ENC2010-00103' Permit No~~-'~~ ~L'1~~ ~ ~0 VC~>
CITY OF CAMPBELL ENCROACHMENT PERMIT X_Ref. File
DEPT. OF PUBLIC WORKS (for working within the public
70 North First St. right-of-way) Application Date ~ ~ °' , 1
Campbell, CA 95008 7~6 ~ (U Application Expiration Date 1 ~ ~. ~ 1~.
(408)866-2150 Issued
Fax (408) 376-0958
Permit Expiration Date ~ ~ ~ ~ ~ APN
APPLICATION -Application is hereby trade 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 is non-ref/u~ndable.) n ~ y~~ ~ ` l ~~
A. Work address or tract #
Utility trench
~.I v e: r z
B. Nature of work L"' ` ~ ~ J
1.
C. Attach four (~ nso hall show thetrelationpof the p oposedeworktto exnsting surface and underground im)provementsheWhe alpprovedgby the CitylEngi eer,
work. The p
said plan becomes a part of this permit.
D. All work shall c and thetS teciahprovision Sfor thispermit,l s[edl below. Fai ure tto abide bylthese ondif ors and provisionsemayPresult in job'shutdlownd on
the reverse side, P
and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and .)
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 ]east 24 hours before/restarting any work. Z1 ~ _ ~ ~ ,
C' J T L.LJ c'-~'Z•~( l.. c> + "h Telephone ~ C ~
Name of Applicant JU 41 ~ " ~~~
print name) %-~ ~ - ~
i + ~ ~y -{~;t L1' ~~ ~,~ ~J ~'~~~ S ~ 1 ~ 24-HOUR EMERGENCY TELEPHONE NO.
Address 1 ~ ~ ~~ ~ ~ ~ ~~ ~
E-Mail Address ~~
No ~~
is this work being done by [he property owners at their own residence? Yes ~~ j~
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers, agents~aU®l.iC;YVVOFlK3 and
harmless from any claim or demand for damages resulting from the work covered by this permit. ADMI(VIBTRIgj~p(~
The ApplicanUPermittee hereby acknowledges that they have read and understand both the front and ~ack of~this permit, and they will inform t etr
e cessors, shall be responsible
contractor(s) of the information. Applicant is ad on of ant u nv ate improvements n the publPc right-of-Jl' }t[ ~r ~/~
for any and all damages arisin~ t of the cord Y P ~~ _ i .- ,
fl It ,R, ~
L. ~ (Applicant Permittee) (sign)
,,}~; ~ I Pr nI D
Contractor (Print Name)
Date
-~-tC
~ 1~!V Date
SPECIAL PROVISIONS
1. Street shall not be open cut for underground installations. Minimum cuts ~ be allowed for connections or exploration holes. Suc cuts >
be specifically anoroved by the Insnector nrior to cutting.
2. Pavement may be cut for underground mstallattons and must be restored in accordance with the Utility Restoration Standard Details Metho
"A" Backfill, unless otherwise approved by Inspector.
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 epartmen
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 an
the inquiry identification number has been entered hereon. USA Phone 1-800-227-2600. 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.
i _6.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & INSPECTION FEE ~
APPROVED FOR
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Revised 12.27.04
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.~1L1-~ ~.~:,u i-t~ t
i ( ~`~~= ,fit X 2r
For City Engineer
hires 12 Months After Date of
AMOUNT
$ 3 So
7 fo r ' p
Date
RECEIPT NO.
~~
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PAGE 01101
SAN JOSE WATER MAINT
0710612010 15:00 4082797868
GEri~~ AL FERMTi' CON1]ITION5
1, A Construction Cash Deposit is regwr~• Charges will be made against this deposit if there is an cn,crgcncy call-out, overtime inspection or
when City grdcrcd bamtading iS retlutrcd_ Any Such COSts in excess of the deposit wi11 be billed to the PCrmicttcc the City.
