96-144
CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
ENCROACHMENT PERMIT
(for working within the
public right-of-way)
lit No.
kAef. File
9b-j44-
"',.,
Issued
Permit expires in 12 mos.
Application Date f ~ / - 5' b
Application expires in 6 mos.
APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application
expires in 6 months if the permit is not issued Application Fee is non-refundable).
A. Work address or tract # 1 ~1If1 ~~ f~ ~.
Utility trench location
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B. Nature of work ~~. f.lV\,.;" ~ ~
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C. Attach four (4) copies of engineered plans 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 plans become a part of this permit.
D. All work shall conform to the City of Campbell Standard Specifications and Details for Public 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 in
job shut-down and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2.)
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 STARTING WORK. NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS
BEFORE RESTARTING ANY WORK.
Name of APPlicant/permitteeJ(W U~ ~j:(tf[{D.\.J ~~.L,'r TelePhone~ )21~-1..4-c't
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 ackno ledges that th y ha e read and understand both the front and back of this permit, and they will inform their
co tractor(s) of the information:
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6-74-8/
SEE PAGE 74
WEST VALLLEY SANITATION DISTRIC
TO: City Clerk
PUBLIC WORKS DEPARTMENT RECEIPT
Effective July 1, 1995
PUBLIC WORKS FILE NO. 9~' j, tj-
PROPERTY ADDRESS /2).9 /l;/#"R 11.
Please collect & receipt for the monies: . I
M:CT;.', .11 .J1EM AM""""
435.535.4921 Proiect Revenue (specify oroiectl $
ENCROACHMENT PERMIT i I
472" Application Fee
Non-Utility Encroachment Permit ($225)
R-l First Permit (No Fee). Subseauent Permit/Yr ($100)
Utility Encroachment Permit I
Arterial/Collector Street ($325) 3.J. ':l. 0 0 I
Residential Street/Other Areas ($225)
220 Plan Check Deoosit ($500) I
220 Faithful Performance Surety (FPS) (100% of ENGR.EST.) ~ I
220 Monumentation Surety (100% of ENGR.EST.) ~ i
220 Cash Deposit (4% of FPS)($500 min.) r I
220 Labor and Material Surety (100% of ENGR. EST.) I
472~ Plan Check & Inspection Fee (Non-Utility) I
1 Engr.Est. < $250,000 (12% of ENGR. EST.) i
I.. 220 Engr.Est. > $250,000 (DeDosit 15% of ENGR. EST.)" . I
1
472 Utility < $100000 1 '2./0.l>C>
I
Conduits/Pipelines up to 500 Feet ($1.60/ft.) (MIN. $105) I
Above 500 Feet ($1.10/ft.)
Manholes/Vaults/Etc. ($105/ea)
Pole Set/Removal ($105/ea)
Minimum Charge Per Location ($120)
Street Tree Planting/Removal ($ 1 05/tree)
.. 220 Utilitv > $100,000 (Deoosit 15% of ENGR. EST.)"
476 Pro'ect Plans & Specifications Proiect No.
476 Standard Soecifications & Details ($l/Pa $12/Book) I
476 Cooies of Enaineerina Maps & Plans ($.50/sQ.ft.) I
472 Penalties: Failure to restore public imDrovements ($1 OO/Calendar Dav)
(Muni Code Section 11.34.010) ,
472 Penalties: Failure to correct unsafe conditions ($l00/Calendar Dav) I i
LAND DEVELOPMENT !
4722 Lot Line Adiustment ($500) I I
472 Parcel MaD (4 Lots or Less) ($1 060 + $25/Lot) I
472 Final Tract MaD (5 or More Lotsl ($1 380 + $25/Lotl
472 Certificate of Compliance ($400)
472 Certificate of Correction ($300) I
472 Vacation of Public Streets & Easements ($550) ,
472 Assessment Segregation or Reapportionment
First Split ($550)
Each Additional Lot ($170)
472 Storm Drainage Area Fee Per Acre (R-1, $2,000)
(Multi-Res, $2,250) I
(All Other, $2 500)
492( Parkland Dedication Fee (75%/25% Due Upon Cert. of Occupancy) I
496 Postage 1
TRAFFIC I
472 Intersection Turn Counts (Two-Hour Count) ($60)
472 Intersection Turn Counts (a.m. or o.m. Deaksl ($125)
472 Traffic Flow MaD (Daily Traffic Volumes) ($27)
472 Camobell Traffic Model (Full Scooe Assessment) ($2250)
472 Camobell Traffic Model (Reduced Scope Assessm$740) I
427 Truck Permits ( $35/trip) !
472 No Parking Signs ($l/each or $25/100) I
OTHER
TOTAL $ 535.00 .
NAME OF APPLICANT rM.~ Va.~ '{4..;f~/6-- /);>i"./~-+
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NAME OF PAYOR (V/ello A'~.1IR..5 PHONE tfof- 377-6/'3 I
ADDRESS ~(J Acb,',.,ct.7 ~; Ca-fJJ; c.4 ZIP 950(J if 1
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"Actual Cost Plus 20% Overhead (Non-Interest bearino deoosit) I
.oR
CITY CLERK
ONLY
.For Plan Check and Cash Deposits, send yellow copy to Finance.
Date/Initials
h:\recfrm3.wk3(mp)rev.1I9/96
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t~...._...._ _=:1L." :"~ . CITY OF CAMPBELL
wv LJ!) ~ N>>J ~ Lc.f;;rol5
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PROJECT NO. 9// - ! 'I-f
REPORT NO:
FIELD ENGINEER'S DAILY REPORT
CONTRACTOR: V0v)f ~ ,
DATE: 4- -)-9~
WEATHER: ~/\r
INSPECTOR: R. ~51fAL.L
ITEM
DESCRIPTION
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PAGE: I
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