HomeMy WebLinkAboutENC2014-00067 Print Form
CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No r"-He- 20111 - Dol3(nr1
DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File �1
70 North First Street right-of-way) Application Date
Campbell,CA 95008 Application Expiration Date 9//Q,//�
Ph. (408)866-2150 Issued - 7,1-/ p-C-4 Z ZO/ APN , j()(/
Fx. (408)376-0958 :)-- tS- OO,
Permit Expiration Date 3l'f Z-c:�/J`
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 Addressor Tract No.: 1 1 1.j ( y1�(�{-e / 1 • n
Utility Trench Location: /1 II(
c4e( /lQ/1l LrL
B. Nature of Work: /a--1 fij . A,Je ' etian 4,4/67/a_.
C. Attach four(4)copies of an engineered plan showing the location and extent of the work,and four(4)copies of the preliminar gineer'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: bnax) ,te_ ( 2n Telephone: 610g) g cg
Address: I I_'/ I ! / M1 1 111
E-Mail Address: 24-HOUR EMERGENCY PHONE NUMBER:
Is this work being done by the property owners at their own residence? r- YES r 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 i ormation. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be
responsible for an I damage rising out of co i any private improvements in the public right-of-way.
e
Accepted: '�Q�� !YII�C-� (4)/
(Applicant Permittee) (sign) Date
(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.
V 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 op RECEIPT NO.
PERMIT APPLICATION FEE $ —r1 ‘''aca toU,c,
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $
CONSTRUCTION CASH DEPOSIT - $
PLAN CHECK&INSPECTION FEE $ "1-)
pp
EMERGENCY PERMIT FEE /% 6
- $
�/APPROVED FOR ISSUANCE (� 21//,‘IL
For 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.
4 ' P4 & (1 °/Y
licant Date: /
Contractor (Print Name) Date:
J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf
Rev.02/14
E
PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT,TRAFFIC &MISCELLANEOUS RECEIPT
Effective July 1, 2013
TO: City Clerk ► 1 ���'
PUBLIC WORKS FILE NO. .+' �` Zr tw L
PROPERTY ADDRESS 141 1 1)`�-i- inn Aki�
Please collect & recei t for the following monies: AMO[JNT
ACGT ITEM AM y;
ENCROACHMENT PERMIT: .. , 5 i4 a.. �.�,.:� , ,-. ;a a-
f 2... ,
4722 Utility Encroachment Permit Application Fee $377.00
R-1 Encroachment Permit N/C
Emergency Permits $107.00
Plan Check& Inspection Fee y J-1 J
Minimum Charge Per Location $377.00
Conduits/Pipelines up to 500 Feet $2.50/ft
Above 500 Linear Feet $1.55/ft
ManholesNaults/Etc. $165.00/ea
Pole Set/Removal $165.00/ea
4760 Storage Container Permit $153.00
4760 Project Plans &Specifications Project No.
4760 Standard Specifications & Details $1/Pg $15.50/Bk
4760 Engineering Maps & Plans
Aerial Plot 24"x 36" $60.00
Aerial Print 8 1/2"x 11" $28.00
Map Research(includes max of two 24"x36"copies) $28.00
Maps and Plans 24"x 36" $14.00
4722 Penalties: Failure to restore ublic im rovements $100/Calendar Da Muni Code Sec. 11.34.010)
4722 Penalties: Failure to correct unsafe conditions $1 D0/Calendar Day
4 Times A lble Fee
TRAFF„I„IG'2 "'. N1/OrkVVIthOUt Permits Applicable
aiNf&
4728 Traffic Flow Map (Daily Traffic Volumes) $35.00
4728 Signal Timing Information 73
4271 Truck Permits $16.00 per trip
4728I No Parking Signs 1 each or$25/100 � �
ia r t : "M^ ,., <:; 'eS., :row. ,r""' 1 aai ,n V.
5
MISCELLANEOUS �..• . �. .,,u _.�,
511.7424 Postage
Other Please S eci
TOTAL 4 U
NAME OF APPLICANT k-a`I-. (�� �7/ �c)./i
iv 1, ,„ , tom. PHONE � '`'�
NAME OF PAYOR l_ C / fi
yOLam'
ADDRESS I IL' l.C C G�a c KY-N. n ZIP
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FOR RECEIVED BYE rye ,, 4 ��
� ,k<x' irk tg }� � � d � J � ?�',a P�'�x� �:� ,�.� �
CITY CLERK Da� � � k 14, 4.4'i gg , a- � a i '
Receipt# ��
ONLY Dafe ..T <<� - ti :td .'. 5,,,.
