ENC2006-00013CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408)866-2150
Fax (408) 376-0958
F' "'ROACHMENT PERMIT
(. corking within the public
right-of-way)
Issued ~~ 1 ~~C' ~
Permit Expiration Date ~~ ~ ~~ 7
X-R ile
Application Date 2/I ~'~'
Application Exp''ira11tion Date f'i
-~
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. ApplicyatiCo~n/F-ee is non-refundable.) A,~
A. Work address or tract # a ` `~ ~~ ~'1 N ~ / ~ v
Utility trench location L V t-Z ~~-~ /~~
B. Nature of work ~t~ t~ ~ 7t }2~.-
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. 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 [o 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 ]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. !~ p ~
Name of Applicant ~~.~~ / ,f C//`~c~T (~ Telephone / ~~D J ~~~ y7~~
/ (print nom; e)
Address- / ~L'i ~ L%/~= T~~~/rte 24-HOUR EMERGENCY TELEPHONE NO. ~~~ - ~ ~~ S ~ ~
ct~,~r~,~~ ~-
E-Mail Address ~ ~ c~L
Is this work being done by the property owners at their own residence'? Yes No
The ApplicandPermittee 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 ApplicandPermittee 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 advised 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 con%d~itJion of any private I'm/~pr-o~v'"ements in the pubiicright-of-way. ///
Accented 1/ .~n~. ~ 1 iiA .s1 JJ ~v21~1~ ~L~j/ O
(Applicant Permittee) (sign)
(Print
SPECIAL PROVISIONS
l . Street shall not be open cut for underground installations. Minimum cuts ~ be allowed for connections or exploration holes. Such cuts >~
be specifically annroved by the Inspector prior to cuttine.
y 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.
_`. Prior to any work, the property owner shall execute an Agrcemcm far Private Improvements in the Fublic Right-of-Way, which shall be
recorded.
_G. Public Notification Requirements:
~7. 1 ~t~~t ul nth ~- Yl~ M~1~~~7~('~ual , A N'i])~ ~~~ia ci- j nnT ~ tSr~t -~ t~ iu ,ztwulR~~
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT N0.
PERMIT APPLICATION FEE ~ ~j _3(:i U~UUcj~~{ (1 ~
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $
CONSTRUCTION CASH DEPOSIT $---r-~- G, I`~` +e~ I I'
PLAN CHECK & INSPECTION FEE ~ $~_
_ +: 2
APPROVED FOR ISSUANCE - ~ ~ ~G; ~~
For City Engineer Date
Permit Expires 12 Months After Date of Issuance
~' 1 ~~ ~~ y
~~ ~{~~~ .~N~ 4
W~"T VALLEY SANITATION DISTRICT
SF-. . A CLARA COUNTY
100 E. Sunnyoaks Ave., Campbell, CA 95008
~nnA1 '~7R_~d(17
LOCATION:
A.P.N. ~ d -
Sewer Location: Bk. Pg•~-
Tract Lot
Proj. Assmt.-~-~
Address ..~ "'" ~Pv' ~~
Jurisdiction
BUILDING TYPE:
Single Family
Condominium/Town Houses
Multiple Dwelling
Number of Units
~. Commercial
Industrial /~
Other Inform 'tion: U
e{ o
Cha e in~,St~tAU,s:
FEES:
Acreage
Frontage
Service Advance
Processing
Other:
Capacity
TOTAL
$ 7 ~- 0
2~ o,
~.~
.l S 1 y~~
as
9G~7 s9
SEWER CONNECTION 3 6 7 7 6
PERMIT NUMBER
Issue Date /~ ~-~ ~ By--l~-=---
BUILDING SEWER CONNECTION:
Feet of Property
line feet from Main Sewer
and feet deep.
Connection to Main Sewer
Feet upstream fro M.H.
Using ~~ -erg
BACKFLOW PROTECTION:
Field Check Required
-Call District for foundation survey
Disposition;
GO Zone R L SJ Device Reyl~~eK:~~/ve~~v^d~~-
Type: ~
INSTRUCTIONS:
o Street encroachment permit required from
o Permit invalid if not connected within 12 months of issue.
o Do not connect until main sewer is accepted by District.
o Obtain a building or plumbing permit from the jurisdiction listed above.
~cn`~ ~i~/~/GS2-
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PUBLIC W ; DEPAK'1'1M1;n'r Klic~En
Effective JWy 5, 2005
City Clerk PUBLIC WORKS FILE NO.
PROPERTY ADDRESS
ILL C~ru~~k ~~'
Reese rnlkct & receipt (or the (ollowlna moNes:
TI'EM
D PERMIT
Appilcatfon Fee
Non-Utility Encroachment Permit (5275.00)
Minor Encroachment Permit < 55,000 (Sbl.~)
Areal
03
'A3 FaithfW Perlormacee Security (FPS)
Labor and Materials Security (100% of ENGR.FSTJ
(100% of ENGR. EST.)
U3 MonumeMalbn Security (l00%of ENCR.EST.)
813 Cash De it l4% or Engr. Kst)fS_S00 mir1IS10.000 max)
f22 Ran Check & Ircpectlon Fec (Non-Utility)
r.Esl.<5250,000
(13%of ENGR.EST.)
