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ENC2013-00071
Print Form CITY OF CAMPBELL R-1 ENCROACHMENT PERMIT Permit No. -013 -Oro 7/ 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 `f'-Z(,, -2013 Campbell,CA 95008 Application Expiration Ph.(408)866-2150 ISSUED: Date Fx.(408)376-0958 Permit Expiration Date: APN Z 3 -le--C:i(3 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: /061 He bite 1 Ad. B. Nature of Work: I`61`r6kife 0/A C1 'reptile.? 1 e(.'i- C. Attach three(3)copies of a drawing showing die 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: Telephone: yO,p— f?"3--IS 77 Address: I0 Ce1 (\A`e,0.tn 1-\V C"�`. �QLyQ �1 C:V% `i504i, E-Mail Address: {-lZ 4Lw h^s rw�� , .°off Auc,e 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 thepiave read and understand both the front and back of this permit,and that they will inform their contractor(s)of the information. ACCEPTED: ( Lt'1 S(a-013 (A ant/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.) $ 2 0 R-1 PERMIT FEE $ APPROVED FOR ISSUANCE: 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. Submit project schedule 10 days prior to proposed start of work.Special provisions may be required for work within City facilities and downtown Campbell. 5. 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. 6. Maintain safe pedestrian and vehicular crossings and free access to private driveways,fire hydrants and water valves. 7. 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. 8. Sawcut for all PCC and AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements. 9. 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. 10. The Contractor or Permittee will have a supervisory respresentative available for contact on the project at all times during construction. 11. 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. 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 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. 14. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 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 is to be made for City-owned or maintained facilities. 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. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above conditions. (J-sid-a,3 Applicant Date J:\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf Rev.03/13 PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1,2012 �� � / TO: City Clerk PUBLIC WORKS FILE NO.PROPERTY ADDRESS i 061 in.,.,62,//�1 Please collect&receipt for the following monies: ACCT. I ITEM I AMOUNT LAND DEVELOPMENT 4722 Encroachment Permit Application Fee Non-Utility Encroachment Permit Major≥$10,000 $370.00 Minor Encroachment Permit<sio,000 $210.00 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) 4722 Enqr. Est. up to$250,000 14%of Engineer's Estimate **2203 Enqr. Est. 4250,000 Actual cost+20%Admin Overhead (Min$35,000 Deposit) 2203 Emergency Cash Deposit 4%of Engr. Est.*($500 min/$10,000 Max) 2203 Faithful Performance Security(FPS) 100%of ENGR. EST.* 2�e6272) 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. _— **Actual Cost Plus 20%Overhead (Non-Interest bearing deposit)oi TOTAL $ &:,15 NAME OF APPLICANT 1 y^l011nCCS CCU'[ NAME OF PAYOR cDOLYA-C PHONE 1l)Qj q U tg-77 ADDRESS 11640 fro shQ{ Ckja4 4 ZIP 95i2 i FOR RECEIVED CITY CLERK l l J ONLY Date "-/ 7 1Th Receipt# 2-4:19\97' - Date/`initials J:,FORMS\TemplalesNdnlnlsUelrveReceipt Form Lena Development 12-1J . » CITY OF CAMPBELL «aDBa CASHIER @060247741 PAYOR: THOMAS : gkS3 TODA1S &e: 04/26/13 REGISTER DATE: 04/2t/13 TIME: 14:m DESCRIPTION AMOUNT REF DEPOSIT - 101 $2.800.00 mq ID: 1087 «GTE AVE 13-011 TOTAL DUE: $.80«00 CHECK PAID: 9.80±00 CHECK NO: 330 TENDERED: $2,800.00 CHANGE: tG /(,)/ P Y.p���S SC0 IA pGF J p� CA � PARKSTRIP MECHANICAL E �- SEPARATOR _'� CONSTRUCTION JOINT SIDEWALK SEE NOTE 5 WEAKENED ' PLANE JOINT 1 OR CUT JOINT oi-• 1/8" WIDE, �,0 2 DEEP WEAKENED PLANE. JOINT OR CUT JOINT 1/8" WIDE, , ‘1,\\..\. P 2" DEEP'' ' .0 `i rjal 3/4" ..,. - E ,CPS S=1" 0 o.b OC- PER FOOT 5/8" T — 1/2" R 4'-6" 4'-6" 2'-0" +10% MAX —' 6 CONFORM_,.. — SLOPE = 1/ 4" PER FT. —6i MAX o-.. p,..: ...o...: ...a.. .B, O6" CLASS A CONCRETE, TYP. g" 6" CLASS 2 AGGREGATE BASE, TYP. DOWEL ° ° NOTES SECTION A-A 1. WHEN THE DRIVEWAY IS NOT POURED AT THE SAME TIME AS THE CURB AND GUTTER, 12" OF NO. 4 REBAR AT 4' INTERVALS SHALL BE INSTALLED AS SHOWN (REBARS TO BE BENT DOWN AND COVERED UNTIL USED). 2. SCORE MARKS SHALL NOT EXCEED 4'-0" O.C., AND USE MECHANICAL SEPARATOR AT EVERY OTHER SCORE MARK. 3. DRIVEWAY APPROACHES (EXCEPT SINGLE FAMILY) SHALL HAVE A 6"X6"X10/10 WELDED WIRE FABRIC 3" ABOVE BOTTOM OF CONCRETE. 4. DOWEL ALL NEW CONCRETE IMPROVEMENTS TO EXISTING CONCRETE IMPROVEMENTS. 5. AT LOCATIONS WHERE NEW SIDEWALK ENDS AND MEETS AN EXISTING SIDEWALK, THE NEW SIDEWALK SHALL TRANSITION TO MEET THE EXISTING SIDEWALK AS DETERMINED BY THE CITY ENGINEER. ov ci CITY OF CAMPBELL REV. DATE BY SCALE: 4. PUBLIC WORKS DEPARTMENT Residential N.T.S. r ..:&ci r DRAWN BY: EA DATE 02/04 Driveway Detail DETAIL • °'Dd''•� CHECKED BY: DATE A (Detached Sidewalk ) N0. 4, \'A. APPROVED BY: c °*CHAO MICHE J:/Drawings/Std_Details/D14.3 D- 14.3 eights not clearly outlined in the plans or ordinate with the Designer/ Engineer to 60 SQ. FT. COVERED PORCH I ..... r,.,...,..,.. . � , 9 g r �. :ctrical device and light fixture locations • • — --- - . .41.1r, , .gip o;: - ctor pulls wire. ° _ — ' ���� � locking as necessary for wall mounted - . .-- .a , . ` ` .es, and fittings, even when work is to be • ' , ' , ••' • ',', + •��% ° -` ` • ` • `. er directly. Review scope of work and / , .., ` .' •...` `, ',* • •-'0= a. • • �, - ` • `- 1 ° • ,. + a 1 interior elevations and coordinate with (E) CONC. DRIVE WAY ` +` ` •*+* ` * - - • • •`.`•`•`•` ` ` igineer. AND WALKWAY-- . ,. `. ` .+ . .. + ... . +.. . .y . . + . . .• .` .'