97-128
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
public right-of-way)
Issued .3h/97gr-r'U
Permit expires in 12 m s
Permit No.
X-Ref. file
97-128
Application Date 3/3/9 7
Application expires in 6 months
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 #
1480 Harriet Avenue (x-street Van Dusen Lane)
Utility treDCh location
EMERGENCY Service Repair on Saturday,
B. Nature of work
3/1 - 4'x3' cut ln
aspnal.t
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 permit.
D. All work shall conform 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 permit, 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 Permit Conditions I 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.
Name of Applicant San Jose Water Company Telephone 279-7979
iPrint name)
Address 1221 S. Bascom, san Jose, CA 95128 24 HOUR EMERGENCY TELEPHONE NO.
Is this work being done by the property owner at their own residence?
Yes
No
The ApplicantlPerminee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers, agents and employees free, safe and harrn1ess from
any claim or demand for damages resulting from the work covered by this permit.
The ApplicantlPerminee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the
information.
Accepted
Jane Leinberger (EMERGENCY VERBAL)
(Applicantlpermiaee) (sign)
3/3/97
Date
SPECIAL PROVISIONS
_I. Street shall not be open cut for underground installations. Minimum cuts.!!J!!Y be allowed for coMCCtions or exploration holes.. Such cutS may be soecificallY
aDDroved by the InsJ)CCtor Drior to cutting.
Pavement may be cut for underground installations and must be restored in accordance with the Utility Trench Restoration Standard. Details, Method 'A' Backfill,
unless otherwise approved by Inspector.
Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Publlc WorksDepartDlellt before starting work..
Per Section 4215 of the Government Code this permit is not valid for excavations untll. Underground Service Alert (USA) bas been notified and the inquiry
identifICation number has been entered hereon. USA Phone 1-800-227-2600. USA TICKET NO.
_2.
_3.
_4.
_5.
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFO
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & INSPECTION FEE
:mg
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t-MOUNT
$ J,.t 5'
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RECEIPT NO.
fX
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
APPROVED FOR ISSUANCE
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