ENC2011-00017' Print Form
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CITY OF CAMPBELL (~~~`~ ~ ENCROACHMENT PERMIT Permit No ~IUC',2l ;j 1-- ~ ~7I -7
DEPT. OF PUBLIC WORJ~G _V 6 011 (for working within the public X-Ref. File
70 North First Street `KV ~, right-of-way) Application Date ~ ° / (c " % /
Campbell, CA 95008 !~~ 1 ~N ~~~o~ ( Application Expiration Date " /l~ j /
Ph. (408) 866-2150 ~( ~~9 APN ~,79 ` ~ 7 " C~~1'~
Fx. (408) 376-0958 Qv~~C1~5~PPrmit Expiration Date ,3 I l;
APPLICATION -Application is herdmade 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 TractNo.: 1760 WINCHESTER BLVD. PG&E PM 30793239
Utility Trench Location:
B. Nature of work: Sidewalk closure only to install an extension on an existing power pole
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 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: PG&E Telephone: 408-725-2061
Aaaress: 10900 N. Blaney Ave., Cupertino CA 95014
E-Mail Address: r3mW@pge.COm 24-HOUR EMERGENCY PHONE NUMBER: 1-800-743-5000
Is this work being done by the property owners at their own residence? r YES r 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 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 th upon issuance of this permit, property owner, or property owner's successors, shall be
responsible for any and all damages arising out of the cond'y io of any private improvements in the public right-of-way.
Accepted: ~ ~'
(Applicant Permittee) ign) Date
(Contractor) (Print Name) Date
SPECIAL PROVISIONS:
1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts ma be
~ecifically 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 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 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
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & INSPECTION FEE
AMOUNT
t ~'~U
RECEIPT NA
$ -
s Su
APPROVED FOR ISSUANCE =~ ~/1 ~'~( ~
For City Enginee Date
Permit Expires 12 Months After Date of Issuance
Mar. 9. 2011 3:05FM ~ Iflc Gas and Electric Co. ~ No. 1904 P. 2
0.s~ er~i ~nll x3: do 408~~ ~~ rutsuC WORKS I'H+at; 02/02
G~N~RAL Pe~a~1f_T_COnf~~TfaN.~
I ~ A ConitrUrdoh Cash Dnposlt Is required. Charges wlfl be made against this deposit If there Is ~ emergettGy cell~out, overtlmo Inrpactlan er When Clty
erdorod bardcading Is required. Any such costs in excess of the deposit will be billed to [he PermhtCe,
a, A on¢•year maintenance period and surety are raqulred, such period will begin on tlate efwrltten acceptance by she Clty.
8. Refund or the cash dt:posit balance and refund or cencellatlon e(the Faithful Aarformance Surety will he initiated by the wrtten acceptance ofthe work
by [hc Clty.
4. The Permlttae mlrst request In wrhing a final Inspect(on and acceptance of the work upon completion. Acceptance hythe Clty will ba madC In wrhing
to the Pt+tmltt~e.
S. Maintain .tare pedestrian and vehicular crossings and frrn access to prlvota drlvts•v0y9, bus nopR, fire hydrants, and watervalves,
6. A Construction Ttaffle t'entrol Pian and fl Construction Srhedula dre requtred for all lane closures, detours, and street ciosttres. Thfs plan must be
reviewed and approved prior to any lane closureq,
7. A construction Traffic Control Plnn shell confor,n tv the Caltrans Manual of 17affic Controls for Construction and Maintenanctr Wgrk toner, dried
1990, av~lldl?In Ot CA{trans. Traffic control r_qulpment shall include Type II flashing arrow signs IF required.
a. Rep(eco rat dtrECted by the Clty Fn~glncer .any damaged or removed improvements In neeardancewlth ClryStondardsand Spoelficetlons of the sole
c>tpt!nse aP the permlttce.
~. Sawcut for alt PCC or AC removals, Atl PCC removals shell be tv the nearest scoremark and shall be daweiedto existing Improvements,
10. Prior approval rff inspector is requited (or anywork done abet normal working hours, on weekends or holidays and may require retmbursttmSnt of
inspertlon [et[9 at the gallant oV9RimC rate.
11- Adequstq 6lgning and baMcading Is required on the job site. Failure to provide such signing and barrlCedhtg may r9bUk In the City's providing signing
and bnrrleades and charging the cost (Including ali labor and materials) against tha cash depoah.
