HomeMy WebLinkAboutENC2014-00103 IPrint Form 1
CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No 'EN 2 I L{-06 03
DEPT.OF PUBLIC WORKS ,for working within the public X-Ref.rile
p .-.. l0 1O...V) ( -- Application Expiration`i-.i. ill,11
70 North First Street right o Application Date ` G/I
Campbell,CA 95008 11
/ n 216
Ph. (408)866.2150 SSUed ( / APN - \Z\
Fe. (408)376-0958 �tU/15
Permit Expiration Date__.-_
APPLICATION-Application is hereby made for a Public Works Permit in accordance with Camph4 w-t i7•;: i-. -lion : 04. Application expires in se
t61 months if the permit is not issued. Application Fee is non-refundable l
A. Work Addressor Tract No. 2(55- 5 4</() e i_yi L' -- C •
Utility Trench Location: O 1,S yews tiftjt
4
�€Ft�,c 4r'. YAP �Y pvc
R. Nature of Work 5'66434-11- IMO c,E ;I^K '-,tranJ O1P+ .045c rI'isr ickr i<t)
C. Attach four{4)copies of an engineered plan snowing the location and extent of the work,and four;41 copies of the preliminary Eng.,
Estimate of work. The plans shall show the relators of the proposed work to existing surface and underground improvements.When approved
by the City Engineer said plan becomes a part of this permit,
0. All work sha!)conform to the City of Campbell Standard Specifications and Details for Public Wor'rs Con it action:the General Permit Cond,t.em
listed nn tae revers_side:and the Special Provisions for this permit,listed below. Failure to abide by these ct:nditio,is and provisions i ray result
in Ur::,hutdowir a,,u.'x forferture of Faithful Performance Sureties and cash oeposits. See General P:rmit 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 arty work.
Name of Applicant: 51714)r;,.s i(j4
Telephone o tL � ,56
Address: 14 33S 3. nn-�, )/, W^'1 ik zso_sPI'40gA/ C 7 615.6
/► e , `.?
E Ma,l Ador.,- e e "-TT f.T/ii fire.
_ a. `8- 6 I /• 6/ •.`�
Is this work being none y 5lw property owners at their own residence( - YES NO
The Applicant/Permittee hereby agrees by affixing their signature to this permit ro hold the City of Campbell.its officers.agents and employees free,sale
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 r and on stand both the front and back of this permit.and they will inform [licit
contrattorlsl of the information. Applicant is advised that u issu c f this permit, property owner. or property owner's successors, shall he
responsible›..any any and all c: get arising out of tho condition ny p ' improvementsvn the public right-of-way-
Accepted tPtt P4\4 , .In ��
1 p6eantPermlt:ee, (sign) - (),.'.e GANT(Cn"'•sctor; (Print Name; Date
SPECIAL PROVI${QN
_1. Street shall not be open cut for underground installations.Minimum cuts tt19y.be allowed for connections or exploration holes. Such cuts may be
st=iff ca!ly aop.c by the IL-Ls2ector prior -cut,Lmg.
—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. Wore to be staked by a licensed Land Surveyor or Civil Enyinee.,end two i2)copies of the cut sheets sent ro the Public Works Department
before starting work.I
_ _4. Per Section 4216 of the Government Code this permit:s not valid for excavations until Underground Sers,ce 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.
_ _b. Public Notfrcanon Requuement,: --- _ T—
(-- . izA to 1,v 7th`-- liktOhorii i fU�*^3 at__.. tek L ? A O r) _
Pl, LIC WORKS FEE SCHcL)'LE FCiri CJRREN;rE.=, AMuUN Rt - p /.
PERMIT APPLICATION FEE 3. 77 2 53 Cj Lf 1
PLAN CHECK DEPOSIT ,_
SECURITY FOR FAITHFUL PERFOFMw.NCE LrBOR&MA i EP r L
CONSTRUCTION CASH DEPOSIT -7+�
PLAN CHECK&INSPECTION FEEL-/ 2 53 q '1
i EMERGENCY PERMIT FEE `
Ili
APPROVED TOR ISSUANCE
__--__
C. A°
-Or L;iy e'1yiri'c'
hermit_its,is 2:Mont:is Attcr Date 0'
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GENERAL PERMIT CONDITIONS
A Construction Cash Deposit is required. Charges will be made against this oeposit if there is an emergency cal:•out,overture inspection or when City
ordered barricading is required. Any such costs in excess of the oepc sit will be billed to the Permittee.
2. A one-year maintenance per rod and surety are required. Such period will begin on date of wctten acceptance by the City.
3. Refund or the cash deposit balance and refund or cancellation of the Faithful Performance Surety seoi be initiated by the written acceptance of the wore
by the City
4. Submit project schedule'0(tent days prior to proposed star,of work Special prov'.sions may be'ecui•ed for work within City facilities and
downtown Campbell.
S. The Pernertee must request in writing a final inspection anti acceptance of the wars,:upon compiowr, A.-eptahcrt by the City.,Vii be matte in wr'itny
to the Permittee.
h. Maintain safe pedestrian and vehicular crossings and free access to private driveways.bus stops.fire fryd'ant s.and water valves.
