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ENC2006-00162CITY OF CAMPBELL DEPT. OF PUBLIC WORKS 70 North First St. Campbell, CA 95008 (408)866-2150 Fax (408)376-0958 ENCROACHMENT PERMIT (for working within the public right-of-way) Issued Permit Expiration Date .mit No ~NC• ~~ 6 --ex~~,62 X-Ref. File Application Date ~ a~~'`° ~~ Application Expiration Date APN ~~Z_~~'C~~1 APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in 12 months if the permit is not issued. Application Fee is nop-refundable.) ~ ~ Work address or tract #, Utility trench B. Nature of work ~. 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 [he 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 1-l.~_ t L Lf^~ Telephone ~(~`~ - ~ ~ 3 ' 7 (o~~ (print name) I Address ~ 5~~~() ~ N ~ ~ ~ ~ ~ ~ fy~ ~N{ 24-HOUR EMERGENCY TELEPHONE NO.~Gi Yf'tE'- Q S Q Y~~ L~ e E-Mail Address ~ J ~J' ~ ~ ~' t`T~ ~-' ~ m e Is this work being done by the property owners at [heir 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 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_ mages arising ou [he condition of any privat~vements in the public right-of-way. (Applicant Permittee) (sign) Date 'o%/© G (Print Name) SPECIAL PROVISIONS _l . Street shall not be open cut for underground installations. Minimum cuts ~ be allowed for connections or exploration holes. Such cuts may be snecifically aonroved by the Insoector prior to cutting. _2. Pavement may be cut 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 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 I-800-227-2600. USA TICKET NO. _5. Prior to any work, the property owner shall execute an Agreement for Private hnprovements in the Public Right-of-Way, which shall be recorded. 6. 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 & INSPECTION FEE APPROVED FOR ISSU For City Engineer Permit Expires 12 Months After Date of Issuance AM~OrUN(T RECEIPT NO. $~ Date J:\forms\pwperm f ~ ~ (N4~~~ Revised 1.20.04 ~ f\V ~ ~~l \~~`J `` 11~~ `~ b 0 n w rn ro w 0 x ~ d `~ n `b ~e ~ .~ N O N O N O '~ m ~ ~ rn ~ O O 'O ~, O~ O~ . O~ .r ~ In W ~- .P W ~ W vii J w 00 O N p~ ,~ c~ rn O W °0 0 0 ~~N o~ ~' z~ ~~ ~ x w ~ =~ ` ' d w ~ •~ b ~ ~ o ~ _ 0 n7 ~ ~ `~ ~ c~ n ~ a 0 . 0 ~ ~ .p •-~ N O tJ C ~ 'i7 O O O O O O ~ y b a ds J N ~ ~ N ~ ~ 0 c 0 o 0 0 o a 0 0 .- 0 ~ 0 p ,; N N ~ N N O N O _ O ~ .-~ O O m ? ~ J ,'.~ -j 0 r ~ r-~ ~ r-r ~ ~ ~ Y C" N O 00 N 00 N ro ~ ~ C~7 z G~ d ~' z ~ Q ~ ~ ~ 0 ~~ v -~ ti a ^. ~ O O O O O O O c .~ ~' ~ O O O O .i V n n m r~ fD .. ~ z ~ x N ~"• O v' O e-~ ~ O o ~ O ~ ~ O N "'! O W N .P ~ .-. O b 7 ~ j:\forma4eceipt form 06-O7.ds t;~~ ?.~ ~.`.t:d t r _ ,.r~. . ~~ C. - ~- f PUBLIC WORKS DEPARTMENT RECEIPT EReetiva July 16, 2006 City Clark PUBLIC WORKS FILE NO. PROPERTY ADDRESS f'L~-', ~ ~- ~ ~ Please collect 8 receipt far the following monies: REM OACHMENT PERMR 4722 Application Faa No Utility Encroachment P rmtt (5275.00) Minor Encnaachmsnt Permit <55 D00 (5725 001 R-1 Fint Penntt No Fse Subs uant 5725.00 Utll' Encroachment Permh ArtsrkUColleetor Strwt 5660.00 2203 2203 Residential StroeVOthsr Aroes Plen Chsok Ds alt 2%of En loser's Estimate Faithful Perlarmance SseuN FPS 5300.00 5500 min 100%of ENOR.EST. 2203 2203 2203 Labor end Materiels Ssewtt Monumentetion Sacurtt Cash De sit 100%of ENOR. EST. 100%of ENOR.EST. d%of En r. Est 5600 mirJ510,000 max 4722 Plan Cheek 8 Inspxtion Fee (Non-Utiltty) E gr Est 5250 000 (13 %of ENOR.EST ) 2203 En r. Eat. >5250,000 Ds stt 5%of En r. EstJS30,000 min " 4722 Utilit <5100,000 Minimum Cherga P r Location (5260.D01 