ENC2009-00067Jun. 1, 2+.109 ~;29RN1 P=~If;r, Gds dnd Elec'tr'ic Co. No.451f) P. 1
CITY Op CAAZI~$BLT~
DEPT. OPPUBLIC WORKS
7U North First St.
Campbell, CA 95a0$
(4as> ~a~-21so
Fax (408) 37G-0458
APFLICAT1pN -Application is
months if llre permit is not issued.
BNCROAGT~MENT PERMIT Permit No~~/~ ~-1 CCU ~
(for working within the publi ~ X•Ref. Idle
right-of way)
/ - ~ Application Date
Issued ~ ~ ` C ~ Application $xpiratian Date
/ ~~++ g
permit Pxpiration Date ~/ ~ APN 7' •
made for a Public Works Permit in accordance with Campbell Munieipat Code, 5ec[ion ] 1.04. (Application expires.in six {G)
catipn Pec is non~refundahle 1 t
A. Work address or tract # C~~ ~ ~ ~~~ n~
Utility trench location '~ (,~L f,r/
0. Nature of work ~ JUN 0 # 1009
C. Attach four (4) copies of an gins ed plan showing the laeation and extent of tlac work, and four (4) copies of the preliminary Engineer' ~ ~~$
plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City C3ngi QN
part of this permit.
L. Att work shall conform to the City of Campbell Standard Speeificstions and Details for Public Works Construction: the General Permit Conditions listed on the ~I
reverse side; and the Speeiat Provisions for this perntit, listed below. paitusc to abide by these condiuons one provisions may result in job shutdown and/or forfeiture
of Faithful Performance Sureties end cash deposilS. {See General Perntir condiuons ]and 2.) ~
E. '171c Conlrac[or moat have this permit and approved plans at the site and must notify the Public Works C]cpartment at lea t two days before starting work, Notic
must be ivcn to Pub ~ Works at least 2d hours befor tatti an work.
g •n1g y ^~l,,
Name of A lican
PA '` y `t ~ .Telephone _ ~~• ~~~_ r ~'-"~~
p~ (prin[namo} ,
Address 24-HOUR EMHRG$NCY TEL&PC~ONE N0. ~ (~fY,~~
E-Mail Address _ J Yti°~~ / 1Y 8 ~
Is this work being done by the praperry o r rs at their own residency;? Yes w No l
+~ ~F
The ApplicanUPcrmiuee hereby ugrees by affixing their signamrc to this permit to hold the City of Campbell, its officers, agents and employees free, safe an
from any claim or demand far damages resulting from the work covered by this permit.
The ApplicanUPermiucc hereby acknowledges that they have read and understand both the front and back of this pe 't, and they will Inform their contractor(s) of the
information, Applicant is advised that upon issuance of this permit, p owner, or property o ucc ssors, 3ha11 be responsible for any and all damages
arising out of the condi41tio of any~y ate im rovcments in the public t-of-wa .
Accepted ~~V~i I.,J~ Ol'~ ~(/
(ApplicaatPerminec) gn) C)at
Conuaetor (Print Name)
Date
_l. Streat shall not be open cut for underground installations. Minimum cu[s m~ 6c aAowed for connections or exploration holes. Such cuts II]flY
be sp~jfically aouroved by the lnsneotol; prior to cuttine,
_2. pavement may be cut for underground installations end must be restored in accordance with the Standard I)ctails 7lrench Restoration Method
"`A",unless otherwise approved by Inspector.
_3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of tha cur sheets sent to the public Works Department
before starting work.
_,.4. Pcr Section 42.15 of the t3ovemment Codcthis permit is not valid for excavations until Underground Service Alert (USA) has been notified end
the inquiry idcnti6cauon numbar has been entered hereon. USA Phone 1-$00-227-2G00. USA TICI{ET NO.
_5. Prior to any work, the property owner~shelt execute an Agreamcnt for Private improvements in the Public Right-of-Way, which shah be
recorded. ,
_6~ Public N teation Requirements:
~7-
S~l,l@LIC WORKS FEE SCr-Ti3DUI~ FOR CURRENT P$RS AMOUNT ~CE/IP}yT N0.