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SS OF CAMPBELL
RECVD p: CASHIER 01000252666
PRe: CHARLIE GISON
m««5G«: 03 1/14
REGISTER «e: 63/411/14 2+/S:S.
DESCRIPTION AMOUNTENJ & mgy FILING F $p%m
CUST D: gS24+Qq
a+ ak2DFLIN tpGm
CUST ID: 1141 ma+hgE
TOTAL DUE: $mum
CHECK PAID: $754.00
CHECK NO: 1S33
TENDERED: $754.00
CHANGE: tm
, � ,
OZ) C4 MA JoAnna Thomason
-k IP City of Campbell
AA
: . r Department of Public Works
U :I r.;' r-' 70 North First Street
o 1""' o Campbell,CA 95008
1. A Phone:(408)866-2150
ok o•° Fax:(408)376-0958
E-Mail:Joannat@cityofcampbell.com
Transmittal
To: Charles Gibson Date: July 16, 2014
Address: 1141 Bucknam Ave., Campbell CA
Re: Recorded Agreement for Private Improvements in the Public Right of Way
O Urgent O For Review O Please Comment O Please Reply O For Information & Use
Please find enclosed a copy of the recorded Agreement for Private Improvements in the Public Right of Way
for the property referenced above.
Sincerely,
,1/4_,.L,,
J. t nna T i mason
cc: Land Dev File
Permit File: ENC2014-00067
C:\Documents and Settings\joannat\Desktop\My Forms\Recording Docs Sent\Bucknam 1141.DOC(Rev.03/08)
TO IIE RECORDED WITHOUT FEE Pages 7
SECTION 6103 GOVERNMENT CODE DOCUMENT: 22613155
AT THE REQUEST OF CITY OF CAMPS CAMPBWz ce i v 7:1 II Fees . . . 43.00
lin
Recording Requested By: axes
City of Campbell 'JUL�U IA 204 I Copies .
p AMT PAID 43 Ba
CITY CLERK'S OFF, ;E
REGINA ALCOMENDRAS RDE # 005
SANTA CLARA COUNTY RECORDER 6/04/2014
After Recording Return To: ) Recorded at the request of 2:31 PM
City
City Clerk )
City of Campbell )
70 North First Street )
Campbell, CA 95008-1423 ) a .(p\ C
APN: 406-15-007 (Space Above for Recorder's Use Only)
Address: 1141 Bucknam Avenue,Campbell CA 95008
AGREEMENT FOR PRIVATE IMPROVEMENTS
IN THE PUBLIC RIGHT-OF-WAY
In consideration for granting permission to construct improvements in the public right-of-way,
Charles E. Gibson and Lori A. Gibson enter into this Agreement with the City of Campbell. The
improvements contemplated under this permit are for the benefit of the real property commonly known
as 1141 Bucknam Avenue. The City of Campbell grants such permission to install a sewer clean-out
under Encroachment Permit No. 2014-00067. All conditions of Encroachment Permit 2014-00067
remain in full force and effect.
The property owner shall be solely responsible for maintaining the improvements in a good and
safe condition at all times; and the property owner shall indemnify, defend, and hold harmless the City
of Campbell, its officers, officials, agents, volunteers, employees and attorneys from any and all claims,
actions, losses, liabilities and costs (including reasonably incurred attorney's fees) arising out of or
connected with, or alleged to arise out of or be connected with the installation, design or condition of the
improvements, except for any claims, actions, losses, liabilities and costs proximately caused by the sole
negligence or willful misconduct of the City of Campbell, its officers, officials, agents, volunteers,
employees or attorneys. This provision is intended to be the dispositive of all rights of indemnity and
contribution between the parties, and property owner waives and releases any and all rights to indemnity
or contribution from the City of Campbell, in law or equity, arising out of, or connected with any and all
claims, actions, losses, liabilities and costs (including reasonably incurred attorney's fees) for which
property owner is obligated under this paragraph to provide indemnity or defense to the City of
Campbell, its officers, officials, volunteers, employees or attorneys.
