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1775 Regina Way I Project Address: ��•oF•cA"'�� City of Campbell vAIMr 0 WASTE nn MANAGEMENT Permit No. oR°HAR° PLAN WMP REQUIRED BECAUSE PROJECT IS A 9 SUBMIT TO: Demolition >-500 Sq. Ft. City of Campbell Construction/Remodel>$250,000 Public Works Dept. 70 N. First St. ❑ Construction/Remodel>_2000 sq. ft. Campbell, CA 95008 Mon.— Fri. 8:00 am-5:00 pm INFORMATION AND SUPPORT: Public Works Dept. -408 866 2150 SECTIONONE: • This Waste Management Plan (WMP) must be completed and approved to obtain a building permit. Separate WMPs must be completed for demolition and construction at the some site unless the Building Department requires only one permit. Step 1 PROJECT INFORMATION FILL'OUT-THE FOLLOWING INFORMATION � f x Applicant's Name: Contact Phone Number: 0R 'n!go ''� � Fax Number: Check one: Ey/OwneT❑ Architect ❑ Builder ❑ Owner/Builder ❑ Other Contractor: f Contact Phone Number- Project Type: New ❑ Remodel ❑ Addition VDemolition Project Square Footage: Project Description: Estimated Completion Date: Step 2 WASTE MANAGEMENT.REQUIREMENTS REQUIREMENTS: You are required to recycle or re-use 50%of all construction and demolition debris. I understand that I am required by the City of Campbell Municipal Code Section 6.12 to alvage, reuse, or recycle a minimum of 50% of all construction and demolition debris (C&D). (Initial) J:\FORMS\Templates\Administrative\Waste Management Plan Form.doc 4 I understand that failure to meet the requirements of Municipal Code Section 6.12 shall constitute a misdemeanor, and shall be punishable by imprisonment in the county jail for up to 6 months, or by a fine of up to$1,000, or both. In addition, a stop order on the job or a delay of final approval may occur.— (Initial) At the completion of this project, or more frequently if required, all receipts or other equivalent documentation from salvage, recycling and waste facilities will be provided to the City of Campbell Public Works Department and I understand that I may not be issued my final inspection unless all receipts nd documentation are submitted to the City of Campbell Public Works Department. Lv Z (Initial) Step 3 RECYCLING CONSTRUCTION AND:DEMOLITION DEBRIS ANSWER,THE,QUESTIONS -.. ,BELOW SALVAGE AND REUSE: What materials will be salvaged? co Salvage Company (if applicable): What materials will be reused on site? How will this be documented? MATERIAL TRANSPORTATION: Will you be using a hauling company or hauling the material yourself? (Check one) ❑ West Valley Collection & Recycling Co. (WVCR)* Self Haul * Permit Applicant is required to contact WVCR (408-283-9250) to request construction and demolition debris box service. All original receipts,weight tags and documentation for salvage, recycling, and disposal must be VC d, ompletion of projec ❑ Other DPW Approval: Date: I SECTIONTWO: • • • APPROVAL Please complete this section and have it approved by the Public Works Department no later than 30 days after completion of the demolition or construction project. This section must be completed and signed, and all original receipts or other supporting rtachA entation must be attached in order to receive final project approval. original receipts or equivalent documentation for salvage, recycling, and disposal are hereby ed. ❑ This proje t h s ecycled at least 50%of all construction and demolition debris generated. Applicant: Date: DPW Approva . Date: UU J:\FORMS\Templates\Administrative\Waste Management Plan Form.doc ' ` ` ` G1 59a�d 9] uuad�xu^ ^ 1. sposa`l_ ' .� � Original ' es Road rckK# 940817 San lose, CAj- 95120 Phi (408) 268-1670 . � h d t Customer Name CashAccountBuad Cash Account , Carrier wpublic weig e publi c ransacti on Ticket Date N4/13/2012 �� - �' � Vehicle# 8580 Voldme ` ~ ' . Payment Type Credit [jard ' � Container - Manual Tickat# � ' / Di- ver ; CC Ate � r # 00N�q�4" ing-��cke�#�� si �� °� \ .' ^ »g ^-- ' � ^ _' . _ � ' ptinption # `v TZ/ e ^' � �~`�� - Scale� � � ��O or . NIn' und �'Bids I TASOO lb In 04/13/2012 15:59:28 Inbound ` SA iA �� "� � ( ;Tare�� 856N lb Out 04/13/1012 15:5908 SAV TLA '' Net .