ENC2003-00126
CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
ENCROACHMENT PERMIT
(for working within the
public right-of-way)
. Permit No. 200'- DO 11.(;,
X-Ref. file
Application Date ~ II 'l)C:> 3
Application expires in' 6 months
APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in 6 months
if the permit is not issued. Application Fee is non-refundable.)
Utility trench location
\ '360 f(bB l'\l t ~ L T ( I ~cy VAN !)Uf> ~)
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A. Work address or tract #
B. Nature of work
C. Auach four (4) copies of an engineered plans 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 shut-down 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 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 C ~ &r I ~ COd }t-OVl Telephone Aq I . 7 74-0
Address 11.50 VBVI 'D~&e'1 }!::...in~ ~?"",d~/I t{7~8 24 HOUR EMERGENCY TELEPHONE NO. ?:.7~~~11 ~
(
Is this work being done by the property owner at their own residence?
)( Yes
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. . / /~../. ._ './ ' )
/ / / ,/ ..... 9/:2-ft:J3
Accepted t....,/ f~c.<...,'?< (..../.._..
_/ . ..... / (Applicant/Permittee) (sign) Date
COWl~t' \ Co"fO-re:- c....W'(fl,uC.,.tcN
SPECIAL PROVISIONS
_1. Street shall not be open cut for underground installations. .
.1IPproved bv the IlISJlector prior to cutlinl!. . . '. . :. : . .' '.' . .'. .'
Pavcmentmay be cut for underground installations and must be restored in accordance with the Utility Trench Restoration Standard Details, Method 'A' Bacll:fin,
unless otherwise approved by Inspector. .. . .
Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to. the Public WorksDepanment before starting work..
Per Section 4215 of the Government Code this permit is not valid for excavations utitil Underground Service Aien (USA) has been.notified and the inquiry
identifICation number has been entered.bereon. USA PhOne 1~soo.227~2600. . USA TICKET NO. .
_2.
_3.
_4.
PERMIT APPLICATION FEE
PLAN CHECKDEPOSIT .' . . .... .. '. . '.' .. .... ...... ..' .....
SECURlTY.FOR.FAITHFUL.PERFORMANCElLABOR.&MATEIUAl..S
CONSTRUCTION CASH DEPOSIT
PLANCHECK& INSPECTION FEE
TYPE
UT\L
AMOUNT.
s 275
$
$
$
$
RECEIPT NO.
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.forCity"Engineer
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TO: City Clerk
PUBL._ NORKS DEPARTMENT RECEIPT
Effective July I, 2003
PUBUC WORKS FILE NO.
PROPERTY ADDRESS
'2~3- ~~ \ ~C
I~~o (l.eN lc..l<
Please coDect &: receipt for the following monies:
ACCT. ITEM
435.635.4921 Project Re..enue (apec1fy project)
ENCROACHMENT PERM1T
4722 Application Fee
Non-Utility Encroachment Permit
Minor Encroachment Permit < $5,000
R-l Fint Penult (No Fee) SubHqucnt
UtWty Encroachment Permit
Arterial/CoUector Street
Residential Street/Other Areas
Plan Check Deposit. 2% of ENGR. EST.
Faithful Performance Security (FPS)
Labor and Materials Security
Monumentatlon Security
Cuh Depolllt
Labor and Material Security
Plan Check &. Inspection Fee (Non-UtWty)
Engr.EIlt. < $250.000 (13% ofENGR. EST.)
Engr.EIlt.>$250. (Deposit 8% of ENGR. EST./$30.oo0 min.)"
