ENC2009-0006205r 1112009 13: 2 r 408364 A^1 W'tJSD
RECEIVE.
PAGE 02104
MAY G ~,f,~rn; a~~~~P'rt,{,r"3F
1 1 2009 ~z,~"~~Y
eITYOFCAMP8EL6 PUBLIC WORKS ETICROACNMENTPERMIT Permit No ~+~~ " ~~~
DEFT. L1F PUBhIC yv~gIMINISTRATION {for working within the public X-Ref. File
70 Nareh First Street right-af•way) Apphcatidn Date ~~
Campbell, CA 95008 ~ Z ~ Applicati Ex ration Date ,r.
Ph. {4p8) 86d-2750 Issued APN _ „~ ,•
Fx. (aoa) 37Cra~sa ~ .L ~ a,
Permit lxpiratlon Date
APPLICATION -Application Is hereby made far a Publlc Works Permit in accordance with Campbell Munldpa! Code, Section 11,0+1, (Application expires in six
{6) months if the permit is not Issued. Application Fee is non-refundable,)
A, Work Address or TractNo.: 123J ~ft' i~fq f4V~. ~' "'11~GG..1 ~~.....•. ... ..._. __.~
.. 9 .
Utility Trench Location: R1~ht 4~' f~ //l~t/~dC7110f'f .t7tiG Vi,~inla.. Aid ThC/LaSR ~r~iyGa. ....
B. Nature of Work: /1 I7~'~ 7a H71Nlhd
. e,.sbf„r ........ _ ........ ...-.. p ,....... ry .>~ch 8`r~2 ply%dP..
C. Attach four (4) copies ofan engineered plan~showl~t~ loco ~n"an exter~ o1~h~wor f4) copra o11f~~the relimina ~ incer's /3r~8~•
Estimate of work, The plans shall showthe ralatron of the proposed work to exrstrng surface and underground rmprevements. en approved
by the [ity Engineer, said plan becomes a part of this permit
D, All work shall conform to the City of Campbell Standard 5pec}flCBtions and Details for Public Works Cdnstructlon; the General Permit Conditions
listed on the reverse side; and the Special Provisions far this permit, listed below. Failure to abide by these conditions and provisions may result
in job shutdown and/orfarfeiture of Faithful Performance Sureties and cash deposits. {see General Permit Conditions 1 and 2.)
E. The Contraetvr must have this permit and approved plans at the site and must notify the Publlc works Department at leastiwo days before
starCing work, Not;ce must be given to Public Works at lea_stt24 hours before restarting any work.
Name ofAppllCant: ~~. J/A'Ca<E~ ..~-n-~~7a! ~JS~'1~7 'Telephone: C~08~ ~~g'2~~.......I
Address:
loo ~f .. Sfmn yoAks Ave.. ~~~r. , cA, .. 9sao8.......... , ....... _..... ,.......,
(. ......
E-Mal{ Address: I ~Ff~d~O ~ w~y~~) sQ~ d I Z4-HOUR EMERGENCY PHONE NUMF3ER: ~,~~ $~~. /9~,~
I
is this work being done bythe property owners at ieir own rem ante? ~"" YES ~ NO
The ApplicantlPermittee hereby agrees by affixing their signature to this permit to held the City of CampbeN, its officers, agents, and employees free, safe
and harmless from any claim ar 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 permk, and they will inform their
contractor{s) 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 damages arising out of the condition of any private Improvements In the public right•of--way,
Accented: Ulcst Va~1~,.5',~nr'r~Ifa~__.~,lslric~ ~~ar~c L, ~'icaldo Monday, Ma~3 f~9
(Applicant Permlttee} (sign} bate
Sa~Ca PipcJir-ts Monola~, May !1, ~odq
(Contractor) (Print Name) Data
SP~S.Ir,t PRfZV15lONS:
1, Street shalt not be open cut far underground installations. Minimum cuts [>]8X be allowed for Connections or exploration holes. Such cuts mayJle
F i al[ ~p roved bv_the Insoogttar prior to cuttinC.
1~ 7. Pavement maybe 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 Ilcensed Land Surveyor or Clvll ingineer and two (2) copies of the cut sheets sent to the Public Works Department
before starting work.
~4, Per Section a21 s of the Government Cvde this permit is not valid for excavations until Underground Service Alert (USA} has been notified and
the Inquiry identiflcatlvn number has been entered hereon. USA Phone: 1-800-Z27-2600. 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.
b. PublitNotillcatlonRequirements: - -
SEE_PUBLIC WORKS FEE SCHEDULE FOR CURRENLEEE~
PERMIT APPLICATION FEE
PLAN CHECK DEP051T
SECURITY FOR I=AITWFUL PERFORMANCE/LABOR & MATERIALS
CONSTRUCTION CASW DEPOSIT
PLAN CHECK & I NSPECTION FEE
SMOUNT ~ZS RECEIPTN
S
S
~ O
APPROVED FOR 155UANCE ~ r.! L 2' l O
For ngineer Date
Permit Expires 12 Monthr. After Date Of Issuance
..`
0511112009 13:27 4083541321 b1VSD PAGE 03104
G~NERAI» ERMIT ~ONDITI_dN5
1. A Construction Cash peposit is required. Charges will be made against this deposit ff thFrr, Is an emergency call-out, overtime inspection or when City
ordered barricading is required. Any such costs in exteSS of the deposit will be bti4ed to the Permittee.
