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ENC2017-00255f CITY OF CAMPBELL DEPT.OFPUBLICWORKS 70 North First Street Campbell, CA 95008 Ph. (408) 866-2150 Fx. (408)376-0958 ENCROACHMENT PERMIT (forworkingwithin the public right-of-way) Issued Permit Expiration Date �( b APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section11.04. (Application expires in six '(6) months ifthe permit is not issued. Application Fee Is non-refundable.) A. Work Address or Tract No.: Utility Trench Location: -rAhtt Q �wk �rios..s d ( i(mr (A/*1 ��� ®� B. Nature.of WorkAl A : ._..... _..... _..... ..... .... ............ .... __ . _ _ C. Attach four (4) copies of an engi 6ee*red plan showingthe location and extentof the work, and four (4) copies of the preliminary Engi neer'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. Allworkshall conformtothe City of ca-mpbe-11 Standard Specifications and Details for Public Works Construction; theGeneral PermitConditions 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 24hours before restarting inywork. Name of Applicant: ep rcg �+V _ "{ Telephone:: Address: AA�5:. E-MailAddress: ♦• . (/_� /�/• 24-idOUREMERGENCY PHONE TVUNIBER��� ZOO Is this work ' being done by the property owners at th'@ir 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.perniit. 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 arising out of improvements completed in the public right-of-way. Accepted: .� 4 R �� v! JApplicant Permittee) (sign) Name) Date SPECIAL PROVISIONS: 1. Streetshalinot beopen cutforunderground installations. Minimum cuts may.beallowed for connections orexploration holes.Such cuts maybe 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 ❑ 5 Prior to any work, the. property owner shall execute an Agreement for Private Improvements in the Public Right -of -Way, which shall betregorded. ❑ 6. Public Notification Requirerhents: h ; `r, - ❑ 7. SEE PUBLIC 1NORKS`FEE SCHEDULE FOR CURRENT FEES n PERMIT APPLICATION FEE PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCE/LABOR 8, MATERIALS CONSTRUCTION CASH DEPOSIT PLAN CHECK & INSPECTION FEE EMERGENCY PERMIT FEE $MOUNT6 ` . RECEIPT NO. APPROVED FOR ISSUANCE ForCitvEneineer L GENERAL PERMIT CONDITIONS 1. The Permittee must provide evidence of insurance and Additional Insured Endorsements as required by the City. Insurance shall be maintained for the duration -of the 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. S. Submit project schedule 10 (tenj-days°p�ldr to pw'ropo ed kaari of work. Additional lead time may be required for work within City facilities and downtown Campbell. 6.': z The.Permitteemust requefst in wnt n a f, inspRc�tion.and accgepfance of the�wo�h upon o�npletigno Acceptance by the City will be made in writing to the Permittee. y: . 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 closuresi cl6ic4rs, 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 thejob site. Failure to provide such signing and barricading may result intheCity'.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 concretepby Permittee is required,unless otherwise stated by the City Engipeer, .. a u•_i.x : �r 15. The Contractor or Permittee will have a supervisory representative available for contact on th`e project at all times during Construction. Contractor or Permittee shall provide a phong number at which. they can be contacted outside the hours of 8:00 a.m. to 4 00 p.m and on weekends, F, 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 orany other.work for which a separate permit may be required, nor does it.relieve the Permittee of any obligation to obtain any otherpermit 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 put),,due to, e'mergehcies regarding this perpft shall:beit the-Gurrentovertime rate,'wdh 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 tothe 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.gov/water 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 �T— Date: Contractor (Print Name) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.03/17 CALL: 811 0EF OR Yp. Qv O� SA h Gyo��cR��NO SEf��� CALL: 811 CALL TWO WORKING DAYS BEFORE YOU DIG TICKET N01 DATE: 1655 WALTERS AVE CAM PB ELL, CA CAUTION! HIGH PRESSURE GAS PIPE. HAND DIG NEAR GAS PIPE NOT TO SCALE 111 AFETY SAFETY PLEDGE I ALVAYS NNFE AFETY FIRST. I LOOK ND ACT TD RESOLVE SITUATIONS. I HELP AND ENCOURAGE OTHERS TO ACT SAFELY. NOTE: ALL TRENCHING AND BACKFILLING TO BE PERFORMED BY BUILDING CONTRACTOR LEGEND 1" SERVICE m . GAS METER LOCATION TAP HOLE 5' X 4' X 18° UNDER GAS PPE PBO 17'x30' 1655 WALTERS O URLTIY POLE AV JOINT TRENCHiT y N Dy ELECTRIC METER 1 � s 2 OF 6D�E � p 2- of L1NE N MAP 3410-A6 CPA 3410-07 BUILDING CONTRACTOR TO DIG GAS TAP HOLE 5' X 4' X 18" UNDER GAS PIPE BUILDING CONTRACTOR TO TRENCH AND BACKFILL ALL BUILDING APPLICANT TO INSTALL 61'-1" PLASTIC GAS SERVICE SEE ELECTRIC CONSTRUCTION DWG FOR FRANCHISE JOINT TRENCH : J ADE..OHN GAMBl1CCl ......._....