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Permit No 20 - Oool
CITY OF CAMPBELL ENCROACHMENT PERMIT v
DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File
70 North First Street right-of-way) Application Date (( S`t 3
Campbell,CA 95008 Application Expiration Date 7115-0
Ph. (408)866-2150 Issued I �� APN 30 s p \ z�
Fx. (408)376-0958 117
Permit Expiration Date I t
APPLICATION-Application is hereby made for a Public Works Permit in accordance wit Campbell Municipal Code,Section 11.04. (Application expires in six
(6) months if the permit is not issued. Application Fee is non-refundable.)
A. Work Address or Tract No.: IQ I S rt L \ �(�•
Utility Trench Location: IV 1 '3 LL12 v> —O
B. Nature of Work: y,vL-e 0 tP
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. (See General Permit Conditions 1 and 2.)
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. J
1
Name of Applicant: -.1-16��>� kj,St li) lj0(y1t 17 n-ei(2-S ` IA- Telephone: Hog 3 7y OW
Address: j 5 V t . CIS C)tAk
E-Mail Address: 9 J PaM.. e--Om 24-HOUR EMERGENCY PHONE NUMBER:
Is this work being done j property ow
ners wners at their own residence? YES NO
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. Applicar is advised that upon issuance of this permit, property owner, or property owner's successors, shall be
responsible for any dIII ,�a//mages arising utof the condition of any private im}proveme t in the public right-of-wan q�/�, n n Y
Accepted: K-�l l�l.� l 4 „ J71 tK(J c CJ
(Applicant Permitted (sign) Date
}} _ co 3c-we/IL( S dal 765357 .
(Contractor) 4 rint Name)W31,-476-0.co) Date
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 4215 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: 1-800-227-2600. USA TICKET NO.
5. 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 AMOUNT 2 1 RECEIPT NO.
PERMIT APPLICATION FEE 5 C..3s1
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $
CONSTRUCTION CASH DEPOSIT $
PLAN CHECK&INSPECTION FEE $ 3 7O
EMERGENCY PERMIT FEE $ Z`( L 2-,
APPROVED FOR ISSUANCE
For City Engineer Date
Permit Expires 12 Months After Date of Issuance
GENERAL PERMIT CONDITIONS
I. 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.
2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City.
3. Refund or the 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. 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.
5. Maintain safe pedestrian and vehicular crossings and free access to private driveways,bus stops,fire hydrants,and water valves.
6. 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.
7. A Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones,dated
1990,available at Caltrans. Traffic control equipment shall include Type II flashing arrow signs if required.
8. 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.
9. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements.
10. 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.
11. 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 cash deposit.
12. Compaction testing of subgrade,base rock,and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer.
13. 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.
14. 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.
15. 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.
16. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency.
17. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon.
18. 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.
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.
20. 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.
21. 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 distribu.91 arnrF1 include dates of work and a contact name and phone number.
Applicant alb sponsible fore ur' g that all those providing services under the applicant are aware and understand all of the above conditions.
1 /—/&.=2-61
Ap :cant Date:
Contractor (Print Name) Date:
J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf
Rev.09/10
III
PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT `ill
Effective July 1,2012 1�,�.,�
TO: City Clerk PUBLIC WORKS FILE NO. JJ ( 2-0 l 3 ` 6,b�•r 1
PROPERTY ADDRESS G[) Mt U.-lC__L1
Please collect&receipt for the following monies:
ACCT. f ITEM I AMOUNT
LAND DEVELOPMENT
4722 Encroachment Permit Application Fee 4—
Non-Utility Encroachment Permit Major≥$10,000 $370.00 '
Minor Encroachment Permit<sio,000 $210.00 2 to
Initial R-1 Permit N/C
Subsequent R-1 Permits within Two Year Period $205.00
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 Grading&Drainage Plan Review
Single Family Lot $260.00
Site< 10,000 s.f. $780.00
Site≥10,000 s.f. <0.5 Acre $1,040.00
Site≥0.5 Acre $1,560.00
4722 NPDES Review(C3 Requirements)
For projects not required to submit numeric sizing $150.00
For projects required to submit numeric sizing
Impervious Area 10,000 Sq. Ft to 1 Acre $650.00
Impervious Area 1 Acre or more $850.00
Plan Check& Inspection Fee(Non-Utility) 3 7O
4722 Enqr. Est. up to$250,000 14%of Engineer's Estimate
**2203 Engr. Est. ≥$250,000 Actual cost+20%Admin Overhead
(Min$35,000 Deposit)
