97-153
CITY OF CAMPBELL
DEPT. OF PUBUC 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 6) \ )CJ 7 grnCJ
Permit expires in 12 months
Permit No.
X-Ref. file
97 -/53
Application Date 5/ / (c; 1
Application expires in 6 months
APPLlCA TION - 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 nOI issued. Application Fee is non-refundable.)
A. Work address ortract# iV/o 3J,t:,. JtINCIIi/'J ~ ~/Jt;u, MII)/JtA; S-a/<.G/, WA-U~k7 Accesf,
Utility trench location
B. Nature of work '~~), \
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C. Attach 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 part of
this permit.
D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Pennit Conditions listed on the reverse
side; and the Special Provisions for this permil. 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.)
Name of Applicant
Address ~b
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.
1)..",,0 tA 'O..,,~ (F~V\ GU-("\.21 Telephon6'i-~M - '~f\
. (prim name) Q ~("_ "'J '1
c.~-~ A h \A. e ~ Cs...."'lb- V\ c...~ 24 HOUR EMERGENCY TELEPHONE NO. -\V\ - ::,- \I~
.)
Is this work being done by the propeny owner at their own residence?
Yes L.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 ackn
information.
and understand both the front and back of this permit. and they will inform their COntraClOr(s) of the
Accepted
(Applicant/Permittee) (sign)
DZ-- 9
Date
_2.
SPECIAL PR0VISIONS
_1. Street shall not be open cut for underground installations. Minimum cuts !JEY be allowed forcollllCCtions or exploration holes. Slichcwmav be sPecificallv
approved bv the Inspector prior to cutting.
Pavement may be cut for underground installations and must be restored in accordance with the Utility Trench Restoration SiandardDetails. Method 'A' Baclcfin,
unless otherwise approved by Inspector.
Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cutsbeets Sent. to the Public Works Dcpanmcm before starting work.
Per Section 4215 of the Government Code this permit is not valid for excavations until. Underground Service Alen(USA) has been notified and the inquiry
identifICation number has been entered hereon. USA Phone 1-800-227-2600. . .... USA TICKET NO.
110Wl::L A}cW CCJNC. Ift"'/ClcK1ffJN6 wrn/ #4 ~_
_3.
_4.
_5.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
I.rffi
u:(i L ·
AMOUNT
RECEIPT NO.
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & INSPECTION F
~
/0/ f6 '-
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APPROVED FOR ISSUANCE
GENERAL PERMIT CONDITIONS
1. A CONSTRUCTION CASH DEPOSIT is required. Charges will be made against this deposit if there is an emergency call-out, overtime inspection
or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee.
2. A ONE- YEAR MAINTENANCE PERIOD AND SURETY are required. Such period will begin on date of written acceptance by the City.
3. REFUND of the cash deposit balance and refund or cancellation of the Faithful Performance Surety 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 Pennittee.
5. MAINTAIN safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants and water valves.
6. A CONSTRUCTION TRAFFIC CONTROL PLAN and a CONSTRUCTION SCHEDULE is required for all lane closures, detours and street closures.
This plan must be REVIEWED and APPROVED prior to any lane closures.
7. The CONSTRUCTION TRAFFIC CONTROL PLAN shall conform with the Caltrans Manual of Traffic Controls for ConstrUction and Maintenance
Work Zones, dated 1990, available at Caltrans. Traffic control equipment shall include Type IT flashing arrow signs if required.
8. REPLACE IN KIND any damaged or removed existing improvements, including planting.
9. Sawcut for all PCC or AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements.
10. OVERTIME INSPECTION PREMIUM will be charged against the cash deposit for inspection required outside the hours of 8:00 a.m. to 4:00 p.m.
at the current overtime rate, minimum one hour charge.
11. SA TURD A Y INSPECTIONS must be arranged in advance. Saturday inspection time is charged at the current overtime rate with a three hour
minimum. Advance payment for the estimated time is required.
