ENC2006-00082CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408)866-2150
Fax (408) 376-0958
Pet. to ~~ ~~~ ~~~° - C7C1C~ ~.~~
X-Ret. File
Application Date `~ ~ O~
Application/E~xpGiration Date ~/ .~
APN ~ lJ J ~ ~ I '- ~ (~ S
ROACHMENT PERMIT
(tor working within the public
right-of-way)
Issued S~~E
Permit Expiration Date 5 2'' V(ca
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. Applic7ation Fee is non-refundable.)
A. Work address or tract # 2/~~`~ `^ ~J ~ ~~ ~ ~ ~~ ~~°
Utility trench location /~-'s'`t/~r ~'tJt'~---.
N
B. Nature of work ~ c~~~~c,..-ti1.~
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 before starting work. Notice
must be given to Public Works at least 24 hours before restarting any work. // ~~ /_
Name of Applicant ~i~!/rte -~t/i9-iC,~rGJ Telephone ~~~'~~ (L~f'~~ ~~ ~ Y'
(print me} ,~/ ~OS~
Address~~. ~J ~~~,,•, J°"tJa~ '~~ +(!) 24-HOUR EMERGENCY TELEPHONE NO ~UZQ~P
~~_~~ h-t.-L-, . Ci4
E-Mail Address - ~ (~~
Is this work being done by the property owners at their own residence? Yes ~No
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 ApplicandP ~rcitteirfl-~tsy-aclrn ead and understand both the front and back of this permit, and they will inform their contractor(s) of the
informatio Applicant is advised upon iss e o t ~s it, property owner, or property owner's successors, shall be responsible for any and all damages
arising o t of the c ~ ition of an rivate impr vemen s in the p Iic right-of-wa}M,
(Applicant Permittee) (sign)
Date
~L ~~>~
Contractor (Print Name) Date
_l. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may
be specificall~pnroved 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 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 properly owner shall execute an Agreement for Private Improvements in the Public Fight-of-VJay, which shall be
recorded.
_6. Public Notification Requirements:
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MA
CONSTRUCTION CASH DEPOSIT ~
PLAN CHECK & INSPECTION FEE r`
APPROVED FOR ISSUANCE `~Z"
For City Engineer Date
Permit Expires ] 2 Months After Date of Issuance
AMOUNT RECEIPT NO.
,$
l~ ~~ $
/Z~~GE_
WEST VALLEY 3ANITAT#QN DISTRICT OF ~,gN~f~ @~LA~A ~6'tl~~% ''\~~v~ ~„~~~ ~~' ~/
r ~~ l7
PUBLIC \, .{S DEPARTMENT RECEIPT
Effective JWy 5, 2005 ~/ /~ ~/q J~ //, ~f,I~~ ~X^' 7 -
TO: City Clerk PUBLIC WORKS FILE NO. /""'~J, ~V~(J ~ ~" `•" `t-J a ~' `-'~~r> AC's v
PROPERTY ADDRESS ~'Y' ~ "~ ~j~7 1j~' ~f.'Yt-E-GJ.
flease colkd & receipt for [he fo8owfna moNes: -f
ACCT. -ITEM AMOUNT
ENCROACHMENT PERMIT
4722 Appllcnlon Fee
Non•Ulllity Encroachment Permit (5275.00)
Minor Encroachment Permit < 55,000 (561.00)
R•1 First Permit (No Fee) Subsequent (5135.00)
Utllily Enctvachmenl PerMl
ArverlaVColleetor Street (5530.00)
Residential StreeVOlher Areas (5291.00)
