97-122
CITY OF CAMPBELL
PUBLIC WORKS DEPT.
70 N. First St.
Campbell, CA 95008
(408)866-2150
FAX (408)376-0958
OWNER OCCUPIED R-l
NO FEE ENCROACHMENT PERMIT
(for working within the
public right-of-way)
($5,000 maximum .value of work) /~
ISSUED :2/d-I/i7 ~
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.)
Permit No. 97 - I :2 2-
X-Ref. File
Application Date .2/20 l-I 7
.. .
A. Work Address C1s'l CRee K ETT AVE.
B. Nature of Work Tie E /t/C II FOR. p. to;. j E, G/15 /-/ IV i:
C. Attach three (3) copies of a drawing showing the location, extent and dimensions of the work. The drawing shall show
the relation of the proposed work to existing improvements. When approved by the City Engineer, said drawing becomes
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
securities.
NAME OF APPLICANT
DALE LEPP!<E
(Print Name)
-If 7n2.
/t//LJO DR. CAP1P/3ELL
TELEPHONEJt'?1r- 3 7cJ-;J.;lO I
ADDRESS '7/0
c/!.
9~ooi
The Applicant hereby confirms that this work is being done by the property owner/applicant at their own residence.
The Applicant 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 hereby acknowledges that they have read and understand both the front and back of this permit, and that they will
inform their contractor(s) of the information.
ACCEPTED '" l)~ ~L
Applica~erm' e Sign)
~//C~/97-
Date
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE
CAMPBELL STANDARD DETAILS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AND MUST ARRANGE TO MEET WITH
THE PUBLIC WORKS INSPECTOR AT THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK.
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY 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
(TICKET NO.) HAS BEEN ENTERED HEREON. USA PHONE: 1-800-227-2600. TICKET NO.3 b 76 S-
SPECIAL PROVISIONS
WIA,NT!J,J;J ~r6 fJ~5-~(U4,J + tlWlCULA-tC: A."cus~ JItT A--LG 1J#lt:5~ . ~Al6
JIM) I~t:i) 'It: 61Vt,y. e.u::c71e'CAl~ ~CP: J'! AJOl "1'/.Iaw,J; Avtr .IIl~e()~ -;2J h-:'
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SECURITY FOR FAITHFUL PERF~
APPROVED FOR ISSUANCE I ( -rJ;.
r City Engineer
Permit Expire 6 Months After the Date of Issuance
STANDARD AMOWT
% OF ENG. EST.) $ AJ,I; .
,
RECEIPT NO.
( SEE OTHER SIDE)
GENERAL PERMIT CONDITIONS
1. A SECURITY to insure FAITHFUL PERFORMANCE and completion of the work is required. This SECURITY
is refundable upon completion of the work and written acceptance by the City.
2. A ONE-YEAR MAINTENANCE PERIOD for all work is required. Such period will begin on the date of written
acceptance by the City. It is the applicant's responsibility to remove and replace unacceptable improvements within the
one-year maintenance period.
3. REFUND or cancellation of the Faithful Performance security will be initiated by the written acceptance of the work by
the City.
4. 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.
5. MAINTAIN safe pedestrian and vehicular crossings and free access to private driveways, fire hydrants and water valves.
6. REPLACE IN KIND any damaged or removed existing improvements, including planting.
7. SAWCUT for all PCC or AC removals. Prior to concrete sawcutting or washing, the Contractor shall place filter fabric
material in the flow line of the gutter to retain all construction debris. All construction debris shall be wet vacuumed,
broom swept, picked up and disposed of by the Contractor. Concrete sawcut debris shall not be swept or water hosed
into the gutter and into the storm drain system.
8. Adequate signing and lighted BARRICADING is required on the job site. Failure to provide such signing and
barricading as specified by the City Engineer may result in the City's renting such signing and barricades and charging
the cost to the permittee.
9. The Contractor or Permittee will have a SUPERVISORY REPRESENT A TIVE available for contact on the project at
all times during construction.
10. This permit shall be kept at the site of work and must be shown to any authorized representative of the City of Campbell
or any law enforcement officer upon demand.
11. No STORAGE of materials or equipment wiII be allowed near the edge of pavement, within the traveled way, or within
the shoulderline which would create a hazardous condition to the public.
12. 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.
13. All necessary ROAD REPAIRS resulting from the permit work shall be made in accordance with City Standards and
Specifications at the sole expense of the Permittee.
14. This permit does NOT RELEASE the Permittee from any liabilities contained in other agreements or contracts with the
City and any other public agency.
15. This permit is NOT TRANSFERRABLE. Work must be performed by the Permittee or his designated agent or
contractor as specified thereon.
16. Prior approval of inspector is required for any work done after normal working hours, on weekends or holidays and may
require reimbursement of inspection costs at the current overtime rate.
17. 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 occurrence.
Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all
of tho ,bovo OOOditiOns.~
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WORKER'S COMPENSATION INSURANCE INFORMATION
The following worker's compensation insurance information is required for all Applicants and
Contractors. One of the following items for each Applicant and Contractor must be submitted
prior to working under a Public Works permit or contract.
WORKERS' COMPENSATION INFORMATION:
Name of Contractor/Applicant
j~ALE LCPj:J/c. E
o A Certificate of Consent to Self-Insure issued by the Director of Industrial Relations; OR
o A Certificate of Workers' Compensation Insurance
Insurance Co.
Policy No.
Expiration Date
; OR
f
A signed Certificate of Exemption from the Workers' Compensation laws as printed
below.
CERTIFICA TE OF EXEMPTION
I certify that in the performance of the work for this contract, I shall not employ any
person in a manner so as to become subject to the Workers' Compensation Laws'of
California.
Signed ~ ~,,~
Date
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{
Title (l U/ r7 e r
NOTICE TO APPLICANT/CONTRACTOR: If after signing this Certificate of
Exemption, you should become subject to the Workers' Compensation provision of the
Labor Code, you must forthwith comply with such provisions or the Permit or Contract
will be cancelled or revoked.
j: \forms \ workcomp(rev6/96)