ENC2009-00050Print Form
CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First Street
Campbell, CA 95008
Ph. (408) 866-2150
Fx. (408) 376-0958
ENCROACHMENT PERMIT
(for working within the public
ri ht f-w )
Issued /I--~~
Permit Expiration Date ~ V
X-Ref.
Permit No.: ENC2009-00050
~
Application Date: 4/8/2009 ~~
Application 10/8/2009
Expiration Date:
APN: 404 25 020
lication is hereb made for a Public Works Permit in accordance with Campbell Munici al Code, Section 11.04. (Application expires in six
Y p
APPLICATION -App
(6) months if the permit is not issued. Application Fee isnon-refundable.)
A, work Address or Tract No.: 491 Sunnybrook Court
Utility Trench Location:
street Kenneth Ave.)
B. Nature of work: Emergency Service Repair, 2 cuts in asphalt, l-6'x6' & 1-6'x4'
C. Attach four (4) COpTheoflans shall) show pherre anion of thelp oposed work to es sting surface and urnderg olund improvementsyWhenapprpved
Estimate of work. p
by the City Engineer, said plan becomes a part of this permit.
D Anted on t ellreoeroe side Land the SpecapProly lions for this permit listed belowlsFailuretosbide by these conditions and prow is onsCmay 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.
Telephone: 408.279.7865
Name of Applicant: Pamela Santos(Emergency Verbal)
Address: 1221 S. Bascom Avenue San Jose, CA 95128 ~~~,
24-HOUR EMERGENCY PHONE NUMBER:
E-Mail Address:
Is this work being done by the property owners 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 acknowiea9eistadvsed that upon issuance of thid botmitheproperty ownek ortproperty'owner'shsuc elssorsoshall be
contractor(s) of the information. App' p
responsible for any and all damages arising out of the condition of any private improvements in the public right-of-way. ~~
Date: 4/8/2009
Accepted: Pamela Santos(Emergency Verbaq
(Applicant Permittee) (sign)
(Print Name) Date
(Contractor)
SPECIAL PROVISIONS:
1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may e
s ecifically approved by the Inspector prior to cuttin .
~2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Metho
"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 an
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.
AMOUNT RECEIPT NQ.~
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES $ ?) 7 ~ ~•7
PERMIT APPLICATION FEE $
PLAN CHECK DEPOSIT S
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS 5
CONSTRUCTION CASH DEPOSIT 5 ~ (;
PLAN CHECK & INSPECTION FEE C_~ ~ / f 3 /~
""-'_.._. (Date
APPROVED FOR ISSUANCE 'For City Engineer
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. 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.
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 are required for all lane closures, detours, and street closures. 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. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest 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 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 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 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 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 Permittee of any obligation to obtain any other permit required bylaw.
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 system otheCthan sto~m wateheAppl cant shall adhelre~o the BEIST MANAIGEMENT PRACTICES establ shed by thelSant oClara ValleypUrbanrRunoff
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.
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 shall be responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions.
Date: 4/8/2009
Applicant: Pamela Santos (Emergency Verbal)
Contractor (Print Name) Date:
J:Reina\Website\Land Dev Forms\Encroachment Permit STATIC form2.pdf
Rev. (11/9/05)