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CI~ Of CAMPBELL ENCROACHMENT PERMIT
tE . Of PUBLIC WORKS (tor working ~n the
70 orth Fint SD b,; G'~ ~ ~ ~I,Ji E.i Rtublic right-ot-way)
Cam bell CA 95t5'b81... "" "'~ w v G ~ . / /
(40 ) 866-2150 Issued ~- (>~ ~"/ Application Date
I" " .. ' '. ,1 Permit exPir n 12 1105. Application expires in 6 1105.
~ ~LICATION _ APP1~c~~~on is hereby made for a Public Works Permit in accordance with Callpbell
Municipal codep~~~6r~E~ino,~ication expire& in 6 aonth& if perait not pulled)
Permit No.
0/ / - / ~J
X-Ref. file
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A.
Work address or tract .
2.tz.&
'ROS~MAK." l'W e 22.5 HIlfl)ILlo,0 ;1U.
B.
Utility trench location
Nature of work: ''P L po. c ~
~'--~. 'C:,..r' .:&--"" ~ c A-C
J'r ./ -v I Co . 'k -./
Co~uU:.;\ WI1H
/~. ./,
. Or Jf [PC;
C. Attach five (5) copies of a drawing showing the location, extent and diaensions of the work
The drawing shall show the relation of the proposed work to existing surtace and underground
improvementa. When approved by the City Engineer, said drawing Deco... a part of this permit.
D. The General Conditions for all peraita are listed on the reverse .ide. Special provisions for
this permit are listed below. Failure to abide by these conditions and proviaions lIay result
in job shut-down and/or torteiture of Faithful Perforaance Bonds and cash deposits. (See
General Conditions 1 and 2).
E. An application tee aust accOllpany this application. This is non-refundable.
.--;) a IA i / ,I '\ ..dal ..... //]/ / QJ.I
Name of Applicant tpoC-1 .=::) C Y?i::i.--L/ l- 112;!tJ,... VA"" WO~"'&12 J Telephone: 1-/ -
Address 15 ~ \ ? A R./CVV\ocP--. A-v' C. 'S",p,t0 ,-T~' J (~A ' 1.<, lB
.
Is this work being done by the property owner at their own residence? ---yes ~o
Complete and attach Workers' compensation and Contractor Information toras.
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City
of
campbell, its officers, agents and employees free, safe and harmless froa any claim or demand for
damages reSUlting trom the work covered by this permit.
The Applicant/Permittee hereby acknowledges that they have read and understand both the front and
back of this permit, and that they will intorm their contractor(s) of the intormation.
ACCEPTEDTIIClH/JJ" C dEA//l./Ar.rY' 7'[, ~'??~3f .Jd-~ -9/
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~H~1 pt;Y,]IAs'~~Oft.:;ON
THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK.
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NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 2. HOURS BEFORE RESTARTING ANY WORK.
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Dublic 'Iii! crks! cnqj'rdc;,in,;
SPECI~L PROVISIONS
~'l. Street shall not be open cut for underground installations. Miniaum cuts lIay be allowed
for connections or exploration holes. Such cuts must be 50ecificallv aocroved bv the
Inspector.
_____2. Pavement may be cut tor underground installations and IIU.t be re.tored in accordance with
the Utility Trench Restoration Standard Drawing.
_____3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the
cut sheets sent to the Public Work Deptartment before starting work.
_____.. The hours of work are lillited to outside the hours of 7-9 a.a. and 3-6 p.lI. for any work
affecting a traffic lane.
_____5.
(R-l1
STANDARD
AMOUNT
$ .t, O<.cJ . c..::cJ
$
$
$
RECEIPT NO.
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PERMIT APPLICATION FEE
($50.0Q)
$100.00
$500.00
(100' OF ENG. EST.)
(., OF BOND, $500 MIN)
PLAN CHECK DEPOSIT
BOND fOR fAITHFUL PERFORMANCE
CASH DEPOSIT
($200.00)
PLAN CHECK' INSPECTION fEE ($0 - $100,000 10':
$100,000 - $500,000 9':~0'000 and above 7': $100 MIN)
APPROVED fOR ISSUANCE ~~~'
for Ci y nee,r '
<F. nl.'t"l1:"'p~T"" .
$ l ex'). c.D
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