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ENC2010-00446Rug 05 10 02:25p.- cm of cAMPeEu DEPT.OF PUBl1C WORKS 70 North Fkst Streit Campbdi, CA 95008 Ph. (4081866.2150 Fx. (408! 376-0958 EN~ROAGHMEDR PERMIT (for working within the public prightof--way) Issued 8 ~ Q Permit F~iration Date 408 ' 0343 p. 3 Print Form Permit No ~NFi Zo~G ^ CJGII((j X-Ref. File Application Date Ib Applcation Expiration Date APN APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Sectlon 11,04, (Application expires in six (6) months if the pernitis not issued. Application Fee isnon-refundable.) A. Work Addressor Tract No.: I ~I O O .tom ~ ^ „ , (~ Utility Trench Location: (~ G t'~C-~ 8. Nature of Work: r1 (~ Z-q- ~ ~ e.,/ ~ ~2 C. Attach four (4) copies of an engineered plan showing the kxadon and nt .•he~rrwodc, and fow () ~~ Estimate of work. the plans shall show the relation of the proposed work to existing surface and undergroeurrd tmprwement ryWhen approved by the Gty Engineer, said plan becomes a part of this permit. D. All work shall conform to the City ofCampbeli Standard Spedfications and Details for Public Works ConstruatOrr the Genera{ permit Conditions ifsted on the reverse side; and [he Spatial Provision s for this permit, listed below. Failure to abide by these mndidons and provisions may result in job shutdown and/or forfeiture of Faithful Performance Sureues and cash deposits. (See General permit Conditions 7 and 2.) E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days bekxe starting work. Notice must be given to Public Works at least 24 hours before restarting any work. Name ofgpplicant: ~t ,s /J _ _ yn n ," f ,~ n Telepf>ora: ~1~, C"/~ ~(„i / Address: ~~~• ~~ '~41./~ 1~LX-'C-~ r~ J (~v ,7(~.~3-~~U fU E-Mail Address: / _ _ /~ ~ /_j _ p' ZyHOUR EMERGENCY PHONE NUMBER: Isdtisworkbei done the t..~Q~l~ //(!'L,QYnt ~°fT~~- n9 by property owners at their own residerxe? r YES ~ NO The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers, agents, and employees free, safe and harmless fiom any daim or demand for damages resulting from the work covered by this permit. The Applicant/Permittee hereby adtnowledges that they have read and understand both die front and back of this permit, and they will inform their contractor(s) of the information. Applicant is advised that upon isswnce of this permit, property owner, or property owneYS successors, shall be responsible for any a~aR damages ~sirg out of the condition of any private improvements In the public rightof-way. Accepted: ~_J (Applicant Pertnittee) (sign) (~ ~ ~I ~j f~'"D"'ate{'` C fhn/1~tS~-//1 / ~ ~ ~/ 7/( C~ (Cantrannrl ro,..,. u, - uate SPECIAL PROYISIONS- _._l. Sheet shall not be open cut for underground installations. Minimum cuts may be aibwed for cwrnections or expbradon fides. Such cuts may tie sBeSLfically ar~r'rn'ed by the Inspg two prior to cuttlna. _2. Pavement maybe cut for underground installations and must be restored in accordance with the Standard Details Trerxh Restoration Method "A", unless otherwise approved by the Engineer. ~3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent re die public Works Department before starting work. _4. Per Sec[foh 4215 of the Government Code [his permit K not valid for excavations until Undergrourxl Service Alert (USA) has been notified and the inquiry identification number has been entered hereon. USA Phone: i-80t)-227-2600. U$q 71C1Q:F NO. __5. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Rightof--.Way, which shall be recorded. _6. Public Notification Requirements: ~' 0 1 dY a ~ t SEE PUBLIC WOR < F SCHFrv n F KnR CU N7 F Fc PERMIT APPLKA110N FEE AMOUNT S 3 StJ PLAN CHECK DEPOSIT 5 SECUPoTYFOR FAITHFUL PERFORMANCE/LABOR& MATERIALS 5 CONS(RUCTK)N CASH DEPOSIT PLAN CHECK & INSPECTION FEE 5 S--' , ir~ APPROVED FOR ISSUANCE ~ / s/~~.~ RKElPT NO. Permit Expires 1? Months Aher Date d Issuance Contractor _ {Prin[Name)-U V t/~ - -- J:~FORMS\Templates~Enaoachment PermintEncmachment Permit 57 AT1C form2.pdf Rev. 3/08 Dace: wv ~ i~ ; ~. u ~ i ~- V Rug 05 10 02:27p GENERAL PERMIT CONAITIONS 4[ 957 0343 p. 1 1. A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency callout, overtime inspection or when City ordered barricading is required. Arty such costs in excess of the deposit will be billed to the Permittee. 