96-174
C--Y OF C:\.MPB~.U
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
ENCROACH~EN;' PERMIT
(for working within the
public right-of-way)
Issued 5/23/ q{p
Permit expires in 12 mos.
Pe:rr;:t No. 96 -1 7 4
X-Ref. file
Application Date 5/1 7/9 6
Application expires in 6 mos.
APPUCATION - Application is bereby IIIIde for. Public Works Permit in acconIance wirh CaqlbeII MUDicipaI Code, Secdon 11.04. (Applialbon expires in 6 IIIOIIIbs
if Ibe permit is DOt issued. Application Fee is _rdimdlble.)
North side of Hollis Avenue, 10' e/o 670 Nello Drive
A. wort Iddress or lnICt ,
Utility tmx:h location
B. NllUre of work
EMERGENCY Main Repair - 2'x2' cut in concrete
C. AllICh four (4) copies of an enaineered plans showina Ibe Iocalion and CIIaIl of Ibe wort, IIId four (4) copies of Ibe preliminary EDaineer's EaimaIe of work. The
plans shall show the relation of the proposed work ID emtina surface and IIIIlIerJrouDd improvallCllll. WbeD Ipproved by Ibe City EDaineer, said plan becomes a part of
Ibis permit.
D. All work shall confonn ID the City of Campbell SIIIldarcI SpecifICllions IIId DeWIs for Public: Worts Coastruc:lion; Ibe GenenI Permit CcmditioDs Iisled 0II1be reverse
side; and the Special Provisions for this permit, listed below. Failure ID Ibide by lbese c:oadiDoas IIId provisions may resuk in job shut-down and/or forfeiture of Failhful
Performance Sureties and cash deposits. (See GenenI Permit CondiIions II11d 2.)
E. THE CONTRACTOR MUST HAVE TInS PERMIT AND APPROVED PLANS AT THE SITE AND MUST NO'I1FY THE PUBUC WORKS DEPARTMENT AT
LEAST TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GIVEN TO PUBUC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
San Jose Water Company T~~-- 279-7979
Name of Applicant .....,.""""
24 HOUR EMERGENCY
Address 1221 South Bascom Avenue. San Jose95128 TELEPHONE NO.
b this work being done by the property owner It their own residence?
Yes
No
The Applicant/Permittee hereby agrees by alllxina their sipature ID Ibis permit ID hold the City of CaqIbeII, iIs officers. apatIlIId employees free, safe and IwmIeu from
any claim or demand for dama&es resultin& from the work covered by this permit.
The ApplicantlPenninee hereby acknowledaes lhIllhey have read and understand both the froDt IIId back of Ibis permit, and Ibey wW infonn their COIIIrII:lOr(s) of the
information.
Accepted
Jane Leinberger (EMERGENCY VERBAL)
(Applicant/Permittee) priDLlsian
5/17/96
Date
=~~~fi~_~T~~"~::%~="':::":".'~
_3. Work ID be Jtaked by a 1ic:enRd Lan4 Surveyor or Civil ~aad tWo (1) eapa of tiJii:.Qit sMelsiciilt t01bCP\JbIie W'oib ~ beI'oRltiniaa wort. ..'
4. . Prior ID swtina work, tile CoiItracIOt sIIa1I DOtlfy USA 1lId shall JeCQrd. thetJSA.lllqlliry Ic1erIific:aIiD NlIlDller JIeNcm. .... . . ....
75.~~~ ;~;;SU ,'tNf.b'fg.. f'.~~1fIJ&l~71;J~> ........
" .", ,.. "........................................
. ':',:'-,".,..-:..:'.,-'--.-:.:-:-:-.-:.'..'.-:...---'-.-.....-.'.:-...-:...:-:-.-:.:-:--...-:-:-.-:-.-:---:...-:-....:........,..'....,.,'.......',.....,'.
.. - ---- .. . ." ... ,....-. ... . ...... ,"," ,",- -,,- -- --.........,',..........
, ... '" ."., - ---. .",' .,",",.-,.-,",.--, -- -,-,-'-" ,.., ,.......
"".".-.,.....",. ...,_....... ,.,.,.... .,".- -,-- . - --,.. """"""-'
--......... .." ..-, -", ,."..... - -- '-.-,---,-- --,..." ,.....",..
.... .". .., - - "'" ,.,.....,..... - -, .-.-.-_..,.....-. "....".
...." "" .."-,--,, . ..",.. ....-.- .- -.,. ,....,...,....
PERMIT APPLICATION FEE ... . ... .... .. .... ...... ................. < .>........:,.....
PLAN CHECK DEPOSIT .. .... .. .. .... .... . '.' > ..........
SURETY FOR FAITHFUL PERFORMANCE (tOOl OPIiNO.BST.) ...
CONSTRUCTION CASH DEPOSIT. .
PLAN CHECK &.INSPECTlON
... __ _d'
_____ d... ___ _ _ _. . . __ ""..
.. "" --,. ,,- ---- ... - -- -- '" ."...
.::-:-:-'-::-:-:::-:-:-:-:::-:-:-:-:.:::::-'-:-::-.'::::-::::: .:.::::::-::::::.:::::-::::::::::;:::::::::::::::::.:::::::::.::-:-::::;.::;::::::::-., :-:.....:.-:::-:::-.-..'-::..':. -'::,-::.-..-'-<::':::';.:,:,::::-'
............<.............<........ttPi......................................................ijuJiii.........<<...REcinPTNO.>.........
.....................................~Z-I.t.....[..... ..........................................~.J2~.~...4iB.......................... ......y$
.<...........><$. ..... .... ... ---
. .....................................s.. . .......
.Q