96-226
CITY OF CAMPBELL ENCROACHMENT PERMIT
DEPT. OF PUBLIC WORKS (ft', worlcing within the
~o,:;::I.F~~ ;~008 .~ . :ic rig~htjf-waY) J ~
(408) 866-2150 Issued /2'fS 1'1 ~~ Application Date 5\ 'U. ~w,
Fax (408) 376-0958 Permit expi s in lZmos. Application expires in 6 mos.
APPUCATION - Application is hereby made for a Public Works Permit in accordance with CamP:I1~~;i~~e, S~~~04. (Application
expires in 6 months if the permit is not issued Application Fee is non-refundable).
Permit No.
X-Ref. Fil.e
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B. Natureofwork IN/?''ALLATION ot:- vJA~R t-IlAl...J AIJo ~"IGE-::' (El..--z."'?) ~~ ~
c. Attach four (4) copies of engineered plans showing the location and extent of the work. and four (4) copies of the prelimi~~tsngin~
Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvemen~~e~ ~ved by.,":"
the CIty Engineer, said plans become a part of this permit. ";,~ ~
A. Work address or tract #
Utility trench location
884~
I
L \ ,-n..ETON
PLACE
Ol"F HAR~IE"
AVElJL IE
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D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditibns
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 TIlE SITE AND MUST NOTIFY THE PUBUC 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 ?AW JOSE WA~ Cot--1PAa.J'<
Yes
5A~ JOSE
>< No
CA
'27"1 -,84,
9C?IZG'
Telephone
Address
Is this work being done by the property owner at their own residence?
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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
col1lractor(s) of the information:
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a.!{:J11oJ ~1~(:J1 c:;,~,'?O,,=
print/sign
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Date
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