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ENC2016-00067oV C4 UfiT r - � v � � • Uk CH ARO CITY OF CAMPBELL - Public Works Department June 20, 2018 CRP Vasona, LLC. 4400 West 78th Street, #200 Minneapolis, MN 5.5435 SUBJECT: PERMIT NO. ENC 2016-00067 1350 Dell and 250 E. Hacienda Aves. Campbell CA FINAL INSPECTION AND ACCEPTANCE To Whom it May Concern: According to our records, there is a deposit refund due for the curb, ramp and streetlight improvements completed at 1350 Dell and 250 E. Hacienda Aves. under Permit ENC2016-00067. The City of Campbell has made the final 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. A check for your deposit refunds totaling $20,800.00 is enclosed. An additional check for $500.00 representing the Plan Check Deposit is being returned to Arc Tec Inc. who we show as the payor of that deposit. Please let me know if you have any questions. Sincerely, LTr�nThomason Office Specialist CC: Mark Velasco, So. Bay Construction 70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAX 408.376.0958 • TDD 408.866.2790 OF C 4`'( 4 .-BCHARn CITY of CAMPBELL Public Works Department August 14, 2018 Are Tee, Inc. 1731 Technology Dr. #750 San Jose, CA 95110 - SUBJECT: PERMIT NO. ENC 2016-00067 250 E. Hacienda Ave. FINAL INSPECTION AND ACCEPTANCE To Whom It May Concern: Please find enclosed the replacement check for the Plan Check Deposit regarding the above -referenced property. If you have any questions, please call me at (408) 866-2150. Sincerel Jo omason Office Specialist .70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAX 408.376.0958 • TDD 408.866.2790 10015069 ARC TECH INC -::;0F.CAMPBELL'. ij�� rAR6o i3ANK, N.A. TY; 11-L4_ STREET 772-10 CHECK ',DATE CHECK NO. 0 8 /i 0 2 9,2 5 3' FIRST STREET FRANCISC CA 94104 0, 1 GAM P B El� CALIFORNIA 96008 AMOUNT **:*-5'0 Q..''O 0-*iI 61 0 VOID AFTER.9A DAYS PAY THE SUM OF FIVE HUNDRED DOLLARS & ZERO CENTS IE 2 TO THE ARC TEC INC ORDER ICI 1731 TECHNOLOGY DR #750 F7� SA14 JOSE CA 95110 ul .2692531I l 1: 12 1 Cl 0 0,2 1, 51: 11 1 21 a S S Ll I S Fri ---- ---- ------- ---------------- - ........................................ . .... . .. ............... ... ..... . ... ...... . .............. ..... ... .................... ............... ...................... . ..... ........ ....... . ................ .... ....... . ..................................... . ........................................ ........................... . ........... . ............... . ................... .... . ............. ................... *See Reverse Side For Eas'y Opening Instructions* CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL,.CALIFORNIA 95008 ARC TEC INC 1731 TECHNOLOGY DR., #750 SAN JOSE CA 95110 To: Finance Director Check Payable To: Address - Line 1: Line 2: City: Description: Account Number: Account Number: Account Number: (Finance Dept only) Total Payable: Purpose: Receipt #: Receipt # Requested by Approved by Roger Storz Refundable Deposit Check Request Arc Tec, Inc. 1731 Technology Dr. #750 San Jose ENC2016-00067 101.2203 101.2203 101.540.7448 Interest Earned State: CA Amount: Amount: Amount: Zip: 95110 $500.00 (Finance Dept only) (Exact Amount) Replacing check made out to Sharol Williamson sib made out to the company (Arc Tec) Permit #: ENC2016-00067 263470 Date: 4/14/2016 Date: Office Spec Date: Sr. Engineer Date: t l� Finance Dept Only: Verified by: Title: Accounting Clerk II Date: Approved by: Title: Accountant Date: Sdecial Instructions For Handlin4 Check mail As Is: mail in Attaches Envelope: Interim t;necK: Return To: JoAnna Thomason Needed By: Public Works (Name) (Department) Other: Please return check to JOAnna CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL', CALIFORNIA'95008 SHAROL WILLIAMSON 99. ALMADEN BLVD. , ,#840 SAN JOSE CA 95113 OF ' C4,y U a r 0 0 9F �� •�RCHAR�• � CITY of CAMPBELL Public Works Department July 11, 2018 