88-184
C~~y OF CAMPBELL
DEPT. OF PUBLIC WOIUtS
70 Borth First It.
Campbell, CA '500.
(40.) aU-2UO
PUBLIC WOR&S PERMIT
(for workinq in the
public riqht-of-way)
Issue4 I ~ ~ 1- ~ '5?
perait expires in 12 .os.
perait Bo.
8' ~ -j'gy
Z-Ref. file
Application Date ~ / I Z; / '8 g
Application exp res n'6 aos.
APPLICATIOB _ Application is hereby aaOe for a Public Works perait in accor4ance with C..pbell
XUDicipal coOe, lection 11.0.. (Application expires in 6 .onths if perait not pulle4)
Work a4c!re.. or tract .~ U){:()dJJVI V~i LiD f1aA-t>> CULrnptLJ J) q 6D3D
utility trench location
Bature of work: ~.mej")r worK.. on p.a.r.Yl'Y13 .?rrlp
Attach five (5) copies of a 4rawinq showinq the location, extent an4 Oimensions of the work
The 4rawinq shall show the relation of the propose4 work to existinq surface an4 UD4erqroUD4
improv..ents. When approveO by the city znqineer, sai4 drawinq becomes a part of this perait.
~he General con4itions for all peraits are liste4 on the reverse side. special PJ6visions for
this perait are liste4 below. Failure to abiOe by these conditions an4 provisions aay result
in job shut-4own and/or forfeiture oi Faithful Perforaance Bon4s an4 cash deposit.. (lee
General Conditio~ 1 an4 2).
A.
B.
c.
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This is non-refUD4able.Jtj^l.rZ2i3S-{W
Telephone: ---7 If
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~es _no
B. AD applicatioa f.. .u.t .ccompany this .pplic.tion.
.... of Applicant II tYJ I Of' Xi) iff./ J'v1 oot? fL
A44re..~UXcl Dr,'vt'..; J L.c6 d;}frfj/" A
%. this work beinq done by the property owner .t their own residence?
Complete an4 .ttach Worker.' compensation an4 contractor Inforaation forma.
~he Applicant/P.raittee hereby aqrees by affixinq their .iqnature to this perait to hold the City of
Campbell, ita officers, aqents an4 ..ployees free, .af. an4 harmless from any claim or d..an4 for
d...qes resu1tinq from the work covere4 by this permit.
~he Applicant/peraittee hereby ackDowle4qe. that they have rea4 an4 un4er.tan4 both the front an4
back of this ~~t, an4 t~ they will infora their contractor(s) of the inforaation. ...,,,)
ACCBPTED ~~lli.{/{.) Yn lJfi? JL ,!I4-J:i57
WOTESI ALL WOIUt SHALL COlQ'ORM WITH TBZ ATTACHED, APPROVED PLABS ABD ALL APPLICABLE CUPBELL
8TABDARD DnWIBGS ABD COBDITIOBI.
"l'D COBTRACTOR WST HAVE THIS PZRMIT ABD APPROVED PLABS ABD KtJST BET WITH TBZ P.W. IBSPECTOR OB
"l'D lITE AT LBUT no DAYS BEFORE STARTIBG WOU.
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IIOTICB KtJST BZ GIVD TO PUBLIC WOUl AT LEUT 24 HOURI BEFORE REBTARTIIIG ut WOU.
IPECIAL PROVISIOBS
_1.
street .hall not be open cut for un4erqroUD4 installations. xini.ua cuts may be al10we4
for connection. or exploration hole.. Such cuts must be specificallY approve4 bY the
Inspector.
pav..ent say be cut for un4erqroun4 installation. and .u.t be re.tore4 in accor4ance with
the utility Trench Restoration Stan4ard Drawinq.
Work to be staked by . license4 LaD4 surveyor or civil Znqineer an4 two (2) oopie. of the
cut .heet. .ent to the Public Work Deptartaent before .tartinq work.
~he hours of work .re liaite4 to outside the hour. of 7-' .... an4 3-6 p... for any work
affectin9 . tr.ffio lane.
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AMOUBT
RECEIPT BO.
/112'5'
ITABDARD
$50.00
$500.00
(100' OP BIIG. BST.)
(4' OF BOlIO, $500 XIII)
(R-1)
PBRKI~ APPLICATIOB FBZ ($35.00)
JlLaII CIlBCK I)ZPOSIT
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BOlIO POR PAITIIFUL PERFORDJICB
CABH DBPOSI~ ($200.00)
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APPROVED POR :IS8VUeZ
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TO: City Clerk
PUBLIC WORKS FILE NO.?8-1&<j
Please collect & receipt
for the following monies:
.lJ. ~. ~d'.tJ
~ g-3-:8'&='
~T.
