ENC2010-00003
Print Form
CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No ANC.. 20 I U - DOUG 3
DEPT. OF PUBLIC WORKS (for working within the public X-Ref. File _
70 North Fint Street right-of--way) Application Date b
Campbell, CA 95008 ~ ~ 1 ~ O Applicati n Expiration Date '~ ,.Z o
Ph. (408) 866-2150 Issued f APN ~ ~ b ~ (q_~L]
Fx. (408) 376-0958 ` ..~ 1
Permit Expiration Date
APPLICATION -Application is hereby made 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 isnon-refundable.)
A. Work Address or Trad No.: r a ~-~ ~,/~~~- ~ o (Z ,
Utility Trench Location:
B. Nature of Work: S~~Q/L ~~,T~/La L-
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: /' tsC- ~ ~ ~ ~~ l e, ~,`~S` ~~-~ , Telephone: ~0~ _ 3 "7'f (9/ Q 3
Address: ~ ~ 0 / ' /G ~~i ivC~ L-0v' ~~~1 /~-'tP~ ~~~ ~ /f~ ~ S a ~
E-Mail Address: ((p~~~Je ~S$L ~Ioba ~ • Ares 24-HOUR EMERGENCY/ PHONE NUMBER: ~,~ ..- ~~,~ - ~.Sgs
Is this work being done by the property owners at their own residence? r YES ~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 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 condition of any private improvements in the public right-of-way.
Accepted:
~- 7 - Zo~O
~/y~ ~ (Applicant Permittee) ~ rfj \ ~+ /} Date
/ ' uC. ~ ~ ~~~P~ ~f ~tL~.SI ~lvG. _ JQ I`~ Y~'~ ~ Lo ~ - ~ '' Z O 1- l7
(Contractor) (Print Name) Date
SPECIAL PROVISK)N5:
1. Street shall not be open cut for underground installations. Minimum cuts ~y be allowed for connections or exploration holes. Such cutsll]~X.-k~
scecifically anoroved by tthe Inspector psjor to cuttlna.
~_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-B00-227-2600. USATICKET 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
PERMff APPLICATION FEE
PLAN CHECK DEPOSIT
SECURffY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS
CONSTRUCTION CASH DEPOSR
PLAN CHECK & INSPECTION FEE
APPROVED FORISSUANCE
AMOUNT RECEIPT NO.
$ 600 2.2,2'1 ~ ~
S 2 ?v
s
Permit Expires 12 Months After Date of Issuance
.' VYEST VALLEY SANITATION DISTRICT
S1dNTl~l CLARA CibUNTY
~ 1d!t?, E. $µrrtiypals ave., Campbell, CA 95008
~ ~~~s> a~a~~ao~
a
j.. LQ.CATION• FEES:
~ -'r' 1 ~ ' -,s
t.; A:l'.N. 1-~'~; ~' ~ ' , i :. Acreage
~svuar Ldcation: 8k. ; ~% Pg. %~ ~` ~~ Frontage
,Tract . .Lot Service Advance
Proj. - Assmt. Processing
Add+rBSr '~ ra ,`~.~,~ ~ + '~ Other:
~' - Capacity
F J,urisdlCtiort,s..~`'t..-; 1 %~ ~ "~.
BU16 INd TV
F -,.,Single Family TOTAL
SEWER CONNECTION ~ ~~
PERMIT NUMBER
Issue bate '?~ ~ y ~ By ^'`~ -~'
,~ ~ '
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,~ . '%
~~
Condominium/Town Houses Disposition;
Multiple Qwetling GO Zone RL SJ
Number of Units f~ ''"
Commercial INSTRUCTIONS:
BUILDING SEWER CONNECTION:
Feet of Property
line feet from Main Sewer _
and feet deep. ~'+ ~` ~ ~
Connection to Main Sewer ~ ' ~ ~ ` ' ~ ` '- '
Feet upstream from M.H.
Using
BACKFLOW PROTECTION:
Field Check Required
Call District for foundation survey
Device Required; ~ Yes No
Type: C Ir1>~1Gt_~rr~.~i.°°"
E Industrial o Street encroachment permit required from ~:. ~=i4!- i- ; ~ r `~
Othe,~ Information. •~~:-~~' =- '"• tk"--~~-~- a Permit invalid if not connected within 12 months of issue.
F"~°'~~--'~t.i~..~~•1i.e~ s o Do not connect until main sewer is accepted by District.
Change in Status: o Obtain a building or plumbing permit from the jurisdiction listed above.
DISTRICT COPY
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PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT & MISCELLANEOUS RECEIPT
Effective July 1, 2009
TO: City Clerk
PUBLIC WORKS FILE NO. '~"~ ~ ~~ " ~GC~L
PROPERTY ADDRESS ~',
Please collect & recei t for the followin monies:
ACCT. ITEM AMOUNT
ENCROACHMENT PERMIT
4722 Utility Encroachment Permit Application Fee
Utilit Arterial/Collector Street
$600.00
rOG
Residential Street/Other Areas $335.00
4722 Plan Check & Inspection Fee
Utilit < $100 000
Minimum Charge Per Location ($270.00) 70
Conduits/Pipelines up 40 500 Feet ($2.40/ft)
Above 500 Linear Feet ($1.45/ft)
Manholes/Vaults/Etc. ($135.00/ea)
Pole Set/Removal ($135.00/ea)
Street Tree Plantin /Removal $500 de osit $155.00
** 2203 Utilit > $100 000 * Actual Cost + 20°/u **
4760 Stora a Container Permit $135.00
4760 Pro'ect Plans & S ecifications Pro'ect No.
4760 Standard S ecifications & Details $1/P $15.50/Bk
4760 Co ies of En ineerin Ma s & Plans
Aerial Plot 24" x 36" $57.00
Aerial Print 8 1/2" x 11" $26.00
Aerial Search Fee $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 Penalties: Failure to correct unsafe conditions $100/Calendar Da
4722 Work Without Permits 4 Times A licable Fee
MISCELLANEOUS
511.7424 Posta e
Other Please S ecif
*Engineer's Estimate shall be as approved by the City Engineer.
II TOTAL
NAME OF APPLICANT W ~i` ~=~-S ~~C (~ ~~
$ Zj ~ GG
NAME OF PAYOR Y~ l ~ ~ ~!~ Q l ~S ~/ C r PHONE ~OFs - 3 ~ ~'~ 6 ~ ~ 3
ADDRESS ~,~ ~ IyI C G ~ r`~fr ~, ~~ ~~Zrw ~ ~ ( ZIP (SO d
**Actual Cost Plus 20% Overhead No ~- nterest bearin de osit
FOR .RECEIVED B
CITY CLERK
ONLY ~ ~~;~
Date ~ ~ Rec ~~~ ~ ~ ~~ r l,~
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GENERAL PERMIT CONDITIONS
] . A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency call-out, overtime inspection or when Clty
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 Ciry.
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.
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 Traffc 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 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. Ail PCC removals shall 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 curcent 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 charging the cost (including all labor and materials) against the cash 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, 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 maybe 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 Ciry 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.
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 in which the same is to be made for Ciry-owned or maintained facilities.
2t. Permimee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the Ciry 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.
Applicant ~ //l/
~ ~ ~.- l ~
Contractor (Print Name)
Date:
~- ~-/~
Date:
J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf
Rev. 3/08