ENC2006-00094FILE No.6?1 0614 'Q6 1'~~05 1D:VTA.UASONA.FIELD.OFFICE. FAK~408 ~'?4 035Q PAGE 2i 4
CITY OF tAlYlPaEll F.NCRt7ACHMEN7 PERMIT ~l Permit No l~ N ~- 7 C~ ~n ~ C~C~~~ L.~
DEPT. QF PUBLIC WORKS (for working within the publi~_/~'~ X-Ref- F11e
~a Nartft First 5traet rightl-of--way) V~V'~!! -- App(Ication Pate
tampbsll, cA 95008 Issued ~ ! (~ 0(i Appliwtian Ex ~ atian pate. i t/ ~ ~+- ~P
Ph. (408) 866-21 sq APN . ~~ ~ - ~ 7 - O
pY. (408) 376.0958 ~1 ~ ._,
Permit Expiration pate
APPLICATION -Application is hereby made for a Public Works Permit in accordance with [ampbell 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 orTraet No.: ~ V/} ~ 0 r/A 4/6yr~~~ /~ P/te,J~~ ~ ~' ~ 7a ,,r" p ~/J/~~ ~/~~(~~
Utillt Trench ..........._...,,.,. ---- ~ C:Arr~r,,,ac'1 hf7~</~L Ed~d/~~~~ ~f7 7H~ O
Y Loeation• ,.. _ y6abr AR~iJ ~a................_._...,,.,,,.._.._._.__....-„,,.....----~._,....._~_ ..................._ ,...a1Z~~..Ti~ r
S. Nature of Work: ~,,r~7AL ~•cL p/~~ //L~f ~tNd L~l6G~N~ L/ ~~y~~2r ~Ip °_._.
/e s it,~,
C. Attach four {4) copies of an engineered plan showing the location and exten(of the work, and four (4) copies of the preliminary EngineeYs
Estimate of work. the plans shall Shaw the relation of the proposed work to existing surface and underground improvements. When approved
by the City Engineer, said plant becomes a part of this permit.
D- All work shall conform to the City of Campbell Standard Spec-fleatians and Details for Public Works Construction;the General Permit tonditions
listed on the reverse side; and the Special Provisions for this permlG listed below. Failure to abide by these conditions and provisions may result
In job shutdown and/or foifelture of Faithful Performance Sureties and cash deposiu. (See General Permit Condhkxis 1 apd 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: ..... ~~ r~NS~Q~'7~7/e///9d7He~/7~ ~H~'AN~Lr Telephone: ~a ~ /f'~3~-'~i r~B..S
Address: Q7~ ~(/ x~/C/t"/.S /rv~') SRS .7"if ~ C/ ~ ,9~~~ 6
_...` ~ -
1:-Mail Address: gg~~ -,~,~y~y ~ i,/y~ , dR ~ 2q_HOUR EMpRGENCY PHONE NUMBEA: If 0 ~ 3 9 j~ 0 2 ~
Is this work being done try the property owners at their own reiidence7 -~..°` ~ .. _ -•° _........__ .................................................I
(~ YES ~ Nb
The Applicant/permittee hereby agrees by affudng their signature to this permit to held the City of Campbell, Its officers, agenu, and employees free, safe
and harmless from any claim or demand for damages resuking from the work covered by this permit,
The Applicant/Permittee 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 atl damages arising out of the condhlon of any private improvements in the public right~f--way.
Accepted: ~ ~NS/tAf ~~ /~ ~ ,r~i 6/~~/C 0
{Applicant Permittee) (sign) Date
[Contraelert ro.~...
..........._. uate
;~E~IAL PROVISIONS
~1. Street shall not be open tut for underground installations. Minimum cuts~y be aAowed for connections or exploration holes. Such cuts may be
~.,2. Pavement may be cut for underground instailatlans and must be restored in accordance with the Standard Details Trench Restoration Method ~~.
"A", unless othervviseapproved bythe Engineer.
`3. Work to be staked by a licensed Land Surveyor or CNiI Engineer and two (2) copies of the cut sheets sent to the Pubic Works pepartment
before startlrtg work
~4. Per Slttion 4215 of the Government Code this permit is nat val Id for excavations until Underground Service Alert (USA) has been notified and
the Inquiry identification number has peen entered hereon. USA Phane: 1-80p•227-26oq, U5A TICKET NO ;.
