96-178
CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
ENCROACHMENT PERMIT
(for working within the ;:::::)
public ri~~t-of-Way) ~J;
Issued 'J 30 g l.p ,
Permit expires in 12 mos.
Permit No. 96-178
X-Ref. file
Application Date 5/2 8/9 6
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.Workaddress ortract# 211 Adler (x-st. Echo Ave)
Utility trench location
B. Nature of work
EMERGENCY Main Repair - 4'x10' cut in concrete
C. Aaach four (4) copies of an engineered plans showing the location BOd extent of the work, BOd four (4) copies of the preliminary Encineer's Estimlte of work. The
plans shall show the relation of the proposed work to existing surface BOd underground improvements. When approved by the City Engineer, said plan becomes a part of
this pennit.
D. All work shall confonn to the City of Campbell Standard SpecifICations BOd Details for Public Works Consttuction; the GeoclaI Permit Conditions listed on the reverse
side; and the Special Provisions for this pennit, 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 BOd 2.)
E. THE CONTRACTOR MUST HA VB THIS 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.
Address
San Jose Water Company Telrphone
(print name)
1221 South Bascom Avenue, San Jose, C~~~O.
24 HOUR FMERGENCY
279-7979
Name of Applicant
Is this work being done by the property owner at their own residence?
Yes
No
The Applicant!Pennittee hereby agrees by affb.ing their signature to this pennit to hold the City of Campbell, its off'K:eI'S, agents and employees free. safe and harmless from
any claim or demand for damages resulting from the work covered by this pennit.
The ApplicantlPennittee hereby acknowledges that they have read and understand both the front and back of this pennit. and they will infonn their contractor(s) of the
infonnation.
Accepted
Jane Leinberger (EMERGENCY VERBAL)
(Applicant/Permittee) (sign)
5/28/96
Date
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