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Th. duwlnl;j Itllll .how tbe r.htlon of the pro~o..d worll to e.i.Ung .urhcI alld undugrollnd
L.prov.acnte. Whln approvld by the C!ty tng!n..r. lald drawlng D.co... a part 01 Chl. p.c.,t.
The General Condltion. tor all per.ltl .re 11'ted On the rev.el. lide. Speclal PrOVll!onl tor
thl1 pccalC arc ll.ted below. tal1ur. to ablde by thea. condltlon. .nd plovl.lona ..V r..~11
ln 10b ahul-down al\a/~r torleltuce ot 'althl~l 'crtoc..nce b~nd. and C.la. a.po.l,.. IS..
C.nec.l C~nd'tlon. 1 and 21.
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.1 Chi, wo,~ being donc'by tbe property OWner at their Own r.~ldenCe1 ___y., ~no
Coapl.L. atcach.d Wockce,' CO.pen.ation and Contr.ctor toca..
The .ppllcant/~erallt.e hereby .gr.., by affixing their 'l~n.tue. to thla p.rait to tlold the Clly 01
Ca"~&lell. lta; olllceC., aljelltl aniJ .aplOY", tr.e. ..ate and haC.le.. tu,. any cl.La or de..,.d tc.r
d....g6:. ee.~hln~ tco.. the wj)(~ COVel.d by cbh peraH.
Ttle A..",laca..r/hlaLuee hereby ~~YOWlcd'.le6 th.t they h.v. r..d and ~ndeUtand both U,e teone
baCk ot th~~ PCI.lt~ana th.t t~ will intor. tnelr cj)nclacc~rf..) ot tbe lnfor..rlon.
ACCtl'TtD (:V.v;-P~ > ~1 / r -:J - ^..~ .. g',f"
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HortS: ALL 'WOk!( SIIIoLL CONI'OIC" WITlt TH~ ATTACHED. APf'ICOV~D PLANS AND AL1. .....1.JCIoJU..t CIo"paat:l.l.
STIoNUAlCD DkIoWINCS ANU CONOIT1UN~.
Tile CONTICACTOfC MUST UIoVt: TillS PCIC"IT AND APPftOVt:o PLANS ANII MUST Kt:CT WITH THt: P.W. IN~f't:CroH ON
Tut: SIT!: AT Lt:.\:OT 1'W1J DAY~ ntOkt STAltTlHG ..oiK.
NOTICE KU~T bE CIVt:" 1'0 ~UbLJC WORKS IT LEAST 2. HOUkS b~rOkE kESTlokTINC ANY WOkK.
S~t:CJAL PHOVISIOHS
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SUed ....11 not be open cut tor underground in.tallat ionli. "Inlalll. CUU ..Y be .ll~"ed
tOI conllecllOII~ oc e.ploratlon hol... ~~ch Cut. all..1 be .Pt'cat&c..lly Approved by III.
I'"'f.cct ur .
Yav..e~r-..y be c~t tor und.cgrollna in.tall.lion. and auet be le.tOled Ln ac:c:oea.nce wltn
the Utll11y Thnch Itca;toratlon Standard Drawing.
W~r~ LO ue Mlaked bV .. 11c:cn.cd L.nd 'urve~ol O( Civll Englneer and two 12) COple~ ot ChI
Clll allect. MCllt t~ lhe "~&ll1C won Oert. bct~rc IralcirUJ WOlk.
TI~ "o~r. of worK ace lLaited to gut. de the hour. ot ,-~ .... and 1-~ p... tor any woe~
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CITY OF CAMPBELL
Department:
Public Works
WIMBERL Y
HELMS
BOLLIER
KRUGER
QUiNNEY
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
September 6, 1991
polyplan, Inc.
1901 S. Bascom Avenue, suite 1625
Campbell, CA 95008
SUBJECT: ONE YEAR MAINTENANCE ACCEPTANCE
PERMIT NO. 88-155
LOCATION: 121 S. THIRD STREET
Gentlemen:
We have made a one year maintenance inspection of subject
public works improvements and find that no maintenance is
required.
By copy of this letter, we hereby release your maintenance
bond.
Your cash deposit will be refunded under separate cover.
Please feel free to call if you have any questions.
sincerely,
Sal Duckworth-Lanzo
Senior civil Engineer
SDL:djr
cc: Bond company
CITY OF CAMPBEll
DATE: 1 //5/1)
ADDRESS: I'd / 5.