__. CONDWG A ADE lv V cr A j olca 4.1 Z' - ' E ® LL a. a. CL m < F TAP HOLE 5'X4'X18" UNDER GAS PIPE SUR ERIN STRAUB 1655 WALTERS AVE REP: BEN MORALES PLNR: CAMPBELL SCALNTS D0511217 ' PACIFIC GAS AND ELECTRIC COMPANY CO: SD: NOTIF: 111470568 OTHER: SHT: SHEETS PM: REV. 31286180 APPLICANT CHECKLIST ■ CONTACT UNDERGROUND SERVICE ALERT "USA" AT 1-800-227-2600 (OR "811" BY LANDLINE), AT LEAST 2 BUSINESS DAYS BEFORE EXCAVATION, TO HAVE EXISTING UNDERGROUND UTILITIES MARKED IN FIELD OBTAIN CITY/COUNTY EXCAVATION PERMIT (IF APPLICANT TO TRENCH) ■ FOLLOW TRENCH INSTRUCTIONS (IF APPLICANT TO TRENCH) APPLICANT TO BACKFILL IMMEDIATELY AFTER INSTALL. MINIMUM OF 4" OF SAND AND 8" OF NATIVE SOIL DAY OF CONSTRUCTION. HAVE SUFFICIENT SAND ONSITE PRIOR TO FINAL INSPECTION, REFER TO GREENBOOK SECTION 2.3.4 MAINTAIN 3' MINIMUM PARALLEL SEPARATION FROM WET FACILITIES (I.E. WATER, SEWER, STORM), REFER TO UO STANDARD S5453, EXHIBIT B -_ TRENCH MUST MEET PG&E STANDARDS (SHOWN BELOW) AND HAVE 2" OF PG&E APPROVED SAND ON BOTTOM OF TRENCH BEFORE FINAL INSPECTION. COORDINATE INSTALLATION OF TELEPHONE AND CABLE IV FACILITIES PER THEIR CONSTRUCTION REQUIREMENTS CALL (408) 725-2202 OR FAX (408) 725-7773 FOR PG&E TRENCH INSPECTION — AT LEAST 2 BUSINESS DAYS ADVANCE NOTICE PLUMB GAS HOUSELINE TO NEW LOCATION AND HAVE MUNICIPALITY NOTIFY PG&E THAT GAS HOUSELINE HAS PASSED INSPECTION GAS METER GUARDS PER GAS STANDARDS AND SPECIFICATIONS MANUAL SECTION J-95 PAYMENT MUST BE RECEIVED BY PG&E, BEFORE CONSTRUCTION WORK CAN BE SCHEDULED TYPICAL JOINT SERVICE TRENCH MIN.zQ3 w BACKFILL °^ o W 4 M � Fa 39' MIN. C T T3' SAND 12' S . 6' MIN, , GJ4' SAND 2° GREENBOOK PG, 2-10 METER TYPICAL 12' MIN, 28' MIN. BACKFILL 4" COVER MIN, S® SAND Q oz M 2' 2" BUILDING CORNER 6' MIN. TO INSIDE BUILDING CORNER 12' MIN. TO OUTSIDE BUILDING CORNER ELECTRIC METER 10, 10, MIN. MIN. 36' / 36" / ENCLOSURE 75' MAX MIN. MIN, �l 66' PREFERRED 48` MIN, SERVICE 9',I II °—° .I® I FINISHED GRADE BUILDING c 2G VENT GAS RISER GREENBOOK PG. 2-29 ELECTRIC SERVICE RACEWAY VENT MINIMUM SEPARATION AND CLEARANCE REQUIREMENTS G T T C S P MINIMUM COVER G GAS — 12' 12" 12" 6" 12" 24"; 30" in street T TELEPHONE 12' — 1" 1" 12" 12" 24"; 30" in street T TELEPHONE (DB) 12" 1" — 1" 12" 12" 24"; 30" in street C CAN 12" 1" 1" — 12" 12" 24"; 30" in street S ELECTRIC SECONDARY 6" 12" 12" 12" — 3" 24"; 30" in street P ELECTRIC PRIMARY 12" 12" 12" 12" 3" 1 — 30"; 36" in street SL STREETLIGHT 6" 12" 12" 12" 1 1" 3" 24"; 30" in street PER UO STANDARD S5453, EXHIBIT B THE MINIMUM CLEARANCES DID NOT APPLY TO FIXED WINDOWS THAT ARE NOT DESIGNED TO OPEN. 36' 36'" SERVICE TEE/ MIN. MIN. HOUSELINE BUILDING VENT 26" METER REGULATOR / ` FINISH GAS VENT GAS RISER GRADE GREENBOOK PG. 2-30 jLENGTH EXISTING PIPE CD 0- Y 0 CD m z W w Of 0 a 6' LENGTH X 4' WIDTH STEEL PIPE. 4' LENGTH X 4' WIDTH PLASTIC PIPE. 77, EXISTING PIPE 18" UNDER STEEL PIPE. 12 UNDER PLASTIC PIPE. GREENBOOK PG. 2-8 COMBUSTION 36' MIN." 36' MIN. COMBUSTION EXHAUST FAN EXHAUST FAN PAD -MOUNTED TRANSFORMERS,. GAS REGULATOR ALL ELECTRIC EQUIP, AND WIRING (E.G„ CENTRA AIR, 26" EXHAUST FAN) COMBUSTION AIR-INTAKE VENTS VENT 91 COMBUSTION AIR-INTAKE L METER SERVICE TEE/HOUSELINE VENTS 8' MIN, GREENBOOK PG, 2-31 GAS RISER 8' MIN. EST: MARK KENNEDY JOHN GAMBUCCI Applicant Trenching Checklist C0: ADE: SD: SUPV: ERIN STRAUB 1655 WALTERS AVE CAMPBELL NOTIF: 111470568 REP: KAMERON DUQUETTE Applicant Copy OTHER: SHT: SHEETS PLNR: SCALE: none DATE: OS 18 11 PACIFIC GAS AND ELECTRIC COMPANY PM 31286180 REv. DEVELOPER NOTES a b BEFORE BEGINNING SUBSTRUCTURE WORK, NOTES N PLEASE CALL THE UNDERGROUND INSPECTOR AT LEAST 48 HOURS IN (n WO_ N r N I ADVANCE AT 725-2202 OR FAX 1. APPLICANT TO TRENCH JOINT WITH ELEC, GAS, TELCO AND CAN ¢� m (408) 725-7773. (WORK NOT PROPERLY INSPECTED MAY BE REJECTED) IF THERE 2. APPLICANT IS TO PROVIDE ALL ELECTRIC SUBSTRUCTURES AS SHOWN =F- cn¢ o m mo ARE ANY CONFLICTS BETWEEN SUBSTRUCTURES INSTALLATIONS AND 3. APPLICANT IS TO PROVIDE MANDREL AND PERFORM MANDREL TEST PG&E 0� 1- w'�' LANDSCAPING CONTACT THE INSPECTOR WITH INSPECTOR STANDBY 00 PRIOR TO INSTALLATION. — 4. THE TOTAL NUMBER OF BENDS IN ANY SECONDARY DUCT RUN IN EXCESS OF 200 FEET �2_:(D SHALL NOT EXCEED 300 DEGREES. ANY SECONDARY DUCT RUN EQUAL TO OR LESS THAN ¢ 200 FEET IN LENGTH MAY CONTAIN UP TO A TOTAL OF 315 DEGREES IN BENDS. cL m: m= w EO 00 I 5. APPLICANT IS RESPONSIBLE TO ENSURE TRENCHING AND SUBSTRUCTURE L) � j = i i ^� N II 04 INSTALLATION MEET PG&E GREENBOOK STANDARDS. GREENBOOKS ARE AVAILABLE Wx o 2 w 0 rn N AT YOUR LOCAL PG&E HEADQUARTERS OR CAN BE FOUND ON THE INTERNET WZ w ® WWW.PGE.COM/GREENBOOK w ww� 0 d cd i� :j Ih 6. FLAME RESISTANT (FR) CLOTHING IS REQUIRED WHEN WORKING ON OR AROUND i-iT o = w z o PG&E FACILITIES AND EQUIPMENT. SEE PG&E GREENBOOK FOR ADDITIONAL DETAILS zv w ¢ Gn Of a z cn D_ 7. APPLICANT IS RESPONSIBLE TO COORDINATE WITH TELCO AND CAN UW FOR THEIR CONSTRUCTION REQUIREMENTS - # 1667 1655 ~c' I 320 AMS I aw Y w a M z 120/240 V N Q w 3W 14 I SCI 18,000 I o \ W N J �W z o # 1639 - � _j a UNDER THE DIRECTION OF THE PG&E INSPECTOR z APPLICANT TO INSTALL DUCT AS SHOWN. ~ < m U APPLICANT TO EXPOSE EXISTING DUCT �a' ' 0 IN JOINT TRENCH. PG&E TO REROUTE L'U � CABLE AND MAKE FINAL CONNECTIONS CO OF DUCT WITH APPLICANT PROVIDED in MATERIALS, APPLICANT TO BACKFILL. r, ::D APPLICANT MUST BE PRESENT DURING 2 (/) '2PG&E CONSTRUCTION FOR REROUTE. 