HomeMy WebLinkAboutENC2014-00032 C4e' /FA v"Pe'tmitNo ).cAuk -0003 L.-
CITY
OF CAMPBELL ENCROACHMENT P MIT Q O '"1'
DEPT.OF PUBLIC WORKS (for working within th isiA, S? X-Ref:File
70 North First Street right-of-way) 1.� 670/* O,i plication Date S
Ph. (408)866 2150Campbell,CA 8 Issued �'lfi 1 1 S'�d/1/�/Std APNlication Exp�at�io`�aQte ` 7/cl 1
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Fx. (408)376-0958 .Z J .'I glie,
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.: 3 87. i/ t////jjj�) G� �(..`.r-) kl _ C..�.1!4.t[.J v ilia) I�
Utility Trench Location: ç5)(5 &tbk it l-.ain
I
.49
B. Nature of Work: qth)_...L/AX.( _( 1 �. .%t
) f3 )
C. Attach four(4)copies of an engineered plan showing a locn 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 AIM,
be given to Public Works at f least
�24 hours
before restarting any work.
Name of Applicant: .....A' t, j/1)tvIf,_C/..._... eD'..... Telephone:
Address: I I/) I 1 . dwupe eA
E-Mail Address: 24-HOUR EMERGENCY PHONE NUMBER:
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 Camp II,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 a isi' out of th condition of any private i pr ements in the public right-of-way. 1
Accepted: 6 J `' eI&) c7 / 1 /
j(A scant Permittee) (J.,,n) ate
am&La g4fD.5 ?- s/r
(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 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: 1-860-227-2600. 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 $ 37'7 Cl
PLAN CHECK DEPOSIT $ -
SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $
CONSTRUCTION CASH DEPOSIT $
PLAN CHECK&INSPECTION FEE $ 3 77 C�
EMERGENCY PERMIT FEE $ I O O �
APPROVED FOR ISSUANCE 2 / (�+!/(it
For City Engineer Date
Permit Expires 12 Months After Date of Issuance