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ENC2016-00146 -Print Form CITY OF CAMPBELL ENCROACHMENT PERMIT Permit NoJ11(, � 9q^� v DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File Z0 70 North First Street Ight -way) Application Date Campbell,CA 95008 Application Expiration D—aate qqlel _ Ph. (408)866-2150 Issued 0 APN Fx. (408)376-0958 Q Permit Expiration Date �' 1 APPLICATION-Application Jis hereby made for a Public Works Permit in acc rdan with Campbell Municipal Code,Section 11.04. (Application expires in six (6) months ifthe.permit is not issued. Application Fee is non-refundable.) A. Work Address or Tract No.: Utility Trench Location: B. Nature of Work: 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. 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. NameofA I'cant: ,/y� f r_ Telephone: u pp I I 1 0.Y� . G rn GEC Jd ►_J 1 Address: E-Mail Address: fno � C1 24-HOUR EMERGENCY PHONE NUMBER: Is this work being done by the proorn wrty owners at their own residence? �• YES The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell,its officers,agents;an emp oyees 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 amages arising out of improvements completed in the public right-of-way. Accepted: 2_0 I c (Appli t Per itt (sign) Date alla 2l7 �(Knnhract�or� (�Pr�lri �Na�me� �. ��atie 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: 1-80 0-2 2 7-2 6001 USA TICKET NO, S. 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 AN40 NT RECEIPT NO. PERMIT APPLICATION FEE $ PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CG CONSTRUCTION CASH DEPOSIT $ PLAN CHECK&INSPECTION FEE - $ EMERGENCY PERMIT FEE $ APPROVED FOR ISSUANCE �tiy=2� For City Engineer ate Permit Expires 12 Months After Date of Issuance GENERAL PERMIT CONDITIONS 1. The Permittee must provide evidence of insurance and Additional Insured Endorsements as required by the City.Insurance shall be maintained for the duration of the permit work. 2. 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. 3. Refund of the construction 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, A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City.Surety posted shall be equal to 25%of the original Faithful Performance Security. 5. Submit project schedule 10(ten)days prior to proposed start of work. Additional lead time may be required for work within City facilities and downtown Campbell. 6. 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. 7. Maintain safe pedestrian and vehicular crossings and free access to private driveways,bus stops,fire hydrants,and water valves. 8. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures,detours,and street closures. [his plan must be reviewed and approved prior to any lane closures. 9. A Construction Traffic Control Plan shall conform to the 2006 California Manual on Uniform Traffic Control Devices(MUTCD). 10. 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 as expeditiously as possible. 11. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and new PCC shall be doweled to existing improvements. 12. Prior approval of inspector is required for any work proposed after normal working hours,on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 13. Work on arterials and collectors may require the use of changeable message boards.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 construction cash deposit. 14. Compaction testing of subgrade,base rock,and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 15. 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.and on weekends. 16. 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. _ 17. 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. 18. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 19. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 29. 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. 21. 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. 22. If the public interest requires a modification of, or a departure from the permit, plans, special provisions and/or 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. 32. 