91-116
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THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AND MUST MEET WITH THE P.W. IMSPE~R OM I
THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK. K E C IE I V IE D
I
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 2~ HOURS BEFORE RESTARTING ANY WORK. FE l3 l:~ Lj.:) I I
SPECIAL PROVISIONS :
V PublifWQrks/Engineer~Q
_1. Street shall not be open cut for underqround installations. llini.WI cut. -y be .1: owed I -
for connections or exploration boles. Such cut. .ust be .oecificallv aDDroved bv the I
InSDector. I
_2. Pavement .ay be cut for underqround installation. and .u.t be re.tored in accordance with :
the Utility Trench Restoration Standard Drawinq. ~
_3. Work to be staked by a licen.ed Land surveyor or Civil Enqineer .nd two (2) copies of the 0
cut sheets .ent to the Public Work Deptareaent before .tarting work.
_~. The hours of work .re li.ited to outside the hours of 7-9 .... and 3-6 p... for any work ~
affecting a traffic lane. '
::l .
CITY OF C",J"HIELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(~081 866-2150
ENCRbACHMENT PERMIT
(for working in the
public right-o~-way)
I..ued OJ/; .:2/9 /
Perait expire. in 12 .os.
P i 4/-11~
era t NO...J..._ '"
X-Ref. file
Application Date "2//2/91
Application expires in 6 .0..
APPLICATION _ Application i. hereby _de for a ~lic Worka Perait in accordance with caapbell
Municipal code, section 11.04. (Application expiTe. in 6 aonth. if perait not pulled)
A.
'r" , - ,- - .-,f, " . -f~ / ( f
Worle address or tract t /~," \.-' VI,/) /,~'7 < ;. ,/' , .'
Utility trench l,ocation '/. f /-::-' //'1/~ ~ 0:~ / ~-;-/ ?.T', . An .'
" /., r,' !"_ -I- _'
Nature ot worle: (... \.- , .. -r O. I; , ;' ( ()- 1,-' ','
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f...."/' ,O"/"'} /~ i' ;" :\~ ',\~
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B.
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C. Attach five (5) copie. of a drawing .howing the location, extent and diaensions of the wor);
The drawing .hall show the relation ot the propo.ed worle to exl.ting .urface and underqround
improvements. When approved by the City En9ineer, .aid drawing beco... a part of thi. perait.
D. The General Condition. for .11 perait. are li.ted on the reverae .ide. Spacial ProYi.lona for
this permit are li.ted belovo Failure to abide by the.e conditions and provi.ion. aay raault
in job .hut-down and/or forfeiture of Faithful Perforaance Bonds and cash depo.ita. (See
caneral condition. 1 and 2).
E. An application fe~_.u.t acc~y thb applicati~n.
\' /, J' J~
lIa_ of Applicant.- i. ,'") ." ,^ / '-"/ j,-,~ ' r. / I /'Y./ /./0
. .-,...., "f' .... ,/ I
Addr..s /.~)..-> / \j~ ...."-':' ~ .' (~rL/ - ,j
'rIli. i. non-refundable.
(^'~ 'l'elaphone: {-:i / /: J -
J,,-!.-;~/ )
x..no
Is this work beinq done by the property owner at their own re.idence?
---ye.
Co.plete and attach Worleer.' coapan.ation .nd contr.ctor Inforaation foraa.
The Applicant/peraitte. hereby aqre.. by affixing their .iqnature to thi. perait to bold the City
of
Campbell, it. officers, aqent. and ..ployee. tree, .afe and barale.. fro. any clai. or deaand for
damages re.ulting froa the worle cov.red by thi. parait.
The Applicant/Paraitte. hereby acknoWledq.. that they heve read and understand both the front and
beck of this perait, ancS thatth.y wll)C1.nfora their contractor(s) of the inforaation.
ACCEPTED :-~~~~l~~~~ (;pet;ilj~~r>p;::tl(.)~V) , ~/ j~/'~ ^ I Date ~ / L (. C) /
MOTES: ALL WORl( SHALL CONFORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE CMPBELL
STANDARD DRAWINGS AND CONDITIONS.
_5.
CR-ll
STANDARD
RECEIPT NO.
AMOUNT
$ k~.>, c:o
$
$
$
$ \C~, c:c:; Cf
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Date
Cf
PERMIT APPLICATION FEE
($50.00)
$100.00
$500.00
PLAN CHECK DEPOSIT
BOND FOR FAITHFUL PERFORMANCE
(100' OF ENG. EST.)
(~, OF BOND, $500 IlIN)
CASH DEPOSIT
($200.00)
PLAN CHECK , INSPECTION
APPROVED FOR ISSUANCE
f: PWPERMIT
Revised 7/90
FEE ,~D' $,,0 "']
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