88-195
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X-Ref. fUe
ApplicaUoD Date 7/.:2...t-./g?
&pplica~ioD asp e. a' .0..
APPLICATIOII _ &pplica~ioD i. bere~y .ade for a Public Work. Perai~ iD accordance wi~b C"p~ell
aUDicipal C04e, 'ectioD 11.0.. (ApplicatioD aspire. iD , .0D~h. if perai~ DO~ pulle4)
eIn O~ CAKl'BELL
DEP'l'. 01' PUBLIC WORD
70 lIor~h I'ir.~ S~.
camp~ell, CA '5008
(.08) '''-2150
PUBLIC WOR~ PERMIT
(for workiDq iD ~he
pUblic riqh -of-way)
work ad41"... or uac~ . Np,AA. wh,Ji""u,l- ~ 1J..... -J-. r=(y ',;',~ ,. t-
UUlit!' traDch 10caUoD K"tkw(u~ "fA. z...4t-
.a~ure of work:~1JV1 ~J LAt';"1 .... 1-"~l;q..J..,~ .. I .... Ie:..
Attach five (5) copie. of a 4rawiDq .howiDq tbe 10catioD, ezteDt aDd dimeDaioD. of tbe work
The 4rawiDq .hall .how ~be relatioD of the propo.ed work ~o .zi.~iDq .urfac. aDd UDderqroUDd
!.mprov_eDt.. OeD approved ~!' tbe cit!' BDqiDeer, .aid drawiDq ~co.e. a p~ of thi. perai~.
The GaDeral eODdi~ioD. for all perai~. are li.ted OD the rever.e .ide. Special PJovi.ioD. for
thi. perai~ are liated ~elow. I'ailure to ~ide ~y the.e cODdi~ioD. aDd provi.ioD. ..!' re.ul~
iD jo~ .hu~-dOWD aDd/or forfei~ur. of ..itbful PerforaaDce BODd. aDd ca.h depo.it8. (See
GeD.ral CODdi~ioD8 1 aDd 2).
B. AD applic.tlu f.. __t .CCOllPaD!, thb .pplicaUoD. Db i. DOD-r.fUDd~le.
.... of Appl1CaD~ -:L~A Klr'f:pl'{~ 1)12(/. (7.-= TelephoDe: ~7Cf- <('S"L{ 7
aure.. ~o lJ. C~.~ It fl"" I<I'VI. /05
I. tbb work ~iDq dODe ~J the property on.r at their on reaideDce? -ye. _DO
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COaple~. aDd att.ch Work.r.' compeD.a~ioD aDd COD~ractor IDforaa~ioD forae.
ft. ApplicaDt/p.rait~ee her~y .qree. ~y affiziDq ~heir .iqDa~ure to thi. perait to ho14 the ci~y of
C..p~ell, ita offic.r., aqeD~. aDd ..ployee. free, .afe aDd harale.. fro. aD! clai. or d"aDd for
d...qe. r..u1tiDq from the work covered ~J thi. permit.
they have read aDd UDder.tand ~tb the froD~ and
ir cODtractor(.) of the iDforaa~ioD.
7/ ~1/8Y
acczr.rED
IIO'l'ZS: ALL WOU SBALL COIII'ORK WI'1'B 'I'D A'1"1'ACDD, APPROVED PLAIIS AIID ALL UPLICABLE CAMPBELL
STAllDARD DRAWIIIGS &lID COIIDITIOIIS.
'I'D COIl'l'ltACTOR WST UVE 'l'BIS PZRKIT AIID APPROVED PLAIIS AIID MUST BET WI'1'B 'I'D P.W. IIISPBCTOR 011
'l'D SITB AT LBAST 1'110 DAYS BEI'Oe STARTIIIG WOU.
IIOTICB MUST .B Gn'DI TO l'UBLIC WORD AT LBUT U BOURS BB!'OU USTARTIIIG &In WOU.
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IPECIAL PROVIIIOIIS
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Itre.t .hall Dot ~ OpeD cnat for UDderqrcUDd iutallatioD.. IliDi.ua cu~. .ay ~ a11owe4
for OODDectioD. or ezplo~.tioD bol... .uch cut. .u.t ~ .DecificallY aDDroved ~Y ~he
ID.pec~or.
