ENC2019-00012 .t
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CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No.: ENC2019-00012"
DEPT.OF PUBLIC WORKS (for working within the X-Ref. File BLD2016-00803
70 North First Street pu lic ri ht-of-way) Application Date 1/18/19
Campbell,CA 95008
Ph.(408)866-2150 Issued I Application Expiration Date
Fx. (408) 376-0958 , /Ilalzo
APN 406-15-030
Permit Expiration Date
APPLICATION-Application is hereby made fora 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: 1162 San Tomas Aquino Rd
Nature of Work/Utility Close existing driveway and replace with-City standard curb and gutter
e' Trench Location: ff II
❑ No Fee Permit for work related to City Project Project Name: �a.�,( �,A)cL•l,l i C��n �'
C. Attach four(4)copies of an engineered plan showing the location and extent of the work, and four(4)copies of the preliminary Engineer's
Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When
approved by the City Engineer, said plan becomes a part of this permit.
D. All workshall conform to the City ofCampbell Standard Specifications and Details forPublic Works Construction;the General Permit Conditions
listed on the reverse side;and the Special Provisions for this permit,listed below. Failure to abide by these conditions and provisions may result
injob 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 notifythe Public Works Department at least two days before
starting work. Notice must be given to Public Works at least 24 hours before restarting any work. .
Name of Applicant: r' Telephone:
f�. �j3 r l,� rs fin-
Address:
y L�— bx—V l
E-Mail Address: �y�U 1, U.� rY1 `r24-HOUR EMERGENCY PHONE NUMBER: Ll
Is this work being done by the property owners at their own residence? ❑ Yes � No T (!L a¢
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.
Accepted:
(Applicant Permittee) (sign) Date
(Contract ) (Print ame) Date
SPECIAL PROVISIONS:
1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections orexplorationholes.SUCII cuts ma be
a prifirally apnrovpd by the Inspertor prior to rutting.
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 be recorded.
6. "Public Notification Requirements:
7.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RE EIPT NO
PERMIT APPLICATION FEE $ `��SS d70
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 ate
Permit Expires 12 Months After Date of Issuance
5 ,
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%ofthe
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 most recent version of the 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 Citys 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 numberat 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 peroccurrence.
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/oroe"rams/np'des/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.
vo
Applicant-;� Date: l
Contractor rint Name) U Date:
J:\FORMS\Templates\Encroachment Perm its\Encroachment Permit STATIC
form2.pdf Rev.04/18
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PUBLIC WORKS DEPARTMENT
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CHECKED BY: DATE Details
APPROVED BY: D— O
ORcgABO MICHELLE QUINNEY
CITY ENGINEER JJDrowmgs Sld_Details D20
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CITY OF CAMPBELL I
70 N FIRST ST
CAMPBELL,CA 95008
01J18J2019 11:28:03
CREDIT CARD
CITY OF CAMPBELL VISA SALE
RECVID 0Y: 01OO,0279O44 Card# .
PAYOR: DOUGLAS IbiANAGi �- XX�XXXX24
TO,s,�Y� 'C DATE. 01.,4 G,i n Chip Card: Visa Credit
REGISTER BATE: 0,1,�18r 19 TIME- 00-00 AID:ATC; A000000003 00
DESCRIPTIONDESCRIPTIONAMOUNTU�T 422
OUST 111;E`WC.2O19—O0012 TC; 23D6FD44C07BCA71
E, T , SEQ 3,/ { � -
r:UST' 1D.-1162 S SAN T11MAS AIGUING Batch#: 764
PERMIT TRACKING SFTWIR $4.50 INVOICE 3 "
------------------ Approval Code: 05184D
TOTAL DUE-. $t29.v0 Entry Method: Chip Read
TENDERB. $229.50 Mode: Issuer
CHANGE: $.CIO
C"PEDIT CARD. $229.50 RE NUM'- SALE AMOUNT $229,50 {
CUSTOMER COPY
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PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MISCELLANEOUS RECEIPT
Effective January 1, 2019
TO: Finance n ^ 1
PUBLIC WORKS FILE NO. G��� —DOO 1Zr
PROPERTY ADDRESS
Please collect & receipt for the following monies:
ITEM t ._.',t-. '
. .. ...�. .,-
ENCROACHMENT PERMIT..
