ENC2011-00039CITY OF CAMPBELL ENCROACHMENT PERMIT
DEPT. OP PUBLIC WORDS (for working within the public
70 North First St. right-of-way)
Campbell, CA 95008
(408) 866.2150 Issued l~/~J~~
Fax (408) 376-0958
Permit Expiration Date ~~ ~.
Permit No '-'" ~- 2t'' ~ ~ EGG
X-Ref. File /1r /
Application Date ~1( ~% ~ ~
Application Expiration bate ~ C i I
APN /~~A
APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbe[i Municipal Code, Section 1 ] .04. (Application expires in six (6)
months if the permit is not issued. Application Pee is non-refundable.) . ~
A. Work address or tract
Utility trench location/ {n I~`SJ i i1~ r .l`J ~ lGY,1R,4. ~ e~h t1n1 • ~~t Yt~t~ ~~~ ~ U~. ,~ •~e' ' StavtLti ~f mart T r-]as
B. Nature of work 1 NtS"~'Cn. ~ t c~~'~ Vl ~~'tr'''' / ~.~>ti~.1'~' 4 t~aJ..~-
C. Attach four (4) copies of an engineered plan showing the location and extent of [he 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 Rsted 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 forfeitw'e
of Paiffifu] Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2.)
E. The Conhactor 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 hopurs beffore restarting any work. (~ J
Name of Applicant e5'~'ca~oS IG~ +Y tJ1tJd?`2.GG ~`P.~--- \ ~~ ~+DLo~ ~.~t Telephone t!J-S~"-~2'~C'--7~ ~',
(print name) ~/~~ z -~
Address 7 Z 7 mk 1'~ ~11"'~-' ~2I'F ~~ r+ )~'v~'1 L.~ 24-HOUR BMBRGBNCY TELEPHONB NO,._~ ~Sd ~ ~ ~%' ~~ ~~G
B-Mail Address ~cs-k~ ~t~ S i~1 ~ ~ ~'a ~ u;~ 1C.1 ~f~ v, Z,yL ~'~.- + G 0 >~
Is this work being done by the property owners at their awn 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 ApplicantlPennittee 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 issttance of this permit, property owner, or property owner's successors, shall be responsible for any and. all damages
arising oat of the condition of any 'vote improvements in the public right-of--way.
Accepted_~~'-- ,__~ ~ ~ 1
(Applicant Pernri[t ) (sign) Dat
'o'af iaS sr< ~ ~r, art o ~+Za {~t2- , ~, c ~~~ ~(,~ ,t', ( / l
Contractor (Print Name) ate
~1. Street shall not be open cut for underground installations. Minimum cuts ~{ be allowed for connections or exploration holes. Such cuts
be suecifically atrorQy~by the In, actor prior to cutting.
~2. Pavement may be cut for underground hrstallations and [Host be restm'ed 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 Under~nund Service Alert (USA) has been notified and
the inquiry idenCification number has been eatered hereon. USA Pltone 1-800-227-2600. USA TICKET NO.
5. Prior to any work, the property owner shall execute an Agreement for Private Improvements in Ure Public Right-of--Way, which shall be
' recorded.
~6. Public Notification Requirements:
7.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES A O RECEIPT NO.
PERMIT APPLICATION FEE $ 3.~ ~ , 5 ~ ~ y
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $
CONSTRUCTION CASH DEPOSIT $
PLAN CHECK 8r. INSPECTION FEE ~~ $-~/ -
APPROVED FOR ISSUANCE ` ~~ i `~-~ ~" ~ ~ =~' / ,'
Por~Ei~tyc.Engineer ~ Date
Permit Expires I2 Months After Date of Issuance
GENERAL PERMIT CONDITIONS
1. A Construction Cash Deposit is requved. Charges will be made against this deposit if there is ttn emergency call-out, overtime inspection or when City
ordered barricading is required. Any such coats in excess of the deposit will be billed to the Pertnittee.
2. A one-year maintenance period and~surety ate 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 Permitter 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.
$. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydtxnts and water valves.
G. A Construcflon Traffic Control Plan and a Consttvc$on 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 Goitrous. 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 Permittee.
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 hows, 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 chazgiug the cast (including all labor and materials) against the cash deposit.
12. Compaction tesdng of subgrade, base rock, atul asphalt concrete by Permittee is required unless otherwise stated by the City Engineer.
13. The Contractor or PertniUee 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 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 slut!] not be construed as authorization far excavation and grading on private property adjacent to the work or any other work for which a
separate permit maybe required, nor does it relieve the Pcrmittee of any obligation to obtain any other permit required by law.
16. This permit does not release the Permittee fora any ]iabilides contained in other agreements or contracts with the City and any other public agency.
I7. This petrnit is not transferable. Work must be performed by the PermiUee or his designated agent of 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 occurrence.
19. Pursuant to Chapter 14.62 of the Campbell Municipal Code, applicant shall not eause to be discharged any material into the municipal storm drain system
other than storm water. Applicant shall adhere to the SBST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff
Pollution Prevention Progrem.
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 modiftcation or departure and to specify the manner in which the same is to be made for City-awned or maintained facilifies.
