ENC2009-00061~~~V~~
MAY 1 1 2QQ9
PUBLIC WORKS
ADMINISTRATION
CITY OF CAMPBELL
I}EPT. OF PUBLIC WORKS
70 North First Sere¢e
Campbell, CA 95008
Ph. (408) 866.2150
4083641821
WVSD
ENCROACHMENT PERMIT Permit N~
(far working within the publl X-Ref. File
right-ofway) Application Date
S' , 2 U U Application~xal
Issued APN ,~
PAGE 02/04
Fx. (4081376.0958 Permlt Expiration Date ~~0
APPLICATION - Application is hereby made for a Public Works Permit In accordance with Campbe{{ Municipal Code, Section 11.04. (Appl;eatlon expires in six
{6) months if the permit is not issued. Application Fees non-refundable.)
A. Work Address orTract No,: ,2 ~ ~ ~ G'aryli?J~p i4VC/~/~ . C'arm~b~ertl ~ CA ~~
Utility Trench location: 50~.._F.~S~ ,a~ ~h~rsec~ion p~,....~li^ar~ini~ Ave A~1 ~11f01nwt...S~:..
R, Nature ofWerk: RBplocL~ (o' p~ d4»tp~nl tv" uCA 5ru~Er mraih~in~ . r~ntyl ~ g'/o'r f ,Wide
... .. . ................ ... ,,,., ,........... I
C. Attach four (a) copies of an engineered plan showing the location and extent of the work, and four (4) copies of the preNminary Engineer's 13'de~P,
Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements, When approved
by the City Engfieer, said plan becomes a part of this permit.
D. All work shall conform to the City of Campbell Standard Specifications and Details far Public Works [onstructlon; 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 oFFalthful Performance Sureties and cash deposits. (See General Permlt Conditions 1 and Z.)
E. The Contractor must have this Permlt 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 2a hours before restarting any work.
Name of Applicant: ~ Telephen¢ rte} ~~~ ,~~~- ~:
!/f~L9f ~!~ SR+IJ1I~~iDM...T~lS~fJC~,., ......... ....... I ......., J ,...... ........ .
Address: fq0 ~Qg~ Sunn OQK,S -711~- C~-~,,obE!l , Cplf~nrn,:u~ 95"LZ78..... '~
E-Mail Address: ~ ~ 14-HOUR EMERGENCY PHONE NUMBER: ~,~~ ~ ~2l3 ~~~ ~
fp/CgG~O WiCStf'lipl) A p I ~.
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Is this work being done by the property owners at th r own res once. ~"'! yE5 ~ NO
The AppllcantlPermittee hereby agrees by afFlxing 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/Permlttee hereby acknowledges that they have read and understand both the front and back of thla permit, and they will inform their
contractor(s) of the information, Applicant is advised that upon issuance of this Permlt, property owner, 4r property owner's successors, shall be
responsible for any and al( damages arising out of the condition of an private improvements in the public right-of-way,
Accepted: (.VeS ii~"Q~l ~tHlT'wT+Pt7 ,~l4?f+~iC ~ /Dye ~ . 1~%Q7Cf0 /b(o»d~ N ~ ~L17 ,
(Applicant Permittee) (sign) Date
(Contractor) (Print Nam¢) bat¢
SPECIAL PROVISIONS;
t, Street shall not be open cut for underground installations. Minimum cuts lilay. be allowed for connections or exploration holes. Such cuts.m9ykti
s.pecifleally aooroved,by t~,~,fpector nrio.LTS.t_cuttlna.
~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 the Engineer.
3. Work to be staked by a licensed Land Surveyor or CNII Engineer and two (2) copies of the cut sheets sent to the Public Works Department
before starting work.
4. Per Section x215 of the Government [ode 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. USATICKET N0.
S. Prior to any work, th¢ property owner shall execute an Agreement far Private Improvements In the Public Right-of-Way, which shall be
recorded,
G. public Notlficatiarl Requirements:
7,
S~E_~UBLIC WORK~„F_E~S.CkLERUJ,E FQFi~C_U.RRENTEF.E~
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS
CON5TRUCTION CASM DEPO517
PLAN CHECK & INSPECTION FEE
APPROVEDFORISSUANCE
AMOUNT RECEIPT N0.
S
S
5
$ ~
5' ~!2/ati
Permit Expires 12 Months After Date of Issuance
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Cont r~ctos must bare fltese plots
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05,•'1112009 13:23 40$3641821 WVSD PAGE 01104
~"~41'esfi ~''af~+ey»
Sani~tron District
FACSIMILE TRA,[VSMiTTAL
DA'C'E: 11 , ~OOg .