Utility < $100.000 (8%)
Minimum Charge Per Location ($180.00)
Condultli/Pipelb1e. up to 500 Feet ($2.25/ft)
Above 500 Linear Feet ($1.35/ft)
Irlaraho1es/Vaulu/Etc. ($125.00jea)
Pole Set/Removal ($ 125.oo/ea)
Street Tree Planting/Removal ($125.00/ea)
2203 Utility> $100.000 Actual Coat + 20% ..
4780 Project Plan8 &. Speclftcations Project No.
4780 Standard Specifications II< Details ($I/Pg $15.oo/8k)
4780 copl.. of Englneerln' Mapo II< PIaIUl
Aerial Plot 24" x 38" ($50.00)
Aerial PrInt 8 1/2" x 11" ($20.00)
Map8 and Plans 24" x 36" ($7.76)
4722 Penalties: Failure to restore public lmproveme:($ l00/Ca1endiilr Da~{MuaI Codoe Bee.U.a..OID}
4722 Penalties: FaUure to correct unsafe conditioJU($ l00/Ca1endaJ' Day)
LAND DEVELOPMENT
4722 Lot LlDe Adjustment
4722 Pucel Map C4 Lou or Leu)
4722 P1nal Tnlct Map (5 or More Lob)
4722 Certificate of Compliance
4722 Certificate of Conection
4722 Notary Fee (per .i~nature)
4722 Vacation of Public Streeu &. Easements
4722 AHa_ment Segregation or Reapportionment
Flnt SpUt
Each Additional Lot
Storm Drainage Area Fee Per Acre
2203
2203
2203
2203
2203
2203
4920
ts:U.742
TRAFFIC
4728
4728
4728
4728
4728
4271
4728
OTHER
($280.00)
($57.00)
($120.00)
$
($500.00)
($275.00)
($500 mini
(100% of ENGR.EST.)
(100% ofENGR. EST.)
(100% of ENGR.EST.)
(4% ofENGR.EST.)($5oo mln/$10.oo0 maxI
(100% ofENGR. EST.)
4722
220
4722
($750.00)
($2.400.00 + $35/lot)
($3.200.00 + $35/lot)
($595.00)
($385.00)
($10.00)
........
4721
($855.00)
($200.00)
(R-l. $2.000)
(Multl.R... $2.250)
(All Other. $2.500)
Parkland Dedication Fee (75%/25% Due Upon Cert. or Occupancy)
Pototage
Intersection Tum Counts (Two-Hour Count) $72.50)
Intenectlon Turn Counts (a.m. or p.m. peab) ($1415.00)
TrafIlc Flow Map (Dally TrafIlc Volume.) ($30.00)
Campbell Traffic Model {Full Scope Aaaeaamenl (Actual)
Campbell Traffic Model (Reduced Scope Aaaesa (Actual)
Truck Pennita ($16.00/per trip)
No Parkin, Signs ($I/each or $25/100)
TOTAL
NAME OF APPLICANT
C\.-\&t"le~ We> ltoVJ
(1
AMOUNT
"'Hi
\ p.a
$
4~S
5 ~W/ e..-.
NAME OF PAYOR
ADDRESS L+5~ l/~ ])~'" LVI
."
"Actual Coot Pluo 20% Overhead (Non-_ bearlnl! depooltl
PHONE ~ - 46f /.- 77~ 0
r~. 3::/1 ZIP Cf5/J tJ'b
,
FOR
CITY CLERK
ONLY
REC~ BY / I (XLP
DatH/1 'v:.ce~~)./) 00g Z, 2--
(
-For Plan Check and Cuh De~lts. send yellow copy to Finance.
Date/lnitials
J:\forms\receipt from 03-04 7/1/03
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CITY OF CAMPBELL, CA
RECVD BY: .JANH
D^Viito. f'UAlli t"C: UAi TOM
i M tuna wUnl\l...L.\J wn'-l Vi"
TuDAY~5 DATE; 09/12/03
01000160822
REGISTER [lATE: 09/12i03 TIME: 11:4t.:35
ItESCRIPTluN c,ioiiiiiNl
III :"J'.n~ \
ENGF . SUBDI\.) FILING F $275.00
I:.U::I:' & CHilToTi i rTi TlJr.: t" $180.00
;.l':WF. 1JUJ.lV.L ~. J.i...tlU; I
T!1TAI
. i i t H~
1''I1U-.