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. ppIic nt is here y resp nsible for ensuring that all those providing services under the applicant are aware of and abide by all of the above conditions. -T Zd Us Ap lica _ Date: 15n,,—,,act A-r!nt Name; ''tq J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.05/14 -;r. )RSEMENT AGREEMENT WAIVES )F SUBROGATION - 9141069-16 RENEWAL co mpr=r.45^TIQN NA FUND PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE JULY 6, 2017 AT 12 . 01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING SEPTEMBER 1, 2017 AT 12 . 01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME APEX ENGINEERING & CONSTRUCTION CO 372 MANOR PARK CIR PACHECO, CA 94553 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST. CITY OF CAMPBELL WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, APEX ENGINEERING & CONSTRUCTION CO IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: JULY 10, 2017 2570 T AUTHORIZED REPRESENT IVE PRESIDENT AND CEO POL,'-` HOLDER COPY NA COMPENSATIONSTATE P.O. BOX 8192, PLEASANTON, CA 94588 ANCS CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 07-06-2017 GROUP: POLICY NUMBER: 9141069-2016 CERTIFICATE ID: 23 CERTIFICATE EXPIRES: 09-01-2017 09-01-2016/09-01-2017 CITY OF CAMPBELL NA 70 N 1ST ST CAMPBELL CA 95008-1458 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Authorized Representative President and CEO EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. 'I M,El • 10 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2017-07-08 IS ATTACHED—TO AND, FORMS APART OF THIS POLICY. THIRD PARTY NAME: CITY OF CAMPBEI L EMPLOYER APEX ENGINEERING & CONSTRUCTION CORP. NA 372 MANOR PARK CIR PACHECO CA 94553 [ENH,CS] (REV.7-2014) PRINTED 07-OS-2017 WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: 1. Please be advised that a waiver of subrogation requires that a 3% surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on job/s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job : $5, 000 . 00 Sample Rate : 13 . 300 Regular Premium equals : $ 665 . 00 Surcharge : 3 . 00 Additional Waiver charge : $ 19 . 95 Total premium equals $ 684 . 95 (665 . 00 + 19 . 95) ,�►coR®� CERTIFICATE OF LIABILITY INSUFr10E DATE (MMIDDIYYYY) 07106/2017 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 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 Phone: (800)750-2663 Fax: (916)914-1313 CONTACT Contractors Brokerage Service,Inc. NAME: g CONTRACTORS BROKERAGE SERVICE,INC. PHONE FAx (916)914-1313 -M E-M 9940 BUSINESS PARK DRIVE,SUITE 150 Nc Ext: 800 750-2663 we No: No www.cbsbond.com SACRAMENTO CA 95827 ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# Agency Uc#:OD58571 INSURERA :Preferred Contractors Ins.Co.RRG,LLC 12497 INSURED APEX ENGINEERING&CONSTRUCTION CORP INSURER B 372 MANOR PARK CIRCLE INSURER MARTINEZ CA 94553 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 21784 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. INSR TYPE OF INSURANCE ADD'L SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD MM/DD MMIDDIYYYY A GENERAL LIABILITY PCA5005-PC213146 01/19/17 01/19/18 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE REMISES RENTED Ea occurence) PREMISESS( $ 50,000 PREMI CLAIMS-MADE X I OCCUR MED.EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STL.. OTH ATU AND EMPLOYERS' LIABILITY TORY LIMITS ER $ ANY PROPRIETOR/PARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? IF NIA E.L.DISEASE-EA EMPLOYEE $ (Mandatory in NH) It yes,descdbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) The City of Campbell,it's officers,employees and volunteers are named as additional insured Re:Replacing City sidwalk:ENC 2016-146;418 Ester Ave Campbell,CA 95008 CERTIFICATE HOLDER CANCELLATION City of Campbell SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 70 north first st THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Campbell,CA 95008 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE r, Attention: Dorisgh@cityofcampbell.com Jason March ACORD 25(2010/05) @ 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD i I I r14*_A Auto FARMERS Auto Insurance Declaration Page INSURANCE Policy Number: 19368-24-48 Premiumsf Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Effective: 8/7/201 6 1 2:01 AM Policy Premium $3,157.10 Expiration: 8/7/201 7 1 2:01 AM Fees(*also see Information on Additional $5.28 Named Insured(s):A.Hamid Ghazanfari Janet Fayzbakhsh Fees below) 372 Manor Park Cir Policy Premium and Pees $3,162.38 Pacheco,CA 94553-5577 e-mail apex383@gmail.com This is not a bill. Address(es): Your bill with the amount due will be mailed separately. Underwritten By: Farmers Insurance Exchange 6301 Owensmouth Ave. Woodland Hills,CA91367 Household®rivers Name Driver Status Name Driver Status A.Hamid Ghazanfari Covered Janet Fayzbakhsh Covered _. . ... _ _. .. .. .... ...... . ... ..... .. Tina Ghazanfari Covered Vehicle Information Veh.