92-133
~!TY OF CAMPBELL
DEPl'. OF PUBLIC WORKS
70 North First st.
Campbell, CA 95008
(408) 866-2150
OWNER OCCUPIED R-1
P.NCROACHMEHT PERKl:T
~r working in the
..Dlic right-of-way)
($2,500 MAXIMUM VALVE OF WORK)
PerJllit No. --32 - J "3. '3
i
X-k . file
Application Date ;3 /'3 i ) q z-
Application expires in 3 m08.
APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell
Municipal Code, Section 11.04. (Application expires in 6 month. if permit not pUlled)
42 J-IUAJT WA y
Vr< t IJ t=.- WA (
A.
Work address
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 propo.ed work to existing improv_enta. When approved by
the city Engineer, said drawing become. a part of this permit.
D. The General conditions for all permits are listed on the reverse side.
this permit are listed below. Failure to abide by these conditions and
job shut-down and/or forfeiture of Faithful Performance Surety.
Name of Applicant Iv1 A TT 1-1 ,;:. w' P. CAR Y
SAM E.. I
Special Provisions for
provisions aay result in
'378 ~4b7L.
Telephone:
Address
complete and attach Workers' compensation and Contractor Information fOrms.
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.
The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back
of this permit, and that th y will info their contractor(s) of the information. .
ACCEPTED :l J I / q z...
Da I
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL STANDARD
DETAILS AND CONDITlONS.
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
SURETY FOR FAITHFUL PERFORMANCE
AMOUNT
9 SOcoll
4 DO~ 0
RECEIPl' 11
(loot OF ERG. EST.)
$
\PPROVED FOR ISSUANCE
~;Y(utud COA-U~-
for City Engine~
Permit expires 6 months after date of issuance.
"3- "$ i - '1 "L-
Date
-. PW PERMIT
~evised 10/91
(SEE OTHER SIDE)
I
I
I
I
1-3
o
b:l
i:':l
(J
o
::s:
'"
t-<
t'=j
1-3
t%::
o
t"1
~
>'
'"
'"
t-<
H
r:::
>
z
1-3
I
I
I
I
P /t......4 Pc oS E7)
., /t..Adi-E ,-..-' .LJ
}.'/,::. .=e7~.r/h3~
;L~,;~~i:~~
.!)l... f'.l.~._.". ....... _.... .
,w.~.~~~"'"","4,.~.:... , -:
, "
6~
. ..:
'.~~.
:J;l~ .'
;!@~~:,:
r: "'; .i~'v.' -( ,
t~:~.~,:~~~.,\\. f.:..... '>-., _
~.Ii "'f' ~.. .>~. '.' - /.;" .....',. ..~
! .~:"J:-:~~~-' ,,~~.,' ':":i"':~; , " ... I
. ~ ~
}::';;..., ., ':. ,,'.l!-.' . ...." -:.... ~... . en
~~'~':'!~~,~"';'~"-'. ,:"",\.,.,.~,"~,,,~ ..'r">~-~~"~~."~~"f.''''!f''I'
""'":'1..... . i, ~ . _
~~,iT' ~I""
.'~':c ,.. ......
;"", .: ".:_-"'JO ,
-:}.,';~::;~;".
, ..
.~.
".
... .;'1;"
-r--
~;......- -
..
Q'K~'~':;:' ..
. ~11~-'~' , 'j .:~,~.
:(~. .,..:
.~?~
. ", ,
:"~!-:... " -.
.' f I
i' f
,.
I
.J
'.
f
r
I
I
.. I
r ... . .1
f 1
.;~~_ l
...~/'J ..dO
M~"> :...
<<"t-..
....' {.
"..;':"~, .
1~._'.t.~
. ~"_"'!~... -~" . I._ a...
'.$f.;.J'; ,.;.~ -:
"~.'''; ~ ..
S-Y'i ~o'.:;..:'.' -:
~.;~':~r-',:: ~'~:_/' ~~'~ '~' .~ ~
~~1~.~. ,~;;"
i~:i::\",i<.....;. : ,;f .
l~~~; \~(i..~\'.'. .