Pav..eDt .aJ ~ cna~ for UDderqroUDd iD.talla~ioD. and .u.t ~ raatorea iD .ccordance with
the Utility TreDch Re.toratioD .~andard DrawiDq.
Work to be .tated by a lic.D.ed LaDd surveyor or Civil BDqiDeer aDd two C2) Gople. of the
out .hee~. .eD~ to ~he Public Work Daptar~eDt before .~artlDq work.
The hour. of work .re li.t~.d to out. ide the bour. of 7-' .... aDd s-, p... for aD! work
.f~ctiDir ~ ~.ff1C lan~ I' I " .f....
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S'1'UDARD
150.00
1500.00
(100' O. "G. BIT.)
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nJlKIT UPLICATIOII nB
ItLUI CDCK DBPOIIT
BOIID lOR I'U'l'JII'UL PZRI'OIUIUICB
&l'PItOVIlD lOR I88UUCZ
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(1200.00) C., 01' BOIID, 1500 XIII)
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CUB DBPOSIT
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REFUNDABLE DEPOSIT
CHECK REQUEST
TO: FINANCE DIRECTOR
CITY OF CAMPBELL
Please issue check payable to:
Ira Kirkorian Dev. Co.
Address:
Line 1:
1820 W. Campbell Ave. Rm 105
(30 spaces)
(30 spaces)
(30 spaces)
Line 2:
City:
Campbell
(20 spaces)
State: CA Zip:
(2)
95008
(10 spaces)
Description: Cash Deposit Refund
(24 spaces)
Exact Amount Payable: $500.00
Account Number: 01446290500
PURPOSE:
Cash Deposit Refund, Permit No. 88-195, Receipt No. 20204
dated 8/1/88
Verified by:
Enqineerinq Manaqer Date: 9/26/88
Requested by:
Receivable
Date: 9/26/88
Date:
,Approved by: Don Wimb
Public Works Dir.
SPECIAL INSTRUCTIONS FOR HANDLING C ECK:
Mail as is
x
Mail in attached envelope
Return to:
(Department)
(N ame)
"
Other:
08/24/88
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Address * {,..//-/'./T~Ot2.L:>
PUBLIC WORKS INSPECTION REPORT
Date
Permit or Project No.
eB~7 S-
(k">d~J~A fJtAZ4-..)
Type of work: Street Storm
Other (describe)
Sanitary Electrical
;:::"~f.c/')Y ~ "lU;)v<::",,';;:~
I
[JPRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached)
[JFINAL INSPECTION WITH DEFICIENCY LIST (attached)
~AL INSPECTION - ACCEPTANCE
Signed plans'?, Y @ (If signed, Council acceptance.)
Charges against deposit? Y
Overtime: hrs. @ $
Date 5 reason:
~
.
$
Barricade rental (attach invoice)?
Date 5 reason:
Y
rW
$
Other?
$
$
Total charges deducted from deposita
(Cash Deposit $ less charges $
$
· Refund $
ck. req.)
DONE YEAR MAINTENANCE WITH DEFICIENCY LIST (attached)
(JONE YEAR MAINTENANCE - ACCEPTANCE
(Release'maintenance bond. Check Request if cash.)
Engineer
e2
or
to: City Clerk
~
PUBLIC WORKS FILE NO. ~X"- ('7S
Please collect & receipt
for the following monies:
JeT.
35-3396
3372
3521
3521
(specify pro'ect)
P eJtr.lU e. e.4 :
R-1 :
($35)
($200)
:t vz.:
($ 50)
'( 500
(4% of FPB)
($500 min.)
(7'1u of FPB)
($ 35 min.)
(Cash) Depos i t
3372
Plan Check & Inspection Fee
3521 Other Cash Deposit (specify)
2373
3373
costs
.SO/sq. ft.
3372 Tentative Parcel Map Fil ing Fee ($350)
~~72 Final Parcel Map Fil ing Fee ($300)
2 Tentative Tract Map Fil ing Fee ($400)
~j72 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
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 Publ ic Works Special Projects
3510 Postage
TOTAL
,
NAME-I.R A K (r Ie 0 r r a. ^ .- (3 \&.r.
