97-116
CITY OF CAMPBELL
DEPT. of.pumR -.-e 1:1 V E
70 N0rt11 Fu'St St.
Campbell, CA 95008 J::'I:C.. 111\ ltn7
(408) 866-2150 r1!;.(J \II ,^,O
Fax (408) 376-0958
ENCROACHMENT PERMIT
I)rr~- working within the
,lie right-of-way)
Permit No.
X-Rer ~-ile
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PUBLIC Vh~...,
APPUCATION - AppADMlN~KiAbe 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).
Issued
Permit expires in 12 mos.
/IJ
Application Date. f' E t? 7'" q '1'7
Application expires in 6 mos. '
B. Nature of work
\ to.) o:;.-rA....
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A. Work address or tract #
Utility trench location
C. Attach four (4) copies of engineered plans showing the location
Estimate of work. The plans shall show the relation of the propos
the City Engineer, said plans become a part of this permit.
extent of the work,....~~ four (4) copies of the prelimina Engineer's
work to exi~ti~gA.,.Kcet!!Jd undergrelU)tf' &;p. ro. verne. ~.~;. .. ~n ~pprov.ed by
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ifications and Details for Public Works Construction; the Ge ral Permit dnditions
it, listed below. Failure to abide by these conditions provisions may result in
d cash deposits. (See General Permit Conditio and 2.)
D. All work shall conform to the City of Campbell Standard S
listed on the reverse side; and the Special Provisions for this pe
job shut-down and/or forfeiture of Faithful Performance Sureties
E. THE CONTRACTOR MUST HAVE THIS PERMIT AND API' VED PLANS AT THE D MUST NOTIFY THE PUBUC WORKS
DEPARTMENT AT LEAST TWO DAYS BEFORE STARTING WORK. BE GIVEN TO PUBUC WORKS AT LEAST 24 HOURS
BEFORE RESTARTING ANY WORK.
Name of Applicant/Permittee '7A~ .J oc:.~ WA -re-f2. COO.
Address 12.2.1 'S, e>ASca.\ Me.! SAN ~O$€
Is this work being done by the property owner at their own residence?
Telephone (.4-08 ") 2,q - 'lB4c..
CA. t::{5128
Yes No
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers. agents and employees free,
safe and hannless from any claim or demand for damages resulting from the work covered by this permit.
The Applicant/Permittee hereby aclmo
wl1lractor(s) of the information: I
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