92-130
CITY OF CAMPBELL
DEPl'. )F PUBLIC WORKS
70 ~~rth First st.
C~mpbell, CA 95008
(408) 866-2150
OWHER OCCOPIED R-1
EHCROACHMEH'l' PERKrl'
(for working in the
public right-of-way)
.-. ($2,500 MAXIMCM VALUE OF WORK)
Permit No.
'--I z. - I 0 C
X-Ref. file
Application Date "3 -,,~ C/ L
/
Application expires in 3 mos.
APPLICATION - Application is hereby made for a Public Works Permit in accordance with campbell
Municipal Code, Section 11.04. (Application expires i~6 months/if permit n~t pulled)
A. Work address ~ 1YJ N. IJ/tlRK I ~{lli} (!fJ ,/}1 /)f)~ II (c j4 r;))) /J f7
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B. Nature of work:
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 iaprovements. When approved by
the City Engineer, said drawing becomes a part of this permit.
D. The General Conditions for all permits are listed on the reverse side. Special Provisions for
this permit are listed below. Failure to abide by these conditions and provisions may result in
job shut-down r ~orfeiture of Faithful Performance Surety.
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Complete and attach Workers' Compensation and Contractor Information torms.
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The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back I
of this permit, and that they will inform theiJOntractor(s) of the information. :
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ACCEPTED '/Y,.e -I J~" J;; r~1i t '7/y;1/ <Xt. lit" 4, 5~ / 9 9 2, ~
Applicant ( ermittee) Iprint/sign - Date
I
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of
Campbell, 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/Permittee hereby acknowledges that they are the owners and occupants of the address
listed above, or are providing services for the owner occupant.
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL STANDARD
DETAILS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AND MUST ARRANGE TO MEET WITH THE P.W. INSPECTOR
ON THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK.
NOTICE MUST BE GIVEN TO THE P.W. INSPECTOR AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
SPECIAL PROVISIONS
3URETY FOR FAITHFUL PERFORMANCE
(100\ OF ERG. EST.)
AMOUNT
7 -z.,-r-", co
$ ~:::::=i -> ----
RECEIPT 1*
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;'PPROVED FOR ISSUANCE / V C"--?j
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for City Eng;neer
Permit expires 6 months after date of issuance.
:?- ~-f)2-
Date
-. PW PERMIT
{evised 10/91
(SEE OTHER SIDE)
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APPROVED FOR CONSTRUCT\ON.
City of Carnpbell
Public Works Permit No.3z-/;::.u
Contractor must /tare these plans
011 the iob site d."iIfg COIIstructlon.
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CITY OF CAMPBEll
PUBLIC WORKS ENCROACHMENT PERMIT/PROJECT
INSPECTION REPORT
DATE: -+ -'7 -'32.
PERMIT/PROJECT NO.: 92. -/30 TRACT NO.
ADDRESS: 8'J 3 N. H/9f!V(JSO/.J.
TYPE OF WORK: STREET:
STORM:
SANITARY:
SIGNALS
LIGHTING:
SIGNING:
STRIPING: IRRIGATION:
P.C.C.:~PARKWAY:
PLANTING:
OTHER:
PRELIMINARY INSPECTION WITH DEFICIENCY LIST:
,/
FINAL INSPECTION AND ACCEPTANCE: 4- -7 -9 Z.
(Date)
(Date)
I<. -I NO H/l/wliNllNCL WND
SIGNED PLANS?
COUNCIL ACTION?
C E ACTION?
FILE NOC?
YES_
YES_
YES_
YES_
V
NO_
NO~
NO ~
NO "l:7
NO~
CHARGES AGAINST DEPOSIT?
YES_
OVERTIME:
HRS. @ $
PER HOUR - $
EQUIPMENT RENTAL: TYPE:
AMOUNT: $
DATE:
REASON:
TOTAL CHARGES:$
ONE YEAR MAINTENANCE WITH DEFICIENCY LIST
ONE YEAR MAINTENANCE ACCEPTANCE
!-I I Mok' A-I/I/A-
INSPECTOR
-4 -7 -9e.
DATE
f:pw insp
9/91
r
CITY OF CAMPBELL
70 NORTH FIRST STREET
C AMP 8 ELL, C A L I FOR N I A 9 5 0 0 8
(408) 866-2100
FAX # (408) 379-2572
Department:
Public Works
April 7, 1992
Helen V. Benjamin
873 North Harrison
Campbell, CA 95008
SUBJECT: FINAL INSPECTION AND ACCEPTANCE
PERMIT NO.: 92-130
LOCATION: 873 NORTH HARRISON
Dear Ms. Benjamin:
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 $2,300.00.
Please feel free to call me if you have any questions.
