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ENC2011-00009Printfotm CITY OF CAMPBELL ENCROACHMEN'T' PERMrf Permit No q DEPT. OF PUBLIC iNORKS (for working within the ublic ~~'~~ ~ G 1 ~ ~~~ 70 North First street P X-Ref. F)l Campbell, CA 95008 right-of-way) ~~ Ph. (408} 8-2150 Issued APplication Date -=f ~~ I 1 0 ~ ~ ~ ~ Application Expiration Da a ~'~ Fx, {4pg} 376-0958 APN _ Permit Expiration pate I Z l ( 2 APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. ( I' (6) months if the permit is not issued. Application Fee is non-refundable.) APP nation expires in six A• Work Address or Tract No,: ~ 1930 BasCOm Ave. ~~-~~-~~~~ --•..-...W.._. Utility Trench Location: ~~~~ Street/sidewalk ---___~ B. Nature of Work: ~8ore approx. 316', place 3 B 36 vhs,1-2" cdt with FOC for new service to customers C• Attach four (4} copies of an engineered plan showing the location and extent of the work, and Lour (4y 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 a by the City Engineer, said plan becomes a part of this permit. pproved ~• All work shall conform to the City of Campbell Standard 5 listed on the reverse side; and the Special Provisions for thiifications and Details for Public Works Construction; the General Permit Conditions in job shutdown and/or forfeiture of Faithful Performance 5urPeeties alnd card ew. Failure to abide t by base conditions and provisions may result E. The Contractor must have this permit and a posits. (See General Permit Conditions i and 2.) starting work Notice must be given to PubUc Woorks at least 24 hours before restart ng ananyuwwk orks Department at least two days before Name of Applicant: ~Cablecom (Jean Lee) Telephone: ~40&564-4016 Address: 825 Chadbourne Rd. Fairfield, CA 94534 ~---w_ E-Mali Address: xJean.Lee@cablecomlic.net Is this work being done by the property owners at their own residence? 24-HDUR EMERGENCY PHONE NUMBER: `q(}g_~Cbg,4U1 B The AppBcant/Permittee hereby agrees by afRxing their signature to this permit to ho d t e City of Campbell its officers, agents, and e and harmless from any claim pr demand for damages resulting from the work covered by this permit. mptoyees free, safe The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and t contractor(s) of the information. Applicant is advised that upon issuance of this permit, property owner, or responsible for any anti all damages arisin out of the condition o hey will inform their - pnv to i Properly owners successors, shall be prvvements in tf~e.public right-of-way. Accepted: . ~ (Applicant Permitteel a~~,._, ___ ___ -.~-.t~......W._.W_ :_ _....-------___._ />~rt l I J ~rY..LL-_L' ~. ~C'......_.... ~y (Contractorl (Print Name) ~'-~~-""""`-° Dot .-. T1. Street shall not be open cut for underground installatk~ns. Minimum cuts i h I r cl~x be allowed for connections or exploration holes. Such cuts r,~av be 2. Pavement maybe 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 5edion 4215 of the Government Code this permit is not valki for excavations until Underground Service Alert {USA) has been notified and the inquiry identification number has been entered hereon. USA Phone: 1-800-?27.2600. USA TICKET NO, .-_....._5. Prior to any work, the property owner shall execute an Agreement for Arivate Improvements in the Public Right-of-Way, which shat! be recorded. __6. Public Nat cation Requirements:,, PERM(T APPLICATION FEE ^~~~- - ~~ AMOUNT PLAN CHECK DEPOSIT $ ?~ ~ Ci RECEIPT NO~ SECURITY FOR FAfiNFUL PERFORMANCE/LABOR & MATERIALS 5---'-'- CONSTRUCTION CASH DEPOSIT T'"~ ---~-_ ---- PLAFI CHECK & INSPECTION Fi*E s-_.. EMERGENCY PF.RMR FFE $-__ 3 _-~ U ~ _._~ _...~ ----- APPROVEDFOR ISSUANCE _._...._ "~~ -- _.._ _~ _-~.~~ .Z_l ..~ ~._._. ~'~' € ~~ ~ For City Engint~er - ~'W'"-"--`" _ P__ arm?t Ex,, ices t2 Months Aher pate of tssuance Date _._._...-----------..__._.._ P s , ~ S ~ ~. ~,~ 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 deposR will be billed to the Permlttee. 2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the Ciry. 3. Refund ar the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated wrtten acceptance of the work by the C'hy. 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 Pian 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. A Construction Traffic Contrd Plan shall conform to the Cahrans Manual of Traffic Controls for Construction and Maintenarxe Work Zones, dated 1990, available at Caitrans. Traffic control equipment shall inciudeType II flashing arrow signs if required. B. 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 the nearest scoremark and shall be doweled to existing Improvements. 70. 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. t t. 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 wsh deposR. t 2. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee h required unless otherwise stated by the City Engrcreer 13. The Contractor or Permittee will have a supervisory representative available for contact on the project at aH times during construction. Contractor or Permittee shall pravide 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 ofpavement, 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 Fo r which a separate permit may be required, nor does it relieve the Permittee of any obligation to obtain any other permft required bylaw. iii. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the tiry and any other public agency. 17. Th's permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 18. Cali back (tali outl due to emeregencies regarding this permit shall be at the current overtime rate with a three i31 hour minimum charge per ocarrence. 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 modif,cation af, or a departure from the plans and specifications, the Gty 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 Cty-owned or maintained facilities. 21. Permitttee must provide advance rwt~cation to all parties that may be affected by the permit activities, Notification shall be reviewed by Cite Gty prior to distribution and include dates of work and a contact name and phone number. Applicant shall be respansibte for ensuring that all those providing services tinder the applicant are aware and understand all of the above conditions. '~~~ C ~1'r1 ~,1 `~~~/ Date: Applicant ~-,~ , Contractor (Print Namel j~J ~~~ Date: J:\FORMS\Templates\Encroacirment Permits\Encroachment Permit STAT IC form2.pdf Rev. 09/10 ~~ ~ O yyz mk~ ~~ly7T S ~p~c~~ f~ Emz _~ ~~ Q ~; o c.n b ti Vi O~ b ::> ~~ o ~ moN o ~ ' °•\ p_ a"~ b o _. ~QA~ u~~ ~°~~m5 3 ° ~ j~A ~~ Y~O ~~m~ riR~ °o m~r' o ~ 3 ~~ ~~~ n ,03 o$ L'i n g 3~a ~ ~ o ~~~~~ ~~~ z ~~~ (N C N A ova z ~' m ,~ ~~ a~~ ~o _~ R n ~ ~~~ i I O z 1 .T a- ~~ ~ ~ ~ ~ s ~ z°, !, w r ~ o m o ~ ~ c ~ ~ ~ m~ m ~ c4i ~ m ~c y i~ C m to v ~, @ : f; t: ~. v ~~. .~.. f«... ~ h \^ ' ~ .+* ~~ w r ~? 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