ENC2016-00148 A � �n
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CITY of CAMMPBELL
Public Works Department
January 18,.2018
Mr. Jerry Donnard
555 Emory Ave.
Campbell, CA 95008
SUBJECT: PERMIT NO. ENC 2016-00148
555 Emory Ave.., Campbell, CA.
FINAL INSPECTION AND ACCEPTANCE
Dear Jerry:
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..
Sincerely,
Syed Wahidi
Public works Inspector
70 North First Street •Campbell, California 95008-1436 TEL 408.866.2150 - FAX 408,376,0958 TDD 408.866.2790
Encroachment Permit Final Sign Off
Encroachment Permit# C.,
Address: �S� -rnvY
Date of Final Inspection and Acceptance: /Ii I
Inspected by:
OK to release deposits: 100% 75%
Comments:
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CITY OF CAMPBELL
Public Works Department
January 25, 2017
Mr. Jerry Donnard
555 Emory Ave.
Campbell, CA 95008
SUBJECT: PERMIT NO. ENC 2016-00148
555 EMORY AVE.
FINAL INSPECTION AND ACCEPTANCE
Dear Jerry:
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 December 13, 2016.
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 Security Deposit in the amount of$500.00 is enclosed.
If you have any questions, please call me at(408) 866-2165.
Sincerely,
Syed Wahidi
Public Works Inspector
Cc: Inspector/Suspense Files
Permit File
70 North First Street - Campbell, California 95008-1436 •TEL 408.866.2150 • FAx 408.376.0958 TDD 408.866.2790
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CITY OF CAMPBELL
Public Works Department
January 25, 2017
Mr. Jerry Donnard
555 Emory Ave.
Campbell, CA 95008
SUBJECT: PERMIT NO. ENC 2016-00148
555 EMORY AVE.
FINAL INSPECTION AND ACCEPTANCE
Dear Jerry:
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 December 13, 2016.
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 Security Deposit in the amount of$500.00 is enclosed.
If you have any questions,please call me at(408) 866-2165.
Sincerely,
Syec h i d i
Public Works Inspector
Cc: Inspector/Suspense Files
Permit File
70 North First Street •Campbell, California 95008-1436 •TEL 408.866.2150 FAx 408.376.0958 TDD 408.866.2790
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CITY OF� CAMPBELL.
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` JERRY DDDNARD
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CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
CLEARANCE FOR FINAL INSPECTION
AND ACCEPTANCE LETTER
Encroachment Permit#: ENC 2016-00146
Name: Jerry Donnard
Property Address: 555 Emory Ave.
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: q
\C7
Administ ator
Reviewed by: �.
Inspector
Reviewed by:
Land Development ngi eer
J:VoAnnaT\Deposit refunds\CHECKLISTS\Emory555.FPS.doe(Rev. 10/11)
Encroachment Permit Final Sign Off
Encroachment Permit# GO
Address: 55S C-rns /�►�'�
Date of Final Inspection and Acceptance:
Inspected by: S
OK to release deposits: 100% 75%
Comments:
-Refundable Deposit.- +
To Fl.nance,Director
Check Payable To:, ' Jerry Donnard
Address-'Line 1,: 555 Emory Ave.
Line 2:
'City: Campb"ell.• State:.'CA_, Zip` :95008
Description: ENC2016.-00148., -
Account Number.. 1U1.2203 Amount: $500.00
Account-Nurrlber: Amount: •,.
