97-104
1Vi(- )'7605
Cfl'Y OF CAMPBELL
DEPT. OF PUBUC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
.nnit No. 9 7 - / DLf
X-Ref. File
Issued
Permit exp
Application Date / J; 3/'1,
Application expires hi 6 mos.
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 permit is not issued Application Fee is non-refundable).
A. Work address or tract #
Utility trench location
E/s
{!,? 606^1 A V,'
/6(;' N/a tJ,
1f/fr111 L T?J 11/ A n€
llCElV"f1)
j
C. Attach four (4) copies of engineered plans showing the location and extent of the work, and four (4) copies of the prel~.$ls
Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvemen~~~n app~~ by
the City Engineer, said plans become a part of this permit. jJuJLIC WOR M
AOM\"'\STRA T'O
D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the Genefal Permi~ffiIions
listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisio~may result in
job shut-down and/or forfeiture of Faithful Performance Sureties and cash deposits. (See Gene~ermit Conditions 1 and 2.)
B. Nature of work
TlCLIi/Cf/
6 I A-;1It7
r:'~I1[L
'/ -
/ - Y CCl/l/t?t/ J J
\1 E. THE CONTRACTOR MUST HAVE TIllS PERMIT AND APPROVED PLANS AT THE SITE AND MUST NOTIFY THE PUBUC WORKS V
-;:::i\ DEPARTMENT AT LEAST TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GIVEN TO PUBUC WORKS AT LEAST 2~iJRS7\
BEFORE RESTARTING ANY WORK.
N~e of ApplicantlPermittee ~/JC/~/C 6'tftL /'I//T/fIt~AI ;i!;L-Lel'f Telephont'LfOfi') V93 -)/:33
3t.f75" 1$ 11/ / E:r ItbOI1 200 !:I1N JOS6 9SI3i.(
x: No
Address
Is this work being done by the property owner at their own residence?
Yes
The ApplicantlPennittee 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.
~~~
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