PUBLIC WORKS INSPECTION REPORT
PERMIT/PROJECT NO.: g? - /55
TRACT NO.
TlUAuV ~T ~
TYPE OF WORK: STREET: -X- STORM:
P.C.C.: PARKWAY:
SANITARY:
OTHER:
ELEC:
[] PRELIMINARY INSPECTION WITH DEFICIENCY LIST
[] FINAL INSPECTION WITH DEFICIENCY LIST
[] FINAL INSPECTION ACCEPTANCE
SIGNED PLANS ? YES NO
COUNCIL ACTION ?
YES
NO
CHARGES AGAINST DEPOSIT? YES
OVERTIME: HRS. @ $
EQUIPMENT RENTAL: TYPE:
AMOUNT: $
DATE: / / REASON:
NO
PER HOUR
s
TOTAL CHARGES:$
[] ONE YEAR MAINTENANCE WITH DEFICIENCY LIST
~ONE YEAR MAINTENANCE ACCEPTANCE
~OR
---
REFUNDABLE DEPOSIT
CHECK REOUEST
TO: SANDY TERPKO
ACCOUNTS RECEIVABLE
Please issue check payable to:
polyplan, Inc.
Address:
Line 1:
1901 S. Bascom Ave. Suite 1625
Line 2:
City :
Campbell
State: ~ Zip: 95008
Description: Refundable Denosit
Exact Amount Payable: $1,000.00
Account Number: 905.4662
PERMIT NO:
88-155
LOCATION:
121 South Third Street
DATE AND NO. OF RECEIPT: $500.00 in Mav. 1988-Receiot #19136 ANn
$500.00 on 7/22/88 -Receipt #20058
~OSE: cash deposit refunds
Requested by: S.Duckworth-Lanzo Title: Sr. Civil EnqrDate: 9-6-91
Approved by: D . Wimber 1 y
Title: Dir Pub Wks
Date: 9-6-91
Verified by:
Accounts Receivable
Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as is
xx
Mail in attached envelope
Return to:
(Department)
(Name)
Other:
04/18/91
l
CITY OF CAMPBEll
70 NORTH FIRST
CAMPBELL, CALIFORNIA
(408) 866-2100
STREET
95008
Department:
Public Works
October 10, 1988
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CASE I \1
""..------=---
Po1yp1an, Inc.
1901 S. Bascom Ave., Suite #1625
Campbell, CA 95008
RE: Final Inspection and Acceptance
Permit No.: 88-155
Location: 121 S. Third Street
Maintenance Bond Amount: $1,075.00
We have made a Final Inspection of subject
find it acceptable and in conformance with
the work is hereby accepted subject to the
requirement indicated below.
public works construction and
City standards. Accordingly,
one-year maintenance
You are responsible for the maintenance, repair and/or replacement of all
work done should any failures occur within one (1) year of this date. To
guarantee this, you must either post a maintenance bond in the amount
indicated above, or maintain your existing faithful performance bond. If
you post a separate maintenance bond, your current bond will be released
by separate action.
We will inspect the work in one year and advise you whether or not
maintenance is needed.
Please feel free to call the undersigned if you have any questions.
Sincerely.
Gregg Eaton
Public Works Inspector
GE:sd
cc: Suspense - 1 year
TO: City Clerk
PUBLIC WORKS FILE NO. <f'cf~/S-S-
Please collect & receipt
for the following monies:
project)
p eJtr.l,{;t F e.M :
R-l :
($'35)
;t 1Vl.:
($ 50)
"( 500)
( % of FPB)
($500 min.)
(n of FPB)
($ 35 min.)
Depos i t
3372
Plan Check & Inspection Fee
3521
Other Cash Deposit (specify)
1373
3373
Project
Gene ra I
&
3372 Tentative Parcel Map Fil ing Fee ($350)
3372 Final Parcel Map Fil in Fee ($300)
--72 Tentative Tract Map Fil ing Fee $ 00
~ /2 Final Tract Map Filin Fee ($350)
3372 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-I ieu Fee per Unit ($1,132)
3380 Public Works Special Projects
3510 Postage
TOTAL
AMOUNT
$
~.::
NAME
r"7~~
/?J / S'.,
$
~S-9~33'1 0
7 SZ> c1' 9?
PHONE
,a~ ::tt112 5>-
ADDRESS
ZIP
FOR
C I TV CLERK
ONLY
RECEIPT NO.
AMOlI'n' PAID
RECEIVED BY
DATE'
July, 1987
TO: City Clerk
PUBLIC WORKS FILE NO. ~~-\."SS
Please collect & receipt
for the following monies:
.~CT .
