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ENCRO~CHMEHT PERMIT
(tor workinq in the
public right-ot-way)
Iuued i~A /
perait eXJHres in 12 .os.
penait No.
'1/ - 125'
CITY or C;~'~(LL
DEPT. or I'C t :'1 C woRKS
70 North fir5t St.
ca.pbell, CA 95008
(408) 866-2150
X-Ref. file
"l ~/' OI(
Application Date ~ - ^ l) - I
Application expires in 6 .os.
APPLICATION _ Application is hereby aade for a ~lic Worka Perait in accordance with Caapball
Municipal code, Section 11.04. (Application expiTes in 6 aonths it penait not pulled)
A.
Work address or tract I
,(~~; 7 ~>;2~ ~lf'd!. ~p ,1':~; if;
.;/{
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0-
Utility trench l~ation
Nature ot work: ~,))
B.
C. Attach five (5) copies of a c1ravin<; showin<; the location, extent anc1 diaanaiona of the work
The drawing shall show the relation of the proposed work to existin<; surface and underqround
iaproveaents. When approved by the City Enqineer, said drawin<; baco... a pert of this perait.
D. The General ConcHtions tor all peraits are listed on the revene .ide. SpeCial ProVi.ione for
this perait are listed below. Failure to abide by these conditione and provisions aay r..ult
in jOb shut-dovn and/or forfeiture of Faithful Perforaance 1ond8 and caab depo.iU. (See
Ganeral Conditions 1 end 2).
Address
.pplication.
, -1-'
/; (y j "
(""
, ( \
!'bb f. non-refundable.
'/" '" ' 'relePhone:.;) '7 C)
/-/ ,f' .-::; /j
/. ,.
E. An application fee .u.t acco~y thi.
(' .
Ifaae of Applicant ':><::.1 n \,' )- /"1 ~ j .-
/ ./ \ "" I,";' - ''\ " ')
/ .-< ..--<., / ' A, . -(~ .:\ (" h.t> "
Is this work baing done by the property owner
~ ./.
.t their own re.idence? ---ye.
_no
Coaplete .nd .ttach Workers' Coapensation .nd Contr.ctor Inforaation foraa.
The Applicant/Peraitte. hereby agrees by .ffixing their .ignature to this perait to hold the City
of
eaapball, its officen, agent. .nd _ployee. free, ..fe and harale.. frea .ny clai. or cS.aand for
daa.qes resulting frea the work covered by thi. parait.
'!'he Applicant/Peraittee hereby .cknovled9.. th.t they have re.d .nd undent.nd both the front and
back of this perait, and, ~at ~ey r'i~fora th~i~ (~~.nif.c~Or(.)/ of the inforaa:ion~, " . I
ACCEPTED L . 1'- ',r7' /, '-t: /'-:.{ l~ :j/C) I
(Peraittee) prin If 9n Date / '
NOTES: ALL WORK SHALL CONFORH WITH THE ATrACHED, APPRO''-ED i'LAHS AHD' ALL APPLICASU: CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR truST HAVE THIS PERMIT AND APPROVED PIANS AND truST MEET WITH THE P.W. INSPECTOR ON
THE SITE AT LEAST 'NO DAYS BEFORE STARTING MORX.
NOTICE truST BE GIVEN TO PUBLIC WORJC$ AT LEAST 24 HOURS BEFORE RESTARTING ANY WORX.
SPECI^L PROVISIONS
_1.
Street shall not be open cut tor underqround installations. Mini.ua cuts may be allowed
for connections or explor.tion boles. Such cuts aust be soeciticallY approved bY the
Insoector.
Paveaent aay be cut for underground inst.llations and .ust be restored in accordance with
the Utility Trench Restoration Stand.reI Dr.ving.
Work to ba staked by a licensed Land surveyor or Civil Engineer and two (2) copies of the
cut sheets sent to the Public Work Oept.reaent bafore starting work.
The hours of work are liaited to outside the hours of 7-9 .... .nd )-6 p... for any work
affec~ing a tratfic lane. '
"'Ah"n7f7:U .~JtH'~ ruJo w~<(' ~/',- AT,q L-L 7'un;;:'S
~.
-).
_4.
..L,s.
lR-l\
PERHIT APPLICATION FEE ($50.00)
PLAN CHECK DEPOSIT
STANDARD
AMOUlfT
RECEIPT NO.
q
$ /~.OO
$
S
SlOO.OO
$500.00
BOND FOR FAITHFUL PERFORKANCE
(100\ OF EMG. EST.)
(4\ OF BOND, $500 KIN)
BOND, $100 MIN)
Ght>..!
ttl
~~1,
te
....---
$
$ /<<J.OO
CASH DEPOSIT ($200.00)
PLAN CHECK' INSPECTION
APPROVED FOR ISSUANCE
f: PWPERHIT
Revised 7/90
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APPROVED FOR CONST;~~t/ .~.TION,
C I: 'L'" f 0" + r"-:,." ", t," 'I
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Public VVorks ' Perrnit ('i('., 9/_-:/ ~ ~_H"
Conl,actof must hav" these pi-:J;'s
on the job site d''';ng const,uct/Olt,