ENC2014-00057Print Form
CITY OF CAMPBELL R-1 ENCROACHMENT PERMIT Permit No. )~ IV ~ 2C-14 -Uer'~ vj'J
DEPT. OF PUBLIC WORKS (Non-engineered work within the public right-of-way) X-Ref File
70 North First Street ($10,000.00 maximum value of work) Application Date
Campbell, CA 95008 Application Expiration
Ph. (408) 866-2150 ISSUED: ~ _ Date _
Fx. (408) 376-0958 Permit Expiration Date: ~ APN L1 ~t~-{ (~ ~`~
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: ~ ~-} /~ ~,Ri SG N ~~V~ t
B. Nature of Work: ~ Its ~T~10 V E ~X 1 `~T(EV ~;,1 C`(~t~S Tj~'~ ~ti (N S-~;4 i~L ~v 1: t,~l C ~t ~~ (~'1 `f~-Tl-)r
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 become 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: ~ Telephone: ~ L~ ~~~
2~~~r~ ~~t d~ ~s ~ ~~;~~ 1~~~~~~s ~~~ ~~
Address: ~ ~~ ~ ~~l ~~~-Jsctr/ ~,~
E-Mail Address: ~~ ~ i ;' ~ ~ L -Y/'~~cr p-- L~'~
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 information., ~,G`' / /
ACCEPTED: ~!"~[ ~ ~ <'1 ~4~C~= ~~ 3 ' ~ L~' ~7
ittee) (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 least two days
before starting work. Notice must be given to Public Works at least 24 hours before restarting any work.
Per Section 4216 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 for Private Improvements in the Public Right-of-Way, which shall be
recorded.
2.
3.
STANDARD AMOUNT RECEIPT NO.
SECURITY FOR FAITHFUL PERFORMANCE (100% Of Engr's Est.) $ 5C?e~ '1 ~'2S ct G
R-1 PERMIT FEE $ -
APPROVED FOR ISSUANCE: 3 ~ 3
for City Engineer Date
Permit Expires 6 Months after Date of Issuance.
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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. Submit project schedule 10 days prior to proposed start of work. Special provisions may be required for work within City facilities
and downtown Campbell.
5. 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.
6. Maintain safe pedestrian and vehicular crossings and free access to private driveways, fire hydrants and water valves.
7. 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.
8. Sawcut for all PCC and AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements.
9. 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.
10. The Contractor or Permittee will have a supervisory respresentative available for contact on the project at all times during
construction.
11. This permit shall be kept at the site of work and must be shown to any authorized representatives of the City of Campbell or any
law enforcement officer upon demand.
12. 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.
13. 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.
14. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other
public agency.
15. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon.
16. 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.
17. 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
~~
Date
J:\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf
Rev. 02/14
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Transmittal
Name: JoA~ `Thomason
Title: Office sistant
City of Campbell
Department of Public Works
70 North First Street
Campbell, CA 95008
Phone: (408) 866-2701
Fax: (408) 376-0958
E-Mail: Joannat(g3cityofcampbell.com
To: Ryan and Cheryl Lauders Date: May 20, 2014
Re: Refund of Construction Deposits, Permit ENC2014-00057
^ Urgent ^ For Review ^ Please Comment ^ Please Reply ^ For Information & Use
Enclosed please find a check in the amount of $500.00 representing your Faithful Security Deposit
for the Encroachment Permit referenced above.
t ,
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JoAnna ~ omason .,
Office Assistant ~
~".....
