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CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No rP►C COG Z
DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File
70 North First Street right-of-way) Application Date I/6(1 _
Campbell,CA 95008 r /80
Lt Application Expiration Date 1/4 (I it
Ph. (408)866-2150 Issued U 1 I APN 4,104 a(n —S
Fx. (408)376-0958 /��f
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.: O S - - N/1142....7—
Utility Trench Location: O y O f lox Q.a-z__-_A
B. Nature of Work: !ltAi "t
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. 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 1 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.
Name of Applicant: IZ ) , 0 itea/r' S ' /NC Telephone: L-LD -. 3 27-6 f,,3
Address: d/' 0_ C G..L/Nc/ L'R
E-Mail Address: LIIo1'/a.e 1e3 L9&l J. -7 24-HOUR EMERGENCY PHONE NUMBER: 4(01T— 76 S3'5'
Is this work being done by the property owners at their own residence? (- YES g:7NO
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 damages arising out of the condition of any private improvements in the public right-of-way.
Accepted:
(Applicant Permittee) (sign) Date
/14.Q,/6 't)2//k 5, A.6_ J e C e yl/te/ to - /V
(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 approved by the Inspector orior to cutting.
V 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 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: 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 $ 377 25(5G 2,
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $
CONSTRUCTION CASH DEPOSIT $
PLAN CHECK&INSPECTION FEE $ 3-71 2515“
EMERGENCY PERMIT FEE $
APPROVED FOR ISSUANCE
Tor City Engineer Date
Permit Expires 12 Months After Date of Issuance
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.
5. 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 scoremark 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.
rh.elto 9,sfe l s / . /-
Applicant Date:
mei 1O
Contractor (Print Name) Date:
1:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf
Rev.03/13
PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT
Effective July 1,2013
TO: City Clerk PUBLIC WORKS FILE NO. Jo.)C `—O COG 12
PROPERTY ADDRESS 70 5 KENNETH
Please collect&receipt for the following monies:
ACCT. I ITEM AMOUNT
LAND DEVELOPMENT
4722 Encroachment Permit Application Fee
Non-Utility Encroachment Permit Major≥$10,000 $377.00
Minor Encroachment Permit<$to,000 $215.00
Initial R-1 Permit N/C
Subsequent R-1 Permits within Two Year Period $209.00
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 Grading&Drainage Plan Review
Single Family Lot $265.00
Site<10,000 s.f. $795.00
Site≥10,000 s.f.<0.5 Acre $1,060.00
Site≥0.5 Acre $1,590.00
4722 NPDES Review(C3 Requirements)
For projects not required to submit numeric sizing $153.00
For projects required to submit numeric sizing
Impervious Area 10,000 Sq. Ft to 1 Acre $663.00
Impervious Area 1 Acre or more $867.00
Plan Check&Inspection Fee(Non-Utility) 377
4722 Engr. Est. up to$250,000 14%of Engineer's Estimate
**2203 Engr. Est.≥$250,000 Actual cost+20%Admin Overhead
(Min$35,000 Deposit)
2203 Emergency Cash Deposit 4%of Engr. Est.*($500 min/$10,000 Max)
2203 Faithful Performance Security(FPS) 100%of ENGR.EST.*
2203 Labor and Materials Security 100%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 Map(4 Lots or Less) $3,775.00+$82/lot
4722 Final Tract Map(5 or More Lots) $4,590.00+$112/lot
2203 Monumentation Security 100%of ENGR.EST.
4920 Parkland Dedication Fee(75%/25%Due Upon Cert.of Occupancy)
4722 Lot Line Adjustment(Includes Certificate of Compliance) $1,785.00
4722 Vacation of Public Streets&Easements $2,386.00
4722 Certificate of Compliance $1,764.00
4722 Certificate of Correction $530.00
4722 Appeal Filing Fee $200.00
4722 Notary Fee(per signature) $10.00
4722 Assessment Segregation or Reapportionment
First Split $846.00
Each Additional Lot $265.00
511.7424 Postage
MISCELLANEOUS
Other(Please Specify)
*Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. 7
**Actual Cost Plus 20%Overhead(Non-Interest bearing deposit) TOTAL $ / J J
NAME OF APPLICANT 3'YLe 11 p Pipe ll k,e_g/ /ow.
NAME OF PAYOR I�'L4 l L c7 Pipe //rNP.5, /,v<- PHONE e— OT' — 3 7 7`G7 a3
ADDRESS )-&O hi //r L o --- ZIP ' 5 oar
PA
FOR RECEIVED BY Ly
CITY CLERK i IC 15
ONLY Date f Receipt# J 7? JAN u 6 Lu
of GAMI-'iit Ll,
Date/ Initials
J\FORMS\Templetes\Administretlw\Recapt Farr,Land Development 13-19
CITY OF CAMPBELL
RECVD BY: CASHIER 01000251553
FA'YOR: MELLO PIPELINES INC
TODAY'S DATE: 01/08/14
REGISTER DATE: 01/09/14 TIME: 08:42
0ESCRIPTION AMOUNT
ENGR & SUBIIIV FILING F $377.00
COST ID: ENC2O14-00012
ENGR ° SUBDIV FILING F $377.00
COST II+: 705 KENNETH
----------------
TOTAL DUE: $754.00
CHECK PAID: $754.00
CHECK NO: 14363
TENDERED: $754.00
CHANGE: $.00
westVattey�/ Sewer Connection Permit No: 414 81
Sanitation Disfna
Issue Date: By:
OFFICE HOURS&CONTACTS: FEES: BACKFLOW PREVENTION:
7:30 a.m.to 4:30 p.m.Monday thru Friday Connection $
100 E.Sunnyoaks Ave.,Campbell,CA 95008. Capacity Field check required
•Phone:(408)378-2407 Processing t•SI O u`' /C Basement
Service Advance !S t
•Information Services Department Check valve required:V No
LOCATION:
APN 1404-Z6:013 BUILDING SEWER CONNECTIONS:
Sewer Map Book,_Page 4 G
Tract $ Lot i Total Due: $ 61(G_" Total number of connections to this
Project Assmt property:
Addres 1-�Q NPaid by Check No: l L�l�f'•
CA•►41f/k-` t C A 1,;704r 1. Lateral ID No.Z31 66 is located
Cn �1 Hillside:Yes_No k feet of property
Jurisdiction line, feet from main sewer and
BUILDING TYPE: INSTRUCTIONS: feet deep.
X Single Family •Permit is invalid if not connected within 12
CondaTown House months of issue. Connection to Main Sewer l feet
Multiple Dwelling Units •Do not connect until the main sewer is accepted US from DS/MH 4,-.6° -O5
Industrial by the District. US MH 4 -oo4 -o S
Commercial •Obtain a building or plumbing permit from the Pipe Type
Jurisdiction listed above.
REMARKS: 'x'-i-kt3rtNtt.."r a •Street encroacOmentpermit is required from List any additional connections on
=laS: -� AdLATE tom- �° Gb 1l reverse side of this form.
,�( •Keep 3'radius around cleanout clear of
OLD PERMIT No. Y1 Sub No. vegetation or obstruction.
Original—Applicant Pink—Accounting Yellow—City/County Bldg.Inspector Card—District File