97-131
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)
u ....0../,
Permit No. 97-131
X-Ref. file
Application Date 3/7 /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 #
200 Dillon Avenue (e/s of street)
Utility trench location
B. NalUI'C of work
3'x4' cut in pavement to repair service
C. AllaCh 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 pan 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
Perfonnance 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.
PG&E
(prjijt name) .
Address 10900 N. Blaney, cupertlno 95014
Name of Applicant
Telephone
725-2033
24 HOUR EMERGENCY TELEPHONE NO.
Is this work being done by the property owner at their own residence?
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 harm1ess from
any claim or demand for damages resulting from the work covered by this permit.
The Applicant/Permittee 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
Chris Maka (EMERGENCY VERBAL)
(Applicant/Permittee) (sign)
3/7/97
Date
_3.
4.
Ls.
L PROVISIONS
Street shall not be open cut for underground installations. Minimum cuts~be alIowedJorconncctions orexplorarion holes. SuChCUlS may be soecificallv
::::e~t ~~~~~~~ru::~~~ouC:i:~lations and must be restored in accordance with the Utility Trench.Restoration Standard Delai~' Badcf~
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 Public WorksDepan.ntent before slatting work.
Per Section 4215 of the Government Code this permit is not valid for excavations until Underground Service Alert (USA) has been notified and the inquiry
identiflca1ion number has been entered hereon. USA Phone I~800-227-2600. USA TICKET NO.
j,4Ft! IIclH<.Ui.Ad -t1UF;1I(~ . - ~~ ACC(;;sf /lAM-JTIJ~ IH~N'/'T1:J1Nt;t() ;17" ..v--Lb -rlA1~J-->
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
~
IA./lL.
AMOUNT
$ JJ.y---
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$'-
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S/o1 is -
RECEIPT NO.
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PERMIT APPLICATION FEE
. PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANilEJ BOR & MATERIALS
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & INSPECTION FEE
APPROVED FOR ISSUANCE V
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Date