cc: Project File No. ENC2014-00057
Inspector' s File
'Thank ~cqu,
J:\JoAnnaTlDeposit refunds\CHECK REQUESTS\Ck Transmittals\Harrison 261.DOC (Rev. 03/08)
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CITY OF CAMPBELL VENDOR No. 10011712 CHECK No. 246461
Accol.[nd Purcylase Order Invoice Number Amount Descrr tion
101 2203 CR050514 500.00 F.NC2014-00057
10011712 RYAN LUDERS
o~'~~n CITY OF CAMPBELL
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CA 94104
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CITY OF CAMPBELL
70 NORTH FIRST STREET
CAMPBELL, CALIFORNIA 95008
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RYAN LUDERS
261 HARRISON AVE
CAMPBELL CA 95008
CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
CLEARANCE FOR FINAL INSPECTION
AND ACCEPTANCE LETTER
Encroachment Permit#: ENC 2014-00057
Name: Ryan and Cheryl Luders
Property Address: 261 Harrison Ave., Campbell CA
Date of Final Inspection:
On File: ^ Bonds ^ CD ^ Cash
~ Faithful Performance: $ 500.00
^ Labor and Material: $
^ Construction Cash Deposit to be released: $
^ Other overdue deposits to be released (Description):
Processed by: ~,,% (~
Reviewed by:
Inspector
Reviewed by:
;`~ kc,(ministrator
~~
opment Engineer
J:VoMnaT\Deposit refunds\CHECKLISTS\Harrison261.Lauders.doc (Rev. 10/11)
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CITY of CAMPBELL
Public Works Department
April 30, 2014
Ryan and Cheryl Luders
261 Harrison Ave.
Campbell, CA 95008
SUBJECT: PERMIT NO. ENC 2014-00057
261 Harrison Ave., Campbell, CA 95008
FINAL INSPECTION AND ACCEPTANCE
Dear Ryan and Cheryl:
The City of Campbell has made a final inspection of subject Public Works improvements
and finds the work to be acceptable and in conformance with City standards.
Accordingly, the City Engineer accepts the improvements.
The one year maintenance period stated in the permit begins as of the date of this
acceptance letter. The permittee is responsible for the repair and/or replacement of any
defective work or failures that occur within one year. The City will inspect the
improvements within one year and notify you, in writing, whether or not any repairs are
required.
Your Faithful Performance Surety (FPS) cash deposit of $500.00 plus any interest due is
now being processed and will be sent to you under separate cover.
If you have any questions, please call me at (408) 866-2165.
Sincerely,
Syed Wahidi
Public works Inspector
Cc: Suspense - 11 month
Permit #ENC 20 ] 4-00057
Inspector File
70 North First Street Campbell, California 95008-1423 Trr. 408.866.2150 F~nx 408.376.0958 ~ ~n 408.866.2790
Refundable Deposit Check ReQuest
To: Finance Director
Check Payable To: Ran Luders ~ ~~
Address -Line 1: 261 Harrison Ave.
Line 2:
City: Campbell State: CA Zip: 95008
Description: FPS Return ENC2014-00057
Account Number: 101.2203 Amount: $500.00
Account Number: Amount:
Account Number: 101.540.7448 Amount:
(Finance Dept only) Interest Earned (Finance Dept only)
Total Payable: (Exact Amount)
Purpose: Refund of Faithful Performance Deposit
Voucher #: Permit #: ENC2014-00057
Receipt #: 252546 Date: 3/13/2014
Requested by: ~~. Title: PW Inspector Date: 5 S
Syed Wahidi
Approved by: itle: Sr. Engineer Date: _ ~~- ~~,
Lisa Peter e ' 4
Finance Dept Only:
Verified by: Title: Accounting Clerk II Date:
Approved by: Title: Accountant Date:
5 ecial I 'ons For Handlin Check
Mail As is Mail in Attached Envelope: Interim Check:
eeded By:
To: JoAnna Thomason ublic Works
(Name) epartment)
Other: Please return check to JoAnna
f/n: Forms/excel/chkreq - Revised OS/00
PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT
Effective July 1, 2013
TO: City Clerk PUBLIC WORKS FILE NO. Div ~ 2c l ~ - G C~c:- 5
PROPERTY ADDRESS 2~ ~ ~".` ~~'dz t S ~ N ~ti~
Please collect & recei t for the followin monies:
ACCT. ITEM
LAND DEVELOPMENT AMOUNT
ncroac ment ermlt IcaUon ee
Non-Utili Encroachment Permit Ma'or z$10 000 $377.00
Minor Encroachment Permit <$~o,ooo $215.00
Initial R-1 Permit N/C
Subse uent R-1 Permits within Two Year Period $209.00
Ins ection Fee Minimum Char a er Location $377.00
Street Tree Plantin /Removal N/C
2203 $500 er Tree Plantin De osit Re wired $500.00/tree
2203 Plan Check De osit 2% of En ineer's Estimate $500.00 min
U_ tility and R-1 Permits no deposit required
4722 Gradin & Draina a Plan Review
Sin le Famil Lot $265.00
Site < 10 000 s.f. $795.00
Site ? 10 000 s.f. < 0.5 Acre $1 060.00
Site ? 0.5 Acre $1 590.00
4722 NPDES Review C3 Re uirements
For projects not required to submit numeric sizing $153.00
Forprojects required to submit numeric sizing
Im envious Area 10 000 S . Ft to 1 Acre $663.00
Im envious Area 1 Acre or more $867.00
Plan Check & Ins ection Fee Non-Utilit
4722 En r. Est. u to $250 000 14% of En ineer's Estimate
*'2203 En r. Est. ?$250 000 Actual cost +20°/D Admin Overhead
Min $35 000 De osit
2203 Emer enc Cash De osit 4% of En r. Est.' $500 min/$10 000 Max
2203 Faithful Pertormance Securi FPS 100% of ENGR. EST.' -,
2203 Labor and Materials Securi 100% of ENGR. EST.'
4721 Storm Drainage Area Fee Per Acre R-1 $2 120.00
(Multi-Res $2,385.00)
All Other $2 650.00
4722 Parcel Ma 4 Lots or Less $3 775.00 + $82/lot
4722 Final Tract Ma 5 or More Lots $4 590.00 + $112/lot
2203 Monumentation Securi 100% of ENGR. EST.
4920 Parkland Dedication Fee 75°/D/25°/D Due U on Cert. of Occu anc
4722 Lot Line Ad'ustment Includes Certificate of Com liance $1 785.00
4722 Vacation of Public Streets & Easements $2 386.00
4722 Certificate of Com liance $1 764.00
4722 Certificate of Correction $530.00
4722 A eal Filin Fee $200.00
4722 Nota Fee er si nature $10.00
4722 Assessment Segregation or Reapportionment
First Split
$846.00
Each Additional Lot $265.00
511.7424 Postage
MISCELLANEOUS
Other Please S eci
*Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work.
"Actual Cost Plus 20% Overhead (Non-Interest bearing deposit) TOTAL
NAME OF APPLICANT ~ r7 /7 '> yl. ~ ~ `i~GLG
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$ ~ C) C;%
NAME OF PAYOR ~_ PHONE ~C~~h ~/C J~C~~
ADDRESS ~ (,~l f~~3,tii~~=~c~" )- ~. ZIP ~ , Z;~
FOR RECEIVED Y
CITY CLERK
ONLY `'~ ~-7
Date ~ t Recei t # li~~i ~
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J'.1FORM51TSmplaleaWtlminiatratlvsUtacgpl iwm lsntl Dwalopmenl131C
AAA Northern California, 1st Mortgagee
Nevada&Utah
Insurance Exchange Homeowners Policy Declarations
PO Box 22221, Oakland CA 94623-2221 See Important Notices on Reverse
For questions or changes call: 1- 800 - 922 - 8228
Renewal Page 01 of 01
Membership Number Homeowners Policy Number
Mortgage Servicing Company/Mortgagee 649-13-63-5 HO -HC-55-42-9
From 12:01 A.M. Pacific Standard
CMG MORTGAGE INC DBA Time, but not prior to the
CMG FINANCIAL ISAOA ~ time applied for or,rf this is
11.28.2013: a replacement Declarations,
3160 CROW CANYON ROAD Your not prior to the time coverage
SUITE 400 policy change was requested.