Shawl Williamson Arc Tec, Inc. J. 1731 Technology Dr. #750 San Jose, CA 95110 SUBJECT: PERMIT NO. ENC 2016-00067 250 E. Hacienda Ave. FINAL INSPECTION AND ACCEPTANCE Dear Sharol: 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. We show you as the payer of the Plan Check Deposit in the amount of $500.00. The reimbursement -check is enclosed. If you have any questions, please call me at (408) 866-2150. r-ncerely, ti lyi H o i Assistant Engineer Cc: Inspector /Suspense Files Permit File ENC2016-00067 70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 FAX 408.376.0958 TDD 408.866.2790 .............. . ............... ........... ................... . ....... ........ . . ..... .... ............. ............ ............................ ........... .................. ........ . ......... . . ...... ........... . ........ ..................................... - - - - - - - - - - - - - - - - - - - - CITY OF CAMPBELL VENDOR 140. 10014463 CHECK NO. 2,68331 /= ... l... _.....� - ---- - -- ---- ;[CITY OF CAMPBELL VENDOR NO. 10'014963 cxECK NO. 26.8417 , -Na Anuunt Descri'non 101 2203 ..:...: CR061218 5 00.00 ENC2016-00067 r' > < I I 10014963 SHAROL WILLIAMSON _ I �•...- �� 1 1• ,t1.e� t7 7 .Y • 1 1 1• • 1 O T �t CAPBELL�� 11'24 CHECK C WELLS FARGO BANK N A 4 +� 4i3O MONTGOMERY STREET 1210 0 6 18 ��- $ _o �* 5 NORTN FIRST STREET 1. �'9'A{� FRANCISCO CA 94104 � Y CAf�IpBELt CALIFORNIA 95008 3 i 2 6 8 417 _. E �` I t 4ta �� VOZA AFTER PAY THE Si7M OF FIDE HUNDRED' DOLLARS`- &� ZERO CENTS, 90 DAYS �� r u To�rxE� SHAROL° WILLIAMSON ORDER 99 ALMADEN BLVD , #840 SAN DOSE CA . 95113` �° , I A.. `. ha .. • . •d �.• 1 'mmm , IT•t• II —I I `I I ! ..., *Sew Reverse Side For Easy Opening Instructions CITY OF CAMPBELL 70 NORTH FIRST STREET I _ CAMPBELL,, CALIFORNIA 9500'8 / i I I J 1 i ' 1 I I SHAROL WILLIAMSON i 49 ALMADEN BLVD., #840 i SAN.JOSE CAS 95113 I OF cA.y A A L� • UkCHAR� • CITE' of CAMPBELL Public Works Department . July 11, 2018 Sharol Williamson Arc Tee, Inc. 1731 Technology Dr. #750 San Jose, CA 95110 SUBJECT: PERMIT NO. ENC 2016-00067 250 E. Hacienda Ave. FINAL INSPECTION AND ACCEPTANCE Dear Sharol: - 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. We show you as the payer of the Plan Check Deposit in the amount of $500.00. The reimbursement check is enclosed. If you have any questions, please call me at (408) 866-2150. jicerely, s i Hoi Assistant Engineer Cc: Inspector /Suspense Files Permit File ENC2016-00067 70 North First Street • Campbell, California 95008-1436 TEL 408.866.2150 FAX 408.376.0958 TDD 408.866.2790 i . C CITY OF CAMP: ACeOunt . ,:? 101 I r .00.14963 CHECK No. 26$417 � Des on I I 500.00 _ ENC2016-00067 � I I I J2. I m - � i I I I I CH}� M4,DAT .-., �,-1T 24 - n�•Lti o /� o;i"i,r,r �.-.,.�'^_` s CHECK �7.G Q-h '1 7 "�: I SHAROL WILLIAMSON i 99 ALMADEN BLVD., #840 SAN JOSE CA; 95113 - i i •y OVq11'i0o CITY of CAti1PBELL �&AN JOSS n r 70 North First Street •6 0 ° Campbell, California USPOSTi4GE y�•ORCHMOD 95008.1423 1• $00.470 �c _ VIST-CLASSRTL w Mailed From 7 r j 95008 06/21 /2018 �., Printed on recycled paper X _ ` 031A 0005180999 �� r i I R_7aF3€ SrN� v r a r gr ,. �'g .ata.e, 2203 Faithful Performance Security FP6) ueposl>; 100%° of ENGR. EST.* 2203 Labor and Materials Security R-1 $2,120.00 4721 Storm Drainage Area Fee Per Acre (Multi Res $2 385 00) All Other $2,650.00). 