ENC2014-00162 i
Print Form
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CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No�)2_0 J 4 V q 2_-'
DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File 22�
70 North First Street right-of-way) Application Date NAI k Lh
Campbell,CA 95008 Application Expiration Date Z
Ph. (408)866-2150 Issued APN �033
Fx. (408)376-0958
Permit Expiration Date
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 No.: �r j 1,� c n 1
Utility Trench Location: CT V
B.IM Nature of Work: LEI K/Vh'I(� 6 ,o� Gfil Iu f"7'
C. Attach four(4)copies of an engineered plan showing the location and extent of the work,and four(4)copies of the prelim�aEngme� eO��J
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 and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions,I 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 before
starting work. Notice must be given to Public Works at least 24 hours before restarting any work,
game o rApplicant: "�((a�� �1 � Telep `-a
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E'NiaildAetress: EMERGENCY PHONE NUMBER:
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"Is this work being done by the property owners at their own residence? 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 a loyees 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 damages arisin t- a condition any private improvements in the public right-of-way.
ptetl�— o 1 `t
(Applica rmittee) (sign) Dat
(Contractor) (Print Name) Date
SPECIAL.PROVISIONS:
1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be
specifically pproved by the Inspector prior to cutting.
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.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO.
PERMIT APPLICATION FEE $
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $
CONSTRUCTION CASH DEPOSIT $
PLAN CHECK&INSPECTION FEE $
EMERGENCY PERMIT FEE $
APPROVED FOR ISSUANCE
For City Engineer Date
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 Permittee.
2. A one-year maintenance 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 City.
4. Submit project schedule 10(ten)days prior to proposed start of work.Special provisions may be required for work within City facilities and
downtown Campbell.
S. 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.
6. Maintain safe pedestrian and vehicular crossings and free access to private driveways,bus stops,fire hydrants,and water valves.
7. 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.
8. A 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 II flashing arrow signs if required.
9. 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.
10. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremairk and shall be doweled to existing improvements.
11. 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.
12. 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.
13. Compaction testing of subgrade,base rock,and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer.
14. 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.
15. 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.
16. 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.
17. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency.
18. This permit is not transferable.Work must be performed by the Permittee or his designated agent or contractor as specified thereon.
19. Call back(call out)due to emeregencies regarding this permit shall be at the current overtime rate with a three(3)hour minimum charge per
occurrence.
20. 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 established by the Santa Clara Valley Urban Runoff
Pollution Prevention Program.
21. 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.
22. Permitttee 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 phone number.
Applicant shall be responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions.
�AppliranL g
Contractor (Print Name) Date:
J.\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf
Rev.02/14
PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT
Effective 2014
TO: City Clerk P �PUBLIC WORKS FILE NO.. ti►`� )�X �� - �---
PROPERTY ADDRESS -J�� �• 1
Please collect&receipt for the following monies:
ACCT.:'. 1TEM
tw
..AMOUNT ,.
LANO, VELOPIIME DE NT.,-, .
4722 EncroachmentPermit Application Fee
Non-Utility Encroachment Permit Major>$10 000 $385.00
Minor Encroachment Permit<$10,000 $220.00
Initial R-1 Permit N/C
Subsequent R-1 Permits within Two Year Period $220.00
Inspection Fee Minimum Charge per Location $385.00
Street Tree Planting/Removal N/C
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 Gradinq&Drainage Plan Review
