ENC2017-00192 Print Form /
CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No ENC2017-00192 �(
DEPT.OFPUBLICWORKS (forworking within the public X-Ref..File
70 North FirstStreet right of y) Application Date 8/9/2017
Campbell, CA 95008 Application Expiration Date
Ph.(408)866-2150 Issued APN 412-06-Og0
Fx. (408)376-0958 OI
Permit Expiration Date
APPLICATION-Application is hereby made fora Public Works Permit in accordance Jith 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.: 177 Alice Avenue
Utility Trench Location: Alleyway behind 177 Alice Avenue
B. Natureofwork: Installation of sewer lateral
C. Attach four(4)copies ofa n engineered plan showi ng the location and extent ofthe work,and four(4)copies ofthe 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. All work shall confor m to the City ofCampbell Sta nclard Specifications 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 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.restartinganywork. G �i
Name of Applicant: I /ret,c�ti'.G' tkic, `1�� Telephone: ��G�)'ZG ` �C Z n
Address: .
E-MailAddress: re,`jt'�, c�(�bHLul c0A 24-HOUR EMERGENCY PHONE NUMBER: 1�� /7ZG� ���c-,
Is this work being done by the property owners at their own✓residence? DYES ❑ 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 ansm ut of improvements completed in the public right-of-way. (s�
Accepted:
pplicant Permittee) (sign) Date
ntractor) (Print Name) Date
SPECIAL PROVISIONS:
❑ 1. Street shall not be open cut for underground installations. Minimum cuts maybe allowed for connections ore xploration holes.Such cutsmaybe
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.
El3. 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 RECEIPT NO.
PERMIT APPLICATION FEE $455.00 a b sdLet
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $
CONSTRUCTION CASH DEPOSIT $
PLAN CHECK&INSPECTION FEE $420.00 LrI b
EMERGENCY PERMIT FEE $
APPROVED FOR ISSUANCE I
For City Engineer Dat
1 � � er i Expires 12 Months After Date of Issuance
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.
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.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.
App is nal t� Date:
Contractor (Print Name) Date:
J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf
Rev.03/17
-1
UUest Iley_ S%ewer Connection Permit
Nrit. x Sa�r>iitatlon'Dlsrict
"too,e:sunnyoaks ave Permit#. 51001_
` cam 11 ea 95008 6608- '
.,,.(` (408)37fl-2407-Office ., , , - , -
Date Issued:, . 8/2/2017
(408)364-1821'Fax `;;,
,.
,
.
Issued By:
"
Scott", Qe m
site.Addr'— 177'ALICE AVE CAMPBELL CI SO
Mailing Address ,177 ALICE AVE CAMPBELL CR'95008 2903
Parcel N.umtier : 412060fi0 :". Bmldmg Type ;, :'SINGLE FAMILY
Loca1.l 11'3urisdictPon' CAMPBECL Cammerc�al Type .iN/R
Previaus'Perm11it ` ."0.5'669-OOQ`' Res"' nt al Units 1
Commercial`Units
Contact Name 30SE 3IMENEZ vyner.Name O
Contact Phone Y€1" .:61 -40i3 726 7926 Business Name .
6 6contact Phone#2
Dwner Phone#
1.
,Ii
icontact Email i,
P.ropased Work REPLACE UPPER LATERAL TO pROPERTYLINE ON EASEMENT LATERAL i
91 ,,.
..� e
i
Property Lme Cieanout Required ❑ Requirement Notes`
BilCkfiaW Protective Device Required; -.�
Pretreatment#64iilred
Enproachment Permit Required
Cut and Cap Regwped
Sept,c Abandonment S;
„- .
s %«.>
PERTIIT PEES Payment Ty, pe .Check
TtemsX
fee; Checi[# ]t15D
01 Processing Fee $335 D0.
D2-CT1/Inspeiton fee'
D3�:Sa�wer 6ervice Fee f'
04 Sewer Cbn it ctL. lon Fee
DS TYeatment Plant Capacity Fee � C
r
Q6 S3:emo Fee
; �� �D7 ,N41i;ide Zone Fee
08 Anne"tion.FeE
D9 Plan Check Fee � i �.M
10 �nspecUon Fee
- _
13 Lateral Fee'; 19 .
, '` Totat Fees: $335 00
InStl'aCtlOA "1. .� ,. ,, -
Additional fees may b-required if permrttetl'wor114 riot compfefed—within 12 months o1ls L" dot
+Do not,connect,until the main sewer is accepted by the Dlskri`ct ,
Discharge of'gromndwater subsurface drainage surface water., roof,water,,oj storm water Into,the Dlstridt`s'sanitary ystem ls,prohlbIb
Obtain a Building-or plumbing permit from,the Jurisdiction fisted above.
•Keep 3 foot radius around cieanout clear of vegetation or obstruction.. - . -
•.Must call West Valley_Sanitation Distr-lctto,coordinate any°required insPeetloris-at{408.).378 2407 select optwn 6.,
. i,,, .
. ,.
The un1.dersig1.ned.agrees to accept and abide by all;permiit requ.Jrementq,including any and all related provisions df the
current West;Val%y;5`anrtatron Djstric>~Orsiir►ance G i,_
. I v,
Issued'To:AU:STIN HARY ;;signature': - - M
Phone#2 4'08 221 5,070 .,:.- 8/2/20178.49A
PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC &MISCELLANEOUS RECEIPT
Effective July 1, 2017
TO: Finance
PUBLIC WORKS FILE NO. NL.Z�%�� —CIO j�
PROPERTY ADDRESS .
Please collect & recei. t for the following monies:
ACCI ITEM ,AMO
ENCROACHMENT:;"PERMIT,
.QI; .. ..�_.�. .;. ,.. =
UNT
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
ManholesNaults/Etc. $190.00/ea
G I rM
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4760 cc. CD Ln c' 1 Lin
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4760LMCo
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4722 _::I ,00
TRAFt?I;C� ..' ca w Cni M U) ca >n c7 :� w k m , ...
ua .mt U.1 Ia.I w Z u`.1 x LJJ
4728 x �x 1— i,1 c i w r-- c s a �z
4728 -
4271 Truck Permits $16.00 per trip
yq {w�`4'72p80' }� No Parking Signs $1 each or$25/100
MISCEI.LANEOIS
511.7424 Postage
Other(Please Specify)
TOTAL 00
-
-NAME OF APPLICANT
NAME OF PAYOR PHONE C
ADDRESS r��� f� ZIP
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d a
FOR RECEIVE lgY
r "x ,atl
CITY CLERK
ONLY DeteW, .Relit # ti ,cg.
J:IFORMS\TemplatestAdministratiye\Receipt Form U011ty Encroachment 8 Misc 17-10.xis