92-124
CITY OP CAIIPULL
DBPJ'. OP PDBUC WORD
70 North Plr.t St.
CUlpbell, CA 9!l0"
(408) 866-2150 .
Pu1a1t N07}.J. ~ q 2- I Z. 4
EIICROAcmmtI'l' PI!RIII'l'
(for working within ~
public right-af_ay) X-Raf. fUe
I..u.s2 - 2. (.. ~ z.. Application Date2!v'L - 2L - 9 2.
hait expire. in 12 _. . Application upiru in 6 110..
APPLICATION - Application i. h~ ..de tor a Public Worb h1'llit in accordance with Caapbdl
MUnicipal COde, Section 11.04. (Application expir.. in 6 IIOntba it ~1'IIit not pulled)
A. Work a~.. or tract. S 7 0 U IV ; o.'\.J A v 7
Utility tnnch location
B. Nature ot work: 5 .~ ' ~ -S ~ <- JI'!:- L "'" ~ A- L
C. Attach tlve (5) copie. ot a drawing ahowing the location, extent ancl d1aenaion. at the work
The drawing ahall ahow the relation at the proposed work to .xi.ting .urtace and undeJ:'l)roUDd
improv_enta. When approv.s by the City Engineer, ..id draw in; beCCIJIU . part at W. pa1'llit.
D. The General Conditiona for all permit. are H.ted on the rever.e .ide. Special Proviaiona tar
thia permit are li.ted below. Pailure to abide by th..e condition. ancl providon. may reault
in jOb .hut-dawn and/or torfeiture at Faithtul Pertormance Sureti.. and caah depo.ita. (See
Ganeral Conditiona 1 and 2).
I. An application
NUle at Applicant
Addre.. I I I"
t.. lIU.t accoapany thi. application.
J :::. IW G (.... A (, L
\)LL~ A-vL. C~P6tL'-
Thi. tee is nan-retundable.
Telephone: 3 79 - "30 i 0
I. this work being done by the property owner at their awn reaidance?
~
-ye.
Complete ancl attach Worker.' coapen.ation and Contractor Into%1llltion tona.
The Applicant/Peaittee hereby aqree. by attixing their eignature to thia permit to hold the City at
campbell, its otficer., aqents and employees tree, .ate and harmle.. tro. any claim or demand tor
damage. re.ulting troa the work covered by this permit.
The Applicant/Permittee hereby acknowledqe. that they have read and understand both the tront and
back at thi. permit, and that the fa their contractor(.) at the intormation.
ACCEPTED \. L -2l9 _e(2
Date
NOTES: ALL WORK SHAL". CONFORH WITH THE ATTACHED, APPROVED PIANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR HOST HAVE THIS PERMIT AND APPROVED PIANS ON-SITE AND HOST" MEET WITH THE P.W.
INSPEcToR ON THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK. APPLICANT HOST CONTACT THE IHSPECTOR
TO ARRANGE FIELD MEETING.
NOTICE HOST BE GIVEN TO POBUC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
SPECIAL PROVTSIONS
_1.
Street ahall not be open cut tor underqround in.tallation.. Kinimua cut. may be allowed
for connection. or exploration hol... Such cut. IllUSt be sl:)eciticallY Ill:)l:)royed bY the
In.aAc~or nrior ~o cu~tina.
pav_ant may be cut for unelerground installationa and lIUSt be re.tored in accordance with
the Utility Trench Restoration Stanelard Drawing.
Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copie. of the
cut aheet. sent to the Public Work Department betore ~tarting work.
The houra at work are limited to outsiele the hours of 7-9 .... and 3-6 p... tar any work
attecting . traffic lane.
~.
3.
=z.
_5.
STANDARD
AMOUNT
RECEIPT NO.
PERKI'1' APPLICHIOH PD
PLUf CHECK DIlIOSIT
SURETY l'OR PAI'l'BPUL PERPOlUWfCE
CASH DEPOSIT
$ IOS.uJ
$
$
$ 50o,oJ
$IOD,GO
2-26-';>2.
$105.00
$500.00
(100' OP ERG. EST.)
