ENC2010-00094-lun.22, 201E 12.~0P~. ,~ Nn. 7607 P, 1
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CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No "~- j1~. •:~ ~~ , t ;' " ~~` ~~ ~(' i
DEPT. OF PUBLIC WORKS (for working within the public X-Ref. File
70 North First 5trstat right-of-way) Appllcatlon Date ___1„-~~ ~ ~ '' -
[ampbell, t;A 95008 0 Appllcatlon Expiration Date ~ ~
Ph. (408) 666-2150 Issued 2- ~ APN
Fx. (406) 376-0968 23 ~
Permit Expiration Date
APPLICATION • Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11,04. (Appllcatlon expires in six
t ift a ermit is not Issued. Appllcatlon Fee isnon-refundable.)
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A. Work Ad Tess or ract No.: s/w corner San Tomas ANuino c/s CamNbell - PM 41097879
Utility'french ocatlon:
t'Uk3LIG WC)HKS
~idM11VIBTR N
B. Nature of Wor cr-. Tag 12047 2 -repair asphalt damaged during leak repair.
C, Attaeh four (4} copies of an engineered plan showing the location and extent of the work, and four (4) copies of [he 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 Clty Engineer, said plan becomes a part of this permit.
D. All workshall conform to the City of Campbell Standard 5peciFcations and Detalfs for Publle Works Construction; the General Permlt Conditions
listed on the reverse side; and the Special Provisions For,this 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 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 feast two days before
starting work. Notice must be given to Public Works at least 24 hours before restarting anywork,
Name oFApplicanC: ~dcific Gas & Electric Cp, Telephone: 40$x`725-2033
Address: Attn: Gas T&D / 10900 N Blaney Ave, Cupertino, CA 95014
E-Mail Address: j6be@pge.com ~4-HOUR EMERGENCY PHONE NUMBER: $00-743-5000
Is this work being done by the property owners at their own residence? r YE5 (~' NO
The AppllcanUPermlttee hereby agrees by affixing their signature to this permit to hold the Clty of Campbell, its officers, agents, and employees free, safe
and harmless from any claim or demand fordamages resulting from the work covered bythls permit.
The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this Permlt, and they will inform their
contractor(s) of the information. Applicant is advised kt3Ftlp n issuance of this permit, pro grty owner, or property owner's successors, shat( be
responsible for r Viand all dam g s arlsl gout ofthe eon ition oFa y private Impro a nth public right-oF way. _
Accepred: ~1
(AppllcantPermlttee} (si n) Date
(Contractor} (Print Name) pate
SPECIAL PROV15lONS:
_1. Street shall nvt be open cut far underground Installations. Minimum cutsplaybe allowed for connections or exploration holes, Such cuts ma
gpgciflcal(y apnraved by the Ins ector prior to cutting
~2. Pavement may be cut for underground Installations and must be restored In accordance with the Standard details Trench Restoratlon Method
"A",unless otherwise approved bythe Engineer.
3. Work to be staked by a licensed Land Surveyor or Clvll Engineer and two (2) copies of the cut sheets sent to the public Works Department
before starting work.
_4. Per Section 4275 of the Government Code [his Permlt Is not valid for excavations until Underground Service Alert (USA) has been notlfled and
the inquiry identification numberhas been entered hereoh. U5A Phone: 1-800-227-2600. USATICKET N0.
_5. Prior to any work, the property owner shall execute an Agreementfor Private Improvements in the Public Right-of-Way, which shall be
recorded.
6. Public Notification Requlrements~
7
SEE PUBLIC WORKS FEE SCHEDULE FOR CUS~NE T FEES
PERMIT APPLICATION FEE
PLAN CHECKDEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS
CONSTRUCTION CASH DEPQSIT
PLAN CHECK & INSPECTION FEE
gPPROVEDFOR155UANCE
AMOUNT RECEIPT N0.