35-3396
(specify project)
PeJl.r.IU eM:
R-1 :
(S'35)
Depos it
Plan Check & Inspection Fee
Other Cash Deposit
.J373
3373
3372 Tentative Parcel Map Filing Fee ($350)
~172 Final Parcel Map Fil ing Fee ($300)
/2 Tentative Tract Map Fil ing Fee ($400)
j372 Final Tract Ma Fil in Fee ($350)
3372 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)
.J395 Park Dedication In-l ieu Fee per Unit ($1,132)
3380 Public Works Special Projects
3510 Postage
TOTAL
-..lM';{ ~ (?c,~ iF' ) ""'-
ADDRESS )'90 ( . "5 f3a q C' ~
PHONE r::;~q- 33'10
-#. /~ 2 S- G.-.,/*>~A ZIP ~'5'DO 51
1)
FOR
C I TV CLERK
Ql(LY
RECEIPT NO.
,;2. 00 6'~
/:'? 0 I CD
J----?
'i/21jS S
AMOUNT PAID
RECE'VED BY
DATE'
AMOUNT
$
~. 0> C::>
~C:>l.o..D
$ ~o\ u,.O
July, 1987
LOS ANGELES, CALIFORNIA
A
AM WEST SURETY INSURANCE COMPANY
BOND NO. 1150358
PUBLIC WORKS - LABOR Be MATERIAL BOND
KNOW ALL MEN BY THESE PRESENTS,
That we,
POLYPLAN, INC.
, as Principal,
and AMWEST SURETY INSURANCE COMPANY, a Corporation organized and existing under the laws of the State of Califor-
nia, and authorized to transact a general surety business in the State of California, as Surety, are held and firmly bound unto:
CITY OF CAMPBELL
, as Obligee,
in the sum of **FOUR THOUSAND THREE HUNDRED**************************** . DOLLARS
($ 4,300.00 ), lawful money of the United States of America, for the payment whereof, well and truly to 6(; mal' we
hereby bind ourselves, our heirs, executors, administrators, jointly and severally, firmly by these presents.
THE CONDITION OF THE FOREGOING OBLIGATION IS SUCH, that
WHEREAS, the above bounden Principal has been awarded and has entered into a contract dated
with the Obligee to do and perform the following, to wit:
STREET IMPROVEMENTS TO 121 S. THIRD STREET, CAMPBELL, CALIFORNIA
PERMIT NO. 88-155
NOW, THEREFORE, if the above-bounden Principal or his subcontractors fail to pay any of the persons named in Section 3181
of the Civil Code of the State of California, or amounts due under the Unemployment Insurance Code with repect to work or
labor performed by any such claimant, the Surety will pay for the same, in an amount not exceeding the sum specified in this
bond, and also, in case suit is brought upon this bond, a reasonable attorney's fee, to be fixed by the court.
This bond shall insure to the benefit of any and all persons, companies or corporations entitled to file claims under Section 3181
of the Civil Code of the State of California so as to give a right of action to them or their assigns in any suit brought upon
this bond.
SIGNED, SEALED AND DATED this
6TH
day of
JULY
1988
POLYPLAN, INC.
Principal
BY.
C'
{J ..kh~u/ 6bfqJS/
, V
A/""E.~J...SeR;I~~~OMP ANY
BY
-----~-~~._------~._-,,_._-~-----
CHERYL M\ WOLOHAN
I
\.J
Attorney.in.Fact
C.l03 (7/78)
A
AMWEST SURETY INSURANCE COMPANY
WOODLAND HILLS. CALIFOR:\IA
BOND NO.
1150358
I'REI\IIl'I\I
$100 00..
PUBLIC WORKS - PERFORMANCE BOND
KNOW ALL MEN BY THESE PRESENTS:
That we,
POLYPLAN, INC.
, as Principal,
and AI\IWEST SCRETY I;\ISURANCE COMPANY. a Corporation organized and existing under the laws of the State of
California. and authorized to transact a general surety business In the State of
CALIFORNIA
, as Surety,
are Iwld and firml~' bound unto:
CITY OF CAMPBELL
, as Obligee,
in the sum of **FOUR THOUSAND THREE HUNDRED**************************** DOLLARS,
($ 4,300.00 ), lawful money of the United States of America, for the payment whereof, well and truly to be made,
we hereby bind ourselves. our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these
presents.
