91-142
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CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North Firs~ S~.
ca.pball, CA '5008
(408) 866-2150
91-142
EHCROACIIIID'I' PKRIU'l'
(for working in the
public righ~-of-way)
I..ued #;;1 / c; /
Parai~ expiru 'in. 12 IIOS.
Panait No.
X-Ref. file
Application Date 4/18/91
Application expires in 6 1108.
APPLICATION - AppUca~ion 18 banby ..de for a Public Worb Perai~ in accordance with CUlpbell
MUnicipal COde, 8ec~ion 11.04. (Applica~ion expires in 6 IIOn~ if parait n~ pulled)
A. Work address or uact. 291 Central Ave. (x-street Tubby)
utility Uanch location
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B. Nature of work:
Kill leakina service
C. A~Ucb five (5) copies of a drawing ehovillCJ the loca~ion, axten~ and diaan810ns of the work
The drawing sball sbow the relation of the proposed work to exis~ing surface and underground
bprov_entB. When approved by the City En9ineer, ..id drawin9 bacoaes a part of thb per1l1t.
D. The General Conditions for all peraitB are Usted on the reveree side. Special Prov18ions for
th18 perait are lb~ed below. Failure to abide by these condi~ions and provbions DY r..ult
in job shu~-down and/or forfeiture of FaithfUl Parfonaance BondB and caeh depositB. (See
General COndi tiOft8 1 and 2).
B. An appUca~ion fee aust accoapany th18 application. This 18 non-refundable.
Name of Applican~
~_J_W_C.
Telephone:
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The Applicant/Permi~~ee bereby agrees by affixing their 81gna~ure to this penalt ~o hold the City of I
Campbell, its officers, agents and _ployees free, safe and barllless froa any claim or deaand for I
damages resulting from the work covered by this permit. I
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Address
1221 S. Bascom Ave.
San Jose, CA
95128
Is thb work being done by the property owner at their own residence? -yes -DO
Complete and attach Workers' Coapeft8a~ion and COntractor Infonaation foras.
The Applicant/Permittee hereby acknowledges that they have read and understand both the
back of this permit, and that they will infona their contractor(.) of the informa~ion.
ACCEPTED Glennette (Emerqencv Verbal)
Applicant (Permittee) print/81gn
front and
Da~e
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACBBD, APPROVED PLUS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MOST HAVE TRIS PERMIT AND APPROVED PLUS AND MOST IIBET trI'l'R THE P.W. INSPECTOR ON
THE SITE AT LEAST TWO DAYS BEFORE STARTING WOO.
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NOTICE MOST BE GIVEN TO PUBLIC WORJtS AT LEAST 24 BOORS BEFORE RBSTARTIHG AllY WOO.
SPECIAL PROVISIONS
_1.
Street shall not be open cut for underground inBtallations. Minlaua cuts aay be allowed
for connectioft8 or exploration hole.. Such cutB 1IU.t: be IlDecificallv almroved bv t:he
Yn.a.ct:or.
Pav_ent aay be cut for underground inBtallations and auat be reatorad in accordance with
the Utility Trench Re.~oration Standard Drawing.
Work ~o be staked by a licen.ed Land Surveyor or Civil Engineer and two (2) copi.. of the
cut sbeets sent to the Public Work Deptartaent before starting work.
The hour. of work are U.mited to outBide the hours of 7-' a.a. and 3-6 p.a. for any work
affecting a traffic lane.
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PERIIIT APPLICATIOB PEB
STAHDARD AMODHT RECl:l:PT NO.
$100.00 . \~ . c:c q:>
$500.00 .
EST. ) . -
(1001 OF BRG.
(41 OF BOIID, $500 IIIJI) .
. \ C':(!) .en CV
4- \~-C1 \
Date
PINf CllBCK DEPOSIT
BOND FOR FAI'1'BI'UL PBRFORlCUCB
CASB DEPOSIT
PINf CllBCK , IHSPECTION PEB
$100,000 - $500.00 'I,
APPROVED FOR ISSUAHCE
t: PWPERMl:T
Revised 4/91