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CITY Of C}~I~ELL
DEPT. Of !'c,:":C WO!U<S
70 North first St.
Caapbell, CA 9~008
(408) 866-2150
~NCRO~CHME~T prRHIT
(for working in the
public riqh -0 -~ay)
parw.it NO.
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X-Rat. tile
Application Date .;'5(/~ / PI
Application expire. In 6 ao..
APPLICATION _ Application ia hereby ..de tor a ~llc Worka Peralt In accordance with C..pbell
Municipal code, section 11.04. (Application expiTea in 6 aontha it perw.it not pulled)
A. Work address or tract I
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utility trench location
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Attach five (5) cople. ot a drawinq .hovinq the locatlon, axtant and" d1aenaion. ot the work
The dra~ing ahall .how the relation ot the propoaed work to axl.tinq .urta~ and underqround
iaproveaentll. When approved by the Clty Enqln_r, aaid clravlnq beco_. a part ot thi. perait.
The Ceneral condition. for all perait. are li.ted on the revarea aide. special ProYi.iona for
thill perait are liated belovo FaUure to abide by the.e condition. and provialon. ..y r..ult
in job ahut-down and/or torfeiture of Faithful Perfo~ Bonda and eaah depoaita. (Saa
General condition. 1 and 2).
II.
Nature ot vorlt:
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E. An epplication fee _.u.t accolJP&l1y Ul. applieat~on.
ft~. La non-refundabla.
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Kaae of Applicant
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III this vork being done by the property owner .t their own re.ldanea? ---ye. ~no
Complete and attach Workers' Coapen.ation and Contr.ctor Inforaation foraa.
The Applicant/Perw.ittee bereby .gree. by affixinc;r their a1gnature to thi. perait to bold the
ot
eeapbell, its ofticara. .ganta and. ..ployaa. fra., ..fa .nd. barale.. from .ny clal. or daaand.
da.ages resulting froa the work covered by Ui. perait.
The Applicant/Peraittee baraby acknowledga. that thay have raad and. und.eret.nd both tha front
back ot this \perait, -.nd, ,:,at_ the~w~~ infora ~d~r?~actor(.) of the inforaa~~on. / ,C) /1
ACCEPTED ~~pi'i~antj.<(p~~\i~~e,) PJ7i.{l/.iqn ,x~' fA; ..{ Date .-!.. - "/ - -
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NOTES: ALL WORK SHALL CONFOM WITH THE ATTACHED, APPROVED PUNS AND AU. APPUCAIIU CIo!'I..PBI!LL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AND MUST MEET WITH 'l'HE P.W. INSPECTOR ON
THE SITE AT LEAST TWO DAYS BEFORE STARTING WOJU<.
NOTICE MUST BE CIVEN TO PUBLIC WORXS AT LEAST 24 HOURS BEFORE RESTARTINC ANY WOJU<.
SPECI~L PROVISIONS
_1.
Street IIhall not be open cut for underqround installations. Mlnlaua cut. ..y be .lloved
for connectionll or exploration boles. Such cuts .ust be soecificallv aDDroved bv the
InsDector.
Pave.ent aay be cut for underground inatallation. and .ust be re.tored in accordance with
the Utility Trench Restoration Standard Dravinc;r.
Work to be IItaked by a licen.ed Land Surveyor or Civil Enqlnaer .nd two (2) copia. ot the
cut .heetll aent to the Public Work Deptartaent before .tartinc;r work.
The hourll of work .ra li.ited to out.ide the boura ot 7-9 .... and 3-6 p... tor any work
attectinq a trattic lane. .
IJI ,*"..'h:Vn#, ~ J4F"E 77.JO t../-9v iD~L)k:!it r4-,',qA.l" V€#,. GUl,.4?C 7;t'.AH Ie.. 4r 41,(.. 77;r, E'5
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S'l'ANDARD
AMotnfT
RECEIPT MO.
IV
IR-ll
PEMIT APPLICATION FEE
PLAN CHECK DEPOSIT
($50.00)
$100.00
$500.00
(100\ OF ENG. EST.)
$ /r;O; 00
$
$
$
$ / f)t) . ,00
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BOND FOR FAITHFUL PERFORKANCE
...---
CASH DEPOSIT
PLAN CHECK ,
APPROVED FOR ISSUANCE
t: PWPERHIT
Revised 7/90
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Contractor must have these plans
on the job site during construction.
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