Condutts/Pipelin up to 600 Faet (f23CJf1) Abov 600 Lino rFset (S1A6/tt) Msnh IeW utts/Etc (572600/ee) Pole SetAiemovel (5/26.00/se) Street Tree Plentin emovel 5746.00 4780 StemlardS ificelionsB Dateila - 4~rr ero.ewox 4760 Co bs of En inesrin Me s 8 PMns Aerial Plot 24' z 36" 564.00 Aerial Print 81f2" x 11' 526.00 Aerial Search Fee 526.00 Me c end Plans 24" x 36• 512.00 4722 Penetths: Feiluro to roatoro ublic Im rovements 5100/Calendar Ds Munl Code Ssc.11.94.010 4722 Penalties: Feiluro to corroct unsafe condttions 5100/Colander Da 4722 Work Without Permits 4 Times A lieabls Fw LAND DEVELOPMENT a»~ t.et Line Adiustment {390000) 4722 4722 4722 Parcel Ma 4 Lota ar Less Final Tnct Me 6 or Mors Lots Csrtifioels of Com lienee 53,400.00 +375AO1 54,200.00 +S100Ao1 5660.00 4722 Certificate of Cometion 5400.00 4722 Orodin 8 Dreine s Plen Review Sin le Famil Lot 5200.00 She < 10,000 s.l. site > 10,000 s.f. < Aere Site> 1 Acre 5600.00 Sago.oD 57,200.00 4722 Nats Fae er si nature 510.00 4722 Vacation of Public Strssts 8 Easements 52,200.00 4722 As anent Segrogstion or Rsepponionment Fi t Spl't (5726.00) Eseh Additional Lot 5200.00 4721 St rm D ineg Aree Fas P r Acre (R-1 S2 120 00) (MuttFRss 52 386.00) Ail Other 52,860.00 4920 Parkland Dedication Fae 75°N2fi%Due U on Carl. of Oeeu ant 511.7424 Poste e TRAFFIC 4726 Interasotion Turn Counts Two-Hour Count 578.50 4726 Intersection Tum Counts e.m. or .m. asks 5160.00 4726 TreHic Flow Me Deil TreHie Volumes 532.00 4726 Cam ball Traffic Model Full Soo Assessment Mtuel 4726 Cem bell Traffic Model Reduoad Sco Asaaaament Actual 4726 Si net Timin Informetlon 562Mr 4271 4726 OTHER Truck Permits No Parkin Si ns 518.00/ rlri 51/oath or 526/100 .AMOUNT NAME OF APPLICANT ,d,~ (/ r `/ ~ y ~ • TOTAL ~ ~ ~ ~ ~ ~ NAME OF PAYOR \ ~ ,y~ /J /y/t l ~ t' / C~~ /~-~C~ PHONE ~/ V'=~ ADDRESS `U~ t• ~ ~'--'~~ C- ZIP ~ ''Actual Cost Piw 20%Overhead o FOR CRY CLERK RECEIVED BY ONLY Date si t 4 'For Plen Check and Cash Deposlis, santl yellow copy to Flnenc . - , Dets/ Inttlels _ j:\forme\receipt form 06-07.x1s y L. ,'l l'; ? °.=.111 .. 'ftl. rr~fL Ts;-;z.( '-3Rt'.7T ; ~Fl;p C;~ ±~.~ _._ -hire-, _. 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 rnade in writing to the Permittee. S. 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 COnSVl1CClOn Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated 1990, available at Caltrans. Traffic convol 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. ]0. 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 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. Conuactor 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 wilt be allowed near the edge of pavement, the traveled way, or within the shoulderline which would create a hazardous condition to the public. 1S. 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. 16. This permit does not release the Permittee from any liabilicies 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 hack (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. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above conditions ~!