ENC2008-00122,.,,~7Print F~o7rm
ENCROACHMENT PERMIT Permit No ~.~~ - V y 12.1~-
CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS (far working within the public X-Ref. File
70 North First Street right-of-way) Application Date
Campbell, CA 95008 Issued ~~~ ~ ~ ~ Application Expiration Date J ~ r:
Ph. (408) 866-2150 APN ~ ~--~ 7 ~-- S y - C7~ 3
Fx. (408) 376-0958 Q~ j7 ~~~
Permit Expiration Date ~L j /'o
APPLICATION - Application is hereby made for a Public Works Permit in accardance with Campbell Municipal Code, Section 11.04. {Application expires in six
(6) months if the permit is not issued. Application Fee is r-on-refundable.)
A. Work Address ar Tract No.: 9b1 W. CAMPBELL AVE.
Utility Trench location: ;INSTALL LATERAL THROUGH W. CAMPBELL AVE. IN FRONT OF PROPERTY
B. Nature of Work: ;INSTALL NEW SANITARY SEWER LATERAL
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 arxi/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.
_...~ ____~~ _-_____.__...~_ .-. _ ~. r-- ..v....__. _.___ .._____
Name of Applicant: ;ABLE SEPTIC Telephone: ;408-377-9990
Address: (1020 RUFF DR. SAN JOSE CA. 95110
E-Mail Address: :MARK@ABLESEPTIC.COM 24-HOUR EMERGENCY PHONE NUMBER: 1408-377-9990
Is this work being done by the property owners at theirown residence? E 'YES iX NO
The Applicant/Permittee 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 ar 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 oui of the condition of any private improvements in the public right-af-way.
Accepted:
tApplicant Permittee)
i1.~i "~
(Contractor) (Print Name)
SPECIAL PROVISK)N5:
1. Street shall not be open cut for underground installations. Minimum cuts ~ be allowed for connections ar exploration holes. Such cuts maybe
~ecifically approved by the Inspectar 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 the Engineer.
_____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 pem~it 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 TKKET 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
PERMR APPLKATK)N FEE
PLAN CHECK DEPOSfr
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS
CONSTRUCTION CASH DEPOSfr
PLAN CHECK & INSPECTK)N FEE f ,
APPROVEDFORISSUANCE
S
S
For City Engineer
Permit Expires 12 Months After Date of Issuance
'V
C_. / 1
GENERAL PERMIT CONDRIONS
t • A Construction Cash Deposit is required. Charges wiH be made against this deposit if there is an emergencycall-out, overtime inspection or when City
o-dered barricading is required. Any wch costs in excess of the deposit wiU be baled 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 or the cash deposit balance and refund or cancekation 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 clowres.
7. A Construction Traffic Control Plan shaA conform to the Cakrans Manual of Traffic Contrds 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 Ciry Engineer any damaged or removed improvements in accordance with City Standards and Specifications at the sole
expense of the Pemtittee.
9• Sawcut for all PCC or AC removals. AN PCC removals shalt be to the 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 Ciry'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 Perrnittee 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 atk~rved 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 bylaw.
16. 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. CaU back (call out} due to emeregencies regarding this permit sha{I be at the current overtime rote 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 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 ui which the same is to be made for City-owned or maintained facilities.
21. Permimee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the 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 and understand alt of the above conditions.
Applicant
-~!tl ___
Date:
Date:
Contractor (Print Name)
J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC fonn2.pdf
Rev. 3/08
e ~ ,' '
-~ '- a
`~ ~ ..
a
~ `~
H ~
p zl
tl
m
~~
z
~ -r
a
~~
~- T
N
T
~~
-~
r
/ VJ
' ~!
~~~
~~tT
F- ~ w x ~
~ ~ ~
f ~ ~
°: 1a ~ ~
~.- ~
~~
~ ~
n
~ J n
- ~ h
T vc= .~ 1 'n.