SAN RAMON CA 94583-1382 Period To
_ 11-28-2014 ~ 12:01 A.M. Pacific Standard Time.
An electronic version of this document was
sent to the Mortgagee(s) by ChoicePomt.
Alt: Premium to be paid by: Primary Secondary
Location 261 HARRISON AVE Home: 408-910-7205 Insured X
of CAMPBELL CA 95008-1402
Insured
Property ror °ffice oas oas o zoo October a, zot 3
_._ use only
Coverages and Limits of Insurance : Insurance is provided for the following coverages only when a limit is shown. The limit
of liability for this structure (Coverage A -Dwelling) is based on an estimate of the cost to rebuild your home, including an
approximate cost for labor and materials in your area, and speck Information that you have provided about your home.
Section I
A B C D E F
Other Personal Personal Liability Medical Payments to Others
Dwelling Structures Property Loss of Use (Personal Injury & Property Damage)
Each Occurrence Each Person Each Accident
$ 408 200 x 41,300 5 306,200 $ 163 280 $ 500,000 $ 1,000 $ 25,000
Section I Only:
Your Section I Coverage Limits have been changed to reflect changes in
Construction costs and other matters affecting replacement costs.
Section II: Additional Residence Premises if any located :(Number, Street, City, State)
This policy does not provide Earthquake Insurance.
This policy does not provide Flood Insurance.
Basic Policy Premium
Forms and Endorsements made part of this policy at time of issue.
Homeowners Policy -special form - $1000 Deductible (HO-3).
Lender's Loss Payable Endorsement (438 BFUNS).
Limited Home Replacement Cost Endorsement - 150% Of Cov A (HO-28).
Replacement Value Endorsement Personal Property (HO-29).
$1000 Deductible (HO-60).
workers' Compensation & Employers' Liability - CA (HO-90).
Private Residence Employees -Class 0910.
Building Code upgrade Limit - $102,050.00
Discounts/Benefits Applied:
Named Insured and Mailing Address
LUDERS RYAN
261 HARRISON AVE
CAMPBELL CA 95008-1402
First Mortgagee Name if other than Mtg. Svc. t;A.
10% FireBurglar Alarm
1,028.00
incl.
255.00
-300.00
incl.
Total Policy Premium
$ 983.00
Automatic Renewal This policy will be renewed
automatically; however, if our rules prohibit renewal,
we will give you advance written notice.
POOC00
1st Mortgage Loan No.
60521795
2nd Mortgage Loan No.
Section II
Total Balance
10750508 (Over)
Renewals and Inquiries
Your AAA Homeowners Policy renews automatically on each anniversary of your inception date. The Homeowners policy
renewal Declarations (both front and back pages), the Billing Plan Explanation, the most recent version of the
Homeowners Policy booklet and anything else we provide to you that states that it is a part of our renewal offer,
together constitute the terms under which we have renewed your AAA Homeowners policy.
As a AAA Member Organization, we take pride in putting members first. Should you have inquiries or complaints
regarding your policy, please contact our Insurance Service Center at (800) 922-8228.
If you have contacted us to discuss your policy and remain unsatisfied by our response, you may have the matter
reviewed by the Department of Insurance. Their telephone number is (800) 927-4357.
Please allow us the opportunity to answer your questions before contacting the Department of Insurance.
Notice of Non-Renewal
We are required to notify you at least 45 days before policy expiration if we do not offer a renewal of your policy. If we
do not notify you 45 days in advance, your policy continues in effect unchanged for 45 days until we provide a notice of
non-renewal.