2. A one•year maintcnanee period and surety am required. Such period will begin on dart of written accepts by
3, Refund of the cash deposit balance sea refund or cancettation of the Faithful Performance Surety will be initiated by the written acceptance of the
work by the City
4, The pCrrnittcc must request in writing a final inspection and acccptancc of [he work upon completion. AcGCptance by the City wilt lx made m
uvriting to the Perntittee,
5, Maintain soft pedestrian and vehicular crossings and free access to private driveways, bus snips, fire hydrants and water valves.
6. A Constructirm Traffic Control Plan and a Construction $chadute are required far all font closures, detours and street closures. This plan mug[ be
reviewed and apprav~ pnm to any lane glpaures.
7. 'Fhe Construction Traffic Control Plan shall eanfortn tom t ah8ll 1nc1u[IeuaType 1i fla hmg a OW signs~r qu red. And Nlainteoanee Work Zones,
dated 1940, available at Caltrans, 'Traffic control equip
S. Replace as directed by the, City 13ngineer any damaged or removed' improvements in accordance with City 5~ndards and 5pecificat9ons at the
sole expense of the Fcrmittee. ~ vemcnts.
9. Sawcut for all 1'CC ar AC rctnavals. All f'CC removals sha11 be to nearest seoremsrk and shalckcndawor hold ys and may require rdtnbursemcnt
10. Prior approval of inspector is requxtcd far any work done after normal working hours, on
of inspection costs attire ctrrrralt overtime rate- .
aired an the job site Failure m provide such signing and barrieadmg may result in the City's providing
11. Adequate signirt$ sod barricading is zcq lost the cash deposit. ,
signing and barricades and charging the cost (including alt labor and materials) ago the Ci Est 'Weer.
12. Compaction testing of sub~adt, base rock, and asphalt concrete by Permittee is required unless otherwise stated by tY &'
will have a supervisory represe:ttative available for contact ~ the project at aJ1 times during cnnstructian.
13. '1"hc Contractor or Pernaittec c number at which the can be conmeted outside the hours of Q:UO am. to 4:00 p.rn. .
Y
Contractor trr pemtitttx sha11 pro+ride a phon
14. No stora8e of materrals or WutPmet't `*"lG be allowed near the edge of pavement, the traveled way, ~ wit}tirl the ahoulderline whtch would orate
a hazardous etmdition to the public.
rmit aha11 not Ix constnted as Ruthori7sti0n far excavation and grading on private property adjacent to the work or any other work ~
15. '['his pc it aired b law,
which a separate pclrtlit may be rtquited, nor dog it relieve the permittee of any obligan~ m obtain any other perm r~ y ublic
1ti. Th{s permit does not release the permittee frortl any liabilities eoatainal in other aglxictncnts nr contracts with ttte Catty and any athd' p
agency.
l7, 'rtris perttit is not transferable, Work most be performed by the' Pcrtnittx 4r his designated agent or contractor as specified thereon.
tg. Colt back (call out) due to emergencies rcgardiag this permit sf1a11 be at the ennent overrime rate with a drrcc (3) hour m'snimum charge per
occurrence.
19. Pursuant to Chapter 14.h2 of wat~ Applicant shallaadhere tnpthe 13~ST M,tpIAGEMANT F[tAC'11t~ESaeatgbli bed by th Santa C1api'alvao~
drain system other than storm
Urban Runoff Pollution Prevention progtana.
20, if the public interest requires a tnodifrcatiau of, or a departure from, the plans and sp~ificatint-n, the caty shall hoot the authority m require ar
d ecify tYte manner in which Ute same is to be ttwdc fm Cityawned or maintained facilities.
approve soy IDodifiCatton or departure an to sp
Applicant shall be responsible for ensuring that all daosc providing services under the applicant arc aware of and understand all of the above cgnditions.
Applicant
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Contre~
t~
(Print Name)
Jbate
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gate
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Revised 12.27.04