�. -, 424N l� ' � ^Tons ' ' Comments PECYCLED MATERIAL - E01NA WAY CAN 7Deputy Weidhmaster Sergio Avila Product � � pf` Cty- ` jU0M ` -��t'ey ' -Tfky��Z -� oOmt~ Origin ' ----------------------------------------------_------------- ------------------------------- 1 73 �9903 CAM 1 DWD-58~Diverted Wuodwast ^ 1�0) 2. 12 Tuns 46�7 , . ~ 2 FUEL-Fuel Surcharge - L�� 1W0 � 7.74 ° $8.75 CAN _ 3 EVF-L-Standard Environme ^ 100 �� 1 Load 14.00 V14.00 CAM � ' Total Tax $2.73 Amt $124.51� Amt 'Tendered $124.51, Chg Due $ .00 Total Ticket - $124.51 � �' , WE SAFETY RULE, S \Abste Alanagemerti is act relsponsihle or liable for any accident or injury fa customers o;flicir properly vdifle on these premises fi • NO SMOKMG • CI-111-DRI'N&.Pl-,T'S,\1LJS'I'Rl-.MAIN iNW,111CLE NO ALCOHOL OR DRUGS ALLOWED • NO SPEEDING OR P"SWO FOLLOW TRAFFIC DIRECTORS SIGNALS ANf)iNSTRUCTIONS WATCH FOR NIOVING IJEAVY EQUIPMENT • NO P17URES ARE TO BE IAKEN ON THIS H\CJLn!'"!THv)UT PRIOR APPROVAL OF MANAGEMENT TRUCK DMITRS ARE MAHMSIBLF,TO t)U'v]P'flA'!---)R LOADS SAFELY.NVASTE. RESPON'SIBLE OR LIABLE FOR ANY ROTLLONIF.Rs MASTE MANAGE ANTENT RESERVES TflE RIC P.-F 10 REJECT ANY LOAD OR CUSTONIER VVEiGHMAS.VEP CERTIFICATE TH!S IS TO CERTIFY that the foiiovkting described cournoditly was we ghed, measurod, or counted by a weighmastei-, 'whose Signature is on this certificate, vvho IS a recognted Whody of acaracy, as pi-escrihed by Chapter 7 (commerncing with Sechon 12700) of Division 5 of the CaPonk Buviness and Wassions Cod% administered by the WNW of Measurement Standards of the- Callforflla Dep,azrtrnent of Fc,,cd and Agr!cu!-,um. � ` Guada � Rubbish Dioposal Original 0999 �"adalupe Mines Road Tic4et# 942707 ' . San Jos, CA, 95120 Ph: (408) 268-1670 . Customer Name CaehAccountGuad Cash Account Carrier wpublic weighedpublictransaction Ticket Date 04/20/2012 Vehicle# 8560 Volume Payment Type 'Credit Card Container Manual Tichet# Driver Route _ #.'� �CC r---�-r-- ^ Hauling Ticket#~~�^ `� / 8iIl�n�# 'Deptination � .�'- ' � Grid � � P � ' ! O# lime `` ' . 1 Scale 1Operator . Inbpund `Gross � i1900 lb In ' / 1 mb��nd 1 � . � '. Tare .� 8560 lb +°��° �v��° �� `' Out /2�/1016��=:2�x4� '�� SAVILA . '` , '' Net `�. 3340 lb - - / - __ � � . Tons . 1.67 ` Comments 1775' RE MATER�AL ' Deput' We+ghmaster Sergio -Avila Product - \ ' � — - aw' 'oo � � ^ AN � ` YOUK' Origin .............. ------------- I DMSM-52'Diverted Sort Ma 100 1.G7 Tons 73.46 2. 15 $122. 68 SJT 2 FUEL-Fuel Surcharge - La 100 A 7.70 $9.99 SI 3 EVF-S-Standard Environme 100 1 Load 7.00 $7. 00 SJ Total Tax $2. 15 Amt $141.82, Amt Tendered $141.82, Chg Due $0.00 Total Ticket $141.82 Driver' s Signature SITE SAFETY RULES AVaste Management is not responsible or liable for any accident or injury to customers or their property while on these premises • NO SMOKING • NO SCAVENGING • CHILDREN&PETS MUST REMAIN IN VEHICLE • NO ALCOHOL OR DRUGS ALLOWED • NO SPEEDING OR PASSING • FOLLOW TRAFFIC DIRECTORS SIGNALS AND INSTRUCTIONS a • WATCH FOR MOVING HEAVY EQUIPMENT • NO PICTURES ARE TO BE TAKEN ON THIS FACILITY WITHOUT PRIOR APPROVAL OF MANAGEMENT • TRUCK DRIVERS ARE RESPONSIBLE TO DUMP THEIR LOADS SAFELY.WASTE MANAGEMENT IS NOT RESPONSIBLE OR LIABLE FOR ANY ROLLOVERS WASTE MANAGEMENT RESERVES THE RIGHT TO REJECT ANY LOAD OR CUSTOMER WEIGHMASTER CERTIFICATE THIS IS TO CERTIFY that the following described commodity was weighed, measured, or counted by a weighmaster, whose signature is on this certificate, who is a recognized authority of accuracy, as prescribed by Chapter 7 (commencing with Section 12700) of Division 5 of the California Business and Professions Code, administered by the Division of Measurement Standards of the California Department of Food and Agriculture. CuaJa e Rubbish DisPosal Original � 15999 Guadalupe MinedRuad Ticket* 94036C San Jose, CA' 95120 Ph: (408) 26B-W7� '^ Customer Name CashRccuuntGoad Cash Account Carrier CASH.Buadalupa Cash Account Ticket Date 04/11/2012 Vehiclef white truck Volumc . ^ Payment Type Credit Card Container H 1 Ti / O � anua �8 r c �e ^ ' ver Route . ^' � ~ ^ a(CheoW4' CC Hauling Tick*t# - �illin�#' 00@�96� - . Destination ' Grid -'' . PO#� � Time ^Bralp Operator ` Inbound Grnss , In 0 /11W12 15;52:23 Inbound 1 SAVlLA ' Tare - ^ Out WA/11/2012 15:50 23 SA LA ', t tons Cnmments RE�Y[1EDW0VD MATERlAL ` . � ' Deputy Weighmaster Sergio Avila ' Product LD% Oty UOM Rate Tax Amount_ �rigin ` ' - _--_-____-_--__-______-_____-__-__---_-�_--_�__-_-_-___----- ---___- '_-_---___-_-_--- 1 ��-��iverted Woodwas � ^ 2. O��s ! .24. 