ENC2006-00045CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408)866-2150
Fax (408) 376-0958
' 'ROACHMENT PERMIT
(,_, working within the public
right-of-way)
Issued ~ 1 3.I ~ G ~'
Permit Expiration Date 5I3i !~~~
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Application Date ~ /3 I ~` ~''
Application Expiration Date 31 c~
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.)
A. Work address or tract #
Utility trench
B. Nature of work
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C. Attach four (4) copies of an engineered plan showing the location and extent of [he work, and four (4) copies of the preliminary Engineer's Estimate of work. The
plans shall show the relation of the proposed work [o existing surface and underground improvements. When approved by the City Engineer, said plan becomes a
part of this permit.
D. All work shall conform [o 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 before starting work. Notice
must be given to Public Works at l/east 24 hours before re/startinDg~a~ny work./ L ,
Name of Applicant_~~ //~ ~f~/, ~.e..~,T /rLir' Telephone - 7~ ~ .7 ~~ G l ~~
^En~ L /~ not name L , / `'~~
Address / ~ C y ~~/~tl~~.q~~ ~Q-~-/-- 24-HOUR EMERGENCY TELEPHONE NO.~~~ ~C7/~~~J
E-Mail Address ~~~5~ '~'~ ~~ ~' l`~~~I ' ~~'
Is this work being done by the property owners at their own residence? Yes f~lo
The ApplicanUPermittee 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 ApplicanUPermittee 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, shall be responsible for any and all damages
arising out of the condition of any private improvements in the public right-of-way.
'- (ApplicanC Permittee) (sign) Date
l 1~ ~ l /~ `3 -- 3 ~ ~.~
Contractor (Print Name Date
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 annroved by the Inspector nrior to cuttine.
V~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 Inspector.
_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 for Private Improvements in the Fublic Right-of-Way, which shall be
recorded.
_6. Public Notification Requirements:
7.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT N0.
PERMIT APPLICATION FEE $ ~-~- (~ ~ ~ Z
PLAN CHECK DEPOSIT $
SECURITY FOR FA11'HFUL PERFORMANCE/LABOR & MATERIALS $
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & INSPECTION FEE `_1 $ I~ ~ '
APPROVED FOR ISSUANCE ' ~- 3~3 )'l L~
For City Engineer Date
Permit Expires 12 Months After Date of Issuance
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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 of 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.
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 closures. This plan must be
reviewed and approved prior to any lane closures.
7. The 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 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 [he 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 he required, nor does it relieve the Permittee of any obligation to obtain any other permit required by law.
l f,. 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 emergencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence.
19. Pursuant to Chapter 14.02 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 shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff
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 [he manner in which the same is to be made for City-owned or maintained facilities.
21. Permittee must provide advance notification to all parties [hat may be affected by the permit activities. Notification shall be reviewed by 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 of and understand all of the above conditions.
Contractor
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(Print N me) Date
J\forms\pwperm
Rev. I 1 /9/05
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PUBLIC' :S DEPARTMENT RECEIPT
....dive Jdy 5, 2005
TO: City Clerk PUBLIC WORKS FILE NO.
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PROPERTY ADDRESS / G (%
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Reese eolkrt k mriPt fnr the fdlowfnR ninnies:
ACCT. - 1fPP2.1 .. _ _ .. .. AMO17M'
ENCROACHMENT PERMIT
4722 Applkatlon Fee ~ j _-,~
Nwt-UBlity Encroachment Pem4t (5275.00)
Minor Encroachment Permit<55,000 (S6L00)
R-1 First Permit (No Fee) cent (SI35.00)
Ut01ty Encroachment Perndt
ArterlaVCdketor Sweet IS530.00)
22113 Falihfd Performatta Security (FPS) (100% of ENGR.EST.) ~ •
2203 Irbor and Materials Security (100% tM ENGR. FSTJ IL
2203 Momtmentation Seturit f100%of ENGR.F3TJ
2203 Cash Deposit (4%of EoFr. Ecq(5500 miruS10,000 max)
d722 Plan CMck & Itupection Fee (Non-Utflily)
&tRr.Est. <S250J100 (1396 of ENGR.EST.)
