91-154
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CITY OF CAMPBELL
DEPT. OF PUBLIC WOJU(S
70 North First st.
Campbell, CIa 15008
(408) 866-2150
EIICROACIIIIEIIT PBRMr1'
(for working in the
public right-of-way)
Issued 3-1.3 -3/
Permit expires . 12 IIOS.
Permit No.
91-154
X-Ref. file
5/13/91
Application Date
Application expires in 6 110..
APPLICATION - Application is hereby ..de for a Public Works Perait in accordance with caapbell
Municipal Code, Section 11.04. (Application expire. in 6 .onths if permit not pulled)
NE corner Dillon and Sam Caba
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A.
Work address or tract .
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utility trench location
8. Nature of work: 3X5 hole - raising gate boxes
c. Attach five (5) copies of a drawing showing the location, extent and dimensions of the work
The drawing shall show the relation of the proposed work to existing surface and underground
improv_ents. When approved by the City Engineer, said drawing beeo.es a part of this permit.
D. The General Conditions for all permits are listed on the reverse side. Special Provisions for
this permit are listed below. Failure to abide by these conditions and provisions aay result
in job sbut-down and/or forfeiture of Faithful Performance Banda and casb depodts. (See
General conditions 1 and 2).
E. An application fee .ust accaapallY this a~plication. 'l'bis is non-refundable.
San Jose water co.
N..e of Applicant Telepbone:
Address 1221 S. Bascom Ave., San Jose, CA 95128
279-7825
Is this work being done by the property owner at their own residence? ---ye. _no
Complete and attacb Worker.' Compen.ation and Contractor Information foras.
The Applicant/permittee bereby agrees by affixing their signature to this permit to bold the City of
Campbell, its officers, agents and employee. free, .afe and harmless from any claim or demand for
damages reSUlting from the work covered by this permit.
Tbe Applicant/permittee bereby acknowledges that tbey bave read and understand both the front and
back of this permit, and that they will inform their contractor(s) of the information.
ACCEPTED Jan (emergency verbal)
Applicant (Permittee) print/sign Date
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AND MUST MEET WITH TIlE P.W. INSPECTOR ON
THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK.
NOTICE MUST BE GIVEN TO PUBLIC WOJU(S AT LEAST 24 HOURS BEFORE RESTARTING AHY WORK.
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SPECIAL PROVISIONS
_1.
Street sball not be open cut for underground installations. Minimum cuts aay be allowed
for connections or exploration boles. Such cuts must be snecificallv aaaroved bv the
Insaector.
Pavement may be cut for underground installations and aust be restored in accordance with
tbe Utility Trencb Restoration standard Drawing.
Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the
cut sbeets sent to the Public Work Deptartaent before starting work.
The bours of work are limited to outside the hours of 7-9 a... and 3-6 p... for any work
affecting a traffic lane.
_2.
_3.
_4.
_5.
STANDARD
AMOOHT
.~, OL?
RECEIPT NO.
PBRJIIT APPLICATION FEE
'100.00
q
PLAN CIIECl[ DEPOSIT
BOND FOR FAI'l'lIFOL PERFORMANCE
CASH DEPOSIT
'500.00
(100' OF BNG. EST.)
(4' OF BOND, $500 KIN)
<<--
f: PWPERMIT
O_,,<lClAt't 4/Q,
---Q:.--
PlNI CHECK , IHSPBCTION FEE
$100,000 - $500,0 9',
APPROVED FOR ISSUANCE