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ENC2006-00072CITY OF CAMPBELL R-1 NO FEE ENCROACHMENT PERMIT Permit No ~~C ~~'~ ``~` .7Z DEPT. OF PUBLIC WORKS X-Ref. File 70 North First St. (Non-engineered work within the public right-of-way) Application Date 2l ~ - Campbell, CA 95008 ($5,000 maximum value of work) ' Q ~a/Q ~ (408) 866-2150 Application Expiration Date Fax (408) 376-0958 ISSUED 5 2b v~7 APN 3os- 31-oa9 Permit 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 ~ ~` ~ S M t ~- i o ~J A'J ~ B. Nature of Work RE N u~l c ~ IZE P L R c.,C p (Z t J E ~. ~ t'LD Pt c.l-) 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 shutdown and/or forfeiture of Faithful Performance securities. NAME OF APPLICANT._I A t~ ~ S ~M ~jU R.~ U ~ t-I S TELEPHONE'4 0 B $ 9 2 - S ~~ y (print name) ADDRESS_ (2o S . µ t ~-"i'p-J AVM' C,krc a 6 ~ i-L E-MAIL ADDRESS 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 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 info a t e ACCEPTED (Applicant/Permittee) (Sign) 2 °~y O 6 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 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.: 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 Che 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. STANDARD AMOUNT RECEIPT NO. SECURITY FOR FAITHFUL PERFORMANCE (100°k (~NG. EST.) ~ ~,~ APPROVED FOR for ~= Date I Permit Expires 6 Months After Date of Issuance. I J:\forms\rlpermit -'*'-` M ~ ~~L~ ~~~J f ~--~ Revised 1.20.04 ~-=~ ~ ~- L' ~`~ (/vr ~ ,11 ~"~,f' ~~ ~~~~ 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 Pertittee. 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. Sawcut 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 bylaw. 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 [o 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 [o 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 conditio>}e~~ Applicant 2 c~ ~ Dat 7:\forms\rlpermit Revised 1.20.04 JUN 2.9,2006 19:16 WALTER AN'' BARBARA KNOLL 14083743229 ,,. ~'.~~ FARM E ~S ~:: ~ '~ FAX June 29, 2006 ATTENTIDN COMPANY: PHONE: FAX # wa4TEa ~ BARBaRa KNOU. KNOLL INSURANCE AGENCY P. O. BOX 110t54b CAMPBELL, CA. 9$012 -054b TEL: 408 374-3220 FAx 408 374-3229 EMAX1,.: knoll211~aot.com LIC_ #05Q1477/0545589 At_AN HOM SENIOR PUBLIC WORKS INSPt=CTOR 4p8-3~b-Q958 FRaM: MAGIE CA5TILL0 PAGt=S (incl. this): ~j SUBJECT: HfJMEOWNER'S INSURANCE INF4RMA'1`ION - J APN# 3d5-31-009 PERMIT ENC2005-00072 POLICY # 911291689 INSURED: JAMES BURROUGHS PRpPERTY: 120 S MILTON AVE, CAMPBELL, CA 9500$-2$pb cQMMENrs; Enclosed is the Homeowner's Insurance information for above property. Should there be any questions/concerns, please contact our office at 4Q$-374-3220 Sincerely, Magie Castillo Farmers Insurance Knoll Insurance Agency ~. ~~~ ~~~~~~~ .~Jl°J ~ k ?(JOb PUBLIC; `vvUhn:: ~!~ /J ~ r ADMINISTRgTIOn, W v ~~ Page 1 JUN c9, 2006 19:16 WALTER AAA" ~3ARBARA KNOLL 14083793229 Household I Insured ~ Dwelling { Reconstruction Cost I Cavwr;iyta .. 17.0 S MILTON AVE Page 3 ;i 1ZD 5 MILTON AVE, CAMPBELL, CA 95006-2806 Po11t:y Number; y11Z91689 Polley Type: PROTECTOR PLU5 Cam an FIRE INSURANCE EXCHANGE p Y% „~ ~_ nVJFI j rNr., 172000 ~598:U; All Peres=?50 Theht: Wlnd and hall: X172000) ~~Fr~srall~~r(Jrt~`; 17x00 ri7+~tirtr~i ' "~~ PERSONAL PkOF 129000 IrEC.lurlF~il t0`~ QF IISF 86000 Iiic:lucJc~cl E€~~1~ ~ ~,-.