THE CONDITIONS OF THIS OBLIGATION IS SUCH, that
WHEREAS, the above-bounden Principal entered into a contract dated the
with said Obligee to do and perform the following work, to wit:
JULY 6, 1988
STREET IMPROVEMENTS TO 121 S. THIRD STREET, CAMPBELL, CALIFORNIA
PERMIT NO. 88-155
NOW, THEREFORE, if the above-bounden Principal shall well and truly perform or cause to be performed, each and all of the
requirements and obligations of said contract set forth, then this bond shall be null and void; otherwise it shall remain in force
and effect.
SIGNED, SEALED AND DATED this
6TH
day of
JULY
19 88_
POLYPLAN, INC.
PRINCIPAL
BY /~I'Ww/rfJtJ.J:tt
// '
( ~URETY[NSURANCECOMPANY
ByC::f>-<~ cd-
CHERYL M. WO ORAN
ATTORNEY-IN-FACT
J
REV l/86
KNOW ALL MEN BY THESE PRESENTS
does hereby make, constitute and appoint
AMWEST SURETY-INSURANCE CO.
P.O. Box 4500
Woodland Hills, CA 91365
-11
its true and lawful Attorney(s).in-Fact,
deliver and affix the seal of the comp
tions in the nature thereof, as folio
Con
and to bind AMWEST SURETY
presents, are hereby ratified
Laws of the company, whic
Article III, Section
This Power of At
the board of director
Ice.president and attested and sealed (if a seal be required) by any sec-
ny vice-president or
authorized attorney-in.fa
(if a seal be required) by one or m .fact or
ced by the power of attorney issued by the company to suc
signature of any authorized officer
I'ney or certification thereof authorizing the
uretyship obligations of the company; and such
as though manually affixed.
IN WITNESS WHEREOF, AMWEST SURETY INSURANCE COMPANY has caused theSe presents to be signed by its proper of-
ficer, and its corporate seal to be hereunto affixed this 1 st day of April 19 85
AMWEST SURETY INSURANCE COMPANY
~/f. ~'''~". P""do"
-1~ A7. C~
Karen G. Cohen, Secretary
STATE OF CALIFORNIA, COUNTY OF LOS ANGELES - 55
On this 1st day of April A.D., 19~, personally came before me Gary R, Peterson
and Karen G. Cohen to me known to be the individuals and officers of AMWEST SURETY INSURANCE COM-
PANY, CALIFORNIA who executed the above instrument, and they each acknowledged the execution of the same, and being by me
duly sworn, did severally depose and say: that they are the said officers of the corporation aforesaid, and that the seal affixed to the
above instrument is the seal of the corporation, and that said corporate seal and their signatures as such officers were duly affixed
and subscribed to the said instrument by the authority of the board of directors of said corporation.
.
OFFICIAL SEAL
JANICE DRUEZ
NOTARY PUBLIC - CALIFORNIA
LOS ANGELES COUNTY
My comm. expires MAY I, 1989
(SEAL)
STATE OF CALIFORNIA, COUNTY OF LOS ANGELES - 55
CERTIFICATE
I, the undersigned, secretary of the AMWEST SURETY INSURANCE COMPANY, a California corporation, DO
HEREBY CERTIFY that the foregoing and attached Power of Attorney remains in full force and has not been revoked, and further-
more, that the provisions of the By-Laws of the company and the Resolutions of the board of directors set forth in the Power of
Attorney, are now in force.
Signed and sealed at
SAN JOSE, CALIF.
this
6TH day of
JULY
19~,
v~ .--1/ ~COh," S&'~.ry
I ~~ I
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q c' ~ 0($. ~ -J' ~ CA'?'
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CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
70 NORTH FIRST STREET
CAMPVELL, CALIFORNIA 95008
!
~
~
~
~,.~ 88-7ss
RECEIVED
DEe 021988
PUBLIC WORKS
ENGINEERING
DEe 0 1 1988
Bond No.: 1150358
Subdivider: POLYPLAN,INC.
Tract No.: PO 88-02
Amount: 4,300~00
Description of
Improvements: PO 88-02 - 121 S. THIRD STREET, CAMPBELL
AMWEST SURETY INSURANCE COMPANY is Surety on the above captioned
bond. We would appreciate your cooperation in providing the
information requested below. Please return the form ,to us so that
we may have current status information on the above captioned
improvements. A postage-paid envelope is provided. Thank you
very much for your assistance.
1.
Have the improvements been completed?
If not, what percentage has been completed?
