ENC2006-00062CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408)866-2150
Fax (408)376-0958
r "ROACHMENT PERMIT
-t. working within the public
right-of--way)
Issued ~~ ~ 1 ~ ~ ~ L
Permit Expiration Date Y ~2 ~ ~
Perr Vo L"~'l 1C:L ~ i C ~iG"Z
X-k. : ile
Application Date `~ [ it 1 ~ ,l~'
Applicati~on(~Expiration (Date ~ ~/
APN Tt,~.~ -~ / ~ C~ ~ /
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.)
~''Q ~.l ~
A. Work address or tract # ~ ~' < < ~v
Utility trench location w ~ ~~' I '~ (!. t-'~~ f) ~ • "~,'
B. Nature of work ~''~~~t'~ lt, (L K /y
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 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 Pub(li~c ~Wo)rks at leastQ24 hours before restarting any work. / / G
Name of Applicant f `~ ` ~ 0 t t~~ ~~ °~ S / ~<VL. Telephone 't'd O ~ ~J 77~ 6 ! O ?j
( rint name) '7
Address ~l~ ~`'IC G ~(e~ y Lev < [p'G~>v/~dL I I t 24-HOUR EMERGENCY TELEPHONE NO. ~*~ ~ / ~ ~ -`~s(f
E-Mail Address ~-~ ! f Q O~,f2~' ~' ~'!3 ~ ~/O.~iA ~ /V'~-7
Is this work being done by the property owners at their own residence? Yes _ ~-°No
The ApplicanVPermittee 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 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 condition of any private improvements in the public right-of-way.
~~
`/ L/ /~ c~(Applicant~P~tnittee) (sign) Date
lJ~
~~
Date
SPECIAL PROVISIONS v J
_I . Sweet shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may
be saecificall~pproved by the Inspector prior to cutting.
~2. Pavement may be cut for undergound 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 [he 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 Fublic Righi-of-Way, which shall be
recorded.
_6. Public Notification Requirements:
SEE PL1BL[C WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIrrP--T NO.
PERMIT APPLICATION FEE $ ?`I ~ ~ ~'F~ ~"~' ( ~
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $
CONSTRUCTION CASH DEPOSIT V u~v
PLAN CHECK & INSPECTION FEE $ (~?
APPROVED FOR ISSUANCE ~ ~ \ ~ _ ~ (~ 2 ~~ G
For City Engineer Date
Permit Expires 12 Months After Date of Issuance
~~
,,,~- \ ,~n N~~
~' 1 ~ i\
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 are required for all lane closures, detours and street closures. This plan must be
reviewed and approved prior to any lane closures.
7. The Cons[mction 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 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 he 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 tnay he 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 he 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
distributior, and include dates of work and a contact name and phone number.
Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above conditions.
Applicant
:-ZG'~6
Date
Contractor (Print Name) Date
J\forms\pwperm
Rev. 11/9/05
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PUBLIC ~ :S DEPARTMENT RECEIPT'
FJfecllve )dy 3,1003 ~
TO: CU Cleric ~v ~ (j ~1 L~ ~; ~ ~-%~-~ (:~ ~.i l
Y PUBLIC WORKS FILE NO.
PROPERTY ADDRESS 1 L' ~ ~ ~1V -~1'\ ~ i 'i..! j~ /'~
Pkme celkel & rrrNpt for the falbwwl; nooks:
.. ...-r .. .. ~.. ..
ENCROACHMENT PERMIT
4722 Applkmlon Fn ~ ~'
Na-Utl11tY Bncroachmed RrMI (5275.00)
Mlnr Faerwchrmm Pernit < 53,000 fS6t.00)
UWIt FaerwehmeM Pern4t
AnerlWCdleewr Street 0{0,00)
ReddeulW Street/OWer Area (5291.00)
2203 Run Ckeck t 2% of r'c Fatlrate (5300 Mo)
2203 Fa1tMYtl Penomroce Seam (FTS) (100%of EI4GR.FST.)
2203 labor and Muterwk Security (100% of ENGR. BSI'.)
2203 Moomnentation Secant (100%of ENCR.ESf.)
2203 Cush t (4% of r. Btt)(5300 midS10.000 max)
4722 Run Check & Impeetbn Fee (Non-UWity)
Eo6r.Fat.<5250,000
(13%of ENGR.BSf.)
2203 .Fat. >5230,000 ( t S% oP Fa . Fat)S311A00 mw)••
d72T Utlllty <5100,000
Mldmun Char({e Per I.ocoUon
CoadultslPfpeunes up to 300 Fen (5180.00)
(52.25(8)
Ahave 500 Lhrar Feet (f13318)
MadmkxNadw/Etc. (5125.00/x)
Pok SeNRetrord (S123.OOlea)
Slreel Tree PlanlinR/Removal (5133.00)
2113 Ulllll >5100,000 Anum Call+20%••
4760 Sw Cauoiuer Permit (S1Z5.00)
4760 t Rum @ lore Fro eet No.
4760 Standard tbm & Dewlls (SI S15SMIk1
4760 C of n Ma & Rum
Aerwl Rm 2d"x36" (534.00)
Aerial Prim 8 I2" z 11" (522,00)
Ma and Rum Zd"x36" (58.25)
4722 Pecmltlne: FoUnre to reotore publk Imprnernentx (SIOWCakodar Ua) (Mvd cwe sa.n H oiol
4722 Pemitkc: FWurt w arrest umufe aMitiom (Si00/Cukrrlor Dar)
4722 Wont Without Pemia (4 Thrcs Applkabk Fee)
!LAND UEVF,LOPMENT
atu t.ot arc
4~ Parcel M
4722 Now Fa ( r d wrt) (510.00)
4722 Vocation of Pabik Strxts & Faxxnema 152,2ma)
4722 Aacomem SeBrtlption or Reapponlamenl
Rrst Split (5723.00)
Euh Addltbnul Lol (5200.00)
0721 Storm DrduaBe Area Fa Per Acre (K-t 52,120.00)
(MdtMRes 52,365.00)
(All Other SIb311.00)
4920 ParldoM Dedkatbn Fee (73%25% Due Uoon Cen. of Ocaoancrl
Iderteetlan Tam Came
Imerueetloo Tam Cao4a
TraTc
A TOTAL S
APPLICANT {~ ~ ~~ L t~~ct~/'e S ~ /~/C .
PAYOR ~/'~~I ~) y~r~ ~ ~~ 9 RIONE ((~~ ~ ~ ~ ~~ 1 O
FoR ~! a n ; .
CITY CLERK 'RE()EI V~~ w - -
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Fur: ~ ,odt~tk' ~?nenfwI'llwp~te,A...a~w` ~ r ~='~' ~ re -if,.. ~ tk„ . ,.,,~ , ' ... . ,~ '._ ,-r ,'..
j:U 4aeipt roan OS-06 rev.b/)Iro3
«~
CITY OF CA~iPHELL, CA
kECVD DY: JA~dN t110Q0186418
FAYQk: hfELLO PIPELINES
TODAY'S DATE: Q4,'2blQ6
kEGISTEk RATE: L~a~z,rob TIME: 08:Q9:24
DESCRIF'TIQN AM[IU~tT
Et~Gk R SUHDIb' FILIi~G F ~291.QQ
Et~Gk R SUBDI6' FILING r' g18a,dQ
----------------
TQTAL DUE: ~471.QG
CHECK PAIi~: ~471.L-0
CHECK ~IQ; 7369
TENDERED: R47f.Q0 ~-
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