ENC2006-00042CITl' OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408)866-2150
Fax (408)376-0958
'ROACHMENT PERMIT
~rur working within the public
right-of-way)
Issued ~ G
Permit Expiration Date ~ 0
Pe Vo ~v C 2 f~~ 6 -0001 Z
X-ket. File
Application Date 3 ~ `~ -~ G
Application Expiration Date `~ -2Lf-6 ~n
APN c~ ~ ~ ~ J U~V
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 non-refundable.)
A. Work address or tract # ^ ~ ~) ~~~~ ~13 `~'l J'y ;~~ ~`~L ,i C1~ 1~1~f i ~L? ZZ L
Utility trench location ~ ~ C ~= ~/- 0 /~ < , ' 1. I%>~ ~C' / //~/f /, c" / ~~~'~ r''~ t,/~1r~ ` ~.y~4/'/ ~=,[ll`Z(,,.
B. Nature of work %/y c ~c,L ~ CG/ ,2,/:2/~Z 7C1~ -~ ~~- ~~~ ~ L ~ 61~ ~/
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 to [he 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 [he 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.
Name of Applicant~LZ~ ~/ ~~/~/L~ /1 /~ ~~rt ~~7: /~L Telephone f~5~ -:.5 ~~ -~r ~~
e,~.~~P~~ 2 ~ e!' ~ ~ /~//~I~YIiL ~ ~ ~t/~~t nC,d!~/~i ~2~C.24-HOAR EMERGENCY TELEPHONE NO. ~ ~ =~ ~' ~ ~'~~'9
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 ApplicanUPermittee 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 up n issuance of permit, property owner, or property owner's successors, shall be responsible for any and all damages
arising out of the condition of an~priva~provemen m e~blic right-of-way.
Z ~j
(Applican ermittee) (sign) Date
Contractor (Print Name) ! Date
SPECIAL PROVISIONS
_l. Street shall not be open cu[ for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may
be specifically approved 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 owncr shall cxccutc an Agreement for Private Improvements in the Fublic Right-of-Way, which shall be
recorded.
_6. Public Notification Requirements:
7.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES IPT N0.
AMOUNT REC
E
~
f
' 2 ~
$ Fj 3U ~
PERMIT APPLICATION FEE `-
PLAN CHECK DEPOSIT $ ~
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $~
CONSTRUCTION CASH DEPOSIT $-T~
PLAN CHECK & INSPECTION FEE $-iU.tL
~,~ - J~~'•j~~
APPROVED FOR ISSUANCE
For City Engineer Date
Permit Expires 12 Months After Date of Issuance
y
Is this work being done by the property owners at their own residence? Yes ~/ No
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 vehicular crossings and free access to private driveways, bus stops, fire hydrants and water valves.
6. A Construction Traffic Control Plan and a Construction Schedule are 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 shalt 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.
1 1. Adequate signing and barricading is required on [he job site. Failure to provide such signing and batricading 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 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 the 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 by law.
1 G. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency.
17. This permit is not 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 Clara Valley Urban Runoff
Pollution Prevention Program.
20. If the public 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 respons/ible for ensue g [hat all those gFecd g s vices under the applicant are aware of and understand all of the above conditions.
_.
3 ~ ~ ~~
Applicant Date
i tee .D , i C /wG
Contractor (Print Name) Date
J\forms\pwperm
Rev. 11 /9/05
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CCNSTRI)~TinN NOTrS:
APP!- ICnNi TO 1~RENC!-~ AN1: BACKFii.l. ALL
* C11-'% OF CAMPBE_LZ PERMIT NEEE)ED
* 9U'~.D?NG CONTRAC'GR 'O DIG 4'x4'x4' GAS TAP HOLE
* PU+L~)ING CONTRACTGR E C TRENCH FROM GAS TA' HOLE
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* B! +ILC+'~jG CONTRACTOR TO T-BENCH FROM P;~t
3?' rn METER MAN1F!~LL LrJCAT{OS`:
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EST: Jason DeOcampo } y ~ ti -----
- Cs:~~ ~,ONST~~J~' LION SKETCH ~:.._;_.___..__
ADE John Gambucci NOTiF. 1018D5767
SuPV:~_wcp„e_~ede•Her~:-- ~3t~ E HAMILTON AVE., CAMPBELL otHER:~---~- ---
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"O: City Clerk
PUBLIC , -cKS DEPARTMENT RECEIPT
FJfective JWy 5, 2005
PUOLIC WORKS FILE NO.
