3495 S. Bascom Ave. (76-8)
~ER-DEPART~~NTAL MEMORANDUM
~o: Building Department
FROM: Public Works Department
The requirements of the Public Works Department have been
satisfied for the following development:
APPLICAN'l'
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BUILDING ADDRESS
'34~~
s. Bo...'Scovv\ A\J Q
COUNTY ASSESSOR'S
PARCEL NUMBER
4 l '3 '- 2.p:::, -- -:tG ~ 2.4
l'IS" APPROVAL
NUNBER
7(;;,-8
4)
PUBLIC WORKS
FILE NUMBER
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JOSEPH ELLIOTT
DIRECTOR OF PUBLIC WORKS
By
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Date
.
RECEIPT
CITY OF CAMPBELL
CAMPBELL. CALIFORNIA
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FOR ,-
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FUND NUMBER
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REVENUE ACCOUNT NO.
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o MONEY ORDER 0 CASH
DA TE AMOU NT
THIS RECEIPT
MUST BE MACHINE
VALIDATED AND
SIGNED BELOW.
DEe 28-76 017 ***3,195.00
DEe 28-76 65 onA **3,195.00
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8804
BY
CITIZEN COpy
Than~ You
CITY OF CAMPBELL
CITY OF CAMPBELL
STREET EXCAVATION PERMIT NO.
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77-036
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Pursuant to the terms of Section 7101 of the Campbell Municipal Code, a permit to excavate within the public right of
way in the City of Campbell is issued based upon the following conditions:
1. The location of the job and the nature of the work to be done within the public right of way is as follows: ..;..~h:5..>
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2. A diagram is attached and thereby made a part to each of these forms showing the location and dimensions of the work and
relating this to existing underground facilities.
3.
Work will begin on
beginning work.
, 19
, or notify the Campbell City Engineer 24 hours before
4. No street shall be closed without full conformance to Section 7106 of the Campbell Municipal Code.
5. Safe crossings shall be maintained in conformance with Section 7105 of the Campbell Municipal Code.
6. (These blanks to be filled in by the City Engineer ONL Y)
a. Special Conditions:
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Import backfill material as required by City Engineer.
Replace existing roadway structural section with equivalent type and thickness of material plus one additional
inch of asphalt; or 4 inches asphalt over 12 inches R-78 base rock, whichever is greater.
Work to be completed prior to occupancy of structure.
Work to be staked 3 feet back of face of curb by a licensed Land Surveyor or Civil Engineer and three copies of
the cut sheets sent to the Public Works Department before starting work.
Open cutting of pavement will NOT be allowed; all pipes or conduit shall be jacked under existing pavement.
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The deposit in 6b above will be returned, in full, upon satisfactory restoration of public right of way. b -3' ) 1
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7.
8.
Deposit (money or bond) required to guarantee restoration of public right of way.
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The Permittee hereby agrees, by affixing his 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.
Acceptance of the Permit by the named Permittee constitutes acceptance of any and all conditions upon which this Permit
is granted. This Permit does not relieve the Permittee of any obligation to obtain any other Permit required by law.
ACCEPTED (J:':ti~~~ ~~4A.AY;'
(signature of Permittee)
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Residence ( ) or
9.
ADDRESS
3 Copies:
Permittee
City Inspector
l..-'i I e
Business (
(date)
<?6 7- D 1-0,i.,.
)
ENGR.
6" '7
DATE
ASSOC. CIVIL ENGR. DATE
OPERATIONS:
Permittee must sign, date and forward to City Engineer for approval. Permit is valid only after signed by City.
Permit is not transferable.
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