. ' . vices to be concealed, unless otherwise 1 . ` . ` • `• ` • `. . ` . ` . .`. .' . , '. , ' • ,' , ' , •` , -, ' ,` ,' _ . . ` (Ey LANDS Af5E. .44 . all exterior doors and windows. W•`• *• � -y •� -` `` • `- `J` �` .` +`� • SHRUB PLANTING . ** *• * **•**- *• •� . wise seal around all openings to limit ,•_- • `- • •`• •• `-` •` - . ` . .`. - . • . ` . • .• . `. .• . ` , ••cluding but not limited to: Exterior joints `•-*,; .A. -.• _ _* (E) GRAS . •+ * • •`•` ` ` • ` • ` •v •` .` . `. `. * ::1" ,.2.: . ( cws and door frames, between sole plates and `•fir •�v+i *•'• ` ` ` ` , :_ •. _ • .- ••• • •• •-• • • •` - :tweenexteriorwallpanels. ,� , `, + , �,� -, - - - � — � •y• -. • � •� •_ . . . ` .+.`..�+• ` + �•��� — . .'.•, _ EE}*f�E* •*.* , + ' , . ' . `.` . _ . . .` ... . ( actor shall verify that all work on the ,;,� - ` O e project is watertight. All joints exposed � . � ` % .', ,` , ` , ' � ' . '• ', ' . ` , ` , ` , ` , ', • , • ,' , • `*`, • , -. . . nts shall be tested for water tightness prior c::✓� i► • , ` * ` ,• • ` ` , ' , ' _- _' _' ' '• '_- ` •- • - II completion. ` Q►a �� , ` .' . ' •. . ' . ` . I 75.00 -)4) ( (E)LOCATION .-- CURB-CUT m.1 URB-CUTS �.. �.w-. u :_u �_ WATER METER Y :._-_..^��i 0.F , ' Wv- i (E) L OCATI .� .., _. _ � __ _ �. � / SEWER CL PROPOSED S IT EP LAN - _- Z:i )/174.74111-r--- 1/8„ ci city of�;arn11 �tA�N1�2��tti�tst®N CL � � ®> NOTE -. flan Gliec;4t �- , ALL NEW ELECTRICAL/CABLE/TELE SERVING THE SITE WILL BE INSTAL ��''' e� -- ')UNDERGROUND PER CMC 21.18.14! 7 Rel ? Vil (..i.,:o....- - q MCBAIN AVE. - FAH ED D HABAYE B r � \h PLANNING & DESIGN PROJECT TITLE Ihr- 1S�( 2©ice ri 686 STOCKTON AVE. FAUCETTE RESIDENCE 3o' Member SAN JOSE, CA. 95126 TEL: (408) 483-0302 1087 M C BAI N AVE- E-MAIL: habayeb3@aol.com CAMPBELL, CA_ a _ _ I w p � _ � m m JJ- N 1 < o agWRpo 3 y s o a < e z iiiz .__ z �sw ws oow e o _LLLL� o9yi o> ≥gam g' o �•a ,w. d o e�m ry� U �m Z o M p(� ❑z m z ILW z w �...�, 1 __ B i �QUJJJfJJTTWZ ���� °o +� / z LL F ❑H 9 a Q -- B W Nrw o,or r o a z W > a p w e bL _ — e "w w ° Z Z -H W _ ��p Fzs�p ❑W Q t � p csc,w o � �� �� � -- '�'%' aw ,i�p `'.; ' °off °� � IL � o � o LZ L �$ r zo as s m .EE y,o tic v a m v _ m •mow /y�,1�IT/j�' ._m 5 c�E 9ah'e 8 = 'm �vqv vtt mm'4 c o E� - da ¢ e c s gF $ �. N amx E @ yg8 ,nom mow^ 0 8Wq e7e� €` 2€_ aE4 �� �qq�@ g°€ g �:� s;m$ olm �ZZ� F2 8=„& sg rsg s s2 a8 -fig&' mg8 B- Y Z & � @ s @g' _ E` ,g. o P s F g @ X48 G� W mz 38 sZ w m u 3683 c,�sm8 s° x g & m pe ass F d� 3° s°@g . $s8 IR 9�mss 8ga „vEB,x:�'ssm ao =_ 8,"o� 8mg e$�o � 2 3 Page 1 of 1 JoAnna Thomason From: JoAnna Thomason Sent: Tuesday, February 18, 2014 10:43 AM To: 'faucette.thomas@gmail.com' Subject: Mail Returned from 1087 McBain Ave. Good Morning Mr.. Faucette, I mailed the reimbursement check for your Faithful Performance Security refund, and it was returned back to me stamped "No Mail Receptacle". Is there another address that you are using for your mail? Thank you JoAnna JoAnna Thomason I Office Assistant Public Works Department Joannat@cityofcam_pbell.com It 408.866.2150 I ,,g5 408.376-0958 (fax) 70. N. First Street I Campbell, CA 95008 www.CityofCampbell.corn °A S \\ 1C) sc C X \aSta— CA . 2/18/2014 • Oj.CA (75 CITY OF CAMPBELL Public Works Department February 12, 2014 Mr. Thomas Faucette 1087 McBain Ave. Campbell, CA 95008 Re: Refund of Faithful Performance Security Deposit Permit ENC2013-00071 Dear Mr. Faucette: The Public Works Department granted conditions of approval prior to receiving your building permit. After further review of your Application for a Building Permit (No. BLD 2013-00052 - Major Remodel and Addition of SFR), Public Works has determined that you will not be required to install portions of the street improvements at this time. Instead, all street improvements shall be installed at a future date when the City determines the improvements are needed. Per the executed Deferred Street Improvement Agreement dated April 29, 2013, the deferred improvements shall include, but are not limited to, relocation of utility poles and facilities as required, installation of curb, gutter, sidewalk, ADA compliant driveways, street trees, street lights, necessary drainage facilities and necessary conforms to existing improvements. Due to our decision to defer these improvements, we are returning your Faithful Performance Security Deposit of$2,800.00 for the portion of improvements that were to be done fronting 1087 McBain Avenue. If you have any questions or need any further clarification, I can be reached at 408-866-2157 or dorisgh@cityofcampbell.com. Thank your 06,tan 11-9-1 Doris Quai Hoi Assistant Engineer City of Campbell Enclosure: Check#245294 Recorded Deferred Street Improvement Agreement 70 North First Street • Campbell, California 95008-1423 • TEL 408.866.21 50 • FAX 408.376.0958 • Trm 408.866.279(1 H CITY OF CAMPBELL VENDOR NO. 10012547 CHECK NO. 245294 Account Purchase Order Invoice Number Amount Description 101.540 7448 CR11014 2,800.00 FPS DEPOSIT REFUND C n 10012547 THOMAS J.FAUCETTE F DO NOT ACCEPT THIS CHECK UNLESS THE PINK LOCK&KEY ICONS FADE WHEN WARMED AND YOU CAN SEE A HEXAGON-SHAPED TRUE WATERMARK WHEN HELD TO THE LIGHT H oC*CA-4//4 CITY OF CAMPBELL WELLS FARGO BANK, N.A. CHECK DATE CHECK NO. • 11-24 4 2 0 MONTGOMERY STREET 1210 02/10/14 245294 t6 70 NORTH FIRST STREET SAN FRANCISCO, CA 94104 , 0, r CAMPBELL, CALIFORNIA 95008 0 ' '1�:; C AMOUNT $ *****2 , 800 . 