77V 0. 64 ` w. 16S &-f 2 FUEL-Fuel gurcharge - La .'i00 % 7. 74 ' $5.91 SJ ' I ' EVF-S''StandArd Environme , 1NN 3 Load 7.00 � $7. 00 SJ ` ` ` . ~ , Total Tax ' $0; �4 Amt $82.91, Amt Tendered $P2. 91, Chg Dux $0.00 Total Ticket $82' 1 n.�....` - c� ..`+... - SITE SAFETY RULES Waste 1`/>ia uagetaae,at is not a m;oie.silc&ua•liable (er any taco'went or injury to euste aler"Or t"dr PrC17"Ors� vil" le oil these premises � NO SMOKING NO SCAVENGiNc3 C;[LDREN& P;='rS 1,AUSTRFMAIN [N V1:111CLL NO ALCOrIOL OR DRUC;S ALLOtVFD a • NO SPEEDING OR RASS'N{] • FOLLOW TRAFFIC DIRECTORS SIGN.ILS AND HNSTRLICTIONS • WATCH FOR MOVING HEAVY EQUIPMENT NO PICTURES ARE TO P.1:"IAKFN ON THIS FACILIl;'WiTIiOUT PRIOR.APPROVAL OF MANAGFI\,IENT " 4 TRUCK DRIVERS ARE RI SPONSIBLP TO DUMP THEIR LOADS SAFELY.WASTE MANAGEivIENT IS NOT F2ESPOP'IM-E OR LIA131_1.FOR A^I�'ROLLOVERS AAASTE IINW-NI'AGE'D'IETNT RESER L.`,'r HE R:tli-i'r To 16--_JF:CT ANY LOO,W OR C'USTOMER R _ i i j NIS IS TO CERTIFY t'r,at the following described commodity was weighed, measured, or counted by a weighITlaster, whose signature is on this certificate, who is a recognized authority of accuracy, as prescribed by Chapter 7 (commencing with Section 12.700) of Division 5 of the California Business and Professions Code, � administered by the Division of ;Measurement Standards of the California, e Department of Food and Agriculture. ^4 ^ ' Guada e Rubbish Disposal Original - 15999 Guadalupe Mines Road Tioket# 941448 ' San Jose, CA, `95120 ' Ph: (408) 268-1670 . ' Customer Name CashAccaontGoad Cash Account Carrier wpVblic, weighedpoblictransaction Ticket Date 04/17/2012 �Vehicle# ' �560 Volume Payment Type Credit Card Container, � Manual Ticket# Driver -- '`Ro`te �� / ��-*�� Hauling Tic ^ # ^� , � �^� ` � �ng# 0@��Q�4 .`�. ` ' � \ Destination � ��^ �� ` �u � ^ ` , � '�� PO#" '-,Vj I ' � � m� ` ��`` or /\ \jnb' un ss 12260 lb '` ` �^�_r ~' - - �r-� In 17/201 b 1 SAVILA ' � �� / "Aare 8560 lb �� .� ~ ^ � \ � � Out W17/2012\09:5042�� =� ~�a � // \` ` ANet V^ 3700 lb Tons . �' � '� T 85 ' ` 1 � Comments IAL �� `� nc�, � � , � /� , V, 1775 QEbINA^WAY ' Deputy Weighmaster Sergio Avila Product - ��^�/` �� _LD/_ us Qt�_ ��^UDM ``��,R�t��/=��Ta�� oamte' Origin -------------------------------------------------------------------------------------------- ^l DWD-58~Diverte�d Woudwast `100 1.85 Tons 46. 71 2. 39 $86. 41- CAM ^ 2 FUEL-Fuel Surcharge - La 100 % . 7. 70 $7. 19 CAM 3 EVF-S-Standard Eovirunme 100 � 1 Load,/ 7.00 $7.00 CAN ~ \ ' ^ Tntal Tax 11.39 - / * � � Amt $102.99, Amt Tendered $102.99, Chg Due $N,Q0 Atal Ticket $102.99 a SITE &A E M Y RULES vl'aste IllanaRca leiat is not respopsii pie or Nabie for any a cc,dent or injury to customers or their pr3iazrr_-;,v".t%&2 oaa t'iese premises • NO SMOKING p • NO SCAVENGING • CHILDREN&PETS ML`ST REMAIN IN VEHICLE NO ALCOHOL OR DRUGS ALLOWED NO SPEEDING OR PASSING FOLLOW TRAI-FTC DIRECTORS SIGNALS r\ND INSTRUCTIONS • WATCI I FOR MOVING i IEAVY EQl,IPiMPNT • NO PICTURES ARE TO BE TAKEN M THIS Fc'�CILi T Y WITIiOUT PRIOR APPROVAL OF MANAGEMENT x • TRUCK DRIVERS ARE RESPONSIBLE 7 DLTxIP T'-IF.iR LOADS SAFELY.WASTE a MANAGEMENT IS NOT RESPONSIBLE OR LIABLE FOR ANY ROLLOVERS WASTE Mfi.N,!.2.JEM EN n'ta.SL{'-RVVE S T' . 