12. Adequate signing and lighted BARRICADING is required on the job site. Failure to provide such signing and barricading tn:ly result in the City's
renting such signing and barricades and charging the cost (including all labor and materials) against the cash deposit.
13. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is REQUIRED unless otherwise stated by the City Engineer.
14. The Contractor or Permittee will have a SUPERVISORY REPRESENTATIVE available for contact on the project at all times during construction.
Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m.
15. No STORAGE of materials or equipment will be allowed near the edge of pavement, the traveled way, or within the shoulderline which would create
a hazardous condition to the public.
16. This permit shall not be construed as authorization for excavation and grading on private property ADJACENT to the wor~ 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.
17. This permit does NOT RELEASE the Permittee from any liabilities contained in other agreements or contracts with the City and any other public
agency.
18. This permit is NOT TRANSFERRABLE. Work must be performed by the Penninee or his designated agent or contractor as specified thereon.
19. 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.
20. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the municipal storm drain
system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Nonpoint Source
Pollution Control Program.
Applicant shall bjPOnSible for ensuring that all those providing services under the applicant are aware of and understand all of the above conditions.
1/-- (if- .e.. f)'S-V&q7
Applicant Date
j:\forms\pwperm2 6/96
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PUBLIC WORKS DEPARTMENT RECEIPT
Effcctive July I. 1996 97-15~
TO: City CIeri; PUBLIC WORKS FILE NO.
W/. 3.JL, ~l tVC,CJJ
PROPERTY ADDRESS 0
~'L
ACCT. ITEM .. .. ............. .................... ....... .......
43l53l.4921 I Project Revenue (specify project) '..
S
ENCROACHMENT PERMIT
4722 Appliclllion Fee
Non.Utility Enetnlchmcnt Permit (S225)
R.I Fint Pennit(No fee), Subsequent PcrmillYr(SIOO)
Utility Encroachment Permit
ArteriaUCollector Street (S325)
Residential SIrcetIOther Areas (S225) ';';'.l ~f -
22fl3 Plan Che<:k Deposit - 2~. of ENGR. EST. (S'OOmin) .
2203 Faithful Perfonnllnce Security (FPS) (I00.I.ofENGR.EST.) .
22fl3 L.abor :lnd Mluerials Security (I()()"/oorENGR. EST.)
2203 Monumentuion Security (I()(JOI.ofENGR.EST.) .
12fl3 C.1Sh Deposit (4'Y. orENGREST.}(S500 minIS 10,000 max) .
Plan Check &: Inspection Fee (Non.Utility)
4722 Engr.E.... < S2.l0.()(llJ (12". or ENGR. EST.)
.. 2203 Engr.Esl>S250.00O (Deposit 8% of ENGR. EST J$JU.OOO min. ).. .
4112 Utility < $100.000
Minimum Charge Per Loeation ($120) 1:10 -
ConduitslPipcJincs up to 500 Feet (SI.60/fil
Above SOO Feet (SUO/n.)
ManholesIVaultsIEtc. (Slfll/ca)
Pole SctIRcmoval (SIfl5/ca)
Street Tree PtantingIRcmoval (SIfl51ln:e)
.. 2203 Utility> SIOO.UOO ActuaJ Cost + 20-/. .. .
