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ENC2018-00042CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No.: INC -GOG2 DEPT. OF PUBLIC WORKS (for .working within the X-Ref. File 70 North First Street public right-of-way) Application Date 7/ t 5 Campbell, CA 95008 c / Ph. (408) 866-2150 Issued Application Expiration Date t/d2%/ !8 Fx. (408) 376-0958 APN _ Permit Expiration Date - APPLICATION -Application isherebymadefora Public Works Permitinaccordance with Campbell Municipal Code, Section 11.04..(Application expires in six (6) months if the permit is not issued. Application Fe is non-refundable.) A. Work Address: 2IV i -4 Nature of Work/Utility B. Trench Location: II _�iGc� Ojlrl �� t oil, ❑ No Fee Permit for work related to City Project Project Name: C. Attach four (4) copies of an engineered plan showing the 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. Allworkshall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; theGeneral PerrnitConclitions listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result injob shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. . E. The Contractor must have this permit and approved plans at the site and must notifythe Public Works Department at least two days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work. Name of Applicant: G Telephone:Afy _ Address: P,J, Yex la //0// /,/ �� L--7 E-Mail Address: t 24-HOUR EMERGENCY PHONE NUMBER: p/4n l' i t.12 Px " Is this work being done by the property owners at their own residence? 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 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 any and all �amages/a�,risiin�g o/ut of'mprove/raen-tts completed in the public right-of-way. % Accepted: , 1 /s/I/1tLl �4171), Yr�1 _ — / / (Appl t Permittee) (sign) Date (Contractor) (Print Name) Date SPECIAL PROVISIONS: 1. Streets hall not be open cut for underground installations. Minimum cuts maybe allowed for connections orexploration,holes. Suchcuts maybe s erifirally annrovad by the Inspector prior to rutting. 2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench 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 to the Public Works Department before starting work. 4. Per Section 4216 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: 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. 6. Public Notification Requirements: 7. NOT I PY Arrj K TEfD- DLJS i N ?-55 E5 IN Anvi C SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT PERMIT APPLICATION FEE $ - 2,f o PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PER & MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK & INSPECTION FEE $ 'LG EMERGENCY PERMIT FEE $ APPROVED FOR. ISSUANCE For City Engineer Permit Expires 12 Months After Date of Issuance RECEIPT NO. ,)J39i'4J 2731�tel Date GENERAL PERMIT CONDITIONS 1. The Permittee must provide evidence of insurance and Additional Insured Endorsements as required by the City. Insurance shall be maintained for the duration of the permit work. 2. A Construction Cash Deposit is required. Changes 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 ofthe deposit will be billed to the Permittee. 3. Refund ofthe construction cash deposit balance and refund or cancellation ofthe Faithful Performance Surety will be initiated by the written acceptance ofthe work by the City. 4. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. Surety posted shall be equal to 25% of the original Faithful Performance Security. S. Submit project schedule 10 (ten) days prior to proposed start of work. Additional lead time may be required for work within City facilities and downtown Campbell. 6. 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: 7. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants, and water valves. 8. 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. 9. A Construction Traffic Control Plan shall conform to the 2006 California Manual on Uniform Traffic Control Devices (MUTCD). 10. Replace, as directed by the City Engineer, any damaged or remobed improvements in accordance with City Standards and Specifications at the sole expense ofthe ,Permittee as expeditiously as possible. 11. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and new PCC shall be doweled to existing improvements. 12. Prior approval of inspector is required for any work proposed after normal working hours, on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. - 13. Work on arterials and collectors may require the use of changeable message boards. Adequate signing and barricading is required on thejob 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) againstthe construction cash deposit. 14. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 15. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times duping 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. and on weekends. 16. No storage of materials or equipment will be allowed near the edge ofthe pavement, the traveled way, or within the shoulderline which would create a hazardous condition to the public. 17. 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. 18. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 19. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 20. 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. 21. Pursuant to Chapter 14.02 ofthe 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 established by the.Santa Clara Valley Urban Runoff Pollution Prevention Program. 22. If the public interest requires a modification of, or a departure from the permit, plans, special provisions and/or.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. 23. Permittee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and a phone number. 24. Applicant shall remove water from utility vaults in accordance with the requirements of State Water Resources Control Board Water Quality Order WQ 2014-0174= DWQ. Said vault water shall not be discharged into the City of Campbell's storm drain system. See http:/Iwww.waterboards.ca.gov/water issu'es/programs/npdes/utilitWaults.shtml for more information. her by responsible for ensuring that A those providing services under the applicant are aware of and abide by all of the above conditions. jl i V Date: Contractor (Print Name) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.02/18 l _ _........_.......... E ....... .....-.I I ...... .............._. l ----- --- - - -- I � � 26,8057 I CITY OF CAMPBELL VENDOR NO. 10014918 CHECK NO. ; - Vendor # (Finance Use Only) City of Campbel`I - Check To: Finance Director Check Payable To: Address - Line 1: Line 2: City: Description: Invoice Number: Total Amt Payable: Account Number: Account'Number: Purpose: Requested by: Jo Approved by: Mail As Is: Return Other: Pinnacle West Exterminators, Inc. (35 Characters) P.O. BOX 219 (35 Characters) (35 Characters) Hollister State( CA Zip: 95024 ENC 2018-00042 (25 Characters) Invoice Date: $660.00 (Exact Amount) 101.730.4722 Amount: $240.00 101.740.4722 Amount: $420.00 Refunding canceled permit fees Mail in Attached Envelope: JoAnna (Name) -- Title: Office Specialist Date: 1 Dates` or Ha - ndl.fn Ch k Iriterim Check: Needed By: Public Works (Department) \\Honouliuli.cityhall.ci.campbell.ca.us.local\Profile_Data$\joannat\Desktop\My Forms\Check Requests\pinnacle canceled permit fee rfnd.xls (Rev. 03/08) PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1, 2017 00 TO: Finance PUBLIC WORKS FILE NO. C I S r-0 2- PROPERTY ADDRESS Please collect & receiDt for the following monies: 'NT- AMOU LAND DEVELOPMENT 41- 22 ncroac m nt Permit Application Fee Non-Utilitv F-nrrn;;rhmen' rl-,-;4 hA-;-, >$10,000 $425.00 Minor Encroachment Permit <$10,OOD $240.00 Initial R-1 Permit NIC Subsequent R-1 Permits within Two YearPeriod$240.00 Inspection Fee Minimum Charge per Location $420.00 Street Tree Planting/Removal - N/U 2203 ($500 per Tree Planting Deposit Required) $500.00/tree 2203 Plan Check Deposit 2% of Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Grading & Drainage Plan Review Single Family Lot $295.00 Site < 10,000 s.f. $885.00 Site 10,000 s.f. < 0.5 Acre $1,185.00 Site 0.5 Acre $1,772.00 4722 NPDES Review (C3 Requirements) For projects not required to submit numeric sizing $175.00 For projects required to submit numeric sizing Impervious Area 10,000 Sq. Ft to 1 Acre $740.00 Impervious Area 1 Acre or more $965.00 ----74-722 For proiects sent to Consultant for review Consultant Cost +20% 4722 Additional treatment facilities $3 15 ea Plan Check & Inspection -Fee ( on-Utilitv) 4722 Engr. Est. < $250,000 .14% of Engineer's Estimate 4722 Engr. Est. -�$250,000 and 5$500,000 $35,000.00 + 8% of Enqineers Estimate 4722 Engr. Est. >$500,000 - $55,000.00 + 7% of Engineers Estimate 2203 Emergency Cash Deposit 4% of Engr. Est.* ($500 min/$10,000 Max) 2203 Faithful Performance Security (FPS) 100% of ENGR. EST.* —ENGR. 2203 Labor and Materials Security 16-0--/. of EST.