ENC2006-00110CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
E' -' OACHMENT PERMIT
(f~ .eorking within the public
right-of-way)
Issued 7~ ~ ~ 1 Q
Permit Expiration Date ~ ~ ~ a
Perm ~ ~'f~i L Zoo (3 " OC' I ~ O
X-Re. pie
Application Date 7 I ~ G
Application Expiration Date 0
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-refundable.) C
A. Work address or tract # ~ `~
Utility trench location ~°`~` ~"""e ~- ~ ~~"~''~' L L Y `~ '
B. Nature of work ~~'~'~-- ~~eR.A ~ $ '
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 I 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~Wjor~ks atf least 24 hours before restarting any work.
Name of Applicant I y~- ~ `~ t- r ~e L f Jv~ Ste` ~iV G Telephone ~ ~ ~
y~ / (print name) ~j~ ~6 (_ ~~~ 5---
Address ~~~ / ' t C ~j ~i jvC~ L- /dar-~ 24-HOUR EMERGENCY TELEPHONE NOS r
E-Mail Address ~- ` l0 ~ ~~ S~C ~~~` L A/~7
Is this work being done by the property owners at their own residence? Yes ~~ No
The Applicant/Permit[ee 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.
V (Applicant Permittee) (sign) Date
Contractor (Print Name) Date
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 anoroved by the Inspector prior to cutting.
V 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 cu[ 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. L'SA Phone 1-800-227-2600. USA TICKET NO.
_5. Prior to any work, the property owncr shall cxccutc an Agrecmcnt for Private Improvements in the Fublic Right-of-Way, which shall be
recorded.
_6. Public Notification Requirements:
~7. ~~ 7~LRtS •~~ IMF' lNS7!'Cl.1.~17 P~ ST 1L~Z (~' ylM~'~ ~(O~Ni Gr i:NC
Z eUS c. ~ t'f i j
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT N0.
PERMIT APPLICATION FEE ~ S SO U I G~c ~ ~ ~
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS S~ J
CONSTRUCTION CASH DEPOSIT $-~-;-~~j~S
PLAN CHECK & INSPECTION FEE ~ ~ ~~
APPROVED FOR ISSU
~~ ~
7/fg/°_
For City Engineer Date
Permit Expires 12 Months After Date of Issuance
.~~
.~
v
vENERAL 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 wit} 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 add 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 Constmction and Maintenance Work Zones, dated
1990, available at Caltrans. Traffic control equipment shall include Type 11 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 reimhursement of
inspection costs at the current overtime rate.
1 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 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 consauction. 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 may 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 he 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 he 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 he 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 Date
Contractor (Print Name) Date
J\forms\pwperm
Rev. I 1 /9/05
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• V y"V ••V n„ENeotiw July 16, 20061f1
TO: Cky Clark PUBLIC WORK3 FILE NO. ` \V~ ~.- CJ ~ ('~
r ~ V
~
~
PROPERTY ADDRESS ~GG ~ L-~
Pl
il
& /
~
9
^\T(M t;
ease oo
act
roceipt for the following monies:
ACCT: .:REM
ENCROACHMENT PERMfi
:.AMOUNT
4722 Application Fas
NorrUtilky Encroeehrront Parmk (5276 DO)
~~ O
Minor Encroachment Permit c S6 000 (5126 00)
R-1 Firot P
tt N
F
8
am
o
aa
uba wnt 2126.00
Util E
h
neroae
ttrnt Permit
ArterkVCollaebr Street 5660.00
Reeidantl
l 8t
t/OtM
A
2209 e
raa
r
rose 5900.00
Pbn Cfaok Da
ft 2%
f E
i
'
2203 a
o
n
naar
a Estimate 5600 min
Faithful Perlomrnee 8
FPS
2203 wu
100%oI ENOR.EST.
Labor end Msteriel
S
2209 a
aaur 100%of ENOR. EST.
Monumentstlon Saco
2209 100%af ENOR.EST.
Cssh De sk
1%0l En r. Eat 5600 mirdS10,000 max
Plan Chwk S Ina
wtbn F
N
U
il
4722
2209 p
on-
ea (
t
ky)
_ _ Engr.Eat. <5260 000 (19%0l ENOR EST )
En r
Est
5260
000 ~ ~ I
4722 .