1 l(-,i5't'TO !RDjC'T r+i.;Y LOAD OR Ci1ST®NEf2 i VtrE_iG Hi•,If',S i ER 'SEi�TiLlC,'-'a E a THIS IS TO CERTIFY that the to!iovvinc, described commodity was weighed, measured, or counted by a waighmaster, Whose signature Is on this certificate, who is a recognized authority Of aCCUracy, as prescribed by Chapter 7 (commencing with Section 1 12700) of Division 5 of the California Business and Professions Code, administered by the Divisioi,. of Measurement Standards of the California Department of Food and A.gricuiture_ 4A - ' . Guad; .e Rubbish Disposal r .yinaI ^ . 15999 Guadalupe Nines Road lickpt# 940268 San Jnsp, CA, 95120 Ph: (408) 268-1670 Customer Name'CashAccnontGoad Cash Account Carrier wpublic weighedpublictransaction Ticket Date 04/11/2012 Vehicle# 8560 Volume Payment Type ' Cash Container, Manua} Ticket# � Driver Route Check* Hauling Ticket# 0001964 f ' Destination �Grid PO# Time �� ` ~`^ �Sca?e . � or ^ /�und Gross � �3140 lb In 04/11/201 �12^3~� Inbound 1�' —'—~^-O �!' , - e 8560 lb c .�� mo uu ,^"�u,� ' `."' � . Out 04/11/2012,12:38:�g� � \ �� AZO ,��/` '' ' / Met 1; ^ 4580 lb � = s ' 2. 29 ' Comments RECYQ_E�e � x Deputy Weighmaster Frank Collazo Product LD% Qt^ UON: Rate. '"_''T91 Amount. Origin ----------- ---------------------------------------------------- 1 DMSM-52~Diverted Sort Ma 100 2129 Tons 73. 46 2.95 $158.22 SJ 2 _ FUEL-Fuel Surcharge - La 100 A % 7. 74 $14. 1N SJ 3 EVF-L-GY&dard Environme 100 1 L'aad ` 14. 00 $14.00 SJ ' . . | Total 'Tax $2. 95 Amt $199. 27, AWT60de d $200.00, Chg Due $073 Total Ticket $199. 27 SITE SAFETY RULES Waste Management is not responsible or liable for any accident or injury to customers or their property while on these premises • NO SMOKING • NO SCAVENGING • CHILDREN&PETS MUST REMAIN IN VEHICLE NO ALCOHOL OR DRUGS ALLOWED • NO SPEEDING OR PASSING • FOLLOW TRAFFIC DIRECTORS SIGNALS AND INSTRUCTIONS • WATCH FOR MOVING HEAVY EQUIPMENT • NO PICTURES.ARE TO BE TAKEN ON THIS FACTLITY WITHOUT PRIOR APPROVAL OF MANAGENENT • TRUCK DRIVERS ARE RESPONSIBLE TO DUMP THEIR LOADS SAFELY.WASTE MANAGEMENT IS NOT RESPONSIBLE OR LIABLE FOR ANY ROLLOVERS NYASTE MANAGEMENT RESERVES THE RIGHT TO REJECT ANY LOAD OR CUSTOPV ER WEIGHMASTER CERTIFICATE THIS IS TO CERTIFY that the following described commodity was weighed, measured, or counted by a weighmaster, whose signature is on this certificate, who is a recognized authority of accuracy, as prescribed by Chapter 7 (commencing with Section 12700) of Division 5 of the California Business and Professions Code, administered by the Division of Measurement Standards of the California Department of Food and Agriculture. ' ' Guad; /e Rubbish Disposal original ^ ' 15996 osadalupa Mines Road Ticket# 942164' San Jose, CA, 95120 Ph: (408) 268-1670 _ ' Customer Name CashAcooxntGoad Cash Account Carrier wpublic weighedpublictranaaotion � ~� Ticket Date 04/19/2012` Vehicle# 8560 Vul"mc ' Payment Type Credit Card cont ainer Manual Ticket# Driver- Route ' ��- C� - - �r Hauling Ti ?t# Bill#g* 0061964 Destingtion ` G r j.d. PO# , J "TIme Scale `. ,~��' �'�u nd Grosa �� ' 12200 lb In 0A9/ Vare 8560 lb Out 04/19/�" � ` 3640 lb o � 1. 82 Tins. �. Comments, ` ` 1 ' /5 ^ RE �L- -� ' Depnty Weighmaster 5ergio Avz/a 7 7 K ��- Product ' � �� ` ��` .LDS 1 . Qty. . QNA Rate_ /� , Tak �� 'Amount ' Origin ----------------------------____-----_-------------_-____-_____-_-______-_____--_-______--_ 1 DWD-58~Diverted Wnndwast 100 1. 82 �nns 46, 71 2. 35 $85. 01 SJ 2 FUBL-Fuel Surcharge - La 100 % 7.70 $7.08 SJ 3 EVF-S-Standard Eovirnnme 100 1 Load 7. 00 $7. 00 SJ ' Total Tax 12. 35 Amt 001. 447 Amt Tendered $101.44, Chg Due $0.00 Total Ticket 4101. 44 Driver' s Signature - �� SITE-SAFETY RULES Waste Management is not responsible or liable for any accident or injury to customers or their property while on these premises • NO SMOKING • NO SCAVENGING CHILDREN&PETS MUST REMAIN IN VEl1ICLE • NO ALCOHOL OR DRUGS ALLOWED • No SPEEDING OR PASSING • FOLLOW TRAFFIC DIRECTORS SIGNALS AND INSTRUCTIONS WATCH FOR MOVING HEAVY EQUIPMENT v NO PICTURES ARE TO BE TAKEN ON THIS FACILITY"W[TIIOUT PRIOR APPROVAL OF MANAGEMENT • TRUCK DRIVERS ARE RESPONSIBLE TO DUMP THEIR LOADS SAFELY.'VASTE MANAG2ANIENT IS NOT RESPONSIBLE OR LIABLE FOR ANY ROLLOVERS WASTE iWMAPNAGE i ENT RE SErj.,!;s H E UGI-IT TO REJEC[ ANY LOAD OR CUSTONIER W Its HMAS i ER CERTIFICATE 1 THIS IS TO C ERTI1 ( that the follcvving described commodity was weighed, measured, or counted by a wei ghmaster, vrhose signature is on this certificate, who is a recognized authority of accurscy, as ;:prescribed by Chapter 7 (commencing with Section 12700) of Divisio,, 5 of ti-e _a!ifornia Business and Professions Code, administered by the Division of Measurement Standards of the California Department Of rood and Agriculture. 