91-148
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CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North Pirst st.
campbell, CA 95008
(408) 866-2150
P.rmit No. 91-148
DCROACIIIIEII'l' PBRIUT
(for working in the
public right-of-way)
Issued 5'/&:/ /9/
Permit expir.. in 12 IIOS.
X-Ref. fU.
Application Date 5/6/91
Application expires in 6 IIOS.
APPLXCATJ:ON - Application i. h.reby _de for a Public Wora Permit in aocordance with CUlpbell
Municipal Code, Section 11.04. (Application expires in 6 aontha if perait not pulled)
A. Work addree. or uact . Union Ave. and Campbell Ave.
utility trench location
B. Nature of work: Cuttino 4 x 10 ln asphalt to repair leaky valve
c. Attach five (5) copies of a drawing showing the location, extent and dlaensions of the work
The drawing shall show the relation of the proposed work to existinCJ surface and uneSerCJrouneS
improv_ents. When approved by the City Engineer, _ieS drawinCJ becoaes a part of thb permit.
D. The General Conditions for all peraits are listed on the revers. sieSe. Special Provisions for
this permit are listeeS below. Failure to abide by these conditions and provisions ..y r.sult
in job shut-down and/or forfeiture of Paithful Perforaance Bonds and cash deposits. (Se.
General coneSitions 1 aneS 2).
E. An application fee au.t accoapany this application. This is non-refundable.
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NUle of Applicant PG&E
Address 10900 N. Blaney Ave., Cupertino, 95014
Telephone:
Is this work being done by the property owner at their own residence? ---yes ___no
Complete aneS attach Workers' Co~ensation and COntractor Information forms.
The Applicant/Permittee hereby agrees by affixing their signature to this permit to bold the city of
Campbell, its officers, agents aneS e.ployee. free, .afe aneS harmle.s fro. any claim or deaaneS for
da.age. resulting fro. the work covered by this permit.
The Applicant/Permittee hereby acknowleeSge. that they have reaeS aneS uneSer.taneS both the front aneS
back of this permit, aneS that they will inform their contractor(s) of the information.
ACCEPTED Julie Coff land (Emerqency verbal) 5/6/91
Applicant (Permittee) print/sign Date
NOTES: ALL WORK SHALL CONFORM WI'1'H '1'HB ATTACHBD, APPROVED PLANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
'1'HB CON'l'RACTOR MUST HAVE '1'HIS PERMIT AND APPROVED PLANS AND MUST IIEE'r 1fI'1'H '1'HB P.W. INSPECTOR ON
'1'HE SITE AT LEAST 'l'W0 DAYS BEFORE STARTING WORK.
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NOTICE MUST BB GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
SPECIAL PROVISIONS
_1.
Street shall not be open cut for underCJround installations. Hiniaua cut. ..y be alloweeS
for connections or exploration hole.. Such cuts .ust be saecificallv aDDroved bv the
In_nectar.
pave.ent may be cut for uneServrouneS installations aneS au.t be rutored in accordance with
the utility Trench Restoration StaneSard DrawinCJ.
Work to be stakeeS by a licenseeS LaneS Surveyor or civil BnCJin..r and two (2) copies of the
cut sheet. ..nt to the Public Work Deptartm.nt before starting work.
The hours of work are U..ited to out. ide the hour. of 7-9 a.a. and 3-6 p... for eny work
affecting a traffic lane.
_2.
_3.
_4.
~5.
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STMlDARD
AMOUNT
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RECE:rPT NO.
Cf>
PERMIT APPLICATION I'D
$100.00
PLAN CllBCK DBPOSIT
$500.00
(loot or DG. EST.)
(4t or BORD, $500 KIN)
.
$
$
$ \ CS:C>. CC>
BOND FOR PAI'1'II1"DL PERPORMAHCB
CASH DEPOSIT
PLUI CllBCK , INSPECTION I'D
$100,000 - $500,00 9t,
APPROVED FOR ISSUANCE
f: PWPERMIT
Revised 4/91
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