3 BnRr. Est. >S250,000 (Ile t S% or ErtRr. Fin./530,000 min)••
722 UWit <5100,000
Mintmun Clu c Per Location
CadWtslPipeOnes up l0 500 Feel (5180.00)
(52.25M)
Above 500 Linear Feet (S1.35M)
MatdnkslVantWEtc. (SI25.OOlea)
Poie SeURemoval (SI25.OOlea)
Strvel Tree PlaMirrR/Removal 15135.00)
V Ulllit > 5100,000 Actual Cost + 20% ••
1760 Store Container Permit (S125.00)
1760 Pro ect Rare & Okatbn+' Project No.
1760 Stardard Illcatbrc & Details (SI/PR S15.SO/lEk)
1761 1 C cs of nrerirtE Ma & Banc
Aerial Pbl 24„x36„ (554.00)
Aerial Print 8 l@" x il" (~•~)
Ma and Pons 24"x36" (~•~
172 2 Penalties: Fa{Inre to reslorc ublic Irrytrovements (5100/Cakrdar Da ) (Mad CMe Fe[.II. N.alll)
072 2 Perultks: Failure b correct w care caditfonc (5100/Caktdar Da )
4722 Work Wllhout perMLC (d T{mes Ap Ikabk Fee)
~EVELOP[dENT
a,,, t ~t r.i.,e Adlaclment
_ (S9tq.00)
4722
4722 Parcel Ma 14 Lots or Less)
Elnal Tract Ma (5 or Mare I.oc) (S3Aw.w+yr~wq
(54,200.00 + Sl01Vlo0
d722 Certi(kate MC Iianrc ~~•~)
4722 Certlfkale of Correction (~~•~)
4722 Noury Fee ( r slp)aturc) (SI0.00)
4722 Vacation of Pobik Streea & F~tsemen4s (52,2w.tln)
4722 Assessment SeFrcpttion or Reapportionment
First It
Each Addltbmrl Lal (5725.W)
(SZ00.00)
d721 Storm DrolruBe Arco Fec Per Acre (R-I S2,120.00)
(Mntti-Res 52,385.00)
(All Other 52,650.00)
4920 Htrk4nd Dedkatbn Fee (75%/2S% Due U Cert. of Occ y)
511.7d24 PanaRe
TRAFFIC
4728 lnkrsertbn Turo CormLS (Two-llour CounO (S76SIp
4728 IMeroeclfon Turn Courts (a.m or .m aks) ISI50.00)
4728 Tre1Rc Flow Ma (Dell Tra1Rc Volumes) (S32.00)
4728 Ca 11 TroRk Model (EMI ' Assessmen0 (Acluaq
4728 C bell Trallk Model (Reduced Sc Assessment) (Actuaq
4728 SI 1 Timl Intormatbn (S62J11r)
4271 Truck Permits (516.00/ r trip)
0728 No Park) SI (Slleach or S25/I00)
OTEIER
(\f NAME OFAR'LICANT
)) NAMF.OF PAYOR
ADDRESS _1
••Actual Carl Rue 20%
FOR
CITY CLERK REC
ONLY
TOTAL
,J ~ ~ RIONE ~~~
L
AMOIiNT
7~ ~
S%s~ 5 G
j9.femrr,4eceipt fomt05-06 rev.621/OS
_~__ .,.. .i'i .iil _!v~ii
Ci~i3-'.. ., ~U~=tai __i('~L`. .~-+~:. ~.._
_,.T7_!„ ~,C 6
„Li!_
V~"'T VALLEY SANITATION DISTRICT
;A. . A CLARA COUNTY
00 E. Sunnyoaks Ave., Campbell, CA 95008
9na1 Q7R_74n7
SEWER CONNECTION 3 6 7 7 6
PERMIT NUMBER
~- l~-O ~ By, '1
Issue Date
.OCATION:
Q.P.N. ~ - O d
fewer Location: Bk. Pg.~-
~ract Lot
'roj. Assmt. /~ ~~
4ddress•~ Jh ~PY Q--
Jurisdiction C
BUILDING TYPE:
Single Family
Condominium/Town Houses
Multiple Dwelling
Number of Units
Commercial
Industrial ~ //
Othe1r Inform tion: U
~~ / PrC~ ~ e- 0177 0
Chapge in St tus:
/~ Q' 9 Q
FEES:
Acreage
Frontage
Service Advance
Processing
Other:
Capacity
TOTAL
Disposition;
GO Zone RL SJ Device R~eyluired; Yes.~~No
Type; ~17><'`/r 1/~~v~~~ 18vnc~~jW1
INSTRUCTIONS:
o Street encroachment permit required from
o Permit invalid if not connected within 12 months of issue.
o Do not connect until main sewer is accepted by District.
o Obtain a building or plumbing permit from the jurisdiction listed above.
$ ~Z SDI'
2i o.
?. ~ a ~
/ S 1 y,.sa~
2S
~ s
BUILDING SEWER CONNECTION:
Feet of Property
line feet from Main Sewer
and feet deep.
Connection to Main Sewer
Feet upstream fro M.H.
Using ~~~ ~ s ~~r"r
BACKFLOW PROTECTION:
Field Check Required
Call District for foundation survey
~~ri~ ~/ia~ ~/GS'7~
WHITE -PERMIT /PINK -DISTRICT /YELLOW -JURISDICTION BUILDING INSPECTOR'S COPY 1 CARD -DISTRICT COPY