(4' OP SURE!Y, $!l00 MZH)
PLUf CHECK . INSPECTION FEE ($0-$100,000 10',
$100,000 - $500,000 9', $500,000 and above 7', $100 KIH)
APPROVED FOR ISSUANCE. ~./ '~.:-zI..-
'--' for City Enqineer ~
f: PW PERMIT
Revised 10/91 (SEE OTHER SIDE)
Date
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(
CITY OF CAMPBELL
70 NORTH FIRST STREET
C AMP BEL L, C A L I FOR N I A 9 5 0 0 8
(408) 866-2100
FAX # (408) 379-2572
Department:
Public Works
June 17, 1992
Mr. John Glage
1116 Dell Avenue
Campbell, CA 95008
SUBJECT: FINAL INSPECTION AND ACCEPTANCE
PERMIT NO.: 92-124
LOCATION: 570 UNION AVENUE
Dear Mr. Glage:
We have made a final inspection of subject Public Works
construction and find it acceptable and in conformance with City
standards. Accordingly, we will recommend the acceptance of the
work to the City Engineer.
Enclosed is your faithful performance deposit of $500.00.
Please feel free to call me if you have any questions.
Sincerely,
Cl- ~ J5 (J--//.~
~~n ~ollier
City Engineer
JB/HI:djr
f:92-124
I.,. /, {. "i.
~ - f<.----~;/ l;:,'
.~ II C)C6---i
/ ,. '7 ./
I ( t .I 2. .c--
REFUNDABLE DEPOSIT
CHECK REQUEST
TO: SANDY TERPKO
ACCOUNTS RECEIVABLE
Pl ease issue check payabl e to: John Glage
Address:
Line 1: 1116 Dell Avenue
Line 2:
Ci ty: Campbell
State: CA Zip: 95008
-
Description: Ref Deposit/Permit No:
Exact Amount Payable: $500.00
92-124 INTEREST EARNED
Account Number: 001.00.905.4662
001.05.540.4448
LOCATION: 570 Union Avenue
DATE AND NO. OF RECEIPT: 2-26-92 #38583
PURPOSE:
Return of Cash Deposit
Requested by: H. Imokawa 7-I.J . Title: P. W. Inspector Date: 6-17-92
Approved by: -F.9J j)~~ Title: City Enqineer Date: (.,/~/9L
, I
oan olller
Verified by: Title: Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as is
Mail in attached envelope
Return to: Public Works
(Department)
Hank Imokawa
(Name)
Other:
tItuk. ~ ~ -10 ~ 6/LjL
fZV ~ /IJ/7/n "f.4J
Rev 11/21/91
92.. - 12.4-
1116 OELL AVENUE
POST OFFICE BOX 112492
CAMPBELL, CALIFORNIA 95011
Telephone: (408) 379-3010
FA 'K# ~Og. 37F .4to38
t~::"';i "tG4:'t:-.: ',;it~.':"':~ t,.>>~ '_.l~;.;;.~.;~.:,.:.,:::.-;:~
Ii JOHN GLAGE"~\
. ..:'.. ....... . )tl..Undergrou~d
\\~<'.:....':'.:'.~. f.... . pl. '. Construction '.'
\ . '\ ",.. . ,..1 LICENSE #504668 .
"~::.5j~~::~;q~~};':' ):.' . . . - .. . . /,.:J'~~~:'
'-~J'; . '~.'''(,.I/. -- _ . _ ':,_'-~
_.. - ,tf ~..',,';..'....-, ..,:,.,._",j ;:..;..~~ -.'
February 5, 1992
Underground Construction, Inc.
Phone #707-746-8800
FAX #707-746-1314
Re: 570 Union Avenue, San Jose
Attn: Mr. Hal Crose
This letter is to confirm the following:
1. Your quote for the bore is NTE $1,800.
2. Use PO#1026 when billing
3. We will need certificates of insurance
4. You are scheduled to begin on 2-13-92
If you have any questions, or problems, please call.
JG:py
***********************************
FA~AJ~~ANSMITTAL MEMO
TO : ~ L.-6 Jt---- 0 ~ NO. OF
DEPT: FAX #: PAGES
FROMr cJ./ 7Q PHONE: 1-
CO: FAX #:
Post-lt..brand fax transmittal memo 7671
--...--~---~.~
. - . ~ .
Certificate of Insurance
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFOFlMATION ONLY .l\NDCONFERS NO RIGHTS UPON YOU THe CERTIFICATE HOLDER. THIS CERTIFICATE IS NOT AN INSURANCE
POLICY AND DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED BELOW.