;;eL~
Sal Duckworth-Lanzo
Senior civil Engineer
SDL/jd
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REFUNDABLE DEPOSIT
CHECK REQUEST
TO: SANOY TERPKO
ACCOUNTS RECEIVABLE
Please issue check payable to: Helen V. Benjamin
Address:
Line 1:
873 N. Harrison
Line 2:
City :
Campbell
State:
CA
Zip:
95008
Description: Ref Deposit/Permit No:
Exact Amount Payable: $2,300.00
Account Number: 001.00.905.4662
INTEREST EARNED
001.05.540.4448
LOCATION:
873 N. Harrison - Permit No. 92-130
DATE AND NO. OF RECEIPT:
PURPOSE:
3/5/92 #38932
Return of surety for faithful performance
Requested by: Hank Imokawa Title: P.W. Inspector Date: 4/7/92
Approved by: ~),t~L~ Title: ~ rr1~ Date: 'f/f/92-
t U I I
Verified by: Title: Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as is
Mail in attached envelope
Return to: Public Works
(Department)
Sal Duckworth-Lanzo
(Name)
Other:
Rev 11/21/91
:1~~!~!~:J1IIII_II.I.lilll::ilil:I.lilililililll._I..IIIIIIIIIIIIIIIIIIIIIIIIIIIIIII!I!IIIIIIIIIIIIIIIIIIIIIIIIIIII!IIIIIIIIIIIIIIIIIIIIIIIIIII!I!I!IIIIIIIIIIIIIInDA~(~:/~/::
~~~FER'S' NORiGHf~ I~~~~ T~~ ~ERTiFICATI~)fHOLDER. THlsc~~~Tc~~f
Compro Ins Serv ices I nc DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
550 South Winchester Blvd POLICIES BELOW.
POBox 611090 CC>>.,PANIES AFFORD"'G COVERAGE
San Jose, CA g5161-1090
408-236-3000
COIFANV
LETTER A
Transcontinental Insurance
COIFANV B
-- LETTER
A&W Cement Company COIFANV C
LETTER
858 No Har r i son Ave
Campbell COIFANV D
LETTER
CA 95008 COIFANV E
LETTER
TransDortat ion Insur..nce
KI:\;ltIVID
mw
APR 11~~Z
Public Works I Enginoorlng
"THIS IS nJCER-TlFY TH'AT THEPOLiCiE"s of-iNSURANcEL'isT"E"6'BE:'I':O\.tHAvE--BEENISSUED~:r6YHE'IN'SUREDN'AMEo"ABO\'E"'"[':ORTHE policy PERIOD'
INDICA TED, NOTWITHST ANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCLMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERT AIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LMITS SHOWNMAY HAVE BEEN REDUCED BY PAID CLAMS,
co
Ln
T'lPEOF INSURANCe
POLICY MlhIIER
POLICY!PROTM! POLICY !XPIlATIClII
DATE (..../OO/VY) DATE (..../OO/VY)
L1h1lTS
G!N!RAL L1ABLITY
I--
A X ClMvlERCIAL GENERAL LIABILITY 206951500
:::::::: I CLAIMS MADE [l{] OCCUR,
I-- OWNER'S & CONTRACTOR'S PROT.
8/01/91
8/01/92
GENERAL AGGREGA TE I 500000
PRODUCTS-CCtv1P/OP AGG, I 500000
PERSONAL & AlN. INJURY . 500000
EACH OCCURRENCE I 500000
FIRE DAMAGE (Any one lire) I 50000
MED, EXPENSE (Any one perso. I 5000
CCtv1BINED SINGLE I
LIMIT 500000
I--
AUTOhlOllL! L1ABLITY
I--
B ~ A~ AUTO
I-- ALL OWNED AUTOS
I-- SCHEDULED AUTOS
~ HIRED AUTOS
~ NON-OWNED AUTOS
I-- GARAGE LIABILITY
906951502
8/01/91
8/01/92
EXCESS L1ABLITY
RLMBRELLA FORM
OTHER THAN LMBRELLA FORM
BODILY INJURY I
(Per person)
BODilY INJURY I
(Per accidenU
PROPERTY DAMAGE I
EACH OCCURRENCE I
AGGREGA TE I
j ~ ~ ~ 1 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ H H ~ ~ ~ ~ ~ ~ ~ ~ ~ n j ~ 1 ~ 1 ~ 1 ~ 1 ~ ~ ~ ~ ~ j j j ~ ~ ~ H H ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ H~ ~ ~ ~ ~
3/31/12
I STATUTORY LIMITS
3/31/93 EACH ACCIDENT
DiSEASE-FOLlCY LIMIT
DISEASE-EACH EMPLOYEE
;,;,;,:-:,:,:,:-:-:,:",:.:.:.;.:.;.;
:;:;:;:;:;:;:::;::::::::::::;;:::::;:
B
WOAK!R'. OOIoF!NSATION
-
!hFLOY!RS'L1ABLITY
WC112129S26
I
.
I
1000000
1000000
OTHER
DESORPTION OF OP!RATIONSILOOATIONIIV!HIOlDISP!CIAL IT!h11
RE: ALL OPERATIONS PERFORMED BY THE NAMED INSURED.
THIS INSURANCE IS PRIMARY WITH THE CITY OF CAMPBELL AS EXCESS ONLY.