V""'"Y e s
No
2.
\
3.
Is the work progressing satisfactorily?
Yes
v/<r:e
No
4.
Has this work been accepted?
NO
5. If not, what is the anticipated date of acceptance?
Comments: Dvl!!? ,~~ H4-'/;V75V~~~ ~~ CZ~~ C)~
~~C:./;"';4L ~/n.t,.c:a~ ,P>e8-h~~/V'c-E 8~0 ~ ..LA:~A-/~
/;..; ~,rE~T.
Above information provided by:
Name ~ ~ Phone No.
T! tle ~A,UI~ tch/U?.!:> ~.s~::z..?ne.... Date
,
(~ BC--b - Z- .; Sa
/~~k
F30 6/87
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f.....~. ~ ~ W
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j~ ~,~ l' ';:o.~~' ~~O' l::' ,...,
~ ~ cV c,~ 0c:i ^-Qj ~ ~c:i <1.' c,c:i ..,
CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
70 NORTH FIRST STREET
CAMPVELL, CALIFORNIA 95008
~._J./tr
RECEIVED
SEP 2 6 1988
PUBLIC WORKS
ENGINEERING
S EP 0,2 3 1988
Bond No.: 1150358
SubdivJ.der.:__POLYPr"AN, INC.
Tract No.: PD 88-02
Amount: 4,300.00
Description of
Improvements: PD 88-02 - 121 S. THIRD STREET, CAMPBELLCJr~~~:~~.J5~
AMWEST SURETY INSURANCE COMPANY is Surety on the above captioned
bond. We would appreciate your cooperation in providing the
information requested below. Please return the form to us so that
we may have current status information on the above captioned
improvements. A postage-paid envelope is provided. Thank you
very much for your assistance.
1.
Have the improvements been completed?
Yes
/ No
2.
If not, what percentage has been completed?
G,O %
3.
Is the work progressing satisfactorily?
Has this work been accepted?
..r Yes No
4.
Yes ..,/' No
5. ~f not, what is the anticipated date of acceptance? ,~~~
,
Comments: _~Ub "'TO RE:v-rz,q :"JI!J, '€' r=~EcT-
'"
Above information provided by:
/' c-~. I
Name (?/,lEGC::, ~f\-I
Ti tIe PUi3~"l.... 'r-fo(l.k:.... ~ 5(2-'
Phone No. (-4;B g(d;., ~ 21 SO
Date C) (2-fO /8B
I I
F30 6/87
PUBLIC WORKS INSPECTION REPORT
.late /ol?~~. Permit or Project No.
Address /2/" ,. : 7#//e.-2;
'88-/?S
Type of work: Street Storm
Other (describe)
Sanitary
Electrical
[JPRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached)
[J FINAL INSPECTION WI:fH DEFICIENCY LIST (attached)
~NAL INSPECTION - ACCEP:fANCE
Signed plans'? Y (E) (If signed, Council acceptance.)
Charges against deposit? y
Overtime I brIO. @ $
Date 5 reAson;
~
-
$
Barricade rental (attach invoice)?
Date 5 reason:
Y
(D
$
Other?
$
$
Total charges deducted from deposita
(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.)
Engineer
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PUBLIC WORKS PERMIT ISSUANCE ~HECK LIST
City of Campbell
Public Works Permit No. e~- I\~':::
\ '- \ ~. \\.ot\ r~t>
Gl
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III
....
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....
~
....
~ Applicant section complete
V Applicant signature and date
~ Permit Application fee, $35.00 for R-l, $50.00 for
standard, paid. Receipt number \ '1. \~
~~
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....
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III
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Plan check deposit, $500.00 for standard only, paid.
Receipt number \C\ \~'-
~ Five sets of improvement plans submitted
------------------------------------------------------------------------
~ Bond for faithful performance, 100% of City Engineer's
estimate for standard only, posted and appropriately noted
Amount $4~.oo Form A Mwe--..;r l.D. # \\"SO~~..
"" u t'''-L.'ISJ'f''''1
for R-l; 4% of FP bond, $500 min.
.,/
Cash Deposit: $200.00
for standard, posted.
Amount $~~oO Receipt No. ~~'~
V
Permit fee of 7% of FP bond, $35.00 min., paid.
Amount $ ~O,. ~ Receipt No. -'_C>~ S ~
~ Worker's compensation information received for Applicant
(see Information Sheet for Public Works Permits)
Land development requirements met (see separate letter
from land development section)
----------------------------------------------------------------------_."._-
I~Worker's comp and Contractor's Information received for .
