ENC2010-0007506/04/2010 04:22 408376°~58
CITY CAF CAMPBELL
1~i:,PT, OF P'l1CiL1C: WORKS
70 North First St..
Carnphell, ('~ 95008
(408)866-2150
Pax 0408) 376-09.58
PUBLIC WORKS PAGE 02/0
ivrFCROACHM. FNT P'BRMIT
(for working within the public
tilhti-of-way)
Issued ~I~ ~ ~~ --
permit Expiration hate 3 I
APPLt(_AT10N - Applicatitn, is hereby rnadC for ~. Puhlic Worhs Pamir. in accordance with C:ampbclI Municipal Code. Section 11.(14. (App)ica.rion expires in aix (G)
months if the permit is nor. issued, Applicatitm Fee is non ~rcf/uJn~dr/Ablc,) ~ _ r1f
A. Work adtlress or tract: i1
Utility trench Incati
B, Nature of wo*k ~_/l ~ / ''+~ __r ~ ~--~-
C. Attach four (4) CopiCS of an cnginected pk'tn showing ihC tocnrion and cxtCltt of the work, and 'four (4) Copies of Yltc prdiminaty Engineer's Estimnl:C of wctrk. The
plan,^> shall sltpw 1'hc relation tt'C titC pfOposcci WOrk t0 CXistin~ scrfacc hod LSnC1CCgr4unc! improvClnCntS, Wl,cn approver! by the City EnglnCCr, sold pion UeCOmCS s+
para. of this permit.
D. cvlc ~< c dc', and the Special !4o isions fnrnehihv permfll,~is~d hc]ow~nFailurr. lcs a~f,Cidalhy~he ~e,concl+t~ans nd prnvisinn~stlmay,rt:sulllin .fob sh tzlowit nncllor forfcitu •c
of faithful i'Crformance $uretias and Cash dCpn#its. (SCe Genernl Permit Condtlions 1 and 2J
E. The Contractor mast imvc this permit and apprnvtal plans ar. the site and must. notify the Public Works rtcpartmcnt. at lctlst two tl,tys~befo~re starting work NntiCC.
must: hC given to Yyb~k Workc nt lens' `hours before restarting any work~~ ~~_ ~L' / 6~
e ..,. n r)
Name of Applic
Address ___~L
"..,
P.-Mail Address __.,_ .,.,. ~--- '""
1^, this work bcin~. done ny t.hC property owners at !heir rnvn residcnCC? Ycfi
'I`I,c Applicant/pcttnitt.ee hereby ngrcas by affixing their si};naturC r0 !hie pCrmit: to hold the City of Campbell, its C1ffICC1'S, agCnts nn¢ cmplnyccc free, sai'a and harmless
from any claim or dcrnand 1'nr dnmapus resulting from tha work cnvcrccl by this permit.
'1•hc Applicnnf/I`Crmitiec hcrrhy acknnwlCdgCS Ihat they have read anti nndcrstand both the front. anti (tack 0'f t.hls pct'mit, ind they will inform their cnntrnatnr(s) of the
inforrnnticnt, Applicant is ntlvised at nn issuance of this permtt, property owner, err property owner's successors, shall ItC responsible. for airy soul alt damages
arisintt nut. of t.hc cttnditio~t of any p v tmpmve to in the public rigltt-of-way. ~ `/ / ~-.~
1iI nt Per ittee) (sigrtl ~'' ILK ~~~ t7ntc '
Print Natrlel I)atc
t,ontrnctor
SPECIAL_PRS?v 1S1C)NS
l . Street. shall not i)C open cltr for undcrgs'oand installations, Minimum cuts ~ be. allowed for wnnecuons or exploration holes- Sltch cut. m~
- r t~Rrinccor nrJl~r ro cuttins_.
1tC~.PC~irtcally nonrnvcd_by~b.
2. 1'tlvomettl. may be cot for undergt'ound insmllttritm.", and mutt he rostnrcd in accordance wirh the Standard Details Trench Ftcst.nratlnn Mct:,oc
-J~,.. "A^ nraess dtllCtyVlsC aprrf/VCd ny lit C'pCCinf. 'f~'~p~'
3. Work to t,c staked by n licensed Land Surveyor nr Civil Engineer anri iwo (~) copies of tttc cut. sheets scut t:o the Pcblic.:V:51'F::~ „tm'snt
bcforr, sntrtinF work,
_ 4. 1'cr Section 47.15 of the (;nvtrnment Coda this permit is not voile! for excavations until Ilndcrgrnui~SAnTtC.'1CET NU 5A) lr~s i,eCn notified and
• the inquiry idcnt'lftcation number has been entered hereon, ce:n nl ~S orlPrivtiCtlmzrovemants in lhC Puhlic R! Itt•t+f•Wa, . whialz giro!! 1?c
p g Y
_ 5 friar to any wtn•k, t.hc pn~,erty ownc+' shn11 axecutc an A@'
G I'ublie Notkfsc:+titn, Requirements: ~,....~-- -_-.,.•
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SEC P[1[3.LIC WQRK4 PEE SCHED[,1LE Ft)12 C(.IRi;,F~l~
PERMIT APPI."1CATIUN FEE
PLAN CHECK pEPQ51T
SEC[ITZ{'t"Y FOR PAI'TFiFCiL PERFORMANCP,/LABOR & MATERiA1,S
CONS'T'RUC;"t"tUN CASH DEPOSIT
PLAN CHECK dt INSPECTION PEE
APPR(1VED FOR iSSU
Pctrltit No ~~~-/ y4. v~C 6'f ~ 'G:' "• ~.~
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Application Aate ~"'"
application Expiration atc1;Z ~?
