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CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North F1~t st.
ca.pbell, CA '5008
(408) 8fi6-21!50
ENCROACHMENT PERMIT
(for workinq in the
public riqbt-at-way)
Iaaued ~~
PeJ:1l1 t n. 12 110..
Permit No. ql-ll n
X-Ret. f11e
ApplicaUon Date 1/29/91
Applicatlon uplru 10 6 110..
APPLICATION - Application ia bereby ..de for a Public Works Pendt in accordance with CUlpbell
Municipal COde, Section 11.04. (ApplicaUon axpiraa in 6 IIOn1:ba if pel1lit not pulled)
A. Work addraa. or 1:ract I
SiB 2451 % Campbell on Bascom @ Fewtrell
Util11:y 1:nnch location
B. lIa1:un of work: F.mergencv DOt hole for fai led teleDhone line
c. At1:&ch five (!5) copiea of a drawinCJ .bowinCJ the location, extant and dimendona of the work
The drawinq aball allow the ralation of the proposed work to exiatinq aurface and underCJrOW1eS
illprov..-nte. Whan approved by the Clty Enqineer, aaid draw10q beco.u a part of thl. pemit.
D. The General COnditiona for all permits are listed on the ravene .ide. Special Provisiona for
this permit are liated below. Failure to abide by the.e conditions and provision. aay reault
10 job aIlut-down and/or forfeiture of Faithful Performance Bonda and ca.b deposits. (S..
General COnditiona 1 and 2).
E.
An application fee maat aCCOllpafty thia application.
Pacific Bell
Telephone:
Thia i. non-refundable.
II... of Applicant
Addraa. 1531 Parkmoor Ave.
San Jose 95128
Is this work beinq done by the property owner at their own ra.idanca? ~_ _no
COmplete and .t1:&ch WorJtara' COIIpanaation and COntractor Information fOl1l8.
The Applicant/Parmittaa bereby .qre_ by .ffixinq their dqn.ture to thiaopermit to bold the City
of
campbell, i1:& offlcen, .qents aneS employee. frae, ..fe and h.rmle.. f~ any cl.im or damand for
damaq_ nault10q from the work covered by thia permit.
The Applicant/Permittee bereby .cknowledCJe. that they have re.d aneS uneSerstand both the front and
back of thi. pendt, and that they will inform their contractor(.) of the information.
AC~ Pacific Bell (Emergency verbal)
Applicant (Permittaa) print/81qn Date
NOTES: ALL WORK SIIALL CONFORM 1fITB THE AftACHED, APPROVED PLlNS AND ALL APPLICABLE CAllPBELL
STANDARD DRAWIlfGS AND CONDrrIONS.
THE CONTRACTOR MUST HAVE '1'BIS PERMIT AND APPROVED PLlNS AND MUST MDT 1fITB TIlE P.W. INSPECTOR ON
THE SITE AT LEAST '1'IfO laYS BEFORE S'tAR'tING WOlUt.
NOTICE MUST BE G%VEN TO PUBLIC WORD AT LEAST 24 BOORS BEFORE RESTARTING ANY WOB.
SPECIAL PROVYSrONS
_1.
Street aball not be open cut: for und&rCJround in.tallationa. Kinbtua cuts _y be allowed
for connections or mtploration bol_. Such cute must be snecificallv aDtlroved bv the
InBb.C"tor.
p.v_ant aay be cut: for underqround 1na1:&llationa and maat be raatorad in accordance with
the Utill1:y Trench Raatoration standard Drawinq.
Work to be .1:akad by a licenaed x.JIcS surveyor or Clvil Enq10eer and two (2) copi_ of the
cut aIleets sant to 1:ba Public Work Dap1:&rtmant before .1:artinq work.
The bour. of work are limited to outside the bour. of 7-9 .... and 3-6 p... for any work
.ffectinq . traffic lane. .. . _
,....,,.J~r;Jt1J;., SA/6 rl.dt.J t4~t./ , /:)1&L>E'5ntIA,.J i 1./~/cut,4A.. 77LA~~I' AT i/lJ1-t. nA?t:="...s
_2.
_3.
~4.
."-~ 5.
(R-ll
s-I'AHDARD
REeEYPT WO.
AMOUH'I'
PERMIT APPLICATION FE!
PLlN CBEClt DEPOSI'1'
BOND FOR FAI'1'BFtJL PERFORMAlfCE
CASH DEPOSI'1' ($200.00)
$ /00.00
$
$
$
q
($50.00)
$100.00
$500.00
(loot OF ERG. EST.)
(4' OF BOND, $500 KIN)
PLlN CBEClt , INSPECTION 1"D
$100,000 - $500,000 9', $5
APPROVED FOR ISSUANCE
($0 - $100,000 10': $ /00.100
o KIN)
E4-7'O~
tp
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/ te
(SEE OIHER SIIE)