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CITY 0' CAKP~~L~
Ot:PI. or t'UbLIC WOkKlt .
70 Horth 'll.t it. .
C..pb.ll. CA '~on.
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PUbLIC WORKS PEkKIT
lTlJrlmtl1n~ lR'tlff
publlc el~h~ot-W'Yl
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APPLICATIOH - Appllcatlon 1. hereby a.d. lor a 'ubllc ~ock. 'er.lt
"uniclpal C04., II.CI1011 11.0..
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AppUcallun D.l. :f- /~- cf".,p-- f,
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ln accordanc. wlth C..~b.ll-
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UtLllty te.nch loc.tlon
...tuc. 01 WQCk:, AZe/:%..-4C-tf"" 2>.4-/'1.;46"- c7:> ~L>6'A/;IIJ'-~
. .
Att.ch Ilv. C~l copl.. 01 . drawlng .ho~lni the loc.tlon, ..tent .nd dlaen.lon. ot the WOck
Th. dr.wing .t.a11 .holll the c.latlon ot the plopo..d WOI~ to e.l.ting .urt.ce .nd undel9tOund
L.proveaent.. ~hen 'PPloved by the Clty tngln..r, .ald dra~lng b.co... . pact ot thi. pcralt.
The Gcnel.l Condltion. tor all peralta .re 11.ted on the rev.rae .1de. Specl.l Prowi.lon. tor
thl. petlllt ar. 11.ted below. t.l1ure to .blde by the.e condltlon. .n4 prowl.lon. ..y eCMult
in 10b .hut-dollln and/or torteltuee of ,.lthful Pertoeaance bund. .nd ca.t. depo.lt~. ISec
e.necal Condltion. 1 and ~l.
t. An .ppllcatlon f~.t acco~p.~ th~~apPllc.tlon. Thl. 1. non-r.fund.ble.
....e ot Applic.nt. ~tuE & HAlo! ~ Telephon.:
Addc.u /19 7/ E L-. S /J ,-'y 0 c'Al'1 ~ G'L-'--
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I' thla ~o,k being done 'by the property owner at th.l, own re~ldenccl ___yea no
Coaplete .tt.ch.d ~orker.' COllpen..tlon and Contr.ctoc tora..
The Appllc.nl/~erlllttec herebY '9r... by .ttl.ing theic .i~n.tuce to thl. perait to tlold the Clty ot
C...p..u:ll. it. OttlCef~, .'lenta .nd e..ployee. teee, ..Ate .nd harale... feull .ny cl..... or delll...d foe
4....9.:. fe.u1tln'J trolll the ~ofk COVefed by thi. pee.it.
ACCtl'TED
hereby aCknolllled'Jeli that they hawe r.ad .nd Ilndcratand both UIC fcont
ana t t th wll1 1ntora thelr contr.ctucC.1 ot the intor.at~.
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"OT~S: ALL'WOkK SHALL CONtOkK ~ITlt TH~ ATTACHED, APP~OV~O 'LANS ANO ALL API'LICAbL~ CAKPb~LL
STANDAkD OKAWIHCS AND CONOITI0H~.
Tilt: CONTkACTOk MUST IIAVt: TillS Pt:kHIT AND APPROVt:D PLo\Hlt ANII "UST Kt:tT 1lI1TH THE P.W. IHSf');;CTOIt OH
Tilt: SITt AT Lt:A:>T '-WO DAY:; b);;10kt STIUtTINCi WOIUl.
H01'ICE KU~T U~ GIV'H TO PUULIC WORKS AT LEAST ~. HOURS btYOkE R~STAkTIHG ANY WORK.
S~ECIAL PkOVISIOHS
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Stred ."All not be open cut tor underground In.t.U.tionli. "lnl"ulIl cut. ..y be .ll..,",ed
tor connectlon:; oe ellplor.tion hole.. Such cut.. aUII" lit! .r~Cdlcolly opprovrd by (hr
IllIi(.rCl lIr .
pavl~e~.ay be cut tor undergcouna Inllt.ll.tion. .nd au.t be relltoeed 1n .ccora.nce wltll
the Ut illty Trench ItcaltOlat Ion Standard 01.lIIin9.
Wurk to ~r IIl.ked by . licenaed Land 6urveyor 01 Civl1 Englneer .nd two C21 cople~ of the
Cll( ehectll acnL tQ lhe Public Woek Oept. bdore at.rting WOCk.
TI~ hour. ot work .,e lLaited to out~ldc the hour. ot ,-~ .... and l-~ p... toe any WOCk
.ttecllng . (Iattlc 1.n..
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PERMIT AP~LIC~TIOH ,tK
,LAN CU~CK DEPOSIT
>>OND 'Ok rAlTl1l'UL ,tkI'OkKAHCE
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ca-l)
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AHOUNT IlJ::CJ::II'T NO. P.
