ENC2011-00008CITY OF CAMPBEL ~.~r 1v~~ ENCROACHMENT PERMIT `ermit No ~ NC~C;I (- CCi(!(`~
DEPT. OF PUB ~i~y (for working within the public X-Ref. File
70 North First S ~~'~ right-of-way)
Campbell, CA 95008~~N'i, 1 ~' S Application Date 1 /Z ( ~ ~
(408) 866-2150 G ~QR ON Issued Application Expiration Date -7 I J
Fax (408) 376-0958 P~~ ~~-~~~'n
~N Permit Expiration Date APN
APPLICATION - AppliPcaMti~o`n' ~is hereby made for a Public Works Perntit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in
six (6) months if the permit is n tissue Appl~tion F e is non-refundable.)
A. Work address or vact #
~~ ~ ~ ~'~
Utility trench locatio
B. Nature of work ~ G~-/c/ '~~T~,
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 pemut and approved plans at the site and must notify the Public Works Department at least two days before starting work.
Notice must be given Public Works at least 24 h urs before restarting any work.
Name of Applicant ~ Telephdne ~~~ ~ 7~1`"7G~~~
J ~ ~) ;, rin ame)
Address 1 [ GV E 24-HOUR EMERGENCY TELEPHONE NO. ~d~~7~ ~~~. 7
E-Mail Address
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 [his 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 private improvements in the public right-of-way.
(Applicant Permittee) (sign) Date
Contractor (Print Name) Date
SPECIAL PROV 1SIONS
I . Street shall not be open cu[ for underground installations. Minimum cuts >l~ be allowed for connections or exploration holes. Such cuts may
be specifically approved by the Inspector prior to cutting.
_2. Pavement may be cut for undergound 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 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.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO.
PERMIT APPLICATION FEE $
PLAN CHECK DEPOSIT $
SECURITY FOR FATi'HFUL PERFORMANCE/LABOR & MATERIALS $
CONSTRUCTION CASH DEPOSTI' $
PLAN CHECK & INSPECTION FEE $
APPROVED FOR ISSUANCE
For City Engineer Date
Permit Expires 12 Months After Date of Issuance
1:\forms\pwperm
Revised 12.27.04
01x''27./2011 11:40 40$27979~P
SAN JOSE WATER MAINT PAGE 02/02
GE ~~, ER T ~~ IU ~
I- A Construction Cash De
when Cit nr pORt1 is required, Charges will be m~dC a
Y dercd barrjcading is r'cquired. Arty such costs in ftainst this tlCpasit if' thcrc is an cmeraen
exCCSS of the deposit wi.p be billed to the Permittee, call-out, overtime inspection or
2. A anc-yCar maintenanCp crj
P od and surety arc required. Such period will bcRin on date of written acccptant:c by the Ciry,
work by the Cjly.
3. Refund of the cash deposit balance and refund or Canccll~('jon of [he Faithful Pcrtormance Surety will be initiated b the
Y written acceptance of the
writing to the 1'Mritittcc.
4.. The Pprmittce mugr requcgr jn writittg a fn;l1 in~'+ection end accepranee of the wank upon cnmplctjan, Acceptance by the Git wilt be
Y made jn
$~ MNntain Safe pedestrian Aad vehicular c
rvsstngs and free access to private driveways, bus grope, fire hydrants and water valves,
G. A Construction']taffic Contro! Plan
r'evicwcd and apprpym grid a Car-struction Sahcdule arc rCquircd for all lane clacures, detours and sheet clpsures_ 7tris plan must be
Pntrr to any lane closures.
7• ~C Construction Traffic Control Plan shalt conform to the Cttitrang Manual of "lYaffxC Controls for Construction and 1vlaintCnancc Wor
dated !990, available at Cal~ans. Traft~: ~nol equiprr~y shall jnCludC Typc if flashing at7ow sighs if rcquimd.
R- Replace as dtrectcd by the Ci En lacer an k hones,
sole expense of the pctrtttjtteo. ty Jt Y damaged ar removed improvements in accordance with City Standards ,tad Specifications at the
9- Sawout for all PCC or aC removals, An 1'CC removals shalt be in nearest gcoremark and shall be doweled to ex;sHn
l0. Prior approval of inspcctnr is required for an work g A tmpravemcnta.
Of inapCC!'ion costa at t!)C Current aVertimc t~tC. done after norms! Workin hours, on weekends ar holidays antl mAy rcgtti[e rcimburscmcnt
1 1 • Ade note ~
q si ing and barriC;lding is required on Utc job site. Failure t4 pmvicte such si in
signing and barricades and charging the cost (inchrdjng all labor and melcrja~ a
gn g and barricading may result in the City's providigg
12. Compaction tasting of sub dc, ) gainer the cash deposit.
~ base mck, and asphalt concrete by Petmittee is required unless otherwise staled by the City Engineer.
13. The Contractor or Permittcc will have a supeiwisa p
Conttactnr or Pcrmjttec ahllt provide a phoac number a! which h tattvc availablC for contact or1 the project at al! tines duran c
t4, No storage of materials or Cgnipmcnt will be allowctl Heart the ed ~Of n be contacted ouLgidc the hours of S:0(1 a,m, p, q; g anstruCtion.
~ p.m,
a hazardOUS condition to the public. $ PavemCtlt, the traveled
~""aY• M' within the shoulderline which would create
15. 't'his permit shall
not be construed as authorjyatirm For exCavatinn and Rradin on
g private propcrt. 'ld'accnl to the Work
which a Separate petrrn! may be required, nor does jt relieve the Pe[mittcc of any obligation to obtain an ether
Y ` ~ or any other wprk for
agency,
16. This pcrTttil doh not rclCase the Fermittre from :toy liabitidas Contained in abet aj;rcements ar ContrnCts wjtl~erCily and 2n w.
17, This permit is oat transferable. Work most be performed by the Pcrlttlttca ar his designated a Y other public
18, Call bac& (Cat! out) due to corer gent m' Contractor as s).rec7ficd tbtrcnn,
acurrcnCC, gcnCies rcgaty]jng this ]~trtil shat] be at rite entreat overtime rate with a three 7 hour
~-) minimum charge per
]9. Pursuant to Chapter 1x:02 of the Campbrdl Munjcjpal Code, a
drain system other than atornt Water. App)ieReL shalt adhere to phctp68ThM1 not Cause to be disChar cd an P
gram,
Llrban ]:tunpfl'Pollution ~vention Pro ANAGBM)?;~• pItAC't7Cl?S cstabtiahcdlby thelSanta C1ara1V q~
20. if the public interesl [equires a modifiCatian of, or a deparnr~ from, the plans and
approve any modification or dcparturo and to s coif the manner in which the game is to be made far Cit -o
p Y SpcciffCatitms, the City shall have the autho><y!y to require m
Applicant shall responsible for ensurjng that al] thoee providjng scrviCes natter the aPPlicant arc aware of and understand alloftthe ab tittles.
~ ave Conditions.
]leant L ~ r
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Contractor {Prim Name}
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