4722 Parcel Map (4 Lots or Less) $3,930,00 + $85/lot + $116/lot 4722 Final Tract Ma (5 or More Lots)$4,775.00 100% of City's Monumentation Estimate 2203 Monumentation Security Deposit Parkland Dedication Fee Remainin 25%will be Due Upon Cert, of occupancy) 4920 4722 Lot Line Adjustment (Includes Certificate of compliance $1,856.00 $2,480.00 4722 Vacation of Public Streets & Easements 4722 Certificate of Compliance $1,840.00 $550.00 4722 Certificate of Correction $15.00/first a e $3 ea. Additional 4722 Document Recording Fees $50.00 4722 Private Improvement in Public ROW 4722 AnDroved Plan Revision Fee $100/shee1 $200.00 4722 A eal FilingFee 4722 Notary Fee (per signature) $10.00 4722 Assessment Segregation or Reapportionment First Split $877 00 Each Additional Lot $275.00 511.7424 Postage MI9CELL"ANEOU5,, .; *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL _ $895.00 NAME OF APPLICANT LCl •\ � (-� NAME OF PAYOR U PHONE \ > l� Sin ZIP ADDRESS ; W FOR RECEIVED BY r d� CITY CLERK ONLY Date ,Receipt;# jftWndDeJPlon Check Comments\1-SP ffl- Proj— -Active Project in Propross dl Ave. 131SFe %F—ts �ao3�3W01SM �NNOW'd 31�iS oo56a� ;aunouid yet ,apoW 00'0'� ,po�aW �Au3 aanssl o p�oaddd peat' d!y3 .ap 31 165Z50 3310 g •,# b35 04 '•31 g '31tl. • 665bQtl4Q33L30atlj ,QId L000 ',pae3 d�y3 OIOj�p4440004tl # pae3 Q�tl3�31StlW 35tlH3 I LBbXX'�� 31tlS OW Q21tl31IQ3�3 gIOZl�jib0 Zb'80bI g40S6 tl3 i1139dWtl0 1S 15�Id N 4L 11346Wtl3 4011I3 . -,+LU -» CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2016-00067 Name: CRP Vasona LLC. Property Address: 1315 Dell Ave. & 250 E..Hacienda Ave. Date of Final Inspection: 6/4/18 On File: Bonds CD Cash Faithful Performance:' $ 20,000.00 Plan Check De posit: $500.00 acTec.W d Construction Cash Deposit to be released: $800.00 Other overdue deposits to be released (Description): Processed by: r 5-1 1 S Reviewed by: Inspector / Reviewed by: LIZ3 Land Development Engineerl C*e c\z, c`e p'os VV �( .Zoe 1% J:VoAnnaT\Deposit refunds\CHECKLISTS\Hacienda.Dell Aves..doc (Rev. 10/1 l) ._ .. , .� - - Ref undable Deposit '. Ce _Regues -_ .. I�, , To Finance Director ,o €` Check Ray_able To V Sharol Williamson,: h[^J s_ , Address.= Line 1 99 Almaden.Blvd'#840 ` f . ., Lme 2 • - ,- <;,.. :' San,Jose :State, -CA Zip 951'1;3 City _ _ .. , .. p _ Dekri tion ENC2016=00067' •.. - P - f , ., �. I T', . it , t Account Number- =101.2203 Amount $500 00 _ . - Account Number: 101 2203 Amount - Account_Number- 101 5407448 , : Amount (Finaoce,Dept only) - Interest Earned _ (Finance Dept only) :.;' ,, 3 'Total-Aayable (Ezac, -m .t)'.• - '; _ - . •, -. -. . . Purpose Plan Check.deposit return - .. _ . a ... ..,, z _:. , Permit-# ENC201'6 00067 • t _ � f b 41,14/2016 r Re`ceipt`# S 263470 _ Date - -_ ;j ;.. Receipt #" Date: ` yZLL J,eeJi `I .`; Requested by - Title t-Eo� Date: �. -So Isn.c� "M.on A 5a✓�% N . . A roved by Title _ _ Sr Engineer Date' w �o, PP . .y - . (toger Stor r ' i .. a -.. .. .. -- - ' Finance Dept Only .I f j Verified by :,- ng C- Title Account) lerk 1, Date :_ , . _ _ Approved by - Title Accountant Date: - �I `,. I '' — _'.-As. _. " ". L. . , Intructions For Handlin Check- , 1. . " :Secial s . _ _, ; y all IS Mau In Attacned`F_nv.elope �mterir l.necK . MI. . ' .AS _ .- i i-` - 1 Y - - .. - NeetledrBy y _t :.^ r r Y Return To JoA`nna TFiomason . ,,,, ' PutSlic'UVorks _.,, (Name) (Department) r r r y �. - .I -- . :, Other Please_ret60n,check:to;JoAnna;: _ . .,I. ..1. -, ._,, c - % • '` _ • r. r . Print Form d CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No (_'1N C-7l� L b coo (o-% DEPT. OF PUBLIC WORKS (for working within the public X-Ref. File 70 North First Street right-of-way) Application Date Campbell, CA 95008 Application Expiration Date Z� 1 Ph. (408) 866-2150 Issued %f �© G� APN L-\Z Lk "Z`L\� 3 3 \t Fx. (408) 376-0958 Permit Expiration Date Z 1'7 APPLICATION - Application is hereby made for a Public Works Permit in actor ante 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 No.: I250 East Hacienda Avenue & 1315 Dell Avenue Utility Trench Location: IN/A B. Nature of work: Upgrade existing curb ramp, upgrade streetlight fixtures, & replace missing street tre� 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 underground 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. Notice must be given to Public Works at least 24 hours before restarting any work. Name of Applicant: Natalya Bach Telephone: 408-496-0676 Address: 199 