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HomeMy WebLinkAboutENC2013-00012 • r, Print Form CITY OF CAMPBELL R-1 ENCROACHMENT PERMIT Permit No. ` +V C 2c 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 t(7 I(3 Campbell,CA 95008 Application Expiration Ph.(408)866-2150 ISSUED: 1I / 3 Date Fx.(408)376-0958 Permit Expiration Date: C i i 1 I 1 APN L' CACA,V,OA APPLICATION-Application is hereby made for a 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: I 9 o -11-\r s A Av B. Nature of Work: R R Dr, A\ -) 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: z-Psif e v S/1/ / Telephone: CfI g3 Address: // 90 r'/ r- e-- gv �'/#I/% 'a'/ E-Mail Address: v/C 67( y {9r ` -O e, C.tfrei 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. �J ACCEPTED: N/.�? WC-42e1/1114 1 F Y / 3 (Applicant/Permittee) (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 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(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.) $ R-1 PERMIT FEE $ APPROVED FOR ISSUANCE: 1/7 l t 3 for City Engineer Date Permit Expires 6 Months after Date of Issuance. 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. 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,fire hydrants and water valves. 6. 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. 7. Sawcut for all PCC and AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements. 8. 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. 9. The Contractor or Permittee will have a supervisory respresentative available for contact on the project at all times during construction. 10. 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. 11. 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. 12. 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. 13. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 14. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 15. 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. 16. 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. 17. 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. 18. 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. C :?-4944 i/JAi4/ti ` - 7 - ZO ) 3 Applicant Date J:\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf Rev.3/10 .�!. Liberty- Policy Declarations r ` Mutual., A summary of your homeowners insurance coverage Thank you for insuring with us. Here is your renewal homeowners policy summary, which is effective as of 11/25/2011. DQUESTIONS ABOUT ®1 INSURANCE INFORMATION YOUR POLICY? tJ Named Insured Policy Number By phone Leslie Grundy H32-268-149159-60 Ii7Carole Grundy For service: s o Mailing Address Policy Period 1 800-869-4009 �, ., 1190 Theresa Ave 11/25/2011-11/25/2012 12:O1AM Campbell CA 95008-6831 standard time at the address of the 50 Francisco Street Named Insured at Insured Location. Suite 257 Insured Location San Francisco CA Same as Mailing address above 94133 Prudential Financial Professionals Krystofiak And Associates Premium Summary 1-415-291-0202 Standard Policy $ 1,620.00 To report a claim Additional Coverages $ 209.00 By phone Discounts and Benefits $ (674.00) 1-800-225-2467 Online Total 12 Month Policy Premium $ 1,155.00 LibertyMutual.com/ insurance Through your affiliation with the AT&T your policy includes exclusive group savings on your home insurance. THIS IS NOT YOUR HOME INSURANCE BILL. . Coverage Information Your policy includes Standard Policy HomeProtector Plus, which provides enhanced Section I Coverages LIMITS PREMIUM coverage in case of a loss. Please see your A. Dwelling with Replacement Cost $ 400,900 endorsement for details. B. Other Structures on Insured Location $ 40,090 C. Personal Property with Replacement Cost $ 300,680 D. Loss of Use of Insured Location Actual Loss Sustained Section II Coverages E. Personal Liability (each occurrence) $ 