96-192
CITY OF CAMPBELL P,NCROACHMENT PERMIT
DEPT. OF PUBLIC WORKS r working within the
~~;~~I,F~~ ;~008 IsPsuUebdliC right(~Wr; L/,/r;
(408) 866-2150 l{/ ~ [: Applk.';o" Date fu /1#,,9 (,e
Fax (408) 376-0958 Permit expires in 12 mos. Application expires in 6'mos , C
APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (A!iltiV, 0
expires in 6 months if the permit is not issued Application Fee is non-refundable). llUN 1 4:
A. Work address or tract # .23 .5aIlJIJ'I.5/.Dt!:: AVeNuE!: ~
Utility trench location MYr...flf -S/IX:.... or ..5?uNNY~/.IE. A-us IDLa' e /0 WII\Jc..H~.s~.!}LtJJ::J
, . '"'II(, .
O~/&/rc: 0 ICf'O/ '~/Jc^,
9 fo -- /qJ-;
B. Nature of work //V.511JLL CtAs -.,;- t:L6cr~/(" pfC/U17CS
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 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.
Name of Applicant/Permittee
Address / OC 00 A.i
Is this work being done by the property owner at thei
Telephone 7;lS-, 2 oLJ9
c~ '-f
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:
XD::YL JJE..QAr-111J
(Applicant/Permittee)
liMN FJ,a~
print/sign
Lc;- 5- '1b
Date