ENC2010-00107DEPTOOFF PUBL1~9•~I ~/ CC
70 North First St.
Campbell, CA 95008~UL 1 3 2010
(408)866-2150
Fax (408) 376-0958 PUBUC WORKS
a~n~iNisrR~nav
ENCROACHMENT PERMIT
(for working within the public
right-of--way)
Issued ~` k I"f' i ~G
Permit Expiration Date ~ ~
Permit No FNE 2U 1 U ' D C / t:7
X-Ref. File
Application Date ~ - /~ - I G
Application Expiration Date ! - (~ - ! ~
APN
APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in
six (6) months if the permit is not/issued. Applicati~o/n Fee is non-refundable.) , / •,~
A. Work address or tract # ' Vi'~ ~/ ~ ~ ~1C. ~ ~~ ~ L' 1 6 i /~t~-~'
Utility trench
B. Nature of work
vvi ~ ,,,, r-, ~..~
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 [o 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 . eithful 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 ho rs before restarting any work.~j //~
Name of Applicant _ ~i ' 't ~` ~~ """ `'"'7 v ~~~~' Telephone ,Tv~ ~ 7 ~
/ l G~ / ,) h 7 ~ rint name) > ~ ~, ~
Address (~l 11 24-HOUR EMERGENCY TELEPHONE N0. ~~ ~ 7I 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 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 ApplicanUPermittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their
contractor(s) of th information. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible
for any and ail d rr ges arising out of the c~ondit~of any privateautprovements in the public right-of-way.
~~/,~/~%
,(Applicant Permittee) (sign)
Date
Contractor (Print Name) Date
SPECIAL PROVISIONS
_1. Street shall not be open cu[ for underground installations. Minimum cuts ~ 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 underground installations and must be restored in accordance with the Utility Restoration Standard Details Method
"A" Backr"ill, 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 $ 4~6" _
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $
CONSTRUCTION CASH DEPOSIT $
PLAN CHECK & INSPECTION FEE $~
APPROVED FOR ISSUANCE 7~ 14' ~ IO
For City Engineer Date
Pernut Ex fires 1 Z Months After Date of Issuance
_.._-._____.r. .. i.-_.__ - ~
Revised 12.27.04
~.~ ( ~ j (,~ L ~
G~~NERAL p~RMY'r CONDY'CYONS
1. A C,OIIStruCtiOn Cash pepnait is rpyuircd. Charges will be made u$0.iust this depi,sit if Ihcre is aY, GYlGrgcnCy Call-out. Overtittle 1tlspccLinn or
When C'9ty ordered barrtcadutg lS rcgmred. Any such COSTS in G7[GGS6 Of the dGpgSit W111~~bG billed [o the pGrnuttee.
3. A one•year muinte,tancG period and eatery arc rGyuired. Such period will besin on data of written accaptancc by the City.
3, Refund of the c:rslt deposit baiauce and refund ar cancellation ai' d,e Faithful parfor,nance Surety will be initiated by [he written accaptanee of the
work by the City,
4. The Permittee mus[ request in writing u final inspection and acccptancc of the work upon completion, Acceptance by the City will be mode in
writing to u,e Permittce,
5, Maintain safe pedestrian attd vehiouL•tr crossings and free access [o prvate driveways, bus stags, firo hydrants arsd wa[er valves.
6, A Construction Traffic Control Plan and a Construction Schedule era required for all lone closures, defOat'S and street closures. Ttus plan must be
reviewed and approved prior to any lane closures.
7, The Coosu~uGtion Traffic Control Plan nhr,11 cottfanrn to the Caltrans lVlanuai of 'Traffic Controls fa' Construction and'Maintcuauce work Zones,
datod 1490, available a[ Ca1t,'ans. Traffic control equiptncnt shall include Typc ^ flashing arrow signs if required.
8, Replai;e as directed by the Gity Engiucar any damaged or rc,novcd improvements in accordance with City Standards and Specifications at the
sale expanse of the partnittce,
y. Suwcut for all PCC or AC removals. All PCC removals shall be to nearest scurerxtark and shall bG doweled to cxisung iniprovGmnnts,
1 U- prior approval of iltspeciot' is required for any wrn'k done aftar norlual working hour&, nn wccktnds or holidays and ntay TGgpirc rcitnbursCment
Of jnSpBC[i011 C06ts aC [lra CurrcnC OYCCCimc rd[e,
l i. Adei{uate sighing atld bamcaditlg is required on the job site. Failure w provide such 3ipr[ing and barricading nl:ty result in the City's providing
signing and barricades and charging the cost (including all labor and tnatcnuls) against d,e cash dcposi[,
12. Compaction testing of subgradc, bast rock, and asphalt concrete by }'ernuuec is required unless otherwise rutted by the Ci[y EnginGCr.
13, The Cuntru[or or Permittee will have u supervisory ,eprescntativc available 'For contact 6n the project at all times during cotuu~uclion.
Conuactor or Permittre shalt provide a phone number at which they can be contacted outslde the hours of 8:00 a.m. W 4:00 p-m.
14. No storage of ,natcrials or equipment will ba allowed near the edgu of pavement, the travt:lod way, or within the shoulderlixrG which would Greats
a hazardous conditia] to urn public-
t5. This permit steal! not be construed as authorization for cxcuvation and grading an private property adjacent to the work ur any other work fur
which a separate permit may be reyuit'ed, nor does it relieve the Parnuttec of any obligation m obtain any other permit required by low.
1G. This permit does eat release the PCrmittce from any liabilities contained in other agreements or cautracu with the City and any other public
agency,
l7. This permit is not transferable. Work mustbc performed by the Pet~l,ittec or his dcsigaated abcn[ or con>zr,ctor as spacificil thereon.
18, Call back (call cu,) due to emergencies regarding this permit shall be at the current over[itnC rate with a tluee (3) hour minimum charge per
ac:CUtTa11CC.
-9. Pursuant to Chapter 1A.02 of the Catnpbail Nluaicipal Code, applicant shall not cause to 6t: discharged a»y matcrirtl into the municipal slam,
drain system otters than storm water. Applicant shall adhere w the BEST MANAGEMENT P[tACTTCES establislud by the Santa Ctsuu Valley
Urban Runoff Foliation Prevention Progrnm,
2U. approve any imodifieationior dGpur[ura and m specify the meatier in which the saute is to be rytiade fortC ys-awned orvmainta,ned facil,[ies.yuire or
Applican[ shall be respoagiblc for ensurinr; tour all those providing services under the applicant arc aware of and understand all oP the abavt: wnditious.
/ y/
Applicant
t~
Contractor (Print Noma}
]:lformslpwpGrm
Revised 1.20.OA
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