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CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No l
DEPT.OF PUBLIC WORKS 1 ,yo�1, (for working within the public X Ref.File
70 North First Street ApR 2 1 L `t right-of-way) Application Date U Z
Campbell,CA 95008 14/
2 ./t11 Application Expiration Date
Ph. (408)866-2150 dminlSt(d; -[ APN D.:1�"\LUDO\ 5
Fx. (408)376-0958pub11C Forks A Cf/2 '( --
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.: FRONT OF 207 N.CENTRALL AVE.CAMPBELL(345'NORTH OF GRANT ST.)Utility Trench Location: `A1. ,(C) .-7 )\ 11
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B. Nature of Work: POLE REPLACEMENT
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: PG&E CAROLINE CARTER Telephone: 559.347.5017
Address: 8 RIVER PARK PL.E.FRESNO CA.93720
E-Mail Address: C6CJ@PGE.COM 24-HOUR EMERGENCY PHONE NUMBER:
Is this work being done by the property owners at their own residence? C"'"' YES (X 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 a vised that upon issuance of this permit, property owner, or property owner's successors, shall be
responsible for an and all damages arising out e co dition of any private improvements in the public right-of-way.
Accepted: .._ ..,_..„„C%�. � .�'t-.,�-' m_ �.. .............�.
(Appl' ant 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 mute
Specifically approved by the Inspector prior to cutting.
_2, Pavement maybe 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.
_T 6. Public Notification Requirements:
7.
5 ,.P, BLIC WORKS FEE 5.C) Q t j QRC AMOUNT RECEIPT NO.
PERMIT APPLICATION FEE $ 311
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS
CONSTRUCTION CASH DEPOSIT
PLAN CHECK&INSPECTION FEE �+ ? „ ..
EMERGENCY PERMIT FEE
APPROVED FOR ISSUANCE 4/221 I LI
For City Engineer Date
Permit Expires 12 Months After Date of Issuance
GENERAL PERMIT CONDITIONS
I. 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 it 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. Ali 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 ail 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,
IS. 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.
1,
Applicant shall be responsible for en;rfring that all those providing services under the applicant are aware and understand all of the above conditions.-4/0/L71 �' /
ppiicant ( Date:
Contractor (Print Name) Date:
J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf
Rev.02/14
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20'APART 72HR PRIOR � '' — sn
TOW-AWAY TO START OF WORK ,,, 1 . :
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ZONE ` t-.l' <10'
NOT TO SCALE
ADDITIONAL TRAFFIC CONTROL ELE
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PERSON TO MAINTAIN CLOSURE ASSIST BUFFER 60 Irt
BICYCLE,PEDESTRIAN AND DRIVE WAY TRAFFIC SHOULD NEED ARISE
O RK AREA : :.
MAX CONE SPACINGS
STREET WIDE ENOUGH STOPPING TRAFFIC IS
NOT REQUIRED BUT TRAFFIC CONTROL PERSON SPEED MIN TAPER TAPER TANGENT
WILL ASSIST HOMEOWNERS IN AND OUT OF THEIR � 25 125 25 50
DRIVEWAYS AS NEEDED. ' : 30 180 30 60
SEE SPEC SHEET 2 FOR ADDITIONAL
TRAFFIC CONTROL STIPULATIONS 35 245 35 70
� a , 40 320 40 30
FOR TCP QUESTIONS CALL: " ' 45 540 45 90
R°A° ALL BUFFER ZONES SHALL BE A MIN OF 60'
ROBERT 209-20U-3351 �soRK w2o 1
28 O I h "° ALL SIGN SPACINGS SHALL BE A MIN OF 100'
PEDESTRIAN AND BICYCLE ACCESS V �✓ I °W"� CITY OF CAMPBELL
TO REMAIN OPEN AT ALL TIMES Project Name Project Number
N.Central Ave @ E.Latimer Ave Campbell ,California
Prime CoMrador Traffic Control Contractor
WORK SHALL NOT EXCEED 12HRS Pc&E ED SAFETYINC
Phone Sheet Number Date
MIN 12' CLEARANCE FOR TRAFFIC 209-333 0807 PS-1 4/1/2014
P M 31052770 MIN SIGN PACING 100' N OTI F# 106051042 Prepared By ED SAFETY SERVICES, INC
HOURS OF WORK SHALL BE DETERMINED BY THE CITY OF CAMPBELL
CLOSURE STIPULATIONS AND SPECIFICATIONS THAT MUST BE FOLLOWED AT ALL TIMES
DRIVEWAY ACCESS SHALL REMAIN OPEN OR ACCESSIBLE AT ALL TIMES
All lane closures shall meet or exceed CA MUTCD 2012 specifications as well as conform to hours of work set forth by the
City. All areas of work when encroaching upon sidewalk access OR pedestrian safety shall have a CA MUTCD 2012 standard sidewalk
closure detour detail in place to ensure pedestrian and public safety.
