ENC2010-00104,.,
CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408)866-2150
Fax (408)376-0958
ENCROACHMENT PERMIT
(for working within the public
right-of-way)
Issued 7/~°` ~~
Permit Expiration Date
rermit No~.~i ~~C~ ~ ~-~ ' ~ ~ f ~~ •~
X-Ref. File_
Application Date ~~ ~
Application Expiration Date - / [~/ - I
APN
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 irs non-re~f7undable.) p i
.1N ~(zc%N~ C3c '~' t~ Its ','\Q~ T7v~'.J '
A. W ork address or tract #
Utility wench location
B. Nature of work ~ ~ l.,!fx.~' ~ ~'X1 ~ ~ ~ ~ ~~~N~~~ `~~N ~ti~~-~`M.r-1 l/ w~ ~ fG'' LY~~-V ~ ~F~IZ-- PE: VE~Ti~-t Ati- 6j~~~~'
~-M~ .
r~C Mttach four (4) copies of an engtneered plan showing the locatton and extent of the work, and four (4) coptes of the preltmtnary Engineer's Esttmate of work. e
/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 e~lnd the S ecial Provisyons for this permit,aisted belowCaFa lu a to aDbida by thesebcondittons and ptrovisionstmay resultlin job shutdowtnoand/or forfeiture
reverse sid , P
of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2 )
E~. a 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. Noticc
`/ must be given to Public Works at least 24 hours before restartin/gtany work. Lr ~` ~ ry ~ , ;., ,,,
-~~!~ ~Ci C' (r~ ~~,,~ ~„~~ lam' \ Telephone G
Name of
E-Mail Address (~~ r ` ~'~
name)
24-HOUR EMERGENCY TELEPHONE NO. ~ ~C\` v~ t'~ ~ ~~~~
1VU
Is this work being done by the property owners at their own residence? es
The ApplicanUPermittee 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 Appli nan A eTmcant iseadvisedkthatlupon issuancey h thisrpermita property owneh,tor propertydowner's sac esso s, shall be responsible for ~any~andLall (damages
informauo pp
arising out of the condition of any private im~veme the publicpublic ri~ ~~ '{G-a/1~ s- ~ p~
~ ` `l ~,~ ~ ~., ~~ ~ 1 ~
Permittee)
tJ r
Convector (Pant Name)
Date
Date
-~~~
SPECIAL PROV ISIONS
I . Street shall not be open cut for underground installations. Minimum cuts ma be allowed for connections or exploration holes. Such cuts
be specifically aanroved by the ]nnaector prior to cuttins.
2. .Pavement may be cut for underground tnstallauons and must be restored in accordance with the Standard Details Trench Restoration Methud
"A", 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 epartment
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 propcriy owner shall cxccutc an Agreement far Private Improvements in the Public Right-of-VJay, which shall be
recorded.
G. Public Notification Requirements:
~C- ~ ~ - _
AMOUNT RECE_____Pr.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES 3 5U
$ ~~
PERMIT APPLICATION FEE $
PLAN CHECK DEPOSIT $
SECURITY FOR FATfHFUL PERFORMANCE/LABOR & MATERIALS $~~
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & INSPECTION FEE ~ 7/G /~ G
APPROVED FOR ISSUANCE For City Engineer Date
Permit Expires 12 Months After Date of Issuance
GENERAL PERMIT CONDITIONS
1. A Construction Cash Deposit is required. Charges will be made against this deposit if there 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 Petmittee.
2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City.
3. Refund of 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 Traffic 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. The Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated
1990, available at Calttans. 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. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements.
10. Prior approval of inspector is required for any work done afrer normal working hours, on weekends or holidays and may require reimbursement of
inspection costs at the current 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.
l3. The Contractor or Permittee will have a supervisory representative available for contacl 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.
l5. 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 may be required, nor does it relieve the Permittee of any obligation to obtain any other permit required by law.
1 G. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City 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 emergencies 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 draiq.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 City-owned or maintained facilities.
21. Permittee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by City prior to
distribution and include dates of work and a contact name and phone number.
Applicant shall be responsibl for ensuring at all those providing services under the applicant are aware of and understand all of the above conditions.
r+ppucant
Date
Contractor (Print Name) ---~-
Date
J\fotms\pwperm
Rev. 11/9/05
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IEWED (_ AS NOTED) BY.
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PERMIT #:
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