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ENC2014-00195 ^.,to ; CITYOFCAMPBELL R1 ENCROACHMENT PERMIT Permit No. ( 2014 - 0&(q5 DEPT.OF PUBLICWORKS (Non-engineered work within the public right-of-way) X Ref File 70 North First Street ($10,000.00 maximum value of work) Application Date Campbell,CA 95008 / + r L Application Expiration " Ph.(408)866-2150 ISSUED: C �� I `�T.. Date r 5 Fx.(408)376-0958 Permit Expiration Date: 1 t C�j APN C�O APPLICATION-Application ishereby madefor a Public Works Permit inaccordancewith Campbell Municipal Code,Section 11.04. (Application expiresin 6 monthsif the permit isnot issued.) A. Work Address: B. Nature of Work: le �'�•c�'y"G w,fl /�iw•' S44�us�t/� av__'_ _' GsfJh�,l�--wo.55 . s c.r� . C. Attach three(3)copies of a drawings howing the location,extent and dimensions of the work. The drawing shall show the relation of the proposed workto existing improvements. When approved by the Oty Engineer,said drawing become a part of this permit. D. All work shall conform to the Oty of Campbell Standard Specifications and Detailsfor Public Works Construction;the General Permit Conditions listed on the reverse side;and the Special Provisionsfor thispermit,listed below. Failureto abide by these conditionsand provisions may result in job shutdown and/or forfeiture of Faithful Performance securities. NAMEOFAPPLICANT: Gr ^ S Telephone: �It! Address: 14,_ fJf EMailAddress: 6M1911_.00tL4 - The Applicant hereby confirms that thiswork 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 Oty of Campbell,Oty of Campbell Fbdevelopment Agency,its officers,agents,and employeesfree,safe and harmlessfrom any claim or demand for damages resulting from thework covered by this permit. TheApplicant hereby acknowledges that they have read and understand both thefront and back ofthispermit,and that theywill inform their contractor(s)of the information. . ACCEPT®: ! (Ap licant/Permittee) (Sgn) 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 havethis permit and approved plansand 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. USAFhone: 1-800-227-2600. Ticket No.: Applicant is advised that upon issuance of this permit,property owner,or property ownerig successors,shall be responsiblefor any and all damages arising out of the design,installation or condition of private improvements in the public right-of-way. SPECIAL PRDVISIONS 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. STANDAFD AMOUNT FECEIPTNO. SECURITY FORFAITHFUL PEFTOFWANCE (100%Of Engrfg Est.) $ 36 G y C 2.5 6, (� R:1 PffW IT FEE APPROVED FOR ISSUANCE for City Engineer Date Permit Expires 6 Months after Date of Issuance. I GENERAL PERM IT 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 isthe applicantlg responsibility to remove and replace unacceptable improvements within the one-year maintenance period. 3. 19--fund 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 maybe required for workwithin Gtyfacil]ties and downtown Campbell. 5. The Permittee must request in writing afinal inspection and acceptance of thework upon completion. Acceptance by the Otywill be made in writing to the Permittee. 6. Maintain safe pedestrian and vehicular crossings and free accessto private driveways,fire hydrants and water valves. 7. Fbplace as directed by the City Engineer any damaged or removed improvements in accordance with Oty Standards and Specifications at the sole expense of the Permittee. 8. Sawcut for ail]PCCand AC removals. All POCremovalsshall be to nearest scoremark and shall be doweled to existing improvements. 9. Adequate signing and barricading is required on thejob site. Failure to provide such signing and barricading as specified by the Oty Engineer may result in the C ityfs 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 ail times during construction. 11. This permit shall be kept at the site of work and must be shown to any authorized representatives of the Gty 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 workfor which a separate permit may be required,_nor does it relieve the Permittee of any obligation to obtain any other permit required bylaw. 14. This permit does not release the Pearmittee from any liabilities contained in other agreements or oontractswith the Oty and any other publicagency. 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 isto be madefor City-owned or maintained facilities. 19. Pursuant to Chapter 14.02 of the Campbell Municipal Code,applicant shall not causeto be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhereto the BESTMANAGEM ENT PF;AC110ESestabIished by the Santa Clara Valley Urban Fbnoff Pollution Prevention Program. Applicant shall be responsiblefor ensuring that all those providing services under the applicant are aware of and understand all of the above conditions. Applicant Date J.