Almaden Boulevard, Suite 840, San Jose, CA 95113 E-Mail Address: nbach@arctecinc.com 24-HOUR EMERGENCY PHONE NUMBER: Is this work being done by the property owners at their own residence? F7 YES FX_ NO The Applicant/Permittee 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 this permit. The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) 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 condition of an private improvements in the public right-of-way. �latalya,Bach 0� 04.11.16 Arrented (Applicant Permittee) (sign) (Print Name) Date SPECIAL PROVISIONS: 1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be specifically approved by the Inspector 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 the Engineer. 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 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 has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO. 5. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right -of -Way, which shall be recorded. 6. Public Notification Requirements: 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT PERMIT APPLICATION FEE $2aI -5�.f3O PLAN CHECK DEPOSIT $_ S;00. i SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS _. $ lz so O CONSTRUCTION CASH DEPOSIT Soo, on PLAN CHECK & INSPECTION FEE EMERGENCY PERMIT FEE $ APPROVED FOR ISSUANCE or City Engineer Permit Expires 12 Months After Date of Issuance RECEIPT NO 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 or 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. Submit project schedule 10 (ten) 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, bus stops, fire hydrants, and water valves. 7. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures, detours, and street closures. This plan must be reviewed and approved prior to any lane closures. 8. A 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. 9. 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. 10. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements. 11. 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. 12. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost (including all labor and materials) against the cash deposit. 13. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 14. 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. 15. 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. 16. 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. 17. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 18. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 19. Call back (call out) due to emeregencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence. 20. 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. 21. 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. 22. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the 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 and understand all of the above conditions. Natalya Bach (ARC TEC inc) 04.11.16 contractor lrnnt ivame) J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev. 02/14 Date: it / (� Date: PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1, 2015 TO: Finance PUBLIC WORKS FILE NO. ENC2016-00067 PROPERTY ADDRESS 1315 Dell Avenue Please collect & receipt for the following monies: ACCT. ITEM AMOUNT LAND DEVELOPMENT 722 Encroachment Permit Application Fee Non -Utility Encroachment Permit Major >_$10,000 $395.00 $395.00 Minor Encroachment Permit <$1o,000 $225.