The City, in its sole discretion, may revoke the rights granted under Encroachment Permit No.
2014-00067 and remove the improvements installed under Encroachment Permit No. 2014-00067 at any
time, without liability to the property owner, or require that the improvements be removed, and property
owner shall have no right to compensation from City in any form.
^s+ir 'NSTaUMEMT IS A TRUE_
OF THE ORIGINAL
Urr .Le IN THIS OFFICE.
ATTEST: ANNE BYBEE,CITY CLERK
CITY OF CAMPBELL.CA
BY er.Page 1 of 3
DATED. 1.4 l�
, •
In the event that Owner fails to reimburse the City for the costs of removing the improvement
("default") as required by this Agreement,the City shall have and may execute the absolute right, at the
City's option and without demand or notice to Owner, to claim and impose a lien, attached as Exhibit A
and incorporated herein by this reference ("Lien"), on said real property (also referred to herein as
"Collateral"). City's failure to exercise this option will not constitute a waiver of the right to exercise it
in the event of any subsequent default.
(a) Amount of Lien: The Lien shall be for the entire amounts then owing under this
Agreement.
(b) Recordation: City is authorized to record the Lien in the appropriate Recorder's
Office(s).
(c) City shall have full authority to perform all acts and things that City may consider
necessary or advisable to impose, maintain and enforce the Lien.
(d) Debtors' Warranty: OWNERS WARRANT that they are the owners of the Collateral and
Owners have the right to make this Lien Agreement.
(e) Debtors' Covenants: Owners agree:
(i) To pay City all amounts payable pursuant to this Agreement on or before the due
date when due and payable, and to perform all terms of this Agreement;
(ii) To defend the Collateral against claims and de ands of all persons and entities;
(iii) To keep the Collateral in good condition; to perform other acts that may be
necessary to preserve the Collateral and protect the Collateral against
unreasonable loss and all hazards, and;
(iv) To immediately notify the City in writing when Owners become aware of any
event that substantially affects the value of the Collateral, or the rights and
remedies of City in relation to the Collateral.
(1) Prohibitions: Without the prior written consent of the City,Owners will not permit any
liens or security interests (other than the City's Lien) to attach to the Collateral;permit the
Collateral to be levied on under legal process; dispose of the Collateral; or permit
anything to be done that may impair the value of the Collateral or of the Lien, which is
the subject of this Agreement.
(g) Notices: Any notice, demand or request required hereunder, or by law, shall be given in
writing(at the addresses set forth below) by any of the following means: (a) personal
service; (b) facsimile; (c) overnight courier or delivery service; or(d)registered or
certified, first class U.S. mail, return receipt requested.
Page 2 of 3
, , •
• Property owner agrees to maintain homeowners or general liability insurance with a limit of at
least $100,000 for damages arising from the installation, design or condition of the improvements.
This provision shall run with the land and be binding on the property owner's successors.
Executed this al I day of 4 , 20 /V
„1 e Charles E. Gibson
Lori A. Gibson
(Attach Notary Acknowledgment
For All Parties)
CITY OF CAMPBELL, a municipal
Corporation
()
Todd Capurso
Public Works Director, City of Campbell
ATTEST:
U COeAnne bee, City Clerk
Page 3 of 3
CALII. ,..RNIA ALL-PURPO'
CERTIFICATE OF ACKNOWLEDGMENT
I
State of California
County of ,;Lx�.r-\4 (Vc,{C
On Mc,,cC\iL. .5 , i4 before me, J n i •r.,c\ ----\r‘n cv\c, Scm\r\ NC'SG.c �`—�� \O\\Q j
(Here insert name and title bf the officer)
personally appeared \ -)C�a, Q,c4 0 U C S,� 1 '
l
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to
the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized
capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph
is true and correct.