- 4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00 (Multi -Res $2,385.00) (All Other $2,650 00) 4722 Parcel Map (4 Lots or Less) $4,200.00 + $90/lot 4722 2203 Final Tract Map (5 or More Lots) $5,115.00 + $124/lot Monumentation Security 100% of CitV's Monumentation Estimate 4920 Parkland Dedication Fee (75%/25% Due Upon Cert. of Occupancy) 4722 Lot Line Adjustment (includes Certificate of Compliance) $1,990.00 4722 Vacation of Public Streets & Easements $2,700.00 4722 Certificate of Compliance $1,970.00 4722 Certificate of Correction $590.00 47'22 Document Recording Fees $15.00/first page $3 ea. Additional 4722 Private Improvement in Public ROW $100.00 47212 Approved Plan Revision Fee $1 00/sheet 4722 9 Appeal Filing Fee $200.00 730.4924 Notice of Improvement Obligation Payment Assessment Segregation or Reappo ionment First Split $940,00 Each Additional Lot $295.00 511.74241 Postage 7, 7 T` Other (Please bpecity) *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL NAME OF APPLICANT I"?l LlaC_�- A/`(r NAME OF PAYOR 17,41 PHONE 831-630-13gam. ADDRESS do lh'- r ZIP lo V A 11 X- FOR 4 RECEIVED BY, CITY CLERK ONLY eceipt, 'Receipt '8 0.1 T -'.10F -C1. AM E L I�Y Syed Wahidi From: JoAnna Thomason Sent: Monday, March 05, 2018 9:52 AM To: Syed Wahidi Cc: pinnaclewestext@gmail.com Subject: RE: Insurance information Attachments: SKM BT_50118030510360.pdf Hi Syed, I reviewed the insurance certificate which is only a sample certificate. The following items need to be included on the actual certificate. 1. We need The City of Campbell (and our address) listed as the certificate holder. 2. The required wording in the "Description of Operations" section (see attached check list). 3. A Waiver of Subrogation for Worker's Comp insurance. 4. Auto insurance Certificate of Insr. (also with the required wording) 5. A City of Campbell business license is required. I am attaching a checklist with the required wording for reference. Let me know if there are any questions. JoAnna JoAnna Thomason Office Specialist City of Campbell Public Works Department 70 N. First Street Campbell, CA 95008 www.citvofcampbell.com 1408.866.2150 -----Original Message ----- From: Syed Wahidi Sent: Monday, March 05, 2018 8:59 AM To: JoAnna Thomason Cc: 'certificates'; pinnaclewestext@gmail.com Subject: FW: Insurance information JoAnna, Please review the insurance for parking a boom lift on street for few hours. Thanks. Syed Wahidi Public Works Inspector City of Campbell Public Works Department 70 N. First Street Campbell, CA 95008 www.citvofcampbell.com 1408.866.2165 1 -----Original Message ----- From: certificates [mailto:certificates@brmins.coml Sent: Friday, March 02, 2018 2:08 PM To: pinnaciewestext@gmail.com Cc: Syed Wahidi Subject: RE: Insurance information Hello, Please see the attached certificate per your request. Let me know if you need anything further. Sincerely, Jenny Martinez Certificate Processor Bone Robertson & McBride, Inc. 1255 Treat Blvd., Suite 100A Walnut Creek, CA 94597 925-674-1000 ext. 110 FAX: 925-674-0188 CERTIFICATE REQUEST'E-MAIL: certificates@brmins.com FOR CERTIFICATE REQUESTS: certificates@brmins.com or Fax (925) 674-0188 "Think of us as a.one stop shop for all of your Commercial Insurance Needs! We have COMPETITIVE markets for General Liability, Auto, Workers Compensation, Bonds, and many more. We would love an opportunity to provide you with a competitive quote for your Commercial Insurance! Please give us a call at (925) 674-1000 or respond to this email for more information. We look forward to hearing from you! Visit Our Website! www.brmins.com AZ License #156745 CA License #0468252; CO License #265733; FL License# L086593, GA License# 181223 LA License# 616093 NV License #17357; OR License #100159697, TX License# 1627903 WA License #110464 -----Original Message ----- From: Shane Wiggins[mailto:pinnaclewestext@gmail.comj Sent: Tuesday, February 27, 2018 10:58 AM To: Mollie Nierhake Subject: Insurance information Please send to syedw@cityofcampbell.com Shane Wiggins Cell (831) 902-0511 Sent from my iPhone sorry for any typos 2 CITY OF CAMPBELL Public Works Department May 29, 2018 Shane Wiggins Pinnacle West Exterminators, Inc P.O. BOX 219 Hollister, CA 95024 Re: Deposit Refund for 20 N. 2"d Street, Campbell, CA 95008 Dear Shane: Enclosed is the fee refund for the canceled Encroachment Permit Application #ENC2018-00042 for 20 N. . 2"d Street, Campbell, CA. The application was withdrawn; therefore, we are returning the application fee. hank you, JoAnna Thomason Off• ecialist 0 70.North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAX 408.376.0958 • TDD 408.866.2790,