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $225.00 Inspection Fee Minimum Charge per Location $390.00 Street Tree Planting/Removal N/C 2203 ($500 per Tree Planting Deposit Required) $500.00/tree 2203 Plan Check Deposit 2% of Engineer's Estimate $500.00 min $500.00 Utility and R-1 Permits no deposit required 4722 Gradinq & Drainage Plan Review Single Family Lot $275.00 Site < 10,000 s.f. $825.00 Site > 10,000 s.f. < 0.5 Acre $1,105.00 Site >_ 0.5 Acre $1 655.00 4722 NPDES Review C3 Requirements For projects not required to submit numeric sizing $160.00 For projects required to submit numeric sizing Impervious Area 10,000 Sq. Ft to 1 Acre $690.00 Impervious Area 1 Acre or more $900.00 4722 For projects sent to Consultant for review Consultant Cost +20% 4722 Additional stormwater treatment facilities $300 ea Plan Check & Inspection Fee (Non-Utilit 4722 Enqr. Est. < $250,000 14% of Engineer's Estimate 2203 Enqr. Est. >$250,000 and :5$500,000 $35,000 + 8% of Enqineers Estimate 2203 Enqr. Est. >$500,000 $55,000 + 7% of Enqineers Estimate 2203 Emer encV Cash Deposit 4% of Enqr. Est.* ($500 min/$10,000 Max) 2203 Faithful Performance Security (FPS) Deposit 100% of ENGR. EST.* 2203 Labor and Materials Security 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 Map (4 Lots or Less) $3,930.00 + 85/lot 4722 Final Tract Map (5 or More Lots) $4,775.00 + 116/lot 2203 Monumentation Security Deposit 100% of Cit 's Monumentation Estimate 4920 Parkland Dedication Fee(Remaining 25% will be Due Upon Cert. of Occupancy) 4722 Lot Line Adjustment (Includes Certificate of Compliance) $1,856.00 4722 Vacation of Public Streets & Easements $2,480.00 4722 Certificate of Compliance $1 840.00 4722 Certificate of Correction $550.00 4722 Document Recording Fees $15.00/first page $3 ea. Additional 4722 Private Improvement in Public ROW $50.00 4722 Approved Plan Revision Fee $100/sheet 4722 Appeal Filing Fee $200.00 4722 Notary Fee (per signature) $10.00 4722 Assessment Segregation or Reapportionment First Split $877.00 Each Additional Lot $275.00 511.7424 Postage MISCELLANEOUS -- -- - - - - -- — - - - - -- *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $895.00 NAME OF APPLICANT NAME OF PAYOR � �C1 PHONE - \ ADDRESS ZIP v FOR RECEIVED BYtzr� r CITY CLERK ONLY L ..Date � AI Ili I ` Receipt # J.UndD.01Plan Check Comments\t - Specific Projects -Acbw Project in Progress\Dell Ave. 1315\Fees\F—As s .1 .`14. CITY OF CAMPBELL 10 N EIRST ST CAMPBELL, CA 95008 14:08:12 0AjjAJ2016 CREDIT CARD MC SALEvlv�871 Card # CHASE Clirp Card'. KSTERCARD ADD00000041010 gD: OD01 pTC'. IAgDC7FEDBAD�59 6 TC', SEQ # . 80 Batch #' INVOICE 6 05TAI Approval Code: Chip Read Envy Mel°d: Issuer Mode: $DAD Tay Amount. �sv5 SASE AM V CUSTOMER COPY V PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1, 2015 TO: Finance PUBLIC WORKS FILE NO. ENC2016-00067 PROPERTY ADDRESS 1315 Dell Avenue Please collect & receipt for the following monies: ACCT. ITEM AMOUNT LAND DEVELOPMENT 4722 Encroachment Permit Application Fee Non -Utility Encroachment Permit Major >_$10 000 $395.00 Minor Encroachment Permit <$10,000 $225.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $225.00 Inspection Fee Minimum Charqe per Location $390.00 Street Tree Plantinq/Removal N/C 2203 ($500 per Tree Plantinq Deposit Required) $500.00/tree 2203 Plan Check Deposit 2% of Enqineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Grading & Drainage Plan Review Single Family Lot $275.00 Site < 10,000 s.f. $825.00 Site >_ 10,000 s.f. < 0.5 Acre $1,105.00 Site >_ 0.5 Acre $1,655.00 4722 NPDES Review (C3 Requirements) For projects not required to submit numeric sizinq $160.00 For projects required to submit numeric sizing Impervious Area 10,000 Sq. Ft to 1 Acre $690.00 Impervious Area 1 Acre or more $900.00 4722 For projects sent to Consultant for review Consultant Cost +20% 4722 Additional stormwater treatment facilities $300 ea Plan Check & Inspection Fee (Non -Utility) 4722 Engr. Est. < $250,000 14% of Engineer's Estimate $2,800.00 2Z9 a, Enqr. Est. >_$250,000 and 15$500,000 $35,000 + 8% of Engineers Estimate 03 2203 2203 Engr. Est. >$500,000 $55,000 + 7% of Enqineers Estimate Emergency2203 .. it 0,000 Faithful Performance Security (FPS) Deposit 1000/aof ENGR. EST.* Labor and Materials Security 100% of ENGR. EST.