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ENC2017-00282CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No �17J2 forworkin within the public X-Ref. File 7 70Nort Firsts reef ( right-of-way) p Application Date It �4 1 70NorthFirstStreet g YI PP Campbell, CA 95008 i �Application Expiration Date 5 �7 Ph. (408) 866-2150 Issued �q /� APN Fx. (408) 376-0958 10 Permit Expiration Date APPLICATION -Application is hereby made fora Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable.) -A. Work Address or Tract No.: 1 a 7 _.._... _. _...-...-._—.__...... .. _—. _...... — __...__..... ........ ........... ..... .... __... ...... ...... Utility Trench Location: B. NatureofWork: C. Attach four (4) copies ofan engineered plan showingthe location and extent ofthe work, and four (4) copies ofthe 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. Al I work shal I conformto the City of Camp be[ [Stan dardSpecifications and Details for Public Works Constructi on; the Genera I 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. 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 startingwork. Notice must be given to Public Works at least 24 hours before restarting any work. Name of Applicant: _ Telephone:. 7 �7(� Address: L ........... ` (........ ,('.. � v1 _...... f...... ...-il,-c�+ ._ _5 E-MailAddress: t o Mob i C�,IMb C b 1 24-HOUR EMERGENCY PHONE NUMBER. ffl ._ _._...- -_... —V Is this work being done property by the property owners _ at their own residenc- ee? - ❑ 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 owner's successors, shall be responsible for any and all damages arming out of improvements completed in the public right-of-way. Accepted: -29 = 2a 1 (Applicant Permittee) (sign) Date (Contractor) (Print Name) Date SPECIAL PROVISIONS: ❑ 1. Streetshall not be open cutfor underground installations. Minimum cuts maybe allowed for connections orexploration holes. Suchcutsmaybe specifically approved by the Inspector prior to cutting. ❑ 2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A", unless otherwise approved by the Engineer. ❑ 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 4216 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. ❑S. 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. Public Notification Requirements: ❑ 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT t RECEIPT NO. PERMIT APPLICATION FEE $ 1 7� Z7�(} PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK & INSPECTION FEE $ EMERGENCY PERMIT FEE $ APPROVED FOR ISSUANCE ' I( 7 For City Engineer Date Permit Expires 12 Months After Date of Issuance GENERAL PERMIT CONDITIONS C 1. The Permittee must provide evidence of insurance and Additional Insured Endorsements as required bythe City. Insurance shall be maintained forthe duration ofthe permit work.. 2. A Construction Cash Deposit is required: Changes will be made against this deposit if there is an emergency call -out, overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 3. Refund of the construction cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. Surety posted shall be equal to 25% of the original Faithful Performance Security. 5. Submit project schedule 10 (ten) days prior to proposed start of work. Additional lead time may be required for work within City facilities and downtown Campbell. 6. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. 7. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants, and water valves. 8. 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. 9. A Construction Traffic Control Plan shall conform to the 2006 California Manual on Uniform Traffic Control Devices (MUTCD). 10. 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 Permittee as expeditiously as possible. 11. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and new PCC shall be doweled to existing improvements. 12. Prior approval of inspector is required for any work proposed after normal working hours, on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 13. Work on arterials and collectors may require the use of changeable message boards. Adequate signing and barricading is 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) against the construction cash deposit. 14. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 15. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m. and on weekends. 16. No storage of materials or equipment will be allowed near the edge of the pavement, the traveled way, or within the shoulderline which would create a hazardous condition to the public. 17. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a separate permit may be required, nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 18. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 19. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 20. Call back (call out) due to emergencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence. 21. 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 BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. 22. If the public interest requires a modification of, or a departure from the permit, plans, special provisions and/or specifications, the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made. 23. Permittee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and a phone number. 24. Applicant shall remove water from utility vaults in accordance with the requirements of State Water Resources Control Board Water Quality Order WQ 2014-0174- DWQ. Said vault water shall not be discharged into the City of Campbell's storm drain system. See http://www.waterboards.ca.govZwater issues/programs/npdes/utilityvaults.shtml for more information. Applicant_is hereby responsible for ensuring that all those providing services under the applicant are aware of and abide by all of the above conditions. Applicant Contractor (Print Name) J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.03/17 1 l - z9 -2_0 l7 Date: Date: PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MISCELLANEOUS RECEIPT Effective July-1, 2017 TO: Finance PUBLIC WORKS FILE NO. C- ©� 7' PROPERTY ADDRESS Please collect & receipt for the following monies: 4722 Utility Encroachment Permit Application Fee $455.00 R-1 Encroachment Permit N/C Emergency Permits $130.00 Plan Check & Inspection Fee Minimum Charge Per Location $420.00 Conduits/Pipelines up to 500 Feet $2.95/ft Above 500 Linear Feet $1.75/ft Manholes/Vaults/Etc. $190.00/ea Pole Set/Removal $190.00/ea 4760 Storage Container Permit (valid up to 60 days only) $170.00 4760 Project Plans & Specifications Project No. 4760 Standard Specifications & Details $1/Pg $15.50/13k 4760 Engineering Maps & Plans Aerial Plot 24" x 36" $65.00 Aerial Print 8 1/2" x 11" $32.00 Map Research (includes max of two 24"x36" copies) $32.00 Maps and Plans 24" x 36" $15.00 4722 Penalties: Failure to restore public improvements $100/Calendar Day (Muni Code Sec. 11.34.010) 4722 Penalties: Failure to correct unsafe conditions $100/Calendar Day 4722 TRAFFIC ~ Work Without Permits 4Times Applicable $500 .. '. A a��r,t45� ,t xc i 4728 Traffic Flow Map (Daily Traffic Volumes) $35.00 4728 Signal Timing Information $73 per hour 4271 Truck Permits $16.00 per trip 4728 No Parking Signs $1 each or $25/100 511.74241 Postage Other (Please Specify) TOTAL NAME OF APPLICANT � vi NA,(\- n NAME OF PAYOR �:�V\, ��� V" A PHONE ADDRESS FOR ITY CLERK ONLY J:\FORMS\Templates\Administrative\Receipt Form Utlity Encroachment & Misc 17-18.x1s