ENC2011-00071r
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CITY OF CAMPBELL R-1 ENCROACHMENT PERMIT Permit No. ~N_~- 20( " OOG~
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 ~-7~ /~ Application Expiration
Ph. (408) 866-2150 ISSUED: L !cam ~ ~ Date ~ (
Fx. (408) 376-0958 Permit Expiration Date 7_~ _~ Z APN ? - L~ - GI `I
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: ~ I Lt.c~C~ Cp„^I,nI ~L~
B. Nature of Work: ~~~^lv,~ ~\ f~~IV~NG"NS~F-ACT ~'~' (~~~
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: J~ C_A~e o p ~1 Telephone: C~~l ~ (a-~ .. (ad ~- ~
Address: I ~ `{ O C~ Lilo cJwG~ ~/~ ~~.~p3 i LL C-~C °t~ oo
E-Mail Address: J LAt.\~d N~ S 3 c_. ~- L c -~
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. / ~ / /
ACCEPTED:
~/ ~°// ~
(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 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 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.) $ ~ "-
R-1 PERMIT FEE $
APPROVED FOR ISSUANCE: 7~G~( ~
for City Engineer Date
Permit Expires 6 Months after Date of Issuance.
~ ~4 F T1t2. TI-1~ F~ C t P ~M1 T
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. Sawcut for all PCC and 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 thejob 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 respresentative 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 representatives 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 to emergencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum
charge per occurrence.
17. 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.
18. 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 ensuringthat all those providing services under the applicant are aware of and understand all of the above
conditions. ~
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Applic Dat
J:\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf
Rev. 3/10
AMCO INSURANCE COMPANY
1100 LOCUST ST
DES MOINES !A 50391-1100
(800) 282-1446
AGENCY S B C INSURANCE SERVICES INC I
LOS ALTOS CA
CONTINUATION DECLARATIONS
The limit of liability for the structure (Coverage A) is based on the 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.
NAME INSURED AND ADDRESS
CAHOON, JDHN B. ,
CAHOON, MELISSA R.
1400 CRONWELL DR
CAMPBELL, CA 85008-0822
HOMEOWNERS POLICY
POLICY NUMBER: HA 0021907481-3
ACCOUNT NUMBER: 871008631
Policy Period
From: OT-02-11 To: OT.-02-12
12:01 A.M. Standard Time
Effective Date of Change
The described residence premises covered hereunder is located at the
above address, unless otherwise stated herein. (No., street, city, state, zip Code)
SFCTI(~N I
POLICY NUMBER
TO BE PAID BY NAMED INSURED
A. B. OTHER C. PERSONAL D. LOSS E. PERSONAL F. MEDICAL PAY
STRUCTURES PROPERTY OF USE LIABILITY EACH PERSON
ACTUAL LOSSES SUSTAINED
568 000 56 800 397 600 IN 12 MOS. r O~ 1000
'OR LOSSES ARISING UNDER SECTION 1, WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF 61,000.
COVERAGE DESCRIPTION PREMIUM COVERAGES DESCRIPTION PREMIUM
H03 01/00 S acts! Form 897.00 HO90 05102 Calii Work Comp
H082 02!07 Personallnjury 14.00 12747 12/01 Fungi/Bacteria
H056 11/05 Identity Fraud 45.00 H065 01/00 Cov C Incr Limit 6.00
12558 02/07 Per Prop Reel 12567A 02107 Replacement Cost 51.00
12669 01/00 Back-up of Sewer 36.00 H0216 01/00 Pram Alarm Prot 20.000R
11796 08/05 CA Res Prop. Dis 438BFUN 05142 Lenders Loss Pay
IN2004 03/04 Consumer Into ~ IN2264 03!06 Merit Rating
10940 OTJ89 CA Ins Guarantee IN2499 1010$ Important Notice
H03000A 09/09 Spec Provisions IN0000 04/09 Privacy Stmt
IN0100 01/10 Important Notice IN2584 02/10 Important Notice
TOTAL PREMIUM 1, 029.00
Additional
Residence
Occupied RETENTION CREDIT
By Insured
_oan Num
e Loss Pavee or Other Interest
WELLS FARGO BANK, N.A. 1ST
ITS SUCCESSORS ANDlOR ASSIGNS MORT
PO BOX 5708
SPRINGFIELD, OH 45501-5708
---
DIRECT BILL 0000 11130 008161 MORTGAGEE
AMCO INSURANCE COMPANY
Authorized Representative
971008631 78
AMCO INSURANCE COMPANY
g1{ YnTNESS WHEREOF, the Comp~y has caused this paacy to be signed by its president and secretary and
countersigned as may be required on the dedarations page by a duty authorized representative of the company.
~~ ~
SECRETARY
PRESIDENT
ALLIED PROPERTY AND CASUALTY INSURANCE COMPANY
IN WITNESS WHEREOF, the Company has caused this policy to be signed by its presiderr4 and secretary and
countersigned as may be requin:d on the dederations page by a duly authorized representative of the company.
~f ~
SECRETARY
PRESIDENT
DEPOSITORS INSURANCE COMPANY
IN WITNESS WHEREOF, the Company has caused this policy to be signed by its president and secretary and
countersigned as may be required on the declarations page by a duly authorized representative of the comparry.
~~w. ~
SECRETARY
12501A (10-tity
a ~. ~-.
z ~ ~~
a~~
PRESIDENT
Page 1 of 1
HA 00219074813 05/10/11 008162 MORTGAGEE 78
Allied
Insurance
a Nationwide' company
oR ro~-swe•
AGENCY - CA - 23076
S B C INSURANCE SERVICES INC
LOS ALTOS CA
650-469-0400
D-003375 003375 78 HOS
WELLS FARGO BANK, N.A.
ITS SUCCESSORS AND/OR ASSIGNS
PO BOX 5708
SPRINGFIELD, OH 45501-5708
AMCO INSURANCE COMPANY
1100 LOCUST ST
DES MOINES IA
50391-1100
INSURED
CAHOON, JOHN B.
CAHOON, MELISSA R.
1400 CRONWELL DR
CAMPBELL, CA 95008-0822
LOAN NUMBER:
0077325116
HOMEOWNERS POLICY NUMBER
HA 0021907481-3
LOSS PAYEE, MORTGAGEE OR OTHER INTEREST INFORMATION ... .
The enclosed material provides loss payee, mortgagee, or other interest information pertaining to your client_ The
coverage provided is subject to premium payment.
If payment is not received by the billing due date or within our grace period, the coverage provided will expire
as of the policy effective date.
DIRECT BILL 0000 11130 008160
971008631 78
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