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88-132 . .. G-~ -: ::- g;e";J" ...... ..5.... .:>Gone ... :) .l> 1\ ,.. n ~ "'.... n .................. .:..::~~:>g f'" ...0 ... n n .... '::I':a. N ::l:"-::: .. :J ~,... On...._o ....:1.-....."' ..... .. .... P\ n ..n"",n ... 0 o:r .c.._.,. nvanC >-"'60 :.; 0 > .. 0 O-U;:a.....n< 0" .. . o:;):r<", ~ C : ~ ~ o. U ..... . "" :l F\ . :a n . .. ..... ~ n Pi "''' ... ~ :J r. o 0 n _ ....n... . ........ n n" :r .-c:..- ':.c. . :l .. o '" r.. . .. ......." :I , ::1"- .. .. ......6AD~..r1 I'n.....O:1., 0.. .; ... "'.. wnr- :J - ... ......,. ...."'..:s- ....." u . ~...:JJs~ .no...Pin. ~"",n . l.oft _ _,"' ;:~;-Z ~'< Con. ~:r ;J~;:a;;::: .-nng .. .,.. :::J .. .- < .: 0 .. .. .... n tn..-nn .. ..:r or ::a W. . . n.. ~.-n :r:J o .. u ._ M .. :>> .. n . .... n :r . (.I...."'U. :1 t\ . n ~.!"~':J=- ...A, .. n ,o1--/3>L- PUbLIC WORKS PERMIT cc-O TTUTlWatlln~ In-tn. p"blle: tl~ht.ot-",.~l X-keto tll. ~l-?-~ IU\.I.d y/ s;/ r::Y rf' AppUC.t IQn Du. ~ '2t-.tP rr ".calt ."lIt.nn I.~ ao.. ..plr.. llY . APPLICATION - Appllc.tlon 1. beceb~ aad. toe. ,,,bile: NOCk. '.calt In .ccordanc. with Caa~bell- "\.In 1 c 1 pal Cod., i.ct1 011 11.0 t. .-j CITY 0' CAMPbfLL D~PT. or PUbLIC WOkK~ 10 ~octh 'ir.t il. . C..pb.ll. CA '~OO' C.OII I IIh-H ~O -' P.ralt 110. l;. P: , . ( 'l' I I' ~. Wor"- .ddUII oc tr.ct' TKAC'~~ 'OS. 410 ~t2-{:2.'ll.- UtU1ty tr.nch loc~t lon 0AC ~ ;::-);<. \ <:.., .--.....,-. " M. Nat"c. ot worll; ~y\O\\:~ \ )ZJ:::.,I:.....~ ...L,2)'<)\......CLA-j":C.O!'--.J C. Att.ch tlv. (Sl copt.. ot a dr.wlng ahowlng the loc.tlon, axtant .nd dlaen.lonl ot th. wocll Tha dra"'lng .tla11 .'Iow the relation 01 th. propo.e4 ",or"- to ....t lng .uetace .lId under9ro\.lnd laproveacntl. Wh.n .pproved by the City tngln..r, .ald dc.wln9 becoa.. . p.Ct 01 thi. pec.lt. O. The Gener.l Condition. tor .11 peralta .re ll.t.d on th. CeV.c.e alde. Speclal Pcovl.10n. tor thl. per.it ara 11.ted belo",. tallure to ablde by the.e condition. and provl.1on. ..y reMult In job ah\.lt-down and/or torteltu.e ot 'althtul 'ectora.nce bonda .nd ca.t. dapo.lt~. I~ce Gener.l Conditione 1 and ~l. P. C U' ~. ;: f' ;;- '\ '\. I" I. t;. An .pphcaUon ~..e IIU:t a-JIIIP.~ny _th~i~ .PP1.1CU Ion. "' Thh h n~-cd\.lnd.ble. . ,_ _.' t- ....11. of Applicant V:.L.C c..,:) r.L. ?LCL 10''- G.:::l)7".c.\... (l-r1\C;u ~ehPhon.( ~- :)~. ),~<1S. AddccuI6'd,:')O 2DcIOI..} 20 (C~ (A"lO"'''- D::... f7;~~l- (~)::x.':-')~.9 , I. thl. "'or"- being dOlle'by the peoperty own.r .t tb.lr own e.