50' �— 4T — — LEGEND -Bv— (1) - 3" PVC SERVICE DUCT BY APPLICANT W A L T E R S AVENUE �" (1) - 3" PVC SERVICE DUCT BY APPLICANT ^ N z m `N ti - s — (1) - 3" PVC DUCT BY APPLICANT FOR RE-ROUTE z o f 240' HARRIET AVENUE 17" X 30" X 30" FVT SECONDARY SPLICE BOX BY APPLICANT ¢ a N 0 3 45'O I-6 J ' `' Hw=w 9 G Z z PT32047-1 "' I Y I� N Z Z SAFETY PLEDGE ® i/®�STRUCTI®N• w O Z O F I ALWAYS PUf SVM DIBf. I LOOK FOR AM ACT TO wsolvc UrsaE smuloNs. � �/}�I T/WI_TTTT��A m. L!d' V� I ¢ p = Z Z I MP AND FNGOUPAGE ,,/ w Z — Q OINFFS l0 AOT 513F1Y. I f+^�y- �L, I A A .�l �2S EXISTING PGEl &P�.dbfi� Works ��Cr®� ��I yr (((///VVV N �- Q w O N O, N H RISER QUADRAN - 52 Z? = m o a o o s w x on the job 5 to during c0nWFud19n. Print Forrn , fQAh CITY OF CAMPBELL ENCROACHMENT PERMIT Per it PNo DEPT.OFPUBLICWORKS (forworkingwithin the public X-Ref. File 70NorthFirst Street, right-of-way) Application Date Campbell, CA 95008 t I r' i l Application Expiration Date Fx. Ph. (408)866-2150 Issued / APN (408)376-0958 i .7 Permit Expiration Date ! V APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section11.04. (Application expires in six '(6) months if the permit is not issued. Application Fee is non-refundable.) A. Work Address or Tract No.: Utility Trench Location:, 7^I kale- B. NatureofWork: S .._ -.. ,..... _ ._..\ __ ......... _ ._ ._..— ................ C. Attach four (4) copies ofan engineered plan showing the 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. All workshall conform tothe City of Campbe-11 Standard Specifications and Detailsfor PublicWorks Construction; theGeneral PermitConclitions 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 toPub] icWorks atleast 24hours before restartingany work. _ Name of Applicant: ( O�rl p��V h Telephone: �� 'TKr' 9 •---.....- . -8 , 844 - Address: E-MailAddress: • - V, �ji � � � 24-HOUR EMERGENCY PHONE NUMBER; »94 GzOO Is this work being done by the property -owners at t it 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 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 arising out of improvements completed in the public right-of-way. • I - I . Accepted: (PrintName) - SPECIAL PROVISIONS: ❑ 1. Street shall not be open cutfor underground installations. Minimum cuts mavbeallowed for connections orexploration holes. Such cuts maybe . 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-Secyorded. ❑ 6. Public Notification Requirements: ❑ 7• SEE PUBLIC WORKS FEE SCHEDCILE FOR CURRENT FEES PERMIT APPLICATION FEE PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS CONSTRUCTION CASH DEPOSIT PLAN CHECK & INSPECTION FEE EMERGENCY PERMIT FEE $EI MOUNTS j� . RECEIPT NO •'j - � APPROVED FOR ISSUANCE For City Engineer Permit Expires 12 Months After Date of Issuance I - Date GENERAL PERMIT CONDITIONS 1. The Permittee must provide evidence of insurance and Additional Insured Endorsements as required by the City. Insurance shall be maintained forth duration -of the 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 (fen) days�pnor to pi&3p6t6d'start-of work. 4d`ditio67 lead time may be required for work within City facilities and downtown Campbell. 6.. 7he.P.,ermittee;.mustreque�t ip writing a,final insppction.and_a ycep'ance of.t a w91,1k.upon �ggipJeti poAcceptance 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, detoprs, 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 thejob site. Failure to provide such signing and barrica_dingymay 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 concretejby Permittee is requiredµunless otherwise stated by the City Engipeer.,,, 15. 'The Contractor or Permittee will have axsupervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall provide,a phon# 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 emerg"ericies regarding this perrfytshall beat the 4urrent, 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.,App.licant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa'Clara Valley Urban Runoff Pollution Prevention Program. 