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CITV Or CA"P8tLL .
DtPT. or PUbLIC ~15
'0 "OUh 'lUI 51.
Ca.Pb<<IIL CA '~OO.
c.OU .. -JaO
?'j/-/7 f
PU8LIC ~kS PER"IT
1tur vor.ln~ In ~n~
publae ,a9hl-o'-va~)
..aued
'ela!~ .'plr.. .n A~ ~a.
'ecait Mo.
a-ad. tUe ~,- L..'~
AppUc.laon Date 7 - I 2... ~,y y-
..pi,.. ~..
~'LJCATION - Applicalion II her.b~ ..de lor a '~blle
"~nlelpal Code, 'ecllon 11.0..
A. "orIL addle.. 01 tuel .Jdk,~GU/~~
Ulllal~ trench location
.. "I~re of woea;ltJ~1p.,\.A....- N\~~o~ />.....::::.0 0 0 ~ ~1. Coil ~t:t fbi.. Ptol'O\'W p(1..'l 0H=tL.C'
C. Attach Il~e 1~1 Cople. 01 a dla.lng .howlng the 10CatJon, a.lenl and 4i..nlJona of the WOI_
7he d,awlng .hall .how Ihe ,elallon of the plopoaed work 10 ellatang aurface and underground
'.prove_nla. ~hen .PPloved b~ the Calf Enilne.c, .ald 4ra.lng Deco.,. a pall of tha. per.lt.
~. 7he ~eneral Condltlon. fOI all pel.Jt. ale 11at.d on the re~el.e .ide. 'pecl.l 'rovillonl for
thll perail arc li.ted below. 'allure to abad, by the.c condltionl and provlllon. "y e..ull
an 10b Ihut-down .nd/or forfeltule of ralthful 'erfol..ne. .ond. and caa~ dCpo.ll.. See
wneral COII'hllona ) and 21.
Di'& .
.
Morka '.,alt in accordanc. With eaapbal1
.:fil)O - w. r' -L,-roAi
1-lh:S.M <;oufl'\ 6f ICfoN hv7c
1. An application f.e ~al .ccoepany thaa applJcatlon.
"a_ of APPI\~/~1 V,t;LLEY S\TLHIOli
Addu.. {DO ~. <;LV.JlJ.ibA~<' ~ I
la Ihll work belng done by the pIOpe(t~
Tnla 11 non-refundabl..
CO;.;tli~pnone; ~\t)-1A-01
LA 90005
own.r at th.lr own '.lldenee} ___yea ~ftO
C:;3.i'~i~T OF S/\i~.~,;~: c-i,/:,~/;
CAI-A..r'\"}Zd.L
Coaplete .ltached ~orke(.' Coapenaatlon .nd Contractor for...
The APrltcant/Pelaitlee helebv a~ree. by affilln~ their .19nature 10 thJa peeeit to hold the CIly of
C..pue I, 11. ottlcera, ag,nl' and e.ployee. free, .afe and hac.leal ftga any elal. or d...nd for
da..gea reaultlng flos Ih<< wor_ CO~eled by thl. peeelt.
Thc Appllcant/Pel.ittec heleby aC_nowledgel that they have read and undereland both the
back of thl per.1 nd t I they wlll lnfor. thelr contraclorlal of the lnfocaatlon.
ACCEPTED '11!L'fb .
I ront and
D:2TfnCT CF St\rIT:' r.; ;;, --., r'''':'!)J~T'(
.....- ,.,.t.._.j,
.oTES: ALL WORk ~HALL CONrOR" Wl~H THEATTACHfD, AI'ROVED ,LAMS AMD ALL ~PLICA8LE ~a[LL
.TANDARD DRAWIHGS AMD CONDJTIONS.
TilE CONTRACTOR "UST IlAVE: THIS PrR"IT AND APPROVED 'LAMS UD RUST 1tf:t;T WI'rIl THE '.W. UtiPfCTCltl ON
Tilt SITE AT LtAST TWO DAYS 8ErOkl: 6TAkTIHG WORk.
JIOTJ Cl: RUST at ~IVf;H TO PUBLJ C NOIlI(S AT L&.\ST j4 MOUltS urou RESTAkTING AMY WORJ:.
5PfCIAL PROVISIONS
_1.
~.
-).
Street .hall nOl be open cut fOI underground 10ltal1ationa. "Inl.u. Cute ..y be allowed
fOI conn~CltOna or ..plorallon hole.. ~ucn CUt. .ual be lpaClflcally approved by th~
J n~~("( or.
