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IAt thcy will tntor. ttle!c COlltCACl1JrC1i1 ot the IntoFl~.fAlion.
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HOTtS: ALL 'WOkl< SIIALL CONI'OIl 10111'11 TtU: ATTACIIED, Al'f'lIOlltLl I'L^N~ AND ALL A~i'LJ C.\.bl.t CMWbt:I..L
ST ANOA/iU DUAW J NGS ANU COtW 11' I OH~ .
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CITY OF CAMIJBEll
Department:
Public Works
E-.-
WIM-BERL '( -~----, .._'.,
,-:;-:----/ HAiJDLU'JG J '
! ' ,ELMS '11 -..-'-'.' --.-./
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1---. I DISCM1[ I 1
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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
July 12, 1989
Mr. Ken Phelps
164 North Third St.
Campbell, CA 95008
RE: One Year Maintenance Acceptance
Permit No.: 88-124
Location: 164 North Third Street
We h~ve made a one year maintenance inspection of subject public works
improvements and find that no maintenance is required.
Sincerely,
Carlos M. Jocson
Associate Civil Engineer
CMJ : sd
cc: G. Eaton
,..
/ 'I[ /'C:::7Z./J7 IT,
Date ~/II,(fi '1 Permit or Project No. . 88- /24"
Addreli& 1'4- Ai -n.I / ;e.,;) <; ...,-
PUBLIC WORKS INSPECTION REPORT
Type of work z Stre,t Storm Sani tary
Other (describe) R c- c. c..V,,~
Electrical
o PRELIMINAR3!' INSPECTION WITH DEFICIENC3!' LIST (attached)
o FINAL INSPECTION WITH DEFICIENC3!' LIST (attached)
o FINAL INSPECTION - ACCEPTANCE
Signed plans? Y N (If signed, Council acceptance.)
Charges against deposit? y
Overtime. hrs. @ $
Date , reason.
N
/hr.
.
$
Barricade rental (attach invoice)? y
Date , reason.
N
$
Other?
$
$
$
· Refund $
~otal charges deducted from deposit.
(Cash Deposit $ less charges $
[JONE YEAR MAINTENANCE WITH DEFICIENCY LIST
.(:JoNE~EAR MAINTENANCE - ACCEPTANCE
(Release'maintenance bond. Check Request
ct. req.)
(attached)
if cash.)
Engineer
~~r
PUBLIC WORKS INSPECTION REPORT
late ~44 ~ .. Permit or Project No.
Address /64-- - A7. ~ ;eL>
, 8~-/Z+
Type of work:
Street Storm Sanitary
Other (describe) ~A/ ~:flVZ.LJ~
o PRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached)
Electrical
o FINAL INSPECTION WITH DEFICIENCY LIST (attached)
~INAL INSPECTION - ACCEPT~
Signed plans? Y ~ (If signed, Council acceptance.)
Charges against deposit? y
Overtime: hrs. @ $
Date' reason:
G)
/hr.
-
$
BArricade rental (attach invoice)?
Date , reason:
CD
y
$
Other?
$
$
Total charges deducted from deposit:
(Cash Deposit $ less charges $
$
- Refund $
ck. req.)
[JONE YEAR MAINTENANCE WITH DEFICIENCY LIST (attached)
o ONE YEAR MAINTENANCE - ACCEPTANCE
(Release'maintenance bond. Check Request if cash.)
~or
Engineer
@
G/pr
CITY OF CAMPBELL
70 NORTH FIRST STREET
CAMPBELL, CALIFORNIA 95008
(408) 866-2100
Department:
Public Works
July 11, 1988
Ken Phelps
164 North Third Street
Campbell, CA 95008
RE: Final Inspection and Acceptance
Permit No. 88-124
Location: 164 North Third Street
Maintenance Bond Amount: N/A
We have made a final inspection of subje~t .Public Works construction and
find it acceptable and in conformance with City standards. Accordingly,
the work is hereby accepted subject to the one-year maintenance
requirement indicated below.
you are responsible for the maintenance, repair and/or replacement of all
work done should any failures occur within one year of this date. To
'guarantee this, you must either post a maintenance bond in the amount
indicated above, or maintain your existing faithful performance bond. If
you post a separate maintenance bond, your current bond will be released
by separate action.
We will inspect the work in one year and advise you whether or not
maintenance is needed..
Please feel free to call me if you have any questions.
Sincerely,
David N. Valkenaar
Associate Civil Engineer
DNV / le
cc:
G. Eaton, Public Wo?ks Inspector
Suspense--l year/
July 5.1988
I
Mr. Eaton
Public Works Dept.
City of Campbell
RECEIVED
JUL 07 1988
PUBLIC WORKS
ENGINEERING
REI Job location; 164 N, 3rd St" Campbell
Mr. Eaton,
This letter is to inform you that the work stated on permit #88-124
has been completed and needs a final O.K.
How soon may I expect my $200 deposit to be refunded?
Sincerely,
~helPS
P,O, Box 1J28
Campbell, Ca 95009
374-8503
C H E C K R E QUE S T
TO: ' FINANCE DIRECTOR
. Ci ty of Campbell.
Please issue check payable to:,
Addre~s: Str~et:'
City: .
