88-196
CXTY OF CAMPBELL
DBPT. OF PUBLIC WOlUtS
7~ Borth First st.
Campbell, CA 'S008
(408) .U-Z150
POBLXC WORKS PERMXT
(for workinq in the
pUblic right-of-way)
I..ued 11/3/ if'
pe~t expire. in 12 .0..
<6 8' -- I '1 C:,
perm.it Bo. ~~
X-Ref. file
Application Date 7 - 2. t - 8' 8
Application expire. i 6 .0..
APPLXCATIOB _ Application i. hereby .ade for a PUblic Work. perm.it in .ccordance with campbell
Municip.l Code, section 11.04. (Applic.tion expire. in 6 .onth. if pe~t not pulled)
A. Work addre.s or tract . 30 q 0 Bu ~o.t\ ~ ~ '. } ~o. ~"o ~ \ \ ) CJ.\ 1 So~
utility trench location
B. B.ture of work: 6~L lov~~~rntC~ B-~=~
c. attacb <i.. (5) oopi.. 0< . dr."'O ....i.. tbe 'oc.tio., :::~:~ -.:; ~~o.. o' tho ..r'
The drawing .h.ll .how the relation of the propo.ed work to existinq .urface and underqround
i.prov..ent.. When approved by the city Engineer, .aid dr.wing becomes a p.rt of this perm.it.
D. The General Condition. for .11 perm.it. are li.ted on the rever.e .ide. special pJbvi.ions for
this perm.it are li.ted below. Failure to abide by these conditions and provision. ..y result
in job .hut-down and/or forfeiture of Faithful Perform..nce Bonds and cash depo.ita. (See
General Conditions 1 and 2).
II. An application fee .ust accomwy this application. Thi. i. non-refundable.
.... .< &poll...t %~ l CA.- n;tYiiL ..,..-. ':iO~ 31'+ . W<di
Address 3<6C,' 0 __--V\..Q LL Rd.) Cu. Mf>lDe l \) C fA. ~ ~ 00 B
x. this work beinq done by the property owner at their own residence? ~es ___no
complete and attach Workers' compensation and contractor Inform..tion form.s.
The Applicant/perm.ittee hereby agrees by affixinq their .iqnature to this perm.it to hold the City of
Campbell, it. officer., .gent. and employees free, ..fe and h.rm.les. from any cl.im or demand for
damaqe. re.ultinq from the work covered by this perm.it.
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ACCEPTED
ereby acknowledges that they have read and understand both the front and
that th ill nform. their contr.ctor(s) of the inform..tion.
7-2-J;--f18
1I0TES: ALL WOU SHALL CONFORM WX'1'B '1'BB ATTACHBD, APPROVED PLANS AND ALL APPLXCABLB CAXPBELL
STANDARD DRAWXBGS AND CORDXTIOBS.
TBB CONTRACTOR JroST BAVE '1'BIS PERMXT AND APPROVED PLANS AND JroST DET WX'1'B '1'BB P.W. IBSPECTOR 011
'1'BB SITE AT LEAST TWO DAYS BEFORE STARTING WOU.
1I0TIC! JroST BE GIVIIII TO PUBLIC WOlUtS AT LEAST 24 HOURS BEFORE RESTARTIIIG JUlY WOU.
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SPECIAL PROVXSXONS
_So
street .hall not be open cut for underground inst.ll.tions. Mini.um cuts .ay be .llowed
for connection. or exploration hole.. Such cuts must be specific.llY .pproved by the
xnspector.
pavement .ay be cut for underground installations and .ust be restored in accordance with
the utility Trench Restoration standard Drawing.
Work to be .taked by a licensed LaDd surveyor or civil Engineer and two (Z) copies of the
cut .heet. .ent to the Public Work Deptartment before .t.rting work.
The hours of work are li.ited to outside the hour. of 7-' .... and S-6 p... for any work
affecting a traffic lane.
_1.
_2.
_4.
_5.
BORD FOR FUTBFUL PERFORllARCE
RECEIPT NO. ~
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PERMIT APPLICATIOII FEE
(R-1)
($35.00)
STANDARD
$50.00
$SOO.OO
(100' OF ERG. EST.)