PIVlm~nr-"r be cut for underground analall.llonA and ~at be r.atored tn accordance With
tho Ullllly Tlench a..tol...oo Standald Dla.lng.
wor_ to be ata.ed by a Ilcen..d Land Sur~crol 01 Ctvil !n~in.ee and two IJI Copte. of the
CUI ah'~IA aenl to lh~ PublIC work Pept. bctore .laltlng WOI_.
Tne hour. of wor_ arc ltalled to oUlalde the hout. of }-, .... and tor any woek
.tf Ctlng a traffic l.ne.
u/- -neGvU{ ON DE . c.. 7V
"" A-rc# E Y t',5.n."i(::o .
_4.
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PC~IT APPLJCATJON PCE
PLAN CHf;CI DEPOSIT
aoHD paM PAJTH'UL '&aPORMAHCE
r. P. (CASH I ~tPOSJT
(It-II
UH.OOI
HeEl PT 110.
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5 500-
5
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APPROV[D P~ JSSUANCE
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PUBLIC WORKS FILE NO.J:>8'~/7 7'
10: Ci ty Clerk
JeT.
35-3396
3372
3521
3521
Please collect & receipt
for the following monies:
ITEM
Pro'ect Revenues (specify project)
Pu Uc. ('lo,-z. Z-6 fxc.ava.-tion Pvu~-U feu:
Ap I i cat ion Fee
Plan Check Deposit
Faithful Performance (Cash) Deposit
AMourn
$
R-1 :
($'35)
so --
::ro 0
($200)
3521
3372 Plan Check & Inspection Fee
3373
3373
';>~-
Other Cash Deposit (specify)
Project
General
&
3372 Tentative Parcel Map Fil ing Fee ($350)
1~72 Final Parcel Hap Fil ing Fee ($300)
r2 Tentative Tract Map Fil ing Fee ($400)
Jj72 Final Tract Map 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
Fi rst 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)
1395 Park Dedication In-lieu Fee per Unit ($1,132)
3380 Public Works Special Projects
3510 Postage
NAME
ADDRESS
TOTAL
~ [~ ~c-~
LY-' Y fJ. C~ -# 70
s - cr-.s- -
$
PHONE 2-')1/- 2'2..03
/ s: ~ ZIP 9::>- OJ/
FOR
C I TV CLERK
Q\(l.. Y
RECEIPT NO.
AMOI.JIIT PAID
l?g7~
5 R s!!..f>
'7-/3- jf ~
~
July, 1987
RECE 'VED BY
DATE
. ,
C H E C K R E QUE S T
TO: ' FINANCE DIRECTOR'
. City of Campbell '
Please, issue check payable to:.
Addre~s: Str~et:'
City: '
State: ~(2 spaces)
Zip: ~(5 spaces)
(20 spaces)
(20 spaces)
(15 spaces)
4 '
Description:
Exact Amount Payable: $500.00
Account Number: 735~3521
1 t (20 spaces)
Purpose: Refund of Cash Deposit - Permit #88-179, Receipt # 19875 dated 7/13/88
Requested by:
Dave Valkenaar
. .
Title: Assoc. Civil Engineer Date: 8/2/88
, Approved by: Title: Engineering Manager
. Bill Helms
,SPECIAL- INSTRUCTIONS FOR 'HANDLING CHECK:
Da te : 8/2/88
..,
Matl as is x
Return to:
Ma.il in attached envelope
Department
Name
Ot~er:
. ~
REV 4/22/83
. . ~ ,. .._,......, .... .::,', .. ~" ~... -- ... ,
r
CITY OF CAMPBELL
70 NORTH FIRST STREET
CAMPaELL. CALIFORNIA 95008
(408) 866-2100
Department:
· Publ ic Works
August 2, 1988
West Valley Sanitation District
100 E. Sunnyoaks Avenue
Campbell, CA 95008
RE: FINAL INSPECTION AND ACCEPTANCE
PERMIT NO. 88-179
LOCATION: Llewellyn Avenue
\'I:I'\Br:<~L';' 'I' i!I!.I,:;L"J~,::; i
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MANLEY
PENOYER
CASE
We have made a flnal,.inspectlon of ' subject Public Works construction
and find it acceptable a.nd In conformance with City standards,. Ac-
cordingly, the work is hereby accepted.
You are responsible for the maintenance, repair and/or replacement
of all work done should any failures occur.
We will Inspect the work periodical1y and advise you whether or
not maintenance is needed.
Please feel free to call if you have any questions.
Sincerely,
~~~
David N. Valkenaar
Associate Civil Engineer
DNV/le
cc: G, Eaton, Publ ic Works Inspector
CR
:!
