91-167
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CITY OF CAHPBELL
DEPT. OF PUBLIC WORD
70 North fir.t st.
caapbell, CA '1001
(408) 166-2150
Perait No. ? / -I (, 7
X-bf. file
Application oat.
Application apir.. in , ...
BNCROACIIIIEIft' PZRIIrf'
(for working in the
public r19ht-of.....y)
I..ued tR -:2-5 -1.1
Perait .xpiru in. 12 _.
APPLICATION - Application i. benby ..d. for a Publio WOrb Penit in aooordance with CUpbell
Municipal COde, Section 11.04. (App ication e.xpire8 in 6 _ntba t parait not pulled)
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A. Work addr... or tract .
Utility trench location
8. Nature of workl
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C. Attach five (I) copie. of a drawi..., showi..., the location, extent and cU.aansions of the work
The drawing .ball show the relation of the propo.ed work to exi.ti.. .urface and undeqround
aprov..enta. Nben approved by the City _ineer, ..id draw1nljJ becoae. a part of thia penit.
D. Th. Gen.ral ConcUtion. for all peraita are li.ted on the rev.n. .id.. special Proviaiona for
thi. permit are 1i.ted below. Fai1ur. to abide by th... conditions and provi.ion. ..y re.ult
in job .hut-down and/or forfeiture of Faithful Perfonaanca Bonds and cash apo.ita. (S..
General COnditions 1 and 2).
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Thi. is non-refundable.
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The Applicant/Permittee hereby agree. by affixing their .iljJft8ture to thi. perait to bold th. City of
Ca.pb.ll, it. officer., agent. and ..ploy... tree, .at. and baral... tro. any c1aa or daand tor
da.age. re.ulting tro. the work covered by thi. perait.
Addre..
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co.plete and attacb Worker.' eoapen.ation and COntractor Intonation foras.
The Applicant/Permittee hereby ecknowledge. that they have read ~~d~::r.tand both the front and
::':D~rt;~~.~;% inf.'t:z:EJt~. inf77'z hI
App icant (Peraittee) print/ailjJD Oar ., ,
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NOTES I ALL WORK SHALL CONFORM WITH THE A'l"l'ACllBD, APPROVED PLANS AND ALL APPLICABLB CAHPBBLL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS UD MUST IIDT WITH THE P.W. IWSPBC'l'OR ox
THE SITE AT LEAST TWO DAYS BEFORE STARTING WOIUt.
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NOTICB MUST BE GIVD 'l'O PUBLIC WOIUtS AT LBAST 24 HOURS azroRE DSTARTIlIG AllY WOJUt.
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SPECIAL PROVISIONS
_1.
Street shall not be open cut: for und.rground install.tion.. Kinlaua cuta ..y be .llowed
for connections or exploration bo1... .uch cuta .uat M alNleifieallv aDDraved bv the
J:n.t).C'tor.
Pavement aay be cut tor underground install.Uons and _t: be restored in aooordance with
the Utility Trench Re.toration Standard Drawing.
Work to be .taked by a licen.ed Land Surveyor or Civil Bngin..r and two (2) copi.. of the
cut .beet. .ent to the Public Work Deptartaent before .tarti..., work.
The bour. of work .re l1ait:ed to outaide the hours of 7-' .... and 3-6 p... for any work
.ffecting . traffic lane. .......
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UC!:IPT NO.
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PERIIIT APPLICATIOJI I'D
$100.00
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PLU CIIBCIt DBPOSIT
BOND FOR FAI'l'IU'UL PBRl'OR'tt'UCB
CUB DBPOSIT
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(lOOl OP BIIG. 1:8'1'.)
(n or .-0, $500 lID)
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PLAIf CllBCIt , DSPBCTIOX rBB
$100,000 - $100,000 l,
APPROVED FOR ISSUANCE
f: PWPERMIT
Revised 4/91 , .. J .".JI'J
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APPROVED FOR CONSTRUCTION.
City of Campbell
:::'i~Public Works Permit No. C(/-(t,.
A: 'I~ ~ \ s' cont~ctor must have the
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"An
3 FT. UTILITY EA
REFUNDABLE DEPOSIT
CHECK REQUEST
TO: SANDY TERPKO
ACCOUNTS RECEIVABLE
Pl ease issue check payabl e to: John Glaqe Underqround
Address:
Line 1: P.O. Box 761
Line 2:
City: Campbell
State: CA
Zip:
95009
Description: Ref Deposit/Permit No: 91-167
INTEREST EARNED
Exact Amount Payable:
$500.00
Account Number: 001.00.905.4662
001.05.540.4448
LOCATION:
549 Virginia Avenue
DATE AND NO. OF RECEIPT:
6/26/91
Receipt No. 30194
PURPOSE:
Cash Deposit
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Requested by: Michael A. Fuller Title: Asst. Enqineer Date: 11/13/92
Approved by: Cl-g /J~ Title: City Enqineer Date: 1/t,,/9 L
Verified by: tfoan . Bollier Title: Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Ma il as i s
xxx
Mail in attached envelope
Return to:
(Department)
(Name)
Other:
Rev 11/21/91
TO:
City Clerk
PUBLIC WORKS FILE NO.
q 1-/&7 7
,
ACCT ITEM AMOUNT RECEIPT NO
Please collect & receipt
for the following monies:
3372
3521
3521
Project Revenues (specify proJect)
Public Works Excavation Permit Fees:
Application Fee
Plan Check Deposit
Faithful Performance (Cash) Deposit
$
35.3396
R-1:
($50)
Other:
($100)
($500)
(100% of)
(ENGR. EST)
(4% of FPB)
($500 min.)
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Other Cash Deposit (specify)
($200)
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3372 Plan Check & Inspection Fee ($0 - $100,000 10%;
$100,000 - $500,0009%; $500,000 and above 7%; $100 min.)
3373 Project Plans & Specifications ($10)
3373 General Conditions, Standard Provisions & Details ($10 or $1/page)
3373 "No Parking" signs ($1Iea. or $25/100)
3373 Work Area Traffic Control Handbook ($5)
3373 Copies of Engineering Maps & Plans ($.50/sq.ft.)
3372 Final Parcel Map Filing Fee ($450 + $20 per lot)
3372 Final Tract Map Filing Fee ($500 + $20 per lot)
3372 Lot Line Adjustment Fee/Certificate of Compliance ($400)
3372 Vacation of Public Streets and Easements ($500)
3372 Assessment Segregation or Reapportionment
First Split ($500)
Each Additional Lot ($150)
3395 Park Dedication In-lieu Fee per Unit ($4,548)
3370 storm Drainaqe Area Fee
3380 Public Works Special Projects
3510 Postage
TOTAL $ 70-0
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NAME OF APPLICANT .::J'olIlJ v-+4t:-E- U 1VClU'e-~ovAJ~ u,;tJ' PHONE d' 79 -J{J 2)
ej'{.? 1 H ~~_LL-. ~r ZIP ?s-oO 7
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FOR
CITY CLERK
ONLY
RECEIVED BY
DATE