ENC2010-00080CITY OF CAMP$f:LL
DEPT. pl? P1J8LIC WORKS
70 Notch First St.
Campbell, CA 95008 -
(408} 8GG-2150
):aX (408) 376-0958
BNCROACC-IMENT PPRMIT
(for working within the public
right-of--way) / `
issued 6l ~ (I U
Permit Expiration Date ~ ~ ~
Perrtat No ~~~- ~ ~ ~ _ ~ V~
X-Ref. File
Application Date r7 `Z ~ 0
Application Expiration Date ~
APN ~ 1 ~~
APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section ! 1.04. (Application expires in six (6)
months if the permit is not issued. Application Fee is nan-refundable.)
A. Work address or tract ti~ {'~~ l~`/e ~Ct~dP,w pr -i!-o ~~uU N~O ~~H,~ K~tc_ct~_ ~,~fY(p~' ~~t/~~~p ~ (jd .~.r~
utility-truwAdocntie°nf° t-tfC+x f r' 1 ~-t- r'C~1G 1~
13. Nature of w«k _ t rn~t~~~ c. ~csw"~ro 1
C. Attach four (4} copies of an engineered plan showing the taation and extent of the w«k, and four (4) copies of the preliminary Engineu's Estimate of work. The
plans shall show the relation of the proposed work to ex{sting surface and undcrgrauad iatpcovements. When approved by the City Bnginur, said plan becomes a
part of this permit.
D. Ati work shall conform to thcCity of Cnmpbell Standard Specifications and Details f« Public Works Couswction; the Qeneral Permit Conditions listed at the
reverse side; and the Special Provlstars for this permit, listed below. Failure to abide by these conditions and provisions may result in Job shutdovnt andlor torfciture
of Faithful Performance Sureties and cash deposits. (Ste Oe»eral Permit Conditions 1 and 2.)
E. The Canuact« must have this permit and approved plans at the site and must notify the Public 1Yorks Department at (east two days before stazling work. Notsce
must be given to Public 1Yorks at least 24 hours before rest~atrti~ng_any wr«k, - /~
Name of Applicant ~-~ a ~ ~ QtAY < ~ e~l~ z L ot"' ~4.K,- ~o~ 2 ~ Tcltphoae `~8~ Z T 7 s~ (.o (7
~l,~ h ~ 7' (print an
Addressl~tU ~TMa~eurh ~~-y, ~ J ~ ~~~ 2q-HOUR EMERGENCY TBLBPNQNE NO.~4o~) ~~ -2647
E-Mail Address o1 a ~ +'~ ~ B 1.1 re ~,.~5 ~ ~ ~ ~J ~ ~ O 5 Q 'L~3 '~ e N
is this work being done by the property owners at their own residence? Yes ~__.No
The ApplicanUPerrnitteehoreby agrees by affixing their signature to this pttntit to hold the City of Campbell, its officers, agents and ertiployees frce, safe snd harmless
from any claim «demand for damitges resulting from the w«k rnveretl by this permit.
The ApplicatsUPermiuechoreby acknowledges that they have read and understand both the front and back of this permit, and tiny will inform their contractor(s) of the
information. Applic t is advised that upon Issuwtco of this permit, property ownu, « progeny owner's suaessots, shall be ruponsible for any atxi ail damages
arising out of thin don any pdv~ improvements in the~pyrblie sightof-way,
fi/~ ~
0
/ _ ` ~ (Applicant Pcrmiuee) (sign} Datc
Conttzet« (Print Name) Datc
.___l. • Street ahali not ba open cut for underground installations. Minimum cuts ~gy be albwed foY connections or exploration holes. Such cuts_It~r
bhp ifi ally AAAfl~LYJlIS<l~:{~It~DJ~ 'uin .
_2. Pavement may be cut for unduground instaliatians and must be restored in accordauce with Ure Standard Details Trench Restoratian Method
"A", unless otherwise approved by Mspector.
~3. ~Yorlc to be stakul by a licetrsed land Surveyor or Civi! Enginur and two (2) copies of the cut sheets sent to the Public W«ks Department
before starting work.
~4. Per Section 42t 5 of the Qovernment Code this permit is not valid f« excavations utttil Underground Suvice Alert (U5A) has been notified and
fire inquiry identificati«t numbu has been tntered hereon. USA Phone 1-g04-227-2600, USA TICKET NO.
~.~,5. Pd« to any work, the property owner shalt execute an Agreement for Private improvements in the Public Riglu-of--Way, which shall be
roc«ded.