..„ JOANN THOMASON
„�,,�;, Commission # 1930682
WI SS my hand and official seal. Ti ti:,` Notary •Public •- California z
z Twill" Santa Clara County t
M Comm.Expires Mar 28,2015 I
�C `. CsQ� �--� (Notary Seal)
Signature cif Ndtpty Public
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Any acknowledgment completed in California must contain verbiage exactly as i
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acknowledgment verbiage as may be printed on such a document so long as the j
(Title or description of attached document)
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CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189
State of California
County of V C\00
LI Q$ y Y� �
On )J �` \L\ before me, � ��' ��,
Date Here Insert Name and i e of the Officer
I
personally appeared e`\tied\e E • L- '►bnon I
Name(s)of Signer(s)
on Lori A - fib ,
who proved to me on the basis of satisfactory
evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged
to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by I
his/her/their signature(s) on the instrument the )
person(s), or the entity upon behalf of which the
person(s) acted, executed the instrument. I
J. G0NZALES I certify under PENALTY OF PERJURY under the
0�'!`- Commission # 2033014 laws of the State of California that the foregoing
_' 7-)!.i Notary Public-California 1 paragraph is true and correct.
V. 1,1 Santa Clara County
M Comm.Expires Au .11.2017WITNESS my hand and official seal.
Signature:
i:
Place Notary Seal Above ignature df N ry Public
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and could prevent fraudulent removal and reattachment of this form to another document.
Description of Attached Docu ent (fit ,�j ,
Title or Type of Document: / � V.� �� 1 `�4Ec1 1 {� ✓ \� 1I�- ,
civti-
Document Date: J 1 Z i `� t �], ` Number of Pages:
Signers) Other Than Named Above: !may 1
Capacity(ies) Claimed by Signers) / c
• Signer's Name: C 001(001(lk S F.(>,I b=5U>1 Signer's Name: LO 1 %�,t ',,
`1.
• ❑ Corporate Officer — Title(s): ❑Corporate Officer — Title(s):
Individual jiY(utlividual
• CIPartner — ElLimited EllGeneral IDPartner — ❑ Limited ❑General
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❑ Other: ❑Other: t4 Signer Is Representing: Signer Is Representing:
I
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O 2012 National Notary Association •NationalNotary.org • 1-800-US NOTARY(1-800-876-6827) Item#5907
Exhibit A
Recording Requested By: )
City of Campbell )
When Recorded Mail To: )
City Clerk )
City of Campbell )
70 N. First Street )
Campbell, CA 95008 )
)
)
Space above this line for Recorder's use only
CLAIM OF LIEN
I, , City Engineer for the City of Campbell, a California Municipal
Corporation("City"), do hereby certify:
A. On or about , 20 , ("Debtors")
executed an Agreement for Private Improvement in the Public Right of Way with the City of Campbell
("Agreement").
B. The Agreement was recorded in the Santa Clara County Recorder's Office on or about
, 20_Document Number
C. The Agreement allowed the Debtor's to provide, construct, and/or install certain private
improvements in front of their property at , Campbell, California, at their
own costs and expense. Pursuant to the terms of the Agreement, the Debtors expressly agreed that if
they failed to comply with the Agreement, the City was authorized to remove said improvements and
recover the full cost and expense thereof from the Debtors or their successors.
D. The Debtors did not remove the improvements after being notified to do so. Therefore,
the City removed said improvements.
E. In , 20_, the City informed the Debtors about the improvements
that would be removed pursuant to the Agreement.
F. The City subsequently completed the work. On or about , 20_, the
City sent the Debtors an invoice for said work in the amount of$
G. Pursuant to the terms of the Agreement, the Debtors expressly agreed that the City is
authorized to, at the City's option and without demand or notice to the Debtors, immediately claim and
impose a lien on the real property commonly known as , Campbell, California,
APN Number , for the entire amounts then owing under, or incurred
pursuant to, the Agreement, including without limitation, the entire unpaid principal amount.
Page 1 of 2
. w ►
WHEREFORE, the City of Campbell, A California municipal corporation, pursuant to the
Agreement, hereby claims a lien upon the work of improvement and the land upon which it is situated,
namely, the real property commonly known as , Campbell,
California, APN Number , in the amount of $
and said amount shall constitute a lien against said property until paid in full.
IN WITNESS WHEREOF the City of Campbell, California, a California Municipal Corporation,
has duly authorized the undersigned to execute this instrument in its name.
Dated: By:
for the CITY OF CAMPBELL, a California municipal corporation
(Notary Acknowledgement Required for Signatures)
Page 2 of 2
L' nal/ ke s
Keep in touch...
Charlie Gibson
/ 54/aCkl,a At,Q
11-44t
408 858-0211 9Sbag
charloosel@gmail.com