\FOWSTemplates\Encroachment Permits\R 1 Encroachment Permit STA71Cform2.pdf Fbv.02/14 PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1,2014 - TO: City Clerk PUBLIC WORKS FILE NO. �—N C Zell} _ �C (� PROPERTY ADDRESS (4-1 v ci,,- C AUL Please collect&receipt for the following monies "ACCT ITEM LAND DEUELOP'MENT NT 4722 EncroachmentPermitica ton ee Non-Utility Encroachment Permit Ma'or>_$10 000 $385.00 Minor Encroachment Permit<sio,000 $220.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $220.00 Inspection Fee Minimum Charge per Location � $385.00 Street Tree Planting/Removal N/C 2203 $500 per Tree Planting Deposit Required) $500.00/tree 22031 Plan Check Deposit 2%of Engineers Estimate $500.00 min - Utility and R-1 Permits no deposit required 4722 Grading&Drainage Plan Review 'Single Family Lot - $270.00 Site<10,000 s.f. $810.00 Site>_10,000 s.f.<0.5 Acre $1 081.00 Site>_0.5 Acre $1 621.00 4722 NPDES Review C3 Requirements) For projects not required to submit numeric sizing $156.00 For protects required to submit numeric sizing Impervious Area 10,000 S . Ft to 1 Acre $676.00 Impervious Area 1 Acre or more $884.00 4722 For projects sent to Consultant for review Consultant Cost+20% Plan Check&Inspection Fee(Non-Utility) 4722 En r.Est. <$250 000 14%of Engineers Estimate 2203 En r.Est.z$250 000 and<$500 000 $35 000+8%of Engineers Estimate 2203 En r.Est. >_$500 000 $55,000+7%of Engineers Estimate 2203 Emergency Cash Deposit 4%of En r. Est.* $500 min/$10 000 Max 2203 Faithful Performance Security FPS 100%of ENGR.EST.* `�C 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 Ma 4 Lots or Less $3 850.00+$83/lot 4722 Final Tract Ma 5 or More Lots $4 681.00+$114/lot 2203 Monumentation Security 100%of Ci 's Monumentation Estimate 4920 . Parkland Dedication Fee 75%/25% Due U pon Cert.of Occupancy) 4722 Lot Line Ad'ustment Includes Certificate of Compliance) $1 820.00 4722 Vacation of Public Streets&Easements $2 434.00 4722 Certificate of Compliance $1 800.00 4722 Certificate of Correction $540.00 4722 Apoeal Filing Fee $200.00 4722 Notary Fee(per signature) $10.00 4722 Assessment Segregation or Reapportionment First Split $860.00 Each Additional Lot $270.00 511.74241 Postage MISCELLdNEQUS Other Please S eci *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $ S;O G NAME OF APPLICANT NAME OF PAYOR v PHONE 9g'o- g 90 ADDRESS zip D FOR RECEIVED BY CITY CLERK ONLY Date Recei t# Q Date/ Initials . 4 - J.T0RMSLTemp1aWMAdm W,tstve%Ra tpl F=L"D—bpmmlI 16- ® DATE(MM/DD/YYYY) �°�® CERTIFICATE OF LIABILITY INSURANCE 11/19/2014 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). CONTACT Jamie Relch PRODUCER NAME: All Spectrum Insurance Brokers PHONE (408)739-8300 AIC No;(966)826-6781 4300 Stevens Creek Blvd aoDRles :Jkelch@asibrokers.com Spite 100 INSURERS AFFORDING COVERAGE NAIC# San Jose CA 95129 INSURERA:Financial Pacific Insurance 31453 INSURED INSURER B:R2 ublic Underwriters Insurance 24538 Sbv Concrete, Inc, DBA: Valley Concrete INSURERC: 1020 Ruff Dr INSURER D: INSURER E: San Jose CA " 95110 INSURERF: COVERAGES CERTIFICATE NUMBER:CL14 618 0 1 627 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 REDU CED BY PAID CLAIMS. POLICY EFF POLICY EXP IN TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGET RENTED 300,000 X COMMERCIAL GENERAL LIABILITY PREMI E E urr nc $ A CLAIMS-MADE ❑X OCCUR X 60430980 6/19/2014 6/19/2015 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEHL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- LOC $ AUTOMOBILE LIABILITY Ea acccid ED SINGLE LIMIT accident) $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED SCHEDULED X 60430980 6/19/2014 6/19/2015 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 A X EXCESS LIAB HCLAIMS-MADE AGGREGATE $ 1,0 0 0,00 0 DED RETENTION$ X 60430980 6/19/2014 6/19/2015 $ B WORKERS COMPENSATION % TQRY LIMITS WC STATUS FIR AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN - E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? [�Y] NIA 1/9/2014 1/9/2015 (Mandatory In NH) TW00104702 E.L.DISEASE-EA EMPLOYE $ 1 000,000 If yes,describe under - DESCRIPTION OF OPERATIONS below E.L.DISEASE,POLICY LIMIT $ 1 00 0 00 0 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) RE: 588 Hawthorne Avenue, Campbell, CA When required by written contract The City, its officers, employees and volunteers are additional insured per endorsement CG2010 02 10 R attached. Concrete work performed in the State of California. CERTIFICATE HOLDER CANCELLATION (408)376-0958 syedw@cityofcampbell.