2203 Plan Check De t 2% of Wear's Estimate (5500 tNn) +
2203 Faithful Performance Security (FPS) (100% of ENGR.FSTJ
2103 Inhor arW MakriWs Security f100%of ENGR. EST.)
Plan Check & Ittspection Fe! (Non•Utility)
Engr.Fat. < 5250,000 (13% of ENGR.FSf J
Eder. Est. >5250.000 (Deoasit S% of Ever. FsY./530.000 mini+•
CandWlslPipelines up to S00 Feet (S2SSA't)
Above 500 L{near Feet (51.35M)
MAnIgIGiIVaWtslElc. (5125.00%A)
Pok SeURemovAl (5115.00/!8)
Street Tree flantlnR/Rerroval (5135.00)
> 5100,000 Actual Cost + 20% ••
e Conlafner Permit (f125.00)
Aerl81 Rot Zd" x J6" (554.00)
Atrial Print 6 1/2" x 11" (522.00)
Maps and Plam 2d"x36" (58.25)
4722 Penalties: Failure to restore public im0rovemenLs (5100/Cakndar Uav) (x+.al cw. s.cu.uola)
DEVELOPMENT
19rce1 Map (4 Lots or Lest) (S3,4W.W +575AO1)
Final Tract Map (5 or More InLS) (54,200.011 + 5100/lot)
Certifkak of Compliance 5630.00)
Certifkate of Correction (5400.00)
Notary Fee (per sipwlurc) (SI0.00)
VatNbn of Publk Streets & Easemenlc (52,2x0.00)
Assexwrcnt Segrcgatbn or Reapportbnment
First Split
(5725.00)
Each Additional Lot (5200.00)
Storm Drainage Area Fee Per Acre (R-i 52,120.00)
(MWti•Res 52,385.00)
IAII Other 52.650.001
Imersroctbn Turn Counts
Inlerseclbn Turn CouWs
Tralik Model (1
doe INormation
TOTAL
OF APPLICANT
ME OF PAYOR
PHONE
••Acttwl Cost Ras ZO% Overhead jNon• ~ bearing de it)
FOR ~.: ~ ~ -
CITY CLERK RECEID' Y
ONLY
Uwe. - VVV
+For Nan CheckaM Cash Deprarti rind yelbw' eopyb Flwance. _
j:\formstreceipt frnm 05-06 rev.621/05
PUBLIC W .6 DEPARTMENT RECEIPT
F1feMive3dy 5.10115
City Ckrk
PUBLIC WORKS FILE NO. -7~~•~ ~ ~/
~~~ G.C/~•~(a • ~ V'4} ~ ' ... `~
PROPERTY ADDRESS ~~
~' U~.) y-•wh(~.Ci~
Pleaec cdlect & receipt for the fslfowltt0 moNes:
ROACHMENT PRRMIT
4722 ApplkNbn Fee
Non•UWNy Eoctralchmeot Perntlt (5275.00)
Mlmr Rtteroaclrtlent Permit a 55.000 (S4t.00)
R•1 Fltxl Pertdt (No Fa) t fS135.00)
Utl1It Etteroachmmt 14rmlt
ArkrWlCa0eelor Street (5530.00)
ReddenWlStreeUOther Areas (5291.00)
2103 1'W Cheek t 2%af rk Fitfnmte (LS00 mht)
2103 FaNlda114rforomeee Secant (FPS) (100%NlSNGR.ESC.)
2103 Ober ml MNerWsSemit (100%atENCR. FSTJ
2103 Motortteatatfao 6ecorlt (1101%of ENCR•FSI'.)
2203 Cosh De t (4% sf Expr. Fit)(SSW mhJf10,00D max)
Plan Cheek & laspecllmt Fee (Non-UWfly)
4722 &ytr.Fat.<S2S0,000 fl3%ef ENOR.EST.)
C~
Q
;J
I
J
~°' s
MWmam ClrrRe Per I.araUon (f100.00)
CaadaltafPlpeltaes aP m 500 Feet (f2.2.SIR)
Above 5001Joear Feet (S1JSAt)
MndtakxlVttdWEtc. (SI25AOlea)
PNe 6eNRemord (5125.OOlea)
Street Tree ~F/Remowl (5135.00)
SI00.000 AMUaI Cast + 20% ~~
Slora0e Ceauioer Permit
C'- C:.J Ci .:J :.J f:J
C" ti) ••~ra CV IMF. Ct:! 1 ti7
Crr~. .~. +r+ .r+ +~+ I
CSI .J .-y I C.,J.
C...J iii I 'µ} M
f~,l a e 1
i
M t:J 1 Li `1 lC~ i:r+
.J ~: I Liz .-•1 V J
tJ.I ^r~ ..,
.L _T_ ., Cs r'i
I.r~ w - }-.. rte.
