ENC2010-00129~ITY OF CAMPBELL ENCROACHMENT PERMIT
DEPT. OF PUBLIC WORKS (for working within the public
70 North First St. right-of-way)
Campbell, CA 95008 ~ ~
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(408)866-2150 ~
Issued
Fax (408)376-0958 '~ ~
Permit Expiration Date
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Application Date- tl Z~' ~ ~.'
Application Expiration Date_ `
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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 is non-refundable.)
A. Work address or tract # / ~ ~~ h~~~~~~~ ~~~~ ~'/.L%,t1~
Utility trench location ~ [.G 4~ i~L,' rep' !fT j ~t'7~ (~~1.~„r/,~~'~' : , }~,J ~~?~o ~ ./~~ i (e~ ~f~~'`~P~,l!~~~/~
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B. Nature of work ~~?'1 I ,~?~L[.(,7'1) u~_'IJ[/A.'}./ (__.~ ~~.~
C. Attach four (4) copies of an engineered plan showing [he location and extent of the work, and four (4) copies of the 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 City Engineer,
said plan becomes a part of this permit.
D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions listed on
the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result in job shutdown
an~L'or forfeiture of Faithful Performance Sureties and cash deposits. (See Generai Permit Conditions 1 and 2J
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 Public Works a??t Least 2/4'h~urs before resta~~~rt111ing any work. n
Name of Applicant ~ \ /_ d~Cl ~ !N ~' f ~ l ~ Telephone ~t/~ ~ 7~7~~5
Address J . ,U 24-HOUR EMERGENCY TELEPHONE NO. ~!)~~~T~ ~~
E-Mail Address
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Is this work being done by the property owners at their own residence? Yes _Z~No ~ N
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The ApplicanUPermittee hereby agrees by affixing their signature to this permit to hold [he City of Campbell, its officers, agents and employees free, f~nd
harmless from any claim or demand for damages resulting from the work covered by this permit
The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their
contractor(s) of the information. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible
for an and awes ar//ring out o~ the ndition o~f-any private improvements in the public right-of-way. (~ /'
Accepted ~ ~~' ~i/',f;tl~ (1 ~ ' ~ ~ %l~/ ~~~ 7 I ~! f ~ ~i
(Applicant Permittee) (sign)
Date
Contractor (Print Name) Date
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SPECIAL PROVISIONS
_1. Street shall not be open cut for underground installations. Minimum cuts ~ be allowed for connections or exploration holes. Such cuts
be specifically approved by the Inspector prior to cutting.
2. Pavement may be cu[ for underground installations and must be restored in accordance with the Utility Restoration Standard Details Method
"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 Department
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 and
the inquiry identification number has been entered hereon. USA Phone I -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.
6.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO.
PERMIT APPLICATION FEE $ y~_
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $
CONSTRUCTION CASH DEPOSTI' $
PLAN CHECK & INSPECTION FEE $
APPROVED FOR ISSUANCE ~/y0/ 1~'
For City Engineer Date
Permit Expires 12 Months After Date of Issuance
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Revised 12.27.04 ~ ~;~yt,p~ ~ Nn , ,~ /
GENERAL PERMIT CONDITIONS
I. 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 Permittee.
2. A one-yeaz maintenance period and surety aze required. Such period will begin on date of written acceptance by the Ciry.
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 vehiculaz 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 Caltrans. Traffic control equipment shall include Type ]I 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 after normal working hours, on weekends or holidays and may require reimbursement
of inspection costs at the current overtime rate.
1 1. Adequate signing and bamcading 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.
13. The Contractor or Permittee will have a supervisory representative available for contact 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.
15. 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.
16. 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
drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES estabiished'oy the Santa Ciara Valley
Urban Runoff Pollution Prevention Program.
20. ]f the public interest requires a modification of, or a departure from, the plans and specifications, the City shall have the authority [o 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.
giant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above conditions.
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Applicant 1 to
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Contractor (Print Name) Date
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Revised 12.27.04