ENC2009-00071PrinT Form
CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No~ 2lJ d~ . V
DEPT. OF PUBLIC WORKS (for working within the public X-Ref. File
70 North First Street right-of-way) Application Date ~
Campbell, CA 95008 ~~ `/0 4 Application Expiration D to
Ph. (408) 866-2750 Issued (( l APN ~~k'~Q~=T
Fx. (408) 376-0958 G r~G ~ O
Permit Expiration Date
APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six
(6) months if the permit is not issued. Application Fee is non-refundable.)
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A, Work Address or Tract No.: / / ha ~. ~~5~,.~ ~G _ /; Q ~ ~1'~
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Utility Trench Location: ~
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B. Nature of Work: ^"' ~ .~ ~.
~/ 2L .S~iQY/(~ fiU,31 Au~/rC~N A"~ $'>E~' 1/~ Gam" Ll/®~fJ~
C. Attach four (4) copies of an engineered plan 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 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 befo rn Y 0
starting work. Notice must be given to Public Works at least 24 hours before restarting any work. ~j~~ s.~ ~ ~
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Name of Applicant: San Jose Water Company - Ed Mello, P.E. Telephone: 408-279-7847 ~~ .~.._ C1
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Address: 1265 S. Bascom Avenue, San Jose, CA. 95128 ~ ~ ~ Z
E-Mail Address: IEd mello@sjwater.com 24-HOUR EMERGENCY PHONE NUMBER: 408-279-7900 ~ 4. ~
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 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 permit, property owner, or property owner's successors, shat! be
any and all damages arising out of the condition of an private improv
responsible for
em
e
n
ts in the public right-of-way.
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Accepted;~~ ~ off. lt~f~'?r-~Q ~~_f~9"~~ / ~ CI ~/N ~~ d
(Applicant Permittee) (sign) s~l - ~~ ,~ Cate
(Contractor) (Print Name) ~ / D to
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 be
specifically aRnroved by the Inspector prior to cutting.
2. 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 of the cut sheets sentto 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 and
the inquiry identification number has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET N0.
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
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & INSPECl'ION FEE
APPROVED FOR ISSUANCE
;~ `,A;~ l,L~r~1
AMOUNT
s 5~ 5
5
S
5
RECEIPT Nj2~
~16 ~o
Permit Expires 12 Months After Date of Issuance
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6E~~21r2669 i3:~i
468-279-7889
SJW ENGINEERING
GE~fERALPERMIT CONDITtdNS
PAGE 62162
1. A Cf:~nStnlCti0n Cash beposit Is.required_ Charges wlll.he made againstthls deposit Ifthere IS an emergenrycall-out, overdme inspection orwhen pry
ordcared be~ricading is required. Any such costF In excess of the deposit wilt be billed to the Perrnfttee,
2. A one-~~•ear maintenance period and surety are required. Such period wlEi begin on date of written acceptance by the Clty. ..
3, Refuntl~ or the Cash deposit balance and refund accancellatlon ofthe Fakhfvt PerformanCE Surety will be Ihitfated bythe written acceptance ofthe work
by the ;~ity. '
4. The'ermlttee must request in writing a final Inspedlon and acceptance Df the work upon completion, Atceptance by the Clty wilt be made In wdting
to.the f~ermlrtee.
•5.- --Malr~+tarn-safp~ped9strian•andvehicular~rossings~andfreea[CesstoRrl+~atedrlveways~bus•staps,fire•hydrants,$nd-water-vahres,--•-•-•
4. A Ccros;:n.itYlon TrafFc Control Plan and a ConstnaCNon Schedule are required far all lane closures, detours, and street closures. This plan must bF
revh!~wr.,d and approved priorto any lane closures.
7. A tcross roction 7rafffGContro! Plan shall conform to the Coltrane Manual ofTraffic Controls for Construction and Maintenance Work Zones, dated
1.99Cb, a~raiiable at Coltrane. Trafflcconirol equipment shall kncludeType II flashing arrow signs tfrequired. .
8. RepLaca ~ as directed bythe fifty Engineer any damaged or removed Improvements in•acsordarice with. City Stahdards and SpeciflCatfans at the sole
expf~nse.ofthe Permittee.
9. Sawr,;ut for all PCC or AC removals, Ali PCC removals shall he#o the nearest scoremark and shall be doweled to existing'imprrnrements:
10, Prior approval of Inspector is required for any work done after normal working hours, on weekends ar holidays and may require reimbursement bf
Insparctl on costs at the current avertlm~2 rate.
1 t. Adeclunre signing and barneading Is required on the }pb site. Failure to provide such signing and batrlcadktg may result In the City's providing signing
and harrlcades and charging the cost (Including all labor and materials) againar the cash deposit
12. Compa~ttioli testing of subgrade, base rock, and asphalt concrete by Pemtittee is tequired.unless otherwise stated by the City.i;nginCCr,
73. , The [:or~tracter or Permlrtee will have a supervisory representaelve available for contact on the protect at all times during con^tntctlon, Contractor ar
Pem~~ltt~ee shalt provide a phone number at which they Gan b2 tontatted outside the hours of 5;00 A.m. to4:40 p:m.
14: No storage of materials or equipment wiR be allowed near the edge of pavement, the traveled way, orwfthin the shauldedlne which would curate a
haze"dour tohditlon to the publlt.
1 S. This permit she II not he construed as authorizatlan for excavation and grading on private property adJacent to the work or any otherwprk forwhlch a
separat~t permit maybe required, nor does Itrelteve the.Permlttee ofany obllgatlon to obtain any other permit required by law,
16. This ',permit does not release the Remtttt2e from any IEabihYles Contained In other agreements or contracts with the City ahd.ahy other publlt agenry,
17. This ~aermlt is nottransferable. Wprk must be pertormed by the Pennirtee or his designated agent or r:entmctor asspetlfied thereon,
1 B. Call k'~ack Gall out) due to emeregendes regarding this permlL shaA be atthe current overtime rate with a three (3}hour minimum charge per
occw~re+tce,
19. Pursr,iantto Chaptei g4AZ of the Campbell Munlapal code, apptlCant shall not cause to be discharged any ma4erlat taco the munktpai storcn drain
systeTt nther than storm water. Applicant shall adhere to the 61s5T MANAGEMENT PRACTICES established k>y the Santa Clara Valley Urban Runoff
Pohuaon Prevention Program,
20, If the pubiirlnterest requires o modification of, or a departutre from the.plans and~speclflcatlons, the; iGNty shall have.the authority to require or approve
any rnorliRcatlon ar departure and to specify the manner In which the same isto be made for i:lty-owned or marmained factlltles.
21. Permittl•eemust provide advance nouficatlon to all partlos that may be affected by the permit activities. Notification shall be reviewed bythe.[tiy prior
to dls~trthutlon and include dates of work end a rontactname and phone number.
Applirant r:httl) be responslbie forensuring that alt those prorolding sen+kes underthe,appllcantere aware and understand all of the above eond'Nons.
Applicant ~ ~
Contractor (PrlntName) I
bptC:
pate:
1:Relnelw~bsltar\Lsnd Dev FormslEncroachment Permit S'CATtC form~:pdf f
Rev. (t1/9Jt?5)