~ -2ra --©{P Date Date J :\forms\pwperm Revised 1.20.04 WORKERS' COMPENSATION INSURANCE INFORMATION The following workers' compensation insurance information is required for all Applicants and Contractors. One of the following items for each Applicant and Contractor must be submitted prior to working under a Public Works permit of contract. WORKERS' COMPENSATION INFORMATION: i Name of Contractor/Applicant C L ©,~ S~ r X 1 0 /1 ^ A Certificate of Consent to Self-Insure issued by the Director of Industrial Relations; OR ^ A Certificate of Workers' Compensation Insurance Insurance Co. Policy No. Expiration Date OR ~._ A signed Certificate of Exemption from the Workers' Compensation laws as printed below. CERTIFICATE OF EXEMPTION I certify that in the erformance of the work for this contract, I shall not employ any person in a man r so as eco s ject to the Workers' Compensation Laws of California. Signed Date ~ ~ ~j Q I Q Title ~C,~~ Y\~.C NOTICE TO APPLICANT/CONTRACTOR: If after signing this Certificate of Exemption, you should become subject to the Workers' Compensation provision of the Labor Code, you must forthwith comply with such provisions or the Permit or Contract will be cancelled or revoked. j:\landdev\forms\street improvements\workcomp (rev. 6/96) DISPLAY BUSINESS RECORDS: DISPLAY EXIT DISPLAY BUSINESS RECORDS --------------------------------------------------------------------- 10/30/06. BUSINESS NUMBER 022531 TOTAL DUE 0.00 BUSINESS NAME C D L CONSTRUCTION SERVICE ADDRESS 9480 MURRAY AVE APT GILROY CA ZIP 95020 BILLING ADDRESS P O BOX 2029 CYCLE 8 TAX N PENALTY N PROPERTY ID GILROY CA UNAPPLIED CREDIT 0.00 95021 SERVICE TITLE BILL REF DATE BILLED PAID DATE PAID 1799A SPCL TRADE 06/09 NEW LIC 09/14/06 35.00 35.00 09/14/06 NEWFEE ADMIN FEE 06/09 NEW LIC 09/14/06 25.00 25.00 09/14/06 PRESS ESCAPE FOR NEXT SCREEN ~,icense• Detail California Home Page 1 of 2 C3ctc~ber 26. 2006 tr ~ c ~. :. ~ ~ .i~ / . #x; , ., License Detail Contractor License # 781723 CALIFORNIA CONTRACTORS STATE_LICENSE BOARD DISCLAIMER A license status check provides information taken from the CSLB license data base. Before relying on this information, you should be aware of the following limitations: . CSLB complaint disclosure is restricted by law (B&P 7124.6). If this entity is subject to public complaint disclosure, a link for complaint disclosure will appear below. Click on the link or button to obtain complaint and/or legal action information. . Per B&P 7071.17, only construction related civil judgments reported to the CSLB are disclosed. . Arbitrations are not listed unless the contractor fails to comply with the terms of the arbitration. . Due to workload, there may be relevant information that has not yet been entered onto the Board's license data base. Extract Date: 10/26/2006 * * * Business Information C D L CONSTRUCTION P O BOX 2029 GILROY, CA 95021 Business Phone Number: (408) 842-1614 Entity: Sole Ownership Issue Date: 07/18/2000 Expire Date: 07/31/2008 * * * License Status * * * This license is current and active. All information below should be reviewed. * * * Classifications * * Class Description ©GENERAL BUILDING CONTRACTOR * * * Bonding Information * CONTRACTOR'S BOND: This license filed Contractor's Bond number 6073543 in the amount of $10,000 with the bonding company SURETY COMPANY OF THE PACIFIC. Effective Date: 07/31 /2006 Contractor's Bonding History_ http://www2.cslb.ca.gov/CSLB_LIBRARY/License+Detail.asp?LicNum=781723 10/26/2006 T,icense Detail Page 2 of 2 * * * Workers Compensation Information This license is exempt from having workers compensation insurance; they certified that they have no employees at this time. Effective Date: 08/13/2003 Expire Date: None Workers Compensation History Personnel List License Number Request Contractor Name Request Personnel Name Reguest Salesperson Request Salesperson Name Request C~> 2006 State of California. Conditions of Use Privacy_ Polio http://www2.cslb.ca.gov/CSLB_LIBRARY/License+Detail.asp?LicNum=781723 10/26/2006