22. If the public interest re wires almcdification of, or a departure from the permit, plans, special Fovisions and ors ecificationS; the Cit shall have the authority to p q P P. P P P % P Y Y 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.6z.gov/water issues/programs/nodes/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. Go%e_?.00- Applicant Date: Contractor (Print Name) Date:- J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.03/17 FA PUBLIC WORKS. DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC &.MISCELLANEOUS RECEIPT Effective July 1, 2017 TO: Finance PUBLIC WORKS FILE NO. PROPERTY ADDRESS Please collect & receipt for the fbllowinq 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 LIVO 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 & Specification's 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 $1 00/Calenclar Day (Muni Code Sec. 11.34.010) 4722 Penalties: Failure to correct unsafe conditions $1 001Calendar Day 4722 Work Without Permits 4 Times Applicable Fee/Min. $500 tMx .0 T 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 03CIELI'AN 77777T,, 'EO _ 511.74241 Postage Other (Please Specify) NAME OF APPLICANT TOTAL NAME OF PAYOR C -es� � L(7-a— LD PHONE ADDRESS loc, ZIP FOR R CITY CLERK ONLY J \FORMSXTemplates\AdministfativelReceipt Form Way Encroachment & Mise 17-18.xls V-� July .-ITY OF CAMP6ELL CITY OF CAMPBELL RECVD -RY: ��IER O1����5 PAYOR: CESAR LOZANO TGDAY`S DATE: 10/27/17 REGISTER DATE: 1O/27/17 TIME: 00r00 DESCRlPTION AMGUNT ' C0ST lD:ENC2017-00255 FNGR & SUBDIV FILING F $455.00 | CUST ID:1655 WATTERS AVE � [NOR 8 SUBDIV FILING F _------_-__- $420.00 � TOTAL DUE: $875 OO � ' . TENDERED: $875 OO � CHANGE: $ OO ' CREDIT CARD: $875.00 REF NUM: CUSTOMER COPY At�OR-1 ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/30/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER RICARDO GONZALEZ 1155 MERIDIAN AVE # 201 SAN JOSE, CA 95125 Lic # OF41021 CONTACT RICARDO GONZALEZ NAME: P,vacNe xt E: (408) 706-0024 FAX No): (408)716-2821 E-MAIL ADDRESS: RICARDOWITHGIA@GMAIL.COM INSURERS AFFORDING COVERAGE NAIC # INSURER A: National Fire & Marine Insurance Company INSURED David Lara, DBA: Core Excavating 14790 Wyvick Ave SAN JOSE, CA 95125 INSURER B : Columbia Insurance Company INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY MM/DD EFF MMLDD� LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 CLAIMS -MADE 191 OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 A 72LPS029753 09/13/2017 09/13/2018 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1.000,000 $ X POLICY PRO LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ B ALL OWNED X AUTOSULED AUTOS 71TRR233147 03/29/17 03/29/18 PROPERTY DAMAGE Peraccident $ NON -OWNED HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ HCLAIMS-MADE AGGREGATE $ EXCESS LIAB DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE WC STATU- JOTH, TORY LIMITS E.L. EACH ACCIDENT $ ' OFFICER/MEMBER EXCLUDED? ❑ N / A E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) -Excavation Work _ Job Location: 1655 Walters Ave., Campbell C`V� a�`�—��a� City of Campbell, its officers, employees, and volunteers are named as additional insured. _ _3A 5 l\ The insurance coverage afforded to the Additional Insured is primary insurance UMK I It ILA I C MULUCK LAIVLtLL.A I IUIV City of Campbell 70 N. First st Campbell CA 95008 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Ricardo Gonzalez ACORD 25 (2010105) @ 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CALIFORNIA COMMERCIALIFLEET INSURANCE IDENTIFICATION CARD Company Name: Columbia Insurance Company Company Address: 1314 Douglas Street, Suite 1400 Omaha, NE 68102-1944 NAIC No.: 27812 Name of Policyholder: DAVID LARA DBA: CORE EXCAVATING 14790 WYRICK AVE. Address of SAN JOSE, CA 95124 Policyholder: Policy No. Effective Date Expiration Date 71TRR233147 07/26/2017 2:27 PM 03/29/2018 12:01 AM Vehicle Make/Model Vehicle Identification No. 2017 FORD F-550 SUPERDUTY 1FDUF5HT6HEB12209 The policy meets the requirements of the California Vehicle Code Sections 16056 or 16500.5 and is a commercial or fleet policy. M4566a (11/1999) CALIFORNIA COMMERCIAL/FLEET INSURANCE IDENTIFICATION CARD Company Name: Columbia Insurance Company Company Address: 1314 Douglas Street, Suite 1400 Omaha, NE 68102.1944 NAIC No.: 27812 Name of Policyholder: DAVID LARA DBA: CORE EXCAVATING 14790 WYRICK AVE. Address of SAN JOSE, CA 95124 Policyholder: Policy No. Effective Date Expiration Date 71TRR233147 07/26/2017 2:27 PM 03/2912018 12:01 AM Vehicle Make/Model Vehicle Identification No. 2017 FORD F-550 SUPERDUTY 1FDUF5HT6HEB12209 The policy meets the requirements of the California Vehicle Code Sections 16056 or 16500.5 and is a commercial or fleet policy. M4566a (1111999) VERY IMPORTANT - Please Read in the event of accident, be sure to secure license number of the other vehicle, also full names and addresses of all other persons in the accident. Also, write down full names and addresses of all witnesses. Report at once full details of accidents to your insurance company's Claim Operations, PO BOX 31361, Omaha, NE 68131-0361. Toll Free 1-800-356-5750 (This identification card should be kept in your vehicle.) VERY IMPORTANT - Please Read In the event of accident, be sure to secure license number of the other vehicle, also full names and addresses of all other persons in the accident. Also, write down full names and addresses of all witnesses. Report at once full details of accidents to your insurance company's Claim Operations, PO BOX 31361, Omaha, NE 68131-0361. Toll Free 1-800-356-5750 (This identification card should be kept in your vehicle.) 