2. A one-year malntenarxe period and surety are required. Such period will begin on date of written acceptance by the City. 3. Refund or 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 Ciry. 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 Permlttee. 5. Maintain safe pedestrian and vehicular crossings and free access to pdvate driveways, bus stops, fire hydranu, and water valves. 6. A Construction Traffic Control Plan and a Construction Schedule are required for all lane dosures, detours, and street dosures. This plan must be reviewed and approved prior to any lane cbsures. 7. A Construction Traffic Contro! plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated /990, available at Caltrans. Traffic control equipment shall include Type tl 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 Pennittee. 9. Sawcut forall PCC or AC removals. All PCC removals shall be ro the nearest scoremark and sha8 be doweled to existing improvements. i0. Prior approval of inspector is required forany work done after normal working hours, on weekends or holidays and may require reimbursement of Inspection costs at the current overtime rate. 11. Adequate signnng and barricading is required on the )ob site. Failure to provide such signing and barricading may result in the Uty's providing signing and barricades and charging the cost (induding all labor and materials) against the cash deposit. iZ. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee Is required unless otherwise stated by the Clry Engineer. 13. The Contractor or Pennittee will have a supeMsory representative available for contact on the project at all times during mrrstruction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 400 p.m. 14. No storage of materials or equipment wiN be allowed near the edge of pavement, the traveled way, or within the shouldedine which would create a hazardous condition to the public. 15. This perm it shall not be construed as authorization for excavation and grading on private property adjacent to the work or any othea~ work for which a separate permit may be required, nor does it relieve the Permlttee of any obligation to obtain any other permit requtred by law. 16. This permit does not release the Permittee from any liabilities contained In other agreements or contracts with the Ciry and any other public agency. 17. This permit is not transferable. work must be performed by the Permlttee or his designated agent or contractor as specified thereon. 18. Call bade (call out) due to emeregencies regarding this permit shall be at the current overtime rate with a three t3) hour minimum charge per occurrence. 19. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applcant shall not cause to be discharged any material into the munkipal storm drain system other than storm water. Applicant sha B adhere to the BEST MANAGEMENT PRACTICES establ6hed try the Santa Clara Vapey 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. Permltttee must provide advance notification to all parties that maybe affected by tfre permit activities. Notification shat! be reviewed by the City prior to distribution and include dates of work and a contact name and phone number. Applicant shall be responsible for ensuring that ail those providing services under the applicant are aware and understand ail of the above conditions. ~~S'[o Applicant ~ ~~ ~ ~ 1J Date: / Contractor (Print Name) Date: 1:\FORMS\Templates\Encroachment Perrnits\Encroachment Permit STATIC fonn2.pdF Rev. 3108 Flug 05 10 02:25p 4[ 957 0343 p.2 ~ ~ ~ MoD ~ c~~ ~..~(-(.~~JC~ i u f' ~y _y 1 w~~--~ f a~~. ~ T~~ ~ ~~ ~ a ~ ~ ~ ~ ~ ~~~ \' ^. ~jca 4t-.~i:g~,,~' (i~;t ~ k M' z 4~~f~~ ~ ~~ o~ ~5 - 0~ ~S2l~ %/, ~ ® o-H~ ~s s ~y'~ .~ ~ v./ ---~ _ o- T ~:--~ ~~ CTS ~~~ ~' vet 3' t~ ~-~/ ULr -~S~ 2r -~ J C ti t~ ~~ z Aug 05 10 02:25p c~ ~2bleCom 4C 357 0343 p.l CA$LECOM, lnc. 825 Chadbourne Road Fairfield, Ca. 94534 Telephone (707) 759-4070 Fax (707} 759-5741 1~ ~~ cFi '~,~~9~s T r a n s m i t t a l Date: ~t ~~r To: From: `~~~ "~`" Number Of Pages: ~ (including covet-) ~~ Comments: i Confidentiality Notice This Lacsimile cover sheet, and any documents which may accompany it, contain information from CableCom Inc_ which is intended for use only by the individual to whom it is addressed, and Which may contain information that is privileged, confidential and/or otherwise exempt from disclosure under applicable law. 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