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ENC2006-00097CITY OF CAMPBELL DEPT. OF PUBLIC WORKS 70 North First St. Campbell, CA 95008 (408) 866-2150 Fax (408) 376-0958 F -"ROACHMENT PERMIT (, corking within the public right-of-way) Issued ~' ~ 2 2 ~ ~ ~' Permit Expiration Date 6~Z2 6 Perm~`'~o ~L 2aG~ - C1LY'`17 X-R, ile Application Date ~~2 2- pG Application Expiration Date 2 ZL APPL]CATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 1 I.04. (Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable.) ~ ` , A. Wor address or tract # %3 ~ ~1 '~~~ ~1''e ' C•• ~c ~jJ~zlf/ ~ !~ f~ Li Utility trench location `~ ~"'~` l/ y c B. Nature of work ~C'cZ/c/v /~/~ '~ // 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. y~ // L Name of Applicant ~ /l6 ~' UE i'c ~~~/Litsr ~ ~~ C Telephone ~^'C~~7 ~ Y ~U ~ ~ Z ~ ~-' (print name) '/ Address ~, , f ? .' i j . ~ /. r i <'~ ~~''1.~ 24-HOUR EMERGENCY TELEPHONE NO. ~~~ ~ C~S•G ~l~ U E-Mail Address l<l~ ~ l~' d~ ~/~ KL"~ ~'L l ~~+ 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 ApplicandPermittee 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. i Arrrnteri ~ ~ /~G7_h+C~'=`~~ `~.. L-''~~Z~L~~~ -- (Applicant Permittee) (sign) Date Contractor (Print Name) Date SPECIAL PROV ISIONS _1. Street shall not be open cut for underground installations. Minimum cuts 111 be allowed for connections or exploration holes. Such cuts may / be snecifically approved by the Inspector nrior to cutting,. 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 [he 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 Requirements: V 7. 1 N S l/a1,~ E'la ~ V\ 1>_"IU1 u /'~ 5 [ .~~ P ~ .-~' ~ ~~ " ' ~ F N 2 u~~ 6 ~ ~~~ ~ I ~ SEE Pi1BLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOOUNT RECEIPT N0. PERMIT APPLICATION FEE $ ,>~` ~ ~~ lU 1 PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK & INSPECTION FEE $ ~lC., u% IUD APPROVED FOR ISSUANCE ~ ~~~ ~' ~? 1 1~ G For City Engineer Date Permit Expires 12 Months After Date of Issuance ..'i ~k\ M u ~~ ~ "J WEST VALLEY SANITATION DISTRICT SANTA CLARA COUNTY 100 E. Sunnyoaks Ave., Campbell, CA ~ J8 (408) 378-2407 LOCATION: ©~~p~~ ~ ~~ A.P.N.^~f1 ~-~~-g3 z<' Sewer Location: Bk.~_Pg.~ Tract Lot Proj. Assmt. Address : ~~i/?1~.^' ~~ ~i~y~~ Jurisdiction ~l~i/ BUILDING TYPE: _,~Single Family Condominium/Town Houses Multiple Dwelling Number of Units Commercial Industrial Other Information: ~,~°-L~~'~ui~~-t`-~ Change in Status: ~,~r,~ ~y ~~~~ ~~7~ la Date ~ /.~ ~US~ gy,~s~ FEES: Acreage Frontage Service Advance Processing Other: Capacity PERMIT NUMBER - ~ b ~ ~ ~} ,.~ o~ .~sS:~~ ~ 3 / BUILDING SEWER CONNECTION: Feet of Property line feet from Main Sewer and feet deep. Connection to Main Sewer Feet upstream from M H. Using ~Cjc:lft~i'_ ~ifFsd-L BACKFLOW PROTECTION: ~~+. Field Check Required TOTAL L-L-LSD=-F~- Call District for foundation survey Disposition; GO Zone RL SJ Device Required; Yes ~ No Type: ~~- U~/v'~c- ~~.~*r.~~/fiu•CJ INSTRUCTIONS: o Street encroachment permit required from ~~ o Permit invalid if not connected within 12 months of issue. a 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 WEST VALLEY SANITATION DISTRICT SANTA CLARA COUNTY 100 E. Sunnyoaks Ave., Campbell, CA 95008 (408) 378-2407 Issue Date ~-l.~'tJ.~ By~_ LOCATION: A.P.N. ~i17-~/'~-©~.~s Sewer Location: Bk. ' Pg ~Z~ Tract Lot Proj. Ass mt. . Address: ~~,/~~' ~~°' L' Jurisdiction ~~G BUILDING TYPE: _L~Single Family Condominium/Town Houses Multiple Dwelling Number of Units Commercial Industrial Other Information: ~~~ ~~~~-' Change in Status FEES: Acreage Frontage Service Advance Processing Other: Capacity TOTAL PERMT CNUMBERI~N 3 6 5 3 5 e ~.:- ~• ` ,. BUILDING SEWER CONNECTION: Feet of Property line feet from Main Sewer and feet deep. Connection to Main Sewer Feet upst am from M. Using ~t/~~- a-•~L. BACKFLOW PROTECTION: Field Check Required Call District for foundation survey Disposition; GO Zone R L SJ~~ Device Required; Yes ~ No Type: i-N~~~~/u.L_ f~ ~O,i~.9~/i'c',i~ INSTRUCTIONS: o Street encroachment permit required from ~~~L-~ 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 .ti 0 ro w 0 x 0 Ix, z N N O O r> O O ~', N N ~ ,, N N .