ENC2009-00080CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408)866-2150
Fax (408) 376-0958
Perm ,~~~ ^~ ~ ~~
X-Ref. rile
Application Date ~' ~ ~~
Application Expiration Date
APPLICATION -Application is hereby made for a Pubhc 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 nolnA-refundable{.~)j (~ P n [/
A. Work address or tract # ~ ~ ~ ~- ~v' ~ P "' ~ ~ ~ ~ ` ' ' " ~ ~V ~~7 ~3
Utility trench lo~c+ation Tim' ,'~ `~lA 7 /fv y ~~'j'~-~// ~ /C~ ~ ~~~j {may` / !Z~`'l/l/t~ "/ ~~ie.L ~^
B. Nature of work` ~ ~ ~ ~ ~ yr ~ ~ ~'/' ` ~0~~ ~ ( ~ ~~r 1 `` ~ ~ ~' , , l ~ r
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 [his 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 before starting work. Notice
must be given to Public Works at least 24 hours before restarting any work.
,.~~..,o ,.r n.,.,t:,..,.,. / ~ ~ ~ 1 ~ ! ~ ~ ~ \ l~ Lr I v/ Telephone - ` V D ~~~ - ~ ! "1 1 t
Address _` 0 OQ ~ ~
E-Mail Address '\
U -'
W ~'
safe i~iarmless
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
from any claim or demand for damages resulting from the work covered by this permit.
The ApplicanUPermittee hereby acknowledges that they have read and understand hoth the front an ack of
information. Applicant is advised that upon issuance of this permit, propery own r, or proper ow s
arising out of the condition of any private improvements in the public right-of-way
and they will inform their contractor(s) of the
shall be responsible For any and all damages
~~ ~~~ ~
Date
Conttactor (Print Name)
Date
SPECIAL PROVISIONS
_1. Street shall not be open cut for underground installations. Minimum cuts ~ be allowed for connections or exploration holes. Such cuts
/ be specifically approved 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 lnspector.
_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 and
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 fcr Private Improvements in the Public night-of-`1.`ay, 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 6: INSPECTION FEE ,-~
APPROVED FOR
AMOUNT
~ (000
$~~
7~2 ~/c°
E. .cOACHMENT PERMIT
(for working within the public
right-of-way)
Issued
Permit Expiration Date ~~ ~~
~~
namek~i ~ P
24-HOUR EMERGENCY TELEPHONE NO-HOUR EMERGENCY TELEPHONE NO /
(Applicant Permittee) (sign)
For City Engineer
Permit Expires 12 Months After Date of Issuance
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RECEIPT N0.
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Jul, 24. 2009a 9;14RN1ze~~~P
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flc Gas and Electric Co,~ wuKKS No, 0776 P. 2 ~1~~1
GENEIt.41V pEIrMIT CONriITIC)NS
.' Ali°' ;'
1 ~', 1
A Cens[i9tdtlt~rl•Casit`l~cheait Is required, Charga~ wklt be made ngnlnt:t tkds deposit If thmv la an enletRe[tay aall•ou6 ovrntimt: Inapoardon qr when City
ordered b¢1TiC.rdin~is roquircd..Any.sltclt"cdscs in erecse of the deponir wiU be billed to the Perminee,
A one-year malntonnnaa pCClo(i and surety arc requited, Such perlotl will begin on date tsf written acceptnacc by the City.
ReNnd of tiro sash depttall balnnee and rafand ar eettoellndon• of rho FatthfLl Perfnrmnnc4 Surory w{kl bo fniti¢tad 1}y ebo written aeceputttae of the work
by the City. ~ , ~ ~ •, ,
The Pcrmiuce must rcquast in vmLin~ a finaC insgcttiari and aceeptaacc aF the work upon co+t+pletion, Acceptance by rho City wil) be m.~cle kn wddng [o
.. ,
the PerrstinCC. ~ r _
Maintain sofa pedestrl4~n pod vGalttllar crossings and free aci:ess ro pr{vrt[e drtveways, bus Mops, ire hydrants inn water valves.,
A Constntettnn 1'rafllc Contt8l Pl¢n and ¢ Corut[uetlon Sahodule Are roqulred for ail lnno alosuCOS, rlotours and Atroet aloAUrea, Th1s plan must be
rgvlowcd and :ippravcd prior to r<ny lane cir>cares~ ,
The Cnnetructlon TrafFic Contrel Plan sFfaN conform m the Caltran~ Manual of 'CmCFic Ccnvols for Cenetruetion Ind Mointcnance Work 7.nnes. doled
1990. available ,t Caltnns- 'frafflt conirol equipment shall incl~rde Type tI flaahino grow aloes if required.
