96-204
CITY OF CAMPBELL
DEPT. OF PUBUC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
lit No.
. _ __ef. File
9fo-20~
9 ~ - 02...
Application Date "7112/ <1(P
Application expires in 6 mos. .
APPUCATION - Application is hereby made for a Public Works Pennit 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. ';;:Ky=~":,~:~~~6?--- ~a-L-
B. Natureofwork~ ~I~ ~CAd- UW~ ~h~~ L0n~)
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 pennit.
D. All work shall confonn to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Pennit 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 Perfonnance Sureties and cash deposits. (See General Pennit Conditions 1 and 2.)
E. TIIE CONTRACTOR MUST HAVE TIllS PERMIT AND APPROVED PLANS AT TIIE SITE AND MUST NOTIFY THE PUBUC WORKS
DEPARTMENT AT LEAST TWO DAYS BEFORE STJ\RTJ.NG WO~K. NOTICE MUST BE GIVEN T9 P!:\BUC WORKS AT LEAST 24 HOURS
BEFORE RESTARTING ANY ORK. .,M~..k. ~\I ~ PeAC.; tl (.. tA(G COfI.jfr.!-n"d C()r~1t (4-cFV177 _/~~.;'
N""" of ApplkontlPennittre () D Td'Ph"""~
Address
Is this work being done by the prope
~ No
The ApplicantlPennittee hereby agrees by affixing their signature to this pennit 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 pennit.
The Applicant/Permittee hereby acknowledges that
co ractor(s) of the informatio :
d and understand both the front and back of this pennit, and they will infonn their
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7~
CI'1'Y OF CAMPBELL
FIELD ENGINEER'S DAILY REPORT
PROJECT HO.
'1t:,- 20 ~
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REPORT HO:
DATE :
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WEATHER:
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CONTRACTOR: J
INSPECTOR:
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ITEM DESCRIPTION
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