4722 Street Tree PlanlingtRcmoval Permit (SI05)
4760 Proiect Plans & Specifications Project No.
H60 Standard Specifications & Details (SlIPS Sl2lBook)
4760 Copies of Engineering Maps &: Plans (S.50/sq.n. )
4722 Penalties: Failure to restore public improvements (SI{)()/Collcndar Day)
(Muni Code Section 11.34.010)
4722 Penalties: Failure to correct unsafe conditions (SinO/Calendar Day)
LAND DEVELOPMENT
4722 LOI Line Adjuslment (S5IXI)
4722 Parccl Map (4 Lots or Lcss) (S1.060 + S251Lo1)
4722 Final Tract Map (j or More Lots) (S1.380 + S251Lo1)
4722 Cenificate of Compliance (S5IXI)
4722 Certificate of Correction ($300)
4722 Vacation of PubJic Streets &. Easements (S550)
4722 Assessmcnt Segregation or Reapportionment
Firsl Split (5550)
Each Additional Lot (SI70)
4721 Storm Drain:1gc Area Fee Per Acre (R-I.S2.fUm)
(Multi-Res. S2.250)
(All Other. S2.500)
4920 Parkl:1nd Dedication Fee
496' Postage
TRAFFIC
472X Intcrsection Turn Counts (Two-Hour Count) (560)
4728 Intersection Tum Counts (a.m. or p.m. peaks) (SI25)
4728 Traffic flow Map (Daily Tl1ltlic Volumes) ($27)
4728 Campbell Traffic Model (FuJI Scope Assessment) (S2.250)
4728 Campbell Tramc Model (Reduced Scope Assessmcnt) (S740)
4271 Truck Permits (S35Itrip)
4728 No Parking Signs (SI/each or S23/11)())
OTHER
TOTAL 5 :j4~- ~
NAME OF APPLICANT \)~ Jl~ ~ ~",~~j"l\,
~ ~ \CC..\."" ~ J C\<S1"'~~r::..- \'L\
NAME OF PA YOR ~,\c ,'I,^- PHONE
ADDRESS A~<" C _W i.( IJ~.A \--'1- \^~ ZIP '1<;00 ~
- j
.. Actual Cost Plus 2('-/" Ovcrne01d (Non.lntcn:st bcarin!j: deposit)
FOR (
CITY CLERK RECEIVED BY ....
[\ ....
ONLY j \ 0 I .. X'~Jo
Dp.. Recc;p. .
I \J . .. ...
... ''f4~..1
.For pr.m Check .1nd Cash Deposits. send>'eJlo\\i copy lormancc.
Ii t 1AA7
CItY ClERICS OffiCE
h:lrecfrm4(c:'tc)mp(rev 1/2/97)
CITY OF CAMPBELL
FIELD ENGINEER'S DAILY REPORT
W)I 1)b ~)/'\C \^
C?eo-;W )AI(,-)J~ .Jc~~./ wJiwj .
PROJECT NO. 97-/ SJ
REPORT NO: (
DATE: 1/ /J() f 51ft;
WEATHER: PAIR.
INSPECTOR: K. .v~:s1fALL
CONTRACTOR: !~/CC);.,. ~Iu-.
ITEM DES CRI Pl'ION
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PAGE: I
OF I
INSURANCE REQUlREl\1ENTS CHECKLIST
Permit # q 7 - /53 CIP Project #
The following insurance is required of all contractors working in the City of Campbell public
right-of-way. Insurance certificates must be accepted by City staff before work can begin.
These insurance requirements apply to work being performed under an Encroachment Permit
and work being perfonned under contract for Capital Improvement Projects.
Limits
Commercial General Liability for bodily, personal injury and property damage:
g $1,000,000 per occurrence, and
LET. $1,000,000 general aggregate limit applying separately to the project, and
c12f $2,000,000 general aggrer lmut. .
~ Policy expiration date I I /9 <(3
.
~~otive Liability - "any auto"~ .
E1 $1,000,000 per accident f'9r bodily injury and property damage
ff Policy expiration date 1/..31 /7 t)
Worker's Compensation and Employer's'Liability
e-- $1,000,000 per accident for bodily injury or disease
~ . Policy expiration date
Course of Construction (if required in Special Provisions)
o Completed value of the project
o Policy expiration date
Required Endorsement to General Liability and Automobile Liability Policies
Additional Insured Endorsement
~ The City, the City of Campbell Redevelopment Agency, its officers,
employees and volunteers are named as additional insured.
o The insurance coverage afforded to the Additional Insured is primary
insurance.
o Workers' Compensation Insurance Sheet Submitted
o For General Contractor
o Subrogation Clause
~
/
Insurnnce Certificate Reviewed ~~.
