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HomeMy WebLinkAboutENC2013-00121 • Print Form, CITY OF CAMPBELL R-1 ENCROACHMENT PERMIT Permit No. t 2a\3-06 I I 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 G721 13 Campbell,CA 95008 /+ / Application Expiration Ph.(408)866-2150 ISSUED: b! 2 r 3 � Date 12725 13 S Fx.(408)376-0958 Permit Expiration Date: C L //`C APN N0 3l> 7 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 y 1c I a:(-)Ski p Drive Carnpbeh CA G5oO b B. Nature of Work: (de.t�al K__ I ( eC... .rev° nq ` 1 i Ve GOd C. Attach three(3)copies of a drawing showing the location,extent and dimensiOris of the work. The drawin 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: <r-i5 - ^ c n Telephone: L 8,Lf I( _3L/77 Address: 19(0( Kp Ca 1pbe l t .T \ citJaa E-Mail Address: 'i a r CO, 1 D r ) `1 .n K , re+ 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 t ey have read and understand both the front and back of this permit,and that they will inform their contractor(s)of the information. arLed ACCEPTED: ' Zs / (Applica t/Permittee) (Sign) D to 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: --------- - C/2-�//3 for City E ineer Date Permit Expires 6 Months after Date of Issuance. v -1-k f -c I 09-el, Y^, • 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 CI Valley Urban Runoff Pollution Prevention Program. Applicant shall be re onsible for ensuring that all those providing services under the applicant are aware of and understand all of the above con ' ' ns. /2 NI V Applican Date J:\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf Rev.03/13 DWELLING POLICY • LUNEFI ALLIED PROP AND CAS INS CO POLICY NUMBER: DPC 0006863484 4 1100 LOCUST ST ACCOUNT NUMBER: 669840966 DES MOINES, IA 50391-1100 (800)282-1446 AGENCY BUTTES INS-OROVILLE Period From: 11/04/20121icy ei11/04/2013 07188 OROVILLE CA 12:01 A.M. Standard Time CONTINUATION DECLARATIONS INSURED NAME AND ADDRESS MORTGAGEE OR ]HER INTEREST i SEVERSON, RON r/4911:) r I t SEVERSON, FRAN 1900 ORO DAM BLVD E STE 12-376 OROVILLE, CA 95966-5934 The limit of liability for the structure(Coverage A)is based on the estimate of the cost to rebuild your borne,including an apprmdmate cost for labor and materials in your area,and specific information that you have provided about your home,THIS POLICY DOES NOT INCLUDE BUILDING UPGRADE COVERAGE, unless you have purchased this ootinnal cayenne for an additional nremium • BILLING INFORMATION TO BE PAID BY NAMED INSURED 'PREVIOUS POLICY NUMBER DPC 0006863484 3 DEDUCTIBLE: In case of loss under this policy, we cover only that part of the loss over the deductible of $250. The described residence premises covered hereunder is located at the Location above address, unless otherwise stated herein. 1461 INSKIP DR 001 CAMPBELL, CA 95008-4404 This insurance applies to the Described Location,Coverage for which a Limit of Liability is shown and Perils Insured Against for which a Premium is state( COVERAGE AND LIMITS OF LIABILITY B. OTHER STRUCTURES C. PERSONAL D. FAIR RENTAL E. ADDITIONAL AMT INCL'D PROPERTY VALUE LIVING EXPENSE AT NO CHG A. DWELLING $ 318,400 $ 31,g401$ 1$ $ 7,500 $ $ PERILS INSURED AGAINST AND PREMIUMS Fire Extended Vandalism or DP3 Coverage Malicious Mischief $ 380.00 $ 113.00 $ INCL $ 119.00 $ $ $ ENDORSEMENT DESCRIPTION LIMIT _ PREMIUM POLICY ENDORSEMENTS DP3 09/83 Special Form DP300CA 09/09 