ADDREss--11?;;""O {l" Ct:vnfbe' ( Ave..- ,,' Rm
PHONE
AMOUtJT
$
5"0
500
$ 5'50. &0
ZIP
15/) a g
10S-
FOR
C I TV CLERK
CI'ILY
RECE I PT NO. :;L() .,A 0 Lf
$/ r-c..- ^, (,.'>-V
AMOUNT PA I D ~ ~ V"-
RECE J VED BY ~I-
DATE' R -1- f 8'
July, 1987
CITY OF CAMPBELL
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.
WORKERS' COMPENSATION INSURANCE INFORMATION
Name of Contractor/APplican~t:l.. IriU VlJJI JIJWl ')Ji> t. e~
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; QR
~ A Certificate of Workers' Compensation Insurance
Insurance Co. .s-h::x--k... Co~ I Yl.e; . Ft.J..V1 d
Policy No. a.Z ~58 - 23 Expiration date
---
; OR
.......................................................................... .
This Certificate of Exemption from the Workers' Compensation
laws printed below (certificate must be signed).
CERTIFICATE OF EXEMPTION
t-..
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.
. .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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. /45"c:J /15
City Business License No ..1'-, 0 14-84-- L
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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PUBLIC YORKS PERMIT ISSUANCE CHECK LIST
City of Campbell
Public Yorks Permit No. g~ -letS-
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Applicant section complete
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E ~ UJ:rf~ive sets of improvement plans submitted
Po.
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Applicant signature and date
Permit Application fee, $35.00 for R-l, $50.00 for
standard, paid. Receipt number
.)/
L1~Plan check deposit, $500.00 for standard only, paid.
\ \ Receipt number
~
Bond for faithful performance, 100% of City Engineer's
estimate for standard only, posted and appropriately noted
Amount $ Form I.D. #
Cash Deposit: $200.00 for R-l; 4% of FP bond, $500 min.
for standard, posted.
j Amount $
~tP~ Permit fee of 7% of FP bond, $35.00 min., paid.
Amount $ Receipt No.
Receipt No.
-rD ~ Yorker's compensation information received for Applicant
~~~ (see Information Sheet for Public Yorks Permits)
~f
r1'/ ~~ All other Public Yorks requirements listed in the Con-
ditions of Approval of the development.
-r;
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Yorker's comp and Contractor's Information received for
Contractor (see Information Sheet for Public Yorks Permits)
~/I Certificate of Insurance with Additional Insured's
Endorsment received from Contractor (see General Summary of
Insurance Requirements for Public Yorks Permits)
~J~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 _ and date and file with permit
UPON ISSUANCE, INITIATE PLAN CHECK DEPOSIT REFUND CHECK REQUEST.
6/88
flpermchklst
CITY OF CAMPBELL
70 NORTH FIRST
CAMPBELL, CALIFORNIA
(408) 866-2100
STREET
95008
Department: Public Works
September 26, 1988
Ira Kirkorian Development Co.
1820 W. Campbell Ave., Room 105
Campbell, CA 95008
,
RE: Final Inspection and Acceptance
Permit No.: 88-195
Location: N/S Whitwood (Kirkwood Plaza)
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.
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,
~~ (;,.~
Bill M. Helms
Engineering Manager
BMH/sd
cc: G. ~pton, P.W. Inspector
Suspense - 1 year
Public Works
CITY OF CAMPBELL
70 NO. FIRST STREET
CAMPBELL, CA 95008
(408) 866-2150
FIELD MEMO
DATE
7/2~/N3
PERMIT OR PROJECT NO.
ADDRESS/LOCATION No~n-/ SiblE W#ITW <-AI.
cA6r ~p PU(..;rc~
TO: CY-C4V4TI/V6 CO, DI( ~~CO!JeING
RE: P"t-/<.K.w.4'1 W6~
A- P tl.5l,J C Wcd!..K.6 f'6 ~ lrr IS
AI t: €"Deb ra~ AN wOIi!-K. IN 71+e=
IJ/J B (.. J c... /<1 b Ifr t:J F WA-; CO^, l!5" 7t:)
H-A-u., f Pr:>~ ONe ,ett;.6J..r
~PE~NGINEER ~ ~
rz -Fr uJ t n4 F~N K. 6c~ TOLUCcJ'
RECEIVED Byff~ Kllt.~/AN::S ,.,FFlt:E ""j
ENGINEER