Initi~ls
S /d/c;)
Date
\.0' Copy of Insurance Certificate placed in tickler file one month prior to expiration,
j:\forms\inscklst 4/96 (rev 6/96)
:::.:.:.:::::::.:.:::::::::.:.:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
.... ..... ......................................................
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...................
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':::::::::;:;:::::::::::;:::;:::;:;:::;:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::;:;:;:;:;:;:;:::;:::::::::::;:;:;:::;:;:::::::::::::::::::::::::::::::::
]IJI::.11I5_1;1I.:::::/
C'/7-/53
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DATE (MMIDDNY)
PROD ,-'CER
05/09/97
Golden Pacific Insurance
Services, Inc.
3280 E. Foothill Blvd., #100
Pasadena, CA 91107-3103
THIS CERTIFICATE IS ISSUED AS A MATfER OF INFORMATION ONLY AND
CONFERS NO RIGIITS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
COMPANIES AFFORDING COY
E
e'l
MAt
COMPANY
INSURED
A
Commercial Union Insurance Co.
COMPANY
Falcon Electric
SSM & Associates Inc.
2255 E. Auto Centre Dr.
B
California Compensation
COMPANY
c
;~.JJ"'t(
4DM
Glendora
CA 91740
COMPANY
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACf OR OTHER DOCUMENT WITH RESPECf TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECf TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY EFF. POLICY EXP.
LTR POLICY NUMBER LIMITS
DATE (MMIDD/YY) DATE (MMIDD/YY)
GENERAL LIABILITY GENERAL AGGREGATE
A COMM. GENERAL LIABILITY CALJ605736A 1/01/97 1/01/98 PROO-COMPIOP AGG.
CLAIMS MADE o OCCUR PERS. & ADV. INJURY
OWNER'S & CONTRACf'S PROT EACH OCCURRENCE
FIRE DAMAGE(On. FIr.)
MED EXP(Any on. peroon) 5000
AurOMOBILE LIABILITY COMBINED SINGLE
A X ANY AurO FAAJ73013U 1/31/97 1/31/98 LIMIT 1000000
ALL OWNED AurOS BODILY INJURY
SCHEDULED AurOS (P.r p.r.....)
HIRED AurOS BODILY INJURY
NON--oWNED AurOS (P.r _d.nt)
PROPERTY DAMAGE
GARAGE LIABILITY AurO ONLY-EA ACCIDENT
ANY AurO OTHER THAN AurO ONLY:
EACH ACCIDENT
AGGREGATE
EXCESS LIABILITY EACH OCCURRENCE 5000000
A X UMBRELLA FORM CDZ69287 1/01/97 1/01/98 AGGREGATE 5000000
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND X STATurORY LIMITS
EMPLOYERS' LIABILITY 1000000
B W971113455 1/01/97 1/01/98 EACH ACCIDENT
THE PROPRIETORI INCL DISEASE-POLICY LiMIT 1000000
PARTNERS/EXECurIVE
OFFICERS ARE: EXCL DISEASE-EACH EMPL. 1000000
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESISPECIAL ITEMS
RE: ProjectlPermit Number and location of Work. All work in public
right of way. City of Campbell, City of Campbell Redevelopment
Agency, It's Officers, Employees and Volunteers are named as
Additional Insureds as respects liability per CG 2010 attached.
............................................................
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.....pi;ilu<NiM;;;;::,tiPi;il:..u'O...;ii::nvU'..................
:::::~~~:I.::;J.~ft:a;:~::.~ : :&i=~a;::::::::::::::::::
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eANeEttAtlON'/:: ...
