ENC2009-00038CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408)866-2150
Fax (408)376-0958
r. .OACHMENT PERMIT
(for working within the public
right-of-way)
Issued ~ ~ ~~ ~''
Permit Expiration Date ~ ~ ~ ~ y l
Pert ~ 7,u ,1-- CSZ~J=~ ~')
X-Ref. File
Application Date ~ " ~~ ~~
Applicatio~n,~E~xpiration Date
APN :rZ~' -~ ° Z ~ - ~ l
APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six (6)
months if the permit is not issued. Application Fee is ~on-refundable^
A. Work address or tract
Utility trench
B. Nature of wor
C. Attach four (4) copies of an engineered plan showing the location and extent of the work, and four (4) copies of the preliminary Engineer's Estimate of work. 't'he
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 shutdown and/or forfeiture
of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 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. ;~} E. (L.rr.1~/I ~; /
Name of Applicant ~ ~ ~ .C ~: b I I~ ~ ~' K Telephone 4~~
q (print name) L~~j ~ tL1z'L.T C ~ ~ i f1L'ZZ " Z• lt'g
Address ~~ t F~ (z~7T ~7T ~iLt I Zf Z~ ; 24-HOUR EMERGENCY TELEPHONE NO.
E-Mail Address ~ i! ' u' ~ /` S . CCY /
Is this work being done by the property owners at their own residence? Yes v No
The ApplicanUPermittee hereby agrees by affixing their 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.
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. Applicant is adv ed that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all damages
arising out of the conditio of an private improvem~ m the public right-of-way.
/~•/ --. A 7 _-~ ~ ~t
Permittee) (sign) „~ - Date
(Print Name) Date
. ... ~ .
SPECIAL PROVISIONS '
_1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts > ~X
be specifically annroved by the Inspector prior to cutting.
_2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method
"A", unless otherwise approved by Inspector.
_3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public Works Department
before starting work.
4. 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 identification number has been entered hereon. USA Phone 1-800-227-2600. USA TICKET NO.
_5. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be
recorded.
6. Public Notification Requirements:
7
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR &
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & INSPECTION FEE
APPROVED FOR
'~'~ Permit
( ~yti.w` tv
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AMOUNT RECEIPT N0.
$ 5 `~- 21515 Z
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S~,
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. ty Engineer Date
12 Months After Date of Issuance
GENERAL PERMIT CONDITIONS
1. A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency call-out, overtime inspection or when City
ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee.
2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City.
3. Refund of the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work
by the City.
4. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to
the Permittee.
5. Maintain safe pedestrian and vehiculaz crossings and free access to private driveways, bus stops, fire hydrants and water valves.
6. A Construction Traffic Control Plan and a Construction Schedule aze required for all lane closures, detours and street closures. This plan must be
reviewed and approved prior to any lane closures.
7. The Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated
1990, available at Caltrans. Traffic control equipment shall include Type II flashing arrow signs if required.
8. Replace as directed by the City Engineer any damaged or removed improvements in accordance with City Standards and Specifications at the sole
expense of the Permittee.
9. Sawcut for all PCC or AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements.
10. Prior approval of inspector is required for any work done after normal working hours, on weekends or holidays and may require reimbursement of
inspection costs at the current overtime rate.
11. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading may result in the City's providing signing
and barsicades and charging the cost (including all labor and materials) against the cash deposit.
12. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer.
13. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or
Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m.
14. No storage of materials or equipment will be allowed near the edge of pavement, the traveled way, or within [he shoulderline which would create a
hazardous condition to the public.
15. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a
separate permit may be required, nor does it relieve the Permittee of any obligation to obtain any other permit required bylaw.
16. This permit does no[ release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency.
17. This permit is no[ transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon.
18. Call back (call out) due to emergencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence.
19. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the municipal storm drain system
other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Claza Valley Urban Runoff
Pollution Prevention Program.
20. If the pubhc interest requires a modification of, or a departure from, the plans and specifications, the City shall have the authority to require or approve
any modification or departure and to specify the manner in which the same is to be made for City-owned or maintained facilities.
21. Permittee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by City prior to
distribution and include dates of work and a contact name and phone number.
Applicant shall be r~onsi~e for ensuring
providing services under the applicant are aware of and understand all of the above conditions.