Rcplneo na dktcnrcd by the Glty 6nglnccr any Oam¢ged oC removed Irnprttveman[5 to accordance with City 5rnnddrds and 5pcciGcatiana or the sole
cxpanna of the hcrenltttc,
Snwcut Cor all PCL or,AC rgmovals. Alt PCC removals shall ho to nearostscarerttark and shall be doweled to existing impttrvt:ments.
Prier approval of {nspeewr Is required for any worl: done ai'tc;• natmt) ~wotking hbur~, nn weekends or holklays and may require reimHuraernent of
Inxpcction coact at rho torrent ovotdmo rnto~ .. . , ~ -
Adcquato signing pad harritndinp is reyuircd en the jab alto. F1iWrc to provide such signing and barticnd;ng may requit in tlrt; City's providing sl4nlna
and barricades and charging the cast Including all lobar and materials) aga;aat the cash deposit. - ~ •
1 Z. Campaotiop tcsdng of sub@nde, hose rook, and asphalt cnnerato by Permltt,w Va required unless olharwise stored by the Clty Engineer.
13, The t"nmractor or Pcrmlrtcc will hove 1 supervisory rcpraaentatlve xvailable for conceal on lha projaoi nt itll Ilrnae rioting Conattltrtlon, Cantmator cr
Pcrmlttee shall provide a phone number at which they can be rnntactad outside the hottra of R:00 a.m. to 4;00 p.m.
t4. Nn sroraga of matapnln nr aynipment wiU ba nllnwad Haar thts cdga o! psvemcni, the traveled way, pr within the shoulderline which would create a
h¢zardova contlltl~n t0 tiro publla,
l3, ThiK perrttit shntl nat.be construed as a,uhorl~tion for oxeavation and.rrading on private properly adjeCant ro thti,work trr any Mher wofk Car whlah a
Sepnralc permit mnybc required, bor dots it rclicvc~lhe'P.ermil.tee Of any obligutlon to obtuln'any other permit reyuirctl by htw,
I G. '11r1s parrrtit tloca oat rolmasc rho Permitter: from 4ey linhikitiaa contnincd in onc~r oFreetnents or Contracts with the Clty zed any other public ngcncy
17. This permit ig nor trnnsicrrble. \Vork muvt he performed by the Pcrmirtoa tit his designnrcd ester ar Cantmetor as sprckficd thertot+•
t g. C¢I1 back (call auq duo to cmergeneiC.S rcFardfng this perrt+ft shah.bc at the current overtime rpec with a three {3) hour minimum charge per occurrence.
19, Pursuant to Clrnprer 14,02 of the C¢n1pbCll Munlclpal Gnde. upplicnnt obeli not cnuRO to b8 dl8ahurgod ony nt~tari¢1 lento the municipal Storm drriq.system
other Bran 4torrrl tvhtcr. Appllennl shall ndhnra to the EfjST MANAg6M8N'C PRACTICES CBlnbllehod by thm Sanq Glnm volley Urban Runoff
7ohutian ['revcnrion Proimrm.
b
xn. if the public inmreat requires a ntodifieation of, or p departure ffoni, the plans and Specifications, the Cily shall hove the isurhbrity to require M appravr
any peerA{f+callon orneparlura and [o specify the manner In Whlah lho sgrnc is In be made for City-owged or maint:tlned fatili[kes.
xl , Pcrmlttcc must ptovido advance notlilcadon [o :+4 parries that[ ha nffcated by the trait aCtlvkttaa• Nodfkantion aha11 ba rovtowod by City prior to
distribution :tad include Cares or' wort: and n enntaet narnc and pt member.
Applicant shall be rdsponakhla for ensuring that all d e tOVirlipg a rvi CS the gp><' ant ar wire pf and undClSrarrd all df the about candlrions,
~~~ ~~~
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Applicnnl Dntc
. Contractor (Print Natno) •. DCte
nfnrm~tpwpertn RECEIVED
Rov, 1119109
PUBLIC WORKS
ADMINISTRATION
PG&E Permit Sketch for: City of Campbell
Address:275 e. Campbell Ave.
Nature of Work: Abandon Gas Service at Main
Surface: Asphalt Cut in Street Excavation size: 4' x 4' x 4'
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