# Year/Make/Model/VIN Coverage Deductible Limit ....._... _- - - ........... _..._.._._. .._......_. __ ......._.............. .......- 1 2008 Bmw 328 I/is/Ci 2D Sulev Comprehensive: $1,000 WBAWV1 3598P 119478 Collision: $1,000 Additional Equipment: $1,000 Loss of Use: K5:$50 per day/ $1,000 max _.. .... _. ._..... .... . ... ._. _ . .._ ._ ........ _ ..... .. 2 1997 Ford Truck F150 Pickup 4X2 Styleside Comprehensive: Not Covered 1 FTEF 1 7W6VKA56461 Collision: Not Covered Additional Equipment: Not Covered __................ ...11........ ..............._...... ................................................................. _ ..._..._ .... . ..__...._........................... ................ .......__ ......... 3 2013 Bmw X3 4D 4Wd Xdrive 281 Comprehensive: - $1,000 5UXWX9C52DOA31937 Collision: $1,000 Additional Equipment: $1,000 Loss of Use: K5:$50 per day/ $1,000 max farmers.com Policy No. 19368-24-48 Questions? Manage your account: Call your agent Arash Hatambeiki Go to www.farmers.com to access Insurance.Agency I at(925)979-5592 your account any time! oremail 56-6176 1st Edition4-15 6/13/2016 ahatambeiki@farmersagent.com Page 1 of Declaration Page(continued) Coverage Information Limits .- — Premiums by Vehicle _.... ... Coverage (applicable to all vehicles) Vehicle 1 Vehicle 2 Vehicle 3 _. .... - Badikyj aiu v Liabll,rt + i� ;'T __ara F Ir A $423.10 $581.60 $459.10 $300,000 each accident Prop ty�DamagP Liability1�00�00reaeheacc�dert# Included 'Included Included .......... _ . ..__. .. .... Medical Coverage $5,000 each person $52.90 $51.00 $55.20 -- --- --- - _ - Uninsured Motorist Bodily $100,000 each person $64.70 $69.90 $71.70 Injury $300,000 each accident Comprehensive $109.00 Not Covered $98.70 _. . ... _ _. . .... ._ ... .......... _ . . .. .. .. . ... .. ... ... .. .. . . .. . .. .. .. .... ..._ . .. . :..._._.._.... . _ .... .-.. ........ . .... . Collision $423.70 Not Covered $451.70 Additional Equipment Included Not Covered Included . ... ...... ... ...... .. .. _.... . _. . ._ .. -_.. _..... .................................. .........._. .......- Uninsured Motorist Property See EndorsementCA050, Not Covered $11.60 Not Covered Damage Without Collision coverage C-1 Uninsured Motorist Property See EndorsementCA050, $12.20 Not Covered $13.50 Damage With Collision coverage C-2 ...................... _. _. . .. .... ... ... ... ... . ......... ..... Towing and Road Service $23.70 $31.60 $19.70 .. ..... .. __ . . - _. _..... _....... _ ........ ..... -..-,.. . Glass Deductible Buyback $10.90 Not Covered $9.90 - _. . . . ... __ . _....... . ... ......_ . . . ....... _ ..... . . . ........ ......._ ........ . _ ... . ......... .... Loss of Use $54.30 Not Covered $57.40 Total Premium Per Vehicle $1,174.50 $745.70 $1,236.90 Policy Premium $3,157.10 Fee Detail Vehicle 1 Vehicle2 Vehicle3 Total ...._. .. ......... ........ _. . ........_ .__.... _, _..__.._ ........ Anti-Fraud Fee $1.76 $1.76 $1.76 $5.28 Fees $5.28 Policy Premium and Fees $3,162.38 Discounts Discount Type Applies toVehicle(s) Discount Type Applies toVehicle(s) -- -...... _.............. .... ..._--- ...... ......... -- Anti-Lock Brakes 1,3 Good Driver 1,2 _....... ...............I.................. ... ... _.... ...... . .. .................... .............. ...... ..................... ........._......................_................................__...................... Auto/Home 1,2,3 Passive Restraint 1,2,3 _ . ----.._ ------------------- Multiple Car 1,2,3 Group-Engineer 1,2,3 ............. --......... .........._.............. ..........._ . ................................ ............ .... .1-1 ..... ,.... .........................................................._................. .............. Stability Control 1,3 Safe Driver 1,3 Persistency 1,2,3 farmers.com Policy No. 19368-24-48 Questions? Manage your account: Call your agent Arash Hatambeiki Go to www.farmers.com to access Insurance Agency I at(925)979-5592 your account any time! orernail 56-6176 1st Edition 4-15 ahatambeiki@farmersagent.com Page 2 of 4 � I 1 INSURANCE REQUIREME TS CHECKLIST Permit# CIP Project# Consultant/Contractor: ` C�V ,kee:"L The following insurance is required of all consultants/contractor or Ing 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: -y�, $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggregate limit. ❑/Policy expiration date •\ Vk 1 r$p--o Any Auto" checked on certificate DC1,000,000 per accident for bodily injury and' property damage I y xp tion date ) e Workers' Compensation and Employer's Liability ..Waiver of Subrogation clause �e - $1,000,000 per accident for bo it injury or disease ❑ Policy expiration date q I I I Course of Constru i/o (If requ' d in Special Pons) Li Completed labe of he pr ject ❑ Policy e piron date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement: \ ❑ The City, its officers, employees and volunteers are named as additional insured. ia The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: - ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR should say: ❑ Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. ❑ orkers' Co pensation Insurance Sheet Sub ' ed� ❑ JGenr Contracr ❑ lope wner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 1 Acceptability of Insurer(s) , ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name'._ \ c 1 `LAIC# a4-fq=RN ing. A horized in CA: Name: NAIC# V\2 11 Rating: 'P� :T� Authorized in CA: Name: NAIC# Rating: Authorized in CA: Name: NAIC# Rating: Authorized in CA: Campbell Business License # Expiration: Contractors License # �� a"'`),SClass:W d1 Expiration: Insurance Certificate Reviewed I� 1 I itials Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 E 5—RKS DEPARTMENT LAND DEVELO Effective July 1,2016 TO: Finance P PUBLIC WORKS FILE NO.t!j(-7-'Ob PROPERTY ADDRESS Please collect&receipt for the following monies: AMOUNT -z A 4722 Encroachment P—erffit Application Fee Non-Utility Encroachment Permit Major>_$l 0,000 $403.00 Minor Encroachment Permit<sio,000 $230.00 Initial R-1 Permit NIC Subseauent R-1 Permits within Two Year Period $230.00 Ins ection Fee Minimum Charge per Location $398.00 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 Utility and R-1 Permits no deposit required 4722 Gradinq&Drainage Plan Review Sin le Family 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 Im ervious Area 10,000 Sq. Ft to I Acre $704.00 Impervious Area 1 Acre or more $918.00 4722, For pro'ects sent to Consultant for review Consultant Cost+20% 4722 Additional treatment facilities $300 ea Plan Check&Inspection Fee(Non-Utility) 4722 Enqr. Est. <$250,000 14%of Engineer's Estimate 4722 Enqr. Est.>_1250,000 and—<$500,000 $35,000+8%of Enqineers Estimate 4722 Enqr. 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 SecuritV(FPS) 100%of ENGR. EST.* 2203 Labor and Materials Security 100%of ENGR. EST.* E70A 4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00 (Multi-Res$2,385.00) (All Other$2,650.00) 47221 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 Security 100%of City'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 47221 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 A-s—sessment Segregation or Reapportionment First Split $895.00 Each Additional Lot $281.00 511.74241 Postage MISCELLANEOUS' Other(Please Specify) *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL OC NAME OF APPLICANT ,rnL NAME OF PAYOR PHONE 4153a ��, fi, J ADDRESS 'i ZIP `I S J:� FOR 2 Vv ,RECEIVED lk JUL-, CITY CLERK ONLY a X", J;TORM.11T-pl,Z­4�Fk�l��R 8Z:;;1Z,1; :Z7; . Q# OF »+BELL «q§ By. CASHIER 010064#9 ERR kR»w +R3 gk9a DATE: PUG . . REGISTER DATE: 0120il& TIME m:m. _. R q Ig! AMOUNT ma m: S mQ& &E Rmg} - m! »m.m OUST R@mEakR_AE REF DEPOSIT - ±! . q!»wm------------- IGk POD #.m&m TENDERED: 0,+6m mq7: «m CREDIT »A; Gl206m +E Aa ��.OF' c44�(A� V OR CH hR9 CITY of CAMPBELL Public Works Department January 8, 2019 ..Maryann Habibi 47532 Avalon Heights Terrace Fremont, CA 94539 SUBJECT: PERMIT NO. ENC 2016-00146 418 Esther Ave., Campbell, CA 