1 Guadaluu+e Rubbish Disposal A Original 1599? iadalupe Mines Road T icket# 943873 Phi Customer Name Ca:;hAcc_ountGuAd Cash Acedun•t Carrier, CASH Gtiadzalupe Gas1h Account Ticket Date 04/25/2012 Vehicle# white truck Vo'1mme Payment Type Credit Card Container Manual Ticketdl Driver. Route i,he04 CC Hauling i`icy t# BU1 i'ng a'+OP 1 964 Destination Grid , Time Scale Operator-. Irit:dpnd Gros:;'': In 04/2 /-'00 11 35;16 inbound +1 SAVILA - .,Tare Out r OR/251 011 103506 ,P+AUILA ;r metTolls i GominN_( c l3ep+ Weighmpter Sergio Avi td . 1 f Tax Amoun . Origin �°r�ad�tcl_ ,:�•,.. - - .�- +.-- i D,��- -. ��t=' ., UO�i. P,��i..c> �_ -------------- I MSWY--01-MSW PY V rd i0o 3.10 AN s _ 30„`_2 = r. 30 $1.11: u 1 CAN FUEL-Fuel- Surcharge - Ld 100 / 7.6141 '$8.99 CAN EW-S-Standard F'nvir onmi 100 1. Loud 7.00 $7.00 CAN " y Total Tax $9. 30 Amt $136.60, Am't; Tendered $Q6.60, Chg Due $0.00 ' Total Ticket $1`6.60 Driver' s Signature SITE SAFETY RULES Waste Management is not responsible or liable for any accident or injury to customers or their property while on these premises • NO SMOKING • NO SCAVENGING • CHILDREN&PETS MUST REMAIN IN VEHICLE • NO ALCOHOL OR DRUGS ALLOWED • NO SPEEDING OR PASSING FOLLOW TRAFFIC DIRECTORS SIGNALS AND INSTRUCTIONS • WATCH FOR MOVING HEAVY EQUIPMENT • NO PICTURES ARE TO BE TAKEN ON THIS FACILITY WITHOUT PRIOR APPROVAL OF MANAGEMENT A _ 3 • TRUCK DRIVERS ARE RESPONSIBLE TO DUMP THEIR LOADS SAFELY.WASTE MANAGEMENT IS NOT RESPONSIBLE OR LIABLE FOR ANY ROLLOVERS i WASTE MANAGEMENT RESERVES THE RIGHT TO REJECT ANY LOAD OR CUSTOMER WEIGHMASTER CERTIFICATE THIS IS TO CERTIFY that the following described commodity was weighed, measured, or counted by a weighmaster, whose signature is on this certificate, who is a recognized authority of accuracy, as prescribed by Chapter 7 (commencing with Section 12700) of Division 5 of the California Business and Professions .Code, administered by the Division of Measurement Standards of the California Department of Food and Agriculture. � ~ r Guac pe Rubbish Disposal 8riginal 15999Guadalupe Minos Road Ticket# 940268 San Jnse, CA, 95120 Ph: (408) 268-1670 ^ Customer Name CashAccauntGuad Cash Account Carrier wpublic weighealpubliotransaction Tic"ket Date W4/11/B012 Vehiolp# 8566 Volume Payment Type Cash Cuntainer Manual Ticket# D,iver Route Hauling Tick ' Destination Grid' | P8# � | � Time 13140 lb In 04/11/ o �! `r/ 8560 lb Out C�LLAZO �' \� � 4590 lb ' 2.29 Comments Deputy Weighmaster Fra�Y��g��lazo ^�' Product ,� �� ~-- ` - LD�' City �o��M � ' R�� T��i�~- ��o�� Qrigin 1 DM5M-52~Diverted Sort Ma 100 2.29 Tons 73.46 2^95 $168.22 SJ 2 FUEL-Fuel Surcharge - La 100 % 7,74 $14. 1N SJ 3 EVF-L-Standard Emvirnnme 100 1 Load 1.11.00 1;14.00 SJ Total Tax $2.95 Amt �199.27, Amt Tendered $20W.0-60, Chg Due $0.73 Total Ticket $199. 27 t 4 oht;li.(;\'t' :�1Z.n,e''I�":'.K .�I�)�Zf,`pie,�1 `, '� :-,••�. I .� a VA,A1VI!. INvi I'll Y 14;L,iPV' NUPM ANDS1RI M HD 1AKFX,, FI L , A; 1 i 1 t.: - :Ki A" tit- nI^ X v(;l.tv1hNT MLI '_ IWO ORS ARLRN WNSFE1I:. h 1 AIR. q -uANAH1 V VA I_ k' t_'•..`.-�:iC SIT\. ;S '�O I KLS,Ptiti.`iLGI L t. L(\ii i OI: 1 Li4i". i y +i L! C;Ciunii,Cl L;V �/ r� i.. Smor V ._ , "gqn 1 is in its �..1.�:(r-� � of is a mulrKed i 7 `[I V "n 1 l tiasY r od f phi P im c an K'- t �. SL(''.t.Unr 9 700) of .•(,V.'1f`Non 5 N To T ..:�ilr,. �1, ��. � Poo � 1.. �9C;s.�1.. m ri�.�Q��.