Account Number: 101.540 7448 ,- Amount:
(Finance Dept'anly) Interest Earned (F-nance Dept only)'
Total,Payable;: -(EXact Argqunt)
Purpose: FPS_eefrind'
-Pe'r'mit#: ENC209'6-00148_'
Receipt#. ..,- - 265070 Date: 8/2/2016
Requested:by; ., Title PWYnspector. Date; �t9al.7_. '
Syed Wahidl
Approved,by: .Title S'r:.Engineer Date: b .� •I .1
Roger Storz
Finance Dept,Only:
:Verified by: Title: Accounting Clerkj J-r Date:,_
Approved by: _ Title Accountant Date:
:5 ec:iah Instructions_ :For :Handl` n Check
M411 As ls:. Mail in Attached Envelope:. Interim Check:
N y
ee Jed B'
Return.To:`. JoAnna;TNomason. _ PublicWoek•s ~
: . (Name). Department)
,Other :Please return'check to JOAnna`
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CITY OF CAMPBELL R-1 ENCROACHMENT PERMIT Permit No. c 2.1(, -0G ILt8
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 I�o
Campbell,CA 95008 � ' ApplicationDatepiration 112 6 A-7
Ph.(408)866-2150 ISSUED: _
Fx.(408)376-0958 Permit Expiration Date: APN "lo. 1
APPLICATION-Application is hereby made fora 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: 555 Emory Avenue,Campbell,CA 95008
B. Nature of Work: Paving the shoulder
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: Jerry Donnard Telephone: 408-761-1001
Address: 555 Emory Avenue,Campbell,CA 95008
E-Mail Address: onnard@aol.com
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. pp yq�Ti ACCEPTED: 4�� &-(/ - of Cp
(Applicant/Per 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.) $ 50CJ 2-6 507G
R-1 PERMIT FEE $
APPROVED FOR ISSUANCE: _ _� 6"/2�I�o
ity 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 by law.
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
conditions.
-ZZ-ZO1
Applicant Date
J.\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf
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TO BE RECORDED WITHOI)T FEE
SECTION 6103 GOVERNMENT CODE
AT THE REQUEST OF CITY OF CAMPBELL pages: 7
DOCU�iER1T : 2339599.4
Fees. . . . * No Fees
Recording Requested By: ) Taxes. . .
Cop i es
City of Campbell ) . .
AMT PAID
70 North First Street -
Campbell, CA 95008-1423 ) REGINA ALCOMENDRAS RDE # 002
SANTA CLARA COUNTY RECORDER 8/10/2016
After Recording Return To: ) Recorded at the request of 11 :31 AM
City
City Clerk )
City of Campbell )
70 North First Street )
Campbell, CA 95008-1423 ) `` � 91"'fin'
APN: 404-26-037 (Space Above for Recorder's Use Only)
Address: 555 Emory Avenue,Campbell, CA 95008 OCT O 5 2016
AGREEMENT FOR PRIVATE IMPROVEMENTS r'ffy CLERR[s.'S OFFICE
IN THE PUBLIC RIGHT-OF-WAY
In consideration f6r granting permission to allow private improvements to remain in the public
right-of-way, Jerry T. Donnard (property owner) enters into this Agreement with the City of Campbell.
The improvements contemplated to remain are for the benefit of the real property commonly known as
555 Emory Avenue. The City of Campbell grants such permission to allow existing brick pavers to
remain in the public right-of-way.
The property owner shall be solely responsible for maintaining the improvements in a good and
safe condition at all times; and the property owner shall indemnify, defend, and hold harmless the City
of Campbell, its officers, officials, agents, volunteers, employees and attorneys from any and all claims,
actions, losses, liabilities and costs (including reasonably incurred attorney's fees) arising out of or
connected with, or alleged to arise out of or be connected with the installation, design or condition of the
improvements, except for any claims, actions, losses, liabilities and costs proximately caused by the sole
negligence or willful misconduct of the City of Campbell, its officers, officials, agents, volunteers,
employees or attorneys. This provision is intended to be the dispositive of all rights of indemnity and
contribution between the parties, and property owner waives and releases any and all rights to indemnity
or contribution from the City of Campbell, in law or equity, arising out of, or connected with any and all
claims, actions, losses, liabilities and costs (including reasonably incurred attorney's fees) for which
property owner is obligated under this paragraph to provide indemnity or defense to the City of
Campbell, its officers, officials, volunteers, employees or attorneys.
