ENC2010-00119 ``Prsnt Form i
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Permit No~.. ~`~'' ~ r ~ ~ `
tITYOF CAMPBELL ENCROACHMENT PERMIT File
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DEPT. OF PUBLIC WORKS (for working within the public .
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70North First Street ryht-of-way) Application Date _
Application Expiration Date
Campbell, CA 95008
(408}855-2150
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Fx. (408) 376-0958
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Permit Expiraitor, Date ~ ...._
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APPUCATIG~i -Application is hereby mad ..,..,
e for a Public Works Permit in accordance with Campbell Municipal Code. Section 11.04. (Applkation expires in irx
(o) months'r:' ;he perrnh is nn[ issued. Ap plication Fee is rtorr-refundable)
A. Work Address or TractNo.: f~34 ~"JlncfiesterF31,•d
UtifnyTrerxh Location: iE?udci r;ve
.._... .._... . ,..._.._,.._._ ,__..__.._ _,.._ ._...._ .. ..~._..w,........._.,..
R. Nature of Work ~^n tno ear ti Re}~iace sidewalk at base of pole aril service bwlding
C. Attach four (4) copies of an enyineered plan showing the tocation and extent of the work and four (4) copies of the preliminary Engintrrs
Estimate of work The plans shall zhow the relatbn of the proposed workno existing surface and underground improvements. When approved
by the City Engineer. said plan becanes a part of this permit.
D. All workshailconformtotheCityofCampbel!StandardSpecificationsandDetailsfarPublicWorksConstruc[ion;theGeneraiPermi[Corditions
listed on the reverse side; artdthe Special Provisions for this pennh, listed bebw. Failure to abide bythese corxi'rtions and provisions may resuh
in job shutdown and/ur forfeiture of Faithful Performance Sureties and wsh deposits. (See General Permit Conditions 3 and 2.)
E The Contractor rtwst havethis permh and approved plans at the she and must notify the Public Works Department aT lead two days before
stetting work Notice must be given to Public Woks at least 24 hours before restarting any work
r......__.._ _.._..........__....__.___...._ ,._..._._. --
Nameof Applicant: Lafalecom Jean Let- Tr:,iephone: E7U?•?59-4f37Ct:211
Address: f 325 Chadtxxtrne Rd., Fairfield, C:ti 9434 ce11:408-564-4016
E-Mail Address: Jean.Ler..~cabiecomlic.rt+~t 2MHOUREMERC,ENCYPHONENUMBEN: 408-639-8796-Chrl5Str2et
Is this work being done by the propertyowners at their own residence? r YES iX. F;:;
The Applicant/Perm ittee hereby agrees by affaing their sgrwture to this permit to hold the Ciry 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 Applicant/Permiriec hereby acknowledges that they have read and understand bath the front and back of ibis perm'tL and they will inform their
contraetor(s) of the information. Appftcan[ is advised that upon Issuance of this permit, property owner, or property owner's successors, shall be
responsible for any and all damages arising out ofthe corxfitiort of any private improvements in the public rghtof-way.
Accepted '~ ~4.,.~. -+•_ ....~: .... ~ ~ '~~
-,.._. --t ~. __.-- __ ......_ Date
(ApplrcantPermtttee) (sign) ;
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fContractorl ;Pant Name) Date
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5 P.~ql~. FR~zVI510N 5;
1. S*.reet shall not be open cut for underground lnstallations. Minimum cuts rn~ be albwed for connections or explorairon holes. Such cuts may ~g
sc~ecifically ap~rpv„„ed..by.tfxf, Inspector prior to cutting.
i 2. Pavement maybe cut for underground installations and must be restored in accordance whh the Standard Details Trench ReRoratiort Method
"A', unless othen=aise approved bythe Engineer.
3. Vork to be staked by a licensed Larxf Surveyor orCivil Engineer and two (2) copies ofthe cut sheets sent to the Publk Works Deparnnent
before starting work.
4. Per Section 4215 of the Government Code this permit is not valid forexcavatbns until Underground Service Alert (USA) has been notified and
theiaquiryidentincationnumberhaslxenenteredhereon. USA Phone: t-800-227-2600. USATICKEiNO._._._.,__
S. FrortoanyworkthepropertyownershallexecuteanAgreemertforPrivatehnprovementsinthePublickight-of-Way. which shall be
recorded. -
__ 6. Public Notificatbn Requirements:._...._........._....~_._ ----
7
SE>i?~P~1.~1,1~4YORKS.EEC_$C'iEDULEFURt;URR~C~.F.~~S AMOUNT Cam RECEIPT NO.
