ENC2011-00132Ptint:Form
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Permit No ~tVC 20 (, l ~ Oo 132
CITY OF CAMPBELL ENCROACHMENT PERMIT
DEPT. OF Pi1BLIG WORKS (for working within the public X-Ref. File
70 North First Strout right-of-way} Appltcaiion Date ~ V I ~) _
Campbell, CA 95008 ~ V/r~~(i Application Expiration Date I z
Ph. (408)866-2150 Issued
APNL J_
Fx. (408) 376.0958
Permit Expiration Date ~ G v Z ~--~"~ ~~' C~ ~J3
APPLICATION - Appllcation is hereby made for a Public Works Permit in accordance with Campbell Municipal!Code,~S~ection t 1.04. (Application expires to six
(b) months if the permit is not issued. Application Fee is non-refundabie.)
A. Work Addressor Tract No.: 1781 GRACE AVENUE, CAMPBELL
UtilltyTrench Location: W/S GRACE AVENUE, 3i 3' N/O GRACE CT.
B. Nature of Work EXCAVATE 4'x6' BELL HOLE
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. Ail 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 forthis 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
NameofApplicant: pG&E Telephone: 408-249-1042
Address: 308 STOCKTON AVENUE, SAN JOSE 95126
E-Mall Address: 24-HOUR EMERGENCY PHONE NUMBER:
is this work being done by the property owners at their own residence? I"' 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 ownerY successors, shall be
responsible for any~andtall da/m_ages arising out 1of~the condition of a pr ate tmprovem,71.,~,~~t/,the public right-of-way.
Accepted: ~i-Y'~IC.~ ~~~~Y~ ~iL,l~ ~Td~"dslr`'" ~a--~9-~ f
(Applicant Permlttee) ~ {;igfiy'" / ~/ Date
(Contractor) (Print Name)
Date
SPECIAL PROVISIONS:
1. Street shall not be open cut for underground installations. Minimum cuts ~y be allowed for connections or exploration holes. Such cuts maybe
specifically approved by the inspector prior to cuttino.
_~. Pavement maybe cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method
'A", unless otherwise approved bythe Engineer.
3. Work to be staked by a licensed Land Surveyor ar Clvll Engineer and two (2) copies of the cut sheets sent to the Public Works Department
before staging work.
4. Per Section 4215 of the Government Code this permit is not valid for excavations until Underground Service Alert NSA) has been notified and
the inquiry Identification number has been entered hereon. USA Phone: 1-800-227-2t~00. USATICKET NO.
5. Prtor 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
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCEMBOR & MATERIALS
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & INSPECTION FEE
EMERGENCYPERMff FEE
APPROVED FOR ISSUANCE
Permit
5 MOUNT 3~ RECEIPT NQ~
~--
5
S
For City Engineer
t2 Months After Date of Issuance
l 2° i I
Date
o ~, ~ /~`~~l S /~ v
GENERAL PERMIT CONDITIONS
1, A Construction Cash Deposit is required. Charges will be made agalnst this deposit if there is an emergency call-out, overtime inspection or when City
ordered barrkading 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 ofthe work
by the City.
4. The Permlttee must request fn writing a final Inspection and acceptance of the work upon completion. Acceptance by the City waif be made in writing
to the Pemtittee.
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, A Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls forConstruction and Maintenance Work Zones, dated
1990, available at Caltrans. Traffic control equipment shall include type If 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 Permlttee.
9. Sawcut for all PCC or AC removals. Ali 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.
i 1. Adequate signing and barricading fs 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) agalnst the cash deposit.
12. Compaction testing of subgrade, base rocly and asphalt concrete by Permittee is required unless otherwise stated by the Clty Engineer.
13. The Contractor or Permittee will have a supervisory representative available for contact on the protect at alt times during constnrction. Contractor or
Permlttee shall provide a phone number at which they can be contacted outside the hour of 8~0 a,m. to 4:00 p.m.
14. No storage of materials orequlpment will be allowed near the edge of pavement, the traveled way, or within the shoulderline which would create a
hazardous condition to the public.
1 S. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work forwhich a
separate permit may be required, nor does it relieve the Permlttee of any obligation to obtain any other perrnlt required bylaw.
16. This permit does not release the Permlttee from any Ilabllities contained in otheragreements or contracts with the City and any 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.
16. Call back (tail out} due to emeregencies regarding this permit shalt be at the current overtime rate with a three (3] hour minimum charge per
occurrence.
19. 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 HEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban 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 modTRcation or departure and to specifythe manner In which the same is to be made for Qty-owned ar maintained fadlitles.
21, Permitttee must provide advance notification to ail parties that may be affected by the permit acthrlties. Notification shall be reviewed bythe 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.
i~'"G".~-~'~.
Applicant
/O- /9- //
Oate:
Contractor {Print Name) Date:
J:\FORMS\Templates\Encroachment Permits\Encroachrnent Permit STATtC form2.pdf
Rev. 09/10
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ADEN CAMPBELL PERMIT DRAWING so
SUPV: Alan Davila REPLA CE GAS SERVICE NOTIF: 105395925
REP: OTHER:
PLNR: 1781 GRAC E AVENUE, SAN JOSE sHT: ~ of ~ S HEETS
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1 =30 DATE`
09-28-2011 ~ PACIFIC GAS AND ELECTRIC COMPANY P~~30869554 REV.