00* okc11Aso• VOID AFTER 90 DAYS o PAY THE SUM OF TWO THOUSAND, EIGHT HUNDRED DOLLARS & ZERO CENTS Ei To THE THOMAS J. FAUCETTE J ORDER 1087 MCBAIN AVE CAMPBELL CA 95008 u' 2I, 5294II' : L210002Lai: 4L2La554L5u■ U • : EA NTHE INKL•CK: KEYIC,NS-CILI WILLFAl THEN E E'. IN N UTHENTICCHECK-IFG'.L0 :,.ESN,TFAIE,,N®T CC T 'See ReverseSide For Easy Opening n tr chons" CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 THOMAS J. FAUCETTE 1087 MCBAIN AVE CAMPBELL CA 95008 Refundable Deposit Check Request To: Finance Director vv' h Check Payable To: Thomas J. Faucette . Address- Line 1: 1087 McBain Ave. Line 2: City: Campbell State: CA Zip: 95008 Description: FPS deposit refund Account Number: 101.2203 Amount: $2,800.00 Account Number: Amount: Account Number: 101.540.7448 Amount: (Finance Dept only) Interest Earned (Finance Dept only) Total Payable: (Exact Amount) Purpose: Refunding FPS deposit -not needed because of De erred SIA Voucher#: Permit#: ENC2013-00071 Receipt#: ^247941 Date: 4/26/2013 Requested by: 2)(0A Title: 1�✓5i%�,I� t cr4 Date: ViOi IDorisuai'H i e.._) r I i Approved by: (�1�,� r Title: City Engineer Date: I:L 1 Michelle Quinney Finance Dept Only: Verified by: Title: Accounting Clerk II Date: Approved by: Title: Accountant Date: Special Instructions For Handling Check Mail As Is: Mail in Attached Envelope: "`'--,� Interim Check: Needed By: Return To: JoAnna Thomason Public Works (Name) Department) Other: f/n:Forms/excel/chkreq - Revised 05/00 DOCUMENT : 2225195 Pages: 14 • Fees. . . . No Fees II HIM Recording Requested By: ) I II Taxes. . . ) Copies City of Campbell ) - �,�.S�qS� AMT PA I D ) C REGINA ALCOMENDRAS RDE # 001 And When Recorded Return To: ) SANTA CLARA COUNTY RECORDER 6/06/2013 ) Recorded at the request of 11 :38 AM City Clerk ) City City of Campbell ) 70 N. First Street ) Campbell, CA 95008 ) APN: 288-10-013 (Space above this line for Recorder's use only.) ADDRESS: 1087 McBain Avenue,Campbell,CA 95008 DEFERRED STREET IMPROVEMENT AGREEMENT THIS AGREEMENT, identified as File No. BLD 2013-00052, made and entered into this 2-9 day of 'p e I , 2013, by and between Thomas J. Faucette and Mindi Kim, husband and wife as community property with right of survivorship, hereinafter referred to as "Owner," and the CITY OF CAMPBELL, a municipal corporation of the County of Santa Clara, State of California, hereinafter referred to as "City." WHEREAS, City granted conditional approval of Building Permit BLD 2013-00052 upon that certain real property as described in deed recorded on September 28, 2012, Document number 21878859, recorded in the Office of the County Recorder, County of Santa Clara, State of California, which property is hereinafter referred to as "said real property" and commonly known as 1087 McBain Avenue; • WHEREAS, compliance with the terms and conditions of this agreement are conditions to the final approval (Exhibit A) of above described application to construct a building addition to and remodel an existing single family residence, NOW, THEREFORE, IN CONSIDERATION OF THE ABOVE-MENTIONED APPROVAL, it is hereby agreed as follows: (1) Owner shall provide, construct and/or install at his own proper cost and expense, public street improvements within 12 months from the date when owners or their successors are notified to do so by the City Engineer. (2) All of said improvements shall be constructed and/or installed within 12 months from the date that Owners, or their successors, are notified by said City Engineer to do so; provided however, that in the computation of said twelve-month period, delays due to or caused by acts of God, viz., unusually inclement weather, major strikes, and other delay beyond the control of Owners shall be excluded. THE FOREGOING INSTRUMENT IS A TRUE AND CORRECT COPY OF THE ORIGINAL ON FILE IN THIS OFFICE. J:\LandDev\Forms\SI\Specific Agreements\McBain 1087 Deferred Agreement.doc(Rev. 04/12) ATTEST: ANNE BYBEE,CITY CLERK �l OF SY (\\130.)/Q DATED /AQ/l2 • It is expressly understood and agreed to that if Owner shall fail to complete the work required by this Agreement within the said 12 month period, the City, after giving thirty (30) days written notice thereof to Owner, or his successors, may construct and/or install said improvements and recover the full cost and expense thereof from owner, or his successors. It is further expressly understood that the purpose of this agreement is to defer construction of the above-mentioned improvements until some future date more conducive to the overall needs of the City of Campbell. In keeping with this understanding, the right of the City to give any of the notices specified herein in Section (2) of this Agreement to install such improvements, or to require construction or installation of such improvements, or to install such improvements itself and recover the costs thereof shall not be barred by the passage of time or delay by the City, but shall remain open and enforceable indefinitely and forever. It is also understood that the passage of time or any delay caused by the City shall not relieve the Owners, or their successors, from performance under this Agreement, but that the Owners, and their successors, shall remain bound indefinitely and forever. Any increased construction or preparation costs caused as the result of the passage of time shall be the responsibility of the Owners, and their successors. Nothing herein shall be deemed to prohibit construction of said improvements prior to notice by the City Engineer to construct or install such improvements, provided that prior to such installation, all of the provisions of Section (3) shall be satisfied. (3) Owner, or his successors, shall cause to be prepared at his cost and expense improvement plans for the construction and/or installation of said improvements prior to such construction or installation. Said plans shall be prepared by a civil engineer registered by the State of California and submitted to the City Engineer for examination and approval. All of said improvements shall be constructed and/or installed in accordance with those plans approved by the City Engineer and shall be made under the supervision and inspection and to the satisfaction of the City Engineer. Said construction and/or installation shall be in accordance with the existing ordinances and resolutions of the City