� j 1 ...l�f"iil(-ii:��.4 i od by lilt', G.0isl(; 0 i� J PLAN REVIEW LOITER CITY OF CAMPBELL �r MNew Submittal ❑Resubmittal: (2"a,3ra 4`n,5"Review) ❑Revision to Existing Permit 0 ] �1 Z Cc RECEIVELZ,dL-7 I C APN# APPLICATION/PERMIT# ) JOBADDRESS/ 775 ` JOB DESCRIPTION /j ❑COMMERCIAL ESIDENTIAL Plans RECIEVED s Structural Calcs. Q `j WVSD Soils Report _School Fee Fonn Truss Cales. Health Department Approval (5�T-24 Calcs. _Response Letter �i Initial B�i�llding 3 Ian Checked By Date: Structural Plan Checker: Date: ❑APPROVED ❑NOT APPROVED l " d lanninQ Zone: b lan Checked By: Date: ❑APPROVED ❑NOT APPROVED 1 ®Public Works c f S'n Checked By: Date: 2 2 12- -U�PPROVED ANOT APPROVED ire l � 1 Checked By: Date: ❑APPROVED ❑NOT APPROVED PERMIT APPLICATION PEP3U' CITY OF CAMPDELL-BUILDING DIVISION f f DATE: e%s�Oi BUMDING ADDRESS: /77 ��` r� l/ '1%V14,Y SUITE PERMIT TYPE: BUILDING L ELECTRICAL ✓ PLUMBING ✓ MECHANICAL, DEMOLITION '/ SIGN GRADING OTHER DESCRIPTION OF WORK: (N) SFDZL RES.ADD REM (N) COMNL DEMO b SIGNS VALUATION OWNER'S NAME: PHONE#: ADDRESS: CITY: .� %L 1� ZIP' APPLICANT'S NAME: PHONE#: ADDRESS: CITY: ZIP: CONTRACTOR'S NAME: �Q��JVJ,N 02u'"cues /LIcCENSE# ( , CONTACT PERSON: �� `P—�G�IC, PHONE#: ADDRESS: CITY: ZIP: ARCHTTECTIENG NAME: CONTACT PERSON: '� ZP`'�i� PHONE#:"t)(—e-3 7/// ,� / ADDRESS: 22;7r) G%�, .b CITY: y{ ZIP: `.4:5 HAZARDOUS MATERIALS: USED ON SITE: YES NO STORED ON SITE: YES NO (For use or storage of hazardous materials,provide a Ha Mat Information Statement to the Fire Dept.Hazardous Materials Specialist for review and comment. / FIRE SPRINKLERED: YES C/ NO LPN 9 "-`/ PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT&TRAFFIC RECEIPT Effective July 1, 2011 TO: City Clerk PUBLIC WORKS FILE NO c 17i PROPERTY ADDRESS J j"M lydkl Please collect,&receipt for the following monies 7�CCT ITiVI ; a � � s� �s408AMIOUNT LAPlD,DEV,ELOPMENT.. .smax. .., > �r�._ A u,a. . , • � ,. .., ,,.. . ...,,..... 4722 Encroachment Hermit Application Fee Non-Lltillty Encroachment Permit $360.00 Minor Encroachment Permit<sio,000 $205.00 Initial R-1 Permit N/C . Subsequent R-1 Permits within Two Year Period $200.00 Street Tree Planting/Removal N/C 2203 $500 per Tree Planting Deposit Required) $500.00/tree 22031 Plan Check Deposit 2% of Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Gradinq& Drainage Plan Review Single Family Lot $255.00 Site< 10,000 s.f. $765.00 Site>_ 10,000 s.f. <Acre $1 020.00 Site>_ 1 Acre $1 530.00 Plan Check& Inspection Fee Non-Utilit 4722 En r. Est. up to$250 000 14%of Engineer's Estimate **2203 En r. Est. >_$250 000 Actual cost+20%Admin Overhead Min$35 000 Deposit) * 2203 Emergency Cash Deposit 4%of En r. Est.* $500 min/$10 000 Max * 2203 Faithful Performance Security FPS 100% of ENGR. EST.* * 2203 Labor and Materials Securit 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 $3 675.00+$80/lot 47221 Final Tract Ma 5 or More Lots $4 490.00+$108/lot * 2203 Monumentation Securit 100%of ENGR. EST. 4920 Parkland Dedication Fee 75%/25% Due Upon Cert. of Occupancy) 4722 Lot Line Ad'ustment Includes Certificate of Compliance) $1 730.00 4722 Vacation of Public Streets& Easements $2 295.00 4722 'Certificate of Compliance $1 730.00 4722 Certificate of Correction $510.00 4722 Appeal Filing Fee $200.00 4722 Notary Fee(per signature) $10.00 4722 Assessment Segregation or Reapportionment First Split $815.00 Each Additional Lot $255.00 5117424 Postage "�6f[�""1,,14 w,.. 3!a� :. .,.,.. ..•a,x�. - ';Y'` 4728 Traffic Flow Map(Daily Traffic Volumes $34.00 47281 Signal Timing Information $72.00/Hr 42711 Truck Permits $16.00/ er trip 47281 No Parking Signs $1/each or$251100 MISCELLANEOUS' , £ . .,. b s.