* :ii ii $20,000.00 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) $3 930.00 + $85/lot 4722 Final Tract Map (5 or More Lots) $4,775.00 + 116/lot 2203 Monumentation Security Deposit 100% of City's Monumentation Estimate 4920 Parkland Dedication Fee(Remaining 25% will be Due Upon Cert. of Occupancy) 4722 Lot Line Adjustment (Includes Certificate of Compliance) $1,856.00 4722 Vacation of Public Streets & Easements $2,480.00 4722 Certificate of Compliance $1,840.00 4722 Certificate of Correction $550.00 4722 Document Recording Fees $15.00/first page $3 ea. Additional 4722 Private Improvement in Public ROW $50.00 4722 Approved Plan Revision Fee $100/sheet 4722 Appeal Filing Fee $200.00 4722 Notary Fee per signature) $10.00 4722 Assessment Seqreqation or Reapportionment First Split $877.00 Each Additional Lot $275.00 511.7424 Postage _ MISCELLANEOUS — Indicates deposits that will be refunded upon successful completion of the project 'Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $23,600.00 NAME OF APPLICANT -9-96 -1�57C Mfe - NAME OF PAYOR efZp VeSONe U-G PHONE fl - t/0- ZW- ADDRESS 4f DO/�llt/!f4ZIP $-f FOR RECEIV D BY "' i\ � CITY CLERK ONLY ' J tN 0 D 2(y16i � 1/ Date 4 it Receipt # 6-C-1 CITY 0, F C,..•.,. ALl ,. JXandDeAPIan Check CommentAl - Swint Prajxf -Active Prgecl in Pn gm nDA Ave. 13MF—AF—A, ...t :•1 ..�'1 (.;'. ..-1 a.., •,:tl ysy rat ...:; ' t,,a fill •i-ii1 Y � ;. � S i� � ,Y •;J li: cis c,:'; . �... ri i i�'� ! ,_•• M. Aso U . `•f G? .r .""; rft�t t,, �,! t J�. �„J YJ 1�... ..;t '�?: e. ��i f"? C •. r �. f t"i. {y_t f Cs ��"` f-) IJI ry- r1 Cl^ C-i flJJ Est t (•.:J L-•i VS-1 Ct y t ..is• C _ CT Y __ State Of CaliforniaCCONTRACTORS STATE LICENSE E BOARD ACTIVE LICENSE 336974 —'CORP S B C C INC DBA SOUTH BAY CONSTRUCTION B A&, P9 03/31/2018 VA".CsIb.ca.gov W:2 PLEASE POST IN A CONSPICUOUS PLACE NOT TRANSFERABLE BUSINESS LICENSE CITY..OF CAMPBELL (408) 866-2174 ESTABLISHED: 0610512002 EXP`DATE: 0513112017 LICENSE NO. 018743 LOCATION: 1711 DELL AVE CAMPBELL, CA 95608" BUSINESS: SOUTH BAY CONSTRUCTION DBASBCC,INC TYPE OF BUSINESS OWNER: RICHARD FURTADO w- ? CONTRACTOR -SPECIAL TRADE The person, firm, or corporation named above is'granted this business license pursuant to,,the provisions of the City Business License Ordinances to engage in, carry on, or conduct the:business-trade; calling; profession, exhibition, or occupation described above. Issuance of the license is not an endorsement, nor certification of compliance with otherordinances or laws, nor an assurance that the proposed use is in conformance with the city zoning regulations. This license is issued'without verification that the licensee is subject to or exempt from the licensing by the State of California.' Valid only within the City of Campbell city limits, CITY MUST BE NOTIFIED ON ANY CHANGE IN OWNERSHIP, LOCATION, OR C�L'OSU,RE.i; r3 ANNUAL TAX PAYMENT DUE ON OR BEFORE THE EXPIRATION'DATE. RENEWAL NOTICE NOT REQUIRED. 9 LNG 7Da\te CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDYYYY) 11/30/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Asero Insurance Services 200 N. Almaden Blvd. 3rd Floor San Jose, CA 95110 CONTACT NAME: Asero Insurance Services A/cNo Ezt : 866-966-8928 FAX No): 408-271-1802 E-MAIL ADDRESS: CertS aseroins.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA : Allied World Assurance Co U.S. Inc. 19489 www.aseroins.com License No. OA91339 INSURED S B C C, I N C DBA South Bay Construction 1711 Dell Avenue INSURER B: Travelers Property Casualty Co of Amer 25674 INSURERC: National Fire Insurance Co of Hartford 20478 INSURERD: INSURERE: Campbell CA 95008 INSURER F . COVERAGES CERTIFICATE NUMBER: 33006915 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LT ILTR R TYPE OF INSURANCE INSD ADDL WVD SUER POLICY NUMBER POLICY EFF MM/DD YYYY POLICY EXP MMIDDYYYY LIMITS A / COMMERCIAL GENERAL LIABILITY j CLAIMS -MADE n OCCUR / / 0309-4606 3/1/2016 3/1/2017 EACH OCCURRENCE $ 1,000,000 DAMAGE TENTED PREMISES (Ea occurrence) $ 300,000 MED EXP (Any one person) $ 5,000 —t--- - ............... ......._..._....