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Campbell 70 N list Street AUTHORIZED REPRESENTATIVE Campbell CA 95008 D m i t r i y Lazarev/DIMAL ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 loins)n1 Tha At r1Rfl name anrd Innn ara ranicfnrarf mnrirc of Ar npn. POLICY NUMBER: 60430980 CG 20 10R 1211 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -.OWNERS, LESSEES OR CONTRACTORS (WITH.. LIMITED COMPLETED OPERATIONS COVERAGE) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART BUSINESSOWNERS COVERAGE FORM SCHEDULE NAME OF PERSON OR ORGANIZATION the. qualifying language above because of Any person or organization to whom or to which payments we make for injury. the named insured is obligated by a virtue.of a written contract to provide insurance that is LOCATION OF JOB: afforded by this policy. Where required by The job location must be within the State of contract, the officers, officials, employees, domicile of the named insured, or within any directors, subsidiaries, partners, successors, contiguous State thereto. parents, divisions, architects; surveyors and engineers are included as additional insureds. DESCRIPTION OF WORK: All other entities, including but not limited to The type of work performed must be that as agents, volunteers, servants, members and described under classifications in the CGL partnerships are included as additional insureds, Coverage Part Declarations. if, required by contract, only when acting within the course and scope of their duties controlled and supervised by the primary (first) additional insured. If an Owner Controlled Insurance Program is involved, the coverage applies to off- PRIMARY CLAUSE: Site operations only. If the purpose of this When this endorsement applies and when endorsement is for bid purposes only, then no required by written contract, such insurance as coverage applies. is afforded by the general liability policy is primary insurance and other insurance shall be WHO IS AN INSURED: (Section II) excess and shall not contribute to the insurance This section is amended to include as an afforded by this endorsement. insured the person or organization within the scope of the qualifying language above, but only EXCLUSION to the extent that the person or organization is This insurance provided to the additional insured held liable for your acts or omissions in the does not apply to "bodily injury", "property course of "your work" for that person or damage" or "personal and advertising injury" organization by or for you. The "products- arising out of an architect's, engineer's or completed operations hazard" portion of the surveyor's rendering or failure to render any policy coverage as respects the additional professional services, including: insured does not apply to any work involving or 1. The preparing; approving, or failing to related to properties intended for residential or prepare or approve, maps, designs, habitational occupancy (other than apartments), shop drawings, .opinions, reports, This clause does not affect the "products- surveys, field orders, change orders, or completed operations" coverage provided to the drawings and specifications; and named insured(s). 2. Supervisory, inspection, architectural. or engineering activities. WAIVER OF SUBROGATION: We waive any right of recovery, when required Endorsement EFFECTIVE DATE: SEE DEC by written contract, that we may have against the person or organization within the scope of Endorsement EXPIRATION DATE: SEE DEC CG 20 10R 12 11 Page 1 of 1 Includes copyrighted material of Insurance Services Office,Inc.,with its permission WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2_5% of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description Blanket Waiver of Subrogation As respects to all CA jobs performed by the named insured during the policy period where by written contract a waiver of subrogation is required prior to the commencement of work. This endorsement changes the policy to w hich it is attached and is effective on the date issued unless otherwise stated (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective . Policy No. ATW 001047-02 Endorsement No. Insured Insurance Company SBV Concrete(A Corp) Republic Underw riters Insurance Company Countersigned By �"6s `°� ©1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. INSURANCE REQUIREMENTS CHECKLIST Permit# L \4 _ CIP Project # Consultant/Contractor: The following insurance is required of all consultants/contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial.General Liability for bodily, personal injury and property damage: pd, $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 60 1 ic-t Is Automotive Liability: "Any Auto" checked on certificate $1,000,000 per accident for bodily jury and property damage 074,Pol.icy expiration date , Iq 5 Workers' Compensation and mployer's Liability Waiver of Subrogation clause L $1,000,000 per accident for bodily injury or disease Policy expiration date \ Course of Construction (if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement: __The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) o 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. ❑ Workers' Compensation Insurance Sheet Submitted —for General Contractor ❑ For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 02 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: NAIC#. S Rating: Authorized in CA: Name:-,.,.