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REFUNDABLE DEPOSIT
CHECK REQUEST
TO: FINANCE DIRECTOR
CITY OF CAMPBELL
Address:
Line 1:
1071 El Solyo
(30 spaces)
(30 spaces)
Please issue check payable to:
Air Service
City :
Campbell
(20 spaces)
(30 spaces)
State: CA Zip: 95008
(2) (10 spaces)
(24 spaces)
Line 2:
Description:
Cash Deposit Refund
Exact Amount Payable:
Account Number:
$116.00
001.00.905.0000.4662
PURPOSE:
Release of cash deposit for Excavation Permit No. 88-138 (see receipt
#18377 dated 4/12/88).
Requested by:
Approved by:
Verified by:
Gregg Eaton
Title: P . W. Inspector
Date: 11/2/88
Date: 11/2/88
Don C. Wimberly
Title: P . W. Director
Accounts Receivable
Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as is xx
Mail in attached envelope
Return to:
(Department)
(Name)
Other:
08/24/88
PUBLIC WORKS INSPECTION REPORT
late Jolt ~8
/ /
Address /,0 7/-
Permit or Project No.
'88-/38
E/~ SO<-/10
/"
Type of work: Street. Storm Sanitary Electrical
Other (describe) .51'~4'I'~ eo/.2).d:"i,...~~ ~..a~..Ie:::S
[JPRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached)
[J FINAL INSPECTION WITH DEFICIENCY
~AL INSPE~TION - ACCEPT~~E
Signed plans? Y ~ (If
Charges against deposit? . ~
Overtime: hrs. @ $
Date Ai rea&on:
LIST (attached)
signed, Council acceptance.)
N
/hr.
-
$ .5eE'~/CA-l?k: kA-1TlC\~
Barricade rental
Date Ai reason:
(attach invoice)? ~ N
J~ - .LJ / b A.h!S7" ..s6i::L.~c
../,013 s,''''';- ,,?li"/l ~U~/~e;s,
$ ..33~ 7D
~T.:rt3S2..1
/fa..f.r,i'r# /8.3 7 7
LGEN~ ~/'J)
Other?
$
$
Total charges deducted from deposit:
(Ca&h 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.)
Engineer
~
Inspector
r
(~ I T}I 0 F C}\ M P It E it
70 NORTH FIRST
CAMPBELL, CALIFORNIA
(408) 866-2100
STREET
95008
Public Works
October 28, 1988
Department:
Mr. Gene A. Haun
1071 El Solyo
Campbell, CA 95008
RE: Final Inspection and Acceptance
Permit No.: 88-138
Location: 1071 El Solyo
Maintenance Bond Amount: Waived
We have made a Final Inspection of subject 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 (1) 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 the undersigned if you have any questions.
Sincerely,
Gregg Eaton
Public Works Inspector
GE:sd
cc: Suspense - 1 year
TO: City C I e rk
Please collect & receipt
for the following monies:
PUBLIC WORKS FILE NO.
c:fYc - /3?
(specify project)
peJLm,{;t eu:
R-l :
($35)
AMOUtn
$
:J~-
Depos it
2-00
Plan Check & Inspection Fee
3521 Other Cash Deposit (specify)
3373
3373 &
3372 Tentative Parcel Map Fil ing Fee ($350)
.-'2 Final Parcel Hap Fil ing Fee ($300)
:2 Tentative Tract Map Fil ing Fee ($400)
1372 Final Tract Ma 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
Ne ative Declaration
3370 Storm Drainage Area Fee per Acre Multi-Res"
$2,060; all other, $2,250)
J395 Park Dedication In-lieu Fee per Unit ($1,132)
3380 Public Works Special Projects
3510 Postage
NAME ~- J!:r u A/
ADDRESS 2(f& ~ V~ ~
TOTAL
$ 2-:3 s--
PH:lNE '3 77- 2- 0 / /
/J /J ~/)
{~~ ZIP fS-u & cY
DATE
/ '7'1
~z:so
0-11;)./ ~S
( J
July, 1987
FOR
C I TV CLERK
ONLY
RECEIPT NO.
AMOUNT PAID
RECE I VED BY
POLICY NUMBER: PR 505 975 0001
COMMERCIAL GENERAL LIABILITY
r>
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person or Organization: City of Campbell and its respective Officers, Agents
& Employees
70 N. First Street
Campbell, CA 95008
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
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.
(:.' "It is hereby agreed that the City of Campbell & its respective Officers, Agents,
~. and Employees are named as Additional Insured from and against any claims loss
liability cost or expense arising out of or in any way connected wtih the construction
of the project.