--.--
35-J396
3372
3521
3521
projec t)
PeJuna eM :
R-l :
($35)
($200)
(Cash) Depos it
3372 Plan Check & Inspection Fee
3521 Other Cash Deposit (specify)
2373
3373
Project
General
&
3372 Tentative Parcel Map Fil ing Fee ($350)
~~72 Final Parcel Map Fil ing Fee ($300)
'2 Tentative Tract Hap Filing Fee ($400)
JJ72 Final Tract Map Fil in Fee (S350)
3372 Lot Line Ad"ustment Fee/Certificate of Compl iance
3372 Vacation of Publ ic Streets and Easements
3372 Assessment Segregation or Reapportionment
First Split ($500)
Each Additional Lot ($150)
3372 Environmental Assessment:
Categorical Exemption
Ne ative Declaration
3370 Storm Drainage Area Fee per Acre Multi-Res.,
$2,060; a II 0 the r, $2,250)
3395 Park Dedication In-lieu Fee per Unit ($1,132)
3380 Publ ic Works Special Projects
3510 Postage
TOTAL
AMOUIJT
$
3"'S. eJ.e>
~o. C>L':::>
NAME -r; ~ -.f-Q:7 h6 I C-- fL100 r e
ADDRESS {Lfl..(3 E:.(l...Couc/ Dr, \ LOS6c.;:./c.S
$ "'"L-~ "S:"" . C>o
d_'5- 0 - .22~'5 (\t.) ~
"6G7b --t, c.:;7 t( H
PHONE
CIS 0 ~ D
ZIP
FOR
C I TV CLERK
ClNL Y
RECEIPT NO. I q 9d.S
AMOUNT PAID ;2 3~J)
RECE IVED BY ~I
DATE 7 -/ ;:)- ~ p f{
July, 1987
C H E C K
R E QUE S T
TO: ' FINANCE DIRECTOR
City of Campbell.
Please issue check payable to:,
Addre~s :
(20 spaces)
(20 spaces)
(15 spaces)
4 .
City:
State: ~(2 spaces)
Zip: ~(5 spaces)
Description: (20 spaces)
Exa~t Amount Payable: .S200.00
Account Number: 735.3521
Purpose: Refund of Cash De~osit - Permit #88-184, receipt #19925 dated 7-15-88
Requested byva1kenaar Title: Assoc. Civil Engineer Date: 8/3/88
Approved by: Title: Engineering Mgr.' Date: 8/3/88
. ~ . SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
. Mail as is x
Return to:
Ma.i1 in attached envelope
Department
Name
Otfler:
~ ':
'.' .
REV 4/22/83
r
70 NORTH FIRST STREET
CAMPBELL, CALIFORNIA 95008
( 4 0 8) 8 6 6 - 2 1 00
iHAHDlING
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CITY OF CAMPBEll
WIMBElY
Public Works
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N\At~LEY 1.1
PENOYER I \1
CASE ~---'i\
Department:
AUgust 3, 1988
Ml: . & MrS. Tim Moore
1443 Elwood Drive
Los Gatos, CA 95030
RE: Final. Inspection and Acceptance
Permit No. 88-184 .
Location: 1443 Elwood Drive
Maintenance Bond Amount: Waived
We have made a final inspection of subjec,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,
,tilt /
Davi~ ~. Valkenaar
Associate Civil Engineer
. .
DNV/
cc: G. Eaton, Public Works Inspector
Suspense- ..1'
Gi)
PUBLIC WORKS INSPECTION REPORT
ate €)/p~~ _ Permit or Project No. . Be ~ (54-
Address /44.3. ~ E LWoOb
7ype of work: Street Storm Sanitary Electrical
Other (describe) PR2~lAJAv ::r:;...,,-.__,...tFlU.-r-
/
[JPRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached)
[JFINAL INSPECTION WITH DEFICIENCY LIST (attached)
6ZI FINAL INSPECTION - ACCEPTANCE
Signed plans'? Y G (If signed, Council acceptance.)
Charges against deposit? y
Overtime: brs. @ $
Date 5 reason:
@
/hr.
-
$
Barricade rental (attach invoice)? Y
Date 5 reason:
~
$
Other?
$
$
$
- Refund $
Total charges deducted from deposit:
(Cash Deposit $ less charges $
ck. req.)
o ONE YEAR MAINTENANCE WITH DEFICIENCY LIST (attached)
o ONE YEAR MAINTENANCE - ACCEPTANCE
(Release'maintenance bond. Check Request if cash.)
Engineer
~tor
Permit No. ~~ - I (l (~ .
Applicant 111e>1:)re /.,:,..... Debbl<C-
INFORMATION SHEET FOR PUBLIC WORKS PERMITS
A separate form must be completed for the applicant and each contractor
that will work under this permit.
CITY OF CAMPBELL
WORKERS' COMPENSATION INSURANCE INFORMATION
Name of Contractor/Applicant ,- un J ~JL~ rYltcA2<-
,
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
.......................................................................... .
This 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 ]JJJJ1~~LfL
Date
7/14-/~
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.
. .
.......................................................................... .
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
Address
Telephone
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)
f:PERMINFO
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