ENC2005-00069
CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
(Non-engineered work within the public right-of-way)
($5,000 maximum value of work)
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ISSUED
Permit Expiration Date ~
Permit No EN l. '70(,5" - oDe {/j
x - Ref. File
Application Date Lj f1 "II (- 5
Application Expiration Dat!$/~(t->5
APN /fob - 10 - 00'+
R-l NO FEE ENCROACHMENT PERMIT
APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04.
(Application expires in 6 months if the permit is not issued.)
A. Work address
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B. Nature of Work
C. Attach three (3) copies of a drawing showing the location, extent and dimensions of the work. The drawing shall show the relation of the
proposed work to existing improvements. When approved by the City Engineer, said drawing becomes a part of this permit.
D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit
Conditions listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and
provisions may result in job shutdown and/or forfeiture of Faithful Performance securities.
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NAME OF APPLICANT K:ci 10 i y1 Vl: I . r-C\fl "5
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TELEPHONE
70S- ...3(.1' -02CJI.5-
ADDRESS
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E-MAIL ADDRESStObl(\~t.5c\rde.1 S(c\pe; (t'")i'Yl
The Applicant hereby confirms that this work is being done by the property owner/applicant at their own residence.
The Applicant hereby agrees by affixing their signature to this permit to hold the City of Campbell, City of Campbell Redevelopment Agency,
its officers, agents and employees free, safe and harmless from any claim or demand for damages resulting from the work covered by this
permit.
The Applicant hereby acknowledges that they have read and understand both the front and back of this permit, and that they will inform their
contractor(s) of the information.
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(ApplicantlPermittee) (Sign)
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ACCEPTED
Date
NOTES: All work shall conform with the attached approved plans and all applicable Campbell Standard Details and Conditions and
applicable insurance requirements.
The Contractor must have this permit and approved plans and must arrange to meet with the Public Works Inspector at the site at least two
days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work.
Per Section 4215 of the Government Code this permit is not valid for excavations until Underground Service Alert (USA) has been notified
and the inquiry identification number (Ticket No.) has been entered hereon. USA PHONE: 1-800-227-2600. TICKET NO.:
Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all
damages arising out of the design, installation or condition of private improvements in the public right-of-way.
SPECIAL PROVISIONS
_1. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be recorded.
_2.
_3.
SECURITY FOR FAITHFUL PERFORMANCE
STANDARD
(10~.......NG.ES.T.)
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for City Engineer
tMOUNk
RECEIPT NO.
APPROVED FOR ISSUANCE
(I ( Lt'! (c S
Date
Permit Expires 6 Months After Date of Issuance.
J:\forms\rl permit
Revised 1.20.04
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AlIstaL .nsurance Company
Summary
RENEWAL
Deluxe Plus Homeowners
Policy Declarations
CONTACT YOUR AGENT AT:
(408) 864-7900
NAMED INSURED(S)
Robin Orans
Peter Wasserburger
337 Bedal Lane
Campbell CA 95008-6541
POLICY NUMBER
03783674210/15
YOUR ALLSTATE AGENT IS:
Adler Insurance Srv
10055 Miller Ave#200
Cupertino CA 95014
POLICY PERIOD
Begins on Oct. 15, 2004
at 12:01 a.m. Pacific Time
and continues until cancelled
PREMIUM PERIOD
Oct. 15, 2004 to Oct. 15, 2005
at 12:01 a.m. Pacific Time
lOCA TION OF PROPERTY INSURED
337 Badal Lane, Campbell, CA 95008-6541
MORTGAGEE(S) (Listed in order of precedence)
· HOMECOMINGS FINANCIAL NETWORK ITS SUCCESSORS
AND/OR ASSIGNS
POBox 100585 Florence SC 29501-0585
· GOLDEN BAY FEDERAL CREDIT UNION ATIENTION
INSURANCE CENTER
PO Box 24481 Fort Worth TX 76124-1481
Loan #0431142041
Loan #201039146
Total Premium for the Premium Period
Premium for Property Insured
TOTAL
(Your bill will be mailed separately)
$1,170.00
$1,170.00
1'1101' . 510000404082453111721402'
I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~II
lnlormallon as 01
August 24, 2004
Page 1
CA070RBD
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Allstate Insurance Company
Policy Number: 0 37 83674210/15 Your Agent: Adler Insurance Srv (408) 864-7900
For Premium Period Begiilning: Ocl. 15, 2004
POLICY COVERAGES AND LIMITS OF LIABILITY
COVERAGE AND APPLICABLE DEDUCTlBLES LIMITS OF LIABILITY
(See Policy for Applicable T elms, Conditions and Exclusions)
Dwelling Protection - with Building Structure Reimbursement Extended Limits $333,660
. $1,000 All Peril DeJuctible Applies
Other Structures Protection $33,366
. $1,GOO Ail Peril Deductible Applies
Personal Property Protection - Reimbursement Provision
. $1,000 All Peril Deductible Applies
$250.245
Additional Living Expense
Family Liability Protection
Up To 12 Months
$500,000
$1,000
each occurrence
Guest Medical Protection
each person
Building Codes
Refer to Policy
Statutory/See Form
Workers' Compensation and Employers' Liability
Coverage for Residence Employees
This policy does not cover earth movement including earthquake
You have elected not to purchase a CEA earthquake policy
DISCOUNTS
Claim Free
Protective Device Rate Applied
Your premium reflects the following discounts on applicable coverage(s):
15 %
RATING INFORMATION
The dwelling is of Frame construction and is occupied by 1 family
InlOlmallon as 01
August 24. 2004
Page 2
CAOIORBD
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