2-l~-oq
Date
~--/7-a 9
Date
Contractor (Print Name)
J\forms\pwperm
Rev. 11/9/05
WEST VALLEY SANITATION DISTRICT
SANTA CLARA COUNTY
100 E. Sunnyoaks Ave., Campbell, CA 95008
1408) 378-2407
LOCATION:
A.P.N. ~iC'.~ - Zi ,~~:` E
Sewer Location: Bk. ~' Pg. ce ~°
Tract Lot
Proj. Assmt
Address: ~~C'~ ~C~ +. ~~l V'v~I~
JurisdictionCrt~.~'~~~~--~-
BUILDING TYPE:
Single Family
CondominiumlTown Houses
Multiple Dwelling
Number of Units
_~S~CommercialC~°~~ a~N ~~
Industrial
Other Information:' t= ~;~;:,u..wzW z:'"
Change in Status:~'~~~~ ~~~=~~~'
Z~% X45
C ~ ~~~ i~ c o~ S \Z.
PERMIT NUMBER ~oN 3 8 7 5 3
Issue Date ~ _ t c~ ~ ~'~C gy ~ ~:
FEES:
Connection
Service Advance
Processing
Capacity
-^ ~ ~::,
;~.-, -..
BUILDING SEWER CONNECTION:
Feet of ~~^~ Property
line ~~~= feet from Main Sewer
and = feet deep.
Connection to Main Sewer
Feet upstream from M.H. ~ '-%~~ ~=
U/S M.H:`~ "`~" " ~' =~'' Pipe Type
BACKFLOW PROTECTION•
TOTAL %~ Field Check Required
4, ;;~*'
Disposition: Call District for foundation survey
GO Zone RL SJ Device Required: Yes
Type: ~ .-« r= ,~. , ~ : ,,~-
INSTRUCTIONS:
° Street encroachment permit required from ~' r''• ~'~ ~ G ~ 3c,:.
° Permit invalid if not connected within 12 months of issue.
° Do not connect until main sewer is accepted by District.
° Obtain a building or plumbing permit from the jurisdiction listed above.
No
WHITE -PERMIT / PINK -DISTRICT / YELLOW -JURISDICTION BUILDING INSPECTOR'S COPY / CARD -DISTRICT
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PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT 8~ MISCELLANEOUS RECEIPT
Effective July 1, 2008
TO: City Clerk ry~ ~,~~ J~~-/ (~
PUBLIC WORKS FILE NO. ~G~C~[.i l' W~'-~['
PROPERTY ADDRESS )~ ru; '
Please collect & recei t for the followin monies:
ACCT. ITEM AMOUNT
'ENCROA CHMENT PERMIT
4722 Utility Encroachment Permit Application Fee
Utilit Arterial/Collector Street
$585.00
~ "~~°~
Residential Street/Other Areas $325.00
4722 Plan Check & Inspection Fee
Utilit < $100,000 *
Minimum Charge Per Location ($260.00) ~ ~
Conduits/Pipelines up to 500 Feet ($2.35/ft)
Above 500 Linear Feet ($1.40/ft)
ManholesNaults/Etc. ($130 00/ea)
Pote Set/Removal ($130.00/ea)
Street Tree Plantin /Removal $150.00
** 2203 Utili > $100 000 * Actual Cost + 20% **
4760 Stora a Container Permit $130.00
4760 Pro'ect Plans & S ecifications Pro'ect No.
4760 Standard S ecifications & Details $1/P $15.50/Bk
4760 Co ies of En ineerin Ma s & Plans
Aerial Plot 24" x 36" $55.00
Aerial Print 8 1/2" x 11" $25.00
Aerial Search Fee $25.00
Ma sand Plans 24" x 36" $12.50
4722 Penalties: Failure to restore ublic im rovements $100/Calendar Da Muni Code Sec. 11.34.010)
4722 Penalties: Failure to correct unsafe conditions $100/Calendar Da
4722 Work Without Permits 4 Times A licable Fee
MISCELLAN EOUS
511.7424 Posta e
Other Please S ecif
*Engineer's Estimate shall be as approved by the City Engineer.
NAME OF APPLICANT
TOTAL ,t ~ 1. ~
$ l~
r
NAME OF PAYOR '- 1.. ~t'" (,~
~(~
PHONE ~1 `}~ - S(.:~C
ADDRESS ~ ~Iht ~ 1 . ~S ~ ~ ZIP ~ Z ~;
**Actual Cost Plus 20% Overhead n-Interest bearin de osit
FOR RECEIVED Y R~~~IV~~`
CITY CLERK
ONLY
Date 3 ~ Recei t # ~~
v~ ~ ~ ............, _...--
J:~FORMS1TempalesVloministratiueU2ecaipi Fonn Lllilily Encroachment 8 Mnc 0&OB Rev 10/00
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