ENC2005-00183CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408)866-2150
Fax (408) 376-0958
R-1 NO FEE ENCROACHMENT PERMIT
(Non-engineered work within the public right-of-way)
($5,000 maximum value of work)
ISSUED I ~ ` ~ y "~~
Permit Expiration Date ~ 2 ' 14 '- CJ
Permit No ~i~JC ~ ~~ ~ -~I
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Application Date 1 -~~t -G~
Application Expiration Diate~`_it//f'''~~, S
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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 ~ ~ `T ~/'~ I I2 t-f"~iV 1~S / \~/
B. Nature of Work ~~ C~1c~VC. ~ ~ t c NS7~~;(~" Li t=~7~~ `>Ip~'b.~~'-\~ ~ (iVi'F~1Ll. (~~~
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 [his permit, listed below. Failure to abide by these conditions and
provisions may result in job shutdown and/or forfeiture of Faithful Performance securities.
NAME OF APPLICANT U T < <, ~,l /f'/ c
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ADDRESS 7 In ~% _ l` c:, , r` f c, .1 cr/S
TELEPHONE ~/ ~''`.r - ~ G•ln - ' ~t ;; ~
E-MAIL ADDRESS ~ C~ r' l ~, vv ~ Wl ~ h c ~ ~ D i^ ~ r1 ~~ ~ O 1/Vj
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, City of Campbell Redevelopment Agency,
its officers, agents and employees free, safe and harmless from any claim or demand for damages resulting from [he 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. ~
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( ACCEPTED ~~; C- C ~l /~ -/ l/- ~a .--
(Ap 'cant/Permittee) (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 at ]east 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.:
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 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 or Private Improvements in the Public Right-of-Way, which shall be recorded.
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_~3. 1 70 ~ U~ 7t+" Iy~7t Irv 5 D ~ T S
STANDARD AMOUNT RECEIPT NO.
SECURITY FOR FAITHFUL PERFORMANCE (100% O NG. EST.) $
APPROVED FOR ISSUANCE ~ Z ' I ~ -~
for City Engineer Date
Permit Expires 6 Months After Date of Issuance.
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Revised 1.20.04
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GENERAL PERMIT CONDITIONS
1. Payment of 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 date of 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 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, fire hydrants and water valves.
6. 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.
7. Sawcu[ for all PCC or AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing
improvements.
8. Adequate signing and 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 providing such signing and barricades and charging the cost to the permittee.
9. The Contractor or Permittee will have a supervisory representative 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 will 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 -aw.
13. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any
other public agency.
14. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified
thereon.
15. 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.
16. 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.
18. 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 the manner in which the same is to be made for City-owned or
maintained facilities.
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.
Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the
above conditions.
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AGG. BASE
SECTION A-A
.. NiSTALL STREET TREES AT 40' O.C.
CURB, GUTTER, AND SIDEWALK
REVISED CONFIGURATIONS
DATE: JULY 1994
DRAWN BY: "eucED ~~ CITY OF CAMPBELL DETAIL 1
APPROVED:
Named Insured
BRIAN DELANEY
764 FAIRLANDS AVE
CAMPBELL CA 95008
~ 5 S A M E R/ C
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Specialty
Insurance Company
^USTOMER SERVICE 888-474-7500
HOMEOWNERS POLICY
RENEWAL DECLARATIONS
N0: CASH000199021
Policy Period: 12 months From: 4/10/2005 To: 4/10/2006 12:01 a.m., STANDARD TIME at the residence premises.