300,000 F. Medical Payments to Others (each person) $ 1,000 Policy Deductibles Losses covered under Section I are subject to a deductible of: $600 Total Standard Policy $ 1,620 Additional Coverages DEDUCTIBLE LIMITS PREMIUM Credit Card, Fund Transfer Card, $ 5,000 $ 3 Forgery Home Protector Plus $ 158 Personal Injury $ 16 1HO 3047 06 11 Policy Number: H32-268-149159-60 1 0 Declarations Effective: 11/25/2011 Page 1 of 3 • _, Liberty Mutual. Coverage Information (continued) Additional Coverages(continued) DEDUCTIBLE LIMITS PREMIUM Workers Compensation Coverage Workers Compensation Coverage S 3 Coverage E increased limit S 29 Total Additional Coverages S 209 Discounts and Benefits Your discounts and benefits have been applied to your total policy premium. ' HOME DISCOUNTS PREMIUMt For more information on • Insurance to Value Discount $ (95) discounts, please visit • Inflation Protection Discount $ (48) LibertyMutual.com/ • Multiple Policy Discount g (119) insurance and click on the "Home Insurance" • Safe Homeowner Program $ (238) link. • Group Savings Plus® (5% discount included in total policy premium) AT&T • Protective Device Discounts: $ (174) Smoke/Heat Alarm-All Floors, Extinguishers and Dead Bolt Locks Complete Local Burglar Alarm Total Discounts and Benefits $ (674) Endorsements — Changes to Your Policy • Home Protector Plus (FMHO-2147 R2) • Personal Injury (HO 24 82 04 91) • Credit Card, Fund Transfer Card, Forgery • Protective Devices (HO 04 16 04 91) (HO 04 53 04 91) • Amendmt Pol Definitions (FMHO-2934 7/04) • Amendatory Endorsement (FMHO-2510 5/03) • Amendatory Mold End (FMHO-2202 R1) • No Secll/Limit I-Daycare (HO 04 96 04 91) • Special Provisions- CA (FMHO-2882 R1) • Workers Compensation Coverage (HO 24 90 01 93) • CA Prop Bill of Rights (FMHO 2942 0711) • CA Res Prop Disclosure (FMHO 4152 0711) • Inflation Protection (FMHO-2936 9/04) • Amendatory Endorsement (HO 04 01 06 93) • Lead Poisoning Exclusion (FMHO-2145 R1) • LMHC Membership (2340) Mortgage Information Mortgagee 1: GMAC MORTGAGE LLC ISAOA LOAN NO. 0000241299 PO Box 4025 Coraopolis, PA 15108-6942 Important Messages Flood Insurance: Your Homeowners policy does not provide coverage for damage caused by flood, even if the flood is caused by a storm surge. Liberty Mutual can help you obtain this coverage through the Federal Emergency Management Agency (FEMA) if your community participates in the National Flood Insurance Program. Please call your representative for more information. FMHO 3047 06 11 Policy Number: H32-268-149159-60 1 0 Declarations Effective: 11/25/2011 Paget of 3 *002654* LIBERTY MUTUAL GROUP n PO BOX 52102 *%.41,f Liberty- PHOENIX AZ 85072-2102 Liberty Pi' Mutual® Please do not send payments to the address above INSURANCE / / M' Thank you! LESLIE GRUNDY We appreciate your business. CAROLE GRUNDY 1190 THERESA A V E CAMPBELL CA 95008-6831 ` .3r � 'fir � � �r yo-.:: Yr z� `k*si�s�r't is°` 'i�.: �.P.en T:�3x saw w-& � d a r THIS- IS YOUR HOME INSURANCE BILL As of October 25, 2012 r-t, INSURANCE INFORMATION QUESTIONS Policy Number: H32-268-149159-6O Questions Regarding Policy Period: November 25, 2012-November 25, 2013 Your Policy or Bill? Bill Frequency: Monthly SERVICING OFFICE Property Insured: 1 190 THERESA AVE K. AND ASSOCIATES 1-415-291-0202 CAMPBELL, CA 95008-6831 PO BOX 52102 PHOENIX AZ 85072.2102 BILLING DETAILS 1-800-869-4009 Want to Pay Online? Renewal Premium $1,188.00 Sign up at LibertyMutual.com/lm-service Payment Activity Need to Report a Claim? Payments Received $0.00 1-8OO-2CLAIMS (1-8OO-225-2467) Policy Balance $1,188.00 Current Amount Due By 11/14/12 $108.00 SAVE TIME & MONEY Eliminate installment charges by signing up for electronic funds transfer payments. Simply sign the 65- ff authorization and return the stub )i ©9 / <' ( -/ below with your payment.