of Campbell and to all plans, specifications, standards, sizes, lines and grades approved by the City Engineer, and all State and County statutes applicable thereto. Upon completion and acceptance of the improvements by City, Owner, or his successors, shall provide reproducible as-built plans to the City Engineer. (4) The construction work of the improvements embraced by this Agreement shall be done in accordance with the specifications of the City of Campbell and West Valley Sanitation District, where indicated. (5) Prior to approval of the plans by the City Engineer pursuant to Section (3) of this Agreement, Owner, or his successors, shall pay to the City for examination of improvement plans, field inspection of construction of improvements and all necessary expenses incurred by City in connection with said improvements, a sum to be determined when said plans are submitted in accordance with the rules in effect at that time. J:\LandDev\Forms\SI\Specific Agreements\McBain 1087 Deferred Agreement.doc(Rev.04/12) - 2 - • (6) Owner, or his successors, shall file with City, prior to commencing work, surety, acceptable to City, to ensure full and faithful performance of the construction of all the aforementioned improvement work, excluding sanitary sewers and water distribution system. Said surety shall guarantee that Owner, and his successors, will correct any defects which may appear in said improvement work within one (1) year from the date of acceptance of the work by City and pay for any damage to other work resulting from the construction thereof, as well as pay the cost of all labor and materials involved. This surety shall remain in effect until one (1) year after date of final acceptance of said improvements by City. Said surety amount may be reduced by the City Engineer after the date of final acceptance to not less than twenty-five(25) percent of its full value. (7) Upon final release of said surety by City, the obligations of Owner, and his successors, contained in this Agreement shall be considered null and void. (8) When called upon by City to do so, Owner, or his successors, will execute a petition for the formation of any special assessment district created pursuant to any special assessment act as provided in the Streets and Highways Code of the State of California created for the purpose of constructing and/or installing any or all of said improvements. (9) Owner, or his successors, shall participate in and become a part of any special assessment district as described in paragraph (8) of this Agreement. It is expressly understood that any obligations of Owner, or his successors, contained in this Agreement that are accomplished to the satisfaction of said City Engineer by said special assessment district shall be considered null and void. (10) Notwithstanding anything contained in this Agreement to the contrary, at any time prior to Owner commencing work on the public street improvements required of Owner, the City may in its sole discretion elect to install the street improvements itself upon giving Owner 30 days advance notice of the City's intention to so do. In the event that the City elects to install the public street improvements itself, Owner shall reimburse the City for all costs of installing the public street improvements within 30 days of being presented with a statement of those costs. (11) Right of Lien: In the event that Owner fails to reimburse the City for the costs of installing the public street improvement ("default") as required by section (10) of this Agreement, the City shall have and may execute the absolute right, at the City's option and without demand or notice to Owner, to claim and impose a lien, attached as Exhibit B and incorporated herein by this reference ("Lien") , on said real property( also referred to herein as "Collateral"). City's failure to exercise this option will not constitute a waiver of the right to exercise it in the event of any subsequent default. (a) Amount of Lien: The Lien shall be for the entire amounts then owing under section (10) of this Agreement. J:\LandDev\Forms\SI\Specific Agreements\McBain 1087 Deferred Agreement.doc(Rev.04/12) - 3 - • (b) Recordation: City is authorized to record the Lien in the appropriate Recorder's Office(s). (c) City shall have full authority to perform all acts and things that City may consider necessary or advisable to impose, maintain and enforce the Lien. (d). Debtors' Warranty: OWNERS WARRANT that they are the owners of the Collateral and Owners have the right to make this Lien Agreement. (e) Debtors' Covenants: Owners agree: (i). To pay City all amounts payable pursuant to section (10) of this Agreement on or before the due date when due and payable, and to perform all terms of this Agreement; (ii) To defend the Collateral against claims and demands of all persons and entities; (iii). To keep the Collateral in good condition; to perform other acts that may be necessary to preserve the Collateral and protect the Collateral against unreasonable loss and all hazards, and; (iv) To immediately notify the City in writing when Owners become aware of any event that substantially affects the value of the Collateral, or the rights and remedies of City in relation to the Collateral. (f) Prohibitions: Without the prior written consent of the City, Owners will not permit any liens or security interests (other than the City's Lien) to attach to the Collateral; permit the Collateral to be levied on under legal process; dispose of the Collateral; or permit anything to be done that may impair the value of the Collateral or of the Lien, which is the subject of this Agreement. (g) Notices: Any notice, demand or request required hereunder, or by law, shall be given in writing(at the addresses set forth below)by any of the following means: (a) personal service; (b) facsimile; (c) overnight