97-109
CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
ENCROACHMENT PERMIT
(for working within the
'ic right-of-way)
Permit No.
X-Ref. File
q 7 - /oq
Issued
Permit expi
Application Date
Application expires in 6 mos.
1/.28/97
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 Application Fee is non-refundable).
A Woc' "'dre" 0""'<1 # 1q~ IS. 1A1, /II c tiP1l:.I2.. [2.,'fP' (e7 - to 7 11=)
Utility trench location J:/"tDli:. OF _."~CH ~. so' N/N ~PAL. L.N.
f
B. Nature ofworkJN~iAL.L Fle.e.. ~eJZ."lc.e r exTeND DONe>T1l. Sf12.Vlc.e.
c. Anach four (4) copies of engineered plans showing the location and extent of the work, and four (4) copies of the preliminary E~i~ t 0
Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvementst!. ven.plov~ by
the City Engineer, said plans become a part of this permit. tl ~ l!> ~,
D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General p~nditions -i-..';)
listed on the reverse side; ~d the Sp~ial Provisions for this .permit, listed belo~. Failure to abide by. these <:<>~ditions and provisions '!la~<!esdH~\O'"
Job shut-down and/or forfeIture of Faithful Performance Sureties and cash depoSIts. (See General Permit CondItiOns I and 2.) ,?v:,)\. ~\S,,~Jlo-
f).O~~
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 ST ARTlNG WORK. NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS
BEFORE RESTARTING ANY WORK.
Name of Applicant/Permittee SA N J O~
Address z.t
Is this work being done by the property owner at their 0 n residence?
~CoM~l
~N~es.E- C-A
XNo
TelePhonem -1E41
s lZ,~
Yes
The ApplicanliPermittee hereby agrees by affixing their signature 10 this permil 10 hold the Cily of Campbell. its officers, agenls and employees free,
safe and harmJess from any claim or demand for damages resulting from Ihe work covered by this permit.
I-ZS>-'17