~ ~_{1(~{,, PG:KS r,.lAC+11, 1TY ~OOOOa 't.za.on ~Ur3ir1~. wvvr ;;:: , :. ADMINISTRAT1Cs" f;UISf MFIi1CA1 1000 InCIUdF'd . "~Ge~'¢ns~rul~bn Lnlst' Ctmit~ . ` "Ci~i~rte 'i$etro~strln6a ~qy~ 1L~iti-~t ~'~; ~ r~41E`•' ' ~#` Caveria e - Rremiurn ~R1iist'alwg~A, .. ;~tettlt#iulrlit `~~,~ • r L1LUt.; t)ftr~INANC-F 10 '~Q,q;) April, F'REMI`E~ ~n.np I_c]~S A'i5L5SM r ~Q.pf) WnTFRC,RAFT :kl).f)() J ~t°~Ab~gWO 5~°"'~h ~,y°'+~~,~ ~:r,~y>•d$~'(: ir', %~A'~m +Jpyr r~ly::::l xk Ty y~,$::.~.. ~:'~nll(t' ~`fi~.-'m! 5r' i:,~...'~~ M "}'n~ac~ya e.ra~nC~t `~a FARMER 5 Walter 8i (Barbara Knell lnxur:u.cc ARcncy (.)IL: (/iORj 37~f.37 ~U Pax: (4U8} !S74-1)~/ G5 Wrs[ li,nuslic,n Avu., ti,iitc 4 c:ampbcll, t~A 9yuori Tpl~'Fi .M,Ath. H' :,L ~I:WKF'~ ~aa f>:1~ ~RIW.:K~lkditl ~ ice/ r Leave it in: Concrete installation acceptable to City of Campbell Job needs to be completed (ac work) Acceptance will require the property owner to provide the one year warranty Remove it: Insurance from the contractor Need notification prior to any work being started so that our inspectors can review work in field License Detail Page 1 of 2 DISCLAIMER A license status check provides information taken from the CSLB license data base. Before relying on this information, you should be aware of the following limitations: . CSLB complaint disclosure is restricted by law (B&P 7124.6). If this entity is subject to public complaint disclosure, a link for complaint disclosure will appear below. Click on the link or button to obtain complaint and/or legal action information. . Per B&P 7071_17, only construction related civil judgments reported to the CSLB are disclosed. . Arbitrations are not listed unless the contractor fails to comply with the terms of the arbitration. . Due to workload, there may be relevant information that has not yet been entered onto the Board's license data base. Extract Date: 06/29/2006 * * * Business Information * * * XL CONSTRUCTION CORPORATION 1500 BERGER DR SAN JOSE, CA 95112 Business Phone Number: (408) 271-2425 Entity: Corporation Issue Date: 06/13/1992 Expire Date: 06/30/2008 * * * License Status * * This license is current and active. All information below should be reviewed. * * * Classifications * * * Class Description ©GENERAL BUILDING CONTRACTOR * * * Bonding Information * * CONTRACTOR'S BOND: This license filed Contractor's Bond number 6008011 in the amount of $10,000 with the bonding company SURETY COMPANY OF THE PACIFIC. Effective Date: 01/01/2004 Contractor's Bonding HistorX http://www2.cslb.ca.gov/CSLB_LIBRARY/License+Detail.asp?LicNum=647480 6/29/2006 License Detail CALIFORNIA CONTRACTORS STATE LICENSE BOARD Contractor License # 647480 License Detail Page 2 of 2 BOND OF QUALIFYING INDIVIDUAL(1): The Responsible Managing Officer (RMO) ERIC WILLIAM RAFF certified that he/she owns 10 percent or more of the voting stock/equity of the corporation. A bond of qualifying individual is not required. Effective Date: 06/13/1992 * * * Workers Compensation Information This license has workers compensation insurance with the ZURICH AMERICAN INSURANCE COMPANY OF ILLINOIS Policy