96-279
CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
Permit No. 96 - 2 79
X-Ref. file
Application Date 12 /17 /9 6
Application expires in 6 months
APPUCA TION - 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 IIllt issued. Application Fee is non-refundable.)
A. Work address or tract #
Sunnyside Avenue - 100' east of Winchester Blvd.
Utility treDCh location
EMERGENCY cable repair - wet cable due to previous unknown
aamage
C. Attach four (4) copies of an 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 plan becomes a part of
this pennil.
B. NatUre of work
D. All work shall confonn 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 pennit, 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 Pennit Conditions 1 and 2.)
E. THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AT THE SITE AND MUST NOTIFY THE PUBLIC WORKS DEPARTMENT AT
LEAST TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
Pacific Bell 980-2261
Name of Applicant Telephone
(print name)
Address 1021 Rj chard Avp.. Santa Cl ara
95050
24 HOUR EMERGENCY TELEPHONE NO.
Is this work being done by the property owner at their own residence?
Yes
No
The ApplicanllPermittee 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 permit.
The ApplicanllPermittee hereby acknowledges that they have read and understand both the front and back of this pennil. and they will infonn their contractor(s) of the
information.
Accepted
Chuck Jensen (EMERGENCY VERBAL)
(ApplicanIlPerminee) (sign)
12/17/96
Date
SPECIAL PROVISIONS
i =~~J=S'"~-:"::::,,-~~~2~~.:;.:.].0......:::.sr~i1:.~:::'~
unless otherwise approved by Inspector. ~ f4Ck. 'J"4N!J/c~. "5'~... -../
_3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to. the Public WorksDepartnlCllt before swting work.
j 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 has been entered hereon. . USA Phone 1-800-227-2600. . ..... ..... USA TICKET NO. . ...
s: ALLUM; CU..1~ ClH h//Jt/r~ ~UJr Mt/e:..iI!AI ~4"wA()~"
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
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a17L.
AMOUNT
S 3..15. --
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RECEIPT NO.
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR'" MATERIALS
CONSTRUCTION CASH DEPOSIT
PLAN CHECK'" INSPECTION F
eX
-
APPROVED FOR ISSUANCE
for City Engineer
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CITY OF CAMPBELL
FIELD ENGINEER' S DAILY REPORT
PROJECT NO.
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REPORT NO:
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DATE: 3 -Z-t-/-1
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INSPECTOR:
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