AAA Northern California,
Nevada&Utah Homeowners Policy Declarations
Insurance Exchange
PO Box 22221, Oakland CA 94623-2221 See Important Notices on Reverse
For questions or changes call: 1-800 - 922 - 8228
Named Insured and Mailing Address
LUDERS RYAN
261 HARRISON AVE
CAMPBELL CA 95008-1402
Renewal Page 01 of 01
Membership Number Homeowners Policy Number
649-13-63-5 HO -HC-55-42-9
Your
Policy
Period
From ~ 12:01 A.M. Pacific Standard
'• Time, but not prior to the
time applied for or, ff this is
11-28-2013 ~ a replacement DeGarations,
not prior to the time coverage
change was requested.
To
11-28-2014 ; 12:01 A.M. Pacific Standard Time.
Alt: Premium to be paid by: Primary Secondary
Location 261 HARRISON AVE Home: 408-910-7205 Insured X
of CAMPBELL CA 95008-1402
Insured
Property For office 045 045 0 200 October 4, 2013
_ use only
Coverages and Limits of Insurance : Insurance is provided for the following coverages only when a limit is shown. The limit
of liability for this structure (Coverage A -Dwelling) 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.
Section 1 Section II
A B C D E F
Other Personal Personal Liability Medical Payments to Others
Dwelling Structures Property Loss of Use (Personal Injury & Property Damage)
Each Occurrence Each Person Each Accident
$ 408 200 ~ 41,300 ~ 306,200 $ 163 280 $ 500,000 $ 1,000 $ 25,000
Section I Only:
Your Section I Coverage Limits have been changed to reflect changes in POOC00
Construction costs and other matters affecting replacement costs. 1st Mortgage Loan No.
Section II: Additional Residence Premises if any located :(Number, Street, City, State) 60521795
2nd Mortgage Loan No.
This policy does not provide Earthquake Insurance.
Basic Policy Premium
Forms and Endorsements made part of this policy at time of issue.
Homeowners Policy -Special form - $1000 Deductible (HO-3).
Lender's Loss Payable Endorsement (438 BFUNS).
Limited Home Replacement Cost Endorsement - 150% Of Cov A (HO-28).
Replacement Value Endorsement Personal Property (HO-29).
$1000 Deductible (HO-60).
workers' Compensation & Employers' Liability - Ca (HD-90).
Private Residence Employees -Class 0910.
Building Code Upgrade Limit - $102,050.00
Discounts/Benefits Applied:
Mortgage Servicing Company/Mortgagee
CMG MORTGAGE INC DBA
CMG FINANCIAL ISAOA
3160 CROW CANYON ROAD
SUITE 400
SAN RAMON CA 94583-1382
First Mortgagee Name ff other than Mtg. Svc. Co.
10% FireBurglar Alarm
Automatic Renewal This policy will be renewed
automatically; however, if our rules prohibit renewal,
we will give you advance written notice.
rremiums
1,028.00
incl.
255.00
-300.00
incl.
Total Policy Premium
$ 983.00
Total Balance
10750508 (Over)
Renewals and Inquiries
Your AAA Homeowners Policy renews automatically on each anniversary of your inception date. The Homeowners policy
renewal Declarations (both front and back pages), the Billing Plan Explanation, the most recent version of the
Homeowners Policy booklet and anything else we provide to you that states that it is a part of our renewal offer,
together constitute the terms under which we have renewed your AAA Homeowners policy.
As a AAA Member Organization, we take pride in putting members first. Should you have inquiries or complaints
regarding your policy, please contact our Insurance Service Center at (800) 922-8228.
If you have contacted us to discuss your policy and remain unsatisfied by our response, you may have the matter
reviewed by the Department of Insurance. Their telephone number is (800) 927-4357.
Please allow us the opportunity to answer your questions before contacting the Department of Insurance.
Notice of Non-Renewal
We are required to notify you at least 45 days before policy expiration if we do not offer a renewal of your policy. If we
do not notify you 45 days in advance, your policy continues in effect unchanged for 45 days until we provide a notice of
non-renewal.