.~~....~ .;r...~~_.,
:"; ~'~/~~}.r~j,;:..~~~:.;.
... .... ....."-....-
.;>... '. ...:'",'. .
~
- "---:,-
---
-.;... ,.......
I
, :- ,
/2-/
'1 .
- ~~-.. ~."
't ~ i,;,,;:'"
~:.~
.... .,!
......;
.-t....
){V/tlT
IdAY
,'.'
.. J ....,
\.
~..
. PLOT:'
PLAN
"~/~ "'= /'-0"
.,~.'~
.;" .
..:
". ....
...., '- - ~
.'.;."-:::. ~
:c. \.
I
.t
~ I
I
I
~1" . .... ".""1..
........,....
I h/~iIAl-;-'--n
C."Vl;Ji!..cD PArlO ,.-
(~,l>tte'l A~ IU-&<'D)
,lLdPos E:1:) I!r I 2~
~ 7I!'IIY t4./)~ 'T, IJ AJ
,II'%. !,",.h.1 r W^ 'f
'.
..........
"
~
...
~
8~. ~~ I "\
... >',.
- - - - ~_..~.-
.
~-
, .
.
-
~
~--
It
t;>
...
~
,.
.rr.'-
~ ..::-:'
~.'~
~"......' .
P'-''';'' ...
I
t
~
~
,
~
~
.....,-
. ....~ ~
I
,
I ·
I
,
I
I. '
,I
, I
-.-
, ,
f
'-~
f"
;t, ,-,~.
15;.1:;[;
"
,.<#<.'
...
.s~4
..,
I
,
,
.L
,
---.
I
~
_,r
/
4} 7'~..
~
<.J
'^
~
.......
e~/~rj,
EX I~II
PI2I)" .
_.
I),
/....o-r II
f"Jq:Pp
-rG
+- "
F€.),
€
..
~
.l(,,- "
'.
I'.....
','-r
Of'C.4At
1o..4.'~AO"~
... . r"
~ ,.;; ~
'" . "-
'So ....
~. ,,'
Ol/CH A Il'"
CITY OF CAMPBELL
Public Works Department
October 12, 1994
Matthew Cary
42 Hunt Way
Campbell, CA 95008
SUBJECT: PERMIT #92-133/CANCELLATION
LOCATION: 42 HUNT WAY
PERFORMANCE SURETY: CASH DEPOSIT, RECEIPT #40090
Dear Matt:
This letter is to confirm our telephone conversation yesterday regarding cancellation of Permit
#92-133 since no work will be performed in the public right-of-way.
Your Faithful Performance Surety cash deposit of $950.00, plus any interest due, will be
forwarded to you under separate cover.
Sincerely,
-/(-f; W.}r/d(
Randy Westfat
Public Works Inspector
~
File: Permit #92-133
h:perm92-133(mw)6.0
70 North First Street. Campbell, California 95008,1423 ' TEL 408.866.2150 ' FAX 408.379.2572 . TOO 408.866.2790
ji<
TO: SANDY TERPKO
ACCOUNTS RECEIVABLE
\,- '-
Please issue check payable to:
Matthew
Address:
Line 1:
42
" Li ne 2:
City : f Campbell ., State:~ CA , Zip: 95008
Description: Ref Deposit/Permit No:
',. -
92-133
INTEREST EARNED
Exact Amount Payable:
$950.00
Account Number:
,~."' ~ . ,t ~;. .0::,-"
LOCATION:
42 Hunt Way
DATE AND NO. OF RECEIPT:! 4/1/92
PURPOSE:
~
Permit work will not be done, only on-site work.
t. - t
Therefore, Faithful Performance "'Surety 'is being refunded.
Approved by: James
,/ "J '.',_, _ ..',.t ., ",.. '';'. ,. "
. ~,",.,'::~.'-;-'.~,._;-;~-:A" ,.. .
Title,: Pub.Wks.lnspectOl:Oate: 10/12/94
Requested by: Randy
( ",~G'.f~.,.J-
Title: Act'g City Engr. Date: 10/12/94
;r-., -....\: -~
Title:
",,:<'.