� .q.. . ,. , ... .. Other Please Specify) *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. V O o **Actual Cost Plus 20%Overhead (Non-Interest bearing deposit) TOTAL $ NAME OF APPLICANT NAME OF PAYOR PHONE —' ADDRESS ZIP FOR W v, .N�, � 5 K CITY CLERK ' t c ONLY *for Plan!Checknctl�CashDepos�ts,send yellow copytoFinance '� z , ` � +� � ' k , J:IFORMS\Templat,&%Administrativel,ceipt Porm Land Development Traffic 11.12 Q2 OF emPRw RECVD 7= l2 20002400 PA: qU m+gK mDAPS DATE: 2+»2 REGISTER DATE: mQyo TIME: gE! DESCRIPTION AMOUNT STORM DRAIN FEES q2 wG.q mS a: IS: REGINA # ---------- TOTAL ma #q.m TEN Km $#«m Dq+: «m Land Development Information ;et Prepared by: DQH Date: 12/14/2011 Address: 1775 REG NA WAS' Lot size: 9223 (SF) If this project is part of a larger development(new subdivision, new townhomes) or commercial development, skip A through D. A. Existing building area(SF): B. Proposed addition area(SF): 3157 C. Total area w/addition(A+B): D. Percent increase(B/A): NEW HOME (if less than 50%, stop research) Tract or Parcel Map(circle one): Date recorded: cie Ae l (Tract#or book& page) �" Any found records of Storm Drain Area fee previously paid? Yes ❑ (provide info below) No (Fee initiated for residential subdivisions —> 8/15/55; all developments 4 5/16/60) Date paid (file# &address or LID#) Storm Drain Area fee: 0.21 X 2120.00 = $449.00 (area in acres) (fee/acre) Any found records of building permits in last five years?Yes ❑ (provide info below)No ❑ Was permit issued? Yes ❑ (provide info below)No ❑ Nature of Work: Permit Number: Within STANP? Yes ® No ❑ (check one) STANP Requirements: Curb ❑ Gutter❑ Sidewalk❑ Rolled curb ❑ None ® NA ❑ Existing improvements present? Curb❑ Gutter ❑ Sidewalk ❑ None ® (check all that apply) Sidewalk dimension(BOW to FOW): Park strip dimension(FOW to BOC): Driveway dimension(s): 15' D/W ADA compliant? Yes❑ No ❑N/A Street light info: JP ❑ older pole❑ galvanized pole ❑ Water meter and sewer cleanout info: Could not locate Street ROW half width(CL to PL): 30' Date that street had been resurfaced: Not resurfaced in the last five years. Electrical panel relocation? Yes ® No ❑ NA ❑ Provide details and attach pictures (8.5x11), assessors map(11xl7) and aerial map (8.5 x 11): J:\LandDev\Land Develop Information Sheets\Regina Way 1775.doc MEMORANDUM CITY OF CAMPBELL TO: Daniel Fama, Project Planner DATE: 12/21/2011 FROM: Doris C; Quai Hoi, Project Engineer CC: Ed Arango, P.E., Associate Engineer SUBJECT: DRC APPLICATION Site Address: 1775 Regina Way For File No(s): PLN2011-00300 Project Description: Adlmin Site and Arch Review Permit to allow the demolition of an existing 816 square foot one-story residence with a 280 square foot detached garage and the construction of new one-story residence with an attached garage totaling 3,156 square feet. (STANP) Applicant: Luka Dvornik PUBLIC WORKS DEPARTMENT CONDITIONS OF APPROVAL l. Storm Drain Area Fee: Prior to issuance of any grading or building permits for the site, the applicant shall pay the required Storm Drain Area fee, currently set at $2,120.00 per net acre, which is $449.00. 2. Utilities: All on-site utilities shall be installed underground per Section 21.18.140 of the Campbell Municipal Code for any new or remodeled buildings or additions. Applicant shall comply with all plan submittals, permitting, and fee requirements of the serving utility companies. 3. Water Meter(s) and Sewer Cleanout(s): Existing and proposed water meter(s) and sewer cleanout(s) shall be relocated or installed on private property behind the public right-of- way line. 4. Utility Coordination Plan: Prior to issuance of building permits for the site, the applicant shall submit a utility coordination plan and schedule for approval by the City Engineer for installation and/or abandonment of all utilities. The plan shall clearly show the location and size of all existing utilities and the associated main lines; indicate which utilities and services are to remain; which utilities and services are to be abandoned, and where new utilities and services will be installed. Joint trenches for new utilities shall be used whenever possible. 5. Pavement Restoration: Based on the utility coordination plan, the applicant shall prepare a pavement restoration plan for approval by the City Engineer prior to any utility installation or abandonment. Streets that have been reconstructed or overlaid within the previous five years will require boring and jacking for all new utility installations. Regina Way has not J:\LandDev\Conditions\Ping\Regina Way 1775.doe Page 1 of 2 1775 Regina Way been reconstructed or overlaid in the last 5 years. The pavement restoration plan shall indicate how the street pavement shall be restored following the installation or abandonment of all utilities necessary for the project. 