PERMIT APPLIGATCON FE$ g 3Z.5 t.~
PLAN CHECK DEPOSIT g
SECURITY FOR FAITHFUL PERFORMANCPJI„ABOR ~ MATERIALS ~~
CONSTRUCTIQN CASH DEPOSIT ~
PLAN CHECK dt fN$Pl~CTCON FAE ~ /~,G?
APPROVED FOk ISSUANCE ~- ~D/~fG
Por City 13nginccc Datc
Pctmit Expires l2 Monlhs After Date of Iasuancc
-~ 1~ ~~ ~ rr^`.~
,~~h ~
.!an. 1, ~OG9 8.~GAM f'--if'~~, Gas and ElFetrlc Co, No,4~10 F'. 2
GENERAL 1'ERl'VIIT CONDITTQNS
1. a Construction Cash Deposit is required. Charges will be made against this deposit if that: is an emergency cali•out, ovcrtfmi; inspection or when City
ordered barricading is required. Any such costs in execs of the deposit will be bitted to the Putnittee.
2. A ono-year maintenance period and~suraty 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 Fnithful Performance Surety Will be initia[td by the wri[Yen acceptance of the work
by Ehc Crty.
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 Pernuttcc,
5. ~ Maintain sofa pedestrian and vehicular crossings and free access [o private driveways, bus stops, fire hydrants and water valves-
6. A Construction Traffic Control plan and a Construction Schedule are required far aA lane closures, detours and sneer cloaures~ This plan moat be
reviewed and approved prior to any lane closures.
7- The Construction 'IYaffrc Control plan shall conform to the Caltrans Manual of Trafftc Controls for Construction and Maintenance Work Zones, dated
199Q, available at Caivans. Traffic control equipment shalt include Type II flashing arrow signs if required,
8. Replace as directed by the City Engineer any damaged or zemoved improvements in accordance with City Standards and Specifications al the sole
expense of the Perrpjttee.
9. Saweut for all FCC or AC removals, All PCC removals shall be w Hearts[ scoremark and shall bo doweled to existing improvements.
]d, 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 ovenimc rate.
11. Adequate signing and barricading is rcqu-[red on the job site. Failure to provide such signing and bamcading may result in the City's providing signing
and barricades and charging the cost (including all labor and materials) against the cash depoait.
12. Compaction testing of subgradc, base ruck, and asphalt concrete by PermittcL is required unless Hthcrwise stated by the City Engineer.
I3. The Contractor or Pcrmittee will have a supervisory representative available for contact on the project at slt rimes during construction, Contractor or
Ferrniecc shall provide a phone number at Which they can be Contacted outside the hours of 8;U0 a.m. to 4:60 p.m.
IA- No storage of materials or equipment will be allowed near the edge of pavement, the traveled way, or within the shoulder[inc which would create e
hazardous condition to the publc.
lS. This permit shall not be Construed as authorization for excavation and grading on private property adjacent to the work or any alhcr work for which a
separate permit may bo required, nor does it rclfeve the Pcrmluee of any obligation [o obtain any other permit required by law.
10. This per[nil does not release the Penniilee from any liabileries contained in other agreements or contracts with the City and any other public agency.
17. This permit is not trsnsferablc, Wark must be perfomrcd by the 1'ermi[tce or his designated agent or contractor as specified thereon.
l8, Call bpct€ (Call out) due to emergencies regarding this permit shall be at the current overtime rare with a three (3) hour minimum charge per oceuvence.
19. Pursuant to Chapter 1b-02 of the Campbell Municipal Caflc, applicant shall not cause to be discharged any material into the municipal storm drain system
other Ihan storm, water. Applicant shall adhere to the BHST MAI~TAGEMENT I'RACTICI3S established by the Santa Clara Valley urban Runoff
Pollution Prevention Program.
2U. ff the public interest requires a modification of, or a departure from, the plans and specifications, the City shall have the sutltorily to require or approve
any modification or departure and to specify the manner in which rho lama is to be made for Cityawned or mainlainCd facilities.
21. Pcrmiltee must provide advance notification to all parties that maybe affected by the permit activities. hiouficaNon shall ba reviewed by City prior to
dislributlon and include dates of work and a contact name and phone number.
Applicant shall bo responsible for enauriag that all [host providing services under the applicant ere aware of and understand a!1 of the about conflitions,
f
~1 ~
Dale
Applicant
Contractor (Print Namej - Date
nformslpwperm
Rev. 11/9/65.