91-161
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CITY or CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
campbell, CA 95008
(408) 866-2150
~ROACHMEHT PERMIT
(tor working in the
public right-of-way)
Iuued ,,:'.-;2 c.( - 9/
Perw.it expire. in l'i aos.
perw.it Ho.
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Application Dat.
Application expire. in 6 ao..
APPLICATION _ Application i. h.reby ..de tor a ~lic Worka Perw.it in accordanca vith C..pbel1
Kuniciral code, s.ction 11.04. (Application expiTea in 6 aontha it perw.it not pulled)
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A. Work addrus or tract' ~': 0 ': A /.1 (f''\.-~ l:J C'
utility mnch ,,,,,.tlonh/ - (~f;d~ '<I~-FI
B. Nature of work:(~""~) ~ _ _ /'.2__'" I in. T( r
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Attach tiv. (5) copie. ot a drawiM ahowiM tha location, axtent and di_naiona of tha vork
The drawing ahal1 ehow tha relation ot the propoaed work to exiatiM aurtace and underqround
iaprov.a.nt... When approved by the city En9ineer, .aid dravinq beeo... a part of thia parait.
D.
The C.neral conditiona for all permita ara liated on the r.verae .id.. special ProViaiona for
thi.. permit are liated below. Failure to abide by th... condit.iona and proviaion. ..y ruult.
in job ahut-dovn and/or forfeit.ure of Faithful Parforaane& Bonde and caah depoaita. (5..
General Condit.iona 1 and 2).
E.
i. non-refundabl..
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An application fe. .uat.
'relephone:
..aae of
Addr.....
I.. this work bei"9 done by the property ovner at their own re.idanc:.? ---Y.. Lno
Coapl.te and attach Workera' coapen.ation and contr.ctor Inforaet.ion foraa.
The Applicant/perw.ittee heraby aqreea by affixinq their .ignature t.o thia permit to hold the city
of
Ca.pbell. ita officer., aqenta .nd ..ploye.. fre., .efe .nd h.rmlea. froe any claia or daaand for
daaages raault.inq frea the work cov.red by thi. parait..
Th. Applicant/Permittee hereby aeknOlo/ledqe. that they have read and understand both tha front and
back of thi.. permit., and that they vill infora their contractor(.) of the inforaet.ion.
ACCEPTEDT/"}'. 1(' c: ;\ /!,h<-" //~)1 Yl /' l'l./ ' /-< :ij:~) /~-"~() LI/
Applicant. (Permittee) pdnyiliqn/ \ Date
;;OTES: ALL TolOtt:': S!'....u. CONFORM WITH THE A'l'TACKED, APPROVED Pu.NS AND ALL APPLXCABIZ ~BEU.
STANDARD DRAWINGS AND CONDITIONS. IC E C Ii I V to r.i
THE CONTRACTOR KUST HAVE THIS PERlUT AND APPROVED PlANS AND KUST MEET WITH THE P.W. INSPECTOR ON
THE SITE AT LEAST TWO DAYS BEFORE STARTING VORl(. Ivl A Y :~ 11 b 91
NOTICE KUST BE ClVEN TO PUBLXC WORJCS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
Public Works/Engineering
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~PECIAL PROVISIONS
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Street shall not be open cut for underqround installations. Kiniaua cut. ..y be allowed
for connectiona or explorat.ion bOleS. Such cuta .ust be soecificallv .""roved bv the
Insoector.
paveaent ..y be cut for underqround inata1l.tiona and au.t be re.tored in accordance with
the Utilit.y Tranch Rest.orat.ion Standard or.vinq.
Work t.o be at.akad by a licenae4 lAnd surveyor or Civil Enqinear .nd twO (2) copie. of the
cut .heets .ent to the Public Work Dapure.ent bafore .tart.inq work.
The hours of work ara liaited to ouuide the houre of 1-9 .... and 3-6 p.a. for any work
aftectinq a traffic lane.
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IR-ll
S'l'AMDARD
'ECEIPT NO.
AMOUMT
$ \c:D. CC)
$
S
$
$ \.C{~. (:$C> ~
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oate
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PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
($50.00)
$100.00
$500.00
,-
-
BOND FOR FAITHFUL PERFORMANCE
(100\ OF ENG. EST.)
CASH DEPOSIT
($200.00) (4' OF BOND, $500 KIN)
'NSPECT'''' ~~ F.P. _D, ,'DO KIN'
'SSUaKet (.J' 6'
for Ci Y 1. ee
PLAN CHECK ,
APPROVED FOR
f: PWPERHIT
Revised 7/90
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