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CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No ANC 2G13 - 60O I it
DEPT.OF PUBLIC WORKS - (for working within the public X-Ref.File
70 North First Street right-of-way) Application Date 1— 10 ` XS
, Campbell,CA 95008 Issued (rj (�j Application Expiration Date 7-l()-13
Ph.(4081866-2150 111 APN -1°,j-9-)\
Fx. (408)376-0958
Permit Expiration Date 1 (S 1'-1
APPLICATION-Application is hereby made fora 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.: 1/ /
Utility Trench Location: f. zt'�Z' ≤'ovi-L of- To/oj
f�f-�DF of �f 4f/'isc�n S J Sr-l-'
8. Nature of Work:
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 mist notify the Public Works Department atleast two days before
starting work.Notice must be given to Public Works at least 24 hours before restarting any work.
r i
Name of Applicant ��,;•' f/� k Lt,J-r'2- ` PG 3 . Telephone; q o - c y_ o (7/
Address . f°900 At LeqK, Al'€ , (_„(.r(-i-tO .r 4 .. . • . . ... .
E-lvtail Address: Y'r p�V& f C'E ,CD(A/� , 24-HOUR EMERGENCY PHONE NUMBER: /..�C)-'4 3 - s-o G C)
Is this work.being done by theproperty owners at their own residence? IT YES NO 1 -
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 daim or demand for damages resulting from the Work covered by this permit.
The Applicant/Permittee hereby acknowledges that they have read and under nd both the front and back of this permit,and they will inform their
contractor(s) of the i alion. pplicant is advised that upon Issue o this permit, property owner, or property owner's successors, shall be
responsible for any a al( arising out e c ''on ny p' ate' provements in the public right-of-way.
Accepted: —E2 i ,7 _ f e /J - LO 13
(Applicant Pe itt (sign) . �~ Date •
7 1rrr12)O iM i_eivo z (116 €E 1 • J- l0 -z r3
(Contractor) (Print Narn@) Date
SPECIAL PROyISIONS; '
�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 orior to cgttinq.
2. Pavement may be cut for underground installations and mutt 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 4215 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 $ 3 70 a
PLAN CHECKDEPOSiT $ •
SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $
CONSTRUCTION CASH DEPOSIT $ 3 '
PLAN CHECK&INSPECTION FEE $ 70 GI
EMERGENCY PERMIT FEE S
APPROVED FOR ISSUANCE — IA s i la .
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. The Permlttee 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.
5. Maintain safe pedestrian and vehicular crossings and free access to private driveways,bus stops,fire hydra nts,and water valves.
6. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures,detours,and street dosures.This plan must be
reviewed and approved prior to any lane closures.
7. 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.
8. 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.
9. SawcutfOr all PCC or AC removals.All PCC removals'shall be to the nearesf scoremark and shall be doweled to existing Improvements.
10. 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.
11. • 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 cash deposit.
•
12. Compaction testing of subgrade,base rock and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer.
13. The Contractor or Permittee wilt havea supervisory represehtative available for contact on the project at ail 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.
14, No storage of materials or equipment will be allowed near the edge of pavement,the traveled way,or within the shoulderiine which would create a
hazardous condition to the public.
15. 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.
• 16. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency.
17. This permit is not transferable.Work must be performed by the Permittee or his designated agent or contractor as specified thereon.
18. , 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.
19. 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.
20. 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
arty modification of departure and to specify the manner in which the same Isto be made for City-owned or maintained facilities.
21. 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 all be r sponsi%e'•rensuring .tall .se providing serv1c- and thea'plicantare aware and understand all of the abosreconditions.
Applicant s '� Date:
1/14A-12 10 VIA5C.gal i Z C F6 4 6 ) (- o
Contractor (Print Name) Date:
•
J:\FORMS1Tentplates\Encroachment Permits\Encroachment Permit STATIC form2.pdf
Rev.09/10
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PGEtE NOTES 10' N L. W r-r)
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1. PGEtE design, Trench, Pave, Et Install new gas srvc. o 0 o I- _ m
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to new meter location. INSTALL PROTECTION
2. Meter in under patio deck. I POST
3. PGEtE to Perform Hot Tie In. 4'x4' DRIVE WAY V
BELL L HOLE cv I PLANTER
4. PG&E to Install 23' of 1" PL HP with NC riser. —.- - N 53' OF 1" PL Q
5. PG&E to install riser 3' from patio deck corner. \ '�e_ — T- 0—
6. PG&E to maintain 3' separation from all I j G x x x I WI S
wet utilities. c x x x )( ,J 0
8. Contact Gas Serviceman after work is completed. X
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9. Plumber to tie in customer day of construction. H X
10. City of Campbell permit required. C — x U
x 11. Install protection post. H x = (Y
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— NEW PLASTIC/STL. SERVICE. x > Qco
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PROPERTY LINE �+
G EXISTING GAS FACILITIES o x V) Q /
G-O CUT-OFF x # 260 C:=4 O (,
4' X 4' HOLE Z N
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FOC FACE OF CURB X - U
P/L PROPERTY LINE H 60' ►x
M EXISTING GAS METER X 0
EM; PROPOSED GAS METER x -
I A PROPOSED EXCESS FLOW VALVE U
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x x >c x x EXISTING FENCE -....-- ►� 10' D___
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( )( )( )( x )( x )( x x x N x ) El-
\ 0 LA PROJECT CONDITIONS STAMP O N
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Type(s) of Work: L_ I— L._ CV
III New Business
❑PG&E Maintenance & Construction >'1 FOR
APPROVED}��`gq' } (f CONSTRUCTION
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Project Conditions: y P! i�.Ew a .D W w W I
❑NONE APPARENT (if project deign change, contact ACE) `` . . _ 0 O Q
❑CONDITIONS APPLY: City of C am p be I l J_ J_ Z LAJ
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❑PERMITS ❑TAILBOARD ❑OTHER c f Q >—
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