The City will attempt to reasonably ensure the continued use of the private improvements in their
existing locations. The City, in its sole discretion after giving one hundred eighty (180) days written
notice to the Owner, or his/her successors, may revoke the rights granted under this agreement and
remove the improvements at any time, without liability to the property owner, or require that the
improvements be removed, and property owner shall have no right to compensation from City in any
form.
J:\LandDev\Forms\2.AGREEMENTS-PIA S1A DEF S1A Maintenance Reimbursement Development\Private Improvements Agreements in ROW\Word
Document\Emory 555 Private Improvement Agreement.docpage I of 5
In the event that Owner fails to reimburse the City for the costs of removing the improvement
("default") as required by this Agreement, the City shall have and may execute the absolute right, at the
City's option and without demand or notice to Owner, to claim and impose a lien, attached as Exhibit A
and incorporated herein by this reference ("Lien"), on said real property (also referred to herein as
"Collateral"). City's failure to exercise this option will not constitute a waiver of the right to exercise it
in the event of any subsequent default.
(a) Amount of Lien: The Lien shall be for the entire amounts then owing under this Agreement.
(b) Recordation: City is authorized to record the Lien in the appropriate Recorder's Office(s).
(c) City shall have full authority to perform all acts and things that City may consider necessary
or advisable to impose, maintain and enforce the Lien.
(d) Debtors' Warranty: OWNERS WARRANT that they are the owners of the Collateral and
Owners have the right to make this Lien Agreement.
(e) Debtors Covenants: Owners agree:
(i) To pay City all amounts payable pursuant to this Agreement on or before the due
date when due and payable, and to perform all terms of this Agreement;
(ii) To defend the Collateral against claims and demands of all persons and entities;
(iii) To keep the Collateral in good condition; to perform other acts that may be
necessary to preserve the Collateral and protect the Collateral against
unreasonable loss and all hazards, and;
(iv) To immediately notify the City in writing when Owners become aware of any
event that substantially affects the value of the Collateral, or the rights and
remedies of City in relation to the Collateral.
(f) Prohibitions: Without the prior written consent of the City, Owners will not permit any liens
or security interests (other than the City's Lien) to attach to the Collateral; permit the
Collateral to be levied on under legal process; dispose of the Collateral; or permit anything to
be done that may impair the value of the Collateral or of the Lien, which is the subject of this
Agreement.
(g) Notices: Any notice, demand or request required hereunder, or by law, shall be given in
writing (at the addresses set forth below) by any of the following means: (a) personal service;
(b) facsimile; (c) overnight courier or delivery service; or (d) registered or certified, first
class U.S. mail, return receipt requested.
.I:\LandDev\Forms\2.AGREEMENTS-PIA SIA DEF SIA Maintenance Reimbursement Development\Private Improvements Agreements in ROW\Word
Document\Emory 555 Private Improvement Agreement.docPage 2 Of 5
Property owner agrees to maintain homeowners or general liability insurance with a limit of at
least $100,000 for damages arising from the installation, design or condition of the improvements.
This provision shall run with the land and be binding on the property owner's successors.
Executed this day of Jv��l , 2016.
OWNER
Jer . Donna
(Attach Notary Acknowledgment
For All Parties)
CITY OF CAMPBELL,-a municipal
Corporation
Todd Capurso
Public Works Director, City of Campbell
ATTEST:
Wendy V1()d, City Clerk
J:\LandDev\Forms\Z.AGREEMENTS-PIA SIA DEF SIA Maintenance Reimbursement Development\Private Improvements Agreements in ROW\Word
Document\Emory 555 Private Improvement Agreement.docPage 3 of 5
CALIFORNIA ALL- PURPOSE
CERTIFICATE OF ACKNOWLEDGMENT
A notary public or other officer completing this certificate verifies only the identity
of the individual who signed the document to which this certificate is attached,
and not the truthfulness, accuracy, or validity of that document.
