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Permit No. i /
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CITY Of CAMPBELL._a. C . I V & j&lCRO-'CHMENT PERMIT
,DEPT. OF PUBLIC KIP ~or working in the
,0 North First St. public right-of-way) X-Ref. file
Campbell, CA 9500BMAR 1 t'"J 190i~/ c/(.( ?' / Ie /cI/
(408) 866-2150 ..J Issued ',yj / l II Application Date ,.:;. t j /
Permit expires in 12 S05. Application expires in 6 mos.
APPLIC-'TION - ~tl~~~!inH~nr~~~naade for u Public Works Permit in accordance with Campbell
Municipal Code, Section 11.04. (Application expires in 6 aonths if permit not pulled)
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A. Work address or tract ,
Utility trench location
SOUTH EAST CORNER OF S. BASCOM AVE & HAMILTON
IN PARK STRIP & SIDEWALK
TRENCH & PL 9 FEET OF 1-1" r,pr,
B. Nature of work:
C. Attach five (5) copies of a drawing showing the location, extent and diaensions of the work
The drawing shall show the relation of the proposed work to existing surface and underground
improvements. When approved by the City Engineer, said drawing beco.as a part of this permit.
D. The General Conditions for all permits are listed on the revers. side. Special Provisions for
this permit are listed below. Failure to abide by these conditions and provisions say result
in job shut-down and/or forfeiture of Faithful Performance Bonds and cash deposits. (See
General Conditions land 2).
E. An application fee sust accompany this application. This is non-refundable.
Name of Applicant
PAC BELL
1531 PARKMOOR AVE, SAN JOSE
Telephone: 491-3477
Address
Is this work being done by the property owner at their own residence? ---yes 1L-no
Complete and attach Workers' Compensation and Contractor Information fOra8.
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City
of
Campbell, its officers, agents and employees free, safe and harmless froa any claim or demand for
damages reSUlting from the work covered by this permit.
The Applicant/Pe~ttee hereby acknowledges that they have read and understand both the front
back of this p 't, and that they wil infor t eir contractor(s) of the information.
3-J')51/
and
ACCEPTED
Date
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AND MUST MEET WITH THE P. W. INSPECTOR ON
THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK.
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NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
SPECI-'L PROVISIONS
Vl.
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WA3.
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V'5.
Street shall not be open cut for underground installations. Kiniaum cuts say be allowed
for connections or exploration holes. Such cuts Dust be seecificallv aeeroved bv the
Insoector.
Pavement may be cut for underground installations and aust be restored in accordance with
the Utility Trench Restoration Standard Drawing.
Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the
cut sheets sent to the Public Work Deptartment before starting work.
The hours of work are liaited to outside the hours of 7-9 a.a. and 3-6 p.a. for any work
affecting a traffic lane.
1~'~U~~ ~'FE-; )'-;,.t,::>e:-q:>0hTE: ~~-n'"U~U ~~.-
WN'-ij l~\t::e ~L-.JE: ~~U~ \~2..- ~L-~L::F-"
~~I..-)\:JD~~) h~__ ~\I2E:C-'"\E'f::::> V3.'-l ~\,8--t::::::.
~~\f-)CC{L
(R-ll
AMOUNT
$ l{~. cc.
$
STANDARD
RECEIPT NO.
PERMIT APPLICATION FEE
($50.00)
$100.00
~--
PLAN CHECK DEPOSIT
$500.00
(100\ OF ENG. EST.)
(4\ OF BOND, $500 KIN)
-
$
$
$ \ es:c.,r~
BOND FOR FAITHfUL PERFORMANCE
CASH DEPOSIT
($200.00)
-4-+-
PLAN CHECK' INSPECTION FEE ($0 - $100,000 10\;
$100,000 - $500,000 g\; ;;~OO'OOO and ab, ve 7\; $lOOMIN)
APPROVED FOR ISSUANCE ~_________r.~
for Ci y ne r
f: PWPERMIT
::t?,. -'\ ce:...q t
Date
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