Pedestrian access or detour will be maintained at all times in the event sidewalks must be closed, all paths of travel shall be similar to one
that is closed.
Pedestrian traffic shall at all times have a minimum 4 feet wide area of travel.
All open excavation areas shall be backfilled or trench plated prior to public usage.
All closures set forth in this TCP are the minimum allowed on project, field conditions may change requiring further traffic safety devices or
traffic control persons to ensure safety of traveling public, pedestrians as well as work forces.
All changes to ensure safety will be made immediately to ensure a safe environment for all parties.
All traffic control devices, vehicles and personnel must be suited for the purpose intended as well as meet or exceed all CA MUTCD 2012
specifications as well as City specifications.
All devices shall be removed when no longer required.
All flaggers shall be certified and all intersections shall be flagged when required as shown on plans.
If work is done at night or encroaches on the hours of darkness all road work ahead signs shall have flashing a beacon, light towers will be
used for flaggers and work areas and all other CA MUTCD 2012 requirements shall be met or exceeded as well.
NOT TO SCALE----SPACING OF SIGNS, TAPER AND TANGENTS WILL BE SPACED AS PER TABLE HAS SET FORTH AS GOVERNED BY
TRAVEL SPEEDS.
All traffic devices shall meet or exceed CA MUTCD 2012. All signs shall be high intensity night time reflective, 48"x48" roll up signs.
All signs shall have a minimum of 2, 18" day time flags attached to sign stands during day time hours and if applicable flashing 12", 12v
beacons for night time work.
Sign stands shall be CA MUTCD 2012 compliant as well allowing for 18" to 7' height for signs as well as spring equipped for windy conditions.
Pavement delineation not exactly as appears in field but traffic plan will still work as shown. All cones shall be 28" 10 lb and shall not be
placed further than 40' apart.
All hours of work shall be dictated by the Cities specified lane closure charts or as directed by the city inspector.
Vehicle path of travel shall never be less than 12' in width. Closures and excavation not to exceed what forces expect to excavate per the daily
shift.
Roadway shall not be opened until safe for public use. All open trenches must be plated or backfilled prior to public usage.
All areas of excavation must have a valid USA dig tag with corresponding dig ticket number, proof must be carried with the excavating forces
at all times.
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PROJECT CONDITIONS STAMP 1 2K
Type(s) of Work:
❑New Business PLAT: Hi 61 6 e
❑X PG&E Maintenance & Construction SSD: FUSE 28877
Project Conditions: CKT: EL PATIO 1 112
❑X NONE APPARENT (if project design changes, contact ADE) DESIGN VOLT: 2
or INSL DIST: B
III CONDITIONS APPLY: Underground Service Alert
❑PERMITS ❑TAILBOARD ❑OTHER �.+a•_++�:.' LOADING AREA: LIGHT
(Provide additional information on line below) ,l 4 Call: TOLL FREE CORR AREA: NON
4/1 /14 fir, 8 1 1 ARRESTOR DIST: 3
BY: _C6CJ ___ TWO WORKING DAYS BEFORE YOU DIG RAPTOR FRAMING: YES
SIGNATURE, NAME, [CORPORATE ID]. DATE
EST: C6CJ 559.347.5017 CO:
ADE: K1µ1559.347.5276 POLE REPLACEMENT SD:
SUPV: TACC 559.347.5297 IFO 207 N. CENTRAL AVE. NOTIF: 106051042
REP: VPN1 408.725.2011 OTHER:
PLNR: CAMPBELL SHT: 1 OF 1 SHEETS
SCALE: DATE: , PACIFIC GAS AND ELECTRIC COMPANY Pµ REV.
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PROJECT CONDITIONS STAMP 12KV
Type(s) of Work:
❑New Business PLAT: Hi 61 6 i
E PG&E Maintenance & Construction SSD: FUSE 28877
Project Conditions: CKT: EL PATIO 1 112
Q NONE APPARENT (if project design changes, contact ADE) DESIGN VOLT: 2
°f INSL DIST: B
❑CONDITIONS APPLY: Underground Service Alert
❑PERMITS ❑TAILBOARD ❑OTHER LOADING LOADING AREA: LIGHT
(Provide additional information on line below) `i'�; Call: TOLL FREE CORR AREA: NON
4/1 /14 fir, 8 ARRESTOR DIST: 3
,: _C6CJ!__ _ --- TWO WORKING DAYS BEFORE YOU DIG RAPTOR FRAMING: YES
SIGNATURE, NAME. [CORPORATE ID]. DATE
EST: C6CJ 559.347.5017 CO:
ADE: K1MttA 559.347.5276 POLE REPLACEMENT SD:
SUPV: TACC 559.347.5297 IF0 207 N. CENTRAL AVE. NOTIF: 106051042
REP: VPN1 408.725.2011 OTHER:
PLNR: CAMPBELL SHT: 1 OF 1 SHEETS
SCALE: DATE: PACIFIC GAS AND ELECTRIC COMPANY Pµ31052770 REV.
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