Date:
Verified by:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
(.
Ma 11 as i s
xx
--',i\ l '
Mail in attached envelope
Return to:
(Department)
(Name)
Other:
Rev 11/21/91
\
TO:
City Clerk
Please collect & receipt
for the fOllowing monies:
PUBLIC WORKS FILE NO,
9 2 -I :s 3
35-3396
ACCT. ITEM AMOUNT RECEIPT NO.
$
3521
Project Revenue (specify project)
Public Works Encroachment Permit Fees:
Application Fee
Plan Check Deposit
Faithful Performance (Cash) Deposit
Other Cash Deposit (specify)
($105)
($500)
(100% of)
(ENGR. EST)
(4%of FPB)
($500 min,)
1~D ~ l.t 00,\<>
3372
3373
3373
3373
3373
3372
3372
3372
3372
3372
3380
3395
3510
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
43 D 4-ooq \
I
TOTAL
$
1~80-
ADDRESS
FOR
CITY CLERK
ONLY
RECEIVED BY
DATE
PHONE 3713 ~4D7L
ZIP qs-oo f3
CITY OF CNAlELL, CITY ENGINEER'S a:NSTRLcr1~ .IMATE
Actress II).. /../ V I/~/- 0,--/'/
, ,
9.rface Ccnstru:t;cn
Clear;rg & GrUb;rg
Sa.r::ut: Ccrcrete
Ccrcrete REmMll
arb & IlJt:ter REmMll
Inlot Ora;n with Pipe
arb & IlJt:ter
Sidewalk
Or;V&By AR:roach
Hal:Ii~ Rmp
Extru:led arb
Barricade
Street Excavat;cn
~ Pa\I8IB'lt
AdjlSt Mcrhole to Grade
AdjlSt Ha1:hole to Grade
Mcn.na1t Box Iol/MCn.IJEnt
Street Tree (15-gallcn)
PaIIaIEl'lt Str;p;rg ($1000;n)
PaIIaIEl'lt Legerds ($1000;n)
Step, Street Nare other S;91
PaIIaIEl'lt Marker
Pa\I8IB'lt Key CUt
AdjlSt for size: ''5'' > $1oo,CXXl,Slbtract 10%
PERMIT t.O.
b( D~.
.::! h n-7
elate ,,--,0 ~ / - / '-
LUIp ~ Est;nate
~() LF iil *$4.50
fr'lr) SF iil *$3.50
(,
LF iil *$5.50
EAiil $600.00
LF iil $16.00
SF iil $4.50
1/ tf SF iil $6.00
EAiil $475.00
EAiil 10.00
I LF iil $60.00
~:: ($0.12) x
(0.35) x
EAiil S425 .00
EA iil $325.00
I EA@ $700.00
EAiil $3SO.oo
LF iil $ .75
EAiil $50.00
EAiil $140.00
EAiil $17.00
LF iil $10.00
9.rface &bt:otal ''5''
F (( ("I !-
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
") =$
") =$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
_.70,("0)
""
,)
(~:" i
)
/
f
/
~L.imti!B
Electrol ;er =E~' $2200.00 =$ I-
Ca'l:iJ; t LF iil $10.00 =$ I
I
Ca'dxtor, psi r LF iil $2.00 =$ I
I I
Pull Box EAiil S2OO.oo =$ I
, ,
,
I =$
/
Storm Ora; r1l!lE!
12- or 15" RCP -=J=LF iil $70.00 =$
18" or 21" RCP LF iil SIll. 00 =$
+EAiil I
Street Inlet $1750.00 =$ =t=
Mcrhole I EAiil S25OO.oo =$
Break & Enter Mcrhole I EAiil $750.00 =$
=$
TOTAL ESTIMATE $ ~/::;. 0 :2
rev;se;:! 3192 USE FCR OCN) $ 9S'o.cr )
F: cxn::ost
CITY CF CAIflIlELL, CITY ENGINEER'S amTRLcrla. _~,IMATE
Id:ress ,,/ =-- /-/ (/,~.J r
9..rface Ca-stru;tial
PERMIT tI).