This coverage shall be primary and any coverage carried by additional insured shall
be excess insurance only."
JOHN GLAGE UNDERGROUND CONSTRUCTION
1116 Dell Avenue
Campbell, CA 95009
CG 20 10 11 85
Copyrtght. Insurance Services Office, Inc. 1984
n
PUBLIC WORKS INSPECTION REPORT
Jate ~~7h~. Permit or Project No. '88-;38-
Address )07(- e L Soyu
~pe of work: Street Storm Sanitary Electrical
Other (describe) .s,~c..V4LIc.....C.U.e~ ~~ ~Q~~
~PRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached)
[]FINAL INSPECTION WITH DEFICIENCY LIST (attached)
o FINAL INSPECTION - ACCEPTANCE
Signed plans? Y ~ (If signed, Council acceptance.)
-(1)
@ $
Charges against deposit?
Overtime: hrs.
Date 5 reason:
1:D
/hr.
-
$
Barricade rental ~~ttach invoice)? CD N
Date 5 reason:_.J4l.a'LL-- At})/) ?Al C,'AJ/tf., au~uE $
Other? $
$
~otal charges deducted from deposit:
(Cash Deposit $ less charges $
$
- Refund $
o ONE YEAR MAINTENANCE WITH DEFICIENCY LIST (attached)
o ONE YEAR MAINTENANCE - ACCEPTANCE
(Release' maintenance bond. Check Request if cash.)
Q
Inspector
Engineer
IQ)
ek. req.)
_~~c;hCLGv:7 L,,,;r
~/T~. 88~/3.f3
/07/- E'L- 5'7'0
~7 Z? /f~t3
~.dj7~~ C-0-;? j:"" L~oE 6p~~~r 0;' E~
._~Lv~~_d-r:'//2 C)4G~
_.j;)-&/~r I~Low~L-~ L-.~or6u~~ AT
_.~_.__V&?L~Lacd72~oS~C>A4.C.. ~5r ,&~ R-,ODCD
._._ m_~ 1M' -k~r/;frl~ .
,
..yJ)_C0-/ _ O-?~ _ .4-??/V~w_ A. C. ~L&F~_j~_~t';)C;7l.-
-'-_u_~a:rI_&XI':S 77';'" (; /f'Q&2~/lc;~
___.q)__6t2Y€Jt4?,. _ _ _C~ u Cd;4-{)E-..5./~7-t.J~L4'&16~/..577L?:;--r-
__~~.~_.L5n2fr- ~._..;:;/? 6;...;,qLL~y.'-~72Q,...j
70 NORTH FIRST STREET
CAMPBELL, CALIFORNIA 95008
(408) 866-2100
[---
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CITY GF CAMPBELL
---
Department:
Public Yorks
, . ..-: ----r-;'- I,
May ~'i~.""JI"'o___,~=IJ
Gene E. Haun
1071 El Solyo
Campbell, CA 95008
RE: PERMIT NO. 88-138
LOCATION: 1071 EL SOLYO
Ye have made a preliminary inspection of the work covered under the
referenced permit. Deficiencies in the work have been found are are shown
on the attached list.
These deficiencies must be corrected before the work can be accepted by
the City and bonds or deposits released. Please contact Public Yorks
Inspector Gregg Eaton to schedule corrective work or clarify any
questions.
Upon completion of all work and correction of all deficiencies, we will
need a written request for final inspection and acceptance of the work.
This then sets in motion the actions necessary to release your bond and
refund your deposits.
Thank you for your cooperation.
DNV/le
encl.
cc: G. Eaton, Public Yorks Inspector
B. Long Sr. Lighting & Traffic Signal Technician
CITY OF CAMPBELL
DEFICIENCY LIST
Permit No. 88-138
1071 El Solyo
May 27, 1988
1. Repair chip in lip of gutter (west of easterly driveway approach).
2, Asphalt is low (below lip of gutter) at various locations. More AC
must be added.
3. Chip seal all new AC surfaces in order to match existing road surface.
4. General clean-up of sidewalk, curb, gutter/street.
5. Submit letter for final inspection,
Permit No.
Applicant
ty~/)?
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
Telephone
Address
State Contractor License No.
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
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
I certify that in
employ any person
Compensation La
work for this permit, I shall not
become subject to the Workers'
Signed
Date YZ-0/9.r
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
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CITY OF CAMPBELL
70 NO. FIRST STREET
CAMPBELL, CA 95008
(408) 866-2150
FIELD MEMO
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DATE
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PERMIT OR PROJECT NO.
ADDRESS/LOCATION
I I:L
INSPECTOR/ENGINEER
G:eeG,,~
-
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RECEIVE08y~EFT o.J ~/~A~
CONTRACTOR/OWNER