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ENC2017-00254Syee/ o ��`�� Pr•.int Forrn CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No��!I--�b��� DEPT.OFPUBLICWORKS (forworkingwithinthe public X-Ref. File 70NorthFirst Street . right-of-way) Application Date Campbell, CA 95008 1 Application Expiration Date Ph. (408) 866.2150 Issued APN Fx. (408) 376-0958 p (� Permit Expiration Date. APPLICATION -Application is hereby madefor.a Public -Works Permit in accordance with Campbell Municipal dode,Section 11.04. (Application expires in six "(6) months ifthe.perniit is not issued. Application Fee Is non-refundable,) ' A. . Work Address or tract No.: Utility Trench Location:. 'Or . B. Nature.ofWork; ,...: ' C. Attach four (4).copiesofan engineeredplanshowingthe location and extent ofthe work, and four (4) copies oftheprelirhinary En gineer'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 work shall conform to the City ofCampbellStandard Spec ificationsandDetails for Public Works Construction; the GeneralPermitCon& ions 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. k. Notice m'ust be given to PubH c Works atleast24 hoursbefore-restarti,ng any work. Name of Applicant: 1 �O�rQ, pace.�+Vh Telephones: C 4 M Address: �tS:: A cTS*dXZ E-Ma Is this'rbeing done b the• EAut-A.0- work art owners at ta. it own ' 24-HOUR EMERGENCY:PFIQNE NUMBER: Y P P Y . esitlenee? 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 ordemand for damages resultingfrom the workcovered;bythis permit. The Applicant/Permittee hereby acknowledges that they, have read and understand_ both the front and back -of this permit, antl whey 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 ouutttoof.improvements completed in the public right-of-way. Accepted,- Accepted: 2 . /�Y L�J /�ti �/�f/! ":(Applicant Permittee) (sign) .Date. (Print Name) SPECIAL PROVISIONS: 1. Streetshallnotbeopencutforunderground installations. Minimum cuts may.beallowedfo r con ne.cti ons or exploration 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 Undergrountl 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 whiel shall•4e<e orded. 6 Public Notification Requirements: SEE PUBLIC 1NORKS"FEE SCHEDULE FOR CURRENT FEES RECEIPT NO. PERMIT APPLICATION FEE AMOUNT14 PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK & INSPECTION FEE $ EMERGENCY PERMIT FEE $ APPROVED FOR ISSUANCE For City Engineer 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 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. r 5. Submit project schedule 10 (tenj days4piidr to Aposed'starY of work'. Additional lean time may be required for work within City facilities and downtown Campbell. 6.. The Rermittee� must requestin wratin a final inspgc on.and acgePt�ance of_ttfq,wo c.upon q pletign 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,.iI8o 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 (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 al PCC or AC removals. All PC C 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 currentovertime 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 barncading�may result inthe City`s providing signing and barricades and charging the cost (including all labor and materials) against the construction 14. Compaction testing of subgrade, base rock and :asphalt conrfretepy Permittee is required ,unless otherwise stated by the City Engipeer dv 15. The Contractor or Permitteewill have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall provide pho 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.relie.ve the Permittee of any obligation to obtain any'otherpermit required by law. 18. This permit does not release the Permittee from an_y 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 Permittee or his designated agent or contractor as specified thereon. 