__-_.._._......... _....................... _..—....---"-- .._....__.._._....- _&ADVINJURY 1 $ 1,000,000 _PERSONAL GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: .PROD.UCTS-COMPIOPAGGy $ 2,000,000 .. .....----. _ ._...... POLICY I...✓_) P I.__..... LOC . OTHER: $ B ! AUTOMOBILE LIABILITY / / DT-810-8G380993-TIL-16 3/1/2016 3/1/2017 COMBINED SINGLE LIMIT $ accident _— _ _1,000,000 BODILY INJURY (Per person) I $ ......... I ............... .. ............ _ _. 1_..------'---- ANY AUTO OWNED ;SCHEDULED _ AUTOS ONLY _ AUTOS HIRED NON -OWNED ✓.,,..,, AUTOS ONLY .,....✓..,, AUTOS ONLY I BODILY INJURY (Per accident) I $ _ PROPERTY DAMAGE I $ Per accidenQ___...... -_.... ... ... ...._...... _.... _... ....... ............ ... . I$ B UMBRELLALIAB �/ j OCCUR ZUP-15S20818-16-NF 3/1/2016 3/1/2017 EACH OCCURRENCE is 5,000,000 .✓ AGGREGATE $ 5,000,000 EXCESS LIAB 1 CLAIMS -MADE DED ✓ RETENTIONS 10,000 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNERlEXECUTIVE Y! N ✓ IDT-JUB-8G380993-3-16 3/1/2016 3/1/2017 V ;STATUTE OERH E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ (Mandatory In NH) N/A j E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1 $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below C Leased/Rented Equipment 6024085132 3/1/2016 3/1/2017 Limit: $500,000 Dedt: $ 1,000 DESCRIPTION OF OPERATIONS I LOCATIONS] VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) SBC#2963 - Vasona Site Upgrades, Dell and Hacienda Ave, Campbell, CA 95008 City of Campbell, its officers, employees and volunteers are named as additional insureds. Insurance is Primary where required by written contract. CERTIFICATE HOLDER CANCELLATION SBC#2963 City Of Campbell Y SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 70 N. First Street ACCORDANCE WITH THE POLICY PROVISIONS. Campbell CA 95008 AUTHORIZED REPRESENTATIVE 1r,1y ✓` aA Marko Trapani ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 33006915 1 16/17 All Lines I Stephanie Scheller 1 11/30/2016 9:25:22 AM (PDT) I Page 1 of 6 AGENCY CUSTOMER ID: LOC #: ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED SBCC,INC Asero Insurance Services DBA South Bay Construction 1711 Dell Avenue POLICY NUMBER Campbell CA 95008 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability (03/16) HOLDER: City of Campbell ADDRESS: 70 N. First Street Campbell CA 95008 General Liability Additional Insured as required by written contract per form CG 20 10 07 04 and CG 20 37 07 04 General Liability Insurance if Primary and Non -Contributory as required by written contract per form GL 00030 00 Workers' Compensation Waiver of Subrogation as required by written contract per form WC 99 03 76 (A) AGVKU 'IU9 (ZUUtS/U9) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ATTACHMENT 33006915 1 16/17 All Lines I Stephanie Scheller 1 11/30/2016 9:25:22 AM (PDT) I Page 2 of 6 POLICY NUMBER: 0309-4606 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - WHERE REQUIRED UNDER CONTRACT OR AGREEMENT (PRIMARY AND NON-CONTRIBUTORY WHERE REQUIRED UNDER CONTRACT) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Section II — Who Is An Insured is amended to include any person or organization to whom you become obligated to include as an additional insured under this policy, as a result of any contract or agreement you enter into which requires you to furnish insurance to that person or organization of the type provided by this policy. However, the insurance provided will not exceed the lesser of: a. The coverage and/or limits of this policy; or b. The coverage and/or limits required by said contract or agreement. Coverage afforded to these additional insured parties will be primary to, and non-contributory with, any other insurance available to that person or organization where required of you by