Underground Construction Company, Inc.
P.O. Box 2000
Benicia, CA 94510
Name and
Addr... of
Inaured
RECE'VHkERlYf&
FEB 1 oNftfffiALW
Thl. fa to Cert that
is, at the date of this certificate, insured by the Company under the policy(ies) listed below. The insurance afforded by the listed policy(ies) is
subject to all their terms, exclusions and conditions and is not altered by any requirement, term or condition of any contract or other document
with respect to which this certificate ma be issued.
RT\FICATE EXP. DATE
* DCONTINUOUS
o EXTENDED
lXIPOlICY TERM
TYPE OF POUCY
POUCY NUMBER
UMIT OF UABIUTY
COVERAGE AFFORDED UNDER
we LAW OF THE FOLlOWING
STATES:
WORKERS 8/1/92 WC7-161-027921-181 California
COMPENSATION
8/1/92 WC7-161-027921-021 AZ, GA, OR, TN
TX, VA, NM
GENERAL UABILITY
DCLAIMS MADE
IRETRO DATE 8/1/92 1 000 000
TB1-161-027921-231 Per80naI and Adver1iling Injury
!XI OCCURRENCE $1,000 000
01her:
AUTOMOBILE UABILITY
1 000 000
!XJOWNED
!XJNON-OWNED 8/1/92 AS1-161-027921-221
IX] HIRED
Each
Accident
PoIlcy
Umlt
ElICh
P8rIOIl
Per
Occurrence
Per PeIlOnl
Organlzallon
01her:
Each Accident. Single Umlt -
B.I. and P.O. Combined
Each P8rIOIl
Each Accident or Occurrence
ElICh Accident or Occurrence
P 0 411026
ADDITIONAL INSURED: John G1age Underground Construction
* IF THE CERTIFICATE EXPIRATION DATE IS CONTINUOUS OR EXTENDED TERM, YOU WIlL BE NOTIFIED IF COVERAGE IS TERMINATED OR REDUCED BEFORE THE
CERTIFICATE EXPIRATIaI DATE. HOWEVER. YOU WILL NOT BE NOTIFIED ANNUALLY OF THE CONTINUATION OF COVERAGE.
SPECIAL NOTICE . OHIO: ANY PERSON WHO. WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN
APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUlL TV OF INSURANCE FRAUD.
NOTICE OF CANCELLATION: (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS
ENTERED BELOW.) BEFORE THE STATED EXPIRATION DATE THE COMPANY WU NOT
CANCEL OR REDUCE THE INSURANCE AFFORDED UNDER THE ABOVE POLICIES UNTIL
AT LEAST -1!l- DAYS NOTICE OF SUCH CANCELLATION HAS BEEN MAilED TO:
Liberty Mutual
Insurance Group
CERTIFICATE
HOLDER
JOHN GLAGE UNDERGROUND CONST.
1116 DELL AVE
CAMPBELL CA 95011
k~
February 6, 1992
~
P1easanton, CA
DATE ISSUED
OFFICE
This certificate is executed by LIBERTY MUTUAL iNSURANCE GROUP as respects such insurance as is afforded by Those Companies
BS 772R6
'l""'""
..
CITY OF SAN .JOSE. CALIFORNIA
801 NORTH FIRST STREET
SAN JOSE, CAUFORNIA 95110
(408) 2774333
FAX (408) 277-3156
DEPARTMENT OF PUBLIC WORKS
::TD::: 3-~/f~S
EXPIRATION DATE:
J /);./Ylj
LOCATION: ~:;{) ItnltJn~
DEVELOPER:
MINOR STREET IMPROlEMENT PERMIT FOR LATERALS
DATE: /h/h2
PLANNI~ P~RMIT ~O. YI/
RECEIPT NO.: /!33Z:?8
;;-;/COO2;~d ~J
When cleared by the City for construction, this is a permit for the
construction of street improvements as shown on the attached planes) and in
accordance with the City of San Jose Standard Details and Specifications.
prior to the issuance of this permit you will be required to:
1. pay a fee of $ 6~(;;r for City Engineering and Inspection.
2. Furnish a Non-Negotlable Deposit Certificate in the amount of $ /'~
which will be held by the City as the security deposit until the project
is completed and the workmanship/materials warranty period is satisfied.
Guidelines for llsing these Certificates are described in Exhibit "C."
