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ENC2005-00182CITY OF CAMPBELL DEPT. OF PUBLIC WORKS 70 North First St. Campbell, CA 95008 (408)866-2150 Fax (408)376-0958 ;ROACHMENT PERMIT (for working within the public right-of-way) ~ .~ Issued Z % ~ ~ G'7 Permit Expiration Date ~ I ~ CI Pet Jo E~JC' c~L~C`~ OCR I~'2 X-Ref. File Application Date ~ ~ ~ ~ ~ ~ ~~' Application Expiration Date ~ ` '~5 APN ~~Z~32-d~~J APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable.~~)~~ A. Work address or tract # ~ C)~ L ;l- ~) (~~ ~-~ ~~ iv Utility trench location B. Nature of work C'CNN~~ ( ~ l~ 7Tc h)Y'I ~~/~ iN ~'~. h/~~k'Gti -'t Ly ~ I O ~~~Ci~~ ~/\S ill . IG C~'~'7Lr~ oft M~ C~ 1_~ N ~ C. Attach four (4) copies of an engineered plan 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 undergound 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 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 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. No[icc must be given to Public Works at least 24.hours before restarting any work. Name of S (print Telephone ~"? 0 0 3~'7 ~]'" ~ 3 l ~ n ~ 24-HOUR EMERGENCY TELEPHONE NO. tijGJs) '`/~7 ":~ ~~G~ // f ~< E-Mail Address (~`f~1 ~7L11~ (C~ 17d~.(- ~.~/ Is this work being done by the property owners at their own residence`? Yes ~No ~(1 c The ApplicanUPermittee 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 [his permit. The ApplicandPermittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(sj of the information. 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 out of the cond#lion of any private improve~rYfb~s in the public right-of-way. Accepted ` ~` l~ ar~,~ ~~~ ~ `L~L(~ ~~~' j /S` C' ~~ (Applicant Permittee) (sign) Date l y~ ~ ~ r ~_ Contractor (Print Name) - Da[e SPECIAL PROVISIONS _1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts be specifically approved by the ]nsnector prior to cutting. 2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A", unless otherwise approved by ]nspector. _3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public Works Department before starting work. 4. 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. 5. Prior to any work, the property owner shall execute au Agreement far Private Improvements in the Public Right-of-VJay, which shall be recorded. G. Public Notification Requirements: v/ 7. <~ L l U hL i ~ W~ 1`1cS~ ~ ~ ~ ~' ~ 11 r~l ~C~ rt ~1v SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO. PERMIT APPLICATION FEE $__~i PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $ CONSTRUCTION CASH DEPOSIT $ ~~ PLAN CHECK & INSPECTION FEE _ "`} $~~'(~ I ~J ~-`P t APPROVED FOR ISSU For City Engineer Date Permit Expires 12 Months After Date of Issuance 5 DEC-09-2005 17 05 MOORE AND MILLER 831 462 3884 P.01i01 ACQI~t~ GERTIFICAT~ OF LIABILI TY INS r ' ~ URAN ~ 12/09/2005 PRDOU~R (831)462-6900 FAX x,,,1)462-3884 THIS CERTIFICATE IS I~~.IED AS A MATTER OF INFORMATION Moore & Mil ler Insurance Agency ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE License No. OA944Z0 P. 0. Box 757 MOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Capitols, CA 95010 -~ INSURERS AFFORDING COVERAGE NAIC a>e INSURED Me o Pipelines, InC. INSURER A' $COitSdale Insurance DBA: ]eff Mello INSURERS California Capital Ins. Co. 260 McGI incey Lane INSURER C' Campbell , CA 95008 INSURER 0' INSUAER E: T ~~ ~nvFOer_Fc THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PER100 INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WI7H RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRtBEO HEREIN IS SUBJECT TO ALL TkE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR Dp' TYPE OP IN6URANC£ POLICY NYMBER POYGY EFFECTIVE POIK:Y EXPIRATION LIMITS ~`Y GENERAL Lus1UTY CLS2200760 12/Ol/ZOOS IZ/Dl/2006 EACH OCCURRENCE E j 0tb QO X COMMERCIAL GENERAL UABIUTV DAMAGE 70 RENTED ; SO, CIAIMS MADE a OCCUR MEO EXP (Any ono Pvrsvn) S 1 Q A X PER$ONAI 8 ADV INJURY S 1 r ODD ~ OD GENERAL AGGREGATE S Z r QOO OO OEN'L AGGREGATE LIMIT APPLIEb PER_ PRODUCTS - COMPIOP AGG S 2 r 0~ r X POLICY PRO LoC JECT AUT OMOBILE LIABILITY 36AP11153648 12/01/2005 IZ/OI/Z006 COMBINED SINGLE LIMIT ANY AUTO ([eexidenl) 8 I QQQ QQ ALL OWNED AUTOb BODILY INJURY $ X SCHEDULED AUTOS IPsrpareonl B X HIRED AUTOS ROPILY tNJURY $ X NON-0WNED AUTOb (Per aaidsn0 PROPERTY DAMAGE S (Per ew~denq GARAGE LJA~LITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S AUTO ONLY' AGG b EXCE93/UNBRELLA LIABA.fTY GACH OCCURRENCE S ~ OCCUR ~ CLAIM9 MADE AGGREGATE 6 -~ s _ OEOUCTIBLE S RETENTION S S tNORKERb COM-ENlATX)N ANO YJC STgTU- OTH~ EMPLOYERS' LUIBILITY E,L. EACM ACCIDENT i ANY PROPRIETORlPARTNERfEXECUTIVE OFFICERIMEMBER EXCLUOE09 E.L. DISEASE - EA EMPt.OVEE S M dowibe Wlder SPECIAL PROV1910N$ below EL DISEASE • POLICY LIMIT S OTHER DESCRIPTION OF OPERATION! / LOCAT 8 /VEHICLES 7 EXLLUSKlN9 AoD~D BY ENDORSEMENT I SPECIAL PROVIb10Nb he City of Campbell. C~ty of Campbell Retleve7opment Agency, its officers, employees and olunteers are named as additional insured. bHOULD ANY OF THE ABOVE DESCRIBED POLK:IEb DE CANCELLED BEFORE THE EXPIRATION GATE THEREOF, THE IbbUING INSURER YRLL ENDEAVOR TO MAIL 3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE sHALL IMPObE NO OBLIGATION OA LIABILITY c; cy of Campbel 1 t t St i OF ANY KING UPON TNElNSURER, ITb AGlNTS OR REPREBENTATIVES- rs ree 70 North F Campbel 1 , CA 95008 AUTMORI2ED REPRESENTATIVE I~~l/LIr.IV1~~J~ esnn~~,n~. anon ACORD 26 (2001!08) FAx: (wa)ste-vy~a o...,...... __._. _..._.._.. t,lae ~ ~ 7 ~ .: 'Z ~~/,~~~~~ TOTAL P.01 u ~ C 0 g 2005 ~uBUC wol~lcs ADMINf87FWTION 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 Permittee. 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 are required for al] 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 to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated 1990, available at Caltrans. Traffic control equipment shall include Type II flashing arrow signs if required. 