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For City Engineer
Permlt Expires 72 Months Aher Gate of Issuance
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Jun, 22. 2414 12:51PM
Paclflt Gas and electric Company
Field Paving IUieasurements
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ORdER NUMBER
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ORDER oeSCRIPTION
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PROJECT TITHE
No, 2b02 P. 3
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Page 1 of
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CON7RgC74RlCONTRACT NO.
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ADDITIONAL LOCATtO INFORMATION
ITEM # E$CRIPTION ~ 1Fl1 ~,
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Q SKETCH ATTACHED
D PERMIT ATTACHED
PERMITTING AGENCY 1 PERMIT NUMBER
i'
Jun. 22. 2010 12:50PM
GENERAL PERMIT tONaITIONS
No. 2602 P. 2
t. a Construction Cash Deposit Is required, Charges will be made against this deposit if there is an emergenry call-out, ovettlrhe Inspection or when City
ordered barricading Is required. Any such costs In excess of the deposltwtll be billed to the Permlttee.
2. A one-year maintenance period and surety are required. Such period will begin on date oiwritten acceptance by the t=iry.
3. Refund orthe cash deposit balance and refund or cancellation ofthe Faithful Performance Surety will be initiated by the written acceptance of the work
by the City.
4. The Permlttee must request in writing a final Inspection and acceptance of the Work upon completbn, Acceptance by the Clry will be made in writing
[o the Permlttee.
5. Maintain safe pedestrian and vehicular crossings and free access to_prlvate driveways, bus stops, fire hydrants, and water valves.
6. A Construction Traffic Control Plan and a Construction Schedule are required for ap faneclosures, 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 Calrrans Manual or7rafFlcContrals for Constructionond Maintenance WorkZones, dated
1990, availableat Caltrans. Traffic contrpl equipment shall Include Type II flashing arrpwsigns if required.
8. Replace as directed by the Clty Engineer any damaged or removed Improvements In accordance with Ctry Standards and 5pecificatlons at the sole
expense of the Permlttee.
9. Sawcut for all PCC orAC 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 anywork done after normalworking hours,on weekends or holidays and may require reimbursement of
Inspection costs at the current overtime rate.
1 t. 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) againstthe cash deposit.
1z. Compaction testing of subgrade, base rock, and asphahconcrete by Permlttee Is required unless otherwise stated bytheCity Engineer.
13. The Contractor orPermitree will have a supervisory representative available for contact on the protect at all [Imes during construction. Contractor or
Permlttee shall provide a phone number at which they can be contacted outside the hours of 8;00 a.m. to k~00 p.m.
14. No storage of materials or equlpmentwill beallowed near the edge of pavement,the traveled way, or within the shoulderline which would create a
hazardous condition to the public.
1S. This permit shall not be construed as autharization forexcavatlonand grading on private propertyadjacent to the work oranyother work For which a
separate permit may be required, nordoes it relieve the Permlttee of any dbligatioh to obtain anyother permit required bylaw.
lti. Th1s permit does not release the Permlttee from any liabilities contained In otheragreements or contracts wlththe Clryand anyother public agency.
17, This permit is not transfereble. work must be pertormed by the Permlttee or his designated agent or contractor as specified thereon.
1 a. Call back (call our) due to emeregencles regarding this permit shall be at the current overtime rate with a three (9} hour minimum charge per
occurrence.
19. Pursuant to Chapter 14.0 of the Campbell Municipal Code,appllcant shall not cause to be discharged any material into the muntdpal storm drain
system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES estabtlshed by the Santa Clara Valley Urban Runoff
Pollution Prevention Program,
~0. If the public interest requires a modification of, or a departure from the plans and specifications, the city shall have the aurhorltyto require or approve
any modification or departure and tospecify themannerin which the same Is to be made for Clty-owned ar malntalned facilities.
21. Pern,ltttee must provide advance notl(ICatlon to all parties that may be affected by the permit activities. Notification shall be reviewed bythe 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.
J:~FORMSITemplates\Encroachment PermltslEncroachment Permit STATIC form2,pd(
Rev. 3/OB
wnuaGGOr tYrlnt Ndme] Date;
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