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ENC2009-00122CITY OF CAMPBELL. ENCROACHMENT PERMIT DEPT. OF PUBLIC WORKS (for working within the public 70 North First Street right-of-way) Campbell, CA 9s008 Ph. (408) 856-2150 Issued L ~ ~) 3 G~ Fx. (408) 376-0958 Permit Expiration Date ~1 ~ a Print Form Permit No ~ ~- 2pG ~ - OG ~"~` X-Ref. File. _ ____ .~ _ Application Date I U Applicatfo Expi ation a e ~ _,___ APN APPLICATION -Application is hereby made for a Pubtic Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six (G) months if the permit is not issued. Application Fee isnon-refundable.} A. Work AddressorTractNo.: ~!~ /(,./ ~~~.~-}~'/, ~~~~~~~~ yr' - ~l Utility Trench Location: B. Nature of Work: ~ ! !~ .- (` t:..{:"K..~c..-. 1 ':,~~ ~ ~:~'dl ~~ f ~'CL~~-N/Y~ ( C) f tl~G~~`~'' ~' .~1~~ j f~~ 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 (..'~,(/.,r'`~-~~~~ 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 Ciry 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 andlor forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions t 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: Address: f ~? ~ c`~ /'y t Telephone: I ~!,()) ~("~~ Gil ~Q ~/ 3 E-Mail Address: (~ C~1 ~ / ~ ~ ~ Y7 ~ HOUR EMERGENCY PHONE NUMBER: SMOUNT 335 RECEIPTNO.~ Is this work being done by the property owners at their own residence) ~ YES ('c,.-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, sftall be responsible for any and albdamages arising out of the condition of any private improvements inthe public right-of-way. `' r - Accepted: fr .~,.~--7~{,C...:,fG.rg------!' /~ J~'~-~J-~~ (Applicant Permittee) ! (sign) ,~! ~s $...._ S U (Contractor) (Print Name) '~,_ ~ Date SPECIAL PROVISIONS: ~1. Street shalt not be open cut for underground installations. Minimum cuts nay be allowed for connections or exploration holes. Such cuts maybe saecifically approved 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 otherxise 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 1s not valid forexcavations until Underground Service Afert {USA) has been notified and the inquiry identification number has been entered hereon. USA Phone: t-800-227-2600. USATICKETNO. _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: 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES PERMITAPPLICATION FEE PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS CONSTRUCTION CASH DEPOSIT PLAN CHECK& INSPECTION FEE APPROVEDFORISSUANCE ~~ .1 ~~ Date /I 3/GS Permit Expires 12 Months Aher Date of Issuance i- I a K ~ 5 ~ ~-= z O ~£ ~~ :.,~ ~_ ~o 9 ~ < "erg ~ a ~~// _ ~~ GJ r_, ~ ~ ~ ~, `' O -G `~-, ~ -~ s- r U) G y_ Nn~ p= ~~" ,l as n? ~i r ~~ ~ "') ~ ~ ~i n O _ > o~ ~ ~ ..~ DD r-; ~~! - ~ ~-, . i U ' ;T i ~ m ~ ~~ ~ ~ ,T :~ o~ O ~ y ~ ~ ~ zo ~, i= I ~ °' ; ~ ;~~ s ~ ~, Ii ~ ~ , . 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