ENC2004-00050
CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
R-l NU FEE ENCROACHMENT PERMIT
Pennit No f3+JC ZeJZi4- Ol)t.iSO
X-Ref. File
Application Date
(Non-engineered work within the public right-of-way)
($5,000 maximum value of work)
Application Expiration Date_
ISSUED
APN :,OS-33--0C;)~
Pennit Expiration Date
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.)
A. Work address 53 (h..in l fA. Lai)e
B. Nature of Work 'f2-etOc-/eJ J'~\{.l,(dsc~ in p:4~-hlp' 41~YJ f~lS-hI'1j- ~~W) -free LLf'c/ IWdst~
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C. Attach three (3) copies of a drawing showing the location, extent anltli~ensions 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 shutdown and/or forfeiture of Faithful Performance securities.
(print name)
ty 0 pbell, City of Campbell Redevelopment Agency,
d for damages resulting from the work covered by this
NAME OF APPLICANT
ADDRESS
E-MAIL ADDRESS
The Applicant hereby confirms that this work is being done by the property ownerl
The Applicant hereby agrees by affixing their s' 't to:Eld th
its officers, agents and employees free, saf an n cl' or de
~~t. /
ACCEPTED
derstand both the front and back of this permit, and that they will inform their
The Applicant hereby acknowledges th
contractor(s) of the information.
(ApplicantlPermittee) (Sign)
Date
NOTES: All work shall conform with the attached approved plans and all applicable Campbell Standard Details and Conditions and
applicable insurance requirements.
The Contractor must have this permit and approved plans and must arrange to meet with the Public Works Inspector at the site alleasl two
days before starting work. Notice must be given to Public Works at leasl24 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.:
Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all
damages arising Oul of the design, installation or condition of private improvements in the public right-of-way.
SPECIAL PROVISIONS
~ 1. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be recorded.
_2.
_3.
SECURITY FOR FAITHFUL PERFORMANCE
STANDARD
(100% OF ENG. EST.)
AMOUNT
$ ~
-~
RECEIPT NO.
APPROVED FOR ISSUANCE
for City Engineer
Date
Pennit Expires 6 Months After Date of Issuance.
J:\forms\r 1 permit
Revised 1.20.04
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Edward _.ango, P.E.
Associate Civil Engineer
City of Campbell
70 North First Street
Campbell, CA 95008
Phone: (408) 866-2166
Fax: (408) 376-0958
E-Mail: EdwardA@ci.campbell.ca.us
Transmittal
... .
. -
To:
Patrice Ash
Date:
March 18,2004
Company:
Address:
1300 Capri Drive
Campbell, CA 95008
Re:
53 Catalpa Lane - Agreement
o Urgent
o For Review
o Please Comment 0' Please Reply
o Please Recycle
. Enclosure:
1. Agreement for Private Improvements in the Public Right-of-Way
2. Encroachment Permit
. Comments:
Ms. Ash, please sign the attached Encroachment Permit, both front and back. Also sign the
attached Agreement, and have both signatures notarized for the agreement. Once signed,
please return all documents to me.
Please contact me if you have any questions or comments.
Thank you.
J:\LandDev\Forms\Transmittal.DOC