,
@)
PUBLIC WORKS INSPECTION REPORT
Date ~~I~e.
Permit or Project No. 8/5-'?~
Address Sl:JO !..J. ~,',-~~
Type of work: Street Storm
Other (describe)
Sanitary ~ Electrical
[JPRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached)
[JFINAL INSPECTION WITH DEFICIENCY LIST (attached)
Iil FINAL INSPECTION - ACCEPTANCE
Signed plans? Y ~ (If signed, Council acceptance.)
Charges against deposit? Y
Overtime: hrs. @ $
Date 5 reason:
(ID
/hr.
-
$
Barricade rental (attach invoice)?
Date 5 reason:
Y
G:J
$
Other?
$
$
Total charges deducted from deposit:
(Cash Deposit $ leas charges $
$
- Refund $
ck. req.)
[JONE YEAR MAINTENANCE WITH DEFICIENCY LIST (attached)
o ONE YEAR MAINTENANCE - ACCEPTANCE
(Release'maintenance bond. Check Request if cash.)
~A!/
J Eng ineer
~
Inspector
GRAY EAGLE
CONSTRUCTION COMPANY
2464 EL CAMINO REAL. STlll. 90. SANTA CLARA. CA 95051 (408) 241-2203
July 25, 1988
Greg Eaton
Public Works Inspector
CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
70 North First Street
Campbell, CA 95008
RECEIVED
RE: CAMPBELL MAIN POST OFFICE PROJECT
Llewellyn and Hamilton Ave.
Campbell
JUL 2 71988
PUBLIC WORKS
ENGINEERING
Dear Greg:
We are requesting final inspection for the off-site Sewer Lateral
installation at the above referenced project; along with the refund
of $500.00 Faithful Performance Bond as required by the city.
Please advise when this inspection has been completed.
Thank you for your assistance in this matter.
Sincerely,
GRAY EAGLE
COMPANY
/ Barbara Silva
for/Frank J. Si
Lie. No. 383766
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PRODUCER
EVERETI' \iT. STARK AND COMPANY
2190 Stokes Street, Suite #103
San Jose, CA 95128
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
(408) 294-4106
COMPANY A
LEITER AMERICAN STAR INSURANCE
INSURED
FRANK SILVA
DBA: GRAY EAGLE CONSTRUCTION
2464 EL CAMINO REAL, SUITE 90
SANTA CLARA, CA 95051
COMPANY B
LEITER
COMPANY C
LEITER
COMPANY D
LEITER
City Of Campbell
75 N. Central Avenue
Campbell, CA 95008
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX,
PIRATION DATE THEREOF, THE ISSUING COMPANY WILL ~R~XS{X
MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT;K~E:XEl~~:klK~~s{~*}t2.t*~x
ElXBlElxv{I!IIKKIlrDOOIlGX~~~RR
AUTHORIZED REPRESENTATIVE
POLICY NUMBER:
AMS 1506752
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OVJNERS, LESSEES OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the followinr.:
COMMERCIAL GENERAL LlPB1LlTY COVERAGE PART.
SCHEDUU':
Name of Person or Organization:
City of Campbell
75 N. Central Avenue
Campbell, CA 95008
All California Operations
(If no entry nppears abol/c, information required to complete this endorsement will be shown in the Declariltions
;)s ~pplic3ble to tt\is 0ndorS0Il1Cnt.)
WriO IS AN INSURCD (Section II) i<; amended to include as nn insured the person or orr,:1niZ3Iion shown in the
SCI1QUuh;. but only with r(:~l)ect to li'-lbility arising out of "your work" for tll;Jt insurccl !JY or lor you.
~
The City of Campbell and its respective officers; agents and employees are named as
additional insureds from and against any clai~s, loss liability cost or expense arising
out of or in any way connected with the constr~ction of the project. This coverage
shall be primary and any coverage carried by additional insured shall be excess
insurance only.
CG 20 10 11 r.S
Cc:pyriCht. Insurance Servicf's Office. 11lr:- . I c)H'1
Permit No.
Applicant
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 Frank J. Silva
Telephone (408)241-2203
Address 2464 EI Camino Real. Ste. #90
State Contractor License No. 383766
Santa Clara. CA 95051
City Business License No.J..:!/..5'JAL~jte~ _
Expiration Date / J' J',fc:;,
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 GRAY EAGLE CONSTRUCTION COMPANY. Frank J. Silva
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. E.W.STARK & CO. Policy No. r1mS@/'1.5/0
Expiration date \.. j......t - i9 OR
--L
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 La~f California.
Signed ~ ~ Date : 9 r.1A~ UOO
NOTICE -g~ OR/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