ENC2019-00087 o
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CITY ®F CAMPBELL
Public Works Department
June 14, 2019
Melanie Tobias
1281 Viroinia Ave.
Campbell,CA 95008
SUBJECT: PERMIT NO. ENC 2019-00087
1281 Virginia Ave., Campbell.CA
FINAL INSPECTION AND ACCEPTANCE
Dear Melanie:
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.
Your Faithful Performance Security refund in the amount of$500.00 is enclosed.
If
e any questions. please call me at (408) 866-2165.
Si
Syed Wahidi
Public Works Inspector
70 North First Street • Campbell, California 95008 • TEL 408.866.2150 • FAX 408.376.0958 TDD 408.866.2790
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Re un Check Request:
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Check.Rayable-T` Melanie Tobias .
Address-'Line 1281 Virginia'Ave: i
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Account Number_: 101,2203 Amount: $500.00 -
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Account Number: 101.540.7448 ' Amount
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4 ^ - Permit,#: ENC2019-00087 ..j
k Receipt#: 280280 Date: 4/10/2019, s
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Requested by; Title: Ins"pector Date: _
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. , Approved by: ?. Title; Sr. Engineer_ Date:
Roger Storz
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Verified by: Title: Accounting Clerk If. Date;
Approved by: Title: Accountant Date :
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CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
CLEARANCE FOR FINAL INSPECTION
AND ACCEPTANCE LETTER
Encroachment Permit#: ENC2019-00087
Name: Melanie Tobias
Property Address: 1281 Virginia Ave.
Date of Final Inspection: 5/29/19
On File: Bonds CD Cash
Faithful Performance: $ 500
Labor and Material: $
Construction Cash Deposit to be released: $
Other overdue deposits to be released (Description):
Processed by:
ministrat r
Reviewed by: 3 I
Inspector
Reviewed by:
Land Development Engi ee
JAJoAnnaT\Deposit refunds\CHECKLISTS\Virginia 128Ldoe(Rev. 10/11)
PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT
Effective January 1,2019
TO: Finance PUBLIC WORKS FILE NO.
PROPERTY ADDRESS
Please collect&receipt for the following monies:
.ACCT. ITEM: ... :AMOUNT'. .
LAND DEVELOPMENT`
4722 Encroachment Permit Application Fee
Non-Utility Encroachment Permit $553.00
Inspection Fee Minimum Charge per Location $553.00
2203 Plan Check Deposit 2%of Engineer's Estimate $500.00 min
4722 Grading&Drainage Plan Review
Site< 10,000 s.f. $1 326.00
Site>_ 10,000 s.f. <0.5 Acre $1,768.00
Site>_0.5 Acre $2 210.00 first acre
Each additional acre $442.00
4722 NPDES Review C3 Requirements)
For protects not required to submit numeric sizing $442.00
For projects required to submit numeric sizing
Impervious Area up to 1 Acre $1 326.00
Impervious Area over 1 Acre $1 768.00
Each additional acre $442.00
Pervious Pavement/Concrete/Asphalt
First 5,000 SF $2 210.00
Each Additional 2,500 SF $663.00
4722 For projects sent to Consultant for review Pass through+20%
4722 Additional treatment facilities $442 ea
4722 Stormwater Treatment Features Operations& $275.00
Maintenance Inspection
Plan Check& Inspection Fee(Non-Utility)
4722 En r. Est. <$250 000 14%of En rs.Estimate-minimum$3536
4722 En r. Est. >_$250,000 and<_$500 000 $35 000.00+8%of Engineers Estimate
4722 En r. Est. >$500 000 $55 000.00+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 d
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 $5 304.00
