96-220
CITY OF CAMPBELL
PUBLIC WORKS DEPT.
70 N. First S1.
CampbelI, CA 95008
(408)866-2150
FAX (408)376-0958
OWNER OCCUPffin R-l
NO FEE ENCROACHMENT PERMIT
(for working within the
public right-of-way)
($5,000 maximum va1tte of work)
8) ,/Q,
ISSUED I 'f I 1 it>
Permit No.
X-Ref. File
Application Date
910 -220
I
9/1.1+ /9 (p
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ADDRESS I 5 3 -
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(Print Name)
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The Applicant hereby confirms that this work is being done by the property owner/applicant at their own residence.
The Applicant 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 hereby acknowledges that they have read and understand both the front and back of this permit, and that they will
inform their contractor(s) of the information.
ACCEPTED /J<7, /:J. /!J~~.. C-c:~~~~
Applicant/Permittee (Sign)
0/\4116
Date
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE
CAMPBELL STANDARD DETAILS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AND MUST ARRANGE TO MEET WITH
THE PUBLIC WORKS INSPECTOR AT THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK.
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
PER SECTION 4215 OF THE GOVERNMENT CODE THIS PERMIT IS NOT VALID FOR EXCAVATIONS UNTIL
UNDERGROUND SERVICE ALERT (USA) HAS BEEN NOTIFIED AND THE INQUIRY IDENTIFICATION NUMBER
(TICKET NO.) HAS BEEN ENTERED HEREON. USA PHONE: 1-800-227-2600. TICKET NO.
SPECIAL PROVISIONS
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APPROVED FOR ISSUANCE
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RECEIP~ NO.
11/,1.
for ity Engmeer
Permit Expires 6 onths After the Date of Issuance
Date
j: orms r 1 permit/rev. 6
( SEE OTHER SIDE)
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~ APPROVED !-OR CONST~UCTION.o
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on the Job site during construction. , 0 0 . 0 G 3 N r.., ..J.....L ~ 3 cd 0 ~ d