6. Utility Encroachment Permit: Separate permits for the installation of utilities to serve the development will be required (including water, sewer, gas, electric, etc.). Applicant shall apply for and pay all necessary fees' for utility permits for sanitary sewer, gas, water, electric and all other utility work. 7. Additional Street Improvements: Should it be discovered after the approval -process that new utility main lines, extra utility work or other work is required to service the development, and should those facilities or other work affect any public improvements, the City may add conditions to the development/project/permit, at the discretion of the City Engineer, to restore pavement or other public improvements to the satisfaction of the City. 8. Stormwater Pollution Prevention Measures: Prior to issuance of any grading or building permits, the applicant shall comply with the National Pollution Discharge Elimination System (NPDES) permit requirements, Santa Clara Valley Water District requirements, and the Campbell Municipal Code regarding stormwater pollution prevention. The primary objectives are to improve the quality and reduce the quantity of stormwater runoff to the bay. Resources to achieve these objectives include Stormwater Best Management Practices Handbook for New Development and Redevelopment ("CA BMP Handbook") by the California Stormwater Quality Association (CASQA), 2003; Start at the Source: A Design Guidance Manual for Stormwater Quality Protection ("Start at the Source") by the Bay Area Stormwater Management Agencies Association (BASMAA), 1999; and Using Site Design Techniques to Meet Development Standards for Stormwater Quality: A Companion Document to Start at the Source ("Using Site Design Techniques") by BASMAA, 2003. 9. Plan Lines: Prior to issuance of any grading or building permits for the site, the applicant shall provide a plan layout showing the correct distance from the street centerline to the property line (30') and other relevant information in the public right of way. J:\LandDev\Conditions\Ping\Regina Way 1775.doc Page 2 of 2 �,, 4$��V�Y `Y� �$g `• �+�i"o,�$`�F�.q�E^a. ,eta .'t 4�? y• �s�_.�•6 ��hS�'; ., WA 'lop • 'i a1e{iyG"�Pa ��`�, / � '"`` � �f. '�� 4' � } •s' Wlh� !!:M � a �` � 1 -�•<� �-_. W1U;w!u'},u'{4WN��,?.��qP,,,�,;',. t� ��. s• ^^ - �, ;c -rt,h� '-, ,.:.�' � -— "h `*?'%t'"�nz?, - w 5.5 Acht z FLQ( p'3,ctC, '/f' ,gyp. yy r ' ^ y 'S 7��. ®1VI �✓�:•��x,. • 'l� ��{I, 11 SIP r�i ��, 'il •�� '�- ,�� i� ?� ^-a�°�`r- _ __ C DEVELOPMENT REVIEW COMMITTEE ?� ROUTING SHEET DEVELOPMENT APPLICATION G Distribution: December 1, 2011 Presentation: December 6, 2011 Completeness Comments: December 13, 2011 Conditions: December 20, 2011 ROUTE TO: X Building Division Police Department X Fire Department Redevelopment Agency d�I). vel'o e51_ Irginfeer Traffic Engineer ems. PROJECT DESCRIPTION: Administrative Site and Architectural Review Permit to allow the demolition of an existing 816 square foot one-story residence with a 280 square foot detached garage and the construction of new one-story residence with an attached garage totaling 3,156 square feet. The project is subject to the San Tomas Area Neighborhood Plan regulations. File No.: PLN2011-300 APN: 403-12-006 Applicant: Luka Dvornik Property Owners: Luka Dvornik Project Address: 1775 Regina Way Zoning District: R-1-9 (Single-Family Residential) General Plan Designation: Low Density Residential PROJECT PLANNER: Daniel Fama DEPARTMENTAL RECOMMENDATION: If it can be determined that this project will require minimal or no comments by your department/agency, please return this comment sheet with your initials to the Project Planner as soon as possible. Status / Initi(al� y/ Conditions No Conditions Additional infonnation/revisions(see attached) i' s r � 5. �. • �.� . ice _ +ir.:. 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