2Q. Call back (call out) due to e'q ergencies regarding this perr yt shalhbeat the Gurpenr -overtime rate with a three (3) hour mmimum.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 Prev....ention Program. ' . ' 22. If the public interest requires a modification of, or a departure from the permit, plans, special ptovisions and/or specification�'the Qty 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/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. �►-re Date: - Applicant 1(.)1/ If, Contractor (Print Name) Date:- J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.03/17 ® o CERTIFICATE OF LIABILITY INSURANCE DATE `WDD/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: PHCN o E (408) 706-0024 FAX, No : (408)716-2821 E-MAILADDRESS: RICARDOWITHGIA@GMAIL.COM INSURERS AFFORDING COVERAGE NAIL # 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 - INSURERC: INSURER D : E: -INSURER 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 S BR POLICYNUMBERPOLICY - MI D EFF POLICY EXP MM/ DNYYY LIMITS GENERAL LIABILITY _ EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence ' $ - 100,000 MED EXP (Ariy one person) $ Am CLAIMS -MADE OCCUR - 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- M LOG AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 11000,000 BODILY INJURY (Per person) $ ANY AUTO - - BODILY INJURY (Per accident) $ B ALL OWNED V SCHEDULED AUTOS /� AUTOS NON -OWNED HIRED AUTOS AUTOS - 71TRR233147 03/29/17 03/29/18 PROPERTY DAMAGE Per accident $ $ UMBRELLA.LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER[EXECUTIVE WC STATU• OTH- O E.L. EACH ACCIDENT . $ OFFICER/MEMBER EXCLUDED? ❑ N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS! VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) -Excavation Work. _ Job Location: 1655 Walters Ave., Campbell City of Campbell, its officers, employees, and volunteers are named as additional insured. �,� i .� The insurance coverage afforded to the Additional Insured is primary insurance t �— ` l;r-K 111-IUA I t MULUtK VAIVtiCLLA I lum 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 J CALIFORNIA COMMERCIAL/FLEET INSURANCE IDENTIFICATION CARD Company Name: Columbia Insurance Company Company Address: 1314 Douglas Street, Suite 140D Omaha, NE 68102-1944 NAIC No.: 27812 Name of Policyholder: DAVID LARA ❑BA: CORE EXCAVATING 14790 WYRICK AVE. Address of SAN JOSE, CA 95124 Policyholder: Policy No.. Effective Date Expiration Date 71TRR233147 07126/2017 2:27 PM 03/29/2018 12:01 AM Vehicle Make/Model Vehicle Identification No. 2017 FORD F-550 SUPERDUTY 1FDUF5HTBHEB12209 The policy meets the requirements of the California Vehicle Code Sections 16056 or 18500.5 and is a commercial or fleet policy. M-4566a (11/1999) CALIFORNIA COMMERCIAL/FLEET INSURANCE IDENTIFICATION CARD Company Name: Columbia Insurance Company Company Address: 1314 Douglas Street, Suite 1400 Omaha. NE 68102-19" NAIL 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 0712612017 2:27 PM 03/29/2018 12:01 AM Vehicle Make/Model Vehicle Identification No. 2017 FORD F-550 SUPERDUTY 1 FDUF5HT6HEB12209 The policy meets the requirements of the California Vehicle Code Sections 16056 or 16500.5 and is a commercial or fleet policy. M-4566a (11/1999) 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.) OB/02/2017 14:32 AF3A3397-B1 F0-4A80-9AC9-95F9BA5003EE PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MISCELLANEOUS RECEIPT Effective July 1, 2017 TO: Finance ?, /�ja� PVC120 ��-- �Or�-S PUBLIC WORKS FILE NO. PROPERTY ADDRESS Please collect & receipt for the followin monies QiCCT... ITEM , AMOUNT ENCROACHMENT,,.',PERMIT. 