91-170
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CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North Fi~t st.
caapbell, Cl '500'
(408) "'-2150
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DCROACIIIIEIft' PZRIII"I'
(for working in the
public rlgbt-of-vay) X-Raf. file
Inuell Application Date 7 - / C - 9 /
Perait uplru ill. 12 _. Application upiru ill , ~..
APPLIClT%ON - Application i. bereby _de for a Public Worb Perait in aocordanca with CUlpbell
llunicipal COde, Sect10n 11.04. (Application up1r.. in . IIOntb8 U perait not pulled)
A. Work addre.. or tract . q /1) 1111(" C;/I/He:J
Utility trench location
Paralt No.
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B. Mature of work:
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c. Attach flve (5) oopie. of a drawing lIbowing the location, extent and dlaerwiorw of the work
The drawing .ball lIbow the relation of the propo.ed work to exi.ting .urface and undeqround
iaprov_ent.. When approved by the city _ineer, ..id drawing becoaa. a part of thla parait.
D. The Cenera1 Condition. for all peraita are U.ted on the rave~e alde. lpecial Prcrvlaiona for
thla penalt are li.ted below. FaUure to abide by the.e COndition. and provialon. ..y ra.ult
in jOb .but-down and/or forfeiture of Falthful Perforaanca Bonde and caab dapo.ita. (I..
General COnditiorw 1 and 2).
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"elapbonal V~ ~ '37 tftrJ q 7 ~
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E. An appUcation fee auat accaapany thi. application. ftla i. non-refundable.
Nue of Applicant AI jjtrrE /'I 1315. R AI fhL
Addr... ? / ~ /fII e ~J tJ-NC' Y
I. thi. work being done by the property owner at their own re.idanca? -Y" ~
coaplete and .ttacb Worker.' c:oapen.ation and COntractor Inforution foraa.
The Applicant/Penaittee bereby agree. by affixing th.ir .i9ftatun to thi. parait to bold the City Of
Cupbell, it. officer., agent. and ..ployee. frae, ..fe and baral... frea any c1a18 or d~ for
da..ge. re.u1ting frOJl the work covered by thi. perait.
Tbe Applicant/Penaittee bereby acknowledge. th.t they bave read .nd under.t.nd both the front and
::':.<hiO .._t, .... that thoy Vi~~~;f~"';,.!c?/
Applicant (Paraittee) priil al9ft if/; " ' - 'f( (.
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NOTES: ALL WORK SHALL CONFORM WITH 'l'HB ATTAClDl:D, APPROVJ:D PLUfS AMI) ALL APPLICABLB CAllPULL
STANDARD DRAWINGS AND CONDITIONS.
'l'HE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLUS AND 110ft IID'1' 111'1'B 'l'BB P. W. IIfInCTOll ON
THE SITB AT LEAST TWO DAYS BEFORE STARTING WORK.
NOTICE MUST BI CIVEN TO PUBLIC WORD AT LBA8T 24 BOUR8 BIPORB DSTARTDfG AIf! 1fOlUt.
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SPECIAL PROVISIONS
_1.
street lIbaU not be open cut for undeqround lrwtaU.tiorw. II1nlaua cuta ..y be .llowed
for connectiorw or exploration bo1... 8uch cute au.t: M .~aifiaallY aDDraved bv t:he
In.aeator.
Pav_ent uy be cut for undeqround lrwtall.tiona and _t be reatored in .ocordanoe with
the Utility Tranch b.t.or.tion Standard Dr.wing.
Work to be .taked by . licen.ad Land Surveyor or Civil angineer and two (2) oopi.. of the
cut sbeets .ent to the Public Work Deptartaent before .tarting work.
The hour. of work .re llaited to wteide the boura of 7-' .... and 3-' p... for any work
.ffecting . traffic lane.
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RBCBIPr MO.
307 '-I c/
PDIII'1' APPLICl.TION nar
'100.00
PLU CIIBCK DBJIOSI'.r
BOND POll FArl'ID'DL PBRI'ORIIUCB
CUll DBPOSI'.r
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3C7 ':(5-
'500.00
(1001 01' aG. JI8'1'.)