State of California }
County of
On r clU\4 before me, oiv,<
(Here insert name and taler of the Omer)
personally appeared
who.proved to me on the basis 6f satisfactory evidence to be the person(s) whose
name(s) is/are subscribed to the within instrument and acknowledged to me that
he/she/they executed the same in his/her/their authorized capacity(ies), and that by
his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that
the foregoing'paragraph is true and correct.
6 LOZ'6 ZEVJ sam.dq-WW00 AW a'a
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WNESS my hand and official seal. i i(IunoD eielo et,ueg
eltuoJlle� �llgnd ts�eloN a
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V, ' �. Nosaw0181 NNvor
Notary=Public Signature (Notary Public Seal)
ADDITIONAL OPTIONAL INFORMATION INSTRUCTIONS FOR COMPLETING THIS FORM
This form complies with current California statutes regarding notar3 wording and,
DESCRIPTION OF THE ATTACHED DOCUMENT if needed,should be completed and attached to the document.Acknowledgments
from other states may be completed for documents being sent to that state so long
as the.wording doesnot require the California nomr y to violate California notary
law.
(Tide or description of attached document) - State and County information must be the State and County where the document
signer(s)personally appeared before the notary public for acknowledgment.
- Date of notarization must be the date that the signer(s)personally appeared which
(Tide or description of attached document continued) must also be the same date the acknowledgment is completed.
- The notary public must print his or her name as it appears within his or her
Number of Pages Document Date commission followed by a comma and then your title'(notary public).
- Print the name(s) of document signer(s) who personally appear at the time of
notarization.
CA❑PACITY CLAIMED BY THE SIGNER - Indicate the correct singular or plural forms by crossing off incorrect forms(i.e.
he/she/they-is/afe)or circling the correct forms.Failure to correctly indicate this
Individual (s) information may lead to rejection of document recording.
❑ Corporate Officer - The notary sea) impression must be clear and photographically reproducible.
Impression must not cover text or lines. If seal impression smudges,re-seal if a
(Title) sufficient area permits,otherwise complete a different acknowledgment form.
❑ Partner(s) - Signature of the notary public must match the signature on file with the office of
the county clerk.
❑ Attorney-in-Fact Additional information is not required but could help to ensure this
❑ Trustee(s) acknowledgment is not misused or attached to a different document.
Other Indicate title or type of attached document,number of pages and date.
El Other the capacity claimed by the signer. If the claimed capacity is a
corporate officer,indicate the title(i.e.CEO,CFO,Secretary).
2015 Version t !rv✓.NofaryC{ass2s.com 800-873-9865 Securely attach this document to the signed document with a staple.
Exhibit A
Recording Requested By: )
City of Campbell )
When Recorded Mail To: )
City Clerk )
City of Campbell )
70 N. First Street )
Campbell, CA 95008 )
APN: Space above this line for Recorder's use only
Address:
CLAIM OF LIEN
I, Todd Capurso, Public Works Director for the City of Campbell, a California Municipal
Corporation ("City"), do hereby certify:
A. On or about , 20_, ("Debtors")
executed an Agreement for Private Improvement with the City of Campbell ("Agreement").
B. The Agreement was recorded in the Santa Clara County Recorder's Office on or about
20_Document Number
C. The Agreement allowed the Debtor's to provide, construct, and/or install certain private
improvements in front of their property at , Campbell, California, at their .
own costs and expense. Pursuant to the terms of the Agreement, the Debtors expressly agreed that if
they failed to comply the work the Agreement, the City was authorized to remove said improvements
and recover the full cost and expense thereof from the Debtors or their successors.
D. The Debtors did not remove the improvements after being notified to do so. Therefore,
the City removed said improvements. _
E. In , 20 the City informed the Debtors about the improvements
that would be removed pursuant to the Agreement.