courier or delivery service; or (d)registered or certified, first class U.S. mail, return receipt requested. (12) Owner, or his successors, shall make such deposits or file such bonds and enter into such agreement as required by West Valley Sanitation District to ensure the installation of a sanitary sewage system to serve said real property, and Owner, or his successors, shall file with City, upon execution of this Agreement, a letter from said Sanitation District stating that Owner, or his successors, have made such deposits or filed such bonds and entered into such agreements. (13) Owner, or his successors, shall enter into an agreement and pay to Pacific Gas and Electric Company any and all fees required for installation of underground wiring circuit to all J:\LandDev\Forms\SI\Specific Agreements\McBain 1087 Deferred Agreement.doc(Rev.04/12) - 4 - electroliers within said real property when Owner, or his successors, is notified by either the City Engineer or the Pacific Gas and Electric Company that said fees are due and payable. Owner's, and his successors', obligations under this section shall not be relieved by delay or the passage of time,but shall remain binding indefinitely and forever. Owner, or his successors, shall enter into an agreement and pay to Pacific Gas and Electric Company any and all fees required for the relocation of utility facilities when Owner, or his successors, is notified by the City Engineer that relocation of utility facilities are required. (14) Owner, or his successors, shall make such deposits or file such bonds and enter into such agreement as required by San Jose Water Company when called upon to do so to ensure that installation of a water distribution system to serve said real property, including fire hydrant. Owner's, and his successors', obligations under this section shall not be relieved by delay or the passage of time, but shall bind Owner and successors indefinitely and forever. (15) Any easement and right-of-way within or without said real property necessary for the completion of the improvements shown upon aforesaid improvement plans shall be acquired by Owner, or his successors, at his own cost and expense. It is provided, however, that in the event eminent domain proceedings are required for the purpose of securing said easement and right-of-way, Owner, or his successors, shall deposit or cause to be deposited with City a sum covering the reasonable market value of the land proposed to be taken and to be included in said sum shall be a reasonable allowance for severance damages, if any. It is further provided that in addition thereto such sums as may be required for legal fees and costs, engineering and other incidental costs shall be deposited with the City. (16) Owner, or his successors, shall carry out any and all negotiations with all interested parties and shall perform or cause to be performed at his own cost and expense and to the satisfaction of the City Engineer any and all work required to abandon, remove, raise, lower, relocate and otherwise modify irrigation line or lines within the boundary of said real property. (17) To the fullest extent permitted by law, Owner, and his successors, shall indemnify, defend and hold the City of Campbell, its agents, employees, attorneys, officers, officials, and assignees harmless from any and all claims, damages, losses and expenses, including, but not limited to, attorneys' fees, arising out of, or resulting from any negligent or intentional act or omission (including misconduct) of said Owner, or his successors, or any subcontractor, or anyone directly or indirectly employed by him, or anyone for whose acts any of them may be liable in the course of performance of this Agreement. The Owner, and his successors, shall also indemnify, defend and hold the City of Campbell, and its agents, attorneys, employees, officers, officials, and assignees harmless against and from any and all claims, demands, liabilities, losses, lawsuits,judgments, damages, costs and expenses (including, but not limited to, attorneys' fees and court costs, whether incurred at trial, appellate or administrative levels) which the City of Campbell may incur or suffer, or to which the City of Campbell may be subjected resulting from the failure of Owner, or his successors, or J:\LandDev\Forms\SI\Specific Agreements\McBain 1087 Deferred Agreement.doc(Rev.04/12) - 5 - his agents, employees, subcontractors, or anyone performing services under him, to fulfill any of the obligations imposed under this Agreement. (18) It is acknowledged that the provisions of this Agreement constitute covenants for the improvement of the subject real property for the mutual benefit of Owner's property, commonly known as 1087 McBain Avenue and the City's property, commonly described as McBain Avenue where it adjoins Owner's property. These covenants shall be considered to affect rights in the above-described real properties, and shall be binding on the heirs, assigns, successors, and grantees of Owner to said real property. (19) Nothing contained herein shall be construed to transfer any unvested interests in real or personal property for purposes of the rule against perpetuities. (20) In the event that Owner, or his successors, should breach any of the terms, conditions, or covenants of this Agreement, the City shall be entitled to recover, in addition to any other relief available in law or equity, all costs incurred in attempting to obtain enforcement of the Agreement, or compensation for such breach. These costs shall include reasonable attorneys' fees and court costs. (21) This is the entire Agreement between the parties and there are no representations, agreements, arrangements, or understandings that are not fully expressed herein. (22) This Agreement can be executed in counterparts by the parties hereto, and as