96-231
CITY OF CAMPBELL
PUBLIC WORKSiJlElI.(~ 21;;
70 N. First St. .
Campbell, CA 95008 SEP 1
(408)866-2150 1 1996
FAX (408)376-0958 tJUuLil \: '. ..-'
ADMINISTR4 TJ~~
APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section
11.04. (Application expires in 6 months if the permit is not issued.)
OWNER OCCUPIED R-l
....NO FEE ENCROACHMENT PERMIT
Iii ~ "Lfpr working within the
public right-of-way)
($5,000 maximuIl,l value of work~
ISSUED 9/11/90 ~. /
Permit No. (I f.~ :;(..5/
X-Ref. File
Application Date q - //- Y"C::
A. Work Address
B. Nature of Work I t-' <-
C. Attach three (3) copies 0 a drawing showing the locat on, exten d di ensions of the work. The drawing shall show
the relation of the proposed work to existing improvements. When approved by the City Engineer, said drawing becomes
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
securities.
NAME OF APPLICANT VIla CANGG.N11
(Print Name)
3 ~ . 1/ I
ADDRESS Z::J I J p.. \:., . (7 :5 :::: D ["'1 ('.) I:. 1.5
TELEPHONE 3 {' C. - (. 7 c --;-
l D l' U 4: ,'-:-,:: , .::./, ~/"'; c> :5 L_
The Applicant hereby confirms that this work is being done by the property ownerlapplicant 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 comractor(s) of the information.
ACCEPTED
-z -< . -,'
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Ap'plicantlPermittee (Sign)
Date
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE
CAMPBELL ST ANDARD 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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SECURITY FOR FAITHFUL PERF
AMO~NT
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APPROVED FOR ISSUANCE
J: orms\r 1 permit/rev.
( SEE OTHER SIDE)
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