J:\LandDev\Forms\2.AGREEMENTS-PIA SIA DEF SIA Maintenance Reimbursement Development\Private Improvements Agreements in ROW\Word
Document\Emory 555 Private Improvement Agreement.docP age 4 of 5
F. The City subsequently completed the work. On or about 20 the
City sent the Debtors an invoice for said work in the amount of$
G. Pursuant to the terms of the Agreement, the Debtors expressly agreed that the City is
authorized to, at the City's option and without demand or notice to the Debtors, immediately claim and
impose a lien on the real property commonly known as , Campbell, California,
APN Number , for the entire amounts then, owing under, or incurred
pursuant to, the Agreement, including without limitation, the entire unpaid principal amount.
WHEREFORE, the City of Campbell, A California municipal corporation, pursuant to the
Agreement, hereby claims a lien upon the work of improvement and the land upon which it is situated,
namely, the real property commonly known as Campbell,
California, APN Number , in the amount of $
and said amount shall constitute a lien against said property until paid in full.
IN WITNESS WHEREOF the City of Campbell, California, a California Municipal Corporation,
has duly authorized the undersigned to execute this instrument in its name.
Dated: By:
for the CITY OF CAMPBELL, a California municipal corporation
(Notary Acknowledgement Required for Signatures)
J:\LandDev\Forms\2.AGREEMENTS-PIA SIA DEF SIA Maintenance Reimbursement Development\Private Improvements Agreements in ROW\Word
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i
i
CALIFORNIA ALL- PURPOSE
CERTIFICATE OF ACKNOWLEDGMENT
A notary public or other officer completing this certificate verifies only the identity
of the individual who signed the document to which this certificate is attached,
and not the truthfulness, accuracy, or validity of that document.
State of California }
County of
OnY 6W v(lo. _�L01 (-Q before me, "kJ-i ;U`k;
(Here insert name an htle offine otticeQ i �^
personally appeared
who.proved to me on the basis of satisTactory evidence to be the person(s) whose
name(s) is/are subscribed to the within instrument and acknowledged to me that
he/she/they executed the same in his/her/their authorized capacity(ies), and that by
his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that
the foregoing paragraph is true and correct.
JOANN THOMASON
VViTNESS m hand and official seal. Commission#2110789 L
y Z ,-o Notary Public-Calffornla D
Z Santa Clara County
.. ` My Comm.Ez Ires May 9,2019+
Lac
No.#ary Pu6tie Sigpature_ J (Notary Public Seal)
ADDITIONAL OPTIONAL INFORMATION INSTRUCTIONS FOR COMPLETING THIS FORM
This form complies with current California statutes regarding notan-wording and,
DESCRIPTION OF THE ATTACHED DOCUMENT if needed,should be completed and attached to the document.Acknowledgments
from other states may be completed for documents being sent to that state so long
as the warding does not require the California notan.to violate California notan•
law.
(Title or description of attached document) • State and County information must be the State and County where the document
signer(s)personally appeared before the notary public for acknowledgment.
• Date of notarization must be the date that the signer(s)personally appeared which
(Title or description of attached document continued) must also be the same date the acknowledgment is completed.
• The notary public must print his or her name as it appears within his or her
Number of Pages Document Date commission followed by a comma and then your title(notary public).
• Print the name(s) of document signer(s) who personally appear at the time of
notarization.
CAPACITY CLAIMED BY THE SIGNER • Indicate the correct singular or plural forms by crossing off incorrect forms(i.e.
lie/she/the}-is/are)or circling the correct forms.Failure to correctly indicate this
❑ Individual (s) information may lead to rejection ofdocument recording.
❑ Corporate Officer • The notary seal impression must be clear and photographically reproducible.
Impression must not cover text or lines. If seal impression smudges,re-seal if, a
(Title) sufficient area permits,otherwise complete a different acknowledgment form.