08/0212017 14:32 AF3A3397-B1 FO-4A80-9AC9-95F9BA5003EE POLICY NUMBER: 72LPS029753 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. me-1- ma I Eel This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organ izati ons : Location And Description Of Completed Operations All persons or organizations where written contract with the Named Insured requires additional insured completed operations coverage. This form does not apply to your work on "residential property". Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section 11 — Who is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sche- dule of this endorsement performed for that addi- tional insured and included in the "products - completed operations hazard". CG 20 37 07 04 c0)SO Properties, Inc., 2004 Page 1 of 1 13 POLICY NUMBER: 72LPS029753 COMMERCIAL GENERAL LIABILITY NX GL 009 08 09 THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. PRIMARY AND NON-CONTRIBUTING INSURANCE (THIRD -PARTY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Third Party: All persons or organizations where required by written contract with the Named Insured (Absence of a specifically named Third Party above means that the provisions of this endorsement apply as required by written contractual agreement with any Third Party for whom you are performing work.) Paragraph 4. of SECTION IV: COMMERCIAL GENERAL LIABILITY CONDITIONS is replaced by the following: 4. Other Insurance: With respect to the Third Party shown above, this insurance is primary and non-contributing. Any and all other valid and collectable insurance available to such Third Party in respect of work performed by you under written contractual agreements with said Third Party for loss covered by this policy, shall in no instance be considered as primary, co-insurance, or contributing insurance. Rather, any such other insurance shall be considered excess over and above the insurance provided by this policy. NX GL 009 08 09 Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with its permission POLICY NUMBER: 72LPS029753 ALI I-. �. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY CG24040509 COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: All persons or organizations where required by written contract with the Named Insured Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Flights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products - completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 ❑ WORKERS' COMPENSATION INSURANCE INFORMATION The following worker's compensation insurance information is required for all Applicants and Contractors. One of the following items for each Applicant and Contractor must be submitted prior to working under a Public Works permit or contract. WORKERS' COMPENSATION INFORMATION: TIn Name of Contractor/Applicant W',7-C— �-ec Q-A �R ❑ A Certificate of Consent to Self -Insure issued by the Director of Industrial Relations: OR ❑ A Certificate of Workers' Compensation Insurance Insurance Policy No, Expiration Date : OR A signed Certificate of Exemption from the Workers' Compensation laws as printed below. CERTIFICATE OF EXEMPTION I certify that in the performance of the work for this contract, I shall not employ any person in a manner s to beco su t to the Workers' Compensation Laws of California, Signe Date r Title 1 NOTICE TO APPLICANT/CONTRACTOR: If after signing this Certificate of Exemption, you should become subject to the Workers' Compensation provision of the Labor Code, you must forthwith comply with such provisions or the permit or Contract will be cancelled or revoked. Documentl (Rev 9/11) v INSURANCE REQUIREMENTS CHECKLIST Permit#C� CIP Project# Consu Itant/Contractor: The following insurance is required of all consultants/conYractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: ❑�-$1,000,000.per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or 1�( $2,000,000 general aggregate limit. ❑ Policy expiration date lv Automotive Liability: L �-- [�� ❑ "Any Auto" checked on certificate `J $1,000,000 per accident for bo ily in'ury and property damage ❑ Policy expiration date Workers mpensation and Employer's Liability ❑ Waiver o bro ation clause S �� g ❑ $1,000,000 pe ccident for bodily injury or disease ❑ Policy expiration date Course Construction (if req 14red in Special Provisions) ❑ Comple value of the proje t ❑ Policy expir 'on date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement: The City, its officers, employees and volunteers are named as additional insured. O\V (Reference Project Location/Permit Number) '7 ❑ The insurance coverage afforded to the Additional Insured is primary insurance. - Cancellation area: ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obliization or liabilitv of anv kind upon the companv. its agents or representatives". OR should say: Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. Workers' Compensation Insurance Sheet Submitted 'For General Contractor ❑ For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 1 Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: NAIC OC6_f� ,Rating: A- X�r Authorized in CA: Name:CA a �,'����CA, NAIC # (Rating: B--1- Authorized in CA: Name: NAIC # Rating: Authorized in CA: Name: NAIC # Rating: Authorized in CA: �\ o Campbell Business License # 0��Wo3Q Expiration: ❑ _ Contractors License # 9 3�5 �'� Class:'Oe(�_ Expiration: Insurance Certificate Reviewed _SL, InJtials Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 I Printi�F-OhriTi CITY OF CAMPBELL ENCROACHMENTPERMIT Permit No DEPT.OFPUBLICWORKS (forworking within the public X-Ref. File 70NorthFirst Street, right-of-way) Application Date \U 1.2r) \1 Campbell, CA 95008 tL: ( `' Application. Expiration Date Ph. (408) 866-2150 Issued 1 � APN r_i "� 1 � U ZI Fx. (408) 376-0958 i� Permit Expiration Date APPLICATION -Application is hereby madefora PublicWor.ks Permitin accordance with Campbell Municipal Code, Section 11.04. (Applicationexpiresinsix '(6) months if the permit is not issued. Application Fee Is non-refundable.) A. Work Address or Tract No.: Utility Trench Location: B. . Nature.of Work: C. Attach four (4) copies ofanengineeredplan showingthelocation and extentofthework, andfour (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 ofthis permit. D. All workshall conform to the Cit yofC amp0qIlStanclud SpeciflcatiDns and Details for Public Works Construction; the General PermitConclitions 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 aril cash deposits: E. The Confractor.must have this permit and approved plans of the site and must notify the Public Works Department.at least two days before startingwork. Notice mustbegiuentoPubl"cWorksatleast24hoursbeforerestarting any:work. Name of Applicant .. 'r12 Telephone: 5 Address: 1 S'7Z yr E-Ma"ilAddress: + 24 HOUR EMERGENCY PHONE NUMBERa Q l `�A�►�� Is this work ,being done by the property owners at t it 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 anti harmless from any claim or demand for damages,resulting from the work covered by this.permit. The Applicant/Perm. ittee 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 erm t, ro .ert owner; or P p p p y property.' :owner's successors, shall be responsible for any and all damages arising out of improvements completed:in the public eight-of=way. l Accepted: {Applicant Permittee) (sign) Date ,,// (Print Name) SPECIAL PROVISIONS: ❑ 1. Streetshallnot beopen cutforundergroundinstallations. Minimumcutsmav:beallowed forconnectionsorexploration holes. Such cuts maybe ❑ 2. specifically approved by the Inspector prior to cutting. Pavement may be for cut underground installations. and must be restored in accordance With the Standard Details Trench Restoration Method ❑ 3. "A", unless otherwise approved by the, Engineer. 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 ❑ S. the inquiry identification number has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO Prior to any work, the. property owner shall execute an Agreement for Private Improvements in the Public Right -of -Way, which shall.b6trecorded. F 6. Public f�otification Requirements: a ..- -: h _• 7. . ;... SEE PUBLIC VtlORKS"FEE SCHEDULE FOR CURRENT FEES ^• � • - - .. __ � - PERMIT APPLICATION FEE PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS CONSTRUCTION CASH DEPOSIT PLAN CHECK & INSPECTION FEE EMERGENCY PERMIT FEE $MOUNT RECEIPT NO. C f APPROVED FOR ISSUANCE 0 _;0I11:4' GENERAL PERMIT CONDITIONS 1. The Permittee must provide evidence of insurance and Additional Insured Endorsements as required by the City. Insurance shall be maintained for the duration -of the 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 tothe Permittee. 3. Refund of the construction cash deposit balance and refund or cancellation ofthe 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'j days,'p'hiorto pwopdsed starC'of work. Additional leas time maybe required for work within City facilities and downtown Campbell. 