97-101
Issued
PUB v.. " Permit expires in 12 mos.
ADMIN TRATiON
APPLICATION - Application is he y made for a Public Works Permit in accordance with Campbell Municipal Code, Seetio 11.04.
expires in 6 months if the permit is no 'ssued Application Fee is non-refun~ble). CA(;TRA~S R l'lfr: (f(... 1tf.
A. Work address or tract # /
Utility trench location
~NCR9ACHMENTPERMIT
(for working within the
public right-of-way)
hit No.
X-Itef. File
17- /,;/
cny OF CAMP_I! ,,. E . V r
DEPT. OF PUB~ \fe~
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
B. Nature of work
Application Date /-- ~ -
Application expires in 6 mos.
(Application
C. Attach four (4) copies of engineered plans showing e location and extent of the work, and four copies of the preliminary Engineer's
Estimate of work. The plans shall show the relation of ill (ierground improvements. When approved by
the City Engineer, said plans become a part of this permit. (s Y\
D. All work shall conform to the City of Campbell Standard Spec lcations ani ~ for Pu IC Works Construction; the General Permit Conditions
listed on the reverse side; and the Special Provisions for this permi listed below. Failur 0 abide by these conditions and provisions may result in
job shut-down and/or forfeiture of Faithful Performance Sureties and General Permit Conditions 1 and 2.)
E. THE CONTRACTOR MUST HA YE THIS PERMIT AND APPROY P
DEPARTMENT AT LEAST TWO DAYS BEFORE STARTING WORK. N
BEFORE RESTARTING ANY WORK.
AT THE SITE AND MUST NOTIFY THE PUBLIC WORKS
E MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS
Name of Applicant/Permittee
Telephone d 79-. 78, q ()
\
No
The Applicant/Permittee hereby agrees by affixing their . nature to this permit to hold the Ci of Campbell, its officers, agents and employees free,
safe and harmIess from any claim or demand for dama s resulting from the work covered by thi ermit.
The Applicant/Permittee hereby acknowledges th
contractor(s) of the information:
ack of this permit, and they will inform their
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