00
y 1 ~
~~ ~
as J" '' rt,G~-~
~ h~T
:~
m
Vy y
- ~~
,_
T
W ~ I
W
~ ~:
~ ~~ j
i ~ i
~~
1 '~
r~
f ~ ~ .__,
i~~ , ,
~i i
~~
~. I
T ~
Ar~~ ~:
~ ~
°o Q
N O1
N
~ N
O
~,,,'" N
~ N
O
O
'C o0
C~ O
~ N
O
"z
ri W
~ ~
~ ~
w U
'J
W
U
c
c
~ ~
A-
c
~ ~
0
d ~
u
Q
7
v
d
v
J ~
L
d
,, E
0 a
C Z
d
> ~'
~ C
Q~. ~
O
v
e,'
G ~
~ ~
L ~
F., U
e
0
~L
U
d
Q
a+
6
v
A
~o
i O`-a
W
~ o °c
~ o c
> o ~
> O
~ -,
~ o0
~ o
V y
7
Q
R
r+
O
F
~ ~
~ O
~ O
'V N
'V N
T O~
~~i
N N
N N
~ ~
V '~
O O
~' d'
~ ~
O o
0
0 0
U ^~
~ ~~
a V
d a
w
a
W
N
~ ~
oW
U .Y
W~
O O
_ O O
~ N N
O O
M M
~ ~
,.. i
L ~ ~
Y ~
t/1 A O O
N N
~ ~
z
~~
~' ~ a a~,
d ~
w
ti
U
0
on
PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT 8~ MISCELLANEOUS RECEIPT
Effective ~fufy ~, 2008
TO: City Clerk
PUBLIC WORKS FILE NQ ~~~~ -- ~' ~ L-Y~
PROPERTY ADDRESS ~ ( (,(,'I ~ n f .
Please collect & receipt for the following monies:
ACCT. ITEM
AMOUNT
ENCROA CHMENT PERMIT
4722 Utility Encroachment Permit Application Fee
Utility Arterial/Collector Street
$585.00
Residential Street/Other Areas $325.00
4722 Plan Check & Inspection Fee
Utility < $100,000
Minimum Charge Per Location ($260.00) ~ 2.~.•~; V
Conduits/Pipelines up to 500 Feet ($2.35/ft) ~ _ ~~
Above 500 Linear Feet ($1 40/ft)
Manholes/Vaults/Etc. ($130 00lea)
Pole Set/Removal ($130 OOlea)
Street Tree Planting/Removal $150.00
** 2203 Utility > $100,000 * Actual Cost + 20% **
4760 Storage Container Permit $130.00
4760 Project Plans & Specifications Project No.
4760 Standard Specifications & Details $1/P $15.50/Bk
4760 Copies of Engineering Maps & Plans
Aerial Plot 24" x 36" $55.00
Aerial Print 8 1/2" x 11" $25.00
Aerial Search Fee $25.00
Maps and Plans 24" x 36" $12.50
4722 Penalties: Failure to restore public improvements $100/Calendar Day) (Muni Code Sec. 11.34.010)
4722 Penalties: Failure to correct unsafe conditions ($100/Calendar Day)
4722 Work Without Permits (4 Times Applicable Fee)
MISCELLAN EOUS
Other (Please Specify)
*Engineer's Estimate shall be as approved by the City Engineer.
NAME OF APPLICANT ~ ~C 1 I,I C
TOTAL $ ~ E,n
NAME OF PAYOR ~./ ~ ~~ ~ ~ i ~ PHONE ~g ~ ~ ~~~~
ADDRESS ~~ ~ ~ ~ ~ ~ ZIP / ~ ~ r~f
**Actual Cost Plus 20% Overhead Non-Interest bearing deposit
FOR
RECEIVED BY ~ cc it
R ~ ~ G ~ H ~~
ITY CLERK
ONLY ~
Date ece'pt# AUG ~ ~ ZOOS
r~,
~~~s,~..~~,.~~..w.~F~uu~E.„~~~., ~,
i ' `~' ,
~.r ~ '~