8. Replace as directed by the City Engineer any damaged or removed improvements in accordance with City Standards and Specifications at the sole expense of the Permittee. 9. Sawcut for all PCC or AC removals. All PCC removals shall be to nearest scoremark and shall be doweled [o existing improvements. 10. 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. 11. Adequate signing and barricading is required on the job site. Failure to provide such signing and batricading may result in the City's providing signing and barricades and charging the cost (including all labor and materials] against the cash deposit. 12. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 13. 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. 14. 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. 15. 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. 16. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 17. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 18. 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. 19. 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 Urban Runoff Pollution Prevention Program. 20. If the public interest requires a modification of, or a departure from, the plans and specifications, the City shall have the authority to require or approve any modification or departure and to specify [he manner in which the same is to be made for City-owned or maintained facilities. 2l. Permittee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by City prior to distribution and include dates of work and a contact name and phone number. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above conditions. •-. ~~ Y l.tJ`~~ Applicant %~/S G ate Contractor (Print Name) Date J\forms\pwperm Rev. 11 /9/05 NG .THOLDER COPY STATE P.o. Box $o~, SAN FRANCISCO,CA 94142-0807 ~ ~'~ ~` COMPENSATION ~ ~ 1 ~~ INSURANCE ~~ ~ ~ CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ~{~ ~ ~~ ISSUE DATE: 08-01-2005 GROUP: 000046 POLICY NUMBER:. ..0014554--2005 CERTIFICATE ID: _ 25 CERTIFICATE ED<PIRES: 08-01-2006 ' os-or=2oQ5/o8-ot-zoos ~~ p~~'" ;~°~ u,C- CITY 'OF CAMPBEtL NG SOB: ~"~. ~~~'`""" ~~b~ 70 NORTH FIRST STREET : ° _ G~ :' CAMPBELL CA 95008: ~y;;~r:~FkY , 4v (~~ .~i'l~i F ~ ~~, This is to certify that we have issued. a valid Workers' Compensation. insurance policy in a .form approved by the California Insurance Commissioner to the employer named below for the policy .period indicated. This policy is not subject to cancellation by the Fund except upon g0 days' advance written notice to the employer. We will also give you 3Q days' advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not,:an insurance policy .and does notamend,'.extentl ~~ alter the coverage of#orded by the policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with .respect to which this certificate of insurance may be 'issued _or may pertain, the insurance afforded by the °° policies described herein is subject to all the