96-166
CITY OF CAMPBELL
DEPT. OF PUBUC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
.3NCROACHMENT PERMIT
(for working within the
public right-<lf-way)
5 ClJ'1lp
1 .it No.
X-Ref. File
C1 (cr~ lto tp
Application Date t.J ~'1J i(P
Application expires in 6 mos.
APPUCATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application
expires in 6 months if the permit is not issued Application Fee is non-refundable).
A. Work address or tract # ;(75 CAR l Y N /:J U 6
Utility trench location /,A.J rR () jl/r t9 P e<?S CI'fI2/ y IV .4116
B. Nature of work RePA//<- of BUI LD/f\l6 S6<.cJ6/<
.
USAH / /(p 09 ~
.4r CvRh LINt?
-START 5-1'1-'1'
C. Attach four (4) copies of engineered plans showing the location and extent of the work, and four (4) copies of the preliminary Engineer's
Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by
the City Engineer, said plans become a part of this permit.
D. AIl work shall conform to the City of CampbeIl Standard Specifications and Details for Public Works Construction; the General Permit Conditions
listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result in
job shut-down and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2.)
E. THE CONTRACTOR MUST HAVE TIllS PERMIT AND APPROVED PLANS AT THE SITE AND MUST NOTIFY THE PUBUC WORKS
DEPARTMENT AT LEAST TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GWEN TO PUBUC WORKS AT LEAST 24 HOURS
BEFORE RESTARTING ANY WORK.
Name of ApplicantlPermittee W G S T U Pt 1/6'1 S 14- J..J/ M +1 0 jV
Address /00 .E S UJVlV'I c94ks A-Ub C~f'b-eu...
Is this work being done by the property owner at their own residence? Yes
Telephone 37ff -). lfol
~ No
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 from any claim or demand for damages resulting from 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 they will inform their
contractor(s) of the information:
VVl6L HOFF
(Applicant/Permittee)
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print/sign
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