92-156
CITY ('IF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First st.
campbell, CA 95008
(408) 866-2150
OWNER OCCUPIED R-1
ENCROACHMEN'l' PERMrl'
~ workinq in the
lie riqht-ot-way)
($2,500 MAXIMOH VALUE OF WORK)
Permit No.
9;2 - /s-~
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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 permit not pUlled)
:: ::::~:.::rk' ~~Ljd~~~~:: ot H",,~ ~m..-J
X-R, file
Application Date L(-- Z 7 - :7 L
Application expires in 3 mos.
C.
Attach three (3) copies of a drawinq showinq the location, extent and dimensions of the work. The
drawinq shall show the relation of the propo.ed work to exiatinq U1provementB. When approved by
the City Enqineer, aaid drawinq become. a part of this permit.
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Telephone:
370 -362.2-
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D. The General Conditions for all permits are liated on the reverse aide.
this permit are listed below. Failure to abide by th..e conditions and
job shut-down and/or forfeiture of Faithful Performance Surety.
Name of APplicant~lu....- \JlC-\<U~..I,JL.....
Idv,J-r l JJ l'V1
Special Provi.ions for
provisions aay result in
Address
0'
Complete and attach Workers' Compensation and COntractor Information forma.
The Applicant/Permittee hereby aqrees by affixinq their .iqnature to this permit to hold the City of
Campbell, its officers, aqents and employ..s free, .afe and harmless from any claim or demand tor
damaqes resultinq from the work covered by this permit.
The Applicant/Permittee hereby acknowledqes that they are the owners and occupants of the address
listed above, or are providinq services tor the owner occupant.
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The Applicant/Permittee hereby acknowledqe. tha
of this permit, and that they will intorm their
ACCEPTED t) u...- \). C\<Ii..~1
Applicant (Permittee) p int/siqn
have read and understand both
actor(s) of the information.
-
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back
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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
(loot OF ENG. EST.)
AMOUNT
$ ~ /O{). (fO
,
RECEIPT 11
ij/59-7
,
~PPROVED FOR ISSUANCE
"
~ S~~in..r
Permit expires 6 months atter date of issuance.
c:5~~ / - 7L
Date
.. PW PERMIT
~evised 10/91
(SEE OTHER SIDE)
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APPROVED FOR CONSTRUCTION,
City of Can1pbell
Public Works Permit NO.~2-/(.Jr-o
Contr:Jctor must have the. plans
on the job site during NII"'to.t'lhn.
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PCA1:/ / ~ 9,,2. -I.:-G:.
CITY OF CAMPBELL
70 NORTH FIRST STREET
CAMPBEll. CALIFORNIA 95008
(408) 866-2100
FAX # (408) 379-2572
Department:
Public Works
April 21, 1993
Mr. Bill Pickering
61 Hunt Way
Campbell, CA 95008
RE: FINAL INSPECTION AND ACCEPTANCE
PERMIT NO. 92-156 (R-1)
LOCATION: 61 HUNT WAY
PERFORMANCE SURETY: RECEIPT #41397
Dear Mr. Pickering:
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.
The one year maintenance period as stated in the permit begins as of the date of this
acceptance. You will be responsible for the repair of any deficiencies sited in the
workmanship within this one-year period.
The performance surety is hereby released. Your deposit will be forwarded to you under
separate cover.
Sincerely,
&
Cruz S.
Public
fnO~F:djr
cc: ~chelle Quinney, Acting City Engineer
File. (Permit #92-156)
h:92-156.1tr
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REFUNDABLE DEPOSIT
CHECK REQUEST
TO: SANDY TERPKO
ACCOUNTS RECEIVABLE
Please issue check payable to:
William H. Pickering
Address:
Line 1:
61 Hunt Way
Li ne 2:
City: Campbell
State: CA Zip: 95008
-
Description: Ref Deposit/Permit No: 92-156
Exact Amount Payable: $2.100.00
Account Number: 001.00.905.4662
INTEREST EARNED
001.05.540.4448
LOCATION:
61 Hunt Way
DATE AND NO. OF RECEIPT:
5/4/92
#41397
PURPOSE:
Performance Surety
,
Mike FUllerJl'YlU~ Title: Asst Engr Date: 't/11 hJ
Michelle QUinne~Title: Acting City Engr Date:
Requested by:
Approved by:
Verified by:
Title:
Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as is
xxxx
Mail in attached envelope
Return to:
(Department)
(Name)
Other:
Rev 11/21/91
TO:
City Clerk
92- -/rG
PUBLIC WORKS FILE NO.
Please collect & receipt
for the following monies:
35-3396
ACCT. ITEM AMOUNT RECEIPT NO.
$
3372
3521
3521
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.)