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City of Campbell
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL --~~"ftCl'~-
MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFf
Attn: Dept. of Public Works
70 No. First Street
Campbell,CA 95008
. _ '.~..]. _ ':2 . 8 5
1 1. C A.
:..:x:
>,-<CU :INS CLENDA.
POZ
--
~
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CL 531
tll-aB)
POLlCY NUM8ER: CALJ605736A
THIS ENDORSEMENT CHANGES iHE POUC':. ?l.EASE READ iT CAREFUllY.
CG2009llSS
ADDITIONAl. INSURED-O"nNERS, LESS~::S OR CONTRACTORS (Form A}
This endorsement mcdiiles insurance provided under the m!fcwing:
COMMERCIAL GENERAL L1ABIUTY CC'JE.c--"GE PART
SCMEDUU:
Name t;i Person Of Organization (Additional Insured):
locdOOI1 ct C-.""'Jered Operati.ons
CQst
Rates
(~r $1000 of cost}
f..-"v3ncs Premium
Premium Basis .'
Bodily InJUIY and
Prope.rt'1 Damage Uability
$
Tctal Advance Prerr'Jum $
<If no ~ntry appears abOVf".. informatlcn required to compiete this endorsement will be stlc~\Vn in the Dedaranons as ap.-
plicable to this endorsement)
1. WHO IS AN INSURED (Section II) is amcr.d...Ad to in-
clude as an insured the person or organIzation (called
"addltiona! insured") S.'CNl1 In the Schedule but only
with l'eS;;ect to liablllt'J arising OtJt. or:
A. "lWr 'Herk" for the additionallnsured(s) at the le-
cation designated aboue. or
e. kJs or emissions of the additional insured(s) in
connection with their general supervislon of your
work" at the iocatioosno.-vn in tlie Schedule.
..,/'
'"
2.
With res~ect to the insura~ afforded these addition-
al insureds. the follGWlng additional provisklns apply:
A. None ct the exclusions under Coverage A, er.cept
E!lCdusions (a), (d', (el, re, (h2J. 0>, em) and {ol, ap-
ply to thb instJraoce.
{a} All work on the project (other than serv-
k:e, rt1ainte~ncs, or repai~ to be pCi"
formed by or on behalf of the additional
insured(s) at the site of the covered oper-
ations tlas been completed; or
(bl ihat p~rtion of "your work'" out of which
the !njuryor damage arises has been put
to its Inter.ded use by any perscn or cr-
g.anizatlon ctr.er than snclher contractor
or subcorrtractcr engaged in performing
opeatfcns fer a prindpal as a part of ~he
saroo project.
s.. ftdditional &dusicns. This iiiSUial1l:a dQes net a;::-
ply to:
(l) .6o<:li1y Injury" or "prcper\y dam. fcrwhk:h
the additlonal insured<s) are obligated to rJ!S'/
damag~ by reason of the assumption of lIa-
bility in a contract or agreement. This EP;Clu-
sian does not apply to liability fer damages
that the additlonal in~red(s) would have in
the absence of the contract or agreement.
(2) -BodIly injury" or "property damage'" oo:umng
aftel':
(3) "Sodify iniury" ar .property c!3rnage" arising
out r::i any act Of.omission at the additional In- .
sured(s} or an'j of their employees. other than
the general StJoeMsicn d 'NO~ perfom1ed for
the additionallnsuredCs) by :'Clu.
e4} "Property damage" to:
(:al Prcpert'j C'mleC. u..<eerlp oCCt!pied by or
rented to tt1e addltiol'\31 insured(sl:
fb) Property in the care. custody, or contrcl
of tI1e additionallnsuredC:.) or owr which
the additicnal fr.su~sl are ior any p'Jr-
pose exerdstng pttysical control; or ..
(c) "'Ibur wori( fur the additicnal insured{sl,
xcc:il2OOStA
C::.7.1-rig;".t. In::..~ce~..s Qt!1~ Inc.. 1984. .196lJ