ENC2008-00043CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
ENCROACHMENT PERMIT
(fo, 'king within the public
right-of-way)
Issued ~ ~~~
Permit Expiratian Date ~ ~ ~~
PerIrtlt Nn ~~~~ • ~~.'_.~/ ~l ~.G -~ ~I~}~1 /L "1
X-Ref. l !X '
Application Date ~ (~ c`~
Application /Expiptr~ation Date
APN l..r[ ~ ll~ ~ G L~ Z L~
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 # &-~'L ~ ~ ~ ~ w ~ ~ / ~ (.,.~ i~
~..
Utility trench location ...~
B. Nature of work ~ vj~l'U G /% (;~ ~~ ~~-~-~'L'~'~- ~~,~P~~.1
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 Ciry 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 pernut, 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 Works at least 24 hours before restarting any work.
Name of Applicant 'Q ~~~ _ Telephone ~(~ ~' ~- ~ 7 ~- ~~ ~~'d~~
(pri t name)
Address i p '7 G ~~ ~~,' 24-HOUR EMERGENCY TELEPHONE N0. S~~ ~' ,$' .,(;1~,n~
SCi,y~ t/US~ Cil 7 s' /~ ~+
E-Mail Address
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 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 upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all damages
arising out of the conditio' of any private improvemen~.s..ia-thy publirr right-of-way.
(Apphant Permittee) (sign) Date
Contractor (Print Name) Date
SPECIAL PROVISIONS
_1. Street shall not be open cut for underground installations. Minimum cuts ~ be allowed for connections or exploration holes. Such cuts may
be specifically approved by the Inspector prior to cuttip~.
_2. Pavement Wray 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 owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be
recorded.
_6. Public Notification Requirements:
7
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT N0.
PERMIT APPLICATION FEE $ ~~ ~1, ~l L~ ~ ~J~~'/.~.,,,L
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR 8r MATERIALS $
CONSTRUCTION CASH DEPOSIT $
PLAN CHECK & INSPECTION FEE $ s- ,~~ ~~ ~~ ,
APPROVED FOR ISSUANCE i~ ~ ~~- l ~~
For City Engineer Date
Permit Expires 12 Months After Date of Issuance
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. ___.., ...,,,.,~ wrnR 1 IYIGIY 1 ~ I ILI 1 ~ CrvclrcuACtimENT & MISCELLANEOUS RECEIPT
Effective July 1, 2007
TO: City Clerk /'' ~ ,.,~,
PUBLIC WORKS FILE NO. G ~/~ ~xC1 v ~ -' C~`~ ~~
PROPERTY ADDRESS '
Please collect & recei t for the followin monies: 5 6 ~~ i;~w t)t1,~ b,
ACCT. ITEM AMOUNT
ENCROACHMENT PERMIT
I I ncroac men erml pp Ica Ion ee
on- i i Encroachment Permit
$300.00
Minor Encr
h
t
oac
men
Permit < $10 000 ($135 00)
R-1 First Per
t N
F
mi
o
ee Subse uent < $10 ~ $135.00
Utili Arte
i
l/C
ll
r
a
o
ector Street $560.00
Residenti
l St
t/O
2203 a
ree
ther Areas
Plan Check De osit 2%
f E
i
' $310.00 ~~, ~
2203 o
n
neer
s Estimate
Faithful Pertormance S
i FP $500 min
2203 ecur
S
Labor and Materials S
i 100% of ENGR.EST.
2203 ecur
Monumentation Se
i 100% of ENGR. EST.
2203 cur
Emer enc Constr
ti
C
h $1000/Monument
uc
on
as
De osit
Plan Check & Ins
ti
F a°i° of En r. Est $500 min/$10,000 max *
4722
** pec
on
ee (Non-Utility)
Engr.Est. < $250 000
(13% of ENGR EST )
2203 En r
Est
>$250 000
4722 .
.
