91-139
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CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Caapbell, CA 95008
(408) 86&-2150
91-139
ENCROACHMENT PBIUIXT
(for working in the
public rigbt-of-way)
Ia.ued .1./// /) / PI
Permit expire. 'in. 12 ao..
Permit No.
X-Ref. fUe
Application Date 4/10/91
Application expire. in 6 ao..
APPLICATION - Application 18 bereby _de for a Publio Worb Permit in aocordance with CUlpbell
MUnicipal Code, Section 11.04. (Application expire. in 6 aontb8 if permit not pulled)
A. Work address or tract .
Northeast corner nillon Ave./Sam Cava Wav
utility trench location
B. Nature of work: Emerqency water valve qate
C. Attach five (5) copies of a drawing .bowing the location, extent and dlaendons of the work
The drawing sball sbow the relation of the proposed work to existing surface and underground
1mprov_ents. When approved by the City Engineer, said drawing becoaes a part of th18 permit.
D. The General Conditions for all permits are listed on the reverse side. Special Provisions for
this permit are listed below. 'ailure to abide by these conditions and provisions aay result
in jOb sbut-down and/or forfeiture of Faithful Performance Bonds and ca.b depodt.. (See
General Conditions 1 and 2).
E. An application fee aust acooapany this application. This is non-refundable.
Na.e of Applicant
S.J.W.C.
Telephone:
San Jose. CA 95128
Address
1221 S. Bascom Ave.
Is this work being done by the property owner at their own residence? ---yes ___no
Complete and attacb Workers' Compensation and Contractor Information forma.
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City
Campbell, its officers, agents and employees free, safe and harmless from any claim or deaand for
damages resulting from the work covered by this permit.
The Applicant/Permittee hereby acknowledges that they have read and understand botb the front and
back of this permit, and that they will inform their contractor(s) of the information.
ACCEPTED Glennette (Emerqencv verbal)
Applicant (Permittee) print/sign Date
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHBD, APPROVED PLANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AND MUST MBBT WITH THE P.W. INSPECTOR ON
THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK.
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
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SPECIAL PROVISIONS
_1.
Street shall not be open CUt for underground installations. Kinlaum cuts ..y be allowed
for connections or exploration holes. Such cuts must be SDecificallv aDDroved bv the
rnsD8c'tor.
Pavement may be cut for underground installations and aust be restored in accordancs with
the Utility Trench Restoration Standard Drawing.
Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copi.s of the
cut sheets sent to the Public Work Deptartment before starting work.
The hours of work are limited to outside the hours of 7-9 a.a. and 3-6 p.a. for any work
affecting a traffic lane.
_2.
_3.
_4.
_5.
STANDARD
PERMIT APPLICATIOH l'BB
$100.00
PLlH CHECK DEPOSIT
$500.00
(loot OF BRG. EST.)
(4t OF BOHD, $500 IIIH)
BOND FOR FAITIIFUL PBRPORMANCB
CASH DEPOSIT
PLAN CHECK , INSPECTIOH l'BB
$100,000 - $500,000
APPROVED FOR ISSUANCE
f: PWPERMIT
Revised 4/91