96-245
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)
Issued /(1. X2 - cl&-' v f.A
Permit expires in 12 months ';1~r
Permit No.
X-Ref. file
It. - A?6-
Application Date 10... 1- t:t I.r:,
Application expires in 6 months
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 lraCt #
/'/oO.1lo,,",,_
Utility trench lOcation
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B. Nature of worle
C. Aaach four (4) copies of an 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 plan becomes a pan of
this permit.
D. All worle 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 0 0 "'Y\ .... \ ), L..Ks:.-/1 e \/
(prin~e) ,
Address :J '3' ~ 1.1 <;;. ~ V I ~\",o".J \ ~', /... 0 5 ~ ~UR EMERGENCY TELEPHONE NO.
1S-o") 0
Telephone
)("3 - '2. "2' S-
Is this worle being done by the property owner at their own residence?
Yes
x
No
W~y~~~
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.
A_qJJ1~
Applicant/Permittee) (sign)
[) f~ t.f) /11~
Date
_2.
SPECIAL PROVISIONS
_1. Street shall not be open cut for underground installations. Minimum cuts ~ be allowed for connections or exploration holes. Such cuts may be 5DCCifica1lv
approved bv the Inspector prior to cuttine.
Pavement may be cut for underground installations and must be restored in accordance with the Utility Trench Restoration Standard Details. Method' A' Backfill,
unless otherwise approved by Inspector.
Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public WorksDepanmcnt before statting work.
Per Section 4215 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.
_3.
_4.
_5.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
IYffi
AMOUNT
$J.lt? ,0 I.)
$
$
s
$/;).0,00
RECEIPT NO.
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS
CONSTRUCTION CASH DEPOSIT
Pu.N CHECK&INSPEcno~
APPROVED FOR ISSUANCE / · 'rJJ
for City Engineer
CAf) L.. .
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1~/tf/7~
Date
PUBLIC WORKS DEPARTMENT RECEIYf
Effective July I, 1996 90 --.2 L/.s /
TO: City Clerk PUBLIC WORKS FILE NO,
PROPERTY ADDRESS
Please collect &
IACCT:< .. . moM ...... .. .. ... ......
4355354921 I Proiect Revenue (specify proiect) S
ENCROACHMENT PERMIT
4722 Application Fee
Non-Utility Encroachment Permit (S225)
R-I First Permit (No Fee). Subsequent Permit/Yr (SIOO)
Utility Encroachment Permit
Arterial/Collector Street S325)
Residential Street/Other Areas S225) .L:U
2203 Plan Check Deoosit - 2% ofENGR. EST. S500 min) .
2203 Faithful Perfonnance Security (FPS) 100"10 of ENGR.EST.) .
2203 Labor and Materials Security 100"10 ofENGR. EST.)
2203 Monumentation Security 100"10 ofENGR.EST.) .
2203 Cash Devosit 4% ofENGR.EST.)(S500 min/SIO,OOO max) .
2203 Labor and Material Security 100"10 ofENGR. EST.) .
Plan Check & Inspection Fee (Non-Utility)
4722 Engr.Est. < S250,000 (12% ofENGR, EST.)
.. 2203 Engr.Est.>S250,OOO (Deposit 8% ofENGR. EST./S30,000 min.).. .
4722 Utility < SIOO,OOO (8%) /./f.UU
Minimum Charge Per Location (SI20)
ConduitslPipelines up to 500 Feet (SI.6O/ft)
Above 500 Feet (SI.IO/ft.)
ManholesIV aultsIEtc. (SI05/08)
Pole Set/Removal (S I 05/08)
Street Tree Plantinw'Removal (SI05/tree)
.. 2203 Utility> Sloo,OOO Actual Cost + 20% .. .
4760 Pro'ect Plans & Soecilications Pro'ect No.
4760 Standard Soecilications & Details (SI/Plt SI2IBook)
4760 Copies of Enltineerinlt Maps & Plans (S.50/SQ.ft. )
4722 Penalties: Failure to restore public improvements (SIOO/Calendar Day)
(Muni Code Section 11.34.010)
4722 Penalties: Failure to correct unsafe conditions (Sloo/Calendar Day)
LAND DEVELOPMENT
4722 Lot Line Ad'ustment S5(0)
4722 Parcel Map (4 Lots or Less SI,06O + $25/Lot)
4722 Final Tract Map (5 or More Lots) SI,380 + S25/Lot)
4722 Certilicate of Compliance S5(0)
4722 Certilicate of Correction S3(0)
4722 Vacation of Public Streets & Easements S550)
4722 Assessment Segregation or Reapportionment
First Split (S550)
Each Additional Lot (SI70)
4721 Stonn Drainage Area Fee Per Acre (R-I, S2,(00)
(Multi-Res, S2,250)
(All Other, S2,500)
4920 Parkland Dedication Fee
4965 Poslal!e
TRAFFIC
4728 Intersection Turn Counts (Two-Hour Count) (S6O)
4728 Intersection Turn Counts (a.m. or p.m. peaks) (SI25)
4728 Traffic Flow Map (Daily Traffic Volumes) (S27
4728 Campbell Traffic Model (Full SCODe Assessment) (S2,250)
4728 Campbell Traffic Model (Reduced SCODe Assessment) (S740)
4271 Truck Pennits (S35/trip)
4728 No Parkinlt Signs (Sl/each or S25/1OO)
OTHER
TOTAL S 3Lf5t5D
NAME OF APPLICANT ~rLr~ f J:L. ~/]
(7
NAME OF PA YOR / PHONE 15'3 -,)./;;)9S~
ADDRESS ,~ 'S & j L/ v1Ic01~J.J -kGUL/~/ ZIP Y/;/5():::S C)
.. Actual Cost Plus 20"10 Overhead (Non-Interest bearing d!,Sitl LCd CftLf--t.'-:;J
/
FOR RECEIVED~"T1J:YMU!. ...~. . ..
CITY CLERK
ONLY '< ......
Date ... ..... ..... · . <. .V)'JI.JVJI'or' ... . .. . <....
. ..<<d .,
.For Plan Check and Cash Deposits,serid yellow copy to Finance.
.\fECE1VED
OCT 2 2 1996
CITY CLERK'S OFFICE
h:lrecfnn4. wk3(mp )rev7 11/96