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CITY OF CAMPBELL q�6 -� t� " ENCROACHMENT PERMIT Permit No F(L/e 20 1(
DEPT.OF PUBLIC WORKS ((77 �cj (for working within the public X-Ref.File
70 North First Street4. 2014 right-of-way) Application Date . $j 1 y- _
Campbell,CA 95008 �'�'U//fs /1 Application Expiration Date (�
Ph. (408)866-2150 /lar Issued Fs! zief i t-I Z`Z
/l1/7j APN LixL-O\- 61
Fx. (408)376-0958 Sprat% 7/1O `
Hermit Expiration Date 7Y Z S�
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.: ' 4c. cAmbEw Ave
L.1 !L. Utility Trench Location: g^c.Ag OF C/w
�1. Natu(e fillork: LAG+E QA,(.1rvwNW 112-6,45f•PAES.
Q. c Atta#fc (4)copies of an engineered plan showing the location and extent of the work,and four(4)copies of the preliminary Engineer's
�1 *-�: Esti `'' a work. Theplans shall show the relation of the proposed work to existing surface and underground improvements. When approved
�, � P P 9 P PP
L by ttt Engineer,said plan becomes a part of this permit.
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up, Q All worghall conform to the City of Campbell Standard Specifications and Details for Public Works Construction;the General Permit Conditions
CC 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.
t,
Name of Applicant P6 E Telephone: Sit 1_ S(0q
Address: I R l VEp. ?M K ;L I BAST • r46500, cA 131242
E-Mail Address: 1.4EMIZ/J e.cowl 24-HOUR EMERGENCY PHONE NUMBER:
Is this work being done by the property cn4fliers at their own residence? r YES g 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 rea and understand both the front and back of this permit,and they will inform their
contractor(s) of the information. Applicant is advised that upo ssuance of is permit, property owner, or property owner's successors, shall be
responsible for any and all damages arising out of the condition of private i eme is in the public right-of-way.
Accepted: FR ANC IS tsAlow4t 51151141
(Applicant Permittee) (sign) Date
(Contractor) (Print Name) Date
SPECIAL PROVISIONS:
1. 5treet 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.
V 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.
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„ RECEIPT NO.
PERMIT APPLICATION FEE $ -74917
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $
CONSTRUCTION CASH DEPOSIT $
PLAN CHECK&INSPECTION FEE $ ,0�j .,
EMERGENCY PERMIT FEE $ ___ __
APPROVED FOR ISSUANCE 1 `Z-Co
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 FCC 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 4O0 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.
F-Riot uctS $' t5- %f
Applicant Date:
PCa E E
Contractor (Print Name) Date:
J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf
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PROJECT CONDf11ONS STAMP W
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Type(s)of Work: A N
0 New Business
❑X PG&E Maintenance&Construction <rl
Project Conditions: 4
ID NONE APPARENT(n project design changes,contact ADE) V
❑CONDITIONS APPLY. CONSTRUCTION DRAWING
❑PERMITS ❑TAILBOARD 0 OTHER
(Provide edORbnal In}wmetbn on he below)
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VICINITY SKETCH
eloHMDeE NMSE[DaRroter q.DATE t i
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Kil CONTACTS: <<,
o VOLTAGEKI
c) TIMBER
AREA 3
FRANCIS MOUA - ELEC. ESTIMATOR
OFFICE NUMBER - (559) 347-51O9 OO NON CORRSION
CYNDY SANDOVAL - ELECTRIC A.D.E. sqN / JOB SITE VASONA 1105
OFFICE NUMBER - (559) 347-5295 TDMAs too, SSD: FUSE 543
MAY NGUYEN - JOB OWNER _/ DELL PLAT: H1525
OFFICE NUMBER - (4O8) 299-114O FIRE AREA: LRA
EST: C SAND. PADMOUNT TX REPLACEMENT CO: -
ADE: C. SANDOVAL SD: -
SUPV: E. HORANIC 840 CAMDEN AVE MOTIF: 107982357
REP: M. NGUYEN OTHER: -
PLNR: - CAMPBELL SHT: 1 of 1 SHEETS
SCALE:N/A DA08%2014 ' 4PACIFIC GAS AND ELECTRIC COMPANY PM:
REV
31076362 1
It!
PG&E � '►
Dependency Management Desk CS",
8 River Park Place East
Fresno CA 93720
August 19, 2014 �j
Re: Permit Application PM 31076362
To: City of Campbell
Dept of Public Works
70 N First St
Campbell, CA 95008
Attached permit application is for the following location:
840 Camden Ave
Approved permit should be mailed to:
PG&E — Fresno RMC/DMD
Attn: Roberta De Fehr
8 River Park Place East
Fresno CA 93720
If you have any questions, feel free to contact Francis Moua, Engineering Estimator—
(Electric) @ (559) 347-5109 or by email: fzm2pqe.com. In addition, please reference
our job #31076362 on all documents & communications, so we may better serve you.
Thank you,
Roberta De Fehr
Dependency Management Desk
Phone (559) 347-5137
FAX (559) 347-5339
Email: rmdc@pge.com