terms, exclu5iorrs and conditions'`of'such policies. AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS:::, $1,000,000..00 PER OCCURt~ENCE. ENDORSEMENT f12065 ENTITLED CERTI'FICATE;HOLDERS' NOTICE EFFECTIVE 08-01-2005 IS ATTACWED TO AND FORMS A PART OF THIS POLICY. EMPLOYER 'MELLO P L..P. EL I NfS, I:NC 260 E MCGLiNCY LN< CAMPBELL CA 95~©8 LEGAL NAME MELLO PIPEtiNES, INC IRev.s-o31 _ PRINTED: 07/ 18/2005 P0408 Dec 12 D5 01:09a MELLO PIPELINES 4083776108 p.l FROM :JEFF MELLO Questions ?Call (40$) 377-6103 Fax (408) 377-6153 RECEIVED UEC 12 2005 AD11MN18TRAT10N TO: ~ era ~ N ~~ PAGES: ~ (including this one) .~- DATE: r L - ~L- - ~' "~ Please call immediately: Please review and respond: ~_ For your information: MESSAGE: ~{~~ _ ~ ~ ~ ~' T? ; 57,`~ ~ L' ~n~ . r- FAX TRANSMISSION 260 McGlincey Lane Campbell, Ca 95008 Dec 12 05 01:09a HELLO PIPELINES 4083776108 DEC-09-2005 t7~03 M~~RE AND M7LLER 831 462 3884 gCQf.~I~, CERTIFtCA'- . Qt= LIABILITY INSURANCE ~~~ (/31)162-6400 FAx (331)462-3584 T}MS CERTIFICATE IS IS&UEDAS A MATTER OF Moore 6 Mil i er Insurance Agency ONLY AND CONFERS NO RIGNTS UPON THE CE License No. OA44420 P. 0. Box 7S7 Capitola• CA 95D10 N6IAIED Me o Pipe Ines. Inc. DBA: 7eff Melly 260 McGlincey Lane Campb911• G 9500E p.2 F.01 on ~ e tnwrvu ~•• 4 I OR INSURERS AFFORDING COVERAGE ~ NAIC 3 +NslxlbRA: Scottsdale Insurance INSLAO:R ts~ GlifOrnia Capital Ins. Co. a+surttA c: RLBURER ~ INSURER E' C TH E POL)CIE9 OF WSUFFANCE LISTED BELOW HAVF BEEN 15SLIEO TO THE I NSURED NannEO A BOVE FOR THE Poucr PERIOD INDICATED. NOTWITHSTANDING AN TERM OR CQNDRION Of ANY CONTRACT OR OTHER D Y RfiDUIREMENT OCUMENT WITH R ESPECT TO WHIGN THIS CERTIFICATE MAY BE ISSUED OR M , AY PEFa;Tp1N. THE INSt1RlWGE AFFORDED 8Y THE POLICIES DESCRIBED H EREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AN1D CONCHTIONS Of SUCH PO LICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REPUCEO BY PAID CLAIMS tNBR TrPE O- IAwRANCE POLK.T N1MER r ~FECTrvE POLICY EKPftAT10N UMfiS GENF.RALLM6RITY ctSizoa760 12/01/2005 lz/o~n008 EAclt000URReNCE : _i 000 00 X COMMERCML OENEAAL LWBILiTY DAIYNOE TO RENTlD i SO DO CWMSMADE ~ OCCUR NEO)sxP(AnyanapNL011) S 1 au A X PER90MAL 6 A01f MIJURI' S 1000. QpNEAAt A0011EOATE A ~ OOa ILYT APM IEB PER: GENL aOGREGATE L PRODUCTS - COMP/OP AGG : 2 , a00 • ~ p X POLX:Y kGT LOC AYI0MOB71l t1A/IIrTY 39AP31153646 12~az~200S 22~01~2aa6 COMBINED SMIGLELIMIT i (Et KOaOm) 1 aaa . a wNY AUTO .ALL OVMEDAUTOS BODILY INJURY f rPa Anon) ~ SCIIEOULEO AUTOS - g X NNEO Auros o001LV IN1URr f {Per•eua«NI X NON4wNE0AUTOS PROPERTY DAMAGE ~ (P~r aciMl) AUTOONLY-EA AGGIOENi f OAAAGE UABUTr ANY Ml-O OtHFA 1-UN EA ACC 3 AU TO OML~_ AGG f ExCE1tiA1w11aLl UAB1LRV EACH OGCURRENGE - f OCCUR ~ CLgIMSMAOE AGGREGATE ~ f ~ 3 DEDUCTIBLE s RlTEMTgN f WC 5 ATU- OTN• wOOfgt{ COtIWEN91LTpN AND EJRPLOYERS•IJABNRY E.L. EACH ACCIDENT f XEC~IV6 ~E d ~ ~ M~ d51EABE •fA ENriOYEE f L 1 .U0E0 Y x I E R . . II yyL ~ plw~ ~~ E.L. dSEASE • 1'OLIGY LIMIT # OTR[R p~ctuF~ ON O ER,LTprLtr L,oeATlo[~II rvE Es r Psc~L~rs Aooen er ENOOASErENT 16PlaAE PROattOMs beil CTty o~Caspbell pedevelopl~ent Agency. its officers. employees and ~Call p luntceT•s are named >ss addi~ W Ot/ LLb~liI.I51NI S)1NOM 01~6f1d ' E S ` E ~~~~~ ~~ URiR W1Ll NC~Ydi TO MAIL THE BSIMNG IN EtlP1RATI0N OATS TNERQOF ~ DA1rs WRITTEN NOTR:E TO TTIE CERTACATE MOLDER NAY[D 70 THE LEFT• _ 6uT CAIWAE TO PAIL fUCl4 NOTICE SHALL IMPOS! NO OBLIGATION OR LIABAATY Ci ty Of Csapbell OF ANY RIND Vrdll THE WliYR6R. RO AOfNT4 OR gEIMEfENTA1Nli 70 North First Street AUTRDWZEO AEPNEfifNTA71VE Csllpbell . G 95008 _ 'iraI 'MrrnL~f) ~ACORQ CORPORATION 1BBE FAX• (103)376-0953 AcQRD 2b i2001f00f flap 3~ 1 (, r i 3 INSURANCE REQUIREMENTS CHECKLIST Permit # CIP Project # The following insurance is required of all contractors working to the CttIV 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 performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: .~(, $1,000,000 per occurrence, and /^" $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggr~eg~te lJim~ it. Policy expiration date ~=-~'-t'LLP Automotive Liability: ~~~~,, ~^ `~ ~•~~~~~""~ ^ "Any Auto" checked on certificate "~, $1,000,000 per accident fo bodily injury and property damage I~ /~, Policy expiration date 12 1-S Workers Compensation and Employer s Liability \~ (~ ~~ f ` ~~'~~` '• j -~-~ ^ Waiver of Subrogation clause r ~-` $1,000,000 per accident for bo ily injury or disease Policy expiration date Course of Construction (if required in Special Provisions) ^ Completed value of the project ^ Policy expiration date ~~ ~ ~ ~ ~~ v ~ 1 ~ ~ ~~ ~~,~ ~ . ~ ~ ,~ Required Endorsements to General Liability and Automobile Liability Policies y Additional Insured Endorsement ~ The City, the City of Campbell Redevelopment Agency, its officers, employees and ,d___._ volunteers are named as additional insured. ^ The insurance coverage afforded to the Additional Insured is primary insurance. 1 ~~ ~ "~~ ~ ~ ~ ^ Cancellation area of certificate edited to delete ``endeavor to" and "but failure to mail r ._,_ such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". C~Y~"r'zL'~-~^ Workers' Compensation Insurance Sheet Submitted A : %v ^ For General Contractor v~`G.~c~ ~ ~'~'~~~ ~IUZ'~1"S ' ^ For Developer or Owner (~(,r, ~fn~a ~ ~~ ~ tnsv~rrc.e,- ~ , ~~i ~ ~Us~111-mod s ~. ,l ~ ;1 t G~ ~,zs ~,.'~ ust (~~ ~~ C~ Acceptability of Insurer(s) ^ Insurer(s) has current A.NI. Best Rating of A:VII and is authorized to transact business in the State of California. Insurance Certificate Reviewed ~~ ~~~~~ __ _ ~ / 'fit Initials ~ Copy of Insurance Certificate placed in tickler file for month of expiration. 12- 13 Date j:\forms\inscklst (rev 11/99) PUBLIC dKS DEPARTMENT RECEIPT Fltective JWy 5, 2005 7 City Clerk 1'UOLIC WORKS MILE NO. t= N ~- G ~' ~ ~ ~~~~ ~ ~7 ( PROPERTY ADDRESS L I (!~ ~ ~j) ~ ~~ ~-~ L..IV l'leau~ r"nett & rrerlpr rot trM r n0»;ag r.a,ai0s: (T.'