2203 r. F6t. >5250,000 (Dc t S% of Fs r. Fat.IS30,000 min)••
d722 Utility <Sl6dJldo 4`'. "~
Midttnmt Charge l4r tucatlon (S10o.00)
ConddtslPfpeRttes up to S00 Feet (52.25M)
Above 500 Linear Feet (51.35/R)
Maohdes/VadWEtc. (St29.00/ea)
Pok Set/Removal IS125.OO/ea)
Street Tree 1'lanting/Itemoval (51-15.00)
'1A3 Ut10t > SI00,000 Actual Cast +211% rr
4760 Stop ConUlcerPerMt (5125.00)
4760 Protect Plans & Speclf{ntbts Ptotect No.
4760 Standard licatiarts & Ikta{k (Sl 515.50/Bk)
4760 Copka of &tElneedoR Ma ~ & Plato
Atriai Ro124"x36" (554.00)
Aerial Pdnl S l2" x Il" (f2200)
Ma and Rata 2d"x36" (50.25)
4722 Peaaltkx: Falure to restore Ik irt4rovemema f510D/Cakttder Ilay) fMart cr. x«.t t_N.atol
4722 Petdtka: Failure la correct uma(e conditions (S100/Cakrtdar Day)
4722 Work Wltbom PermlLS (d Tlmea Applicable Fee)
DEVELOPMENT
4722 Lot Line Adjustment (5900.011)
4722 Parcel Map (4 Lola or Leas) (53,400.00+S7Vkt)
4722 Fitul Traci Mao (5 or Morv t.ota) (S4,zao.W + f100/bU
Vacation of Publk Streets & Fysenems IS2,2ott.a0
Aasexament SeRreptlon or Reapportkntrettt
Flit Splil (5725.00)
F~ch Addlliowl Lot (SZ00.00)
Storm Drafnaae Area Fec IRr Acre (R-1 52,120.00)
(Mdti-Res 52.105.00)
(All Other S2,6504g1)
ParkWtd Ihdicatbn Fee (75 %/25 % Uwe Utton Cert. of Ocettttancr)
7'raRic Model
Trafilc Model
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NAME OF APPLICANT \\\\\ ///~V /`X` G~iC.~~
NAME OF PAYOR V~~ ~~ ~~~
ADDRESS e~ ~ f [ C.- ~! L~ 7/
••Actual Call Plus 20% Overhead iNen-Interco[ bearlrtR deposit)
TOTAL S ~1
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j:\f rrtac4rceipt tomt05-06 rcv.(J21/05
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WEST VALLEY SANITATION DISTRICT
SANTA CLARA COUNTY
100 E. Sunnyoaks Ave., Campbell, CA 95008
1408) 378-2407
LOCATION: ! :';-~,; ~, Y=
A.P.N. ~-f 1' .'' _ ~' '' /
-~~ ,~ _ r-
Sewer Location: Bk. Pg._~_
Tract Lot .3
Proj. Assort.
Address: '7 r r' ~'.' _.~# ~~ ~~.~r 7'.
Jurisdiction 1.Tr_'~~'%`'!:: a~- r'._~
BUILDING TYPE:
-~`~ Single Family
Condominium/Town Houses
Multiple Dwelling
Number of Units
Commercial
Industrial
Other Information: ~`~'<''' ~`;~i`'`-''%~
Change in Status:
Issue Date - ~ ` ey "~Y
FEES:
Acreage
Frontage
Service Advance
Processing
Other. ~` ~
Capacity
TOTAL
PERMTCNUMBEFE QN•. l~~~~~
$ -
! _.. ~
r ~::.
BUILDING SEWER CONNECTION:
Feet of Property
line feet from Main Sewer
and feet deep.
Connection to Main Sewer
Feet upstream from M.H.
Using ' ';~ . ~ r.:,~•' ~! '
BACKFLOW PROTECTION:
Field Check Required
Call District for foundation survey
Disposition; _
GO Zone RL ~_ ~ Device Required; Yes~No
~~ Type: - - .~ ,. ,,`;;~y f/.
INSTRUCTIONS: ..~sv-~
Street encroachment permit required from _ _ . ~~L3f~
a Permit invalid if not connected within 12 months of issue.
Do not connect until main sewer is accepted by District.
o Obtain a building or plumbing permit from the jurisdiction listed above.
WHITE -PERMIT /PINK -DISTRICT /YELLOW -JURISDICTION BUILDING INSPECTOR'S COPY /CARD -DISTRICT COPY
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