91-134
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INSPElloloC . , Vi t)
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MAR 2 8 1991 :
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Public W orb/ Engineertng
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_1. Street shall not be open cut for underqround install.tions. Ilini.ua cuta -y be .llowed
for connections or explor.tion boles. Such cuts aust be .oecificallY approved by the
. ~ Inspector.
~2. Pavement aay be cut for underqround inst.ll.tion. .nd au.t be re.tored in accordance with
tne Utility Trench Restor.tion Stand.rd Dr.winq.
Work to be staked by a licen.ed Land surveyor or Civil Enqineer and twO (2) copies of the
cut .heets sent to the Public work Dept.rtaent before .tartinq work.
The hours of work .re li.ited to outside the boura of 7-9 .... and 3-6 p... for any work g;
affectil'g, a tr.ffic lane. .' ' ~ ~~. '
",.. J ""',.,.....,..'" \ ~""""" i "-' \~\ 1f'mP ~ "IT?""""'" " ~< .c... n
k" ~T1M~ ~\"-'.~H'..l .-.c>p. ~f"AC- V'>o-es:- ~
\W - -", t::>\.:- '-\.C~I g ~~ ~ ~ ~
~'-.)~ ~ Lh'Ue CLD~. D\ ~ ~
~'-.:.---r~~ -S\~I~~~ ',,~~-(2"-\C- ~~ ;..>~c..?c:'~
CR-_ STANDARD AMOUNT RECEIPT NO. ~
~.CD
CITY OF CAMPBELL
DEPT. OF PUBLIC WURKS
70 North First St.
ca~pbell, CA 95008
(408) 866-2150
ENCRO"CHMENT PERMIT
(for working in the
public riqbt-of-way)
I..ued ~~~;iCl/
perait expire. in 12 aos.
perait No.
&'1/-/3~
X-Ret. file
;?'J,'! / ?
Application Date ,,} 0-' c I
Application expir.. in ~ .0..
APPLIC"TION _ Application is hereby ..de for . ~lic works Perait in .ccordance with caapbell
Municipal Code, section 11.04. (Application expire. in 6 aonth. if perait not pulled)
Work .ddress or tract' ':?i15 I
Utility trench location t\l:~~
lIature of work: fleE. 3B~V'(F~
S. e:AS:L:OM AVE-.
A.
B.
'5 f';t'I...q-nM A'-/f'=- '
AN 0 U.JMi7-..1l C. S~V' leE--
"VDe~
C. Attach five (5) copie. ot e 4r.vinq abowinq the location. extent and 41aerwions of tbe work
The drawing sball show the rel.tion of tbe propo.ed work to exiatinq aurtace and un4e~
iaprove_nts. When approved by tbe City EncJin-r. _i4 dravinq becoaea a part of tbia perait.
D. The General Conditions for all peralta are lbted on the mene aieS.. SpeCial ProYlaiona tor
this perait are li.ted below. Failure to abide by tbe.e conditions and proviaions aay re-ult
in job .hut-dovn .nd/or forfeiture of F.itbful Perforaance IIon4a and caab depolliU. (5_
General Conditions 1 and 2).
E. An applic.tion fe. au.t .cc:08P&IlY tbi. application. ~ ia non-refundabl..
.... of Applicant SAN ~C~E:- ~A~ ~MP~I' ~lepbone: Z-r"'l-tl0L\-'
AddreSS 12.2..1 S. E':>A:..,,=,Co(--"\ A'\.Je.. \ c::;,f><~ ~~~- CA. "")5/2f;;
Is this work beinq done by the property owner .t their own re.idence? --ye. ~
Co.plete and attach workers' Coapensation and Contr.ctor Inforaation toras.
The Applicant/Peraittee berebY aqr... by affixinq their aiqnature to tbi. perait to bold the City
of .
eaapbell. its officer., .qents and _ployee. free. _f. and barale.. frea any cla1a or deaan4 for
da..qes resulting fro. the work covered by thi. perait.
The Applicant/Peraittee hereby
back of th' it. and th
ey bave reed and understand both the front and
r contractor(a) of the inforaation. \
2-7/Vl/JR91
Date
ACCEPT
NOTES: ALL WORK SHALL CONFORM WI'l'H 'l'HE A"l"'l'ACHED, APPROVED PLANS AIID ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR truST HAVE 'l'HIS PERMIT AJfD APPROVED Pu.HS AIID ICUST MEET WI'l'H THE P.W.
THE SITE AT u:AST TWO DAYS BEFORE STARTING WORJC..
NOTICE truST BE GIVEN TO PUBLIC WOIU(S AT LEAST 24 HOURS BEFORE RESTARTING ANY WORJC..
SPECIAL PROVISIONS
_3.
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t---- 5.
PERKIT APPLICATION FEE
($50.00)
$100.00
$
$
$
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PLAN CHECK DEPOSIT
$500.00
BOND FOR FAITHFUL PERFORMANCE
(100\ OF ENG. EST.)
(4\ OF BOND, $500 KIN)
APPROVED FOR ISSUANCE
$
$ l~.co ~
4--,--0( \
Date
CASH DEPOSIT
($200.00)
PLAN CHECK , INSPECTION
f: PWPERKIT
Revised 7/90
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