96-235
CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
ENCROACHMENT PERMIT
(C-. working within the
.ic right-of-way)
Issued CjJ;g/7'1o
Pennit expires in 12 mos.
Pennit No.
X-Ref. r';le
9b-d.- } 5
~ t::U-'2'1? (~)
Application Date qj 1'1 /l:l'"J
Application expires in 6'mos. I
APPUCATION - 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 pennit is not issued Application Fee is non-refundable).
A. Worl< ""',="' '"'" # LAl-1!'!:1ELJ.. MIPPLE ~~ - 29'7 CI-la:lN' LMIS
Utility trench location-=:::1l/~IDf' CHE~ LAlJE \l.-o' WJ~ CA\..tf'~'''' c::.T.
B. Nature of work 1t..l<7TAU.A'11d.\ OF 10'.. (.," WA~ "1~1tJ e c,H f\~ <;a(IJ\C.E; ^~ Relc<AT\~ OF ~. DOMESTIc..
c:;.ERJIc.~. ~~Ul.Eb 10 010 10/,2-'/"1"
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 pennie
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. THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AT THE SITE AND MUST NOTIFY THE PUBUC 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 ApplicantlPem1ittee S M JO?E WA~ COM p ~L1
Address I "2.'2.\ ~. BA"?t:c:::>M AvENUE" SAt--l
Is this work being done by the property owner at their own residence? Yes
Telephone
"219 -184/
9t?I7.B
.Joc;e
)l... No
CA.
The ApplicantJPennittee hereby agrees by affixing their signature to this pennit to hold the City of Campbell. its officers, agents and employees free,
safe and hannJess from any claim or demand for damages resulting from the work covered by this pennit.