!.luc.-
$455:00
TENnEF~En i
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WEST VALLEY SANITATION DI~.. ,ICT
SANTA CLARA COUNTY
100 E. Sunnyoaks Ave., Campbell, CA 95008
(408) 378-2407
SEWER CONNECTION
PERMIT NUMBER
34678
By flY
Issue Date
h II / / t/2-
I ,
LOCATION:
A.P.N. .tf~~- (ttf:- P 2 b
Sewer Location: Bk. 6 Pg. !?.f
Tract Lot
Proj. Assmt.
AJd3~~~--YMr tlUsJi/ ~
Jurisdiction _~~;"
BUILDING TYPE:
VSingle Family
_ Condominium/Town Houses
_ Multiple Dwelling
Number of Units
_ Commercial
Industrial J
~a~Nff-;;fk~ ,.
Chana~ in Status: :R~
~T 2~~
~ -fee- fleJlA1 /{ .3' 4b7 7
FEES:
Acreage
Frontage
Service Advance
Processing
Other:
Capacity
$
BUILDING SEWER CONNECTION:
_ Feet of Property
line _ feet from Main Sewer
and _ feet deep.
Connection to Main Sewer
Feet upstream from M.H.
Using AI R"W
BACKFLOW PROTECTION:
~ Field Check Required
_ Call District for foundation survey
Device Required; Yes _ No V--
Type:
o Street encroachment permit required from C~~A.eo/-I_
o Permit invalid if not connected within 12 months of issue.
o Do not connect until main sewer is accepted by District.
o Obtain a building or plumbing permit from the jurisdiction listed above.
WEST VALLEY SANITATION DISTRICT
SANTA CLARA COUNTY
100 E. Sunnyoaks Ave., Campbell, CA 95008
(408) 378-2407
-#
WHITE _ PERMIT I PINK - DISTRICT I YELLOW - JURISDICTION BUILDING INSPECTOR'S COpy I CARD -DISTRICT COPY
SEWER CONNECTION
PERMIT NUMBER
34677
TOTAL
*-
Issue Date
r;//I/~
ByHY
Disposition;
~1 Zone l~
I NSTR UCTIONS:
LOCATION:
A.P.N. 4~3-/9-p7Zb
Sewer Location: Bk..6 Pg.54
Tract Lot
Pr~. A~mt.
Address: /45'p !/4IIPU5n/ L//
Ju risdiction e.Afrl fY?1!t.L.
BUILDING TYPE:
_ Single Family
_ Condominium/Town Houses
~ Multiple Dwelling
Number of Units
_ Commercial
_ Industrial
Other Informatio~'f t/AIIT
B:~() ?Pile- _ --L .
Change in Status:
CHecjL,A../O, 65:'rp
6-kvDLI') 6; 1/I/fJ'f
/?treY
0/>>/ () 3
FEES:
Acreage
Frontage
Service Advance
Processing
Other:
Capacity
Af4~'fjfatRl,
TOTAL
$
BUILDING SEWER CONNECTION:
Property
/ bl~,~/)
'Z7~ PO
6/J. f': Ii 0
25'S: t/v
/z/~3o
_Feet of
line _ feet from Main Sewer
and _ feet deep.
Connection to Main Sewer
Feet upstream from M.H.
Using 1EX/:97J#7
BACKFLOW PROTECTION:
~ Field Check Required
_ Call District for foundation survey
Device Required;
Type:
Yes~ No
t?6~1Y
AI/}
Disposition;
~ Zone ~
I NSTR UCTIONS:
o Street encroachment permit required from
o Permit invalid if not connected within 12 months of issue.
o Do not connect until main sewer is accepted by District.
o Obtain a building or plumbing permit from the jurisdiction listed above.
WHITE - PERMIT I PINK - DISTRICT I YELLOW - JURISDICTION BUILDING INSPECTOR'S COPY I CARD -DISTRICT COPY
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