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06/04/2010 04:22 40837F'a958 PUBLIC WORKS PAGE 03/03
GENERAL PER1~[iT CONDITIONS
1. A ConsiruCtion Cash Deposit is rcquired. Charges will be made a~ainsL this deposit: If thcrC is an cmer~cncy call out, overtime inspection or when City
ordered barricading is rcquired Any such costs in excess of the deposit will he billed m the Pcrmittcc
2. A one-year maintenance petted and surety are required. Cush period will begin on dots of written aeecptanec by the City.
3. Refund of the cash deposit balance and refund or eanccllation of nc~ Pait:hful Performance Surety will be initiated by the wrid.cn accept<lnce of the work
by the City
4. The Fct•mlttee mast request in writing a final inspection and acceptance of [hc work upon cr7mplctipn. Acccptancc by the City will i7c made in wt•It.ing to
the Pcrmittcc.
5. MaintSin safe pedaarian and vchicnlar crnsteings and tree access to private driveways, bus stops, fire hydranLc and water valves.
G A Cnnsvuctinn Traffic Control Plan and a Construction 5cherJulc arc rcquired for n.ll tans ciosures, datollrs ;Ind street closures, T11i,^, pion must be
rCviCweti and approved prior to any lane closlrres.
7, The. Consirttction Traffic Control Pian shall conform to the Ca-trans Manual of Traffic Controls for Ccrostruction and Mainicnuncc Work 'l~tncs, dated
f 99(l, availahlc ar C:altrans. Tmific cant.ml cquipmcm shall include Typc ll flashing arrow signs if rcquired.
8, Replace as directed by the Ciry Ens;ineer any damaged Cr removal imorovcmcntc in accordanec with City StandardQ and Spccificatinn5 ai the s01c
~,:pcnzc of t::c PcrmiC:CC.
9. Sawcut for all pCC ar AC removals. All PCC removals shall he to ttcarCSr scofemark ant! shall he doweled to cxial.ing imprnvcmonts -
10, i'rior approval of inspector is rcquired for ally work dons after normal working hrn7rs, nn weekends err holidays and mny Ycquirc rcimhtnse)ncnl of
insl7crtion casts at nc~ current overtime. rats.
t 1. Adcgtt.•ttc si~ming and b1ri'iCathng IR rcquired Ori the .fob SItC, P:tilurc tD plnvidc Such .flgtling and barricading may resuh in Lhc City's provl(liltg sigllln~•
sect tnttticados and charging nc~ cast (including a31 labor and matcrin.-s) upuinst the cash dcpo,4it.
12 C:ompacunn tcatinp of subgrndc, bass rock, and asphalt concrete I?y Pcrmittcc is rognirctl unless otherwise stated by the City L?ngincer
13. The Cnntrnctnr ar Pcrmittcc will have a supervisory reprecentativc av:tilahlc for Ct)nttlCl Cn 1118 prof@C( al. all limes dUr11t~ C(NISLPLICL1On. Ca)niractt.>r nr
PcrmincC shall provide a phohc number al which they can i7c eontactctl outside I:hc hours of R:00 a,m, to ~IttH) p.m.
14, Nn S[nr,1gC of materials nr cquipfiCnl. will he allowed near the edge of pavt:mcnt, the rravcicd way, nr wit.hin the shoulderl(nc which wppltl ctc;Aln u
17axsrrdous condition to t.hc pahtic.
15. 'Chirpermit, shalt ern hC constrtrcd as aut.hnrixation for excavation and grading nn private property aQjaccnl ro the work or anY Pthcr work far which a
SoparalC. permit may hr reyuircd, nor doss it relievt: she Pcrmittcc of any Obli,Rnlion try obtain any ether permit rcquired by law.
1(i. Thiz permit. duos not rClCasc the Petinittee from ;.toy liabilities cnntaincd in othCr agrecmenl's nr ¢pntracis with the City sect any nt.her pnhiic ,yE~;trc:y,
17. This permit iF not rransfcmhlc. Work mast. be pCrformed by the Pcrmittcc nr his dC•eignatcd agent nr contractor as specified thcrcrnt.
I K. Gail hack (call out) clue to cmcrFCnCiCS regarding thi,c permit shall beat fhL' Current overtime tart with a three (;i) hour minimum ch:Irgc per occurrence
19. Pursuant 1n Chapter 14.02 of the Carnpl7Cll Mhniclpal {'ode, applicant shah not Caltse. to be discltarged any mal.erial into the municipal slortn (fain ::ysltm
other then ss:orrn wa.t.cr, Applicant shall adhere to the >3B5T MANAGEMENT PRACTICES catabhshed by the. Santa Clara Vailcy Urban Runoff
Polhstion Prcvcntion Program.
20. If the public intcresl rCquires a mtxlification q!, nr a dcpat'tt7rC from, the plans and specifications, the City shall hove the aulhortty+ to require nr ttpprnvC
any modification or dcparturc and t.n specify chc manner in which plc same is to be mnde'for City•ownccl or mainG•titlct! facilities.
2i Pcrmittcc must provide ndvancc not.ificatinn to ell parties Thal. may be affected by the permit acilvitlcs. Notification shall bc. reviewed by City prior to
distribution and indadc dates of work and a contact name and phone nurtbcn ,
Applicant shall be respCrnsible for' cns~tring that ail those proviClittF serv(ces unricr the applicant arc nwttl'L• of ahd understand all of the above wndititms.
AppliCUnl
Ctmtractcr (Print Name)
~ U
a k'
Datf
.l\formslpwpcrm
Rct~, 11/9/05