PERMR APPLICATION FEE 5_~~+y __........._........__ -
PLAN CHECK DF.VOSIT ~-- . - --
SE~URITY FUR FAf1HFl11. PERFORMANCE/LABOR&fstATERIALS 5 _,,....._ ...__..... __. __-
CUNSTRW'CTIONCASH DEPOSIT 5-,_.~..... _/.~ -
PLAN CHECY,& INSPECTION FEE 5..._ .J.....c-Gr!......... -
APPROs1ED EON ISSiIANCE _.......- --....__._.__._..._......_. _ _ ...............---....._._. _._____...,.,_ ~ ~ --~-G
~~ Fox Gry Weer Da
Permit Fxoires I) Months After Cate of Issuancc
GENERAL PERMIT CONDpI'f')ONS
1. A Construction Caxft f>Nposit ix recprired. Charges wih be made against this deposit if there is an rrnergency call-out, overtime Inspectiott or when Gty
ordered barricading is required. Any such costs in excess of the deposit will he billed to the Permittee.
2. A one-year maintenance period aril wretyare retuired. Such period will begin on date of written acceptance by the City.
3. Reftu+d or the cash depastt balance and refund or cancellation of the Fahhful Performance Surety will be inkiated by the written acceptance of the work
by theCiry.
4. The Permittee mull request in wr',ling a Oral inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing
to the Permittee.
~. tvlaiMain safe ped=^strian arxl vehicular crossinGS and bee access [o fxivate driveways, bus stops, fire hydrants, and water valves.
6. A Consvuction Traffic Control Plan and a Construction Schedule are required irx all lane closures, derours, and street dosures. This plan must be
reviewed and approved prior to arty lane dosures.
7. A Construction Traffic Control PLxt stroll conform to the C;aftrans Manual ofTraffic Contras for Construction Mxl Mainrenarxe Work Zones, dated
1990, avasiable at ~2ltrans. Traffic contrd equipment shall incksde Type II Flashing arrow signs if required.
B. Rep;ace as dvected by the Gty Engkteer any damaged or removed improvements in accordznce with Ciry Stxtdards and Spec(fications at the sde
expense of the Pemittee.
9. Savxut for ail PCC or AC removals. All PCC removals shall be to the nearest scoremark anal shall be dowelat to existing improvements.
)0. Prior approval of lnspettor is required for any work done aher normal working hours, on weekends or'nolidays and may require reimbursertteru of
Inspectim costs a[. cite current wertitr+e rate.
11. Adequate signktg and barricading is required on the Jab site. Failure to provide such signing and barricading may resuh in the Gly's providing ssgnirg
and barricades and charging the cos[ Gndudiny all labor and materials) against the cash deposit.
1?. Compaction iesiing of subgrade, base rock.end asphalt. concrete by Permittee is required unless otherwise stated by rite City Engineer.
i 3. The Contractor or Permittee wi`:I have a supervisory represenlatlve available for contact on the project at all times during construction. Contractor «
Permittee chalk provide a pttone number at which they can be contacted outside the ho[as of BUO a.m to 4:00 p.m.
74. No storage of materials orequipment will be allowed near the edge of pavement, the vaveled way, or within [he shouiderline which would aeate a
hazardous condition to the public
t S. This permit shall rot be construrJ as authorization for excavation and grading on private property adJacent to [fie work a arty other work for which a
sep:+rate permit maybe required, nor does it relieve the Permhtee of any o6ligatgn to obtain any other permit required by law.
i6. This permit. does not release the Permittee from am ifabilitles contained n other ayreements or' contracts with the Gty and arty other public agency.
11. This perms: is not transferable. Work must be performed by the Permittee a his designated agent or contractor as specified thereon.
t R. Cal! back Icall out-due to emeregerxies regarding this permit shall be at the current overfime rate vrth a three (3} hour minimum charge per
occurrence.
9. WrwaM to Chapter 14.02 of the Campbell Municrpal Code, applicant shall not cause to be discharged any material into the municipal storm drain
system other than storm water. Applicant shall adhere [o the IiE:STMANAGEMENTPRACTlCES established by the. Santa Ceara Valley Urban Runoff
PdluCOn Prevmtior. Program.
20. If the puNic interest requires a modification oi, or a departtxe from the pWns and speciflcatiass,che City shall have the authority to require or approve
any rstodifcation or departure and to specify the manner in which the same is to be rtade for City-owned or maintained facilities.
21. Pemtitttee must provide arhrance notificatkut to all ponies that may be affected by the permit activities. NotiFication shall be reviewed by the City prior
to distr;bution and Include dates of work and a contact name aril phone number.
Applicant shaA be resp~~nsible fa ensuring that all those providing services under the applka[tt are aware and understand all of the above corxiitions.
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1:\FORMS\Tempiate~~.Encrcatitment Perm!ts\Encroachment ?er mit STA17C fonn2.pt1 f
Rev. 3/08
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