3. Submit to the City of san Jose evidence of insurance coverage. Developer,
at developer's sole cost and expense and for the full term of this permit
or any renewal thereof, shall obtain and maintain at least all of the
minimum insurance requirements as described in Exhibit "A" prior to
comnencing' any work under this street improvement permit. Said insurance
shall be filed with and approved by the Risk Manager before a permit shall
be issued. The Risk Manager's approval shall be labeled Exhibit "B."
This permit may be revoked if installation is not completed within
days.
If you need further information, please contact ~~ ~11~~
(408) 277-5161, or in Room 340, City ij~ll.
public Works Inspection must be notified a~~77-~68Q!/21 ?ours prior to
beginning work. Jl.lso, ~fa,c.1 J.1~~1 j/J /~ J.(tnl n/ldY1 ~,Yr/ct-f 2f
ItJ:V$ ;PlITT ~ ~Mi/1y dItP'"t', cJJ!~ ()'~7fl')N: .
.~ ..~~
p~e'~. Magglanl . ~'V
principal Civil Engineer
Development Eng. Division
9tJ
, at
1521W(GJl )l
92. -/21-
NG
STATE
COMPENSATION
INSURANCE
FUND
P.O. BOX 807, SAN FRANCISCO,CA 94101-0807
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 12-01-91
POLICY NUMBER: 1049054 - 91
CERTIFICATE EXPIRES: ":12-01-92 "
0..
CITY OF CAMPBELL
ATTN: BUILDING DEPT.
75 N CENTRAL AVE
CAMPBELL CA 95008
.
t:
L
..---
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 30 days' advance written notice to the employer.
We will also give you 30 days' advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document
with respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the
policies described herein is subject to all the terms, exclusions and conditions of such policies.
-LZ_ A ~
C/-PRESIDENT
EMPLOYER'S LIABILITY LIMIT: $3,000,000.00 PER OCCURRENCE.
STANDARD EXCLUSION: INDIVIDUAL EMPLOYERS AND HUSBAND AND WIFE EMPLOYERS ARE NOT ELIGIBLE
FOR BENEFITS AS EMPLOYEES UNDER THIS POLICY.
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 12/01/91 IS ATTACHED TO AND
FORMS A PART OF THIS POLICY.
EMPLOYER
LEGAL NAME
"[JHlI GLAGE UNDERGROUND
CONSTRUCTION
PO BOX 112492
CAMPBELL CA 95011
,",OHN GLAGE
PRINTED: 11-23-91 P0408
FEB-26-1992 14:40 FROM pnCIFIC TRE~ICH
rES 2~ '8~ 14:25 r-~~M RICO PFiTZER PIReS
TO
3792572 P.01
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NO 1llQM'T'S UPON TI4Ii e~TE HOlDER 1l4CS CSFrTIFlOAT8 005 HOT I,MCN!).
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3373
3373
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3510
City Clerk
PUBLIC WORKS FILE NO. '9"2 -, L 4
Project Revenue (specify project)
Public Works Encroachment Permit Fees:
Application Fee
Plan Check Deposit
Faithful Performance (Cash) Deposit
($105)
($500)
(100% of)
(ENGR. EST)
(4%of FPB)
($500 min.)
500 00 ~~S&3
/ 00 0V '~I( S'8i
Other Cash Deposit (specify)
Plan Check & Inspection Fee ($0 - $100,00010%;
$100,000 - $500,0009%; $500,000 and above 7%; $100 min.)
Project Plans & Specifications
General Conditions, Standard Provisions & Details ($10 or $1 /page)
"No Parking" signs ($1/ea. or $25/100)
Copies of Engineering Maps & Plans ($.50/sq.ft.)
Final Parcel Map Filing Fee ($475 + $21/ per lot)
Final Tract Map Filing Fee ($525 + $21/ per lot)
Lot Line Adjustment Fee/Certificate of Compliance ($420)
Vacation of Public Streets and Easements ($500)
Assessment Segregation or Reapportionment
First Split ($500)
Each Additional Lot ($150)
Storm Drainage Area Fee per Acre (R-1, $1,875;
Multi-Res., $2,060; all other, $2,250)
Public Works Special Projects
Park Dedication In-lieu Fee
Postage
NAME OF APPLICANT
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TOTAL
$ 7oS.DO
:570; - "3>010
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DATE