4722 Utility Encroachment Permit Application Fee $553.00
4722 R-1 Encroachment Permit $225.00 .00
2203 R-1 Faithful Performance Deposit $2,500
4722 Plan Check&Inspection Fee
Minimum Charge Per Location $553.00
Conduits/Pipelines up to 500 Feet $3.54/ft
Above 500 Linear Feet $1.77/ft
Manholes/Vaults/Etc. $221.00/ea
Pole Set/Removal $221.00/ea
2203 Street Tree Planting/Removal-Deposit(refundable) $500/tree
4760 Storage Container Permit(valid up to 60 days only)' $175.00
4760 Engineering Maps &Plans
Aerial Plot 24"x 36" $35.00
- -- - Map-Research-(includes-max of two-24"x36"-copies:_$35;00
Maps and Plans 24"x 36" $35.00
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 2 Times Applicable Fee
r
4728 Traffic Flow Map(Daily Traffic Volumes) $35.00
4728 Traffic Control Plan Review
Minor(Lane Closures) $221.00
Major(Detours) $884.00
4728 Signal Timing Information $221 per hour
4271 Truck Permits $16.00 per trip/Annual$90 per year
4728 No Parking Signs $1 each
554.4214 Technology Enhancement Fee 2%of total permit fees ]
511.74241 Postage
Other(Please Specify)
TOTAL
NAME OF APPLICANT
NAME OF PAYOR PHONE
ADDRESS ZIP
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FOR RECEIVED BY � x s�
FINANCE
USE ONLY r
Date _;;
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J:WORM51Temptate'AdministraWelReceipt Form UhUty Encroachment&Misc 18-19.xls -
OF C 4,y
•Gk CHAR
CITY OF CAMPBELL
Public Works Department
February 20, 2019
Mr. Douglas Iwanaga
Tokui Builders, Inc.
1366 York Ave.
Campbell, CA 95008.
Re: Permit#ENC2019-00012; 1162 San Tomas Aquino Rd., Campbell, CA
Dear Douglas:
Enclosed is the refund check for the duplicate Application Permit Fee paid on the above-mentioned
Encroachment Permit.According to our records the Application Fee was previously paid on Permit
#2016-00189 by the homeowner.
Sincerely,
i� ,
Jd�nna}Thomason
Off ce Specialist
70 North First Street • Campbell, California 95008-1436 TEL 408.866.2150 FAX 408.376.0958 TDD 408.866.2790
................. ................
....................... ....... ......... .... ............................
....................................... ...... . . ............
----------------------- ------------------ ---- -------
CITY OF CAMPBELL VENDOR NO. 10015360 CHECK NO. 271998;
..........
.. .........
.............. ... ...................
. ..................
.......... .0thdM,0 ................ ....
101.554 4214 CR021119 4.50 ENC201900189 REFUND
101.730 4722 CR021119 225.00 ENC201900189 REFUND
10015360 DOUGLAS IWANAGA
,g::rA.Go BANK, N.A. CHECK.DATE r' CHECK NO:=��
A
'BELL 11�24-
02 OMERY STREET-
2719
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XsaN 1210
NGRTH�TIRST STREET 01,1TRI ......
SC�',� C�A 113.04
:CAMPBELL CALIFORNIA 95008'
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AMOUNT,
4
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Wi THE, SUM:OF O�: 50, CENTS co
�TW ,HUNDRED TWENTY NINE DOLLARS
To ,THE -- DOUGLAS' IWANAGA
I.' CiRDIIR:_,: 1366 YORKAVE
CAMPBEL
L CA 95098
&:E%1115�S,44
lim�2,71 9 100,0, 4.A C.
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See Reverse Side Forlasy Opening(lnstrucoons*
------------ ------
CITY OF CAMPBELL
70 NORTH FIRST STREET
CAMPBELL, CALIFORNIA .95008
DOUGLAS IWANAGA
1366 YORK AVE
CAMPBELL CA 95008
Vendor#.
(Ftnanic Use Only)' j
-C it,
i of C�arnpbell :Check �R;equest
'To. -Finance•Director
Check Payable T6:- Douglas Iwanaga (35`Gharacters)
Address Line1: 1366:York Ave: (35.61haractets)
Llne'2: (M Characters)
city: Ganipbell'_ State: _ CA. "Zip: 95008 -
Receipt#279044' 1/18119• ,:25 characters
Description: p ( ) )
Permit Number: ENC 2019-00012 Invoice Date:
Totalf Amt Payable; $229.60, (ExactAnount).
y
Account Number:- 101`7.30.4772. : , _ ..Amount: _.$225.00-
Account Number: 554.42,14 Amount: $4.50
,Purpose: Refunding duplicate permif fe&,char6ed,-see ENC2016-00:189"
IJL. .ZO�
l : O , 02/04119 Requested bo son Sa4 ,
Approved by: Title: Date .1
Special Instructions For Handling. "Check
Mail-As Is Mail in Attached'•Envehope:; : Interim.Check:
eeded':By
Pturn To: JoAnna - _ blic Works i
(Name) (D artment)
1, • - -
"Oth'er l
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