91-153
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CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North Fir.t st.
campbell, CA IS008
(408) 866-2150
Perait No.
91-153
ElfCROACHJIII:II"l' PKRMr1'
(for working in the
public rigbt-of-way) X-Raf. file
I..ued J- IJ -1 / Application Date 5/13/91
Permit expire. in 12 ao.. Application expire. in 6 ao..
APPLICATION - Application b bereby _de for a Publio Worlca Perait in accordance with CUlpbell
Municipal Code, Section 11.04. (Application expire. in 6 aontba if perait not pulled)
A. Work addre.. or tract .
~R rnrn~r ~T W;n~hA~+Ar ~ rrimphpl'-
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Utility trench location
B. Nature of work: replace box
c. Attacb five (5) copie. of a drawinq nowinq the location, extent and diaendon. of the work
The drawing .ball sbow the relation of the proposed work to exi.tinq surface and underground
iJDprov..ents. Ifben approved by the City Engineer, .aid drawing becoae. a part of thb p8rait.
D. The General Conditions for all perait. are listed on the rever.e .ide. Special Provi.ion. for
this perait are listed below. Failure to abide by these conditions and provisions _y re.ult
in job sbut-down and/or forfeiture of Faithful Perforaance Bonda and can depodts. (See
General Conditions 1 and 2).
E. An application fee lI1l.t accoapany thb application.
Nue of Applicant Pacific Bell
1531 Parkmoor Ave.
Addre.s
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Thi. i. non-refundable.
491-7107
San Jose, CA
Telephone:
95128
I. this work being done by the property owner at their own residence? ---yes ---no
Complete and attacb Worker.' Compensation and COntractor Information foras.
The Applicant/Peraittee bereby agree. by affixing their signature to this perait to bold the City of
Campbell, its officers, agents and employee. free, safe and barmle.. froa any claim or deaand for
damages resulting from the work covered by this permit.
The Applicant/Permittee bereby acknowledges that tbey bave read and understand botb the
back of this permit, and that they will infora their contractor(s) of the information.
Bobbie (emergency verbal)
Applicant (Permittee) print/sign
front and
ACCEPTED
Date
NOTES: ALL WORK SHALL CONFORM WITH THB ATTACHED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THB CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AND MUST MEET WITH THE P.W. INSPBCTOR ON
THE SITE AT LEAST TWO DAYS BEFORE STARTING WOB.
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NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE USTARTING ANY WOlUC.
SPECIAL PROVISIONS
_1.
street sball not be open cut for underground installations. Niniaua cuts ..y be allowed
for connections or exploration bole.. Such cuts must be eDecificallv aDDroved bv the
IneDeetor.
Pav_ent ..y be cut for underground installations and II1lst be restored in accordance with
the utility Trench Restoration Standard Drawing.
Work to be .taked by a licen.ed Land Surveyor or civil Engineer and two (2) copi.. of the
cut sbeet. sent to the Public Work Deptartaent before .tarting work.
The bours of work are li.ited to out. ide the bour. of 7-1 .... and 3-6 p... for any work
.ffecting a traffic lane.
_2.
_3.
_4.
VS.
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STANDARD
AMOUNT
. \ ~t a:.J)
RECEIPT NO.
~
PERlIn' APPLICATION I'D
nOO.OO
PIM CIIBCI: DBPOSIT
BOND FOR I'AITIIFUL PERFORMANCE
CASH DEPOSIT
$500.00
(lOOt OF ERG. EST.)
(<It OF BOND, $500 lID)
.
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PLAN CBBCB , INSPBCTIOH I'D ($0-$100,000 lOt,
$100,000 - $'OO'O~ 7t, $100MIH)
APPROVED FOR ISSUANCE ~
tor Cit E e r
t: PWPERMIT
Revised 4/91
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Date
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