;2ICc~oO H-/317
3372
3373
3373
3373
3373
3372
3372
3372
3372
3372
3370
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
PHONE
4 '7:,6. Of:) tfI.19 t
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0--(;
$ 2.5' 30--
/
J I () ,-:J r- h::"----
ZIP c; J -0 0 ~
FOR
CITY CLERK
ONLY
TOTAL
N~
VENDOR'S CFRTIFICATE OF COMPLIANCE
Certificate
2096
o (PRECAST CONCRETE PRODUCTS) OR IX] (READY MIXED CONCRETE)
To:
State Highway Engineer:
We certify that the portland cement, chemical and mineral admixtures contained
in the material described below are brands stated and comply with specifications for:
CONTRACT NUMBER .
Cement Brand:
TYPE:
CHEMICAL ADMIXTURE
1. BRAND:,N( (~
TYPE:
...
)ct ~CTURER: ~
l"l3){~c/l
MANUFACTURER:
List products whic this certificate applies. (Show size and lin. ft. of pipe,
etc., delivery slip numbers for ready-mix.)
ffl 11/ ~9
Orig. to Res. Engr.
Retain Duplicate
0., INC.
By:
CCSFORM1fOO4.12/91
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PERMIT tD; I ".:... )
.
CI TY Of CAIflIlEll., CITY ENGINEER I S CtNSTRI..CTlCW .'lATE
Ad::ress (0/ // (/ /C /;7-1;( /,../ '/
9.rface Ca-stf'lct i en
Clearirg & GnJ:birg
Sa.r::ut ea-crete
ea-crete REmMll
asb & QJtter REmMll
Inlot Drain with Pipe
asb & QJtter
Sidewallc
Dri veway AR:roac:h
Ha-di~ Ra1p
Extru:led asb
Barricade
Street Excavatien
N:. P8IIaTeIlt
AdjLSt Marhole to Grade
AdjLSt Hardlole to Grade
Ma1.Jrent Box Iol/Ma'Unent
street Tree (15-gallen)
P8IIaTeIlt Stripirg ($1000in)
PaYarent Legen:is ($1000in)
Step, Street NaJe other Si~
PlI\ISIEI'lt Marlcer
P8IIaTeIlt Key QJt
AdjLSt for size: "S" > $1oo,CXXl,Sl.btract 1m:
Street Li!t1til'll
Electrolier
CaWi t
Cadetor, psi r
Pull Box
Storm Drainage
12- or 15" RlP
18" or 21" RlP
Street Inlet
Marhole
BreaIc & Enter Marhole
revised 3/92
F:an:ost
/-./0 TEe-
~ ~re
LUIp 9Jn Estirrate
-3 / LF Q *$4.50
/0 ') SF Q *$3.50
LF Q *$5.50
EAQ S6OO.oo
LF @ $16.00
SF @ $4.50
J.t>y SF @ $6.00
$475.00
10.00
$60.00
($0.12) x
(0.35) x (
S425 .00
S350.oo
$ .75
$50.00
$140.00
$17.00
$10.00
9.rface 9.btotal "S"
EA@ S22OO.oo
LF @ $10.00
LF @ 52.00
EA@ S2OO.oo
LF @ $70.00
=i=~ : $00.00
$1750.00
EA@ S25OO.oo
EA@ $750.00
TOTAl. EST IMA TE
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ISSUE DATE (MMIDD/YY)
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CERTIFICA_F INSURANCE
.
~
PRODUCER. _.
Frank R. Olmo & Son
P. O. Box 58152
Santa Clara, CA 95052
ApEi._~__~2?_ _ !292
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
f~T~~~NY A Ae tna Casualty & Sure ty
INSURED
f~T~~~NY B
Floor to Ceiling Construction, Inc.
P. O. Box 362
Felton, CA 95018-0362
f~T~~~NY C
f~T~~~NY D
f~T~~~NY E
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MM/DD/YY) DATE (MM/DDIYY)
LIMITS
GENERAL LIABILITY
A X COMMERCIAL GENERAL LIABILITY AE 0021491623
CLAIMS MADE X OCCUR.
X OWNER'S & CONTRACTOR'S PROTo
11-16-91
GENERAL AGGREGATE $ 2,000,000
11-16-92 PRODUCTS-COM PlOP AGG. $ 2,000,000
PERSONAL & ADV. INJURY $ 1,000,000
EACH OCCURRENCE $ 1, 000, 000
FIRE DAMAGE (Anyone fire) $ 50,000
MED. EXPENSE (Anyone person) .~____._.._~2...Q.Q.Q._._.