(4t OJ' ..u. $500 lID)
PLAlf CllBCJ: , IlfSPBCTIOR nar ($0-$100,000 101,
$100,000 - $500,000 'I, $500,000 and above 71, $100 lID)
APPROVED FOR ISSUANCE
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for City Engin.er
f: PWPERMIT
Revised 4/91 ,,-~hz~d:h '/ -/c;.',- 9z
Date
City of Campbell- Check Request
To: Accounts Receivable
Please Issue Check
Payable to: Marten Bernal
Address - Line 1: 910 MCG1incey Lane
Line 2:
City: C'amphp11 State: CA Zip: 95008
Finance Only:
Description: REFUNDABLE DEPOSIT INTEREST EARNED
Amount Payable: $500.00
Account Number: 101.2203 101.540.7448
Date and Receipt No: 7/11/91 30745
Permit No: 91-170
Purpose: Encroachment Permit never issued. Applicant dop~ nOT inTPnd
to pursue work intended per 4/22/96 phone C'!a 11 wiTh C'iTY F.ngineer
Requested by: Mar1.n. pom.rny~~ Title: Secretarv Date: .4 1?.4 /Q&:;
Approved by: Michelle Quinney tu1!.... Title: City Engineer Date: 4/24/96
FINANCE ONLY:
Verified by: Title: Date:
.
Approved by: Title: Date:
Special Instructions For Handling Check
Mail As Is: x Mail in Attached Envelope:
Return To:
(NAME) (Deparbnent)
Other:
.
rev: 3/25/95
TO:
City Clerk
PUBLIC WORKS FILE NO.
'Y/-/7c'
Please collect & receipt
for the following monies:
ACCT ITEM AMOUNT RECEIPT NO
3372
3521
3521
Project Revenues (specify project)
Public Works Excavation Permit Fees:
Application Fee
Plan Check Deposit
Faithful Performance (Cash) Deposit
R.1:
($50)
Other:
($100)
($500)
(100% of)
(ENGR. EST)
(4% of FPB)
($500 min.)
$
/: ' ,'!.:- 301c.tt
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<)G0'~ 3o,,+,)
/
35-3396
3521
Other Cash Deposit (specify)
($200)
3372 Plan Check & Inspection Fee ($0 - $100,000 10%;
$100,000 - $500,0009%; $500,000 and above 7%; $100 min.)
3373 Project Plans & Specifications ($10)
3373 General Conditions, Standard Provisions & Details ($10 or $1/page)
3373 "No Parking" signs ($1Iea, or $25/100)
3373 Work Area Traffic Control Handbook ($5)
3373 Copies of Engineering Maps & Plans ($.50/sq.ft.)
3372 Final Parcel Map Filing Fee ($450 + $20 per lot)
3372 Final Tract Map Filing Fee ($500 + $20 per lot)
3372 Lot Line Adjustment Fee/Certificate of Compliance ($400)
3372 Vacation of Public Streets and Easements ($500)
3372 Assessment Segregation or Reapportionment
First Split ($500)
Each Additional Lot ($150)
3395 Park Dedication In-lieu Fee per Unit ($4,548)
3370 storm Drainage Area Fee
3380 Public Works Special Projects
3510 Postage
PHONE
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$ u:-; C{
37~ - J/7q-7
ZIP 9:S7J () f1
TOTAL
NAME OF APPLICANT //J /lI<!Tr7V !5efi?A.lfl-L-
ADDRESS 9/6' //1//_ G ~ / A./ ce:t/
RECEIVED BY ~ Q. C -"A (\D~
~~yCLERK DATE 71~~' -- G ----
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ENCROACHMENT PERMIT ISSUANCE CHECK LIST
City of Campbell
Department of Public Yorks
Encroachment Permit No.
7/-
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~App1icant section complete
~~App1icant signature and date
~Permit Application fee $100.00 paid
Receipt number 3 G' 7 (./' y-'
~lan check deposit, $500.00 paid
Receipt number -S c 1 '-lor;-
Five sets of improvement plans submitted
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_____Bond for faithful performance, 100% of City Engineer's
estimate, supplied or paid
Amount $ Form 1.0. #
_____Cash Deposit:
Amount $
4% of FP bond, $500 min. paid
Receipt No.
_____Plan Check & Inspection fee of 10% of F.P. Bond for
amounts of $0 - $100,000; 9% for $100,000 - $500,000;
7% for $500,000 and above; $100 min. paid
Amount $ Receipt No.
_____yorkers' compensation information received for Applicant
(see Information Sheet for Encroachment Permits)
_____All other Public Yorks requirements listed in the
Conditions of Approval of the development.
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_____yorkers' comp and Contractor's Information received for
Contractor (see Information Sheet for Encroachment Permits)
_____Certificate of Insurance with Additional Insured's
Endorsement received from Contractor (see General Summary of
Insurance Requirements for Encroachment Permits)
_____Three sets of off-site plans, stamped APPROVED (Tract or
Development and Public Yorks Permit number and property
address on plans)
_____Permit signed for City Engineer
WHEN ALL OF THE ABOVE ITEMS ARE COMPLETE, PERMIT MAY BE ISSUED
Issuer: Initial and date and file with permit
UPON ISSUANCE, INITIATE CHECK REQUEST FOR PLAN CHECK DEPOSIT REFUND
f:pmtck1st (Mise forms)
Revised 4/91