6.: e T= e Permute e must req est 5nswritin a --final inspection.and aacept�ance of.`h.e,. V .upon �o�npletiT P4ceptance 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; d"rs, 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 (MVTCD). 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 ail 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 bu rrerit overtimerate. - _ - 13. Work -on arterials and .collectors may:require the use of changeable message. boards. Adequate signing and barricading'is required on thejobsrte:ifailureto provide such signing and barncad'inp,may result mthe.City's,providing signing and barricades and charging the cost (Including all labor and materials) against the construction cash �epnsit: ,. �, t; y a� fir. a= r � =• �:> �, �, 14. Compaction testing of subgrade base rock and.asphalt concreteby Permittee is required unless otherwise stated by the City Engipeer ' "`� c"'�-` -"1•''•' �ax-s . � "v ,.' y, ti a;s § � :�> 3 r. 3+� a r i;;. = r,: a:. .e m �r+e. 15. 'The Contractor.or Permittee will have a supervisory representative 'available for contact on the project stall=times during construction. Contractor or Permittee shall provides pho .number at,which they can be contacted outside the hours of$•_00 a:m. to 4 00 pm and on weekends 16: No storage of materials or equipment will be allowed nearthe edge.ofthe, 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 ifor excavation and grading on private property adjacent to the 'work or any otherwork for Which a separate. permit maybe required, nor does it:relievethe Permittee of any obligation to obtain any otherpermit required by law. 18. Thisperrtiit does not release the Permittee from any liabilities, contained in other agreements or contracts With the City and any,otherpubiic agency. 19. This perm `it'is not transferable. Work must be performed by the Permittee or hls designated agent or contractor as specified. thereon. .. 20. Gall back (call out).due to, egi.erg'erities regarding tms,per tt shall beat the' qurrento'vertime rate wWl h three (3) hgg.minimum charge.per occurrence. 21. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any,maieriai into the municipal storm drain system otherthan storm water,Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. q 22. If the public interest requires a, modification of; or a departure from the permit, plans, special provisions and%r specifcationg"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 notiflcationto-allparties that may be affected by the permit activities. Notification shall be reviewed, bythe City priorto 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 watershall not be discharged into the City of Campbell's storm drain system. See http://www waterboards ca p.ov/water issues/programs/npdes/utilitvvaults.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 Date:/ 1b Contractor (Print Name) Date:- J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.03/17 : ACOO DR ® CERTIFICATE OF LIABILITY INSURANCE ��. / DATE 10/3030/2017 I) 017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER RICARDO GONZALEZ 1155 MERIDIAN AVE # 201 SAN JOSE, CA 95125 Lic# OF41021 CONTACT RICARDO GONZALEZ PHONE 408 706-0024 3 Fax (408)716-2821 A/C No Ext • ( ) A/C No EMAILSS: RICARDOWITHGIA@GMAIL.COM ADDRE INSURERS AFFORDING COVERAGE NAIC # INSURER A: National Fire & Marine Insurance Company INSURED David Lara, DBA: Core Excavating 14790 Wyvick Ave SAN JOSE, CA 95125 INSURERB: Columbia Insurance Company INSURER C : INSURER D : INSURERE. INSURER F : rnvconr_rc CERTIFICATE NUURI=R- REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR I TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MMIDD POLICY EXP MMIDD LIMITS GENERAL LIABILITY .. EACH OCCURRENCE $ 1,000,000 - X COMMERCIAL GENERAL LIABILITY - DAMAGE TO RENTED PREMISES Ea occurrence $ 1 OO,000 MED EXP (Any one person) $ .5,000 A CLAIMS -MADE OCCUR 72LPS029753 09/13/2017 %/Ja2W911 P' ERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1.000,000 $ X POLICY PRO- LOC AUTOMOBILE LIABILITY Ee acci EDtSINGLE LIMIT CMB'NANY 1,000,000 BODILY INJURY (Per person) $ AUTO BODILY INJURY (Per accident) $ B ALL OWNED X SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS 71TRR233147 03/29/11 03/29/18 PerOPERTntDAMAGE $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ ti EXCESS LIAB CLAIMS -MADE - DED I I RETENTION $ $ WORKERS COMPENSATION WC STATU- I OTH- TORY LIMITS ER AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICERIMEMBER EXCLUDED? (Mandatory in NH) N / A - E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT , $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) _Excavation Work _Ri Job Locationi'q655Itil Rer'S v A. ampbell City of Campbell, its officers, employees, and volunteers are named as additional insured. The insurance coverage afforded to the Additional Insured is primary