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CITY OF CAMPBELL
DEPl'. OF PUBLIC WORltS
70 North First st.
e&.pball, CA 95008
(408) 866-2150
9/-/0{;,
ENCROACHMENT PERMIT
(for workinq in the
publ1c ri.qbt-af_ay)
Iaaued ~~
Permit in 12 110..
Pel'llit NO.
X-Ref. tile
ApplicaUon Dat. / ~ /
Application axptr in 6 110..
APPLICATXON - Application 18 hareby _de far a Public Worke Parmit in accordance with caap.bell
Municipal COde, Section 11.04. (APplication expire. in 6 IIOntb8 if paE'llit not pulled)
A. Work addr... or tract: . 6. r. A. R. ~ C.:97?!",acl.(. A~E. - A(~ L.4~
utility trench location
II. Batura of work: L4/11fif L.LQSU~
C. Attach fiva (5) copia. of a drawinq abowinq tha location, extant and diaeneione of the work
Th. drawinq ahall abow the relation of the proposed work to exiating aurface and underqround
iJlprvvaaanta. Whan apprav8Cl by the City Enqinaar, .aid drawinq bacoJIu a part ot th18 permit.
D. 'l'he Genaral COnditions far all perJllits are liated an the revarse aide. Special Proviaione for
th1a panait are 11.tad belovo ..ailure to abide by the.e conditione and prvvidona uy re.ult
in job abut-down and/or forfaitura of Faithful Performanca Bonda and caab depoaits. (S..
Genaral CDndiUons 1 and 2).
z. Aft application faa IlUat accoapany th18 application. 'l'h18 18 non-refundabl..
H... ot Applicant#~r,..pr ~e& ~.,.-~,,/ 'l'alapbona: A;7" 71..? ;?
Addre.. ~ I/r J" ~H~ ~e. 7r'/~ Ji~ ,]7:>./e ~ f'"/7 .?!..J-
I. thi. work baing don. by the property owner at their own reaidanc:a? --Y" _no
COlIpleta and attach Workers' COIIpanaation and COntraetor Intormation to~.
The Applicant/P8l'IIitt.a bereby aqra.. by attixinq their .iqnatura to thi.'penait to bold the City
ot
campbell. ita officers, aqants and employea. frea, aafe and barmla.a f~ any claia or demand for
daJlaq.. re.ultinq trom the work covared by this penlit.
ACCZP1'ZD
v. read and understand bath the tront and
n actor(.) of the informat~~
~ ./, 7t /
Date
NO'l'ZS: ALL WORlt SIIALL CONFORM 1fr1'H 'l'BE A'l"l'AamD, APPROVED PLANS AHD ALL APPLICABLE CAHPBZLI.
STANDARD DRAWINGS AHD COHDI'nOHS.
'l'BE CON'l'RAC'1'OR MUST HAW TRIS PZRHI'l' AND APPROVED PLANS AHD MUST HZE'1' 1fr1'H TBZ P.W. INSPEC'1'OR ON
'l'BE SITE AT LEAST '1'IfO DAYS BD'ORE STARTING WOIUt.
BOTICE MUST BE GXVZN 'to PUBLIC WORD AT LEAST 24 HOtJRS BEFORE RES'l'AR'l'ING ANY WORlt.
SPECIAL PROVISIONS
_1.
Street .ball not be open cut tor underqround in.tallations. Hinilna cute _y ba allowed
for connactions or exploration bol... Such cuts JIIU.t be .Decifical1v atmraved bv the
In.Deetor.
pav_ant ..y be cat for underqround installations and auat ba raatorad in accordance with
tha Utility 'l'rancb Raatoration Standard Drawinq.
Work to ba .takad by a licen.ed Land surveyor or Civil ZR9inaer and two (2) copi.. ot the
cut abeata .ant to the Public Work Daptartmant batore .tartinq work.
The boun of work are liaited to outaide the hours of 7-9 a... IUId 3-6 p... tar any work
atfactinq a traftic lane.
SEe: ATrACt/E:7\ ~rFi''- C~./~DL '/:U".4N
_2.
_3.
_4.
~!5.
(R-ll
STANDARD
AHOUN'l'
$ 1-.10 re.E
~
REeEYPT wo.
PERKIT APPLICA'l'IOH nz ($50.00)
PIAN alZa DEPOSI'1'
BOND FOR FAITBFtJL PERFORMANCE
CASH DEPOSIT ($2 00. 00)
PIAN alZa , IHSPECTIOB nz
$100,000 - $500,000 9t, $50
APPROVED FOR ISSUANCE
$100.00
$500.00
(loot OF ENG. EST.)
(4t OF BOND, $500 MIH)
($0 - $100,000 lOt,
MIH)
f~?6:
$ N.o rE:E:
6-,r>,J
(SEE ontER SIIE)
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