4722 Final Tract Ma (5 or More Lots) $6,630.00+$111/lot
2203 Monumentation Security 100%of SurveV Cost Estimate
4920 Parkland Dedication Fee(75%/25% Due Upon Cert. of Occupancy)
4722 Lot Line Adjustment/Parcel Merger $3,315.00 includes Cert.of Correction
4722 Vacation of Public Streets&Easements
Summary Vacation $3,536.00
All Other Vacations $221/hour
4722 Certificate of Compliance $2,210.00
4722 Certificate of Correction $774.00
4722 Street/Easement Dedications
Homeowner Occupied R-1 $0
All Others $1,105.00
4722 Private Improvement in Public ROW Agreement $165.00
4722 Approved Plan Revision Fee $111/sheet
730.49241 Notice of Improvement Obliqation Pa ment
554.42141 Technoloqv Enhancement Fee 2%of total permit fees
Other(PleaseSpecify)
JAME gineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL L $ 5 d 0
OF APPLICANTME OF PAYOR 14411twc `OUs PHOME-)
DRESS ZIP
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21VI,11t
FOR RECEIVED.-BY,
FINANCE v YArVlVbtLL
USE ONLY Date: - Receip c
JVORM51TempUfle dm gfatim'Ameipt Fnm land DeveIoMm 1&19ds
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�TYOF iLAMPBELL
REUDBY: CASHIER 5100260288
PAYOR: MELANIE TO8IAS
T8DAY`S DATE: Oq/1G/19
REGISTER DATE: 04/10/19 TIME: 00:00
DESCRIPTION AKOUN�
CUST lD:ENC2019-80087
REF DEPOSIT - 1O1 $5OO.8O
-------------
TOTAL DUE: $5GU.O0
TENDERED: $5OO.0O
� CHANGE: $.00
CHECX $500.30
REF NUM: 7358
Encroachment Permit Final Sign Off
Encroachment Permit# �N,C "?ca lci- 000y
Address:
Date of Final Inspection and Acceptance:
Inspected by:
OK to release deposits: 100% `� 75%
Comments:
5fiat "Fari>rt 'State'Farm General,lnsurance,Compan @(�
AMENDED JUL 10 2b'18
A Stock p y DECLARATIONS PAGE
soo wa R,Company
6o d an With Home Offices,;m oomm ton;.= rnols, Polic Number, 05 EE OA�59 8
Rakermfield;CA 933ii-950i
Named insured
Policy'Period Effective Date' . Expiration'Date
AT1 H-02-3633-FBOIr H 'F' 12 Months DEC 11.2017 DEC 11 2018
000z42 ooas The polls ,period be and ends at 1.2:01 am
TOBIAS,. JOHN S & PIEL°ANIE; L C standard ime at'the residence premises.
1281:VIRGIdIA AVE ,
CAMPBELL CA"
A 9500.876808 ,
Loan##0515385676.
v Mortgagee
SHELLPOINT MORTGAGE SERVICING
PO BOXa7050
s TROY .MI 480.07=7050
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HOMEOWNERS-POLICY .
Automatic'Renewal m If the `policy period is shown as 12 months, this policy will be renewed'automatically. subject to the
premiums, rules ariid jarms in effect for each succeeding policy period. If:this. policy,is terminated, we will give you and the
Mortgagee/Lienholder written notice in compliance with the policy provisions or as required by law.
Location''of-Residence.Premises Your policy is amended JUL 10 201`l$
Same as Insured's Address SECON I COVERAGE LIMITS CHANGED
DWELLING UNDER CONST ADDED:
ENDORSEMENT FE-7342.3 ADDED
ENDORSEMENT.FE-5251 ADDED
This policy does not pprovide coverage for loss by earthquake,:
This policy includes Building Code Upgrade Coverage of$ 51,700
Coverages&:hropeirty Limits,of Liability Inflation Coverage Index:305.9
SECTION] Deductibles-Section I'
A Dwelling 517,000. All Losses 1/2%
Dwelling Extension up.to 51.,700
B Personal Property 387 750
C Loss of Use Actual Loss
Sustained.
SECTION 11
L Personal Liability..
DEach Occurrence)
amage to Property 1n case of loss under this policy, the deductibles'will'be applied
of Others $ 500 per occurrence and will be deducted from the amount of the
M Medical Payments to loss:Other deductibles'may apply-refer to policy.