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
A. X HIRED AUTOS
X NON-OWNED AUTOS
GARAGE LIABILITY
COMBINED SINGLE
LIMIT
$ 1,000,000
BODILY INJURY
(Per person)
$
AE 0021491623
11-16-91
11-16-92
BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
EACH OCCURRENCE
AGGREGATE
$
$
WORKER'S COMPENSATION
STATUTORY LIMITS
EACH ACCIDENT
$
AND
EMPLOYERS' LIABILITY
DISEASE-POLICY LIMIT $
DISEASE-EACH EMPLOYEE $
OTHER
SCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/SPECIAL ITEMS
ALL CALIFORNIA OPERATIONS AND LOCATIONS
RTIFICA TE HOLDER
CANCELLATION
City of Campbell
Building Inspection Dept.
Attn: Donald King
75 N. Central Avenue
Campbell, CA 95008
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ~K"g~6o~-jQ
MAIL ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, li<<KJUCX1XF.JEKm:~Sllt'AU:XM~fltGtXlilXl2K'R~!}t~
Jl:IlIUlIKIlQ(XlXIDQXX~m6X::aowR~~M~~~~K!}t'Mll:WX~
AUTHORIZED REPRESENTATIVE
~~
a, l-.L r. LL,
@~C~~~ON 1990
)RD 25-5 (7/90)
COVERAGE PART NUMBER: COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMEN- ~HANGES THE POLICY. Pl'" ~E READ IT CAREFULLY.
ADDITIONAL INSURED-OWNERS, LESSEES OR CONTRACTORS
(FORM B) Floor to Ceiling Construction, Inc.
AE 0021491623
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the
Schedule. but only with respect to liability arising out of "your work" for that insured by or for you.
SCHEDULE
NAME OF PERSON OR ORGANIZATION:
City of Campbell, its respective officers, agents and employees
75 N. Central Avenue
Campbell, California 95008
It is hereby understood and agreed that as respects the above project and additional
insured this insurance is primary as per section IV-Commercial General Liability
condition number 4 on pg. 10 of Form SD003.
CG2010 (ED. 11-85)
768200
PRINTED IN U.S.A.
d. No "insureds" will, excepf :heir own cost, voluntarily make a payrr
a~y expense, other than for IIrst aid, without our consent.
assume any obligation, or incur .
3. Legal Action Against Us.
No person or organization has a right under this Coverage Form:
a. To join us as a party or otherwise bring us into a "suit" asking for damages from an "insured"; or
b. To sue us on this Coverage Form unless all of its terms have been fully complied with.
A person or organization may sue us to recover on an agreed settlement or on a final judgment against an
"insured" obtained after an actual trial, but we will not be liable for damages that are not payable under the
terms of this Coverage Form or that are in excess of the applicable limit of insurance. An agreed settlement
means a settlement and release of liability signed by us, the "insured" and the claimant or the claimant's
legal representative.
4. Other Insurance.
If other valid and collectible insurance is available to the "insured" for a loss we cover under Coverages A or
B of this Coverage Form, our obligations are limited as follows:
a. Primary Insurance
This insurance is primary except when b. below applies. If this insurance is primary, our obligations are
not affected unless any of the other insurance is also primary. Then, we will share with all that other
insurance by the method described in c. below.
b. Excess Insurance
This insurance is excess over any of the other insurance, whether primary, excess, contingent or on any
other basis:
(1) That is Fire, Extended Coverage, Builder's Risk, Installation Risk or similar coverage for "your work";
(2) That is Fire insurance for premises rented to you; or
(3) If the loss arises out of the maintenance or use of aircraft, "autos" or watercraft to the extent not
subject to Exclusion g. of Coverage A (Section I).
When this insurance is excess, we will have no duty under Coverage A or B to defend any claim or
"suit" that any other insurer has a duty to defend. If no other insurer defends, we will undertake to do so,
but we will be entitled to the "insured's" rights against all those other insurers.
When this insurance is excess over other insurance, we will pay only our share of the amount of the
loss, if any, that exceeds the sum of:
(1) The total amount that all such other insurance would pay for the loss in the absence of this
insurance; and
(2) The total of all deductible and self-insured amounts under all that other insurance.
We will share the remaining loss, if any, with any other insurance that is not described in this Excess
Insurance provision and was not bought specifically to apply in excess of the Limits of Insurance shown
in the Declarations of this Coverage Form.
c. Method of Sharing
If all of the other insurance permits contribution by equal shares, we will follow this method also. Under
this approach each insurer contributes equal amounts until it has paid its applicable limit of insurance or
none of the loss remains, whichever comes first.
SD003 (ED. 01 -90)
Page 10 of 17
PRINTED IN U.S.A.
CITY OF CAMPBELL
Perm.&.c No.
INFORMATION SHEET FOR ENCROACHMENT PERMITS
~ORKERS' COMPENSATION INSURANCE INFORMATION
Name of Contractor/Applicant f~rt- LV CEtu(Ij G C:c>N5'1'RLl(..1l~ :f1J <-
One of the following must be on file with the Public Yorks Department:
A Certificate of Consent to Self-insure issued by the Director of
Industrial Relations; QR
____ A Certificate of Yorkers' Compensation Insurance
Insurance Co.
