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X-Ret. file :
Application Date 5t#lq~ tii C fi, ~ ".\
Application expi e. in 6 aoa. I
t'li A Y :~ Ii 'I
APPLICATION _ APplication i. haraby aada for a ~lic Worka Perait in accordance vith caapbeli '
Municipal Code, section 11.04. (APplication expire. in 6 aonthI5 if perait not pulled). :
~ublie W ork4./ Enainotrio<1
E AS T D ~ \-\ 'W '(. \7 I
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CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
ca~pbell. CA 95008
(40B) 866-2150
~NCROACHMENT PERMIT
(for vorkin9 in the
public ri9ht-o,-vay)
Iuuad 'ti~ 3 / q /
perait a ira.' in 12 aos.
parait No.
9) - /~> 2-.
A.
Work address or tract I
ON
HAMILTDN
AYE.. .
II.
Utility trench location ~
Nature of vork: PQT\-\DLG: MAIN Ceo: 51-74cd\f7)I),;}
Attach five (5) copiaI5 of . dr.vil\9 .hovil\9 tha location, axtent and d1aeNliona of the work
The drawin9 .h.ll I5hOV tha ral.tion of tha propo.ed work to exbtil\9 .urf.ce and underc,r0un4
iaprova_nts. When .pproved by tha City El\9in-r. _id drav1!\9 becoaea a part of thi. perait.
C.
D.
Tha Cenaral conditiona for .11 per1aU. ara 1bted on tha reverea .1da. Ipacla1 ProVl.101W for
thi. perait .ra U.tad below. FaUura to abida by tha.a conditione and prov1alona aay reau1t
in job I5hut-clown and/or forfeiture of F.ithful Parforaance IIO~ and caab dapoaiU. (Saa
canerd Conditione 1 and 2).
E. An application faa w.t accOllp8JlY thia .pplication. 'tbi. ia non-nfunclable.(. ~
.... of Applicant SAN cJD5E.. WAT'E:.R C-OMPA-t'JY 'h1aphona:~D~
\2.2..\ 5;0. YbA-SC.OMAVE. SAN'JOSE CALiF. 0)5\2.8
2. 7 OJ - 7 2:A;Go
Address
~no
Is this work beinq dona by tha property ownar .t thair own ra.idanca? ---ya.
coaplete and attach Workers' Coapeneation .nd Contr.ctor Inforaation fOr1a&.
Tha Applicant/peraittee bareby .qraas by .ffixinq thair .iqnetura to thi. perait to bold tha City
of .
ea.pbell. its ofUcers. a9anU and _p1oyaa. fna. _fa .nd berala.. froa any cl.1.a or daaand tor
4a..ges resulting froa the work covar.d by thi. perait.
The Applicant/Peraittee bareby .cknoWladI,JeI5
back of this perait. and that thay 101111 info
ACCEPTEDF-:.:> E.N ~ A)I.J A R.E. ~
Applicant (peraittaa) print/.19n
thay5. ha a raad .nd undersUnd both tha front and
thair tr.ctor(.) of tha inforaatlon.
atA ~ ~~y 24. 199'
Data / /
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PUNS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MUST KAVE THIS PERKIT AND APPROVED PLANS AND MUST MEET WITH THE P.W. INSPECTOR ON
THE SITE AT LEAST TWO DAYS BEFORE STARTINC WORX.
NOTICE MUST liE CIVEN 'l'O pUlILIC WOIUCS AT LEAST 24 HOURS IlEFORE RESTARTING AMY WORX.
SPECIAL PROVISIONS
_1.
Street shall not be open cut tor undarqround instaU.tiona. Klni.ua cuU -y be aUowed
for connections or exploration boles. Such cuU ~ust be .oecificallY aDDroved by the
Inspector.
pave.ent aay be cut for underground Inatall.tion. and w.t be ra.torad in .ccordanca with
the Utility Trench Restoration Standard Drawing.
Work to be .taked by a licen.ed Land surveyor or Civil El\9inear and two (2) copiaI5 of the
cut aheets sent to the Public Work Daptartaent befora .urti1\9 work.
The hours of work .re llaitad to out. ide tha bourtl of 7-9 .... and 3-6 p... for any work
affecting a traffic lane'\wt,_
, """ :"-I"-'Y'... I~l""'-- """ze, h~t 'Y:) "'2,,",= P"'I
MoL)~'lt\UU"\\ ~_ \-IOi""f'lL1:=- N.~- e.~~ Ct-
Lr::...t....h=-:...-,.- .~ L;.~~ \ ~~ -rr, ~,,1I.....~ O\~. U~~
~0\C- h~ ~tz.r.::::. '"S,.l{..al. J, ~~LY'S
~ L- C) e:- "'\n../':=. . C- <:::-c t:-) ~\..- ' \.! eJ
(R-H _~AN01.RD AMOUNT HCEY" NO.
,\~.00 a
($50.00) !;100.00 S .~ "..,..., -;
v;.
_:l.
1,./""...
\./'"5.
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
$500.00
(100\ OF ENG. EST.)
(4\ OF BONO, $500 KIN)
$
S
-
BONO FOR FAITHFUL PERFORMANCE
$
. ~SS;.~
$ \~.K:.-
CASH DEPOSIT
($200.00)
~
'1-'"2-~ -q \
Oata
PLAN CHECK , INSPECTION
~~ ~ $100","'
for Of ~ ee (}
APPROVED FOR ISSUANCE
f: PWPERMIT
Revised 7/90
5~ '3-24-O)l
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