Contracto~ (see Information Sheet for Public Works Permits)
~ Certificate of Insurance with Additional Insured's
Endorsment received from Contractor (see General Summary of
Insurance Requirements for Public Works Permits)
I /
~ Three sets of off-site plans, stamped APPROVED (Tract or
Development and Public Works Permit number and property
address on plans)
~ Permit signed for City Engineer
.
.
WHEN ALL OF THE ABOVE, ITEMS ARE COMPLETE, PERMIT MAY BE ISSUED
Issuer: InitiaL L >': and date :;. 2 .,-,Jt.. .A' and file with permit
"" -.
UPON ISSUANCE, INITIATE PLAN CHECK DEPOSIT REFUND CHECK REQUEST.
4/88
f/permchklst
Y:' x'" ..-
, _ ! L:: f-..-.
PermJ. t No. ( . ( ) )
(' ~.~ I
~") 61 1 r; \('1_,
Address
I~~ I
Tract No. or
IMPROVE!.:Et,T PLAt~ CHECK LI ST
DEVELOPtlENTS
CHECK~D:
ITEH:
~~
1) Permit number and prop-
erty address on plan?
co;..rlEnTS:
~.;>12.........
2) Site review completed?
~~
3) Applicable standard notes
~~
4) Engineer's Stamp, Signa-
ture and Expiration Date
c:~~ 5) Conformance with City
standard specifications
and details
u/~
\...J..C:l ~ t---t~~-<:::/':::aD>c
~~ 6) Street geometries
~~ 7) Street grading plan con-
fomity with overall
street grades and/or
official grading plan
~~
8) Approved roadway
structural section
~~ 9) Street lighting
requirements
~~c.r 10) Storm sewer design
~~~ 11) All relevant conditions
of approval have been
DIet
C"S.C:s:r 12) Traffic review
C:~~ 13) Service Center review
Plan check co~pleted by
Recommeded for approval
Send originals for signing
w/J.:=.-
'-.)/IS:..
"-t/ .c-
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-,
Bill M. Helms Date
Engineering i.lanager
Donald C. Wimberly Date
Birector of Public Works
Permit No.
Applicant
-~
cTo- / )
t:::::>u '-;/ P LAA/'
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
License, State Contractor's License and Workers'
Name of Contractor OVISc6 /tiC.
of Campbell Business
Compensation Insurance.
Telephone fI-Of- .;- ry 3 Yi'D
Address ('for It, isasc()fl1 ;t1-..e. ffe 1f 16 ?-(- &?i7?e'~ //~tyIJ7 _'
State Contractor License No. i.l-71C :::.:z. City BuSiness License No. 1- lfcc 7'7'> - L
Expiration Date 6- 30- "Og
Will do the following types of work:
_____underground _____P.C. concrete _____A.C. paving _____electrical
Name of Contractor/Applicant
(specify) :fr~;;' tva/l (~' (l)(;~i('" l~a ~f
"--~
WORKERS' COMPENSATION INSURANCE INFORMATION
01/1;:; (' r:-' ;;'u
_____other
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' C~mpens~tion Insurance
Insurance Co. <.51fJr;r76f _']cdl{~(..t,c,/ !wc;(;;' Policy No. [11('(;. -;Z-o(;?)~_ 4
Expiration date J)ec 3/, / '1,r Ef ; 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
A
TRUCK INSURANCE EXCHANGE
INTERIM CERTIFICATE AS TO EVIDENCE OF INSURANCE
.
THIS IS NOT AN INSURANCE POLICY. THIS IS ONLY A VERIFICATION OF INSURANCE. IT DOES NOT IN ANY WAY AMEND, EXTEND OR ALTER THE
COVERAGE PROVIDED BY THE POLICIES LISTED BElOW.
Named
Insured
MICHAEL OVEYSSI
DBA; POLY PLAN
1901 SOUTH BASCOM AVENUE
CAMPBELL, CA. 95008
RECEIVED
Address .
5587 35 51
96-90....39A I Policy #. Gen. Liab
Agent Policy # . Auto Liab.
AUG 241988
PUBLIC WORKS
This is to certify that policies for the above named insureIiNGlN-EER~~s follows:
Pol icy # . CARGO
Policy # Work Camp.
This Intenm Certificate As To EVidence of Insurance shall expire sixty days from 12; 01 AM.,
8-24 ,19 88, unless cancelled prior to such date by written notice to the named insured.
...