Special Provisions- California INCLUDEI IN2499 10/08 Important Notice INCLUDEI IN0000 04/09 Privacy Stmt INCLUDEI IN2004 03/04 Important Notice INCLUDEI IN0100 01/10 Important Notice INCLUDEI IN3001 03/91 Important Notice INCLUDE] 10783 12/88 Amendment of Conditions INCLUDEI 10940 07/89 California Guarantee Association INCLUDEI TOTAL POLICY ENDORSEMENTS (continued) Not a bill.Your bill is sent separately . TOTAL PREMIUM THIS LOCATION $ 656.00 Effective Date of Change: $ TOTAL PREMIUM ALL LOCATIONS $ 656.00 Additional Premium $ Return Premium $ A Z, This Declarations page replaces all previous Declarations pages for this policy. X ALLIED PROP AND CAS INS CO Countersigned by-Authorized Representative DIRECT BILL 0000 12256 INSURED COPY 78 669840966 4710 / / • ADDITIONAL DWELLING ENDORSEMENTS / Company: ALLIED PROP AND CAS INS CO Policy No: DPC 0006863484 4 DES MOINES, IA 50391-1100 (800) 282-1446 Agency: BUTTES INS-OROVILLE 07188 OROVILLE CA Insured: SEVERSON, RON SEVERSON, FRAN Location ID Described Location: 1461 INSKIP DR 001 CAMPBELL. CA 95008-4404 COVERAGES DESCRIPTION LIMIT PREMIUM LOCATION ENDORSEMENTS 13449 05/95 Inflation Protection INCLUDED IN2014 11/92 Important Notice INCLUDED 11796 08/11 California Res Prop Ins Disclosure INCLUDED 13447 03/93 Lead Poisoning Exclusion-Liab Coy INCLUDED 12567P 01/07 Dwelling Replacement Cost 7.00 15363 12/01 Fungi Property 5,000 INCLUDED 12680 01/98 Personal Liability Schedule 300,000 37.00 13410 12/86 Dwelling Liability Coverage - OL&T INCLUDED 15367 12/01 Fungi Exclusion - OL&T INCLUDED TOTAL LOCATION ENDORSEMENTS 44.00 15070 (01-98) DIRECT BILL 0000 12256 INSURED COPY 669840966 78 4,711 / IN WITNESS WHEREOF, the company listed in the Declarations has caused this policy to be signed by its President and Secretary, and countersigned as may be required on the Declarations page by a duly authorized representative of the company. zrev Lf--�- President-Gary A. Douglas President-David G.Arango Nationwide Agribusiness Insurance Company Nationwide Assurance Company fl -(4 President-Mark A. Pizzi President-W. Kim Austen Nationwide Affinity Insurance Company of America ALLIED Property and Casualty Insurance Company Nationwide General Insurance Company AMCO Insurance Company Nationwide Mutual Fire Insurance Company Crestbrook Insurance Company Nationwide Mutual Insurance Company Depositors Insurance Company Nationwide Property and Casualty Insurance Nationwide Insurance Company of America Company n1. � . President-Lisa E.Gobber Secretary—Robert W. Homer, III Nationwide Insurance Company of Florida ALLIED Property and Casualty Insurance Company AMCO Insurance Company Crestbrook Insurance Company Depositors Insurance Company baetAj _ � Nationwide Affinity Insurance Company of America Nationwide Agribusiness Insurance Company Nationwide Assurance Company Nationwide General Insurance Company President—David A. Bano Nationwide Indemnity Company Nationwide Indemnity Company Nationwide Insurance Company of America Nationwide Insurance Company of Florida Nationwide Mutual Fire Insurance Company Nationwide Mutual Insurance Company Nationwide Property and Casualty Insurance Company Nationwide,the Nationwide framemark, and On Your Side are service marks of Nationwide Mutual Insurance Company. ©2011 Nationwide Mutual Insurance Company. 13402A(11-11) Page 1 of 1 DPC 0006863484.4 0000 12256 INSURED COPY 78 04712