12. CompaUion testing of suhgrade, 6se rock, qnd asphalt concrete byPermittee is raqulred unless othetwfse stated 6ythe Cltyl:nglneer,
13, 71,e Contractor or Permlttnx will have a supervisory representative available for contact on the projegt at all times during construction. Contractor or
Permittee shall provide n phone number nt which they can be contacted outside the hours of 800 0.m.ta 4:00 p,m,
tA, NO Storage ofmatrrflls or equipment well be allowed near tha ed8a trf pnvrmrn4 thetraveied way, or 1vlthln the shoulderllne whlchwauld veatca
hazardous condition to the public.
f 5. Thfs permit shall not be construQd o6 euthorlietlon for excavatlen and grading on private property adjacent to the work or any other wgrkfor which a
separate permit may be raqulred, nordaes ft relieve the Permittee of any obligation to obtain any ether permit raqulred bylaw,
t6. Thu perm] dvee not releaso the Permittee from anyiiabtllties contained In otheraQreembnt! oreontrectt<wlth theCityand any other publlcagency.
17. This permit Is not transferahie. work must tie performed by tho Perrnlttae ar hl~t d~slgnated agent or contractor as specified thereon.
1 A. Cali back (call out) due to Pmerrgon[Ies regaMing this permit shall be at the current overtime rate with a three f3) hour minlrnum charge per
occurrence,
19. plirSUant to Chapter 14,0 of the Campbell Municipal Code, applicant shall not cause to b4 d18Chorged any matcrlat Into the municipal storm drain
ryrtarn othcrthan storm water. Applicant shall adhere to the BESTMANAi36MON'f PRAC7IC@5 AstabllshEd by the5anta Clara Va11ey Urban Runoff
Pollution Prevention Program.
20. IF the public interest rCqulrer a rrtodlAtatlon of, or a departure fFam the plans and speclflcatlans, the City shall have the authorhy [o tequiro of approve
any modtflcatron qr departure and to specify she manlier In which thrs soma Is to be made forCity^owned or maintained (acllitleg.
~ 1. Permlrttea mutt provide advance netiacalion to all partlesth~t may be affected by the pefmlt acdvhlea. Nogfacatlon Shall be reviewed by the City prior
to dl5trlbutlon and Include dates of work and a contact name and phone number,
Applicant shall hr, responsible for ensuring char nil those providing services undertheappl[cantore awareand understand ail ofthe above condltlons.
., [z[z ~ ~~ Gbh ~,..~ 3 `~ ~o ! I
APPIlG8t1t DAtel
Contractor
(Print Nrmr)
Date;
1:1F4RM517emplateslQncroechmant Permitsl[neroachrnentPermit STATIC form2.pdf
Rev,$/06
Figure CSJ-22. Sidewalk Closure
Note: aSee Table A p~ ]AJp
for Sign, Cone Spacing, ~Jl
and Taper Lengths.
REVIEWED (_ AS NOTED) BY:
DATE: - / - / 20_
PERMIT #:
PROJECT INSPECTOR MAY MODIFY
TRAFFIC CONTROL PLANS AS stocwnucc~oseo
FIELD CONDITIONS DICTATE H cRO~-
Typical Application 22
Mar. 9. 2011 3: 44PM ~' i f i c Gas No, 1944 P, 1
t~3I09i2011 13:36 4ee3i ~$ MAR - 9PI~`i~`' wol~s F'HUt 01102
PUBLIC WORKS ~rflt~b ~; ,.