C.J H +'y~ ~^'. C:'1 L_ZI 4'2'1 LS:1 GZI :'1
M
' •- [J tti t'r." }..... f 1, I~J f fj I:X x ~ != 1
.r CC:1 ~+~5 !--r (_5 iY.. s:C 'Y: 'i': f l L.7 t=ip
L.J - C...: f a C3J !.,J L',J Cwl C~% LL! LJ_1 '"' '"`
L.. l`4. }•... 4'L !_~! LA.1 iJJ LJJ i1J f„} (..^! }"` '-••
Tra0k Makl
Tra0k Model
TOTAL
PHONE
Fox
clTV c1.ERK
ONLY
j:VormaVicei}x farm OS-(16 m•.6/21A5
--~,.t~.,p..~.~e,.st.E.,~- ,~~,.~,.~~TS.;~.z.. .~. ~-,-•-- .:.._ -~.°~.--*, , .; rr...-.-.--:_.-.+.~_ ~..., - - - „~--~-- ~ i« - .,.>~.a,:m-~s~ ;-.: ~.v.~'r.~:ra^-L °s'
_: T r
rSEWERCONNE~TlON
WEST VALLEY SANITATION DISTRICT PERMIT NUMBER ~ ~.<
SANTA CLARA COUNTY
100 E: Sunnyoaks Ave., Campbell, CA 95008
(408) 378-2407
LOCATION:
A.P.N..~.ts~ ~ ~'^' 0~~.
Sewer Location: Bk.~_Pg. ~`'
Tract ~ "~t~~~.~`.e:' ~ ~ ~~~-Lot <
Proj. Assort.
Address: --- ~" ~"a' ~~ a~ - ~" ~ ~`"~~
Jurisdiction ;~,9~ ~''t.:r'°°t_°''
BUILDING TYPE:
Single Family ,,~~''----~-•.
'°~ Condominium/down
Multiple Dwelling
Number of Units
Commercial
Industrial
Other Information:
Change in Status: ~" _~`~ -~° ~ -
Issue Date ,.._ By : ~,~ ~_,
fr
FEES:
Acreage
Frontage
Service Advance
Processing
Other / '
Capacity
$ ~.'
~~~•~
~- `
;, k,
BUILDING SEWER CONNECTION:
Feet of Property
line feet from Main Sewer
and feet deep.
Connection to Main Sewer
Feet upstream from M H
Using ~ ~
BACKFLOW PROTECTION:
~ ~ ~~ Field Check Required
TOTAL ~~ Call District for foundation survey
Disposition; , ~: ':r'~~! ,%
GO Zone RL SJ Device Required; Yes No ~-''~ r
Type:
INSTRUCTIONS:
... :ti :~f t r ~.
o Street encroachment permit required from -~ -
o Permit invalid if not connected within 12 months of issue.
o Do not connect until main sewer is accepted by District.
a Obtain a building or plumbing permit from the jurisdiction listed above. i
.._.,.:. ~"~l: " a~-.,^'~. ~ - °.~~. ' .fall/..~ I .1- :.;'aV.`t f _ ...<,. ~ ~ ".~„°'l'4fI'.i~`. .._,.c ~''~..~.1/f~="C...~.J .: V
~~ ~~ ,
WHITE -PERMIT /PINK -DISTRICT /YELLOW -JURISDICTION BUILDING INSPECTOR'S COPY /CARD -DISTRICT COPY
- ~ i4 4 ~ o~,+ ''
SEWER CONNE(~~C1N '"~'
WEST VALLEY SANITATION DISTRICT PERMIT NUMBE~t`? > ~ f
SANTA CLARA COUNTY
100 E. Sunnyoaks Ave., Campbell, CA 95008
(408) 378-2407
LOCATION: ,
A.P.N. ~tti.~ - ~ /~....O]'-3 -
Sewer Location: Bk.__d~Pg. -'"
T.ratT, ~r ~ fyr~.~. Lot ,.
Proj: Assmt.