~ldcncel ___y.. ~o Coaplete .ttach.d Wo.kec.' COlllpene.tion and Contc.ctoc toca.. The Appllcanl/~erllllttee heCeby agr... by .tfixing thelc .l~n.ture to thla peralt to hold the Clt~ of C."plJell. It. ottlccI~, .'lenta and ...ployeCI tece, ..ate .nd hac.le.~ hOIl .ny cl.La or de..l.d tor 0....9.:. Ic.u1tJn~ ttOIll the "'01"- cOvered by thll PCCllit. el th.t they have cc.d .nd \.Inderatand both the tcont and OC. th~h contraCturlli) of the InfoCIIIAtlon. Y-4~~~. 11<<. ACCLnLD ...OTtS: ALL'WOkK SIIALL CONYOkK WIT" TNt ATTACHED, APPkOV~D PLANS AND ALL A~~LICAbL~ CAKPbLLL STANDAkD DKAWI"'~S AND CONOITIOH~. Till: CONTkACTOk KUST IIAVt: TillS PLk"IT AND APPkOVJ::D PLAHS AHu "UST "t:t:T WITIt TItE P.W. IN:if't:CTOk ON TIU; SITE AT Lt:~T 1'WO DU:; Ut;YOkt: STAltTIHG WOltl. ~OTICE "U~T &iL CIVt:H TO PUbLIC WORKS AT LEAST 2. HOURS berOkE kLSTAkTJHC ANY WORK. 5YECIAL PROVISIO~S ., r -' V1. 2. - Street ..hall not bc open cut for underground lnt;tallati.onji. "lnlll\.lll CUll a6~ be .lluvcd tor conlleCtlons oc ..plocatlon hol._. S\.Ich C\.Il. IIUbt be .p~CltlCollV opprovtd by tilt I IUip"ct ur . PAVlm~.ay be cut for und.c~couna lnMtall.lion. And IIU.t be CCMtoced 1n .ccora.nce "'ltn the Utility TrenCh kct;lOratlon Standard Dra",i.ng. Wurk to Ue atAked by . llccn~cd Land 6\.1rveyor 01 Clvll Engln.er .nd two C2) COples ot the cut .'Iel:la aellL tQ the PUlJlic Work Dept. beture .tlutlng "'ork. The tlour. of "'00l .r. lillltcd to olltlildc the hour. ot l-j .... .nd )-il p... foc .n~ "'01" .ltectlng . (ratllc l.n.. '" I~ ('-; a;. I'. 3. - -- t. - -~. ~. (II c:; a: ~~kKIT AP~LICATlON 'Ll ,LAN CULCK DEPOS1T >>ONO 'OM rAITJlJ'UL PEkYORtlANCE r. P. ICA~UI D~POS1T '1:kftIT J't:t: (a-l) (US.OO I c ST~DAkD / iSO~OO AIIOUNT .50 kt:Ct:IJ>T NO. /.,p.2. cO / \ tc4c::A ~: -rP'.!.."1,.q c...~;0'" \ "1",,- 40 / co. r- APPMOVt:D 'OM ($:lOOI $ Jr IJ' 2 ~ / 4-~-~ uat. t; PWP~KKIT kevi..d 1/U1 VltL f~ ~. 350 MCu' kra~c:Jdf 15 is' S <r C;SJ33 PUBLIC WORKS INSPECTION REPORT Date 4/'ijet:, Permit $''- Project No. '8, eo -/3Zy/t/J1 Address 410 ~L-ZAU;I1R.. 7}e.4e..r 8/0:;;'- I Type of work: Street Storm ~ Sanitary Electrical Other (describe) [JPRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached) [JFINAL INSPECTION WITH DEFICIENCY LIST (attached) ~NAL INSPECTION - ACCEPTANCE Signed plans? Y ~ (If signed, Council acceptance.) Charges against deposit? Y OVertime: hrs. @ $ Date' reason: ~ - $ Barricade rental (attach invoice)? Y Date , reason: ~ $ # Other? Total charges deducted from deposita (Cash Deposit ~_~ less charges $ o ONE YEAR MAINTENANCE WITH DEFICIENCY LIST $ $ $ - Refund $ r:;;t;7 (: -i"ck. req.) (attached) o ONE YEAR MAINTENANCE - ACCEPTANCE (Release' maintenance bond. Check Request if cash.) Engineer ~ Ins or 0/ol ,1A.' ._^i._JL-A--V~ .