- ITEM CROACHMENT PERMIT AMOUNT:.. 0722 Application Fec Non-Utility Fatctaachmenl Permit (5275.00) Mimr Encroachment Permit <SS,OOO (561.00) R-1 First Permit (No Fee) Subsequent (SI35.00) Utility Encroachment Permit ArterlnUCdlector Street (5530.010 ResldentiAl SlreeUOtberAreas (5291.W) 2203 Nan Check De it 290 of Engicecr's Estimate (55110 min) 2203 FAI[h1W Performance Security (FPS) (10096 of ENGR.ESI'J 2203 labor and MAterials Security (100% of ENGR. FSTJ 2203 Manrrrrentalion Security (iW%of EN(:R.M2i i'.) 2203 Cash Dcpmlt (d R, of 6ngr. Est)(550o rWrti510,0011 max) 6722 Nan Check & Impection Fce (Non-Utility) Fagr.Fsl.<S250,000 (1396 of ENGR.EST.) 2203 Engr. Est. >5250,0181 (Uepasi[ 896 of Engr. EsU530,000 min)rr 4nz utehy<sloo,la)o Mi Wmum Clwrge Per Location (518().00) CondWLS/Pipellnes up to 500 Feel (SZ.zSnt) Above 500 Linear Feet (Sl.lS/R) ManholesNaWtslEtc. (5125.00/ea) Pole Sct/Itemoval (5125.011/ca) Street Trec NantlnfJNemoval (5135.00) 2203 Utllit > 5100,000 Actual Cast + 2096 " 4760 Stores Contafncr Permit (5125.110) 476U IhnJect Nam & S CIfMAIiOIti Protect No. 4760 Standard S cffieations & UetaiLc (Sl/1'g 515.50/Irk) 4760 Co les of Fagirreering Maps & Nam Actual Not ZQ"x36" (554.00) Aerial Print S 112" x ll" (522.W) Maps aral Nam 24"x.16" (58.25) 4722 Penalties: Fallure to restore public improvements IS10U/Calendar Uay) (Mud Cade xer.11.J1.olU) 4722 Pemdtks: Fallure to correct Wsafc conditfom (5100/CalcrWar Day) 4722 Wnrk Without Permits (4 Times Applicable Fec) ND DIiVELO1'MENI' Yarcel Map (4 Lotx or Le.ti) Mlnal Tract Map (5 or Morc I.WS) (S 1,aW.W +b75/tot) (54,200.00+SIOIVIOt) Certificate of Compliaree 5650.00) CcrtlOCatc of Corrcctbn (5400.00) Notary Fec (per signature) (510.00) VACalian of WMic Slreelx & FYcemenLC (52,21AI.OIn A.acxsment Segregation or Reapportionment MIrsK Split (5725.Iq) N~ch Additlorwl Int (52011.00) Storm Dmirtage Arta Fec Per Acre (Rd 52,120.00) (MWtI-Res 52,:i85.W) (All Other S2,(d0.U11) ParkWral Dedication Fee (7596/2590 Due Upon Cert. of Occupancy) InMrsectbn Tum Counu (Two-lh Intersection Tum COWLS la.m or '1'rotRc Now Map (Dally TnfOc Cangrbell Traffic Model (FWI Sca Campbell Traffic Model (Reducer No TOTAL 5 .~/ Yl~ ~ j / -. ~(~)~ ~'~- NAME OF APPLICANT `-' I ~ Y.`YJ {~Il G °~ ~~ <~ i NAME OF PAYOR ~ (,~~~y~~ ~ LL G' ~~ J NIONE ~C ~ ~~L%' ~~ ~ ) -//~, / 1 /\ ADDRESS ~ ~l W;(r~, ~~u l~ ~~;~LyL!~ %II' L~/ /~-C''/ \ r"ActWl Cast Nu'20%Overbead (NW-lore ~i beAring de 'It) FOK CITY CLERK RECF.I RY. ONLY Y7 1 / '7 / `--/- _ _ rFor PWn Check and Cash Ikpasfts, acrd yelbw copy to M7trurce. Date/ lWW6 - - - _ _ ~.~ j:\furm:4eceipt fiam OS-06 rev.G/2I/OS L~i r } i tt- S.fti"ii •i:~L; 1. F? a :1 Vl lili ~ %,i i~ "~,it~h„ E~Ltlt ~ ~ 4 3i'~lt?~j f~Ll~ir +11 ~.. IC'i 1~I; t L ' ~ z~ .; ~.. . ~ ~ ~E~:~:R; `Tr~~" iLtt jet t' ~((r+ 7 ~I IJL~it 1 ErtU~. L~ .t{jy'~T~1jv~ ~-Tl F++{{ r' Lit. ~, 1 Y1 \~iJSL~V +{' l l 1~i e L'L' -.1 :r-.~ a t E(t~.~+~ Y Ei~ C r r ~l;~v,vEf _ ~;;~lH;~'GE a y a =t~' ,)