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CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Callpbell, CA 95008
(408) 866-2150
ENCROACHMENT PERMIT
(for workinq in the
public ri;ht-of-w.y)
.,. .i ,".
I..ued ;/1" ,I '/1
Perait expir.. in 12 aoa.
Penai t No.
'j" /-
X-Ref. file
ApplicaUon Date "/ / .'
Application expire. in 6 ac..
o
z
APPLICATION - Applic.tion i. hereby ..de for . Public WOrks Perait in .ccordance with CAapbell
Municipal Code, Section 11.04. (Application expir.. in 6 .ontha if perait not pulled)
A.
Work addu.. or tract' ROSEYA?"y LAiiE!LUCOT FAY
Utility trench locaUon ROSElW','y LA:'~E 165 I EAST OF T,rnCr-IESTE?
Nature of work: EXCAVATE TEST PITS LUCOT \JAY 382 I UEST OF VALE
B.
C.
Attach five (5) copies of . dr.win; .howinq the location. .xtent and diaan8iona of the work
The drawlnq .h.ll .how the r.l.tion of th. propo.ed work to .xi.tin; .urf.ce and und.rqround
i.prove..nts. Wh.n .pproved by the City Enqin..r. ..id drawing DecORS. a part of thi. parait.
The General COndition. for .11 penaie. ar. li.ted on the rav.nae aid.. Special Proviaions for
this permlt are li.tad belovo Fail~re to abide by the.e conditior~ and provi.ion. ..y r..ult
in jOb shut-down and/or torteitur. of Faithful Pertoraance Bond. and cash depo.it.. (S..
General Conditions 1 .nd 2).
D.
E. An .pplication te. .u.t .ccoapany thi. .pplication. !bia
Halle ot Applicant :-lest Valley Sanitation District
100 East Sunnyoaks Avenue, Ca~pbe11, CA
Address
i. non-refundabl..
Tal.phon.:
95003
408-378-2407
Is this vork beinq done by the property owner at their ovn re.idence? ---ye. ___no
COllplete and attach Workers' Co.pen.ation and Contractor Inforaation foras.
The Applicant/Permitte. hereby aqre.. by affixin; their si;nature to thi. perait to hold the City
of
campbell. its ofticers, aqente and ..ploye.. fr.., .ate and h.ral... froa .ny cla1a or deaand for
damages resultlng fro. the work covered by thl. peralt.
The Applicant/Permittee hereby acknowledqe. that th.y have read and under.tand both the front and
back of tnl& permlt, and that they will infora th.ir contractor(.) ot the intora&tion.
ACCEPTED Don Arnstrong 2-15-91
Appl1cant (Peralttee) print/81qn Cons truc t ion Inspec tor DAte
NOTES: ALL WORK SHALL CONFORM WITH THE A'M'ACHED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLAlfS AND MUST IIEET WITH THE P.W. INSPECTOR ON
THE SITE AT LEAST TWO DAYS BEFORE STARTING WORX.
NOTICE MUST BE CIVEN TO PUBLIC WORXS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORX.
SPECIAL PROVISIONS
_1.
Street snall not be open cut tor underqround installation.. Miniaua cute .ay be .llowed
for connectlona or exploratlon holes. Such cuts .u.t be scecificallv accroved bv the
InSDector.
Pavement lIay be cut tor underqround installation. and au.t be re.tored in accordance with
tne Utility Trench Restoration Standard Drawinq.
Work to be staked by a licens.d Land surveyor or Civil Enqin..r and two (2) copies ot the
cut sheets .ent to the Public Work Oept.reaent before .tartin; work.
The hours ot work are lillited to outside the hour. of 7-9 .... and ]-6 p... tor any work
affecting a trattic lane.
...........-- 2.
_3.
_4.
_5.
IR-ll
STANDARD
RECEIP'I' NO.
AMOUNT
PERMIT APPLICATION FEE
($50.00)
$100.00
$ ~c0. (t^:)
q
PLAN CHECK DEPOSIT
$500.00
(100' OF ENG. EST.)
(4' OF BOHD, $500 KIN)
$
$
$
BOND FOR FAITHFUL PERFORMANCE
CASH DEPOSIT
($200.00)
PLAN CHECK , INSPECTION
$ <--.:,<."::J.. r.C <1'
"L-- \ <t-:-> -~"\. i
Date
APPROVED FOR ISSUANCE
t: PWPERMIT
Revlsed 7/90
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