95008 MAINTENNACE INSPECTION AND ACCEPTANCE Dear Maryann: The City of Campbell has made the final maintenance inspection of the subject Public Works-improvements and finds that no remedial work is required. Your warranty requirements and any surety, therefore, are hereby released. Sincerely, Syed Wahidi Public works Inspector Cc: 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# � Address: Date of Final Inspection and Acceptance: Inspected by: OK to release deposits: 100% 75% Comments: ��•OF C4MA`�rt, •Ok CHARO CITY OF CAM]PBELL Public Works,Department February 6, 2018 Maryam Habibi 47532 Avalon Heights Terrace Fremont, CA 94539 SUBJECT: PERMIT NO. ENC 2016-00146 418 Esther Ave. Campbell CA FINAL INSPECTION AND ACCEPTANCE Dear Maryam: 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 January 18, 2018. 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$8,706.00 and your Construction Cash Deposit in the amount of$500.00 have been sent under separate cover. If yop have any questions,please call me at (408) 866-2165. Sincerely, 1- - - Sy dVahidi Public Works Inspector Cc: Permit File ENC 2016-00146 Suspense File 70 North First Street • Campbell, California 95008-1436 TEL 408.866.2150 • FAX 408.376.0958 •TDD 408.866.2790 i F I _ _ ......................__._....... ..............._ _............. ................_....._. ...._... _ _. ... - -............ ; . CITY OF CAMPBELL VENDOR-NO. 10014745 CHECK No. 266363 Account Purchase.:Ord�r 101 2203 CRO13018 9,206.00 ENC201600146 FPS RFND l o- I I � I 10014745 MARYAM HABIBI \� i � I CHECK DATEt, CHECK NO CTX QF CAlYIPBELL� �.: WEGI,$ FARGO-BANK,,'N.A. 11-24 ' 4'Z.Q MONTGOMERY STREET 1210 - 02/.0 2 6 6:3 6 3 0 Nt�4 H FIRST STREET w. 'SAN'FRANCZSCO, CAp94.104 F U CAMPBELL rC/aLIFORN(A 95008 i � s o 0 00 0�I *****g yam, • �..��� ,.�. .,. ,.._ .. �_. :� ... ,.�� '� ! , S ,� AMOUNT VOID TER AYS �� Ro[tAR D n l AF 90 ~> PAY:THE SLIM T OF NINE THOUSAND TWO` HUNDRED •SIX )DOLLARS& ZERO CENTS w - 1, I ' e ! To��rx� MARYAM• HABIBI ,, � � � :` ,.�;` � ., ..; .�,: , ... �, ORDER -4•,7532 'AVALON HEIGHTS A FREMONT CA 9 5 3 9 I 1 ,, • _ ru L i :% ti■ 2 6 6 3 4 L 2L 8 5 5 4 L 5 iI' �4. ________________r__ _ _________ ________._ _ __ __ _ ________ ; _-_______ ____-_. ._ _ _--. __. __ _ _ ____ _______ __ ___ _ __--__ .._.._.__�.__.._ _.._............:_._..._..._...._ __ ......___ _ __..._......._........ _........... i [ •� l *See Reverse Side For Easy.Opening Instructions*. - - - ------------------------------ ---------------- ------- -- --------- -- - ------------- -------- -- - CITY ,OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 i MARYAM HABIBI , - I 47532 AVALON HEIGHTS TERRACE FREMONT CA 94539 i CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT, CLEARANCE FOR ONE YEAR MAINTENANCE ACCEPTANCE LETTER Encroachment Permit # ENC2016-00146 Property Address 418 Esther Ave. „ Date of Final Inspection: 11/6/17 On File: Bonds CD Cash Faithful Performance $9,206.00 Labor and Material $ Construction Cash Deposit to be released: $ Other overdue deposits to be released (Description): 1 Processed by: � dministrator Reviewed by: � ae Inspector Reviewed by: 21�� � I 3o l� Land Development Engineer J:UoAnnaT\Deposit refunds\Esther418.doc(Rev. 10/11) r :, - .. 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Frna.nce Director I.,;-I�...:,—i�-i--:;,�-.-.-."1..I-,..-.�,..I.`.-.-.,,1,",!�"..—,,,�-,_.I,I-,.,,111,�,,._--,,....-.,,I,-�.,�,,I�.-.,.��44444444444444444-'I-/.I 1--�—-.,4�,,,-,,-.-�.A.-..1'1.,,,,:-.:--.,-.--..-.----:,�"",�-.1,,',.-�--�.-%-:-.,,,I---�..,,-,:.-:.,I,.1-I-�-.-:,,-v.,�-,-.1,-—�-.-Z-----�,-,-,,....�,,-I-.-,�--':),, } Check PayableTo Maryam Habibi r S s - Address Ui P 1; t .- 47532 Avalon Heights Terrace - It Line 2 w ; - City. Fremont _ - State CA Zip 9.4539 - 1 t _ 4 ., -..- ' - Descrlpfion ENC2016 AOf46 - s - _ , Account Number` a f01,:2203 Amount $9 206:00 _ N Account Number n. Amount r Account Number 101 540.7448 Amounf 5 ' (Finance Dept only), ;`InterestEerned - ,-` - (FinanceDeptonly) j, Exact mount Total Payable ( P ) _ - i Purpose FPS.Refund r 1 ' r - _ ,, Permit# ENC2016 001y,&1 l - 1 'Receipt# 264969 gate 7/10/20'17 '7 - 5' ' .I Requested:by Title Office Spec Date 1/29/2018 :I. 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