written contract or agreement. GL 00030 00 (10/09) 33006915 1 16/17 All Lines I Stephanie Schaller 1 11/30/2016 9:25:22 AM (PDT) I Page 3 of 6 POLICY NUMBER: 0309-4606 COMMERCIAL GENERAL LIABILITY INSURED: South Bay Construction CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organ izations : Locations Of Covered Operations (Where required by written contract) Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 © ISO Properties, Inc., 2004 33006915 1 16/17 All Lines I Stephanie Scheller 1 11/30/2016 9:25:22 AM (PDT) I Page 4 of 6 Page 1 of 1 ❑ POLICY NUMBER: 0309-4606 INSURED: South Bay Construction COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERAT0ONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organ izations : Location And Description Of Completed Operations (Where required by written contract) Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 - Page 1 of 1 ❑ 33006915 1 16/17 All Lines I Stephanie Scheller 1 11/30/2016 9:25:22 AM (PDT) I Page 5 of 6 T�Q�/E�..FRS'�► WORKERS COMPENSATION it G AND EMPLOYERS LIABILITY POLICY ENDORSEMENT WC 99 03 76 ( A) — POLICY NUMBER: DT-JUB-8G380993-3-16 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -- CALIFORNIA (BLANKET WAIVER) We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. The additional premium for this endorsement shall be % of the California workers' compensation pre- mium. Schedule Person or Organization Blanket Waiver - Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver Job Description This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 03-01-2016 'olicy No. DT-JUB-8G380993-3-16 =ndorsement No. Insured South Bay Construction Premium Insurance Company Travelers Prop Cas. Co. of Amer. Countersigned by DATE OF ISSUE: - - ST ASSIGN: Page 1 of 1 33006915 1 16/17 All Lines I Stephanie Schaller 1 11/30/2016 9:25:22 AM (PDT) I Page 6 of 6 INSURANCE REQUIREMENTS CHECKLIST Permit # E�IA°O, CIP Project # Consultant/Contractor: The following insurance is required of all consultants/contractors working in the City 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 14, $2,000,000 general aggregate limit. Policy expiration date A tomotiye Liability: l Any Auto" checked on certificate ,�$1,000,000 per accident for bodily injury and property damage '6,Policy expiration. date Workers' Compensation and Employer's Liability L Waiver of Subrogation clause ,2f— $1,000,000 per accident for bodily injury or disease Policy expiration date 3(1 1� Course of Construction (if required in Special Provisions) ❑ Completed.value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement: 5 The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) ❑ The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liabilitv of anv kind upon'the companv, its agents or representatives". OR should say: a Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. Porkers' Compensation Insurance Sheet Submitted For General Contractor ❑ For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 1 Acceptability of Insurer(s) . ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the state of California. Name: AAG,?� W0118 SS NAIC # l l Rating: Authorized in CA: Name:c��e�e.(S NAIC # as(o I $Rating: Authorized in CA: Name: , NAIC # Rating: Authorized in CA: Name: NAIC # Rating: Authorized in CA: Campbell Business License # ( Expiration: �l 3tl - Contractors License # (c2 �� —`lass: 6 .Expiration: 3 l 1 Insurance Certificate Reviewed Initials I on U -/Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 I I - ______ ___ ____ __ _____ I i i i i I I I I I I I I I f i I I iI � I I 11 I � 'IrlaUNVO I i i or :Sa pau_'�Tsa(j � I � ViNuodri'vo: - --------- ,________________ I ! --"---,-----r--------------"--,-----,-- ; I I . NI : -I-- � , . -9TOZ 'ON IINHHd INIANHOVOUNH i tt,9s,LZL (got') XT?j t"SOS6 L,Iuj0jjl,e:) 'ejul:yelues I 1 49000 �AVR.24. 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