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ENC2011-00041CITY OF CAMPBEI..L DEPT. OF PUBLIC 70 North First St. Campbell, CA 45 8 (408)866-Z 150 Fax (408) 376-0958 J~o ~~° ~ r..riCROACHMEN7 PERMIT 101 (for working within the public ~ ~~~9`~oP~~s~Itt-of-way) /~ Q. J~G„~ Issued ___ ~'/ ~(~ _ Q Permit Expiration Data 4' ~ L Permit No ~ti~~,Z Gel/ l ~ _CiC~ y/ X-Ref. File Application Date Applicaaon Expiration Datc / d ~ // APN ~~'~ 'O~'OC?. APPLICATION - Appticatitm is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section I I.04. (Application expires in six (6) months if the pernsit is not issued. Applicati9ongFee is nGott-rcfundablt,) ~J A. Work address or tract # ~~ / / G_ L- ~OGyC~ ff y~ . Ph'1 3 0 ~ ~/ S /~'/ Utility trench $. Nature of work /~8~~oe~/ . •. ~s7 3/¢lSrc Gam' SF.ey~c~ ~~X~ %.~-f~OG C. Attach four (4} Copies of an engineered plan showing the location and extrnt of the work, and four (4) dopies of the prtliminary• Engineer's Estima[t of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Ent veer, said plar, 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 tht Special Provtsions for this permit, listed be)aw. Failure to abide by these canditions 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 siu and must notify the Pubic Works Department at least two days before starting work. Notice must be given to Public/Works a€ Ica/st 24 hours before restarting any wprk. /fin Name of Applicant (/©/y/~Gs/~!'~1~uCG'~/ "- /~~ ~ ~ Tele hone( 7T~~~ ~Zr ~~~,~ {print name) ~ P ~~ E-Mail Address v ~~~~~G ~ - ~~ 24-HOUR EMERGENCY TELEPHONE NO. is this work being done by the property owners at their own residence" +~ Yes No The AppiicanUPermittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its offrctrs, agent_e and employee 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 hack of this permie. and they will inform their amtractnr(s) of the information. Applicant is advised that upon issuance of this permit, prapery awner, or property owner's successors. shall be responsible for any and all damages arising out of the condition of any private improvements in the-ubic ng(tt-of-w~.y -~APPli:ant Permiuee) (sign) I}a~ Contracwr (Print Name} Date _1. Streit Shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may b~ecificaliv approved by [he inspector prior to cucttns. _2. Pavtmtni may be cut far underground installations and must be restored in accordance with the Standard Details Trench Restoratior, Method "A", unless otherwise approved by Inspector. T3. Work to be staked by a Gccnsed Land Surveyor or Civil Engineer and two {3) copies of the gut sheets stns to the Public Works Department before starting work. ~4 Per Section 4215 of the Government Cade this permit is not valid for excavations until Underground Service Alert (USA) has been notified and the inquiry identification number has bern entered hereon. USA Phone I -800-^_27-2604. USA TICKET NO. _5 Pror to any work. the prapt-ty owner shat3 exc:.utc an Agreemcrt for Private Improvements m the Public night-of-V:ay, which shall be recorded. - `. G. Public Notification Requirements: 7. SEE PLJ$LIG WORKS FEE SCHEDULE FOR CLJRREIdT FEES AMOUNT RECEIPT NO. PERMIT APPLICATION FEE $ 3S0 PLAN CHECK DEPOSIT g SECURITY FOR FATTHFLJL PERFORMANCE!LA$OR & M.4TERlALS g CONSTRUCTION CASH DEPOSIT ~~ PLAN CHECK & ]NSPECTION FEE $___.~~ r! APPROVED FOR ISSUANCE ~{'~~LG~I ~ For City Engineer Date Permit Expires l~ Months After Date of Issuance a(~ s/[1 /~S A `~ GEi~fERAL PERMIT COAtDITIQ?VS 1. A Canstructicxi Cash Deposit is required, Charges will be made against this deposit if there is an etnerganry cat{-out, overtime inspection or when City ordered battitxdiug is required. Aay such coati is excess of cite deposit will be billed to the Permittce, 2. A one-year rtrainteatance period and surety are regtired. Such period wilt bt~a oa data of writtmt aceeptattce by the Ciry. 3. Rcfsmd of t3se rash deposit balance and reflood or caactslarioa of the Faithful Perfotmaace Surety will be iuittased by dx wriis~ep ax~tance of the work by the City. 4. The Paaaittae roust requrtst is wnau@ a 6aal iaspex~eiaaa and acceptarue of tLe work upon completion. Acceptattcx by the City will be made is writing Do the Pexmiuee_ S. Maintain safe pedestrian and vehicular crossings and frert access to private driveways, bus stops, fire hydrants and water valves. 