~ ~ ADMINISTRATION ~ r ~'~~.:p~ Y~' ~~
CItYOFCAMPBELL ~1 M ~ ENCRDACHMENTPBAMIT Perml[ No ~rv~'~~ l ~~ OGY)l~ •-
DSPT, OF PU6LIL WD ~~ 01~ {forworking within the publle X-Ref. File
7d North Flrst9treax ~ ~ ~, right-of way) Application Date,--,-~~ ~' /_~ _
Camp6e11, CA 99406 G~ 1 It,~~\ Applleat[On F.Hpiration bate.~Wf /p~/
Ph. t4oe} aas-ztso ~ \C~-- APN _._~79 "~~~ ` b0 "/
Fx. (408) 376.0956 ~pj\r \~~.(P -^^-
Q ~\N Permit Gxpfratlon Date
APPLICATION • Application Is het~mAdA for a I~ubllc Works Permit in accordancewleh Campbell Municipal Codo,5ectlon 11,04, (Appllcatlon expires In six
(R) months 14 the permltis noC issued- Appllcatlon FOe 14 nomrefundableJ
A. WerkAddressorTractNo.: 17®0 WINCHESTER BLVD. PC1&~ PM 30793239
Utility Trench Location:
e. Nature orworir: ~Idewelk closure only to instal( en 9xkG1151on on an existing power p016
C. Atteeh fpur (41 copies Oran engineered plan Showing the Ipcap on and extent of th 5 ork, and four {~ ~ ~ ~,...., ~ ~ -
4)copies oFthe preliminary Engineer'f
Estimate of work, The plans shall show the relation of th® ro osed worlc to exist~n surface and underground Improvements. when approved
by the t:+ty finglnee6 said plan becomes a pert of this pormit,
D, All work shall conform to the Cltyof G>jmpbell Standard Spedtlecatlons and Datolls for Public Works Construction; the GehArel Permlt Conditions
listed on the revcrse•slde; and lira Spcclal Provlslons forthls permit, listed below. Pollute to abldebythesetondltions ehd provisions mayfesule
In JoU shutdown and/or Fortelture of Folthful Performance Sureties and cash deposits. (See General Permlt Conditions ]and 2,}
L. The [ontrnctor roust have this Permit and approved plain a[ the site and must notify the Public works papflrtment at least two days before
startrng work. NotlCe rnuet be given to public works at least 24 h0Ur9 beforo restarting any work.
-- ~ • ---
NameofApplicant; PG&E ~ .Telephone: q~08-725-2061 1
Address: 10@00 N. Blaney Ave., Cupertino CA 95094
E•Mail Address: r3mw a[?pge,com ! 24~HOUR EMERt3ENCY PWONE NUMBER: 9-840-743-6000
Is this work being done by the property owners ai their own residence? r' YF.S )X+ NO ~ -
The Appllcaht/Permlttee hereby agrees by affixing their slgnaturo to [his ptrrmlt to hold the City of tamp6e11, Its offlcere, agents, and employees free, safe
and harmless from pny CIAIm of dQmand for damages resulting FCem the Work covered by this permit. ,
The AppllwntlPermlttee hereby acknowledges that they have read and understand both the front and bacir of this permit, and they will Inform their
contractor(s) of the informakion. Applicant Iw edvlaed th upon issuance of this permit, property owner, or property owner's successors, obeli be
responslblc for any and gll,damages arising out or the cond to of any private improvements (n the publle right•o(Way, ,
Ac<epted° , __!~t"'t--f ~(~-~-~-LG- _ ~~ ~f~,/f -~
(AppNcant Permltree)
(Contractor} {Print Name3 ~ n~*o
SPECIAL pROV1510}1{$;
_1. Street shrill oat be open curfor underground Instal[atlons. Minimum ctltsn(tay,beallowed For conr,eck+ans orexplorntlan holes. Such cuts a~~e
sR~GIR~a(ly appr_oVe„d~~e I~)~,~}~~ox„tosy,[tl~tg.
2. Ppvement may be cut for underground Inst'o110tlons and must be restored In accordance with the Standard Details Trench Restoratlan Method
".A", unless otherwlsQ approved by the Pnglne2r.
_3. Worl<te b4 ltOked by a licensed Land Surveyor of [lull Anglnaer and two (2) copies of the cut sheets Eent to the Public works Department
before start{ng work
~4. Per Section h27 5 of the Govemmant Code this permit is not valid for excava~tlonli until Unde-graund Service Alert (USA) has been notified and
the inquiry ldentlflcatlon number hoe been entered hereon. U5A Phone: 1-800-Z37.7.600. USATICKET N0._____
~5. Prlpr to anywork, the property owner sltall execute an Agreement for private improvements In the Public Righk~of-Way, which shall be
recoMcd,
6. Public NogflCOtlon Requirements:_,__„_„
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f)ato
7.
~F~LIDL~C_WORKS FEE S[HEbULF. FOR CURRENT f•~
pERM1T APPLIUTION FEE
PLAN CNF,tK PEPt)SIT
SECURITY FOR FAITHFUL PERFORMANCHlLABOR & MATERIALS
CONSTRUCTION t-ASW DEPOSIT ~~
PLAN CIdCCI(& INSPE[TION FF.E
AMdUNT
S -,..~
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5_ ,_
5
R@CEIPT N0.
APPAOVFO FOA ISSUANCE
'~mm For ity ngneer Date
_ Permlt EKp+res 12 Months Aker gate of 153ugnCC
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