91-132
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CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North first St.
Campbell, CA 95008
(408) 866-2150
ENCROACHMENT PERMIT
(for working in the
public right-of-way)
Iasued 3/.:l::L/ 9/
Perait expire. in 12 IIOS.
perait No.
91-/3;;2/
X-Ref. file
Application Date ...J;/ J(/'9 /
Application expire. in 6 .os.
APPLICATION - Application is heraby ..de for a Public Worka Perait in accordanca with Caapbell
o Municipal code, Section 11.04. (Application expires in 6 ~nths if perait not pulled)
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A. Work address or tract ,
1 r::, 7 1 f, 7 .1 7g Hi'! rri snn AvpnllP
Harrison Avenue
Utility trench location
B. Nature of work: Repair 4" sanitary sewer laterals
c. Attach five (5) copies of a drawing .hoving the location, extent and di..nsions of the work
The drawing shall show the relation of the proposed work to exi.ting .urface and underground
improve.ents. When approved by tha City Enqineer, .aid drawing beco... a part of this perait.
D. The General Conditions for all perait. are li.ted on the reverse .ide. Special Provi.ions for
this permit are li.ted belovo Failure to abide by these condition. and provisions aay reault
in job Shut-down and/or forfeiture of Faithful Perforaance Bond. and cash depo.its. (See
General Conditions 1 and 2).
ia non-refundable.
Telephone: 378-2407
E. An application fee .u.t accoapany thb application. 'l'hb
Nallle of Applicant ~'1est Valley Sanitation District
Address 100 E. Sunnyoaks Avenue, CAmpbell
Is this work being done by the property owner at their own re.idence? ---ye. XXno
Complete and attach Workers' Co.pensation and Contractor Inforaation foras.
The Applicant/Permittee hereby agrees by affixing their .ignature to this perait to hold the City
of
Campbell, its officer., agents and employee. free, aafe and harale.. fro. any claim or de.and for
damages resulting from the work covered by this perait.
The Applicant/Permittee hereby acknowledges that
back of this permit, and that the 11 fo
ACCEPTED Mike Fuller .,;..-
Applicant (Permittse)
they have read and under.tand both the front
air contractor(s) of the inforaa~'/9- /
Date
and
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.
NOTICE MUST BE GIVEN TO PtJBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
SPECIAL PROVISIONS
_1.
Street shall not be open cut for underqround installations. Minimum cuts aay be allowed
for connections or exploration holes. Such cut. must be soecificallv aDDroved bv the
InSDector.
Pavement .ay be cut for underground installations and .u.t be restored in accordance with
the Utility Trench Restoration Standard Drawing.
Work to be staked by a licensed Land surveyor or Civil Enqineer and two (2) copies of the
cut sheets sent to the Public Work Deptart.ent bafore starting work.
The hours of work are limited to outside the hour. of 7-9 a... and 3-6 p... for any work
affecting a traffic lane.
1,.00"""' 2.
........--3.
_4.
_5.
CR-l\
STANDARD
AMOUNT
$ \ CC::>.00
$
$
$
$\.~'ec.
RECEIPT NO.
't
PERMIT APPLICATION FEE
($50.00)
$100.00
$500.00
PLAN CHECK DEPOSIT
BOND FOR FAITHFUL PERFORMANCE
(100' OF !MG. EST.)
(4' OF BOND, $500 MIN)
CASH DEPOSIT
($200.00)
PLAN CHECK , INSPECTION
<r
.~ --1- '- -~ i
Date
APPROVED FOR ISSUANCE
f: PWPERMIT
Revised 7/90
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