NOTE.• When an effective date appears, this is a revised declaration EFFECTIVE:
and voids previously issued decs bearing the same po/icy number BROKER NUMBER: 002097 (408) 292 -4329
MA/L TO: BROKER: BROWNE INSURANCE AGENCY
330 W HEDDING ST, #207
SAN JOSE, CA 951 10
BROWNE INSURANCE AGENCY
330 W HEDDING ST, #207 The described location covered by this policy is located at:
SAN JOSE, CA 951 10 764 FAIRLANDS AVE
CAMPBELL CA 95008
REMARKS: Annual Renewal;Coverage under this policy will become effective provided the premium is paid as indicated on the enclosed Renewal Invoice
Insurance is provided only with respect to the following coverages for which a limit of liability and/or premium is specified, subject to all
conditions of this policy. In case of loss under this policy, we cover only that part of the loss over the deductible stated. The deductible
applies par occurrence. Based on the information available to us, the premium shown is the lowest we offer for which you qualify.
CaveragefLirnit Policy 'Coverage Forms and Endorsements
£ov~rage gescriptiQn Amount ' Deducti#~le :' Premitun made ,part of tF~is po€iey
af' issue:
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COVERAGE A -DWELLING $279,450 $1,073.00
Fsao1 ii/oa
COVERAGE B -OTHER STRUCTURES $27,945 INCL. Fseos of/os
COVERAGE C -PERSONAL PROPERTY $139,725 INCL.
COVERAGE D -LOSS OF USE $55,890 INCL.
COVERAGE E -PERSONAL LIABILITY $500,000 $30.00
COVERAGE F -MEDICAL PAYMENTS TO OTHERS $1,000 INCL.
DEDUCTIBLE $500 INCL.
HOMEOWNERS PLUS END.W/5% INFLATION GUARD INCL.
INCLUDES BUILDING CODE UPGRADE COVERAGE $27,945 INCL.
PERSONAL PROPERTY RCC $116.00
CREDIT CARD COVERAGE $500 INCL.
FIRE DEPT SERVICE CHARGE COVERAGE $500 INCL.
BUSINESS PROPERTY $2,500 INCL.
JEWELRY, WATCHES AND FURS $1,000 INCL.
LOSS ASSESSMENT COVERAGE $1,000 INCL.
SILVER, GOLD AND PEWTER $2,500 INCL.
REPORTED SO FT OF DWELLING: 1875 REPLACEMENT DOLLAR PER SQ FT USED: $149 TOTAL PREMIUM: $1219.00
The limit of liability for this structure (Coverage A- is based on an estimate of the cost to rebuild
your home, including an approximate cost for labor and materials in your area, and specific
information that you have provided about your home.
BRIAN DELANEY, AUMM
VESTING:
NOT/CE.• TH/S POL/CY DOES NOT PROV/DE COVERAGE FOR THE PER/L OF EARTHQUAKE
Mortgagee/Lienholder Name and Address:
WELLS FARGO HOME MTGE #708 ISAOA PO BOX 5708 SPRINGFIELD, OH 45501 0023123029
WELLS FARGO BANK /HOME EQUITY ISAOA PO BOX 49069 COLORADO SPRINGS, CO 80949 65471897531 199
OWNER, Protection Class-03, Family-1, 1951 Tier 2
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Countersigned: 2109/05 Santa Ana, CA By:
utt on ed Representative gKR
THESE DECLARATIONS TOGETHER WITH POLICY JACKET, HOMEOWNERS FORM, AND ENDORSEMENTS, IF ANY,
0ooooosesisoa ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY AGENTS COPY
WORKERS' COMPENSATION INSURANCE INFORMATION
The following workers' 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 of contract.
WORKERS' COMPENSATION INFORMATION:
Name of Contractor/Applicant
^ A Certificate of Consent to Self-Insure issued by the Director of Industrial Relations; OR
^ A Certificate of Workers' Compensation Insurance
Insurance Co.
Policy No.
Expiration Date
OR
^ A signed Certificate of Exemption from the Workers' Compensation laws as printed
below.
CERTIFICATE 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 _~ ~ ~~-~G-~~ Date ~' - ~ -~ ~` ~ .
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Title ~~. ~,., / ~` P('~',t r
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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:\landdev\forms\street improvements\workcomp (rev. 6/96)