. >
,
Da ak 8%of En r. EstlS90,000 min •'
UtIIN c 5100
000
,
Minimum Ch
P
L
i
arge
ar
¢cst
on (5260 00)
Gonduks/Pi
li
t
600 F
pe
nas up
o
wt (S22fi/I[)
Above 600 Lmeer Feel (S7 96M)
ManholasN
ll
/Et
au
a
c. (5726.00/ee)
Pok 8et/Ramoval
(5126 OOlasl
Strast Trae Pl
m
l
2209 e
m nove
5146.00
Utik >5100
000
4780 ,
Actual COSt+20%"
Storo Container P
it
4780 am
5126.00
Pm t Pkns 6 S ifi
ll
4780 oe
ons Pro act No.
standard S elliaetbna A D
t
il
4780 e
a
s S7/P 516.60/Bk
Co lea o/ En Inseri
M
8 Pk
n
a e
ns
Aerial Plot 24' x 96"
564.00
Mrlsl Print B 1h' x 11'
526.00
Aarkl Search Fse
526.00
AAa and Plans 24" x 98'
4722 512.00
Parokies: Failuro to ro
t
bli
I
4722 e
aro u
c
m rovemanta 51 o0/Cebnder Ds Munl Coda 9ec.11.94.010
PanaltMa: Felluro to coma u
t
dkl
4722 nae
s con
ons 5100/Celender De
Work Without Permits
4 Times linable Fea
LAND DEVELOPMENT
d722 Lot Line Ad ustmsnt
1722 3800.00
Paroel Ms 4 Lots or Lass
4722 S9 400.00 + 576Aot
Final Tract Me 6 or M
L
t
4722 oro
o
s 54,200.00 + 5100/lot
Certllbeb of Com Iien
4722 oa 5860.00
Certificate of Cometi
4722 on 5400.00
Orodin b Dnins Plan R
vk
s
w
Sin la Femil Lot 5200.00
Ske < 10
000
f
,
s.
. 5800.00
sk.> 1n
ooo
f
A
,
e.
. <
aro 5800.00
sit. > 1 Acro
4722 51,2oo.oa
Nate Feo r of neturo
Q22 570.00
Veoatbn of Public St
t
8 E
4722 ree
s
aeemanb 52,200.00
yuaaaemant 8e
ro
slbn
R
i
g
g
or
eapport
onment
Flrot SPlit (5726 00)
Eeoh Additional L
t
4721 o
5200.00
StormIHtins
e Ana Fes P
A
g
ar
cro (R-1 52120 00)
- ~
~MuIN•Re+52,9116.00)
1820 All Other 52,860.00
Parkland Dedication F
76W26%D
fi11
7424 sa
us U n Cart. of Oo¢u nc
Poste e
.
TRAFFIC
4728 Intarowtion Tu
C
t
N
4728 rn
oun
s ww
OUr Count 578.60
Intaroaetb
T
C
t
4728 n
um
oun
s e.m. or .m. W 5160.00
Trofflo Fb
M
D
ll T
fli
V
47211 w
s
e
n
e
olumes 532.00
Ca
trail Trottle M
d
l F
ll S
47211 m
o
a
u
ao Aawssment Actual
Ca
bellTnffi
M
d
l R
d
d
4728 m
c
o
e
a
uoe
Soo lussasmant Actual
Si net Timin Inf
ti
4271 orma
on S82Mr
Truck Permks
4728 518.00/ rtrl
No Perkin Si
OTHER na 51/ueh or 526/100
TOTAL S ~ 32 ~ ' 75
/
NAME OF APPLICANT ~ ~ ~ (! ft/'~ ~ ._
NAME OF PAVOR
~CO ~ C~~
C PHONE
/ (J ~ 3~7 •'-Ejlt~
{~/~
/' ~
OI
ADDRESS C7 / • 7C C' !~•' C LLB v-~ ~(7'/Y/ L,~Q, ~ ZIP ` ~C7
"Actual Coat Plus 20%Overhsad Non-b rin de oak
?. ~, r.:
FOR
CRY CLERK
RECEIVED Y ~.
ONLY
Data i'
'Rwei N -
~ y' ^~
'For Plan Chaok snd Ceah Deposka, saint yellow copy to'Finerwe. '., :--- , _ 1 •.., p
_
' Osta/ Inkiwla
j:\formeVecaipt term 06.07.Ms