$l '-a, ...-t,' 'f -y0--<!'t -'---Y '-' : -1. L-1/ "L'- ./ L.C-r - .{~CG.L- 'fa 6~ 7 '-d-S/3 t~1.i \--. -----... ''''/-:' ~ ~ c.i ID "- "" "" CI) '? ~ .... I I't) v) C\I I q, I I't) ll-OS :II: NO 14NOW.l ,."01 ... J1 i:r:rll 6~ ...- " N'ifS )"'\1MSS3~dX3 S'if~O.l ~ 1 J\ ~-. ~ ~ ~. ~; -; ~ .t~ ; :: ~;j~ ~ -L~~~. 'K);~ Ii ~ jo~ ,) f'Q~' ,;"StfOgc+o( =;,~ '\~ -l. ,., ;:- - =.or---' t '" - - $i."06 I't) >- ,0' ~ ~ ~ if; ,.. ,. '?i~.,:~ .. ~ ':. ... ~ :-;-~ .' .-: :.~ ~ U ..~ ,'- N ~- >- ~ - ,'? ~ ..J IIJ o @ 1 i" I I~ \ ~ - ~ '$ t ~ I~ ~ ~ to-. OL"~' ~ti.- I ~ ..-..;; "';:: , ~ "3"mol.> ~- a3'''~::'0~:r/ f~~o'o' ~o., .md:'~:~s... ~ ::;~ ;; ~\~ \.i) ~~ ;::c 10 g .. ca ~ .... l~ 2 ,dd' I .L Jl .....__. (II< 10 ~ - Lr,~;)~ M\ V" ~ ~"",::I ~ g;:- ~ g_ I- . ~ .~o OO'\1~ "."," . 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III .. i: I\. .. .. II> .... I C) .... 1 ( - .-".--- _. -. -_.~--.- PUBLIC WORKS INSPECTION REPORT . j Permit or Project No. '~ B -13~ ~Ate f~~~ Address 4lo ~l.- ~r 8/0~- ~pe of work; Street Storm.",..,. SAni tAry Other (descri!)e) ElectricAl o PRELIMINARY INSPECTION WITH DEFICIENCY LIST (AttAched) Cl FINAL INSPECTION WITH DEFICIENCY LIST (AttAched) ~AL INSPECTION - ACCEPTANCE Signed plAns? Y ~ (If signed, Council AcceptAnce.) ChArges agAinst deposit? y OVertime; bra. . $ DAte, reAlion; ~ . $ BarriCAde rentAl (Attach invoice)? y DAte , reAson; .. €) $ . Other? $ $ $ · Refund $ TotAl chArges deducted from deposita (Cash Deposit $ less charges $ DONE YEAR MAINTENANCE WITH DEFICIENC! LIST (AttAched) o ONE YEAR MAINTENANCE - ACCEPTANCE (ReleAae'maintenance bond. Check Request if CAsh.) ek. req.) Engineer ~ Ins or TO: City Clerk PUBLIC \oJORKS FILE NO. t"t,..) 32- Please collect & receipt for the following monies: ).,1 ITEM Project Revenues (specify project) Pu.bUc. (~O!tlU, EXc.a\!