PROPERTY ADDRESS
eNc `~GoG - v~~~2
5 5 u E ~ 1~~-M ~ L`r ~ N _
Rease collect R receipt for the follovdng monks:
ACCT. ITEM _. _ AMOIiMf
ENCROACHMENT PERMIT
4722 Application Fee ~ ~b
Non-UOlity Encroachment Permit (5275.00) V
Minor Encroachment Permit <55,000 (S61.OD)
R-1 First Permt (No Fee) Subsequent (S135.00)
Utility Fitcroachmen[ Pernd[
ArterlaVCollrelor Street (5530.00)
Residential Street/Other Arcre (5291.00)
2203 flan Check De t 2% of Engineer's Fatimate (5500 min)
2203 Faithful Performance Securit (FPS) (100% of ENGR.FSTJ
2203 Lahor and Makrlals Security (100%of ENGR. F3fJ
1203 Monumentatbn Security 1100%of ENGR.FST.)
2203 Cash Deposit (4 % of Fngr. Fst)(55go miN510,01p max)
d722 Ran Check & Irepeclion Fee (Non-Utility)
EngcFst.<S250,000
(13%of ENGR.F.Sf.)
2203 r. Fst. >5250,000 (Deposit 8% of Engr. FstJS30,000 min)rr
d7u uauty<Sloo,(loo
MiWmam Charge Per Location
CaWWts/Rpe0nes up to 500 Feet (x180.00)
(52.25/R)
Above 500 Linear Feet (51.35/h)
ManbksNaWts/Etc. (SI25.00/ea)
Pole SeURemoval (5125.00%x)
Street Trce Plaming/Removal (5135.001
2203 Utility>5100,000 Actual Cart+20%rr
4760 Storage Container Permit (5125.00)
0760 Project Raps & S Ificatbre Pro ecl No.
0760 Standard IOcalbre & DetafLs (SlA'g SIS.50/Dk)
0760 Copies of Engineering Ma & Rare
Aerial Rot 24"x36" (S54.00)
Aerial Print 81/2" x I I" (522.00)
Ma and Rare 24" z 36" (58.25)
d722 Penalties: Failure to restore public improvemenLS (5100/Cakrdar Uay) IMzai r.ae sK.eLJ/.oto7
4722 Penaltks: Fa{lurc to correct urea(e condilbrxs (SI00/CakrWar Day)
d722 Work Without Permits (d Times A icable Fee)
LAND UEVELOPMEN'f
4722 Lot Line AdJrelment (5900.00)
d722 Parcel Ma (d Lots or Lezs) (S3,d00.W +575AOI)
d722 Firul Trac[ Map (5 or More Lots) (SdZ00.00 + SI00/lotl
Certificate of Correctbn (Sd00.00)
Notary Fee (per sipu[ure) (510.00)
Vacation of Public Slrcels & Easemenu IS2,xuo.aa)
Asccssment Segregatbn or Reapportbmrenl
Rrst Split (5725.00)
Each Addllbnal Lot (S200.00)
Storm Umiruge Area Fee Prr Acrc (R-1 S2,120.00)
(MWti-Res 52,385.00)
Intersection Turn Counts (a.m or
Traffic Row Mao fDaliv Traffk
or
/^y f~ !~ /''~ ~ / Z TOTAL / S I v
APPLICANT ~ ~ „ E/ ~ ~j lU V ~/ G ( ~ ~ G ` `~ ~
PAYOR / ~ / i Z~ ~ /~~ A~~`f /yG-~Uf,~- 'n RIONE (~(j~~ v/ -~ C.^ ~ V v~
~~.~ l /~ ~~J 1 2~~fN~i.F/ `--' ~l ( ~~f ZIP -/ ~~1 h 3
Cost Rre zo%
Fox
CITY CLERK RKCEI VFD BY
ONLV
Uate `Receipt - - r
rFor RanChrck aad Cacti Ueposus, xeod yellow copy to Fhtaace.
DHe/IeAL~/ AI [rglt/fA wana.awa.r i
~'1~\
j:lform;4eceipt form 05-06 rev.621N5
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RECEIPT DATE ~I L~~C'3~ ND 8 8 ~ 1
RECEIVED FROM ~ A ~ ~u+ id~~ -~ ~ ~iO "
ADDRESS ,3.,.3G C ~ ~w~~1(~a•-~ ~ r~t't . ~' b - oOoc~1.,.
FOR "~ -~i ®"~
=1.JULLANS $ ~ ~"
ACCOUNT
AMT. PAID
BALANCE DUE
HOW PAID
CASH
CHECK
MONEY ORDER
BY.
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