ENC2000-00100cTrY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) S66-2~50
Fax (408) 376-0958
APPLICATION - Applic~ion h
it' tl~ pen~ is not issued. App
A. Work address or ~ #
Utility trench location
B. N~ of work ~'~ s
C. A~ch fo~- (4) copies of an
phns s~all show the relation of
this permit.
D. All work shall corlfor~ to th
side: and the Special Provisions
Performance Sureties and cash ~
E. THE CONTRACTOR MUS'
LEAST 'tWO DAYS BEFORE
Is tl~ work being done by thc l
The Applicam/Pc~ hereby
any ~ or demand for d~mag~
Tbe Applican~Permi~e hereby
iaformafion.
SPECIAL PROVISIONS
Street shall not
2. ~proved bv the
~ . Pavemem may be
unless otherwise a
~3, Work to be staked
.._.4. Per Secfio~ 4215 ~
idgntif~:ation numl
SEE PUBLIC WORKS FEE 5
PERMrr APPLICATION FEI
PLAN CHECK DEPOSIT
SECURYFY FOR FAITHFUL
CONSTRUCTION CASH DE
PLAN CHECK & INSPECTI¢
APPROVED FOR ISSUANCI
ENCROACHMENT PERM1T
(for working within the
public right-of-way)
Issued
Permit expires In 12 months
Permit No.
X-Ref. file
Application Date
Application expires i/l 6[months
hereby made for a Public Works Permit m accordance with Campbell Municipal Co~. Section 11.04. (Application expires ia 6 months
ication Fee is non-refundable.)
mginecred plans showing the locadon and exlem of the work, and four (~,) copies of the preliminary Engin~r's Estimale of work. The
he proposed work to existing surface and underground improvements. Wben approved by the City Engin~,'r. said plan becomes ,. pan of
City of Campbell St.a~t~d Specific qons ~xl Det~iis for Public Works Construction; the General Permit Condifion~ listed on ~ reverse
~or this permit, listed below. Failure to abide by these conditions ~ provisions reay result in job shut-down and/or forfeiture of F~thful
~osits. (See General Permit Conditions 1 and 2.)
HAVE THIS PERMIT AND APPROVED PLANS AT THE SITE AND MUST NOTIFY THE PUBLIC WORKS DEPAR~ AT
,'fARTING WORK. NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 2~ HOURS BEFORE RESTARTING ANY WORK.
- O,~ ~lev _~t~ ,t,.4,o,,.) ,~,,p~o,, ~/ooc''
(prfnt I~m.e)
/
roperty owner a~ thcir own residence? Y~s "*"' No
~rees by affixing their signature to ~his permit to hold the City of Campbell, its officers, agents and ~:mployees free, safe and harmless from
resulting from thc work covered by this permiL
:knowledges that thc), h~ve read and understand both thc from and back of ~ permit, and they will inform their co~Ks) of the
(Applicant/Permiuee) (sign) Date
be open ~t for underground installations. Minimum rots ma~ be allow~xl for cora~ctions or exploration hobos. $uch cuts may b¢ specif~dly
spector prior to cutting.
,'ut for underground installations and must be restored in accordance with thc Utility Tremh R. estor~tion Standar~ De~ls, M~md 'A' BackfiIl,
:~proved by Inspecwr.
by a lic~sed Land Surveyor or Civil Engin~r ami ~wo (2) copies of ~be cut sh~ts ser~ to the Pubr~c Works Depanm~ before sm,.i~ worL
,f the Governmem Code ~ pem~ is nol vaiid for excavations umii Underground ~-rvice Aim (U~A) I~s b~n n~ified and '~' inquiry
~r has been enu:red hereon. USA Phone 1-800-227-2600. USA TICKE'r NO.
2HEDULE FOR CURRENT FEES TYPE ' AMOUNT RECEIPT NO.
PERFORMANCE,q-~OR & MATERIALS $ ~
C~ENERAL PERMIT
1. A CONSTRUCTION CASH DEPOSIT is required. Charges 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 hilled to the PermJttee.
2. A ONE-YEAR MAINTENANCE PERIOD AND SURETY are required. Such period will begin on date of writmn acceptance by the City.
3. REFUND of the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the
work by the Cit~.
4. The Permit, ce 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 PemU~e.
5. MAINTAIN safe pedestrian and vehicular cwssings and free access to private driveways, bus stops, fire hydrants and water valves.
6. A CONSTRUCTION TRAFFIC CONTROL PLAN and a CONSTRUCTION SCHEDULE is required for all lane closures, detours and street closures.
This plan must be REVIEWED and APPROVED prior to any lane closures.
7. The CONSTRUCTION TRAIl:lC CONTROL PLAN shall conform with the Caltrans Manual of Traffic Controls for Construction and Maintenance
Work Zones, dated 1990, available at Caltrans. Traffic control equipment shall include Type tl flashing arrow signs if required.
8. REPLACE IN KIND any damaged or removed existing improvements, including planting.
9. Sawcut for all PCC or AC removals. All PCC removals shall be m nearest scoremark aza;I shall be doweled to exis~ng Lmprovements.
I0. OVERTIME INSPECTION PREMIUM will be charged against the cash deposit for inspection required outside the hours of 8:00 a.m. to 4:00 p.m.
at the currem overtime rate, minimum one hour charge.
I I. SATURDAY INSPECTIONS must be arranged in advance. Saturday inspection time is charged at the current ovenmte rate with a three hour
mL,~mum. Advance payment for the estimated time is required.
12. Adequate signing and lighted BARRICADING is required on the job site. Failure to provide such signing and barricading may result in the City's
renting such sigmng and barricades and charging the cost (including ail labor and materials) against the cash deposit.
13. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is REQUIRED unless otherwise stated by the City Engineer.
14. The Contractor or Perm/tree 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.
15. No STORAGE of materials or equipment will be allowed near the edge of pavement, the traveled way, or within the shouldefline which would create
a hazardous condition to the public.
16. 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 Permi~e of any obligation to obtain any other permit required by law.
17. This permit does NOT RELEASE be Permktee from any liabilities contained in other agreements or conn'acts with the City and any other public
agency.
18. This permit L~ NOT TRANSFE~LE. Work must be performed by the Permittee or his designated agent or contractor a.s specified thereon.
19. 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
20. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material inw the municipal storm drain
system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the S, anta Clara V~ey Nonpoint Source
Pollution Control Program.
Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above conditions.
pplica Date
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