(1.;t.iol1 peJl.r.l,u Fee.4: A 1 i ca t i on Fee Plan Check Deposit Faithful Performance (Cash) Deposit R-l : ($'35) ($200) Plan Check & Inspection Fee 3521 Other Cash Deposit (specify) 3373 3373 3373 3373 OthVL: ($ 50) "( 500 (4% of FPB) ($500 min.) (7<;" of FPB) ($35min.) AMOUln $ s-o -- r:3r-.J 3372 Tentative Parcel Map Filin Fee ($350) 3372 Final Parcel Hap Fil in Fee 300 3372 Tentative Tract Map Fil in Fee $ 00 3372 Final Tract Map Fil in Fee $350 3372 Lot Line Adjustment Fee/Certificate of Compl iance 3372 Vacation of Publ ic Streets and Easements ($500) 3372 Assessment Segregation or Reapportionment First Spl it ($500) Each Additional Lot ($150) 3372 Envi ronmental Assessment:' Categorical Exemption ($500 plus actual cost Negative Declaration 'above $500) 3370 Storm Drainage Area Fee per Acre (R-l, $1,875; Multi-Res., $2,060; all other, $2,250) ~395 Park Dedication In-lieu Fee per Unit ($1,132) 3380 Public Works Special Projects 3510 Postage 3373 3373 ~520 TOTAL NAME I J/IC K >: /G '2.. ~o L ' C--. ?, PELINe- j3 v ~r(J ;1/ RJ ADDRESS PHONE RECEIPT NO. FOR C I TV CLERK OoIl.Y /<?~!Ol <g~? Clrrj ~-s-~ct AMOUNT PAID RECE I VED BY DATE $p~ 55&' - 73 3S-- ZIP 9 ~-o.3 2. July, 1987 ') , , NAME (~/(;,,/'~,"b":I-o.-.J,.0 ',; J' ADORES!'; / (; -;:,' S-;."':) "(;...,(J -- f~_ (c.' / - . ,.to .-'c..J...",-" "~d -A.:....'__ (\ r" .'..._r:'" U ~! .( c- " - ,- FOC,n.-<4" U ~,.P . ~....d."t<, ,'/., ,.,'f..::. .<;~\?-e\/ 3~~\ Ci)~ f~F / . 1:.~' FSUL '-._k.tJrJ' ;.- ,/' <', ~-. <::'-~'. / ?, 7_ REVENUE ACCOUNT NO. FUND NUMBER /..::;;':;7'1 0 () ""------ c..). . .......~(:) c? . ,--:" .") 00 ,~:'(J, -~ :s.' ~ :'l:':::_ (")0 besS", ";l. 5 ~ ;) 72..- 2) 2-{ C~ 5k:J ~ THIS RECEIPT MUST BE MACHINE VALIDATED AND SIGNED BELOW. 18261 o MONEY ORDER DATE o CASH 3"3/2- 3 SL..I 2 AMOUNT 135~vD.6oo 40 5"00...00 ~ .o:!> q"'b -~v BY (2/;,'7~) Thank You CITY OF CAMPBELL t:, '3 S 00 CITY CLERK Permit No. Applicant J<f> -/3 ?- VI eN'. 'S 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\/rcl2:~ 2?CLr:..0~ (}-:",:rx::~ lelephone ~jS ~d:-).)'::>"';js, Address I h:.:J.'SJ:'J~'-J?T\.j,,-~ '2~ ([)2:, (y.>...TO'-:::. CA. QSos;j State Contractor License No. ~S ~a t City Business License No. Expiration Date Will do the following types of work: ~underground _____P.C. concrete _____A.C. paving _____electrical _____other (specify) WORKERS' COMPENSATION INSURANCE INFORMATION Name of Contractor/Applicant \/s-C' \6 .;:L;)"LL..J::.....JIL. (}'l0"~\. 7:--.v:....) 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 --L 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 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 California. Signed Date NOTICE TO CONTRACTOR/APPLICANT: 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