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70 North First St. right-of-way) 1-( -1 5
Campbell,CA 45008 Application Date
(408)866-2150 Issued t��0 3 Application Expiration Dale -10 l
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Fax(408)376-0958 I \
Permit Expiration Date t/l a APN -k\ ‘?t'', C'-'f)?-
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 uon-refundable.)
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A.Work address or tract H LLJ1 C� I s
location y� x 5 4/PL. e E)?-C i(--+ �lLiei.)&JJ— - •
Utility tenth
B.Nature of work U 1���1\r-fit U-r"1 1(-e 1O kac!c'-tiyi e--vi-I- L l H 3- 0 1 - i -
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 I and 2.)
E.The Contractor must have this permit and approved plans at the sift and must notify the Public Works Department at least two days before starting work.
Notice inust be given toPublic 1Works at least 24 hours
/before restarting any work. bY 7
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Name of Applicant`-- '1'O iD✓e "0`_U QI ` y�r�am Telephone J .2-1q-73 /
Address I I D l ), i t1 L( I -1 L}r L5 p l nLif1 e) ( 11 Li 2'. -, p.EMERGE1dCY TELEPHONE IE NO.
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E-Mnil Address y
is this work being done by the property owners at their own residence?. 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/Permittce hereby acknowledges that they have read and understand both the front and back of this permt;and they will inform their -
. contractors)of the information. Applicant is advised that upon issuance of this.permit, property owner,or property owner's successors,shall be responsible
for any and all damagees arising out of the condition of any private impro ements in th bIle right-of-way. • '' . '
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• Accepted S-t LL'�� )l t•1`-- ('ice-r{Iv7'( d S/a//3
(Applicant Pe •tree). (sign ...f. Date /
Contractor (Print Name) Date.
• SPECIAL PRQViSIONS
1. Street shall not be open cut for underground installations. Minimum cuts ooi be allowed.for connections or exploration holes. Such cuts may, V
ppp 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 Utility Restoration Standard Details Method
"A"Backfill,unless otherwise approved by Inspector.
_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 .1
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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. '
SEE PUBLIC WORKS FEE SCHEDULE FOR QURRENT FEES AMOUNT ptECE1PT NO.
PERMIT APPLICATION FEE $ 370
PLAN CHECK DEPOSIT • . S
SECURITY FOR FAITHFUL PERFORMANCPJLABOR Sr.MATERIALS 5
CONSTRUCTION CASH DEPOSIT S
PLAN CHECK Sr.INSPECTION FEE ( - SI_ !� r_.;2._
6 AYYI<UVEU 1-UK ISSUANCE *� - •- `/I G'i 3 • G
i For City Engneer n,• r
Permit Ex ire 12 Months After Date of Issuance
I:\forms\pwperm
Revised 12.27.04 • '
1. A Construction Cash Deposit is required. Charges will he 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 of•the cash deposit balance and refund or cancellation of the Faithful Performance Surety will he initiated by the written acceptance of the
work by the City.
4. The Permit-tee must request is writing a final inspection and acceptance of the work upon completion. Acceptance by the City•will he made in
writing to the Permittee.
S. Maintain safe pedestrian and vehicular crossings and free access to private driveways,bus stops,fire hydrants and water valves.
6. •A Construction Traffic Control Plan and a Construction Schedule arc required for all lane closures,detours and street closures. This plan must be
reviewed and approved prior to any lane closures.
7. The Construction Traffic Control Plan shall conform to the Caimans Manual of Traffic Controls for Construction and Maintenance Work Zones, •
dated 1990,available at Calrrans. Traffic control equipment shall include.Type iI flashing arrow signs if required.
B. 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. Sawcut for all PCC or AC removals. All PCC removals shall be to,nearest scoremnrk 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.un the job site. Failure to provide such signing and barricading may result in the City's praeidr..g
signing and barricades and charging the costAincluding all labor and materials)against the 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 Perinittce will have a supervisory representative available for contact on the project at all times during construction.
Contractor or Pemiittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m.'to 4:0D p.m. ' .
14. 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.
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 Permitter 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 nay other public
agency.
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11. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon.
113. Call.back (call out)due to emergencies 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 maletial•into the municipal storm
drain system other than storm wafer. 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 any modification or departure and to specify the manner in which the same is to be made for City-owned or maintained facilities.
Applicant shall be responsible for ensuring that all those providing services under the applicant arc aware of and understand all of the above conditions.
'311.0(1_} 11 _ Gl_I3
Applicant V/ Date
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Contractor (Print Name) '' •Date
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-1:\forms\pwperm
• Revised 12.21.04 ••