❑ Partner(s) • Signature of the notary public must match the signature on file with the office of
the county clerk.
❑ Attorney-in-Fact Additional information is not required but could help to ensure this
❑ Trustee(s) acknowledgment is not misused or attached to a different document.
Other Indicate title or type of attached document,number of pages and date.
❑ • Indicate the capacity claimed by the signer. If the claimed capacity is a
corporate officer,indicate the title(i.e.CEO,CFO,Secretary).
20'i 5 Version vrvaw.NctaryCiass«s.t;om 800-873-9865 • Securely attach this document to the signed document with a staple.
PUE IORKS DEPARTMENT LAND DEVELOPME
Effective July 1,2016
TO: Finance PUBLIC WORKS FILE NO. Co- CO 1 k '�+
PROPERTY ADDRESS 555 Evvtpyy A,,
Please collect&receipt for the following monies:
`-ACCT. ITEM AMOUNT
LAND DEVELOPMENT
4722 Encroachment Permit Application Fee
Non-Utility Encroachment Permit Ma'or>_$10 000 $403.00
Minor Encroachment Permit<$to,000 $230.00
Initial R-1 Permit N/C
Subsequent R-1 Permits within Two Year Period $230.00
Inspection Fee Minimum Charge per Location $398.00
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 Famil Lot $281.00
Site< 10,000 s.f. $841.00
Site>_10,000 s.f. <0.5 Acre $1,127.00
Site>_0.5 Acre $1 688.00
4722 NPDES Review C3 Requirements)
For projects not required to submit numeric sizing $163.00
For projects required to submit numeric sizing
Impervious Area 10,000 S . Ft to 1 Acre $704.00
Impervious Area 1 Acre or more $918.00
4722 For projects sent to Consultant for review Consultant Cost+20%
4722 Additional treatment facilities $300 ea
Plan Check&Inspection Fee(Non-Utility)
4722 En r. Est. <$250 000 14%of Engineer's Estimate
4722 En r. Est. >_$250,000 and<_$500,000 $35,000+8%of Enqineers Estimate
4722 En r. Est. >$500 000 $55 000+7%of Engineers Estimate
2203 Emergency Cash Deposit 4%of Enqr. Est.*($500 min/$10,000 Max)
2203 Faithful Performance Security FPS 100%of ENGR. EST.* G�
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) $4009.00+$87/lot
4722 Final Tract Map(5 or More Lots) $4,871.00+$118/lot
2203 Monumentation Securitv 100%of Citv's Monumentation Estimate
4920 Parkland Dedication Fee(75%/25% Due Upon Cert. of Occupancy)
4722 Lot Line Adjustment(Includes Certificate of Compliance) $1,893.00
4722 Vacation of Public Streets& Easements $2,530.00
4722 Certificate of Compliance $1,877.00
4722 Certificate of Correction $561.00
4722 Document Recording Fees $15.00/first page$3 ea.Additional
4722 Private Improvement in Public ROW $50.00 5o
4722 Approved Plan Revision Fee $100/sheet
4722 Appeal Filing Fee $200.00
4722 Notary Fee (per signature) $10.00
4722 Assessment egregatlon or Reapportionment
First Split $895.00
Each Additional Lot $281.00
511.74241 Postage
MISCELLANEOUS r `
Other(Please Specify)
*Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $
NAME OF APPLICANT -C40
NAME OF PAYOR 43, a�, ._.,PHONE 7- - O O
ADDRESS P�j Lt G '4 ZIP
70!67
FOR RECEIVED BY
CITY CLERK d a T fi -JA-AW !t`
ONLY Date Receipt#
J'TORMSIT—plat
eaa�u-eare�A DA11-1411l,,C 1JUr— INV I II.0 Ll
tate Farm CZeneral Insurance Company POLICY'NUMBER )5 BU--A726-1
® 900 Old River Rd. Homeowners Pc..