Policy No. Expiration Date
QR
This Certificate of Exemption from the Yorkers' 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 th Yorkers' Compensation Laws of California.
-
Date
r~ 2Y-1L
Signed
NOTICE NTRACTOR/APPLICANT:. If, after signing this
Certific e 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 Yorkers'
Compensation Insurance.
Name of Contractor fLctf( '7C CClLlI\JC. IN<::. Telepho~e fog ~ 7;1--/8/7
Address P c:". /J'b>G 3b2..- f1;L/l:;,.,'\J CA 9Sc/S
I
State Contractor License No.,. ~3S'57'Z-
City Business License No. ~~~ Expiration Date
Will do the following types of work:
Underground _____P.C. Concrete _____A.C.Paving ~lectrical
V Other (specify) fY'lANI,f\.)(. ~r1 ,'-J(, P_>5.S S IO,.0G
r
f:perminfo
10/91
-
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PUBLIC WOl REVIEW SHEET - BOJ:LDING
.HIT APPLICATION
IPERMIT ADDRESS:
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r~d-i-OS-- C>s-s.
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1'(.. ~ .e V" t V\ j
I IDATE ~o:J
rNAME OP APPLICANT:
w;/I\QW\ H.
IDA~ :~~~~
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;:=ti~:?c::M~~':' . ...:. ;'~:'H::::~r.:.:' :':'.:::::..:~:..SL~~l!..:'::'-~
CHECKLIST YES NO CHECKED BY:
street Im~rovements Required )(.
Dedication Required ~
storm Drain Fees Paid ''>(
I PW - ENGINEERING REQUIREMENTS: (
~~ouJ J, \tOl..4f-c.. t...-.. c t'" 1.'\..( c,r L I~ -c..
..s..t D I'" \.Ao-t e\ \- ~ I." '\. Cl.r ~ ~
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IAPPROVED BY:
I DATE:
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7..
8.
STREET IMPROVEMENT CHECKLIST
PROPERTY LOCATION:
DATE: '2~/z.r/9 2...
/
~/ #C/A./r t/[/4c/
1.
Are there existing PCC improvements
.--- ::-'\
/~. yes \
~
no
2.
If not, where are the nearest improvements?
3.
00 the eXisting improvements meet current
standards? ye~ C3
Width of sidewalk? (Do not include curb) ~/~_
" '-" --. . KJ 4:' Gv~~J-:;
List non-standard improvements that need replacement:
4.
5.
l
~~ D/ t.u ~$i
'/1/5<
,~ ~ ,-~.{",.'
Are existing standard improvements in
acceptable condition?
A''''
yes
no
Is there an existing street lighting system?
.-,
no
yes
'~-'
Pole type?
Luminare type?
Location of nearest electrolier?
Describe the pavement condition:
ff:., ,.... /;
Is it acceptable as is?
yes ci~
yes no
'I. ~S) no
yes no
Does it need an overlay?
Does it need to be removed and replaced?
Does it need a partial replacement?
/J
'/! ,.
C. ./ - _./
.'" .<- ~
COMPLETED BY:
From: Bill Pickering
Date:
11/9/92
To: Mike Fuller
Subject:
Permit Extension
Mike,
I would like to request that my Public Works permit be extended. The permit number is 92-
156. The address of my house is 61 Hunt Way, Campbell. My contractors are currently
planning on finishing the new drive way and sidewalk to my house sometime in the next two
weeks.
The reason for the non-use of the permit has been underestimating the length of time the
house remodel would take.
Please let me know if I need to provide you with further information or actions.
Thank You and Best Regards,
~Q~~
Bill Pickering
(408) 720-3063
NO'll 0 ',3~t
vublic W or~{iJ Engineering
r
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
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CITY OF CAMPBELL
Department:
Public Works
W O"V'Z.:D
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/N W (2. 1 Tl /116 . /J'I1(J ;
II/oh~
Mr. Bill Pickering
61 Hunt way
Campbell, CA 95008
RE: ENCROACHMENT PERMIT 92-156,61 HUNT WAY
Dear Mr. Pickering:
Your encroachment permit to construct the driveway at the above address will expire on
November 1, 1992. You must reapply to extend the time, and, we suggest you request
a 6 month extension, to terminate on April 1 , 1993.
The City hereby grants you a 15 day grace period to reapply. For your convenience you
may reapply with a written, signed and dated statement on the reverse side of this letter.
Please return the letter in the enclosed self-addressed envelope. Please contact our office
at your convenience if you have any questions.
Very truly yours,
Mike Fuller
Assistant Engineer
jdjr
Enclosure
cc: File (Encroachment Permit 92-156)
f:92-156