ENC2006-00095CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
ENCROACHMENT PERMIT
(for working within the public
right-of-way)
Issued
Permit Expiration Date
Permit No ~~~ ~~ 6 "- r~
X-Ref. File_~_~ ~+1-r~ ~ --~6'~
Application Date ~- ~
Application Expiration Date
APN
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-refund(abl~e.) n~~~ / ~ Q~ ~
A. Work address or tract # ~ ~ ~~ "`~ ~ (~~_ _ _ _ `~~~~f~'//~
B. Nature of work
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 Public Work~s'a)t least 24 hours before restarting any work.
Name of Applicant K.~/m~~ ®J~.Cje~i~~ Telephone ~~,0~. Li~~4~_,Z2
/ ' 1(print name) ~~(`
Address~~. ~L t ~ V/ll' S I-~ / ~ ~ i1" 24-HOUR EMERGENCY TELEPHONE NO.
E-Mail Address V~~Ct . ~ iiyJ,T~~ L c;\U~c, \ ~ h L~
Is this work being done by the property owners at their own residence? Yes ~_No
The ApplicanUPermittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, iLs 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 condition of any private improvements in the public right-of-way.
(Applicant Permittee) (sign) Date
Contractor (Print Name)
Uate
SPECIAL PROV 1SlONS
_l . Street shall not be open cut for underground installations. Minimum cuts >~ be allowed for connections or exploration holes. Such cuts m~'
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 owncr shall cxccutc an Agrcemcnt 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
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & INSPECTION FEE
APPROVED FOR ISSU
For City Engineer
Permit Expires 12 Months After Date of Issuance
AMOUNT RECEIPT N0.
g.~~s:~ ors/g
$ 1 ..
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Date
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PUBLIC {S DEPARTMENT RECEIPT
EReclivc JWy 5, 2005
City Clerk PUBLIC WORKS FILE NO. ~ . ~ ~~~ + ~/ 9S'
PROPERTY AUDNFSS O ~~ ~ ( V
Please collect & receipt for the following monies:
f... ITEM AMO[)NT
ROACAMENT PERMIT
4722 Application Fee m
Non-Utility Encroachment Permit (5275.00) O~ / ~s O D
Minor Encroachment Permll <SS,000 (561.00)
Rd First Permit (No Fee) Subsequent (5135.00)
Utility Etroachment Permit
ArterktVCollecmr Slreel !5530.00)
Resldenlial StreeUOther Areas fS291.00)
IMan Check Deposit 2 % of En peer's Estimate (5500 min)
FailhfW Performance Security (FPS) (100%of ENGR.EST.)
Labor and Materials Security (100%of ENGR. ESTJ /
QQ ~,
_
Monumen[alion Security 000%of ENGR.EST.) Py
Cash Deposit (4% of Engr. FsU(f500 minB10,000 max)
Plan Check 8 Irepectbn Fec (NumUtility)
Engr.Ect. < 5250,000 (l3% of ENGR.FST.)
Fatgr. Est. >5250,000 (Ueposit S % of Engr. Esl./530,000 min)~•
Utility < 5100,000
MlNrmnn Charge Per Iacation (51!10.00)
Caa1WIslPipelines up to 500 Feel (S2.25/ft)
Above 500 Linear Feet (51.35IR)
ManlwlesNaWts/Etc. (SI25.OO/ea)
Pole Set/Itemoval (5125.OOlea)
Slrcet Tree %antingJRemoval (SI35.00)
Illllity> SIOO,p10 Ac[ual Cost+ 20% ~~
Sloroge Container Permll (5125.00)
Project Harts & SpeclAcaliom Pmiecl No.
6760 Co ies of Engineering Ma . & Rare
Aerial RW 24"x30" (554.00)
Aerial Print S I/2" x Il" (522.00)
Maps and PWm 24"x30" (SS.25)
d722 Penalties: Failure to rMore public improvements (5100/Calerdar Uay) (Mvd cm. srr.u_w.ato)
4722 Penaltes: Failure w correct mtsak conditbrts (SI00/Cakrdar Dav)
ND
Times
4722 Parcel Ma (41.o1s or Lcxc) (53,400.00+S75lloq
4722 Fiml Tract Ma (5 or Morc iwtlc) (54,200.00+SIIMIOoq
4722 Certllkate of C.o IWnce f650.00)
4722 Certificate of Correction ($400.00)
0722 Notary Fee ( r signature) (510.00)
4722 Vacation of Publk Streets & Easements 152,200.w)
4722 Asct~cment Segregation or Reapportbnmenl
First Split
(5725.00)
Each Addltfonal I.ot (5200,00)
d721 Storm Drainage Area Fec Per Acrc (K-1 52,120.00)
(MWti-Res S2:tS5.00)
Campbell TnRtc Mudel (F
Campbell Traffic Madel (N
Signal Timing IMormatbn
Truck Permltc
No Parkins Sims
TOTAL
y /] ~J ~•
OF APPLICANT `~J/ I. ~ ~ G~jr W/W
OF PAYOR / ~ I/IAt I r ~W N (X//V~/
7.IP
r
Sc/D~.~Q~.~/
••Actual Cosl Plus 20% Overfiea8 tN
FOR /
CITY CLERK RF~(:EIVED AY
ONLY O.
Ihte -Recelpt•
sFor PIanCheck and Cash Deposits, seed yelbw copy to FbnuaY.
.Dale/ IWtials
j:\forms4eceipt fenm OS-06 rev.f/1I/05
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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 [o
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 [o 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 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 occunence.
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 he 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 responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above conditions.
Applicant
Contractor (Print Name)
Date
Date
J\forrns\pwperm
Rev. 11 /9/05