MAY 13 2016 to M 13 2017
Bakersfield, CA 93311-9501
A'Y
1-1-02-3152-FBOC H F DATE:DUE PLEASE,PAY.THIS AMOUNT
001801 0001 MAY 13 2016 $770.00
DONNARD, JERRY
555 EMORY AVE
CAMPBELL CA 95008-4639
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Location: Same as Mailing Address
Important Message(s)
17 3725 4245
See reverse for important information.
Agent MARK CHAPMAN Please keep this part for your record.
Telephone (408) 370-7100 or (408) 370-6439 Plea Prepared MAR 16 2016
1 se fold and tear here 1
IIIVIl.Jl711aU1 LJUJIIIV JJ a—IU✓allay `IVI a1,VUG' VL'l all GI1 II.VI�IV,Iau, V +Va,:, �aaa a.alV, •+,— +1v+++v1 "_
Jewelry and Furs (for broadened coverage and higher limits)
Loss Assessment (for neighborhoods with Homeowners Associations)
Nurses Professional Liability (for those in the nursing profession)
Personal Injury (for our liability to others caused by certain acts of libel,slander,
invasion of privacy, false arrest)
N **Optional Coverages continued on the reverse side**
N
b
This notice contains only a general description of the coverages and is not a contract. All coverages are subject to
the provisions in the policy itself. Should you have a need for any of these coverages or higher limits, contact your State
Farm Agent to discuss details, cost and eligibility.
0
IMPORTANT INFORMATION ABOUT DAMAGE CAUSED BY FLOODING
This policy does not cover damage to your property caused by flooding. You may be eligible for such coverage through the
National Flood Insurance Program ("NFIP"), if you live in a participating community. For more information, contact your
State Farn-Pagent or visit floodsmart.gov.
_ 4529 2011 1 Agent MARK CHAPMAN
2N,DR,NP,I2,PD Telephone (408) 370-7100 or (408) 370-6439 REB Prepared MAR 16 2016
,State Farm General Insurance t )any (J
::: ) ;rilFJwfi=ii ':i€isii ::i€;;ii :i€ i=
900 Old Raver Rd. PE]L1YNUNISEI:::::
Bakersfield, CA 93311-9501 ::.::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.:::::-:::::::::::::::
HOMEOWNERS AVAILABLE COVERAGE NOTICE
- -H 02 1 2 FBOC H W F
3 5
:::::-:::::::::::::::::::::::::::::::::::::::::::::::.:::::::::::::::::::::::::::::::::::::-::::::::::::::::::::::::::::::::::::::::::
001801 0001 SEE RENEWAL CERTIFICATE
'f DONNARD, JERRY
555 EMORY AVE
CAMPBELL CA 95008-4639
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IT IS IMPORTANT THAT YOU OCCASIONALLY REVIEW THE COVERAGES AND LIMITS IN-YOUR HOMEOWNERS
POLICY TO BE CERTAIN YOUR NEEDS ARE BEING MET. THE FOLLOWING INFORMATION WILL ASSIST YOU IN THE
REVIEW PROCESS.
THE COVERAGE LIMITS FOR COVERAGE A- DWELLING, COVERAGE B- PERSONAL PROPERTY, COVERAGE L-
PERSONAL LIABILITY, AND COVERAGE M - MEDICAL PAYMENTS TO OTHERS ARE LISTED ON THE ACCOMPANYING
RENEWAL NOTICE. PLEASE REVIEW THESE LIMITS TO DETERMINE IF THEY ARE ADEQUATE IN THE EVENT OF A
LOSS.
THE FOLLOWING IS A PARTIAL LIST OF THE OPTIONAL COVERAGES YOU HAVEAQT ADDED TO YOUR POLICY.
THEY MAY BE AVAILABLE TO YOU FOR AN ADDITIONAL PREMIUM.