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 Work Without Permits 4 Times Applicable Fee/Min. $500 F,,FiC 4728 Traffic Flow Map (Daily Traffic Volumes) $35.00 4728 Signal Timing Information $73 per hour 4271 Truck Permits $16.00 per trip 47281 No Parking Signs $1 each or $25/100 :ELLANEOUS � 11 742 Postage Other (Please Specify) CITY OF CAMPBELL RECVD BY: CASHIER 61000272094 PAYOR: CESAR LOZAHO T00AY`S DATE- 10/27/17 REGISTER DATE- 10/27/17 TIME: 00:00 AMDiu' NT DESCRIPTION CUST ID�ENC2O17-OD254 & SUBDIV FILING F �455.8O ENGR CUST ID:1655 WATTERS ENGR 8 SUDDIV FILING F $42O'OO ------------------- TOTAL BE., $975.00 TENDERED: $875.00 CHANGE: $.00 CREDIT CARD: $875.00 REF NUM: CUSTOMER COPY ,DEVELOPER NOTES_ BEFORE BEGINNING SUBSTRUCTURE WORK, PLEASE CALL THE UNDERGROUND INSPECTOR AT LEAST 48 HOURS IN ADVANCE AT 725-.2202 OR FAX (408) 725-7773. (WORK NOT PROPERLY INSPECTED MAY BE REJECTED) IF THERE ARE ANY CONFLICTS BETWEEN SUBSTRUCTURES INSTALLATIONS AND LANDSCAPING CONTACT THE INSPECTOR PRIOR TO INSTALLATION. # 16 6'7 UNDER THE DIRECTION OF THE PG&E INSPECTOR APPLICANT TO INSTALL DUCT AS SHOWN. APPLICANT TO EXPOSE EXISTING DUCT IN JOINT TRENCH. PG&E TO REROUTE CABLE AND MAKE FINAL CONNECTIONS OF DUCT WITH APPLICANT PROVIDED MATERIALS, APPLICANT TO BACKFILL. APPLICANT MUST BE PRESENT DURING PG&E CONSTRUCTION FOR REROUTE. SAFETY PLEDGE I ALWAYS PUT SAFETY FIRST. I LOOK FOR AND ACT TO RESOLVE UNSAFE SITUATIONS. I HELP AND ENCOURAGE OTHERS TO ACT SAFELY. # 1655 320 AMS 120/240 V 3W 10 SCI 18,000 > NOTES Q N Li N 1. APPLICANT TO TRENCH JOINT WITH ELEC, GAS, TELCO AND CATV �w I o 0 Q 00 _ 2. APPLICANT IS TO PROVIDE ALL ELECTRIC SUBSTRUCTURES AS SHOWN ccn 1�8- o 3. APPLICANT IS TO PROVIDE MANDREL AND PERFORM MANDREL TEST p� ¢w Lj WITH PG&E INSPECTOR STANDBY �� N 4. THE TOTAL NUMBER OF BENDS IN ANY SECONDARY DUCT RUN IN EXCESS OF 200 FEET Hm SHALL NOT EXCEED 300 DEGREES. ANY SECONDARY DUCT RUN EQUAL TO OR LESS THAN Q DO 200 FEET IN LENGTH MAY CONTAIN UP TO A TOTAL OF 315 DEGREES IN BENDS. ��_ m w 00 5. APPLICANT IS RESPONSIBLE TO ENSURE TRENCHING AND SUBSTRUCTURE U� � a o- o INSTALLATION MEET PG&E GREENBOOK STANDARDS. GREENBOOKS ARE AVAILABLE w2 > = N o _N rn AT YOUR LOCAL PG&E HEADQUARTERS OR CAN BE FOUND ON THE INTERNET �Z w cV ® WWW.PGE.COM/GREENBOOK bi [If m � _w� r) 6. FLAME RESISTANT (FR) CLOTHING IS REQUIRED WHEN WORKING; ON OR AROUND o �Lj �n o m w Z o v PG&E FACILITIES AND EQUIPMENT. SEE PG&E GREENBOOK FOR ADDITIt7 AL DETAI lS Zo w a cn a- z cn a 7. APPLICANT IS RESPONSIBLE TO COORDINATE WITH TELCO AND ICATV 0 <- FOR THEIR CONSTRUCTION REQUIREMENTS Uw Q U = Q v CUB Z of J V Ld aw �cn, j Qw W w o m z co � W (3:!:J z CD m LA_1639 Ial [L._2 Q z a t� p U �a �z V) U 'a v I v� L>Li Lo o a �6_ co 3 o > . C3 0. w m C13a. Q 0. Qj LEGEND a. WALTERS AVENUE t 240' HARRIET AVENUE 45' PT32047-1 EXISTING PG&E RISER QUADRANT —sv (1) — 3 PVC SERVICE DUCT BY APPLICANT —sv1. (1) — 3" PVC SERVICE DUCT BY APPLICANT co — S (1) - 3" PVC DUCT BY APPLICANT FOR RE—ROUTE L2J 17" X 30" X 30" FVT SECONDARY SPLICE BOX BY APPLICANT Lail a EL Q -- Vic' W M To Y d- r- rn I� N Z U_ Q CDaj- C4 M �¢wU cii 9 a V) U C7 w M o � N Q Ix 2n dUfonNm N �o 0 � 0 V) UJ UJ5 �N am Z i Z L�7 Q � Z O Z 0 sm OO YA v