91-111
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CITY OF CAMPBELL
DEFl' . OF PUBLIC WORltS
70 Noreb F1r8~ St.
ea.pbell, CA '5008
(408) 816-2150
91-111
ENCROACHMENT PERMIT
(for working in the
publ1c: dlJht;-of_ay)
I..ued I~A,
Pu1Iit "i in 12 JIG..
Pemit Ho.
X-Ret. file
Appl1ca~ion Da~e 1/3 0/9 1
Appl1cation expira in 6 110..
APPLICAT%ON - Appl1ca~ion 18 bereby _d. for a Public Works Permit in accordance with C8JIpbell
llunicipal COde, Section 11.04. (Application expira in 6 IIOnth8 if perait no~ pulled)
A. workmcsn..ort:ra=. w/s Creekside. 300' slo Hamilton
utility trenell loca~ion
B. Na=n of work: Emergency Service Repair
c. A~taell five (5) copies of a eSrawinq .bowinq the loca~ion, exten~ aneS eSillen.ioM of the work
'!'he clrawinCJ aball ehow the rela~ion of the proposed work to ex18tinq .urface ancS uneSerqround
illproveaenta. When approved by the City Enqineer, .aid drawing beCOlleS a ~ of thi. perIIli~.
D. '!'he Genenl COneSitioM for all perlllita are li.~ed on the reveree deSe. Special Prov18ioM for
th18 perlllit are li.~ed below. Failure to abieSe by these coneSitioM and prov18iOM _y re.ult
in job ehu~-cSown and/or forfeiture of Faithful Perforlll&nce Banda and ca.h eSepodta. (S..
General concu tioM 1 ancS 2).
E. An application f.. IlUat aCCOllpany th18 applica~ion. 'l'h18 18 non-refundable.
Naae of Applicant SJWC
MeSras 1221 S. Bascom Ave., San Jose, CA
95128
Telephone: 279 -7 9 0 0
Is this work being eSone by the property owner a~ their own residence? --.:t- _no
C01Iple~e and attaell Worker.' Coapenaa~ion and COnt:ra=or Inforlll&tion foras.
'!'he Applican~/PermittH hereby aqre_ by affixing their dqna~ura to th18-perlllit to boleS the City
of
campbell, ita offic8r8, aqenta and .-ployees free, safe and harmless f~ any claill or eSeaand for
daJlaq_ re.ultinq f:rom the work covered by th18 perlllit.
'l'he Applican~/Permit~ee bereby acknowledqe. that they bave read and undentand both the front ancS
back of this perlllit, and that th.y will inrom th.ir contra=orcs) of th. inforlll&tion.
Glennette - verbal emergency permit 1/30/91
A~~~
Applicant (Permittee) print/81qn Dat.
NOTES: ALL WORK SBALL CONFORM 1fI'l'B THE ATrAaIED, APPROVED PLA.HS AHD ALL APPLICABLE ClllPBELL
STAHDARD DltA1fINC:S AHD COHDI'nOBS.
THE CONTRACTOR MUST HAVE TBIS PERIII'1' AHD APPROVED PLA.HS AHD IIOST IIEET 1fI'l'B THE P.W. INSPECTOR ON
THE SI'l'E AT LEAS'l' '1'1fO DAYS BU'OlU!: STARTIHC: WORK.
NO'tICE IIOST a GIVEN '1'0 PUBLIC WORD AT I.EAS'1' 24 HOORS aFORE RESTARTING ANY WORK.
SPECl:AL PROVYSYONS
_1.
Street ehall no~ be open cut for underqround installations. llinillua cuta MY be allowed
for conne=i0ft8 or exploration bol_. Suell cuta IIllst be sDecificallv aDElroved bv t:be
In.-a8ct:or.
Pav_en~ _y be cu~ for uneS.rqround 1natalla~iorw ancS .wit; be re.tored in accordance with
the utility 'trench Ra8toration Standard Drawing.
work to be staked by a licensed Land Surveyor or Civil Enqine.r aneS arc (2) copi_ of the
cu~ eh..ta sen~ to the Public work Deptartmen~ before .tarting work.
'th. boun of work are lillited to wtaid. th. bour. of 7-' a.a. and 3-6 p.a. for any work
aff.~ a traffic lane. / .
.-,d,,,,;nlfhd ~,c€, ~ 1'-//7'>1' L'cOGSJ7C,4-;1/ d I/ol,;.u,'c../..u./.;/ 77t~;::j L fir.A-U.. r7"??~
...., / I'
_2.
_3.
_4.
...........-5.
(11-1 \
STANDARD
RECEYP'l' NO.
AMotJR'l'
PERKI'1' APPLICAT%ON FEE
PlAN alECIt DEPOSr.r
BOND FOR FAITBnJL PERFOlUIAHCE
CASH DEPOSr.r ($200.00)
$ //J(). OV
$
1?
($50.00)
$100.00
$500.00
....---
$
$
$ / txJ ..C)l/
$100 KDf)
817V..J
(100' OF ERG. EST.)
,..---
--
-
(4' OF BOND, $500 KDf)
10':
4'
I~
PlAN alECIt , INSPECTION I'D
$100,000 - $500,000 ,.,
APPROVED FOR ISSUAHCE
(SEE anIER SIIE)