TIME: ~ ~ ~5 P_•~
TO: Ci,~, off' Gbnr~-b~If _ _ FAQ NO.: (~) .~~' orl56
ATTEN"Z'ION: -5 Ulph%d'
k'~OM: (.UP~~ Fall ,r'~a Won ~%s~ic~ .
St78TECT: 5'twrmt~ main/,.'rG re Q%+~ c7f 6! c~rni~ ~Qv~nv~.
TOTAL PAGES TRANSMITTED ~' _ (including this cover sheet)
MESSAGE:
Pl¢ %ssc,~ vS ~ e+~~GChn~tif r~r~ for S~or r~:~/rraQ /~ %f
in ~»~ of ~vrbp~.~h. ~~ ~,~o ~/ CaW-~,rnPfo Avg
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ltitia~ l~~l c~R+ri~iq~ron ~siiirf.
X408 3 ~8 ~.~ ~
~, 00 EAST ST7NN~''DAKS AVENUE, CAMPBELL, CA 9500$
TELEPHONE (408) 378-407 FAQ (408) 364-Z 821
B-12E
05!1112009 13:23 4083641821 WVSD PAGE 03/04
G~~ I~RAL_I?ERMIT GONDIT14J35
1. A Construction Cash DeposR is requlred, Charges will be made agalnstthis deposit if there is an emergency call-out, overtlrne inspection orwhen City
ordered barricading is requlred. Any such costs an excess of the deposh will be billed to the Permittee.
2. A one-year malntCnance period and surety are required, Such period will begin on date of written acceptance by~he C1ty,
3. Refund or the cash deposit ba{anee and refund or caneCllatlon of the Faithful Performance Surety will be Inhlated by the written acceptance of the work
bythe City.
4. The Permittee must request In writing a final inspection and acceptance of the work upon completion. ACCeptanc¢ by the City will be made En writing
to the Permittee.
5. Maintain safe pedestrian and vehicular crossings and free access to private driveways, Bus stops, fire hydrants, and water valves,
B. A Construction TrafFlc Control Plan and a Construction Schedule arc required for all lane closures, detours, and street closures. This plan must be
reviewed and approved prior to any lane closures.
7, A Construction Traffic Control Plan shall conform to the Cakrans Manual of7raffic Controls for Construction and Melntenancc Work tones, dated
1990, available at Cattrans. Traffic Control equipment shall include Type II flashing arrow signs If requlred.
e. Replace as directed by the City Engineer any damaged or removed improvements In accordance. with City Standards and Specifications at the sole
CxpenSe Of the: Permittee,
9. Sawcut for ail PCC or A[ removals. All PCC removaL^ shall be to the nearest scoremark and shalt b¢ doweled to existing improvements.
t o. 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.
t 1. 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 barricades 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 requlred unless otherwise stated bythr_ Gty Engineer.
13. The Contractor or Permittee will have a supervisory representative available far contact on the pra)ect at a{i times during construction. Contractor or
Permittee shalt provide a phone number at which they can by contacted outside the hours of 8,00 a,m, t0 4:00 p.m-
14. No storage of materials or equipment well be allowed near the edge of pavement, the traveled way, or within the shoulderline which would create a
hazardous condition to the public.
15. Tl,ls permit shall not be construed as autharization for excavation and grading on private property adjacentto the work or any atherwork for which a
separace permit maybe requlred, nor does It relieve the Permittee of any obiigatlvn to obtain any other permh required bylaw.
16. This permit does not release the Permittee from any Ilablllties eontalned in other agreements or contracts with the City and any other public agency.
t7. This permit is nottransferable. Work must be performed bythe Permittee or his designated agent or contractor as specified thereon.
18, [all back (call out) due to emeregendes regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per
occurrence.
14. Pursuam to Chapter "lh.o2 of the Campbell Munldpal [ode, appf leant span not cause to be discharged any material Into the munldpal storm drain
system otherthan storm water. Applicant shall adhere to the BEST MANAGEMENT PRACryCES established bythe Santa Clara Valley Urban Runoff
Pollution Prevention Program.
Zp, If the public Interest requires a modlflcatlon of, or a departure from the plans and spedficatlons, the Clty shall have the authority to require or approve
any modlttcatlon or departure and to specify the manner in which the same Is to be made For Cltyawned or maintained faculties.
21. Permittt¢e must provide advance notification to all parties that may be affected by the permit activities. Notiflcatlon shall be reviewed by the Clty prior
to dlsttibution and include dates of work and a contact name and phone number.
Applicant shall be responsible for ensuring that all thane providing services under the applicant are aware and understand all of the above conditions.
tc~s >~ (ht JI Sane ~a {r~r Dis~ic ~ . ..~ e l.. ~iC4~ M~ N1 a~. !1, .a7r~9' . -
Appllcani Date'
~Anco ~iple lines Mond , IJ, 100 j.
Contractor {Print Name) Date:
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