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CITY OF CAMPBELL R-1 ENCROACHMENT PERMIT Permit No. •Et C 2 c'13 0,0
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 c5/23( l
Campbell,CA 95008 I Application Expiration
Ph.(408)866-2150 ISSUED: 9/2 2 1 i 3 Date
Fx.(408)376-0958 Permit Expiration Date: '/2.3 I/LI- APN .27`-i5clo 5
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: Z0 3 F (PST cT
B. Nature of Work: R Sl 3)Lys-"-LI<
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: f1j1V Telephone: �i }.5.--go2—� C/
Address: c�3 Pr
E-Mail Address: 4j4 //)
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 u stand both the front and back of this permit,and that they will inform their
contractor(s)of the'
ACCEPTED: / Z G�iC�e ( , ?a/ o/
(Applicant/Permittee) (Sign) Date
NOTES: All work shall conform with the attached approved plan 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: D//2 3 1 I
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.
Aplicant shall be responsible for ensuring that all thos oviding services under the applicant are aware of and understand all of the above
conditi
Applicant Date
J:\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf
Rev.03/13
� F \ FARMERS .
OFFER OF CALIFOR...,, EARTHQUAKE
AUTHORITY POLICY A participating Insurer of the
California Earthquake Authority((EA)
AGENT NAME: EMIL SCALIA RESIDENTIAL
AGENT NUMBER: 96 41 375 AGENT PHONE NUMBER: (408) 917-1800 PROPERTY POLICY: 90243-23-24
PRINT DATE: 08-27-2012
INSURED'S NAME:MARIA T.RUIZ,AN UNMARRIED WOMAN
PROPERTY 203 N 1ST ST
LOCATION: CAMPBELL CA 95008-2031
THIS IS AN OFFER OF A CALIFORNIA EARTHQUAKE AUTHORITY(CEA)POLICY IN THE LANGUAGE REQUIRED
BY CALIFORNIA LAW.PLEASE REVIEW THE CONTENTS OF THIS OFFER CAREFULLY.
Your policy does not provide coverage against the peril of earthquake. California law requires that earthquake
coverage be offered to you at your option. California Insurance Code Section 10081 requires all insurers to offer earthquake
coverage with the residential property policy. This requirement may be satisfied by an offer of a California Earthquake
Authority(CEA)policy.This is an offer of a CEA policy.
WARNING:These coverages may differ substantially from and provide less protection than the coverage provided by
your homeowners' insurance policy. There are exclusions and limitations such as outbuildings, swimming pools,
masonry fences, and masonry chimneys.This disclosure form contains only a general description of coverages and is
not part of your earthquake insurance policy. Only the specific provisions of your policy will determine whether a
particular loss is covered and,if so,the amount payable.
The coverage,subject to policy provisions,may be purchased at additional cost on the following terms:
(A) Amount of Dwelling Coverage:
(Referred to as "Building Property" coverage in the CEA Condominium or Cooperative $ 324,000
Unit Policy;this coverage is optional and may be rejected.)
(B) Applicable Deductible: 15%
If your loss is below this amount,you may not receive any payment from your
coverage.Your insurance company or agent will provide written notice as to how the $ 48,600
deductible applies to the market value of your coverage,the insured value of your
coverage,or the replacement value of your coverage.
(C) Contents Coverage: (Referred to as "Personal Property"coverage in the policy.)
If you have a Dwelling Policy and your loss does not exceed the deductible for the
dwelling,you will not receive any payment for this coverage.A$750 deductible $5,000 Per Dwelling Unit
applies to this coverage for Tenants Policies and Condominium or Cooperative Unit
Policies.Your insurance company or agent will provide written notice as to how
the deductible applies to the amount you receive pursuant to this coverage.
(D) Additional Living Expenses: (Referred to as "Loss of Use"coverage in the policy) $1,500 Per Dwelling Unit
(E) Loss Assessment Coverage:
(This coverage is only available for Condominium or Cooperative Unit Policies.
Coverage is optional and may be rejected.) A 15%deductible applies to this coverage.
Your insurance company or agent will provide written notice as to how the deductible $ NO CVG
applies to the amount you receive pursuant to this coverage. *A limit of$25,000 is
available if the condominium unit is valued at$135,000 or less.
Rate or Premium: $ 1,025 .00
THIS COVERAGE SHALL BE EFFECTIVE ON THE DAY YOUR ACCEPTANCE OF THIS OFFER IS RECEIVED BY
YOUR AGENT. WE WILL NOT CONSIDER THE OFFER RECEIVED UNTIL THE EFFECTIVE DATE OF YOUR
RESIDENTAL PROPERTY POLICY.
IF YOU WISH TO ACCEPT A CEA POLICY,PLEASE NOTIFY YOUR AGENT.YOUR AGENT WILL COMPLETE A CEA
APPLICATION FORM.
NO REPLY IS NECESSARY TO DECLINE THIS OFFER.
25-3482 I-09 /3482501