Utilit < $100 000 Actual Cost + 20%/Min. $30,000 De osit
Minimum Ch
P
L
arge
er
ocation ($250 00)
Conduits/P
li
ipe
nes up to 500 Feet ($2 25/ft) J5 0
Above 500 L
F
inear
eet ($1 35/ft)
ManholesN
lt
/Et
au
s
c. ($125 00/ea)
Pole Set/R
l
emova ($125 00/ea)
Street Tree Pl
ti
/R
** 2203 an
n
emoval
Utili > $100 000 $145.00
4760
Stora a Containe
P
it Actual Cost + 20% **
r
erm $125.00
4760 Pro'ect Plans & S
ifi
i '
ec
cat
ons Pro
ect No.
4760 Standard S
ifi
ti
&
ec
ca
ons
Details $1/P $15.50/Bk
4760 Co ies of En i
i
M
neer
n
a s & Plans
Aerial Plot 24"
36"
x $54.00
Aerial Print 8 1/2"
11"
x $25.00
Aerial Search F
ee $25.00
Ma sand Pla
24"
3
"
ns
x
6 $12.00
4722 Penalties: Fail
t
4722 ure
o restore ublic im rovements
Penalties: Fail
t $100/Calendar Da Muni Code Sec. 11.34.010)
ure
o correct unsafe conditions $100/Calendar Da
4722 Work Witho
t P
it
u
erm
s 4 Times A licable Fee
MISCELLANEOUS
Other Please S eci
*Engineer's Estimate shall be as approved by the City Engineer.
NAME OF APPLICANT '~ ~~ ~ ~
TOTAL $ ~(o ~ f~
NAME OF PAYOR ~ ~ ~ ~ / 1 ' PHONE `~o~`.S ~~ /J/C~
ADDRESS / n 2 U ~~ • ~ ~ ZIP /D
**Actual Cost Plus 20% Overhead Non-Inter
FOR RECEIVED BY
ITY CLERK
ONLY
Date - Recei t #
"For Plan Gheck and Cash Deposits, send yellow copy to Finance .
D to lals
V
J-.FOPMTT.+9M.I~.IiwVYOlp1 Fmn IAMY Emvd.~r„,fK WJI, MEV_ tA,)
WEST VALLEY SANITATION D'"TRICT
SANTA CLARA COUNTY
100 E. Sunnyoaks Ave., Campbell, CA 95008
(408) 378-2407
FEES:
Connection $ ~` ' ~ ~
Service Advance ~~ La
Processing ~ ~~%
Capacity ~--~ ~~~' ~`~'
LOCATION:
A.P.N.-~ -- ~r - d~C~
Sewer Location: Bk. ~ Pg.~~ .
Tract Lot
Proj. Assmt
Address: '`~ GAG c~~c~u ~~
Jurisdiction ~~-~T ~L
BUILDING TYPE:
>C _Single Family
Condominium/Town Houses
Multiple Dwelling
Number of Units
Commercial
Industrial
Other Informatign~~!"~`~%4 '..~^%~
Change in Status:
..`'~%
SEWER CONNECTION 3 8 3 2 4~
PERMIT NUMBER '~~ ,~
Issue Date ~~ ~~ t~ By ('~~__
BUILDING SEWER CONNECTION:
Feet of Property
line feet from Main Sewer
and feet deep.
Connection to Main Sewer
Feet upstream from M.H. T"~J~Ge -~~:j
U/S M.H. Pipe Type
BACKFLOW PROTECTION:
_ C~_ Field Check Required
TOTAL ~ ~~ Call District for foundation survey
Disposition:
GO Zone RL l SJ Device Required: Yes~_ No
I I I Type: i<!z•°-,~ f~i~i-~-'~-='
INSTRUCTIONS:
° Street encroachment permit required from Cam,-,w~~L
° Permit invalid if not connected within 12 months of issue.
° Do not connect until main sewer is accepted by District.
° Obtain a building or plumbing permit from the jurisdiction listed above.
WHITE -PERMIT / PINK -DISTRICT / YELLOW -JURISDICTION BUILDING INSPECTOR'S COPY / CARD -DISTRICT
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