Number: WC399169903 Effective Date: 03/31/2006 Expire Date: 03/31/2007 Workers Compensation HistorX Personnel listed on this license (current or disassociated) are listed on other licenses. Personnel List Other Licenses License Number Request Contractor Name Request Personnel Name Request Salesperson Request Salesperson Name Request © 2006 State of California. Conditions of Use Privacy Polite http://www2.cslb.ca.gov/CSLB_LIBRARY/License+Detail.asp?LicNum=647480 6/29/2006 Personnel List f`alifnrnia 1-Imm~ Click on the person's name to see a more detailed page of information on that person. Page 1 of 1 29, 2006 Name Title Association Date Disassociation Date Class More Class MARIO P WIJTMAN OFFICER 05/22/2000 ERIC WILLIAM RAFF RMO/CEO/PRES 06/13/1992 B DAVID GORDON BECK OFFICER 06/13/1992 License Number Request Contractor Name Request Personnel Name Request Salesperson Request Salesperson Name Request © 2006 State of California. Conditions of Use Privacy Policy http://www2.cslb.ca.gov/CSLB_LIBRARY/Personnel+List.asp?LicNum=647480 6/29/2006 Personnel List CALIFORNIA CONTRACTORS STATE LICENSE BOARD Contractor License # 647480 Page 1 of 1 Joanne D' Ambrosia From: Syed Wahidi Sent: Thursday, June 22, 2006 11:04 AM To: Michelle Quinney Cc: Joanne D' Ambrosia; Alan Hom Subject: 120 Milton Michelle, I talked to Jim Burrows (120 S Milton) yesterday and told him that in order to redo the dwy approach using `AC Tractor' as contractor, we need to co-lect the insurance of AC Tractor. He said that he will ask the contractor to send the insurance. I also asked him to remind AC Tractor to have inspection done prior to concrete pour. Syed 6/22/2006 JUN t9, 2006 19:16 WALTER AN" ~3ARBARA KNOLL 14083743229 ~ _ _ « .~ ~ ~. ~~~ ' ~ d ., ~~ Horne Summary Q Household + insured ~ UwelUng ~ Rr•eonslruCtlurt Cr)st ~ Coverage 12U S MILTON qVE Bound: yes ~ifective Date: 06/29/200b ~select~actlon ~ ~~~~~ µ~µ~ - + Primary Insured » Residence Address I Phgn@ Househaid Number JAMES M. BURROUGHS: 120 S MILTON AVE, 408-271-2425 1945134221 CAMPBELL, CA 95008-2806 t G ,ll~ ,~~ h 1 t S ~ ~ aNy, '4 ~i. ~. .,~, r„ a~g..i>• ~, ,~,.ti,~ ,, +,,, y Pt ,,r . ~ Property ~ s Policy Addresx Rating Covprege Details Pay Plan 911291689 ~,~ 110 S MILTON FIRE INSURANCE DWELI.TNG ; 172000 Year Built: 1947 FuH Pay ~ 1 r 9G•GO.358 AVE, EXCHANGE PERS LIABILITY : i Reconstruction Cost: i Renewal Date: CAMPBELL, PPG: 41 300000 177000 Fult Term s 03/09/2007 CA 95008-2806 GUEST MEUICAL : opl Out Status: 1 Prerrrium: i Inception Uate: 1000 Malied Pdte: 01/13/2006 I 03/09/1993 AR. Perils: 2S0 Status bate: 02/08/2003 618.03 I I InForte Pate; More CuverayNS Who Pays: INSURED i U3/U~J/Iyy_! Endorsements B Homeowners SWCUrity Devices '- PROTECTOR PLUS , DiSC~nurts & Surcharcies i 4TH edition Mi,rly~,yeN OWNER OCCUPIfU Lasses (PRIMARY RES. } vrint center action 0 select action Q Page 2 N ,~, 911291689 ~ Name Age Date oT Birth JAME5 M. BURRg11GHS 44 02/15/1962 ! select action Relationship to Primary Irt6ured SELF Details ~ MAL<= Sinyle ~t~~~i (~ FARMERS Walter tot 11grh,~rq T[nnll InFnrancc Agency (7l1.; (q OR) 1'/q l)20 P,tx; {qp$}:)/q.:S22H G5 WCSC k lamiltun Arc., Suicc 4 L;:uupbcil, t=A 95UU8 ~~. _ ~~~~~b '~'~..'~!_I~ wQ ~annirwsr~~on-