(20 spaces)
(20 spaces)
(15 spaces)
State: ~(2spaces)
4 Zip:. [}[]I][]I]](5 spaces)
Description: (20 spaces)
Exact Amount Payable: $200.00
Account Number:
01446290500
Purpose:
Release of cash deposit for Excavation Permit No. 88-124. See '
Receipt #18034 dated 3/23/88.
Requested by:
D. Va1kenaar
. '
Title: Assoc. Civil Engr.
Da te :
7/11/88
Approved by: D. Wiinber1y
Title: P. W. Director
Da te : 7/11/88
."'
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as is
Return to:
x
Ma.il in attached envelope
,.
Department
Name
Ot~er:
. .~
REV 4/22/83
TO: City Clerk
PUBLI C WORKS FI LE NO.a> 5- /.2 j
Please colleet & receipt
for the following monies:
project)
eJl.r.l-t-t f e.M :
R-] :
($.35)
(Cash) Depos it
($200)
3372 Plan Check & Inspection Fee
3521 Other Cash Deposit (specify)
3373
3373
Project
General
&
3372 Tentative Parcel Map Fil ing Fee ($350)
3372 Final Parcel Hap Filin Fee ($300)
~~72 Tentative Tract Map Fil ing Fee $ 00
12 Final Tract Map Fil in Fee ($350)
j372 Lot Line Ad.ustment Fee/Certificate of Compl iance
3372 Vacation of Publ ic Streets and Easements
3372 Assessment Segregation or Reapportionment
First Spl it ($500)
Each Additional Lot ($150)
3372 Environmental Assessment:
Categorical Exemption
Ne ative Declaration
3370 Storm Drainage Area Fee per Acre Multi-Res.,
$2,060; all other, $2,250)
3395 Park Dedication In-l ieu Fee per Unit ($1,132)
3380 Public Works Special Projects
3510 Postage
TOTAL
NAME
~v ;0 /vzLr~
v
/ to Y 11/, 3 ./L-~C
a<-- ..'----> rz-f!-<-- ~ (
y
ADDRESS
FOR
': I TV CLERK
OIiLY
RECEIPT NO.
r
?:> SO 0
~
h- /LJ~ ~y
AMOUNT PAID
RECE J VED BY
DATE'
AMOUln
$
3C;--
$ '3 ~
3 7 y - P ) -CJ .-:)
PHONE
ZIP
July, 1987
TO: City Clerk
PUBLIC WORKS FILE NO.
Please collect & receipt
for the following monies:
:CT.
;396
3372
3521
~
3372
3521
(specify project)
P eJtr.1U 'F ee.4 :
R-l :
($.35)
($200)
:t eJ/..:
($ 50)
'( 500)
(4% of FPB)
($500 m in. )
(7~ of FPB)
($ 35 min.)
(Cash) Depos i t
Plan Check & Inspection Fee
Other Cash Deposit (specify)
}373
3373
Project
Gene ra I
&
3372 Tentative Parcel Map Fil ing Fee ($350)
3372 Final Parcel Map Fil in Fee ($300)
~172 Tentative Tract Map Fil ing Fee $ 00
72 Final Tract Ma Fil in Fee (S350)
Jj72 Lot Line Ad.ustment Fee/Certificate of Compl iance
3372 Vacation of Pub! ic Streets and Easements
3372 Assessment Segregation or Reapportionment
First Spl it ($500)
Each Additional Lot ($150)
3372 Environmental Assessment:
Categorical Exemption
Ne ative Declaration
3370 Storm Drainage Area Fee per Acre Multi-Res.,
$2,060; all other, $2,250)
3395 Park Dedication In-lieu Fee per Unit ($1,132)
3380 Public Works Special Projects
3510 Postage
R j/ -/2Y
AMourn
$
:;"'CJo-
NAME
I(~ ?~
/ & '-/ /I/~ 3~
$ 2.00-
3 '7 y-?5'cJ .3
9 ^~-o 0 ?
TOTAL
PHONE
c~_
ADDRESS
ZIP
FOR
': I TV CLERK
.:lNL.Y
RECEIPT NO.
/ ~3tj-
;;2..0 eJ 0_<'
~
3'd-~' ~~
AMOUNT PAID
RECE 'VED BY
DATE'
July, 1987
Permit No.
Applicant
cPy- /..2->L
I<~ p~
INFORMATION SHEET FOR PUBLIC WORKS PERMITS
A separate form must be completed for the applicant and each contractor
that will work under this permit.
CONTRACTORS INFORMATION
Note that all contractors must have current City of Campbell Business
License, State Contractor's License and Workers' Compensation Insurance,
Name of
Contractor S (.f
; (:J cf N -")'{:d-- c-:;t
Telephone
J) c;--g5LJ5
Address
State Contractor License No.
City Business License No,
Expiration Date
Will do the following types
_____underground ~P.C.
of work:
concrete
_____A.C, paving
_____electrical
_____other (specify)
Name of Contractor/Applicant
WORKERS' COMPENSATION INSURANCE INFORMATION
Kef' Phc (fDS
)
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
The Certificate of Exemption from the Workers'
Compensation laws printed below (certificate must be
signed) .
CERTIFICATE OF EXEMPTION
Signed
performance of the work for this permit, I shall not
ny manner so as to become subject to the Workers'
alifornia.
I certify that in
employ any pe on
Compensatio
--------
Date
r, . UI
"S-O -<So
NOTICE TO CONTRACTOR/A 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.
f:PERMINFO
REV. 11/87
Z.w