____,6. Public Notification Reguirentcnts:
7.
SEE PUDL[C WORKS FPF SCHHDULE t-0R CIIRR~NT FFFS AhS,QSjKT RBCP~jPT NO.
PERMiI' APPLICATION FEE ~ S ~
PLAN CHECK DEPOSIT ~ s
SECURiCY POR FAl'1'HFUL PBRFORAlANCE/LADOR 8c MATERIALS
CON$'IRUGTION CASH DEPOSTI' S
PLAN CHECK dt INSPECTION FBB g
APPROVED FOR 1SSUANCB ~Pi~( 0
P«CiryEngineer Date
Pumil Expires 12 Months After Date of Issuance
":~ i S ~ ~
GL~NERAL PERMIT CONDITIONS
1. A Construction Cash [kposlt is required. Charges will bo made against this deposit if there is an emcrgeucy call•eot, overtime inspection or when City
ordered baaicading is required, Any such costs in rxcess of the deposit will be billed tb the Permittee.
2. A one-year maintenance period and surety ara required. Such period will begin on date of written acctptance by the City.
3. Refund of the rash deposit balance and refund or canceNation of the Fallhfut Performanca Surety will be initiated by rho written acceptance of the work
by the City.
4. The Peruduee fnust request in writing a final inspection and acceptance of the work upon completion. Acceptance by rho City wilt be made in writing to
the Pumittee.
S. Maintain sofa pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants and water valves.
6. A Construction 't'raffic Control Plan and a Construction Schedule are required for all -aae closures, detours and street closures. This plan must be
reviewed and approved prior to any laue closures.
7. The Construction Traffte Control Plan shall conform to the Caltrans Manuat of Traffic Controls for Conslruclion and Maintenance Work Zones, dated
1990, available at Caluans. Ttafflc control equipment shall lnctude Type II flashing arrow signs if required.
8. Replace as directed by the Ciry Engineer any damaged or removed improvements in accordance with City Standards and Specifications aF the sole
expense of tha Permittee.
9. Sawcut for at) PCC or AC removals. Al! PCC removals shall be to nearut scocernark and shall be doweled w existing improvements.
10. Prior approval of inspector is required for any work done after normal working !tours, 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 m provide such signing and barricading may result in the City's providing signing
and barricades and ehargiug the cost (including ati Tabor and materials) against the cash deposit.
12. Compaction testing of subgrade, base rock, and asphalt concrete by 1'emtittee is required unless otherwise staled by the City Engineer.
13, The Contractor or Petmittee will have a supervisory representativa available for contact on the project at all times during construction. Cattraetor or
Permittee shall provide a phone number at which lheycan be contacted outside the hours of g:txi a.m. w 4:00 p.m
I4. No storage of materiols or equipment will be allowed near tTk edge of pavement, the traveled way, Or within the shouldertine which would create a
hazardous condition to the public:
I5. This permit sl>all not be construed as authorization for excavation and grading on private property adjacent to the work or any other wok for which a
separate pumil racy be required. nor does it relieva the Permitter o(any obligation to obtain any other permit required by taw.
l G. This permit does not r<lease the perntittee from any IialHtities contnintd in ahu agreements or contrecu with the City and any ocher public agency.
[7. This permit is not transferable. Work must be performed by the Permitter or his designated agent or contractor as specified thereon.
i 8. Cali back (call out) due to emergencies regarding this permit shall ba at the current overtime rata with a three (3).luwr minimum charge per occurrence.
19. Pursuant to Chaptec 14.02 of the Campbell Municipal Code. applicant shalt not cause to be discharged any material into the municipal storm droin System
other than storm water. Applicant shall adhere to Ilte DF.ST MANAQEMENT PRACTICPS estsblishal by the Santa Clara Valley Urban Runoff
Pollution Prevention Program.
20. If lire public interest requires a modification nf, or a departure from, the platu and specifications, the City shall have the authaity to require or approve
any moslitication or departure and to specify the manner in which the lama is to be made for Cityowned or maintained facilities.
21. Permittee must provide advance notification to sll parties that tray be affected by the permit activities. Notification shall be roviewed by City prior to
d{stribudon and lnctude data of work and a Contact Hama and phone number.
Applicant shat[ he responsible for ensucing that all (hose providing services under the applicant are aware of and understand al( of the above rnnditions.
-~-- Ap scant Date
Contractor (Print me) lyato
Nornulpwperm
Rev. t 1!9105
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