-. ~, cn ~n N N J J ? W ~W Oo N N W O O CrJ o ~ ti ~' r. b7 ~ ] ~ ~ 7J N '~ 'U n 'p I I ~~ -j g ~* v x ~~ o ~ ~, o ~ W 0 0 0 ~, S o ~, d a ~„ o o b o o S o a 0 N N `. ~ ~ ~ N N J d ~ ~ n -: ? ~ ~, ~ ~- ~ i. ~ ~ ~ ,~ o0 0o n a r., o o ~' z z d •• x ~ ~ .., x 0 0 ~~ L{. C O O .-~ O O p r O n1 m r; ~ ~ ~ ~ .. ~ z ~- ~ x o o c o~ .~ o `~ o ,~ ~ ~ W N W N .yb O a ~ City Clerk PUBLIC KS DEPARTMENT RECEIPT EReclive JWy S, 2005 PU6LIC WORKS FILE NO. PROPERTY ADDRESS f 3 ~o ~ 13`i6 ~-/1Z 1 M 1`'R Please collect & receipt Por the following monits: ITEM AMQUNT ff PERMIT Application Fee _ Non-Utility Encroachment Permit (5275.110) h 3 Minor Encroachment Permit <55,000 (561.00) R-1 First RmYI (No Fee) Subseaftent fS115.M1 FST 2203 Cash De it (4% of Engr. Est)(SSW mitl/510,000 max) d722 flan Check & Impecllon Fee (Nun-Utility) Engr.Fat.<5250,000 (l3%of ENGR.EST.) 2203 Engr. Fst. >5250,000 (Deposit 8% of Engr. Es[J530,000 Mn)«« dnz unlby<slao,ooo MlWmmn Charge Per Location CaWWts/Pipelines up to 500 Feet (5180.00) (52.25/6) Above 500 Linear Feet (51.35I1't) Manlnles/VaWLC/Elc. (5125.00/ea) Pole SeURemoval (SI25.ONea) Sheet Tree flantinglltemoval (5135.00) «« 2203 Utility>S100,OW Actual Cosl+211%«« 4760 Storo ContainerRmdt (5125.00) 4760 Project flam & S itkallom Pm'tct No. 4760 Standard S i0catioas & Details (51/1'g 515.50/Bk) 4760 Co s of Engineering Maps & ('Inns Aerial Plot 24"x36" ($54.00) Aerial Print 8 1/2" x l1" (522,00) Ma and Plain 26" z 36" (58.25) d722 Iknalties: Failure to restore ublic i rovements 8100/Calendar Uay) (MeN CMe xer.Il.rl.alal d722 Penaltks: Failure to correct mzwk conditio s (5100/Calendar Da ) 4722 Wark Without Permits (4 Times Ap licable Fee) LAND DEVELOPMENT 4722 lot LIre Adheamem rcum n.n map fr r.ou ar r.exsl Fimfl Troll Map (5 or More Intl) (Af 4W.W + S75/bl) (54,21q.00 + S1110/loq Certl6cate of Compliance 5650,00) Certl0cate of Corrtcllon (SgOp,00) Notary Fec (ptr signature) (510.00) Vacation of Publk Streets & Easements (52,2ua.0a) A.cscssment Segregation or Rtapportionmenl Fltxt spot (a7zs.an Fych Addillonal I.ot (52p1.00) Storm Drainage Area Fee Per Acrc (N-152,120.00) fMWti-Res 52355.ai) (All Olher 52,65(1.00) ParklnM Dedicatbn Fes (75 %/25 % Dm Uoon Cert. of Occuoancvl Interaction Tum CounLc Intetstctbn Tum Counts Traffic Flow Mao (Dilly' ~ 4728 Sigrwl Timing IMormatbn (562/1{r) d271~ Track Pentdtc (516.00/per Mp) L_ d728 No Parking Sighs (Sl/each or 525/100) OF APPLICANT lfl Gv /J(~F~~IUi//Lr Kam./J /`2 (~ OF PAYOR !' 6~~~ J~ va ~I ]f+t "s-t ~/ 1-z"` C ss ~ X12 ~ ~l ~ ~~ />~~ d Cast flln 20% Overheat tNon-InterestCast Overheat Interest bearln~depasiD TOTAL V PI IONE ~~ ~~ ~ ~ t~ ~ ~~, s--~ - ~rn %~ S / J' ~ FOR CITY CLERK ONLY j:\forns4eceipl form 05-06 rev.621 /05 ,;ENERAL 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 Constmction and Maintenance Work Zones, dated ] 990, available at Caltrans. Traffic control equipment shall include Type It 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 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. I5. 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 other than stormtwaer02Applicantnsha111adherertolthedBEST1iMANAGEMENTSPRACTICESrestablishedtbyathetSanta Clara'Valley~Urlban 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 rs to be made for City-owned or maintained facilities. 21. Permittee must provide advance notification [o all parties that may he affected by the permit activities. Notification shall be reviewed by City prior to distribution and include dates of work and a conact 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. ' ~ ~r ' ~/~'~c v~ (Lc V UE Date Applicant ~ ~ C i1G / Cif sir /~~fc1C.c f ~) i t D Contractor (Print Name) a e J\fortns\pwperm Rev. 11 /9/05 r ~r+;.,_. .,... ~ i :-~ ~~ ~ .. ... .. .... ~. ..f'i i'.,_ _. ..