so executed shall consist of one agreement, binding on all the parties. J:\LandDev\Forms\SI\Specific Agreements\McBain 1087 Deferred Agreement.doc(Rev.04/12) - 6 - IN WITNESS WHEREOF, said City has caused its name to be affixed by its City Engineer and City Clerk, who are duly authorized by Ordinance 2059 adopted September 20, 2005, and said Owner has caused his name to be affixed the day and year first above written. Thomas J. Faucette and Mindi Kim, husband and wife as co ty property with right of survivorship Thomas J. Faucette (. _ Mindi m A a(-h-ti R c. ,J le.c3O„-,,c-,f (Notary Acknowledgment for above signator(ies) MUST be attached) CITY/� OF CAMPBELL � ` � AT -8T: /l��L��-l�f � � Michelle Quinney 7./_ ______ City Engineer, City of Campbell e' Anne Bybee 70 N. First Street Campbell, California 95008 (Attach Notary Acknowledgment for all parties) J:\LandDev\Forms\SI\Specific Agreements\McBain 1087 Deferred Agreement.doc(Rev.04/12) - 7 - MEMORANDUM CITY OF CAMPBELL TO: Bill Bruckart,Building Official DATE: 02/15/13 FROM: Ed Arango, Associate Engineer (408) 866-2166 CC: Arsin Ghazancheir SUBJECT: BUILDING PERMIT APPLICATION Site Address: 1087 McBain Avenue For File No(s): BLD 2013-00052 Project Description: Major Remodel and Addition of SFR Applicant: Arsin Ghazancheir PUBLIC WORKS DEPARTMENT CONDITIONS OF APPROVAL 1. Plan Lines: Prior to issuance of any grading or building permits for the site, the applicant shall provide a plan layout showing the correct street dimensions (dimension widths of entire street and dimension from property line to centerline of roadway), and existing street improvement dimensions (sidewalk, curb, gutter, etc) and other relevant information in the public right of way. 2. Proof of Ownership: Prior to issuance of any grading, drainage, or building permits for the site, the applicant shall provide a current Preliminary Title Report, grant deed, or other satisfactory proof of ownership. 3. Storm Drain Area Fee: Prior to issuance of any grading or building permits for the site, the applicant shall pay the required Storm Drain Area fee, currently set at $2,120 per net acre, which is $445. 4. Deferred Street Improvement Agreement: Prior to issuance of any grading or building permits for the site, the owner shall execute a deferred street improvement agreement for construction of standard street improvements. Unless otherwise approved by the City Engineer these improvements shall include, but are not limited to,relocation of utility poles and facilities as required, installation of curb, gutter, sidewalk, ADA compliant driveways, street trees, street lights, necessary drainage facilities and necessary conforms to existing improvements. 5. Street Improvements: Prior to issuance of any grading or building permits for the site, the applicant shall cause plans for public street improvements to be prepared, pay various fees and deposits, post security and provide insurance necessary to obtain an encroachment permit for construction of the standard public street improvements, as required by the City Engineer. The plans shall include the following, unless otherwise approved by the City J:\LandDev\Conditions\Bldg\McBain 1087.DOC Page 1 of 3 1087 McBain Avenue Engineer: a. Show location of all existing utilities within the new and existing public right of way. b. Removal of existing driveway approach and necessary curb and gutter. c. Installation of City standard ADA compliant driveway approach. d. Installation of asphalt concrete overlay per street pavement restoration plan for utility installation and/or abandonment, as required by the City Engineer. e. Construction of conforms to existing public and private improvements, as necessary. 6. Maintenance of Landscaping: Owner(s), current and future, are required to maintain the landscaped park strip and tree wells in the public right of way. This includes, but is not limited to: trees, lawn, plantings, irrigation, etc. Trees shall not be pruned in a manner that would not allow the tree to grow to a mature height. 7. Utilities: All on-site utilities shall be installed underground per Section 21.18.140 of the Campbell Municipal Code for any new or remodeled buildings or additions. Applicant shall comply with all plan submittals, permitting, and fee requirements of the serving utility companies. 8. Water Meter(s) and Sewer Cleanout(s): Proposed water meter(s) and sewer cleanout(s) shall be relocated or installed on private property behind the public right-of-way line. 9. Utility Coordination Plan: Prior to issuance of building permits for the site, the applicant shall submit a utility coordination plan and schedule for approval by the City Engineer for installation and/or abandonment of all utilities. The plan shall clearly show the location and size of all existing utilities and the associated main lines; indicate which utilities and services are to remain; which utilities and services are to be abandoned, and where new utilities and services will be installed. Joint trenches for new utilities shall be used whenever possible. 10. Pavement Restoration: Based on the utility coordination plan,the applicant shall prepare a pavement restoration plan for approval by the City Engineer prior to any utility installation or abandonment. Streets that have been reconstructed or overlaid within the previous five years will require boring and jacking for all new utility installations. McBain Avenue has not been reconstructed or overlaid in the last 5 years. The pavement restoration plan shall indicate how the street pavement shall be restored following the installation or abandonment of all utilities necessary for the project. 