Single Family Lot $270.00
Site< 10,000 s.f. $810.00 Site>_ 10,000 s.f. <0.5 Acre $1 081.00
Site>_0.5 Acre $1 621.00
4722 NPDES Review C3 Requirements)
For projects not required to submit numeric sizing $156.00
For projects required to submit numeric sizing
Impervious Area 10,000 S .Ft to 1 Acre $676.00
Impervious Area 1 Acre or more $884.00
4722 ' For projects sent to Consultant for review Consultant Cost+20%
Plan Check&Inspection Fee(Non-Utility) -
4722 En r. Est. <$250 000 14%of Engineer's Estimate
2203 En r. Est.>_$250 000 and<$500,000 $35 000+8%D of Engineers Estimate
2203 En r. Est. >_$500 000 $55,000+7%of Engineers Estimate
2203 Emergency Cash Deposit 4%of En r. Est." $500 min/$10,000 Max
2203 Faithful Performance Security FPS 100%D of ENGR.EST."
2203 Labor and Materials Security 100%D of ENGR.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 Ma 4 Lots or Less 3 850.00+ 83/lot
4722 Final Tract Ma 5 or More Lots 4 681.00+ 114/lot
2203 Monumentation Security 100%of Cit 's Monumentation Estimate
4920 Parkland Dedication Fee 75%/25% Due Upon Cert.of Occupancy)
4722 Lot Line Ad'ustment Includes Certificate of Compliance) $1 820.00
4722 Vacation of Public Streets&Easements $2 434.00
4722 Certificate of Compliance $1 800.00
4722 Certificate of Correction $540.00
4722 Appeal Filin Fee $200.00
4722 Notary Fee(per signature) $10.00
4722 Assessment Segregation or Reapportionment
First Split $860.00
Each Additional Lot $270.00
511.74241 Postage
9
SCELLANEOUS1.,. a ..
Other Please S eci
*Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $ v J�
NAME OF APPLICANT
NAME OF PAYOR PHONE 409
ADDRESS ZIP
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FOR RECEI�/E .SY, '
CITY CLERK k
ONLY Date Recei
�_ r a t ial
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J:IFORMS1Tampi.W.s Admini..US.VR..ipt F.-Land D—I.p—t 14-15
JoAnna Thomason
From: Roger Storz
Sent: Wednesday, March 06, 2019 4:16 PM
To: Ana Rios;John Formale
Cc: JoAnna Thomason; Doris Quai Hoi
Subject: RE: 337 E Hamilton Ave (ENC2014-162)
Thank you Ana. Can we get a copy of that once it is completed for our records?
I appreciate your help.
Roger
From: Ana Rios
Sent: Wednesday, March 06, 2019 4:13 PM
To: Roger Storz; John Formale
Cc: JoAnna Thomason; Doris Quai Hoi
Subject: RE: 337 E Hamilton Ave (ENC2014-162)
Hello Roger,
I will prepare a journal entry to make the transfer per your request below.
Ana
From: Roger Storz
Sent: Wednesday, March 06, 2019 4:11 PM
To: John Formale
Cc: JoAnna Thomason; Doris Quai Hoi; Ana Rios
Subject: RE: 337 E Hamilton Ave (ENC2014-162)
Excellent. This project from 5 years ago has effectively died, and we need to transfer this money(a plan check deposit)
into our revenue account(4722)to reimburse the City for all of the staff time spent reviewing this old project. What do
we need to do make this happen?
Thank you,
Roger
From: John Formale
Sent: Wednesday, March 06, 2019 4:08 PM
To: Roger Storz
Cc: JoAnna Thomason; Doris Quai Hoi; Ana Rios
Subject: RE: 337 E Hamilton Ave (ENC2014-162)
Roger,
Yes.
Ana has it in her file.
Khaziri, Hossain 09/03/14 255108 ENC2014-00162 6,390.00
1
ov•CA,s�, John Formale
;!� Accountant
U c City oi'Carnpbell Finance Department
0 o 70 N. [First Street �Campbell, C'A 95008
y %� ell _c,ihofc_�rl�.al?c;lE coin,; li)li 8{iEi ?7;'
9Br;;.0 .._..... ___ _w_e
From: Roger Storz
Sent: Wednesday, March 06, 2019 4:03 PM
To: John Formale
Cc: JoAnna Thomason; Doris Quai Hoi
Subject: 337 E Hamilton Ave (ENC2014-162)
Hi john,
Do you have a refundable deposit on file for$6390 collected with receipt no. 255108 on 9/3/2014?
Thank you,
OV•CA41 Roger Storz, PE
:iO Senior Civil Engineer
U r' City of Campbell j Public Works Department
0 o 70 N. First Street I Campbell,CA 95008
y� Get www.cit. oY fcampbell.com 1 408.866.2190
IIRCHARI
2
JoAnna Thomason
From: Doris Quai Hoi
Sent: Tuesday, March 05, 2019 11:06 AM
To: JoAnna Thomason
Cc: Roger Storz
Subject: 337 E Hamilton Ave
Morning JoAnna,
Please could you close out this project ENC2014-162.
All deposit are NOT to be refunded.
Applicant did not complete this work in a timely manner and I did 3 plan checks on this project.
Here is a plan check deposit in the amount paid: $6390 receipt 255108 on 9/3/2014.
Thank you.
Doris
OVCAA Doris C. Quai Hoi
A;W
Assistant Engineer
UCityoFCaniphell I'uhlie \,h��orlsD4p�irtiticiik
0o 70 N. First Strect C`arnpt ell, ("A 950086� ww .city >Ican pf�cll_c�>��l 408.866.21 7
()RCHARO
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