insurance CERTIFICATE City of Campbell 70 N. First st Campbell CA 95008 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Ricardo Gonzalez ACORD 25 (2010105) @ 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CALL: 811 C ®N D W � A ORE y1 V W' W' `�A v 1-655 WALTZERS AVE SA CAlV�I1PB- ELL, CA h CAUTION! HIGH PRESSURE RO�NDs�� GAS PIPE. HAND DIG CALL: 811 NEAR GAS PIPE CALL TWO W❑RKING DAYS BEFORE YOU DIG TICKET NO, NOT T TO SCALE FETY so � SAFETY PLEDGE I ALWAYS AFETY FIRST. I LOOK AND ACT TO RESOLVE UN FE SITUATIONS. I HELP AND ENCOURAGE OTHERS TO ACT SAFELY, DATE, BYl NOTE: ALL TRENCHING AND BACKFILLING TO BE PERFORMED BY: BUILDING LEGEND 1' SERVICE m GAS METER LOCATION TAP HOLE ' 5' X 4' X 18" UNDER GAS PIPE 2 BOX 17" X 30' O UTILITY POLE. JOINT TRENCH �y ELECTRIC METER CONTRACTOR 1655 ALTERS AX� �U a . PROPER- EDGE qF � O� �A C EDGEpER�Y LINE PRO TAP HOLE 5'X018" UNDER GAS PIPE MAP 3410—A6 CPA 3410-07 BUILDING CONTRACTOR TO DIG GAS TAP HOLE 5' X 4' X 18" UNDER GAS PIPE BUILDING CONTRACTOR. TO TRENCH AND BACKFILL ALL BUILDING APPLICANT TO. INSTALL.... 61'-,1 ". PLASTIC GAS ,SERVICE SEE ELECTRIC CONSTRUCTION DWG FOR FRANCHISE JOINT TRENCH EST: MARK KENNEDY ' CONDWIG A 1655 WALTERS AVE CAM P B E LL PACIFIC' FI C GAS AND : E_LECTR I C COMPANY CO: ADE: JOHN GAMBUCCI SD: SUPV: ERIN STRAUB NOTIF: 111470568 OTHER: REP: BEN MORALES SHT: SHEETS PLNR: PIS: 31286180 REV. SCALE: NTS DATE: 105/12/17 APIIROVED FOR CONSTRUCTION. City of Campbell Public Works (:ont dtor must have *m plaw On gab s#s durlq W+rudisft APPLICANT CHECKLIST ■ CONTACT UNDERGROUND SERVICE ALERT "USA" AT 1-8DO-227-2600 (OR "811" BY LANDLINE), AT LEAST 2 BUSINESS DAYS BEFORE EXCAVATION, TO HAVE EXISTING UNDERGROUND . UTILITIES MARKED IN FIELD ■ OBTAIN CITY/COUNTY EXCAVATION PERMIT (IF -APPLICANT TO: TRENCH) ■ FOLLOW TRENCH INSTRUCTIONS (IF APPLICANT TO TRENCH) ■ APPLICANT TO BACKFILL IMMEDIATELY AFTER INSTALL., MINIMUM OF 4" OF SAND AND 8" OF NATIVE SOIL DAY OF CONSTRUCTION. ■ HAVE SUFFICIENT SAND ONSITE :PRIOR TO. FINAL INSPECTION, REFER TO GREENBOOK :SECTION 2-.3,4 ■ MAINTAIN 3' MINIMUM PARALLEL SEPARATION FROM WET FACILITIES (I.E. WATER, SEWER, STORM), . REFER TO UO STANDARD S5453, EXHIBIT B ■ 'TRENCH MUST MEET PG&E STANDARDS (SHOWN BELOW) AND HAVE 2" OF PG&E APPROVED SAND ON BOTTOM OF TRENCH BEFORE FINAL INSPECTION. ■ COORDINATE INSTALLATION OF TELEPHONE AND CABLE TV FACILITIES, PER THEIR CONSTRUCTION REQUIREMENTS . ■ CALL (408) 725-2202 OR FAX (408) 725-7773 FOR PG&E TRENCH ,INSPECTION - AT LEAST 2 BUSINESS DAYS ADVANCE NOTICE ■ PLUMB GAS HOUSELINE TO NEW .LOCATION AND HAVE MUNICIPALITY NOTIFY PG&E THAT GAS HOUSELINE HAS PASSED INSPECTION ❑ GAS METER GUARDS PER GAS STANDARDS AND SPECIFICATIONS MANUAL SECTION J-95 ■ PAYMENT MUST BE RECEIVED BY PG&E, BEFORE CONSTRUCTION WORK CAN BE SCHEDULED TYPICAL JOINT TYPICAL SERVICE TRENCH GAS ONLY TRENCH 12" MIN, z ¢ W MIN; r � w¢ BACKFILLLj Q z 39' MIN. z C T 3" 28" MIN. BACKFILL N z SAND 12" 4' COVER MIN, S© S G 4" 2" SAND 2° SAND 2' GREENBOOK PG. 2-10 GREENBOOK PG. 2=8 30" MIN. TO BUILDING CORNER 6" MIN, TO INSIDE BUILDING CORNER ELECTRIC 12" MIN; TO OUTSIDE METER BUILDING CORNER ELECTRIC METER 10, 10, O /V, MIN. MIN, COMMUNICATIONS 36" 36" ENCLOSURE 75° MAX MIN.. MIN. .660 PREFERRED I 48` MIN, E SERVICE TEE/HOUSELINE 9" Ell Rl BUILDING FINISHED GRADE VENT BUILDING 26" REGULATOI VENT. . GAS RISER GAS VENT GREENBOOK PG, 2-29 ELECTRIC SERVICE RACEWAY COMBUSTION 36° MIN, 1` -360 MIN. — EXHAUST FAN USTION GAS REGULATI COMBAIR-INTAKE VENTS VENT 9# Li 8' MIN,- GREENBOOK PG. 2-31 26° METER MINIMUM SEPARATION AND CLEARANCE REQUIREMENTS G T T C S P MINIMUM COVER. G GAS — 12" 12" 12" 6" 12" 24"; 30" in street T TELEPHONE . 12" — 1" .111 12" 12" 24"; 30" in street T TELEPHONE (DB) 12 1 — 1 12 12 24 ; 30 In street C CAN 12 1 1 — 12 12 24 ; 30 in street S ELECTRIC SECONDARY 6" 121, 12" 12" — 3" 24"; 30" in street P ELECTRIC PRIMARY 12" 12" 12" 12" 3" — 30"; 36" in street SL STREETLIGHT 6" 12" 12" 12" 1 " 3" 24"; 30" in street PER UO STANDARD S5453, EXHIBIT B THE MINMUM CLEARANCES DO NOT APPLY TO FIXED WINDOWS THAT ARE NOT DESIGNED TO OPEN. 36° 36"" SERVICE TEE/ MIN, MIN. HOUSELINE BUILDING / VENT I cV 0 a_ Y 0 0. m z w w 0 6' LENGTH X 4' WIDTH STEEL PIPE. 4' LENGTH X 4' WIDTH PLASTIC PIPE. 6 EXISTING ' PIPE METER FINISH GAS RISER GRADE 18" UNDER STEEL PIPE. 12" UNDER PLASTIC PIPE. GREENBOOK PG, 2-30 GREENBOOK PG. 2-8 COMBUSTION EXHAUST FAN PAD -MOUNTED TRANSFORMERS,, ALL ELECTRIC EQUIP. AND WIRING (E.G., CENTRAL AIR, EXHAUST FAN) COMBUSTION AIR-INTAKE VENTS SERVICE TEE/HUUSELINE — 8' MIN. EST: MARK KENNEDY ADE: JOHNGAMBUCCI Applicant Trenching Checklist SUPV: ERIN STRAUB 1655 WALTERS AVE CAMPBECL REP: KANERON DUQUEfTE AppIIC011t COPY PLNR: SCALnone SOS 18 11 ' PACIFIC GAS AND ELECTRIC COMPANY CO: SO: NOTIF: 111470568 OTHER: SHT: SHEETS PM: REV. 31286180