11. Utility Encroachment Permit: Separate permits for the installation of utilities to serve the development will be required (including water, sewer, gas, electric, etc.). Applicant shall apply for and pay all necessary fees for utility permits for sanitary sewer, gas, water, electric and all other utility work. J:\LandDev\Conditions\Bldg\McBain 1087.DOC Page 2 of 3 1087 McBain Avenue 12. Additional Street Improvements: Should it be discovered after the approval process that new utility main lines, extra utility work or other work is required to service the development, and should those facilities or other work affect any public improvements, the City may add conditions to the development/project/permit, at the discretion of the City Engineer,to restore pavement or other public improvements to the satisfaction of the City. 13. Stormwater Pollution Prevention Measures: Prior to issuance of any grading or building permits, the applicant shall comply with the National Pollution Discharge Elimination System (NPDES)permit requirements, Santa Clara Valley Water District requirements, and the Campbell Municipal Code regarding stormwater pollution prevention. The primary objectives are to improve the quality and reduce the quantity of stormwater runoff to the bay. Resources to achieve these objectives include Stormwater Best Management Practices Handbook for New Development and Redevelopment ("CA BMP Handbook") by the California Stormwater Quality Association (CASQA), 2003; Start at the Source,. A Design Guidance Manual for Stormwater Quality Protection ("Start at the Source") by the Bay Area Stormwater Management Agencies Association (BASMAA), 1999; and Using Site Design Techniques to Meet Development Standards for Stormwater Quality: A Companion Document to Start at the Source ("Using Site Design Techniques") by BASMAA, 2003. 14. Occupancy and Building Permit Final: Prior to allowing occupancy and/or final building permit signoff for any and/or all buildings, the applicant shall have the required street improvements installed and accepted by the City, and the design engineer shall submit as- built drawings to the City. J:\LandDev\Conditions\BldgVvlcBain 1087.DOC Page 3 of 3 Exhibit B Recording Requested By: ) ) City of Campbell ) ) When Recorded Mail To: ) ) City Clerk ) City of Campbell ) 70 N. First Street ) Campbell, CA 95008 ) ) ) Space above this line for Recorder's use only CLAIM OF LIEN „ I, MICHELLE QUINNEY, City Engineer for the City of Campbell, a California Municipal Corporation ("City"), do hereby certify: A. On or about , 20_, ("Debtors") executed a Deferred Street Improvement Agreement with the City of Campbell ("Deferred Street Improvement Agreement"). B. The Deferred Street Improvement Agreement was recorded in the Santa Clara County Recorder's Office on or about , 20_ Document Number C. The Deferred Street Improvement Agreement required the Debtor's to provide, construct, and/or install certain street improvements in front of their property at , Campbell, California, at their own costs and expense, within 12 months from the date when [owner name] or their successors, were notified to do so by the City Engineer. Pursuant to the terms of the Deferred Street Improvement Agreement, the Debtors expressly agreed that if they failed to complete the work required by the Deferred Street Improvement Agreement within the specified 12 month period, the City was authorized to construct and/or install said improvements and recover the full cost and expense thereof from the Debtors or their successors. D. The Debtors did not complete the work as required by the Deferred Street Improvement Agreement. Therefore, the City constructed and installed said improvements. E. In , 20 , the City informed the Debtors about the improvements that would be installed pursuant to the Deferred Street Improvement Agreement. - 1 - • F. The City subsequently completed the improvements. On or about , 20 , the City sent the Debtors an invoice for said improvements in the amount of$ G. Pursuant to the terms of the Deferred Improvement Agreement, the Debtors expressly agreed that the City is authorized to, at the City's option and without demand or notice to the Debtors, immediately claim and impose a lien on the real property commonly known as , Campbell, California, APN Number , for the entire amounts then owing under, or incurred pursuant to, the Deferred Improvement Agreement, including without limitation, the entire unpaid principal amount. WHEREFORE, the City of Campbell, A California municipal corporation, pursuant to the Deferred Improvement Agreement, hereby claims a lien upon the work of improvement and the land upon which it is situated, namely, the real property commonly known as Campbell, California, APN Number 5, in the amount of $ and said amount shall constitute a lien against said property until paid in full. IN WITNESS WHEREOF the City of Campbell, California, a California Municipal Corporation, has duly authorized the undersigned to execute this instrument in its name. Dated: By: for the CITY OF CAMPBELL, a California municipal corporation (Notary Acknowledgement Required for Signatures) - 2 - • CALIFORNIA ALL-PURPOSE CERTIFICATE OF ACKNOWLEDGMENT State of California County of 5 0,n�,k. C.c,v- On GjI2 1201 before me,(--ao50-no- el lJo+c r (Here insert nUrrfe and title of the office personally appeared o m a 5 . A u..C.e_t e d M; A d t k; n--) who proved to me on the basis of satisfactory evidence to be the person(s)whose name(s) is/,re ubscribed to the within instrument and acknow -•,ed to me that he/she e -xecuted the same in his/herftheir authorized capacity(ies), and that by his/he ;their ignature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. 