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FILL MIX -STYRENE PIPS WITH PLASTIC SLOT
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DATE: JANUARY 2008
APPROVED -CHECKED BY ~_ CITY OF CAMPBELL DETAIL 12
1'-6" MIN.
STATE FARM INSURANCE COMPANIES®
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900 Old River Road
8akersHe/d CA 93311-9501
24A
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000337 0093
CITY OF CAMPBELL
70 N 1ST ST
CAMPBELL CA 95008-1459
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DATE OF NOTICE: MAR 07 2014
CODE:
NOTE: PLEASE NOTIFY STATE FARM AT THE
ADDRESS LISTED AT THE TOP, LEFT CORNER
OF THIS PAGE REGARDING ANY CHANGE OF
ADDRESS INFORMATION.
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I ADDITIbNAt_ INSURED'S NOTICE OF COVERAGE
State Farm Mutual Automobile Insurance Company 7794-FAD3J
NAMED INSURED: POLICY NO: 259 7871-617-551 COVERAGE:
o COX, ANTHONY L & KATHY L YR/MAKE/MODEL: 1988 FORD FLAT BED $ Ij M D PD LIABILITY
N DBA AC TRACTOR & DEVELOPMENT VIN/CAMPER: 1 FDMF60H4JVA26741 $250 DED COMP.
1112 N MAIN ST # 301 AGENT NAME: SFO MANTECA, CA
> MANTECA CA 95336-3208 AGENT PHONE: (209)823-0556
ENDORSEMENT NO: 6028BU POLICY EFFECTIVE
o MAR 03 2014 UNTIL TERMINATED
~ POLICY MESSAGES: This policy shown above supersedes policy# 2597871-55H.
~ The policy includes a loss payable clause protecting the additional insured'a interest in the described car to the e~dent of the insurance
~ provided and subject to all policy provisions. The additional insured will be given 20 days notice if the policy is terminated. Until such notice
is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of
any change of interest or ownership coming to their attention. Failure to do ao will render this policy null and void.
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ADDITIONAL INSUREDS NOTICE OF COVERAGE
State Farm Mutual Automobile Insurance Company 7794-FAD3J
NAMED INSURED: POLICY NO: 271 4266-C10-55D COVERAGE:
COX, ANTHONY L YR/MAKE/MODEL: NONOWNED AUTO BI AND PD LIABILITY
DBA AC TRACTOR & DEVELOPMENT VIN/CAMPER: $ 1 MIL I$ 1 MIL I$ 1 MIL
1112 N MAIN ST # 301 AGENT NAME: SFO MANTECA, CA
MANTECA CA 95336-3208 AGENT PHONE: (209)823-0556
ENDORSEMENT NO: 6o286u POLICY EFFECTIVE
6164DL 6165CP MAR 03 2014 UNTIL TERMINATED
POLICY MESSAGES: This policy shown above supersedes policy# 2714266-55C.
The policy includes a loss payable clause protecting the additional insured's interest in the described car to the e~dent of the insurance
provided and subject to all policy provisions. The additional insured will be given 20 days notice if the policy is terminated. Until such notice
is provided, it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of
~ any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void.
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~?ubtie Works E3epartment
May 19, 2015
Ryan and Cheryl Luders
261 Harrison Ave.
Campbell, CA 95008
SUBJECT: PERMIT NO. ENC 2014-00057
LOCATION: 261 Harrison Ave
ONE YEAR MAINTENNACE INSPECTION -ACCEPTANCE
Dear Ryan and Cheryl:
The City of Campbell has made the final one year maintenance inspection of the subject
Public Works improvements and finds that no remedial work is required.
Your warranty requirements and any surety, therefore, are hereby released.
Sincerely,
-~
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Syed Wahidi
Public works Inspector
Cc: Permit File: ENC 2014-00057
'(~ Nor;h First Stree+.. Campheil; California 95005-1436 • TsL 40&.865.2t5Cp • Fax 408.3~5.09~8 ~ ~~em 408.865.2790