Building Ordinance or Law (higher limits)
Business Property (for higher limits)
Business Pursuits Liability (for teachers, school administrators, sales persons, and clerical workers)
Child Care Liability (for those providing child care in their home)
Firearms (for broadened coverage and higher limits)
Home Computers (for higher limits)
Identity Restoration
Incidental Business Liability (for those with an incidental office, studio, or school in the home)
Jewelry and Furs (for broadened coverage and higher limits)
Loss Assessment (for neighborhoods with Homeowners Associations)
Nurses Professional Liability (for those in the nursing profession)
Personal Injury (for our liability to others caused by certain acts of libel, slander,
invasion of privacy,false arrest)
N **Optional Coverages continued on the reverse side**
N
9
This notice contains only a general description of the coverages and is not a contract. All coverages are subject to
2 the provisions in the policy itself. Should you have a need for any of these coverages or higher limits, contact your State
co
Farm Agent to discuss details, cost and eligibility.
0
IMPORTANT INFORMATION ABOUT DAMAGE CAUSED BY FLOODING
This policy does not cover damage to your property caused by flooding. You may be eligible for such coverage through the
National Flood Insurance Program ("NFIP"), if you live in a participating community. For more information, contact your
State Farn-Pagent or visit floodsmart.gov.
4529 2011 1 Agent MARK CHAPMAN
E 2N,DR,NP,I2,PD Telephone (408) 370-7100 or (408) 370-6439 REB Prepared MAR 16 2016
:: 11VIB~R'€ ': €€
900 Old River Rd. ::::::::::::::::::::::::�::::::::::::::::::::::::,:::::::: ::,::::::::::::::::::::::::::::::::
Bakersfield, CA 93311=9501 Homeowners Policy
MAY 13 2016 to N 3 2017
Rl,AtE4fEtQ?IfE . ` I
.Eo...- E.'.:::::::::::::::::::::::::::
H-02- 3152-FBOC H W F ::.................................._.............................................
001801 0001 MAY 13 2016 $770.00
DONNARD, JERRY
555 EMORY AVE Coverages and Limits
r; CAMPBELL CA 95008-4639
Section I
A Dwelling $541,000
-- Dwelling Extension Up To 54100
B Personal Property 405:750
C Loss of Use Actual Loss
Sustained
Deductibles-Section I
All Losses 1/2% 2,705
Location: Same as Mailing Address
Section II
L Personal Liability $300,000
Damage to Property of Others 500
M Medical Payments to Others 1,000
Loss Settlement Provisions (See Policy) (Each Person)
Al Replacement Cost- Similar Construction
131 Limited Replacement Cost - Coverage B
Forms, Options,and Endorsements
Homeowners Policy FP-7955.CA
Increase Dwlg up to$108,200 OPT ID
Ordinance/Law 100/o/ $54,100 OPT OL Annual Premium $770.00
Jewelry and Furs $1,500/$2,500 OPT JF Amount Due $770.00
Back-Up Dwell/Listed Property FE-3560
Form 438bfu NS Lndr Loss Pay FE-1313
Homeowners Policy Endorsement FE-3422 Premium Reductions
Amendatory Endorsement FE-3247 Home Alert Discount 14.00
Home/Auto Discount 192.00
Claim Record Discount 275.00
Inflation Coverage Index: 280.9
CALIFORNIA LAW REQUIRES US TO PROVIDE THE FOLLOWING NOTICE: Our records indicate that you have not
purchased Earthquake Coverage.
This policy includes Building Code Upgrade Coverage of $54,100.
Please help us update the data used to determine your premium. Contact your agent with the year each of
your home's utilities (heating/cooling, plumbing, or electrical) and roof were last updated.
/�- Moving?See your State Farm agent.
Xs frt5' � c. t G �OKMAN CuS' i See reverse for important information.
4520 201 i i Ag MARK CHA� Prepared
2N,DR,NP,I2.PD Telephone (408) 370-7100 or (408) 370-6439 REB MAR 16 2016
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