1ROSANAEAZNAD W ESS m hand and officials c Commission #�1906454 y -�; � Notary Public -Calitomla L7M. Santa Clara County Comm. Tres Nov 6,2014 (Notary Seal) Signature of Notary Public ADDITIONAL OPTIONAL INFORMATION INSTRUCTIONS FOR COMPLETING THIS FORM Any acknowledgment completed in California must contain verbiage exactly as DESCRIPTION OF THE ATTACHED DOCUMENT appears above in the notary section or a separate acknowledgment form must be ,JJ properly completed and attached to that document. The only exception is if a J�f r� , +rat Z►�► f o try e / document is to be recorded outside of California.In such instances,any alternative (Title or description of attached document) acknowledgment verbiage as may be printed on such a document so long as the verbiage does not require the notary to do something that is illegal for a notary in ti;:if—trvitle � � Califontia (i.e. certifying the authorized capacity of the signer). Please check the or description of attached document continued) document carefully for proper notarial wording and attach this form if required. • State and County information must be the State and County where the document Number of Pages 1 Document Date 04 I Zq 12..►3 signer(s)personally appeared before the notary public for acknowledgment. • Date of notarization must be the date that the signer(s)personally appeared which must also be the same date the acknowledgment is completed. (Additional information) • The notary public must print his or her name as it appears within his or her commission followed by a comma and then your title(notary public). • Print the name(s) of document signer(s) who personally appear at the time of notarization. CAPACITY CLAIMED BY THE SIGNER • Indicate the correct singular or plural forms by crossing off incorrect forms(i.e. ❑ Individual(s) he/she/thej;-is/are)or circling the correct forms.Failure to correctly indicate this information may lead to rejection of document recording. ❑ Corporate Officer • The notary seal impression must be clear and photographically reproducible. Impression must not cover text or lines. If seal impression smudges, re-seal if a (Title) sufficient area permits,otherwise complete a different acknowledgment form. ❑ Partner(s) • Signature of the notary public must match the signature on file with the office of the county clerk. ❑ Attorney-in-Fact Additional information is not required but could help to ensure this ❑ Trustee(s) acknowledgment is not misused or attached to a different document. ❑ Other •. Indicate title or type of attached document,number of pages and date. Indicate the capacity claimed by the signer. If the claimed capacity is a corporate officer,indicate the title(i.e.CEO,CFO,Secretary). • Securely attach this document to the signed document 2008 Version CAPA v12.10.07 800-873-9865 www.NotaryClasses.com • -------- - ._.11 II !� CALIFORNIA ALL-PURPOSE CERTIFICATE OF ACKNOWLEDGMENT State of California ! County of=)-,,,n-cx_ (:_\__'\c,,.,(O,.._- 1 On \Mo...\ 30 ac(� before me, j\. c \�"\t3NC - T\A- \AC:Ac��t1 �lAb\t(1 , r (Here insert name and tlitle of the officer) personally appeared k c.c E\\E,, (((i t,(w\C:?` , who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s)on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. .. JOANN THOMASON WITS my hand and official seal. . Commission 0 1930682 tt �� c -V.- Notary Public-California Z ) Santa Clara County �,,. e -21-,C tot/�R (Notary Seal) _ _ MI Comm.Expires Mar 28,2015 C Signature of(�`lotary`ILtblic _ —— — — — — ——— • ADDITIONAL OPTIONAL INFORMATION INSTRUCTIONS FOR COMPLETING THIS FORM I Any acknowledgment completed in California must contain verbiage exactly as DESCRIPTION OF THE ATTACHED DOCUMENT appears above in the notary section or a separate acknowledgment form must be properly completed and attached to that document. The only exception is if a (,PA 11f C '\ ll's,le document is to be recorded outside of California.In such instances,any alternative acknowledgment verbiage as may be printed on such a document so long as the (Title or description of attached ocument) verbiage does not require the notary to do something that is illegal for a notary in . �� �P e����� California (i.e. certifyng the authorized capacity of the signer). Please check the (Sitle or description of attached document continued) document carefully for proper notarial wording and attach this form if required. • State and County information must be the State and County where the document Number of Pages Document Date signer(s)personally appeared before the notary public for acknowledgment. • Date of notarization must be the date that the signer(s)personally appeared which must also be the same date the acknowledgment is completed. i (Additional information) • The notary public must print his or her name as it appears within his or her commission followed by a comma and then your title(notary public). I • Print the name(s) of document signer(s) who personally appear at the time of notarization. CAPACITY CLAIMED BY THE SIGNER I • Indicate the correct singular or plural forms by crossing off incorrect forms(i.e iI he/she/the,,-is/are)or circling the correct forms.Failure to correctly indicate this ❑ Individual(s) information may lead to rejection of document recording. ❑ Corporate Officer • The notary seal impression must be clear and photographically reproducible. Impression must not cover text or lines.If seal impression smudges,re-seal if a I (Title) sufficient area permits,otherwise complete a different acknowledgment form. ❑ Partner(s) • Signature of the notary public must match the signature on file with the office of the county clerk. ❑ Attorney-in-Fact •. Additional information is not required but could help to ensure this I ❑ Trustee(s) acknowledgment is not misused or attached to a different document. ❑ Other Indicate title or type of attached document,number of pages and date. •. Indicate the capacity claimed by the signer. If the claimed capacity is a I,corporate officer,indicate the title(i.e.CEO,CFO,Secretary). I+ • Securely attach this document to the signed document LL_. __::_:--- _.._. 2008 Version CAPA v12.I0.07 800-873-9863 ww.w.NotaryClasses.com