Address: -~ ~ 'h7` .- f+,J "''
Jurisdictions,=,~~ • `"~= ~~
BUILDING TYPE:
Single Family .- ---~~.,
_;~ Condominium/down Houses t)
:~_.. _.~
Multiple Dwelling ~ ~ "~
Number of Units
Commercial
Industrial
Other Information:
Change in Status:
Issue Date ~ z'~ ° ~%`~ By '~ =~` ~
FEES:
Acreage
Frontage
Service Advance
Processing
Other:
Capacity
$ "`""
~ r ~, ~,
i ~y.
BUILDING SEWER CONNECTION:
Feet of Property
line feet from Main Sewer
and feet deep.
Connection to Main Sewer
Feet upstream from M.H.
Using ` ~ ~~
BACKFLOW PROTECTION:
r r Field Check Required
TOTAL %~' ~_ `~ ` Call District for foundation survey
Disposition; ? ~' '>
GO Zone RL SJ Device Required; Yes No
Type: "w~-`~:_~-~=-~.=~,-."~::~;~,~°-~„,~,,~:.`
INSTRUCTIONS:
o Street encroachment permit required from "' j -
Permit invalid if not connected within 12 months of issue.
o Do not connect until main sewer is accepted by District.
a Obtain a building or plumbing permit from the jurisdiction listed above.
WHITE -PERMIT /PINK -DISTRICT /YELLOW -JURISDICTION BUILDING INSPECTOR'S COPY /CARD -DISTRICT COPY
,....'m+../ -:i'eR''}•. ••~..: -.n.'S'+l~..n._.-.._'^t<*.%-.~..r ~•n.r-~:-~~r=F P~s.~~~Y•.~- m1v~.+ce _ - 'R.~. - t .rev.. .. T:.. --: ~'~~'~ - • r I4= '.t~':.. 1~~. ea.van.
... ... - .. -:,-g
SEWER CONNECTION ,
WEST VALLEY SANITATION DISTRICT PERMIT NUMBER' -~ ~~
SANTA CLARA COUNTY
100 E. Sunnyoaks Ave., Campbell, CA 95008
(408) 378-2407
LOCATION:
A.P.N. ~ d ~ , 3/~'" D~~
Sewer Location: Bk. 4:~, Pg. _""
T-Fa6t :...k ;''r __ ~ ~ ,- Lot
Proj. ~ Assmt.
Address: `'
Jurisdiction
BUILDING TYPE:
Single Family ----.,,~
''"Condominium/Town Houses'
...
Multiple Dwelling° ~ ° - -~-- ~ `'
Number of Units
Commercial
Industrial
Other Information:
Change in Status:
- ' fit,.- `i', .
/'~
,-
Issue Date •f •~ BY °-"'' i
FEES:
Acreage $
Frontage
Service Advance ~_ f~°
Processing -
Other:
Capacity ~ `
TOTAL ~= .'
BUILDING SEWER CONNECTION:
Feet of Property
line feet from Main Sewer
and feet deep.
Connection to Main Sewer
Feet upstream from M.H.
Using ~''" ~ .
BACKFLOW PROTECTION:
Field Check Required
Call District for foundation survey
Disposition;
GO Zone RL SJ Device Required; Yes No »-'^
Type:
INSTRUCTIONS:
a Street encroachment permit required from '
o Permit invalid if not connected within 12 months of issue.
o 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
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 vehiculaz crossings and free access to private driveways, bus stops, fire hydrants and water valves.
G. A Construction Traffic Control Plan and a Construction Schedule are required for all -ane 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.
1 1. Adequate signing and barricading is required on the job site. Failure to provide such sib ing and barricading may result in the City's providing signing
and barricades and charging the 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 be required, nor does it relieve the Permittee of any obligation to obtain any other permit required by law.
1 G. 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 the manner in which the same is to be made for City-owned or maintained facilities.
21. Permittee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by City prior to
distribution and include dates of work and a contact namy~ and phone number.
Applicant shall be responsible for ensuring hat a those p " viding services under the applicant are aware of and understand all of the above conditions.
cant
c ~ a ~/ O~
Date
J\forms\pwperm
Rev. 11 /9/05
Contractor (Print Name) Date
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