~S. Prior to any work, the property owner shall execute an Agreement far Private Improvements in the Public Right-of-Way, which shall be
recorded.
6. Public Notification Requirements:
7. _®LL ~lu~K ~N V 1"A f2.r)'I,J.. v TA iwii i i~y . ~:~.~ ~ ae >.-~_.. a ~ ... .. -- _
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SEE PU(~( IS WORKS FFF SfHr=ni i " A(Gc A
LF,F.QR CURREN7~g AMOUNT RECEIPT NQ.
PFRMR APPLICATION FEE S
PLAN CHECK pEP~SIT 5-
SEt:URITYFOR FAfTNFUI PERFORMANCEMRQR 8, MATERIALS $ _ '~
CONSTRUCTION CASFf DEPt751T $- "" -
PLAN [NECK & INSPECTION FEE $ ,~ '
APpROVEDFORISSUANCE C/ 1 ~ O~
For City Engineer pate
Permit Expires 12 Months After Pate of issuance
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FILE No.671 06:14 '06 17:06 iD:VTA.UASONA.FIELD.OFFICE. FA~:408 a?0 0350 PAGE 4i 4
~.~~;=4)?rInOC1T1 y;,
CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No
DEPT. OF PUBLIC WORKS (for working within the public X-Ref. File
70 North First Street right-of-way) Application Date ~//~ ~ F
Campbell, CA 95008 Application Expiration Date
Ph. (408) 866-2150 Issued
Fx. (408) 376-0958 APN
Permit Expiration Date
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 isnon-refundable.)
A. Work Address or Tract No.: ~//q S Q ~1/,A `/Gf/T /t/f ~G /J~e ~l L j C 3 ~a S o L /7/F,~ P/("Ff (/}G('/~f
- / ~ u ~iV
Utility Trench Location: L/~yOcG/o/ /i,~Fil /'a/Z CsN7~!'!7a/Il /yA'9~ie//1"L~ ~~///~~y~j/~ ~J7 THE
_. ..........................._.............................._........................................................._......................._.........................._._....._..........................................~_ ..........._O.BZ~.... s..: .... 7
B. Nature of Work: ~//S~y~~ ScGD/~/~ ~/Lf1 rl/v0 LrtG"G/NG W L dfli/ff %lJo '
-~-~-~.+~Lf.~L_ ~` ,~/El~~;~-~~~i/~/C 3! C,dG L oc~>~_e /tLs'/a s~~~'~
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: ~, ~//y,f,~l~, L , : ~jl ~ f ~yy} _ e ~cs
_//~.~_~.~y.......__T~~N~f 0,~7,itT1e// /IiJ7/fc/1/1 y~Telephone: 7 B / / C
q. _ ...........................................................................................................
Address: ~~~ rtUZ~/~C/r/S ~Uf ~ 51~r/ ~~5,~ C/r 9S~Z
E-Mail Address: ~~ y,v/! •,G~~j ~~ if 7,r'{ - (1 /C E"-~ 24-HOUR EMERGENCY PHONE NUMBER: yd £ 3 S~- /' PJ'
OZ
III ......................................................_...._..........._._...............................................................................
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, 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 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 privat/e improvements in the public right-of--way. / /
Accepted: ~ T~, F/1S/)r~' ,~L'`.9f L t!^/,~ 1-~~ 6/~~/ d 0
(Applicant Permittee) (sign)
Date
~7-n R~= 1~~>~/z /-/~~PO (G'iJ~S a ~'~~ ~~ 7v,~E 2~~ 0 6~
(Contractor) (Print Name) ~_._
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 approved by the Inspector prier 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 the Engineer.
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 Public Right-of-Way, which shall be
recorded.
6. Public Notification Reouirements:
7
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT
PERMIT APPLICATION FEE $
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $
CONSTRUCTION CASH DEPOSIT $
PLAN CHECK & INSPECTION FEE $
APPROVED FOR ISSUANCE
RECEIPT N0.
For City Engineer
Permit Expires 12 Months After Date of Issuance
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 or 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.
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. A 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 the 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.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
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.
Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer.
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.
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.
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 bylaw.
This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency.
This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon.
Call back (call out) due to emeregencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per
occurrence.
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.
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.