21. Permittee must provide advance notification to all parties that tray 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 sca•vices under the applicant are aware of and understand all of the above conditions.
Applicant ate
Contractor (Print Name) bate
Jlforms~pwpenn
Rev, 11/9/05
S'TOLOSKI & GONZALEZ, ING.
GENERAL ENGIN86R1NCi COTRRACTORS L1C6NSB NO. 4$9 f 7S
727 MAIN ST. HALF MOON BAY, CA 9~L0 i 9
(sso> 725.7 i i s FAx: {SSO) 726.9055
Letter of Transmittal
TO: John Fawcett
Luhdorff and Scalmanini
500 First st. Woodland CA
P H 530-661-0109
FX 530-661-6806
(Date: 3128/11/11 S&G Job # 630
:W. Campbell Ave Wells A,B & C
Re: Submittals 12
We are sending you: [ X ]Attached [ ]Under separate cover the following items;
NO. Date Co fes Descri tion
12 3/28/2011 1 Traffic control lan for sewer tie in on W Cam bell ave
These are transmitted as checked below:
[ ]For your use [ ]Action required [ x ] For your approval
[ ]Per your request [ ] For your signature [ ]For your review and comment
Remarks:
Signed: ~""`"
Dan Stoloski
Copy To:
Flle
PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT & MISCELLANEOUS RECEIPT
Effective July 1, 2010
TO: City Clerk
PUBLIC WORKS FILE NO. ~ °°l`N~ ~ ~ ` ~ ~ w~ ` 1
PROPERTY ADDRESS - ~ <~ i,~ ~/~1. '~~~1'1 t~
Please collect & recei t for the followin monies:
-ACCT. ITEM - -AMOUNT
ENCROACHMENT PERMIT
4722 ~ Utility Encroachment Permit Application Fee
R-1 Encroachment Permit
Emergency Permits
I Plan Check & Inspection Fee
4722 Utilit < $50 000 * $350.00
N/C ~
$100.00
i '?~
Minimum Charge Per Location
$350.00 ! ~- -
~ 1 ~'
~ Conduits/Pipelines up to 500 Feet $2.40/ft
Above 500 Linear Feet $1.45/ft
i ManholesNaults/Etc. $150.00/ea
Pole Set/Removal $150.00/ea
** 2203 Utilit ? $50.000 * Actual Cost + 20% **
minimum de osit $5,000 !
4760 Stora e Container Permit $150.00
4760 Pro ect Plans & S ecifications Pro ect No.
4760
Standard S ecifications & Details $1/P
$15.50/Bk _
4760 En ineerin Ma s & Plans
Aerial Plot 24" x 36" $57.00
~ Aerial Print 8 1/2" x 11" $26.00
~! Ma Research includes max of two 24"x36" co ies $26.00
Ma sand Plans 24" x 36" $13.00
4722 ~ Penalties: Failure to restore ublic im rovements $100/Calendar Da Muni code sec. 11.34.010)
4722 1 Penalties: Failure to correct unsafe conditions $100/Calendar Da ~
4722 Work Without PermltS 4 Times A plicable Fee
.MISCELLANEOUS
511.74241 Posta e
Other Please S eci j
`Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work.
**Actual Cost Plus 20% Overhead (Non-Interest bea(ri'n~g~ deposit) TOTAL $
NAME OF APPLICANT ~~OLC-~ ~,1 ~ ~tCV~-ZPit~~~'Z- `~7
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FOR RECEIV D BY 'Lr~' ~ ~
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ONLY ,Date
Recei t # APR
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124
~est Valley
W Sanitation District
SD v
Sewer Connection Permit No:
Issue Date: By:
OFFICE HOURS & CONTACTS:
7:30 a.m. to 4:30 p.m. Monday thru Friday
100 E. Sunnyoaks Ave., Campbell, CA 95008
• Phone: (408) 378-2407
• Information Services Department
LOCATION:
APN
Sewer Map Book Page
Tract Lot
Project Assmt
Address
Jurisdiction
BUILDING TYPE:
Single Family
Condo/Town House
Multiple Dwelling Units
Industrial
Commercial
REMARKS:
OLD PERMIT No. Sub No
FEES:
Connection $
Capacity
Processing
Service Advance
Total Due: $
Paid by Check No:
Hillside: Yes No
INSTRUCTIONS:
• Permit is invalid if not connected within 12
months of issue.
• Do not connect until the main sewer is accepted
by the District.
• Obtain a building or plumbing permit from the
Jurisdiction listed above.
• Street encroachment permit is required from
• Keep 3' radius around cleanout clear of
vegetation or obstruction.
BACKFLOW PREVENTION:
Field check required
Elevation Basement
Check valve required: Yes _ No
BUILDING SEWER CONNECTIONS:
Total number of connections to this
property:
1. Lateral ID No. is located
feet of property
line, feet from main sewer and
feet deep.
Connection to Main Sewer feet
Upstream from DS MH
Upstream M.H .
Pipe Type
List any additional connections on
reverse side of this form.
Original -Applicant Pink -Accounting Yellow -City/County Bldg. Inspector Card -District File