expire. in , .onth. it permit not pulled)
Otility trench location
B. lIatuu ot vork: l?f::!-orjJ.ll:::
C. Attach tive (5) copies ot a dravinq .howinq the location, extent and di.en.ion. of the work
The drawing .hall .how the relation ot the propo.ed vork to existinq .urtace and underqround
improve.entl. When approved by the City Enqineer, laid drawinq beco.e. a part ot thi. permit.
D. The Oeneral Condition. tor all permit. are li.ted on the reverse lide. special .roviaion. for
thi. permit are li.ted below. Failure to abide by the.e condition. and provi.ion. ..y re.ult
in job ahut-down and/or torfeiture of Faithful Performance Bonda and ca.h depoaita. (Se.
General Condition. 1 and 2).
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.. An application fee .u.t accompany thi. application. Thi. i. non-refundable.
llaae of Applicant p,q C' IFIC B EI,G ~fh--J /3/ (;;0 '!'elephone:
Addu.. /5)( rAlzJ--1vl66P...... AvE' S.J: ?5/~g.
II thil work beinq done by the property owner at their own re.idence, ---ye. ~no
Co.plete and attach .orkerl' Co.pen.ation and Contractor Information foral.
The Applicant/Peraittee hereby aqree. by affizinq their liqnature to thi. permit to hold the City
of
Campbell, it. officer., aqentl and employee. tree, lafe and harmle.. fro. any claim or demand tor
d..aqe. re.ultinq from thl work ooverld by thi. plrmit.
The Applicant/Permitte. hereby acknowledqe. that they have read and under.tand both the front and
back of thi. plrmit, and that they vill info!- their contractor(.) of the information.
ACCEPTED j- ".2 ~ 7/
pr1nt/.1
Date
NOTUI ALL WORX SKALL C0H70RM WITB '1'KI ATTACIlBD, AI'PROVE~ ,LANS AH'D ALL AI'PLICABLE CAHPBELL
STANDARD DRAWINGS AND CO~ITIONS.
THE COHTRAC'1'OR MUIT DVE '.t'BII PERKI'1' AH'DAPI'ROVllD ,LAlfS UD KOST Un.I'1'K 'fU'P....:IIIIPICTOR ON
THE aITI AT LEAIT '!'WO DAYS BEFORE STARTINO WORK.
lIO'1'ICI WST I. GIVZII TO 'UILIC .01.0 AT LZAI'1' U BOOll8..BlPOU U8'1'UTIIIO AllY .ORK. i
SPECIAL 'ROVISIONS
_1.
atreet .hall Dot be open out for underqround in.tallation.. Mini.ua cut. .ar b. allovld
for oonnectionl or exploration hole.. 'uch cutl .u.t be IPecifically approved by the
In.pector.
'avament .ay be out for underqround inltallation. and .u.t be re.tored in aocordanoe vith
the utility Trench ReltoratioD Standard Drawinq.
.ork to be .taked by a licen.ed Land Surveyor or Civil Inqineer and two (2) copiee of the
cut .heeta .ent to the Publio Work Deptaitaent bltore .tartinq vork.
The hour. of vork are limited to out.ide the hour. of 7-' .... and I-I p~.. for any work
affeotinq a traffio lane.
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'IRKI'!' A'PLICA'1'IOII FEI ('35.00)
'LAlf CHlCI DlPOSIT
ITAHDARD
bOUN'l'
, {eac,.oo,..
.
,
,
,
DCnPT NO.
<t>
'50.00
$500.00
(100' OF I.G. BST.)
(4' OF BOlIO, '.00 XIII)
OF F.'. BOlIO, '35 .I~)
~
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Date
BOlIO FOR FAI'l'JD'UL 'ERPOIUC.Ul~
--
CABB DlPOSIT ('200.00)
p~ CHBCI , %.S.ICTIO.
\ ~ . ClC-,
a'PROVllD POR ISSOAHCE
f I PWP!RKI'1'
.eviaed ./88