:;:;;:;; SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
:::::::: EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO
tt MAIL 30 DA YSWRIT TENNOTlCE TO THECERTlFICA TE HOLDERNAMEDTO THE
City of Campbell :!:!!::: LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL MPOSE NO OBLIGATION OR
70 N. Fir s t St reet II LIABILITY OF ANY KIND UPON THE COMPANY. ITS AGENTSORREPRESENT ATlVES,
~
TO:
City Clerk
PUBLIC WORKS FILE NO.
..:7 Z-I,.~(:'
Please collect & receipt
for the following monies:
ACCT. ITEM AMOUNT RECEIPT NO.
3372
3521
3521
Project Revenue (specify project)
Public Works Encroachment Permit Fees:
Application Fee
Plan Check Deposit
Faithful Performance (Cash) Deposit
$
35-3396
3521
Other Cash Deposit (specify)
($105)
($500)
(100% of)
(ENGR. EST)
(4%of FPB)
($500 min.)
:J. 30 (,60_1 ~ ~ cY~:l-.
3372 Plan Check & Inspection Fee ($0 - $100,00010%;
$100,000 - $500,0009%; $500,000 and above 7%; $100 min.)
3373 Project Plans & Specifications
3373 General Conditions, Standard Provisions & Details ($10 or $1/page)
3373 "No Parking" signs ($1/ea. or $25/100)
3373 Copies of Engineering Maps & Plans ($.50/sq.ft.)
3372 Final Parcel Map Filing Fee ($475 + $21/ per lot)
3372 Final Tract Map Filing Fee ($525 + $21/ per lot)
3372 Lot Line Adjustment Fee/Certificate of Compliance ($420)
3372 Vacation of Public Streets and Easements ($500)
3372 Assessment Segregation or Reapportionment
First Split ($500)
Each Additional Lot ($150)
3370 Storm Drainage Area Fee per Acre (R-1, $1,875;
Multi-Res., $2,060; all other, $2,250)
3380 Public Works Special Projects
3395 Park Dedication In-lieu Fee
3510 Postage
NAME OF APPLICANT
ADDRESS ~ 1~
FOR
CITY CLERK
ONLY
/jf ftt~t5~:/ ;ilthtJ~ ~~
I RECEIVED BY . ~
DATE ~ - S -Cj'"::L-.
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$ .v _~ {. (,
PHONE
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ZIP Y S- /J IJ >7'
CITY OF CfHlBEll, CITY ENGINEER'S a::wsTJU:TICJlI::>f1MATE
1dhss 67.-:;' /' /- ../t' // // ,r '_" "/ . ,.' /{'. by
9.rface CaBtru:ticn
PERMIT 19. 9' z. -/:3 d
, .
(~..~,-,' ,;-
Clesril'll & GnJ:bil'll LuJp &.m EstillBte =$
Sa<<:ut:t Calcrete LF iiI *$4.50 =$
CCn::rete RaltMIl /I_,/{\ SF;;) *S3.50 =$
,
ClJ'b & ~ter RaltMIl 78 LF iiI *$5.50 =$
Inlot Drain with Pipe EAiiI S6OO.oo =$
z: r,>
ClJ'b & ~ter . ts LF ;;) $16.00 =$
Sidewalk SFiiI S4.50 =$
DriWWIIY Aj:p"oBch J00J SF;;) $6.00 =$
Hardi~ Rarp EAiiI S475.oo =$
----.-
ExtruB:I ClJ'b =i=aa 10.00 =$
Barricade LF ;;) $60.00 =$
Street Excavaticn i SFx (SO.12) x ( ") =$
!
N; PaYmEnt i SF x (0.35) x ( ") =$
1
AdjlSt Mirhole to Grade I EA;;) S425 .00 =$
AdjlSt Hard10le to Grade =t=EA iiI S325 .00 =$
Mcrunent Box wJMcnment ENil $700.00 =$
Street Tree (15-gElllcn) EAlil S350.oo =$
PaYmEnt Stripil'll ($100mn) LF lil $ .75 =$
PaYmEnt Legerds ($100mn) EA;;) $50.00 =$
St~, Street Nane other Sil11 EAlil $140.00 =$
PaYmEnt Marker EAlil $17.00 =$
P8V8lB'It Key QJt \ LF iiI $10.00 =$
I
\ =$
=$
9.rface 9.btotal liS" =$
AdjlSt for size: liS" < S30,lXXl,adj 20:(, liS" > $1oo,lXXl,Slbtract 10X (+ or -) =$
Street Li~tirg
Electrol ier
CaIiIi t
---l-EA lil
----1-LF ;;)
I_LFlil
SZ2OO.oo
$10.00
$2.00
CcrdI;tor, pili r
Pull Box
EA lil SZOO.OO
LF iiI $70.00
LF ;;) SlIl.oo
EAlil $1750.00
EAG) S25lXl.00
EA;;) $750.00
TOTAl. EST MATE $
Storm Drainage
12- or 15" ReF
18''' or 21" ReF
Street Inlet
MErhole
BrelIk & Enter Mirhole
date
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