Q Please issue a Permanent Certificate
COVERAGE COMBINED LIMITS OF LIABILITY
COVERED NOT AUTO
COVERED LIABILITY
0 0 Owned Bodily Injury $ ,000 each person
0 0 Hired $ ,000 each occurrence
0 0 Non-Owned Property Damage $ ,000 each occurrence
0 0 Employer's Non-Ownership
Contingent Liability
Single limit liability for Coverages checked IXI above $ ,000 eoch occurrence
GENERAL LIABILITY $
M&C - OLT Bodily Injury ,000 eoch person..
{ Owoe" & Coo"octo" $ ,000 eoch occurrence
rn 0 Contractual. $ 000 annual aggregate
Elevators $ , products...
Property Damage ,000 each occurrence
0 0 Products and/or $ 000 annual aggregate
Completed Operations ' products. . .
Single limit liability for Coverages checked IXI above $ 500 ,000 eoch occurrence
$ 500 annual aggregate
,000 products.. .
0 0 CARGO $ ,000 each vehicle
$ ,000 each occurrence
0 0 WORKERS' Statutory
COMPENSATION
. .
. Includes Goods or Products Warranty, Written Lease of Premises, Easement Agreement, Municipal Ordinance
Agreement, Sidetrack Agreement, Elevator or Escalator Maintenance Agreement only, unless accompanied by
specific endorsement providing additional Contractual Coverage.
O Described
below
O De5ulpllon
waived
YEAR, MAKE, TYPE OF BODY, LOAD CAPACITY
IDENTIFICATION NUMBER
OWNED
AUTO-
MOBilES, <
IF
COVERED
LAST 3
DIGITS
SHOWN
POLICY NUMBER
Umbrella Liability
$
$
$
,000 retained limit
each occurrence
aggregate
If this Interim Certificate As To Evidence Of Insurance is to be cancelled prior to the expiration date, we shall
provide 30 days advance notice in writing to whom this certificate is issued.
Certificate issued tt>:
Name THE CITY OF CAMPBELL AND ITS RESPECTIVE OFFICERS~ AGENTS AND EMPLOYEES ARE
And . NAMED AS ADDITIONAL INSUREDS FROM AND AGAINST ANY CLAIMS, LOSS LIABILITY?
Address. COST OR EXPENSE ARISING OUT OF OR IN ANY WAY CONNECTED WITH THE CONSTRUCTION OF
. THE PROJECT. THIS COVERAGE SHALL BE PRIMARY AND ANY COVERAGE CARRIED~Y ADDITIONAl
INSURED SHALL BE EXCESS INSURANCE O~l.titersigned . //hlf?~1 6t'Z'.(r1 ~
79 ~~ l$T STREET. / Authorized Representative
.. Not Af(5'AM'J5' KEiexaCA 9 ')008
... In Texas the aggreg&te also app1,es to owners and contractors protective, contractual and/ or completed operations.
ADDITIONAL INSURED
56.05144.87 11261 WI200 CI1200 PRINTED IN U.SA 0 M
r.:RANK R..OLMO & SON COMPANIES AFFORDING COVERAGES
.005 DE LA CRUZ BL. =::200 COMPANY A
P. o. BOX 58152 IITHR SUPERIOR NATIO~n~
SANTA CL.ARA, CAL. IFOr~NIA 95052 COMPANY B
LlnUl
COMPANY C
OVISCO, INC. lflTER
MAHMOUD OVEYSSEI COMPANY 0
1901 S. BASCOM AVE =::1625 lETTER
CAMPBELl., CALIFORNIA 95008 COMPANY E
LETTER
This is to certify that policies of Insurance listed below have been issued to the insured named above and are in force at this time. 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.
I Y f'E OE INSURANU
POLICY NUMBE R
GENERAL LIABILITY
o COMI'REHf NSIVE fORM
o Pfl[MISES OPERATIONS
o I Xf'LOSION AND COIL APSE
-- HA/ARD
o UNDE RGROUND HAIARD
o 1'110DIJCTS.COMPlEIED
- opr RAT IONS HA/ARD
o CONIRACTUAI INSURANCf
o flROAll fORM pHOPUiTY
DAMAGf
o INDEf'fNII[NI CONTHACTORS
o fl[ r;;:;ONAL INJURY
- .----j- AUTOMOBilE LIABILITY
10 OMI'Rl HINSIVI 10HM
10 CiWNIll
o Hllilll
10 N(IN UWN[ D
EXCESS LIABILITY
[J lIMBllf I LA f OF<M
10oTHtPIHAN\IMRRfl.lA
IOflM
--twoRKERS' COMPENSATION
A-+ and
_ n~~~lOY~RS' LIABILITY
OTHER
I
I
limits of liability in Thousan
EACH
OCCIJRRENCl
POLICY
IXPIRATION DAlf
I
I
I
I'HOpI R r Y DAMAGE I $
-~---+
BODIL Y INJURY
i $
I
I
..___ ._~_-L.
