91-112
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CITY OF CAMPBELL
DEPT. OF PUBLIC WORD
70 North PirBt st.
e&.pbell, CA 95008
(408) 866-2150
Pensit No. 91-112
X-Rete file
Application Date 1/3 0/9 1
Application expir.. in 6 lIOa.
ENCROACHMENT PERMYT
(for workinq in the
....,io r"'~h:.YI
Ia.ued I !
Pu1Iit .. in 12 1108.
APPLICATION - Application 1a hereby ..de for a Public Works Pensit in accordance with C&JIpbell
Municipal COde, Section 11.04. (Application expiru in 6 lICIntha if per.it not pulled)
A. Work addru. or tract' 341 Harrison (x-street Tubby)
Otility trencb location
B. .aturw of work: Ernerqency Gas Line Repair
c. Attach five (5) copi_ of a dravin9 ahowin9 the location, extent and dillenaione of the vork
The dravimJ ahall ahow the relation of the propo.ed work to exiatinq aurface and underqround
iaproveaenta. When approved by the City En9ineer, aaid dravinq becoaea a part of thi. pensit.
D. The General Conditiona for all pensita are liated on the reverBe aide. Special Prtw18ione for
th18 pensit are l18ted below. ..ailure to abide by theae conditione and prov18iona _y reault
in job ahut-down and/or forfeiture of Faithful Performance Bonde and ca.h depo.ita. (8_
General Conditione 1 and 2).
E. An application f_ IlU8t accoapany th18 application. Thi. 18 non-refunclal:lle.
.... of Applicant P G & E
Mdrua 10900 N. Blaney Ave., Cupertino, CA
Telephone:
95014
Ia thi. work beimJ done by the property owner at their own reaidence? ---y- _no
COJIIplete and attach Worx.r.' CoJIIpenaation and COntraetor Information fOE1l8.
The Applicant/Pensittee hereby aqre_ by affixin9 their 819ftatun to th18'pensit to hold the City
of
e&.pbell, ita officerB, aqente and .-ployee. free, aafe and hansleaa f~ any claim or demand for
duaq.. reaultinq from the work cavered by thia penlit.
The Applicant/Pensittee hereby acknowledqea that they have read and underatand both the front and
back of thia pensit, and that they vill infons their contraetor(a) of the information.
ACCEPTED Julie (Ernerg. Verbal)
Applicant (Pensitt_) print/aiqn Date
NOTES: ALL MORIt SHALL CONlORII 1fI'1'Il TIlE ATTACHED, APPROVED PLUS AIfD ALL APPLICABLE CAMPBELL
STANDARD DRA1fIlfGS AIfD CONDrr%ONS.
TIlE CONTRACTOR MUST HAVE 'l'BIS PERIIIT AND APPROVED PLUS AIfD MUST IIEE'1' 1fI'1'Il TIlE P.W. INSPECTOR ON
'l'BE SITE AT LEAST '1'IfO DAYS 8D'ORE STARTING 1fOIUt.
NOTICE MUST BE GIVEN '1'0 PUBLIC WORD AT LEAST 24 HOURS BEFORE RESTARTING ANY 1fOIUt.
S~CIAL PROVISIONS
_1.
Street ahall not be open cut for undarqround in.tallationa. lliniJauJI cute ..y be allowed
for connectione or exploration hol... Such cuta must be sDl!cificallv aDDrovl!d bv th.
InsDeetor.
pav_ent _y be cut for unduvround 1natall.tiolW and .u.t be rutored in accordance vith
the Utility Trench a-toration Standard Dravinq.
Wcrk to be stak.~ by a licensee! L&r.d surveyor or Civil Enqineer and two (2) copi.. of the
cut aheeta .ent to the Public Work Deptartllent before atart1nq work.
The hOUrB of work are liJIited to outaide the hOUrB of 7-' .... and 3-6 p... for any work
affeetinq a traffic lane. .". . .
"nA/;'/:n:h:'/ -54Fe /t../o k/1t/ ?€OE:S77t/A",.,Il f./E/I'CUt...4"/l "'-/V1r0<:. /4-;- .4tL 77dO
_2.
_3.
_4.
~5.
(R-ll
STAHnARD
HC!:IPl' NO..
AMotJR'l'
PERMIT APPLICATION FEE ($50.00)
PIAN CBEClt DEPOsr.r
$ /~O,eJD
$
$
$
$ /00.00
/?
$100.00
$500.00
(100' OF ERG. EST.)
(4' OF BOND, $500 KIN)
BOND POR FAITBFOI. PERFORllANCE
CASH DEPOsr.r ($200.00)
PIAN CBEClt , INSPECTION FEE
$100,000 - $500,000 9', $500
APPROVED POR ISSUANCE
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