ENC2004-00124CITY OF CANLPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 9008
(x08)866-2150
Fax (408)376-0958
___ ENCROACHMENT PERi~tIT
(for working within. the public ---
righ[-of-way)
Issued ~f' -
Permit Expiration Date ~,
Permit No~"~L ~~ ~ `V~ ~ ~~ -
X-Ref. File
Application Dace
Applica[ion'Expiration Date + "7
APN ~~~~'~ d.~p ~? CO
`~: _' ~f_
APPLICATION - Applicadoa is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Applic~expiY~ in '~
12 months if the permit is not issued. Applicarioh Fee is non-refundable.) t,,q
A. Work address or tract #_- ! ,n .~ ~ ~E' c~ ~ u ~ 'y"~ ~ ~~. ~,~ ~ ` i ~ ~,'
0. ^~_ ~ g
Utility trench location ~ k ~ ~ ~O
nn 1 ' ~Q
B. Nature of work II, tkr~ ~/ ~ Q ,,,r L ~ r7/! e _f ~ ;.c1c, ..~ ~~ r•~'1..a / C-! ,...~ ,,,
C. Attach four (4) copies of an engineered plan showing the location and extent of the work, and four (4) copies of the preliminary Eno neer'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, fisted 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 [he Public Works Department at least two days before starting work.
Notice must be given to Public Works at11leas[ 24 hours before restar/tin fg any work. -
Name of Applicant (~ C S "I- 1 L n'bPS V O (I ~p~ Telephone ~~~ ~S" 9 ! g - Gp/
(P )
Address ~~1 b~ ~ - jC~'1-` g ~ ~S/^~~1~ `o print n~ S// 3 24-HOUR EMERGENCY TELEPHONE NO.
E-Mail Address ~ C rns S _ Vo //mar Fc~ C e btu , C o +r. c a o "~'7 ~ v m~
Is this work being done by the property owners at their own residence? Yes _J~No
The ApplicanbPetminee hereby agrees 6y 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 [he 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~trising out of the condition of any private improvements in the public right-of-way.
,,\\ ~ . n
(Applicant Permittee) (sign)
Contractor (Print Name) Dace
SPECIAL PROVISIONS
_l. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may
. / be specifically approved by the Inspector prior to cutting.
Y 2. Pavement may be cu[ for underground installations and must be restored in accordance with the Utility Restoration Standard Details Method
"A" Backfill, 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 [his permit is not valid far cxcavadons 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.
_~. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shallbe
r~jcord~ed. / / (~ 1
~6• 1"~~l~IrarP 011,1 l~us-4~1a0~ 1ti ~,,,..1,
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT N0.
PERMIT APPLICATION FEE ~\~1 [,'1 S ''L'7C>
PLAN CHECK DEPOSIT
$~ .
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS ~~{ g
CONSTRUCTION CASH DEPOSIT $
PLAN CHECK & INSPECTION FEE $ U
APPROVED FOR ISSUANCE Q. W` ~ 'Z, p
Far City Engineer Date
Permit Expires I ~ Months Aftei• Date of Issuance
1:\forms\pwperm
Revised 1.20.04
--------- -
GENERAL PERNIIT CONDITIONS
1. A Consvuction Cash Deposit is required. Charges will be made against Chis deposit if there is an emergency call-o$t, overtime inspection or
when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permiuee.
2. A one-year maintenance period and surety are required. Such period will begin on dace of written acceptance by the City.
3. Refund of the cash deposit balance and refund or cancellation of the Faithful Performance Surety will 6e initiated by the written acceptance of the
work by the Ciry.
4. The Permittee must request in writing a Etna( 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 wale: valves.
6. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures, detours and sweet closures. This plan must 6e
reviewed and approved prior to any lane closures.
7. The Construction Traffic Convol Plan shall conform to the Calvans Manual of Traffic Convols for Consvuction and Maintenance Work Zones,
dated 1990, available at Caltrans. Traffic convol equipment shall include Type Il 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 Per-mittee.
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 bamcades and charging the cost (including all labor and materials) against the cash deposit.
12. Compaction testing of suhgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer.
l3. The Convactor or Permrittee will have a supervisory representative available for contact on the project at all times during construction.
Contractor or Pemtittee 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 vaveled way, or within the shoulderline which would create
a hazardous condition to the public.
l5. 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 be required, nor does it relieve the Petirtittee of any obligation to obtain any other permit required by law.
16. 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 [his 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 [he 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 the manner in which the'same is to be made for City-owned or maintained facilities.
Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above conditions. __
APP
~D~`~y-
Contractor (Print Name) Date
J:\forms\pwperm
Revised 1.20.04
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