Permitttee must provide advance notification to all parties that maybe affected by the permit activities. Notification shall be reviewed by the 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 and understand all of the above conditions.
Applicant 5EN/~/~ ~/K/~7'~~/~a~~-'fllo// ~"/`/~fz•
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Date:
Contractor (Print Name) Date:
J:Reina\Website\Land Dev Forms\Encroachment Permit STATIC form2.pdf
Rev. (11/9/05)
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FILE No.671 0614 '06 17:06 1D:t1TA.UASONA.FIELD.OFFICE. FA7~:408 aa0 0350 PAGE '3i 4
GENERAL PERMIT COf11~IT(OINS
1. A construction Cash Peposlt is required Charges will be made against this deposit if there is an emergency calE•out, overtime inspection or when Chy
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 re ulred. Such
q period wIN begin an dale of written acceptance by the City-
3. Refund ar the cash deposit balance and refund or cancellation of the faithfW performance Swety will be Inl[iated by the written acceptance of the work
by the thy.
4- The permittee must request In writing a final inspection and acceptance of the work upon completion. Acceptance by the Ciry will be made In writing
ro the permittee.
S- Malntarn safe pedestran and vehicular crossings and free access to private driveways, pus steps, fire hydrants, and water valves.
6. A Construcgon Traffic Control Plan and a Construction Schedule are required for ail lane cosures, detours, and street cosures. This plan must be
reviewed and approved pfiorto any lane closures.
~. A Construction Traffac Control Plan shall conform to the Cakrans Manual of Traffic Controls for Construdion and Maintenance Wark Zones, dated
7990, available at Cahrans. Traffic control equipment shall include Type 11 flashing arrow signs If required.
B, Replace as directed by the City Engineer any damaged ar removed improvements in accordance with City Standards and Specifications at the sale
expense of the permittee.
9- Sawcut for all FCC or AC removals. All PCC removals shall be to the nearest searemark 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
lnspectton costs at the currant overtime rate.
t t • Adequate signing and barcieadirig is required on the job site, (allure to provide such signing and barricad~g may resuh In the City's providing signing
and barrkades and charging the cast (including all labor and materials} against the cash deposit.
12. tempaction testing of subgrade, base rock, and asphalt concrete by permittee Is requited unless otherwise stated by the Clty Engineer.
13. The Contractor ar Permlttee will have a supervisory representative available for contact on the praJect at all times during construction- Contractor or
permittee shall provide a phone number at which they can be contacted outside the hours of B~0 a-m. to a:oo p.m.
14- No storage of materials or equipment will be allowed near the edge of pavement the traveled way, or within the shoulderUrte whkh would create a
hazardous condition tothe public.
t S• Phis permit shall not be construed as authorization far excavation and grading on private property adjacent to the work or any other work for which a
separate permit may be required, nor does Ii relieve the permittee of any objigation to obtain any other permit required by law.
l6. This permit does not release she Permlttee from any liabllltles carttalned in other agreements or contracts with the Clty and arty other public agency.
17. This permit is not transferable. Work must be performed by the Permlttee or his designated agent or contractor as specified thereon.
t 8. Call back (call out) due to emerogencies regarding this permit shall be at the current overtime rate with a three {3) hour minimam charge per
acurrence.
19. Pursuant to Chapter i 4.02 of the Campbell Municipal Code, applk:ant shall not Wuse to be discharged any material Into the municipal sWrm drain
system other than storm water, Applicant shall adhere to the BEST MANAGEMEPii PRACTICES estabilshed by the Santa Clara Valley urban Runoff
Pollution Prevention program.
24, If the public Interest requires a modification of, or a departure from the plans and specifications, the Ciry shall have the authority to require or approve
any modlfleation or departure and to specify the manner in which the same is to be made for Clry-owned or maintained facilities.
21 • Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notlflcation shall be reviewed by the City prior
to distribution and Include dates of work and a contact name and phone number.
Applcant shall be responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions.
v 7~ , ~HS~ x~y~f f~~~.-,
Applicant SAN/r~ r,~1Pa~7iiy/d~/ ~NEQ.
6/ ed
Aare:
Contractor (PIfnL Name)
dale:
J~ReinalWebsice~Cand laev farmslEncroaehment Perini[ STATIC formz.pdf
Rev. (1 t/9/DS)