91-150
~ ~ ~
...-.
...,i:
!:1
i ~ :;
iji
~!j
..
- .... ..
f C ·
., ~ ,i:
0.........
. .., ,;
... z
,i: .,
.. -
i C
u
..
.
...
:: u 0
u ~ z
'iH
J ... s
1lI_ ...
., ... .., ~
iSf]~
'1;=>>:='"
:3
.... ::: ,
-''is
~ 5,- 8
S'>-~
~ ,~ 't ~
.. : '- 'fi.
.
t ~ 1 ~
A. ., .. ~
CZTY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North Firs~ S~.
eaapbell, CA 95008
(408) 866-2150
91-150
BHCROACIIIIEII'l' PBRKrT
(for workinq in the
public riqb~-of-way)
I..ued 5//0/'l/
Perait expire. in 12 110..
peraU No.
X-Ref. file
Application Date May 9. 1 9 91
Application expire. in 6 110..
APPUCATZON - Applica~ion 18 bereby _de tor a Public Worb Perait in accordance with CUlpbell
Municipal COde, Section 11.04. (Application expi~, 6 IlOnth. if perait n~ pulled)
A. Work address or tract . NW corner~FQ.nt br. and Leiqh Ave.
-
"i
o
t=
t'Iil
n
i
"t:l
t"'4
t'Iil
"i
t'Iil
t::l
t=
~
>'
"t:l
"t:l
~
~
~
"i
B.
utility trench location
Emergency water main repair
Na~ure of work:
C.
Attach five (5) copies of a drawinq 8bowinq the location, extent and d1aensions of the work
The drawinq sball sbow the relation of the proposed work to existiD9 surface and undervround
iaprov..ents. When approved by the City Bnqineer, said drawinq becoaes . part of th18 penait.
The General CondUions for all peraUs are listed on the reverse .ide. Speci.l ProviB1ons for
this penait are lis~ed belovo Failure to abide by these conditions and provisions ..y resul~
in jOb sbu~-dovn and/or forfeiture of Faithful Perforaance Banda and ca.b deposits. (See
General Condi~ion. 1 and 2).
D.
B.
An applica~ion fee aust aCCOJlpany th18 applica~ion.
SJWC
279-7825
Thi. is non-refundable.
Name of Applican~
1221 S. Bascom Ave., San Jose, CA
Address
Telephone:
95128
Is this work beinq done by the property owner at their own residence? ---yes ___no
Comple~e and a~~acb Workers' Compensa~ion and COn~ractor Znforma~ion forma.
The Applicant/Penait~ee bereby aqrees by affixinq their siqnature to this perait to bold the City of
Campbell, its officers, aqents and employees free, safe and baraless from any claim or demand for
damages resulting from the work covered by this penait.
The Applicant/Permittee hereby acknowledges that they have read and understand botb the
back of this permit, and that they will infona their contractor(s) of the information.
Glennette -(Emergency verbal)
Applicant (penaitt.e) print/siqn
front and
ACCEPTED
Date
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPUCABLB CAMPBBLL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AND MUST MEET WI'l'B THB P.W. INSPBCTOR ON
THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK.
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RBSTARTDfG ANY WORK.
-
"i
o
t=
t'Iil
n
i
"t:l
t"'4
t'Iil
"i
t'Iil
t::l
t=
~
n
~
"i
~
SPECIAL PROVYSIONS
_1.
Stre.t shall no~ be open cu~ for underqround installa~ions. Nint.ua cuts ..y be allowed
for connections or exploration bole.. Such cuts aust be saecificallv aaaroved bv the
Insaector.
Pav_en~ may be cu~ for underqround installations and aus~ be r_~ored in .ccordance with
the Ctili~y Trench Res~ora~ion S~andard Drawinq.
Work to be s~aked by a licensed Land Surveyor or Civil Bnqin_r .nd two (2) copies of the
cut shee~s sent ~o the Public Work Dep~artmen~ before starting work.
The hours of work are limi~ed ~o outside the bours of 7-9 .... and 3-6 p... for any work
affec~ing a traffic lane.
_2.
_3.
_4.
_5.
STANDARD
AMOtJIfT
. \ese.co
RECEIPT NO.
PBRIII'1' APPLICATIOH PEE
Cf
$100.00
PLUf CIIBCI: DBPOSIT
BOW FOR FAr1'BFDL PBRFORlWfCB
CASH DEPOSIT
$500.00
(loot 01' DG. EST.)
(4t 01' BOHD, $500 1IDf)
.
.
.
. \ec:>.CO
PLAN CBBCK , IHSPBCTZOH FBB
$100,000 - $500,000
APPROVED FOR ISSUANCE
cp
S~\O-9 )
Date
f: PWPERMIT
Revised 4/91