Others (Each Person) $' 1,000
Loss Settlement Provision(See Policy). En arsernent Premium
Ai Replacement Cost,- Similar Construction INCREASE $ 92.87
61 Limited Replacernent,Cost Coverage B
Discounts Applied
Forms,'Options', & Endorsements ' .,,"'Home/Auto
Homeowners Policy FP-7955',CA Claim Record
*Theft- New,Construction. FE-5251
*D.wellingg Under Construction FE-73.42 '3,
Form 43Sbfd NS L-ndr Loss Pay FE-1313
Homeowners Policy Endorsement ,: . FE-3422
Amendatory Endorsement FE-3247
Jewelry and Furs$1.500.Each Option JF -
Article/$2,500 Aggregate
Increase Dwlg Up to.$ 103,400 Option ID
* New Form Attached.
Other'llmits and exclusion sp,may.applytl refer,to your policy, .
Your policy consists of this page, any endorsements
and the policy.form. Please keep these together,
FP-70180 Continued on Reverse
AARON SESSIONS. LUr.
0813 151 I 408-866-7766 -
N Prepared JUL 20 2018 ----
CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No.: �t�1 C I�—0000 7
DEPT.OF PUBLIC WORKS (for working within the X-Ref. File
70 North First Street public right-of-way) Application Date
Campbell,CA 95008 Issued H (a 6 / ( L
Ph.(408)866-2150 Application Expiration Date
Fx. (408)376-0958 L/ APN HOG
Permit Expiration Date I
APPLICATION-Application is hereby made fora Public Works Permit in accordance with Campbell Municipal Code,Section 11.04.(Application expires in six
(6) months if the permit is not issued. Application Fee is non-refundable.)
A. WorkAddress: ' 29,I U)
B.
Nature of Work/Utility
Trench Location:
❑ No Fee Permit for work related to City Project Project Name:
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 workshall conform tothe City ofCampbell 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
injob 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.
Name of Applicant: Telephone:
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Address:
f g1 i t�r n i a4
E Mail Address: V1'I yv7 �bf,&S,Cgs f IO��I �24-HOUR EMERGENCY PHONE NUMBER: �Q�� a 0S
Is this work being done by the property owners at their own residence?�X Yes ❑ No / O
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell,its officers,agents,and employees free,safe "
and harmless from any claim or demand for damages resulting from the work covered by this permit.
The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit,and they will inform their contractor(s)
of the information.Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all
,damages arising out of improvements completed in the public right-of-way.
Accepted: 6 -s/ a G`
(Applicant Permittee) (sign) Date
SPECIAL PROVISIONS: (Contractor) (Print Name) Date
_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 identirication number has been entered hereon. USA Phone:1-800-227-2600. USA TICKET NO.
Prig to any wor opert cv r srrtr�lia 1 eke ute an A ree for Private Im rovemen Sn-the-Pttbli Right-of-way,which shall be recorded.
6.Public Notification Requirements:
V 7. CAU, i-o -P & - rrcT(cim �cI2 C C; (NSz I&
[SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO.
PERMIT APPLICATION FEE $
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ y� /
CONSTRUCTION CASH DEPOSIT $ 1
PLAN CHECK&INSPECTION FEE $
2%TECHNOLOGY FEE $
TRAFFIC CONTROL REVIEW _, $
APPROVED FOR ISSUANCE
For City Engineer
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 ofthe
permit work.
2. A Construction Cash Deposit is required.Changes 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 ofthe Faithful Performance Surety will be initiated by the written acceptance ofthe 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 ofwork.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.This plan must be reviewed and
approved prior to any lane closures.
9. A Construction Traffic Control Plan shall conform to the most recent version of the 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 ofthe
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 ofthe 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.
20. 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.
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.
23. Permittee 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 a phone number.
24. Applicant shall remove water from utility vaults in accordance with the requirements of State Water Resources Control Board Water Quality Order WQ 2014-0174-
DWQ. Said vault water shall not be discharged into the City of Campbell's storm drain system.
See http://www.waterboards.ca.gov/water issues/programs/npdes/utilityvaults.shtml for more information.
Applicant is hereby re s onsible for ensuring that all those providing services under the applicant are aware of and abide by all of the above conditions.
Applicant Date:
Contractor (Print Name) Date:
J:\FORMS\Templates\Encroachment Perm its\Encroachment Permit 3 29 19