11( D, /e.
Clearirg & GrU:.birg LUIp SUn EstillBte
Sa.o.Jt Calcrete 10 LF iil *$4.50
Calcrete REJIDI/8l B6 SF iil *$3.50
arb & G../tter REJIDI/8l -LO LF iil *$5 .50
Inlot Drain with Pipe EAiiI S6OO.oo
arb & G../tter 2-0 LF iiI $16.00
Sidewalk SF iil $4.50
Dri ve.ey Af:proac:h /~-V SF iiI $6.00
Han::liap Rarp EAiiI $475.00
Extn.ded arb EAiil 10.00
Barricade LF iiI $60.00
Street ExcaIIat i al SF x ($0.12) x (
N:.PCMm:nt SF x (0.35) x (
Adjust Mailole to Grade EAiiI S425 .00
Adjust Hm:tlole to Grade EAiil S325 .00
Maunent Box W/MCI1..Irent EA@ $700.00
Street Tree (15-gallal) EAiiI l35O.oo
P8Io'EIIS'lt Stripirg ($1000in) LF iil $ .75
PCMm:nt Legen:i; ($1000in) EAiil $50.00
Step, Street NaTe other Si9'l EAiiI $140.00
PCMm:nt Marker EAiiI $17.00
P8Io'EIIS'lt Key M LF iiI $10.00
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
") =$
") =$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
=$
9..rface Slbtotal "S"
Adjust for size: liS" > $1oo,00J,Slbtract 10%
::-' i /-I ' /Pi /1 oj/I el;
date
""
,""..... ..
.; ., .
I ,
"/v--:uc.
;;~),
/Io-/~
"---
;/'2'0.,.., L-
./" / c/ ;
/ '-, ~. 0 (L
Street Li!l1tirg
Electrolier EAiiI $2200.00 =$
CaliJi t LF iil $10.00 =$
Ccrd.J::tor, pai r LF iil $2.00 =$
Pull Box EAiil $200.00 =$
=$
Storm Orai I'11Qe
12- or 15" RCP LF iil $70.00 =$
18" or 21" RCP LF iil $00.00 =$
Street Inlet EAiiI $1750.00 =$
Mailole EAiil S25OO.oo =$
Break & Enter Mailole EAiil $750.00 =$
=$
TOTAL ESTIMATE $ !;~79/Cj
revi sed 3192 USE FeR IDI) $ ~ 700 - 0-0
F:cm::ost
CITY OF CAMPBELL
Permit No.
12-/33
INFORMATION SHEET FOR ENCROACHMENT PERMITS
Name of Contractor/Applicant
Iv1AITffflA/
f
INFORMATION
P. (AR\/
(
WORKERS' COMPENSATION INSURANCE
One of the following must be on file with the Public Works Department:
A Certificate of Consent to Self-insure issued by the Director of
Industrial Relations; OR
A Certificate of Workers' Compensation Insurance
Insurance Co.
Policy No. Expiration Date
OR
This Certificate of Exemption from the Workers' Compensation
laws printed below (certificate must be signed).
CERTIFICATE OF EXEMPTION
I certify that in the performance of the work for this permit,
I shall not employ any person in any manner so as to become
subject to the Workers' Compensation Laws of Califo nia.
Signed /J1.o;r-1, N ,- P. {p J, Date
NOTICE TO CONTRACTOR/:PPLICANT: If, after signing this
Certificate of Exemption, you should become subject to the
-Workers' Compensation provision of the Labor Code, you must
forthwith comply with such provisions or this permit shall be
deemed revoked.
CONTRACTORS INFORMATION
Note that all contractors and sub-contractors must have current City of
Campbell Business License, State Contractor's License and Workers'
Compensation Insurance.
Name of Contractor
Address
Telephone
State Contractor License No.
City Business License No.
Expiration Date
Will do the following types of work:
_____Underground _____P.C. Concrete _____A.C.Paving
_____Other (specify)
Electrical
f:perminfo
10/91
.'