ENC2011-00077~~1`~""
~(" ~ ~+LC Prirx Form
CITY OF CAMPB V ~h ~~.~~ ENCROACHMENT PERMIT Permit No E (~I ~Q ~ ~ ~ ~~7 -7
DEPT. OF PUBLI~R ~ v ~ .~ (for working within the public X-Ref. File
70 North First Street ~ ~ ~ right-of-way)
~r Application Date _ .7 ~~? ~~
Campbell, CA 95008 J~'
Ph. (408) 866-2150 Q Issued _ 7/Z,G f ~ ~ Application Expiration Date_ (~f~ `~
Fx. (408) 376-0958 -7 I APN _ -3CJ~ i C~ ~
Permit Expiration Date l ~ Z
APPLICATION -Application is hereby made for a Public Works Permit in accordance with'.Campbell Municipal Code, Section 7 7.04. (Application expires in six
(6) months ifthe permitis not issued. Application Fee is non-refundable.)
A. Work Address or Tract No.:
tom/ ~ 1
Utility Trench Location:
t'1 l LL l G4~ ~ ~YL,
B. Nature of Work I ~~,~ ` TO
v.~ 'F't~lc1~ 5~'t ~ Lt,' • ~--1 Ac w) - ~.. i O,cJ
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 exjsting surface and underground improvements. When approved
by the City Engineer, said plan becomes a part of this permit.
i
D. All work shall conform to the City of Campbell Standard Specifications and Det i ils for Public Works Construction; the General Permit Conditions
listedon 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 debosits. (See General Permit Conditions 1 and 2.)
E. The Contractor must have this permit and approved plans at the site and must ~otify 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:
_ Address:
•NC"T
Y PHONE NUMBER: Gj ~`7 ~ ~ O ? QOb
E-Mail Address: I J) L-l~l~lV ~~~ v ~ ~ C/~i~~HOC U EMERL GEN
Is this work being done by the property owners at their own residence?
YES O
The-ApplicanUPermittee hereby agrees by affixing their signature to this permit to holdlthe City of Campbel' I, its officers, agents, and employees free, safe
and harmless from any claim or demand for damages resulting from the work covered by Fhis permit.
The ApplicanUPermittee hereby acknowledges-that they have read and understand 6bth-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~or~ition oijany priv~mprovements in the public right-of-way.
Telephone: 17 p--7 5~ ~~r _t Q
~~D AC'l_~ ~ f ~ k ~~' C~J4
Accepted:
(sign)
(Contractor) (Print Name) ,' Date
SPECIAL PROVISIONS:
1. Street shall not be open cut for underground installations. Minimum cuts may 6e allowed for connections or exploration holes. Such cuts may be
specifically approved by the Inspector prior to cuttino.
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 Civit Engineer and two (2) copies of the cut sheets sent to the Public Works Department
before starting work I
4. Per Section 421 S of the Government Code this permit is not valid for excavation's until Underground Service Alert (USA) has been notified and
the inquiry identification number has been entered hereon. USA Phone: 1-800 X227-2600. 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 DEPOSfT
PLAN CHECK & INSPECTION FEE
APPROVED FOR ISSUANCE
AMOUNT RECEIPT NO~
s_ 36
$ ~tZ-
For Gty Engineei
Permit Expires 12 Months After Date of Issuance
GENERAL PERMIT CONDITIONS
I. 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 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 or 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.
a. 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 alljlane closures, detours, and street closures. This plan must be
reviewed and approved prior to any lane closures.
7. A 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 Permittee.
9. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scorem rk 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. 1
i
t 1. Adequate signing and banicading 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 Fash deposit.
12. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee 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 allowed near the edge of pavement, tFje traveled way, or within the shoulderline which would create a
hazardous condition to the public
15. This permit shall not be constrtied 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 obligatior~lto obtain any other permit required bylaw.
16. This peimtit does not release the Permittee from any liabilities contained in other agi eements 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. Call back (call out) due to emeregencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per
occurrence.
t 9. Pursuant to Chapter 74.02 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. 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 all of the above conditions.
COntraCtOr (Print Name)
7/~'/ll
Date:
Date:
J:Reina\Website\Land Dev Fortes\Encroachment Permit STATIC form2.pdf
Rev. (11/9/05)
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