2. A one•year malntenancr period and surety are required. Such period wilt begin an date of written acceptance bythe City.
3. Refund arthc cash deposit balance and refund or cancellation aathe Faithful Performance Surety will be initiated by the written acceptance of the work
by the City.
4. The Permittee must request in welting 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 hydrants, and water valves.
6. A Construction Traffic Control Plan and a Construction Schedule are required for all Lane closures, detours, and street cosures. This plan must be
reviewed and approved prior to any lane Closures.
7. A Construction Traffic Control Plan shalt conform to the Caltians Manual ofTraffic Controls for Construction and Maintenance work Zones, dated
1990, available at Caltrans_ Traffic control equipmem shall InciudeType 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 FCC or AC removals. All PCC removals shall be to the nearest scaremark and shalt be doweled to existing Improvements.
i t?. 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 stte. 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 materl?ts} against the cash deposit.
12. Compaction testing of subgradc, base rock, and asphalt concrete 6y Permittee is required unless otherwise stated by the City Engineer,
13. The Contractor or Permittee will have a supervisory representative available for contact an the project at all tomes during construction. Contractor or
Permittee shall provide a phone number at which they Can be tontaCted outside the hours of 8;00 a.m. to 4:00 p.m.
1 a, No storage of materials ar equipment will be allowed near the edge of pavement, the traveled way, or within the shoulderline which would create a
hazardous tonditlon to the public.
15. This permit shat{ not be construed as autheriiation for excavation and grading on private property adjacent to the work or any other work forwhich a
separate permit maybe required, nor does it rFlicve the Permittee of any obligation to obtain any other permit required bylaw.
1B. This permit does not release the Permittee from any liabllftles contained In other agreements or contracts wiCh the: City and any other public agenty-
17. This permit is not transferable. Work must be performed by the Permittee or hIs designated agent or Contractor as specified thereon.
19. Call back (eau out} due !o emeregencies regarding this permit shalt be at the current overtime rate with a three (3} hour minimum charge per
occurrence.
19. Pursuant to Chapter 14.07 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 shoo adhere lathe BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff
Pollution Prevention Program,
20. If the public interest requires a modlHcatlon of, or a departUYC from the plans and spedficati0ns, the City shah have the authority to require Or deprave
any modification er departure and to specify the manner in which the same is to be made far City-owned or maintained facilities.
21. Permitttee must provide advance notification to all parties that may be affected by the permh attivitiCS. Notlflcation shalt be reviewed bythe lily prior
to disirlbution and Include dates of work and a contact name and phone number.
Applicant shalt be responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions.
West Yb-1llcry SAni ~la~on Tlisaj~ic~~ ~.. ~'ia+da _ Monetary , M 11, Z~G9
Applicant bate:
SAnCP #~%p~Gl)i'IGS ~ /w{aMd~ f /1 ~ ~9. --
CentrdGtoT (Print Name) Date:
J:\FORM51TemplateSlEnCrod[hment Pcrmtts\EncroaChmCnt Permit STATIC form2.pdf
Rev. 3/08
05%11i'2009 13:27 40$3641321 irJl~'~D PAGE 04104
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05;''11!2009 13:27 408364121 WVSD PAGE 01104
San~~ahan
FACSIMILE TF~ANSMITTAL,
DATE: 1~'1 I- .2Gt?
TO: G~i pf ~ k~1j Lfr ~. a~ Pvylrc tli~rxs , FAX NO.: t~~~ 3~a- 0~~8
ATTENTION: ~' cd ftJghrdi
FXtOM: GUe~ !/al! ..~-ay,rir. ~ l~is~t'r'c~ .
SUB.TECT: ~Cnracy ~ m~f ~~' ~c r rya' /ire rc it Rf i -' r'
TO'N'AL WAGES 'X'~tANS1V11TTEA (including this cover sheet)
MESSAGE:
~arScd~
Plea issue vs cin c~~ogrhrneyr~ ~rmr~ ~r ~G sew rrai~aJi c
1"~pxri' art ~rd/+ a r a~ I.Z31 it Mier. c:~P
Th~,-,K~:
Gc~~,~ YaX ~u~a ~s~c~
(40~ .3 - 2~a -
100 EAST' SUNNYOA.KS AVENUE, CAMPBELL, CA 9500$
TELEPHONE (408) 37$2407 ~'AX {40$) 364-1821
>3-126