96-172
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CITY OF CAMPBBNL f,,. ,'.. )it"; ..
DEPT. OF PUBLIC WORKS
70 North First St. M
Campbell, CA 95008 AY 151996
(408) 866-2150
1.,;0,,,),, '"
Fax (408) 376-0958 ,f' ~ 't.ll"-- -
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~CROACHMENT PERMIT
, ,
('{for working within the
public right-of-way)
Issued 5/ I fo}~b~
Permit expires in 12 mos. - -
lit No.
A-Kef. File
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Application Date 5 - 1!5 - 9 f..p
Application expires in 6 mos.
APPLICATION - 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 #
Utility trench location L"l /i ..s
B. Nature of work r?- E. l_ D L fl - E
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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.
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D. All work shall conform to the City of Campbell 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 HA VB TillS PERMIT AND APPROVED PLANS AT THE SITE AND MUST NOTIFY THE PUBLIC WORKS
DEPARTMENT AT LEAST TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS
BEFORE RESTARTING ANY WORK.
Name of Applicant/Permittee
;:; 6 t E
Telephone
7L.-r) 700J
Address I 0 ~ () () rJ - )5 L. A ". E. '1 ,~ \J E -
Is this work being done by the property owner at their own residence'! Yes
LuP EJ~' II ,J u
No
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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:
~~
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s~ 14 - 9 (
print/sign
Date
APPROVED FC>R C;ONSTRUCTION.
City of Campbell
Public Works Permit No. 1& --Jz;:!J/7L
Contractor must have these plans
on the ;ob site during construction.
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CITY OF CAMPBELL
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31 N. ;.3-
PROJECT NO. 1t- /7.2..
REPORT NO: {
FIELD ENGINEER'S DAILY REPORT
WEATHER: ;;;, / I"'
CONTRACTOR:
INSPECTOR: K. ~5jfALL
ITEM
DESCRIPTION
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