6 A Coastrttction Tnfftc Corttrol Plan and a Consuuction Schedule are required far all lent closures, detours and street ctosurts. This plan must be reviewed and approved prior to any hurt cbsttres. 7. Tlu Caasaurtoa Tmffrc Catttrol Ptah shall axtfotm to the Caluatas Manual of Traffic Controls for Constntcaaa z~ Maiatatanex Wtrk Zaaex, dated 1990, available at Caluans. Traffic rnrttmt equipment shall inchuk Type >l ftashan$ arrow signs if required, g. Replace as directed by the City E.rtgineer any damaged er re:rnovexi improvements io accordance with Gity Standards and Specifications at tltrt st~c expense of the Ptxmittee. 9. SdWCUt far alt PCC or AC removals, Alt PCC removals shalt be to nearest scoretnark and shall be dowelrtd w existing improvements. IQ Prior approval of isispectrz is required far arty wort; dome after normal working hours, an weekends ar hahdays and may rexluire reimbursement of inspacaao costs at the girrerN av«urtie rite. i i Adequate sicniag alad barria~ding a requirai an the jab site Failure w provide such siz~r. aiag and barrirtdng mau resutt in the City`s providug sigmag and trarsicades arul charging the cost {iaxh~iag all labor and materials against the cash deposit, 12. Compaction tGtuag of sub~ade, bast r~k. and asphalt concrete by Perntittec is required unless athcrwisc statai by the City Engineer. 13. The Contracwr or Permitter wilt have a supervisory representative available Cor contact on the project at alt times during coaistructiaa. Cana°sctor or Permittee shall provide a phone number at which they can be cantactcd auuide the hours of 8:40 a.m, to 4:00 p.m. 14. tVO stalage of artateriats or equipanertt will be allowed near thrt alge of pavement, the traveled way. oz within the shoulderline which wowld create a haurdaus condition to tiro public. l5. This permit 53raU oat be coasssrurtd u autiloaizntioat for excavation and gading oat private property adiaxat to Ilus warl: Cr any aches work #ar which 5 separate permit maybe required. tior does it relieve the Pcrsnittex of nay obligation to gain any other permit requited Iry,taw. l G. This permit darts oar release the Permittee from nay liabiiitics caxttaine~ in other a$reentrtnts or contracts with thrt City aril nay other public u$tncy 1 ~. This permit is not trartsfcrable. Work must be performed by the Pcrmittec err hix designated agent err contractor as specifirtd thereon.. l 8. C-atI back (call owl} due to arxrgeacirts rc~rdng this permit shall brt at the current overtime rate with a three f3) hour minimum ctsarge per ocettrrcnce. l4. Ptarstrant sa Chaptrtr l 4.0'Z of the Campbell Municipak Code, applicant siral3 non .:ause to be discharged any naateriat iota the municipal storm drug systrass o[tser than stars waur. Applicant shalt adhere to the BEST ti9A+~tAGEMIlr? PRACTICES established by the Santa Clara ~1aUcy tirbm Rrmaf! Pollution Prcvcntioa Program. 2{l. If the public interest requite a modification af, or a depaxntrc from, the plans and speufacanons. the City= shall have the authority to require ar appravr nay modification err departure arui to specify tine mannax in which the same is to be made fa Ciry-awned or maintained facititits. 21. Permittee must provide advance notificaticm to ail parties that may be affected by the permit uctivities. Natificatian shall be reviewed by City prior ec> disttbutior, ar,d ircludc data of work and a canes. aamr. and phone nu~.:,cr. Apphcaat shall be rtsponsibk fat ensuring that alt iheut providing services tmd~ the applicaaat arc aware of and undrxstand all of tht above :,anditioas. Applicant Date Contracwr (Print blame) Data Jl~rrats~pwpcrm R.-v. 1119145 PG&E Permit Sketch for: City of Campbell Address: 1199 El Solyo Ave. Nature of Work: Abandon Gas Service at Main Surface: Concrete Cut in Sidewalk Excavation size: 4' x 4' x 4' N~ ~~ ~+ >~ ~ ~ 1 ___~ __~, d' ~r r~ L ~ 0' ~ fi ~ ~ ~ ~ ~ ; ~ DR. 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