96-190
CITY OF CAMPBELL ENCROACHMENT PERMIT 'lit No. q 0 - I qo
DEPT. OF PUBLIC WORKS (for working within the _,ef. File ~,~ q 3"3CDB
70 North First St. public right-of-way) (;
Campbell, CA 95008 &. 3/
(408) 866-2150 Application Date ~ /. 'rtIP
Fax (408) 376-0958 Application expires in 6 mos. C l, "
APPUCATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, SectiovlM. (APPlicatiol I:)
expires in 6 months if the permit is not issued Application Fee is non-refundable). UN 1 a ~
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A. W"'k......... '" """. ~ ~ A ~ee.'->'I - t'lW":fi"I (U) = "1"'" c.... ~ 'D"". l w~ ~
Utility trench location I ~~ I ,,^,,~"T o~ '\S~C4M... ~ ~~etI- AVcE ""'SrR '\~S
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B. Nature of work 3)( S ~~ ~ 7S (\~ ~c3lUIc...€ ~ #Vi iH IV
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. 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 HAVE 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 PUBUC WORKS AT LEAST 24 HOURS
BEFORE RESTARTING ANY WORK.
Name of Applicant/Permittee ~ ~ &C... G.Ao.; ~ ~uac... -rCl.4.L.
Address , C) ~ ~O kl. ~c....A-N e"r.""1 4v c.# ~ , . PI
Is this work being done by the property owner at their own residence? Yes
Telephone 1 Z. "5 ZOC\1.-
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1(_ 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/P rmittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their
contractor(s) the . formatio
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RECEIVED
JUN 131996
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ADMINISTRA TION
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