ENC2010-00077~Jurl, 3. 2010 8.32RM PaQ,~fi~ Gas and Ele~trl~ Co, No. 7557 P, 1
Print Form
I;ITY QF CAMPBELL ENCR4ACHMEN7 PERMIT PermiC Na ~N G 20 ~ U - GUO77
DEPT. OF PUBLIC WORKS (For working within the public X-Ref. File
70 North Firsk Street right-oF-way) Application Date 6 ( ~
[ampbell, CA 95008 Application Expiration Date d
Ph. {aos) a6s-x~so Issued ~~ ~1 ~ APiJ ? 7 g 'z, f ~~7
Fx. (40B) 376-0958 ~ 3/' ~
Permit Expiration Date
APPLICATION -Application is hereby made for a Publlc Works Permit In accordance with Campbell Municipal Code, Section ~ 7,04. (Application expires In six
(6) months If the permlt Is not Issued. Application Fee is non-refundable.)
A. Work Address or Tract No.: 1035 MITCHELL ST X5T ALMARIDA pR
Utility Trench Location:
0. Nature of Work: REPAIR GAS LEAK
C: Attach Four (4) copies of an engineered plan showing the location and extent ofthe work,and four (4) copies oFthe preliminary Engineer's
Estimate ofwork, 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 [his permit.
D. All work shall conform tothe City afCampbell Standard Specifications and Details For Public Works Construction; the General Permit Conditions
listed on the reverse side; and the Special Previsions for [his permlt, 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 Condltlons 1 and 2.)
E, The Contractor must have this permitand approved plans at the sate and must notify the Publlc Works Department at least two days before
starting work. Notice must be given to Publlc Works.at least 24 hours before restarting any work.
Name of Applicant: ROBYNMACIAS PCB d' ~ Telephone, 408-299-1160
Address:
308 ~TOCKTON AVE, SAN 105E, CA 95126 l
E-Mail Address: RMBYpPGE COM 24-HOUR EMERGENCY PHONE NUMBER; 408-299-1160
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 permlt to hold the City of Campbell, its officers, agents, and employees free, safe
and harmless from anyclalm or demand for damages resulting from thework covered by this permlt,
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 formation. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be
responslbfe/for any arah dam~ges arising out of the condition of any private Improvements In the pubAc right-of-way. i /' ,,
Accepted:
(sign}
to
(Contractor) {print Name} Date
SPECIAL PROVISIONS
t. Street shall not be open cut Far underground Installations, Mlnlmum cuts p~ybe allowed for connections or exploration holes. Such cuts maybe
specifically aaaroved b~th~ Ins ector prior to cutting,
2, Pavement maybe 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 he staked by a licensed Land Surveyor or Clvll Englneerand two (Z) copies of the cut sheets sent to the Publlc Works Department
before starting work,
a, Per Section 42t 5 of the Government Code this permlt 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-BDO-227-2600. USA TICKET NO.
_-„_,_ 5. Prior to any work, the property owner shai{ execute an Agreement For Private Improvements In the Publlc Right-of-Way, which shall be
recorded.
6. Publlc Notlflcatlon Requirements:
7
5 P B I WDAK F .. HEO LE FCIR CURRENT FEES
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FDR FAITHFUL PERFORMANCE/LABOR & MATERIALS
CONSTRUCTION CASH PEPCI$IT
PLAN CHECK & INSPECTION FEE
APPROVEDFORISSUANCE
AMOUNT 33S
5 .._~
$-
5= ~1~
Permit Expires 12 Months Aher Pate of Issuance
RECEIPT tJp~
~3~r ~
Date
d ~ u ~`G-~1 ~ L ti ~I ~
Jinn. 3, 2010 $:33RM Parifl~ Gas and Ele~trl~ Co, No, 7557 F. 2
GENERAL Pf:RMIT CONDITIONS
I. A Construction Cash Deposit is required. Charges will be made againstthis deposit ifthere 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 Clty.
3. Refund or the cash deposit balance and refund or cancellation of the Faithful Performance Suretywill be initiated by the written acceptance of the work
by the Clry.
a. The Permittee must request In writing a final Inspection and acceptance of the work upon completion, Acceptance by the Clty will be made In writing
to the Permittee.
5. Malntaln safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants, and watervalves.
f,. A Construction Traffic 4ontrpl Plan and d Construction Schedule are required for all large Closures, detours, and street closures, Thls plan must be
reviewed and approved prior to any lane closures.
7. A Construction Traffic Control Plan shall conform to the Caltrans Manual of TrafflcControlsfor Constructlonand Malntenancework Zones, dated
1940, 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 Speciflcatlons at the sple
expense of the Permittee.
9- Sawcut for all PCC or AC removals, All 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 ar holidays and may require reimbursement of
Inspection costs at [he current overtime rate.
1 t. Adequate srgning and barricading Is required on the Job site. Failure to provide such signing and barricading may resultin the Clry's providing signing
and barricadesand 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 Ciry Engineer.
l;i. The Contractor or Permittee will have a supervisory representative available for contact on the protect at all times during construction, Contractor or
Permittee shall provide a phone number at which they can be contacted outside the hours of 6;00 a,m. to 4;00 p.m.
~ 4. No storage of materials or equipment will be allowed near the edge of pavement, the traveled way, or wirhin the shoulderline which would create a
hazardous condition to the public,
15. This permit shall not be construed as authorixatlon Forexcavatlanand grading on private property adJacen[to the work oranyother work Far which a
separate permit may be required, nor does it relieve the Permittee of any obligation to obtain any other permit required bylaw.
lti. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the Ciry and any other public agency.
t 7. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specl@ed thereon.
] S. Cell 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 Cade, 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 modlFlca[lon of, or a departure From the plans and speciflcatlons, the Clty shall have the authority [o require or approve
any modification or departure and to specify the manner In wh1Ch the same Is to be made For Clty-owned or malntalned fadlltles.
21. Permitttee must provide advance notification to all parties Chat may be affected by the permit activities. Notification shall be reviewed by the City prior
to dlstrlbutlon and Include dates of work and a contact name and phone number.
Applicant shall be responsible far ensuring that a({ those providing services under the applicant are aware and understand all ofthe above conditions.
Contrauor (Pant Name)
Date:
Date:
J:IFORMS~Templates~Encroachment PermltslEncroachment Permit STATIC Form2,pdf
Rev. 3/OB