�n1�C l;gkdecwN';t-e(S NAIC#55'SRating: Authorized in CA: Name: NAIC#. Rating: Authorized in CA: Name: NAIC# Rating: Authorized in CA: Campbell Business License # Expiration: Contractors License# �? ?!} ) l] class:v Expiration: C1 ? �. Insurance Certificate Reviewed ` Ini'taI 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 F�R Z V 1 , f I I i u I � , 0 i QV M1, CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2014-00195 Name: Gregory Fine Property Address: 588 Hawthorne Ave. Campbell CA Date of Final Inspection: On File: Bonds CD Cash Labor and Material: Construction Cash Deposit to be released: Faithful Security Deposit: Other overdue deposits to be released (Description): {14L�•e+�'P�O,S ITS RETIit. N l !D is Processed by: Administrall,r.3 Reviewed by: Inspector Reviewed by: Land Development Engineer J:UoAnna'Meposit refunds\CHECKLISTS\Hawthorne588.doc(Rev. 10/11) of CAS �A: •pRCfi AiZ� CITY OF CAMPBELL Public Works Department December 4, 2014 Gregory Fine 588 Hawthorne Ave. Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2014-00195 588 Hawthorne Ave., Campbell, CA FINAL INSPECTION AND ACCEPTANCE Dear Gregory: 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 the date of this acceptance letter. 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$500.00, plus any interest due, is now being processed and will be sent to you under separate cover. If you have any questions, please call me at(408) 866-2165. Sincerely, Syed Wahidi Public works Inspector Cc: Inspector file Permit#ENC 2014-00195 Suspense File 70 North First Street Campbell, California 95008-1423 TEL 408.866.2150 FAx 408.376.0958 • Tnfl'408'866.2790 ..._................................: ................._........_.__...... ............ .............-_...J ._._.......____........... CITY OF CAMPBELL VENDOR NO. 10013040 CHECK No. 249466 Account P rchbxe bider lmroice Number3 iiin�iint Descri'tiom 101 2203 CR120914 500.00 588 HAWTHORNE AVE ' I I I I I I 'c • 10013040 GREGORY FINE - - � ee e o e �e � � o e o e ► o �. CX�Y QF`CAMPBELL , CHECK DATE CHECK NO. I WELLS PARGO DANK, N.A. 11-24 , 420MONTGOMERY STREET - 1210 12/.22/14 249466` >70 NOR. FIRST STREET S$N F•RANCISCO, CA 94104 r CAMPBELL, CALIFORNIA 95008 `o o. AMOUNT � .***.****500 . 00* , VOID,AFTER 90 DAYS 0' a 3� PAY THE.--SUM OF FIVE HUNDRED DOLLARS & ZERO CENTS - mf , -To THE GREGORY FINE i t, oan>R 588 HAWTHORNE AVE ( ! 7: CAMPBELL CA 95008 ` �+ u' 21,94GC3 121000- 2,481: 4b2L8554 IS , ' o e e PEE e e a a e ee e e o0 0 --- -- ---------------- I "See Reverse Sine For Easy Opgning Instructions* CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 GREGORY FINE 588 HAWTHORNE AVE CAMPBELL CA 95008 i ,�--'I,_,,,��,'',-I,1;�t��.',.`,w,:,-,,,.,�-I�,.j"����,,�"'_,,z..,,,�,-'1I1,,.��_-rII�---*,��.,�L��--7;"_W�,-�I.,,,;,�',,. 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Check Payable To Gregory Fme�, ] ,,;. - 1 , Addfess-:Line 1::. 588 Hawthorne=Ave.. Line 2 - j' I y City. ' r, . , Campbell ry-; Zip: -.: State CA 95008 ., { , -- a1 - I ,Description `588.Hawthorne Ave.. r Adcount Number 101.2203 Amount ;$500 00 ., fl: Account Number:, 101 2203 Amount - °Account N"umber'- , 101 540.1448 Amount . (Finance Dept only) an Interest Earned (Fw ept nly)ce D o c II n Total Payable`: . Exact Amount) r. E, - .�_. i , Pur ose Securit De osit Return ," P y p Voucher#:'` Permit# ENC2014 00195 -r , G -., ,. , Receipt#: 256186 Date: _ 1.111 912 0 1 4 __ i .' - .- ,. . . , - Requested by. Title PW Inspector Date'iZ( ,, Syed V1/ahi �� - , . I Approved by: Title $r.Civil Engineer Date: ?. t r_, , _ Roger Stori , , Finarice Dept Only'; r j y Verified b Title Accounting Clerk II Dater -: - - . Y. . i ' Approved by` z tle Accountard Date: Ti .. �. °- ,. S ecial Instruct ions For Hand— Check , - - , , _ . 1 .-Mail As Is. Mail in Attached Envelope •`,Interim Check „ x,; Needed By ' , - .. . . Return to --Jor nna Thomason _ Public Vllo�ks I (Name) - (Department) ,,,, . h 1 Other: ,,, - .:.: 1. ,. .. -:• _ r, . ,. ....,. :- ...:,., s r....,,: - .. ... �. ., - - , fin.Fomis/excellchkreq. Rewsed;,05l00 , " - . . .