ENC2008-00052CITY OF CAMPBELL ;'~OACHMENT PERMIT Penr~p ~- ~C. 2 UC>U " C.i CUG~~z
DEPT. OF PUBLIC WORKS ! ;orking within the public X-Rt. tle
70 North First St. right-of-way)
Campbell, CA 95008 5-/2 G/G ~ Application Date ~ d~j
(408) 866-2150 Issued Application Expiration Date ~ ~
Fax (408) 376-0958 G~ /~
Pertnit Expiration Date ~/~ G I APN ~ 7--I y" ~ ~~~
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-~~Fe~'e~`is non-re/fundable.) c ~ , n ~Q~ ~
A. Work address or tract # ~ ~ ~~ G ,.~~1-~~/~ )L /'fi`r
Utility trench location
B. Nature of work ~r^ ~ ~ ~Yt'" /y Cln
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 [o 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 pemrit, 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 worrk. ` /
Name of Applicant ~ ~~G,~e//~'' ~. Y .:, r~ S "h~v ~. •-~ j ~~ Telephone~f~` 0 ~) 2 `~ a - ~ ~ (~ 3 f~
I~ ~ G G~rC-T(9~' ~ ,A( rint nam~ '
Address /~ ~-s 1 4-HOUR EMERGENCY TELEPHONE NO.
E-Mail Address ~~ r~ P r ~ ~~~ .., ~ ~; ~ (_ ,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, 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 condition of any private improver~letyts in the public rigor-oY-way.
/~~ ~ ~
(Applic~a tt Pet~nittee) (sCign) D e
Contractor (Print Name) Date
_1. Street shall not be open cut for underground installations. Minimum cuts >l~ 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 lnspector.
_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. s~~iNG, L+nntz5 wt~~ 13~ A(~r°(~v~l~ f3Y >_t~~iN~~- ~' CG~~-0lrc~c• lStlU~~( Piwtt,~,
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT N0.
PERMIT' APPLICATION FEE $ ~~iO _~
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $
CONSTEtUCTION CASH DEPOSIT
PLAN CHECK & INSPECTION FEE $~ ~(T1~
APPROVED FOR ISSUANCE ~~2~~°~
For City Engineer Date
Permit Expires 12 Months After Date of Issuance
GENERAL PERMIT CONDITIONS
i
1. A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency tail-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.Petmittee.
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 Petmittee 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 a[ 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 Permit[ee of any obligation to obtain any other permit required by law.
] 6. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency.
]7. 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 occu>tence.
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 responsible for ensuring that all those providing services under the applicant are aware of and understand a11of the above conditions.
J Applicant
Contractor (Print Name)
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Da
Date
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Rev. I 1 /9/05
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RECEIPT DATE -f' ~~ '~ ~ ND. ~ U ~ Q
RECEIVED FROM ~ ~Z +~~'`
ADDRESS
43~ " ~) ~ SG~,man2. ~ ~ ~ '0 ~-~S~ DOLLARS $ 8' I ~ ''
FOR
ACCOUNT HOW PAID
ACCOUNT CASH
AMT. PAID CHECK
BALANCE DUE MONEY ORDER BY
PUBLIC WORKS DEPARTMENT UTILITY ENCRVACMmtn i ik MI,I.CLLHrvcv~~ rc~~.~~r ~
Effective July 1, 2007
TO: City Clerk
PUBLIC WORKS FILE NO. ~~~ ~~~ _CwU7Z
PROPERTY ADDRESS ~ 3~ - LtSO Si-i LMA ~
Please collect & recei t for the followin monies:
......ACCT. ITEM AMOUNT
ENCROACHMENT PERMIT -
I I ncroac men erml pp Ica Ion ee
hment Permit
E
00
$300
~~ o
ncroac
on- I I
hment Permit < $10 000
E
Mi .
00)
($135
.
ncroac
nor
00
it No Fee Subse uent < $10 i $135
t P
1 Fi
R
erm
rs
-
r Street
ll
t
l/C
rt
i .
00
$560
ec
o
o
er
a
Utili A
t/Other Areas
l St
ti
i .
00
$310
ree
den
a
Res
eer's Estimate
i
f E
it 2% .
$500 min *
2203 n
n
o
Plan Check De os
i FPS
S 100% of ENGR.EST. '
2203 ecur
Faithful Performance
i
l
S
i 100% of ENGR. EST. *
2203 ecur
s
a
Labor and Mater
it $1000/Monument *
2203 Monumentation Secur
h De osit
ti
C
t Est $500 min/$10,000 max
a°i° of En r *
2203 as
on
ruc
Emer enc Cons
Plan Check & Inspection Fee (Non-Utility)
< $250 000 .
(13% of ENGR.EST.) Z ~ U
4722
** Engr Est
>$250 000 Actual Cost + 20%/Min. $30,000 De osit *
2203 En r. Est.
000
4722 Utilit < $100
cation
L
P
Ch ($250
00)
er
o
arge
Minimum
to 500 Feet
li
/Pi .
25/ft)
($2
nes up
pe
Conduits
F
t
Li .
35/ft)
($1
ee
near
Above 500
lt
/Et .
00/ea)
($125
c
s
Manholes/Vau
l
R .
00/ea)
($125
emova
Pole Set/
oval
/R
ti
Pl .
00
$145
** em
an
n
Street Tree
0 .
Actual Cost + 20% ** *
2203 Utili > $100 00
it
P $125
00
4760 erm
Stora a Container
if
ti
' .
Pro'ect No
4760 ons
ica
ect Plans & S ec
Pro
il
t
& D
i .
50/Bk
$1/P $15
4760 a
s
e
ons
Standard S ecificat
& Plans
i
M .
4760 a s
n
Co ies of En ineer
"
" $54
00
x 36
Aerial Plot 24
"
" .
$25
00
x 11
Aerial Print 8 1/2 .
00
$25
Aerial Search Fee
36"
" .
$12
00
.
x
Ma sand Plans 24
store ublic im rovements $100/Calendar Da Muni Code Sec. 11.34.010)
t
F
il
4722 o re
ure
a
Penalties:
onditions
f
t $100/Calendar Da
4722
4722 unsa
e c
Penalties: Failure to correc
Work Without Permits 4 Times A licable Fee
MISCELLANEOUS'
Other Please S eci
*Engineel's Estimate shall be as approved by the City Engineer. TOTAL $ U f U
NAME OF APPLICANT '1' ~ " ~~-f I
NAME OF PAYOR I I a t PHONE U' ~4
ADDRESS •~ - ~- Z S ~ ZIP
**Actual Cost Plus 20% Overhead Non-Interest bearin
FOR RE ~ ~~~
ITY CLERK ~aF~[1 ~ AY Z (~ ZOOB ~~
ONLY Date e
'For Plan Check and'Cash'Deposits, se~idye ow copy to Finance.
Date/-Jnitials- -
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