2203 Emergency Cash Deposit 4%of Enqr. Est.*($500 min/$10,000 Max)
2203 Faithful Performance Security(FPS) 100%of ENGR. EST.*
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) $3,700.00+$80/lot
4722 Final Tract Map(5 or More Lots) $4,500.00+$110/lot
2203 Monumentation Security 100%of ENGR. EST.
4920 Parkland Dedication Fee(75%/25% Due Upon Cert. of Occupancy)
4722 Lot Line Adjustment(Includes Certificate of Compliance) $1,750.00
4722 Vacation of Public Streets&Easements $2,340.00
4722 Certificate of Compliance $1,765.00
4722 Certificate of Correction $520.00
4722 Appeal Filing Fee $200.00
4722 Notary Fee(per signature) $10.00
4722 Assessment Segregation or Reapportionment
First Split $830.00
Each Additional Lot $260.00
511.7424 Postage
MISCELLANEOUS
I Other(Please Specify)
*Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. 0 0
**Actual Cost Plus 20%Overhead on-Interest bearing deposit) TOTAL $ !�
NAME OF APPLICANT Lit i i �a/{ _N r c- )e,Q fht)
NAME OF PAYOR c_474711 C. • P ONE ,� JF � �
ADDRESS //^/� f� , 0#74PlIEQj ZIP g`�
FOR RECEIVED BY
CITY CLERK
ONLY Date Receipt# -., (P2 G/ i ` i 7 , 2-�4
Date/ InitiaTir ---.''''4 04 _o.r a_
I FORMS\TempletesNdmimatretive\Receipl Form Land Development 12-13
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DUPLICATE RECEIPT
CITY + ++3
RECVD q; CASHIER 01001)24639:
PAm: HAMILTON EAST
TODAY'S k«: 01»6/1
REGISTER 0.3: 3/10015 TIME: y:y
DESCRIPTION #yltJ
gm & m2D SQ« E $210.00
CUST ID: ENC 2013-000127
gmamAR FILING F $370.00
CUST ID: 615 MILLICH DR
TOTAL DUE: $90.00
CHECK PAID: $560.00
CHECK NO: 1035
TENDERED: $30.00
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01/17/2013 THU 11: 51 FAx 8314761207 U001/001
Client#:664606 LEWITREE
ACORD, CERTIFICATE OF LIABILITY INSURANCE DATE(MMl0DIYYYY)
1/15/2013
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 en endorsement.A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER AMP!CT
Hub International a TH Eelir 805-682-2571 FAx
HUB Int'I Insurance Serv.Inc. E-MAIL
-- (ac,NO 805.832-6581
ADDRESS:
40 East Alamar Avenue IN@URER(6LAEEONDINO COVERAGE NAIC#
Santa Barbara,CA 93105 INSURER A:Sparta Insurance Company 20613
INSURED INSURER B:American Flre and Casualty Comp 24066
Lewis Tree Service Inc. INSURER c:
INSURER D:
1500 Brommer Street
INSURER E:
Santa Cruz,CA 95062 INSURER III:
COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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 SUCI-I POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TAR AODL SUBR v---- P8 yp��
LTR TYPE OF INSURANCE IN>SR MD POLICY NUMBER iMM'ktiSM)fsfn kigici i LIMITS
A GENERAL LIABILITY 021CP01057 12/31/2012 12/31/2013!EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY FAMAQETO ENTED
� FiEM�otB� fl occurrence) �100,000
CLAIMS—MADE n ^I OCCUR MED EXP(Arty one person) $5,000
X PD Ded:1,000 PERSONAL&ADVINJURY $'1,000,000
GENERALAQQRSOATE $2,000,000
OENL AGGREGATE LIMIT APPLIESPER: PRODUCTS-COMPIOPAGO $2,000,000
----I_POLICY n_28_I I LOG I _ i S �/
A AUTQMQRILE LIA@IUTY 021CP01057 41213112012 12131/2013 r
eskalEaVINCILE LIMIT z1,000,000
Xl ANY AUTO BODILY INJURY(Per person) 9
-'ALL OWNED SCHEDULED BODILY INJURY(Per aooidenl) S
AUTOS AUTOS
X HIRED AuToe X-A p9wNED g0a QC dq DAMAGE $
$ /
B UMBR$LLA LIAR OCCUR 3EUA1254665846 12131/2O12112131I2O13 EACH OCCURRENCE $1,000,000 v
X EXCESe UAD X CLAIM&MADE p44REOATEc _$1,000,000
DEO I I RETENTION$ A
A WORKERS COMPENSATION 021 WK00302 12/20)2012 12/2012013 X IW�TA Q H-e I IE0.AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNeINg ECUTIVE Y I N EA.,EACH ACCIDENT s1,000,000
OFFICERIMEMBER EXCLUDED? y N/A '
(Mandatory In NN) E.L.DISEASE•EA EMPLOYEE,§1,000,000
II yos,describe under
DESCRIPTION OFSSERATIONB below EL,DISEASE•POLICY LIMIT $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Pismires Schedule,IT mere epece le required)
RE:Hamilton East,Gall Camp. Proof of Insurance.
Ot ' i S- \\).- ?).. \i/,-\\\ -._
CERTIFICATE HOLDER CANCELLATION
Clt of Campbell SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
70 N. let Street ACCORDANCE WITH THE POLICY PROVISIONS.
• Campbell,CA 95008
AUTHORIZED REPRESENTATIVE
I
(4 19892010 ACORD CORPORATION.All rights reeerved.
ACORD 25(2010/05) 1 o f 1 The ACORD name and logo are registered marks of ACORD
NS2041185/M2006606 DV43