7. A Construction Traffic Control Plan and a Construction Schedule are requ red for all lane closures,detours,and street closures.This plan must be
reviewed and approved prior to any lane closures
8 A Construction Traffic Contra'plan snail conform to the Caltrans Manual of Traffic Controls for Zonstruct+on and Maintenance Work Zones.dated
7990.available at Ceitrans. Traffic control equipment shall include Type S flashing arrow signs if required
a Replace as directed by the City Engineer any damaged or removed improvements in accordance with Cis;Standards and Spec.ifi,auons at fee sole
expense of the Permittee.
10 Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest sco'emark and shall be doweled to existing improvement,
11. Prior approval of inspector is requ reu for any work done after normal working hours.on weekends or'no(days and may require retmoursernent of
inspection costs at rise i.urrent overtime rate.
12 Adequate signing and barricading is required on the job site Failure to provide such signing and bar icad ny may resuk in the C ty's providing signing
and barricades and charging the cost(including all labor ant:materialsi against the cash deposit.
13. Compaction testing of subgrade.base rock,and asphalt concrete by Permittee;s required unless o:ire-wise stated by the City Engineer.
14 The Contracts!or Permittee will have a supervisory representatve available for contact on the project at a'i*ernes outing construction Contractor or
Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m to e:00 p.m.
`5. No storage of materiars or equipment will be allowed near the edge of pavement.the:raveled way.or within the shoulderline which woulo 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 oche'agreements or contracts,sit r ire City and any other public agency.
18. This perm't is not transferable. Work roust be peifornied by the'ermittee or ors designated agent or contra.rtor as specified thereon.
19. Call back tear out)due to emeregencies regarding this permit shall be at the current Overtime rate wah a three.31 hour minimum charge per
occurrence
20. Pursuant to Chapter 14.02 of the Campbell Municipal Code,applicant snail riot cause to be discharged any materal into the municipal storm drain
system other than storm water App„cant snail adhere to the SEST MANAGEMENT PRACTICES esrabiunr_d uy rise Santa Clara Valley urban Runoff
Pollution Prevention Program
21. if the pubt:c interest requires a rundihcatian 01.or a departure from tune plans and specifications,rise Crty shall nave rune authority to require or approve
any modification or departure and in specify the manrnrr:n which the same is to be made for City-ownee or maintained facilities
22, Permitttee must provide advance no;ifi.avon to all parties that may be affect-_d by the permit activ2res. Nouf cation snaii be reviewed by the City Drior
to distribution and include dates of work and a ontact name and phone numbe•,
Applicant shall be responsible for insuring tit all Kt J,ng services Under tine applicant are aware and understand all of the above ccnd'.tions.
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Cates.
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Contactor 'Prfrlr Nam,' -
J:IFORMS`,Tempictes;Encroachment Permit:',,Encroacri•raen :TAT;4 iii
Rev-02 14
• PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT,TRAFFIC & MISCELLANEOUS RECEIPT
Effective July 1, 2013
TO: City Clerks 2e l - OO (c3
PUBLIC WORKS FILE NO.
PROPERTY ADDRESS 2 l ei c '5 (3�5 e
Please collect & receipt for the following monies NI AMa �
ACCT.:` i • ITEM '{ :
ENCROACHMENTPERMIT
4722 Utility Encroachment Permit Application Fee $377.00
37 1
R-1 Encroachment Permit N/C
Emergency Permits $107.00
Plan Check& Inspection Fee 3�
Minimum Charge Per Location $377.00
Conduits/Pipelines up to 500 Feet $2.50/ft
Above 500 Linear Feet $1.55/ft
Manholes/Vaults/Etc. $165.00/ea
Pole Set/Removal $165.00/ea
4760 Storage Container Permit $153.00
4760 Project Plans&Specifications Proiect 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 public improvements $100/Calendar Day(Muni Code Sec.11.34.010)
4722 Penalties: Failure to correct unsafe conditions $100/Calendar Day
4722 Work Without Permits 4 Times Applicable Fee
xs+ kzx it '� W t Y I t ,jt. qdy p y412:" 1 ,, € j. 3601: �, '�'h ' , s n,` 5,�.=^G t `' ''an'r., .. ,.
TfFJL ,. ". ... �``'Ga`��Z�,,��� '� ��: t °. '�.... �?�,�. ,��.�' ��_Rt.x.r _, r �
4728 Traffic Flow Map (Daily Traffic Volumes) $35.00
4728 Signal Timing Information 73
4271 Truck Permits $16.00 per trip
4728 No Parking each or$25/100q Signs
511.7424 Postage
Other(Please Specify)
TOTAL 754
NAME OF APPLICANT 1 '11 h fl-)S ' A./ 2 ,
NAME OF PAYOR d i A C-5 e PHONE t1 e7 — b 3S- $-o
ADDRESS .2 (It __Drui LA ZIP 1 s I Zc}
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a� Receipt'€ 4‘;‘"3:44'
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