BODll Y INJUHY AND
PROPfHl y DAMAGf
\UMBINED
r-[ f';><:':I,.lNM !N.JlH~Y
BODIL Y INJURY
,EACH pI[{SON)
BODIL Y INJURY
(EACH ACCIDENT)
PROPE RTY DAMAGE
BODll Y INJURY AND
PROPERTY DAMAGE
COMBINED
"loon Y IN IUR" AND
~ PROP[ RT Y ['\AMAGE
( MH,NED
S I AT LJ r ORY
WCG-20689,..B
07/01/89
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES
ALL CALIFORNIA OPERATIONS AND LOCATIONS
Cancellation: Should any of the above described poliCies be cancelled before the expiration date thereof, the Issuing com-
pany WI mail -3.Q.... days wntten notice to the below named certificate holder. ~, 'U"u' v ,~
y.
f~[ ANDADDRESSOf CERTIIICAH HOI DfR
-'-l
I
I
I
I
.J
CITY OF CAMPBEl.L
BUILDING INSPECTION DEPT
75 N. CENTRAL AVENUE
CAMPBELl., CAl.IFORNIA
95008
"~:;?;?-71 ~
AIITHO~N1ATIVI
CONSTRUCTION COST ESTIMATE FOil PERMIT No.~g'-I ~B"/Date <. - \ ~ -4!i>'"
, i
Name , Address ) -~ \ >, <0 IY'" (('C
Surface Construction
Clearing and Grubbing Lump Sum Estimate · $ -z....c,.c, -
Sawcut Concrete \0 L.F. @ $ 4.00 . $ 4.-0-
Concrete lemoval ""l.. (.. <Ib. S.F. @ 3.00 . $ (, e..d.-
Curb , Gutter Removal ""LO L.F. @ 5.00 . $ lOO-
Inlot Drain with Pipe EA. @ 500.00 . $
Curb and Gutter "'l...O L.Y. @ 15.00 . $ ~~-
Sidewalk ,~~ S.F. @ 3.50 . $ ~-
Driveway Approach ""\...e>'t. S.Y. @ 5.50 . $ \l ~-
Bandicap Ramp EA. @ 1000.00 . $
Extruded Curb L.F. @ 6.00 . $ -
Barricade L.r. @ 50.00 . $ -
Street Excavation (4l' s.r.)x($0.15)x( C- ") . $ ?. \. (::) -
A.C. Pavement ( S.F.)x($0.45)x( ") .'$
-
Adjust Manhole to Grade - EA. @ 300 . 00 . $
Adjust Bandhole to Grade EA. @ 200.00 . $ -
Konu.ent lox v Monument - EA. @ 500.00 . $ -
Street Tree (15 sallon) EA. @ 200.00 · $ ..../1:)0-
Pavement Striping ($100 min) - L.F.@ 0.65 . $
Pavement Legends (S100 min) EA. @ 40.00 . $
Stop.Street Name or Other Sign EA. @ 120.00 . $ -
Pavellent Markers EA. @ 15.00 . $
Pavement Key Cut L.r.@ 8.00 . $
-
. S
. $ -
Surface Subtotal "s" · $ ~~., ~ -
Adjust. for sbe: S < $30.000 add 20%. S'> $100.000 subtract 10% 4"2..t:>"-
Street Lighting
Electrolier
Conduit
Conductor. pair
Pull Box
EA. . 3000.00
L.r.@ i2.00
L.r.@ 4.00
EA. @ 200.00
Storm Drainage
12" or IS" lep
18" or 21" RCP
Street Inlet
Manhole
Break and Enter Manhole
L.r.@
L.r.'
EA. @
EA. ,
EA. ,
60.00
65.00
1800.00
2000.00
600.00
TOTAL ES'.rIMATE
USE FOR BOND
Revised 6/85
. $
. $
. $ -
. $ -
. $ -
- $ -
- $ -
-$ -
- $
. $ -
. $ -
$ ~""2..bq-
$ 4~ C)Q-