ENC2009-00046r31'?612008 14:58 1-408-:~p4-1821 WUSD PAGE 02104
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CITY OF CAMPBELL t:NCRDA[HMENT PERMIT rr~~~ ~~~~
Permit Nq ~{^1~(iL. Z M~~ff
oD-1 ~ DC~~h
bEPT. OF PUBLIC WORKS (for working within the public X-Ref. File
TO North First Street right-of--way) gpp)i~tion bate
Campbell, [A 95008 2 7 /~
~/ Applicatio E pir tin a'l'e
Ph. (408) 866.2750 Issued
/ APN +
Fz. (A08} 376-0958 '3 2 7 ~ ~
Permit Expiration Pate
APPLICATIQN -Application is hereby made far a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six
{6) months ifthe permit is not issued. Application Fee is non-refundable.)
A. Work Address orTratt No_
Utility Trench Location:
f l._ _ __REGEIVED
r
2009
B. Nature of Work; ~~e ~ f j~,~
~.....~..... . i/r 1, ,~,,,,,,,,,,,,, ,, ,,, ,,,,,,,,, ,, ,,,, ,,,,,,P B~LIC.. WORKS
C. Attach Four (4) copies of an engineered pia sh Ing the location and extent of the work, and four {4) copies of the preliminary Er-9i6DRIlINISTRATION
Estimate of work The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved
bythe City Engineer, said plan becomes a partof this permit.
D. All work shalt 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. {gee General Permit Conditions 7 and 2.)
E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at feast two days before
starting work. Notice must be given to Public Works at least z4 hours before restarting any work.
Name of Applicant: ~ ~ ~ Telephone: ~ •
I
Address;
.w y s
E-Mail Address:
........
IG. ~ ,,d~ , ,, .. , , ,,
24-HOUR EMERGE CY PN" HONE NUMBER:
is this work being done bythe property owners at theirpwn residence? ri yEg ~ NO
The AppllcanVPermlttee hereby agrees by affixing their signature to this permit to hold the C;ty of Campbell, iu 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/Pem,ittee 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. Applicant is advised that upon issuance of this ermit, property owner, or property owner's successors, shall be
responsible fo any and all da ges arisi/jg~outjy~~the condltlon~of a1ny+p)rivateMlmprov ents In t t-of- '"~ y•~ //
Accepted: ~~~ 1/C. P {A.JV ~ rl l • ~ _ _~ L~~ ~_
(Applicant Permittee) (sign)
ntractor) (Print Name) Date
SP IA PROVISIONS:
1. Street shall not be open cut for underground installations_ Minimum cuts may be allowed far connections or explaratian hales. Such cuts.ma~tbe
specifical ly approved by the Ins ctor prior to cuttino_
Z. 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. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies pf the cut sheets sent to the Public Works Department
before starting work.
4. Per Section 427 5 of the Government Code this permit is not valid for excavations until Underground Service Alert {USA) has been notified and
the Inquiry IdenUflcatlon number has been entered hereon. USA Phone; t-80o-x27-2600, USA71t;KET Np,
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 Notfflcatlon Requirements:
7,
E P BLItW RK FEESCIjF~iJJ,E~O•~QJRRENTFEES
PERMIT APPLIGATIpN FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFpRMANCElLABpR & MATERIALS
CONSTRUCTION CA5H DEPOSIT
PLAN CHECK& INSPECTION FEE
APPRpVED FQR ISSUANCE
MOUNT 32 S
S
RECEIPT NO.
S
S D ~~
3/27/a q
For City Engineer
Permit Expires 7z Months After Date of Issuance
~~ ~,~t ~
03f26f2009 14:53 1-408-~F4-1821 WVSD PAGE 03f04
GENERAL PERMIT CONDITIONS
1. A Construction Cash bepaslt is required. Charges will be made against this deposit If there Is an emergency cal{-oui, overtime inspection or when City
ordered barricading is required. Any such costs in excess of the deposit will be billed to the Pennlttee.
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 Clty.
q, The Permittee must request In writing a flna[ Inspection and acceptance of thework upon completion. Acceptance by the City will be made in wrong
to the Permittee.
5. Maintain safe pedestrian and vehicular crossings and bee access to private driveways, bus stops, fire hydrants, and water valves.
6. p Construction Traffic Control Plan and a Construction Schedule are required forall lane closures, detours, and street closures. This plan must be
reviewed and approved prior to any Zane closures,
7- A Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls farConstructian and Maintenance Work Zones, dated
1990, available at Caltrans. Trafficcontroi equipment shall includeType II flashing arrow signs if required.
8_ Replace as directed by the City Engineerany damaged or rnmovcd improvements in acCOrdanee with City Standards and Specifications at the sole
expense of the Permittee.
9. 5awcut for all PCC orAC removals. All PCC removals shall beto the nearest scoremark and shall be doweled to existing improvements.
~ 0. 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 provid ing signing
and barricades and changing the cost (including all labor and materials) against the cash deposit,
12- Compaction testing of subgrade, base rock and asphakconcrete by Permittee is required unless orhervvise stated by the City Engineer,
13. The Contractor or Permittee will have a supervisory representative available far contact on the proj2tt at al I times during construction. Contractor or
Permittee shall provide a phone number at which they can be contacted outride the hours of 8:00 a.m. to 4:00 p.m.
14- No storage of materials or equipment wilt be allowed near the edge of pavement. thctraveled way, or within the shaulderline which would create a
hazardous condition to the public.
15. This permit shall not be construed as autharizatlon forexcavatlon and grading on private propertyadJacentto theworkor anyotherworkfor whlclt a
separate permit may be required, nordoes It relievethe Permittee of any obligation to obtain anyotherpermltrequired bylaw.
t6. This permit does not releasethe Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency.
t 7. This permit is not transferable. work must be performed by the Permitteeor his designated agent or eorrtractor as specified thereon.
7 8, Call back (Gall gut}due t4 emeregencfes regarding th is permit shall be at the current overtime rate with a three I3] hour minimum charge per
occurrence
79. Pursuant to Chapter 14-02 ofthe Campbell Municipal Code, applicant shall not cause to be discharged any material intothe municipal storm drain
system gther than storm water, Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff
Pollution prevention Rrogram.
20. If the public intcresr requires a modification of, ar a departure from the plans and specifications, the Clty shall have the authority to require or approve
any mod cation or departure and to specify the manner in which the same is to be made for Clty-owned or maintained facilities.
21. Permimee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the Gty 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 awareand understand all ofthe above conditions.
Date'
Date:
1:\FORM51TemplateslEncroachment Permits\Encroachment permit STATIC form2.pdf
Rev. 3/OS
03,!26;{200] 14:53 1-408-3~~-1021 WVSD PAGE 01104
'1~1`E'S~ ~1"a~~~y
S~a~i~~~ion I]stri~ct
FACSiNiiLE TRANSMITTAL
DATE:
TIME:
TO:~^- ~ S
ATTENTYI
FROM: ,
SE'BJECT:
EAJ~ N~.: '~~ ~rs* ~~
(ineludiz~g this coyer sheet)
TOTAL PAGES T~tANSMITTED
MESSAGE:
100 EAST S'C)'N~i~''O~1,~S ,AVENCTE, CAM~'BELL, CA 95008
TEI.EF~ONE (40$) 378-2447 FAX (408) 364-1$21
B-126