91-157
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Cl:TY OF CAMPBELL
DEPT. OF PUBLIC WORD
70 North Fir.t st.
C8apbell, Cl '1001
(401) "1-2110
PuIIU: No. Y/ -/5-7
X-ltaf. fUe
Application Date
Application upiru in I _.
DCROAaDID'l' PERIIrl'
C for workinV in the
public r19h~-of-vay)
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"nait up in 12 _.
APPLIClTION - Application 1. bezoeby _de for a Publio Worb Pezai~ in aoccrdance with caJlpbell
Municipal Code, SecUon 11.04. (Application expir_ in 6 1IOftt.ba if peza1~ not palled)
A. Work addr.aa or tract 'ILA"'~ ~o~ ~.A.4'---.21 (j ':Dd P/e./t-.2>il 0.c ,
Utility trench location
B. Na~un of workl ~~ ~~~...JL.-.' s:..:.-/€.~~~~
C. A~ueb five (I) copie. of a drawlftlJ aIlowiftlJ the loca~~ extent and cU.aenalone of the work
'l'he dravinv .ball allow the nla~ion of the propoaed work to axiaUftlJ aurface and undeqround
iaprov..enu. lIhen approved by th. City b9ineer, Aid drav1ncJ bec:oae. a part of thia pera1~.
D. 'l'he General Conditiona for all peraiu are liated on th. rav.ree aid.. 8pecial Providone for
thia permit are li.ted below. pailure to abide by th... condi~iona and proviaion. ..y r..ult
in job ahut-dovn and/or forfei~un of Paithful Perfonaenca Banda and caab d.podu. C8_
General Conditione 1 and 2).
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B. An applica~ion f_ aut .cooapany thia .pplication. 'l'bi. 18 non-refundable.
Nue of App1ioan~ -:Jl b.h b L ~ ~ /CLA H - f> /Ie < Z6 c-. LL hlephonal f'1l- 7 /(557
AcSdre.. 1~';-3 / '7.4/CK ~/,L)O,t4 ,-C::;~;LJ VD<S L c? 5-( ..2-P--'
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Ia thia work being done by the property owner .t their own ruidenca? --ye. -JlO
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'l'he Applicant/Permittee hereby .gree. by .ffixing their aip.tun to thia perait to bold the City of
Campbell, it. Officer., agent. .nd ..ployee. free, ..fe and banal_. frea .ny cl.ia or daand for
da.age. re.ulting fro. the work cov.red by thi. perait.
Coaplete and attach Worker.- COIIpen.ation and Contractor Inforaation foraa.
The Applicant/Permittee hereby acknowledge. that they have nad and under.tand both th. front .nd
back of thi. permit, .nd th.t they vill infora their contractorC.) of the inforaation.
ACCEPl'ED 06 l~ 61E&A .j;(21/V
Appl1can~ CPenait~ee) ~e
NOTES: ALL WORK SHALL CONFORM 1fX'l'H 'l'HB AT'l'ACRBD, APPROVI:D PlANS AND ALL APPLICABLB CAIIPBBLL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MOST HAVE 'l'HIS PERllIT AND APPROVED PLUS AND 1108'1' IID'1' 1fI'l'B '1'BB P.W. DSnC'1'QR OK
THE SITE AT LEAST TWO DAYS BEI'OJlI STARTING WORK.
NOTICE MOST BE GIVD '1'0 PUBLIC WORD AT LD8'1' 24 BOORS BUOU U8'1'AR'l'IIfG All! 1fOJUt.
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SPECIAL PRovrsrONfI
_1.
SUeet aIla11 not be open cut for undeqround lnau11atione. Kiniaua cu~. _y be .llowed
for connectione or exploration bol_. .ueb cuu IIU.~ be __~cifleally almrovatl bv tile
In8Daet:or.
pav..ent ..y be cut for undeqround lnaull.tiona and _t be natored in .OCCJ:danoe vith
the Util1~y Trench h.toration Standard Drawing.
Work ~o be .taked by . licen.ed Land 8urveyor or Civil Bft9inaer and ba (2) copi_ of the
cut .bee~. .ent to the Public Work Departaent befon .t.n1ncJ work.
'l'he bour. of work are lia1~ed to cub ide the boun of 7-' .... and 3-1 p... for any work
.ffecting . U.ffic lane.
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8'1'AND&IlD
AIIOUN'1'
uewrPl' .0.
PBIIIII'l APPLtCU'IOJI I'D
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1100.00
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JlIM CIIBCK DBP08U
BOND FOR PAI'1'BrUL PBRI'OlaWIcs
CA8II DBPOSU
PLU CRBCIt . DSnC'1'IOII I'D
$100,000 - "00,000
APPROVED FOR ISSUANCE
f: PWPERMIT
Revised 4/91
floo.oo
(100' OP aG. BB'l'.)
(4' OF .-0, '500 lID)
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Dat.
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