AXOOllT
$ 35'.l>O
$
$
$ 200.00
$
PLAN CBBCIt DBPOSXT
APPROVED FOR XSSUARCB
($ZOO.OO) (4' OF BORD, $500 MIB)
4P~' ,.. WU,
for lne.r .
~&B
Date
CASH DBPOSXor
PBRIlXT DE
f: PWPERMXT
___~__.. ..I......
CITY OF CAMPBELL
Permit No.
Applicant
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INFORMATION SHEET FOR PUBLIC WORKS PERMITS
A separate form must be completed for the applicant and each contractor
that will work under this permit.
WORKERS' COMPENSATION INSURANCE INFORMATION
Name of Contractor/Applicant
One of the following must be on file with the Public Works Department:
A Certificate of Consent to Self-insure issued by
the Director of Industrial Relations; OR
A Certificate of Workers' Compensation Insurance
Insurance Co.
Policy No. Expiration date
; OR
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. .
: This Certificate of Exemption from the Workers' Compensation :
: laws printed below (certificate must be signed). :
CERTIFICATE OF EXEMPTION
Date 7 - 2--~ - f;f
NOTICE TO CONTRACTOR/APPLICANT: If, after signing this Certificate
of Exemption, you should become subject to the Workers' Compensation
provision of the Labor Code, you must forthwith comply with such
provisions or this permit shall be deemed revoked.
. .
. .......... ........ .............. .. .......... ................ . . . . . .... .. . . .
CONTRACTORS INFORMATION
Note that all contractors must have current City of Campbell Business
License, State Contractor's License and Workers' Compensation Insurance.
Name of Contractor
Address
Telephone
State Contractor License No.
City Business License No.
Expiration Date
Will do the following types of work:
_____underground _____P.C. concrete _____A.C. paving _____electrical
_____other (specify)
f:PERMINFO
~.: ~ 4/8<;.
TO: City Clerk
PUBLI C ~JORKS FILE NO. gg -/9 f:,
Please collect & receipt
for the following monies:
pro 'ect)
PVU!l-<.-t Fecu:
:t VI.:
($ 50)
{ 500)
( % 0 f FP B )
($500 min.)
(n of FPB)
($ 35 min.)
Depos i t
3372
Plan Check & Inspection Fee
3521 Other Cash Deposit (specify)
.J373
3373
Project
General
&
3372 Tentative Parcel Map Fil ing Fee ($350)
3372 Final Parcel Hap Fil in Fee ($300)
172 Tentative Tract Map Fil ing Fee $ 00
J372 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 Split ($500)
Each Additional Lot ($150)
3372 Environmental Assessment:'
Categorical Exemption cost
Ne ative Declaration
3370 Storm Drainage Area Fee per Acre Multi-Res"
$2,060; all other, $2,250)
.J395 Park Dedication I~-lieu Fee per Unit
3380 Public Works Special Projects
3510 Postage
TOTAL
AMOUNT
$
35-00
::ADo. 00
C7/1 Treil
CSuef<Y1Q I (
$ ~3~-. DO
'-=<, 7 t./ - ~ 0(0 <I
ZIP 9-..::; O()~
NAME Va n " Y
ADDRESS -3 ~ '10
A<<:lNE
(c~p~ ('
FOR
C I TV CLERK
a-iLY
RECEIPT NO. d. 0')-- d- 3
AMOUNT PA I D ~ ~ .s;:- to!?
RECEIVED BY a m
DATE "B-I-g $!
July, 1987
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TO: FINANCF; DIR~CTOR
CITY OF CAMPBELL
Please issue check payable to:
Address:
Line 1:
Line 2:
City :
(\
Description:
Exact Amount Payable:
~ccount Number:
REFUNDABLE DEPOSIT
CHECK REQUEST
j
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DAN CANTRELL
,(30 space~)
(3Q spaces)
(30 spaces)
State: CA Zip: 95008
(2) . (10' spaces)
(24 spaces)
DAN CANTRELL
3890 BUCKNALL RD
CAMPBELL
(20 spaces)
REFUND
$200.00
35.00
ACCOUNT #905.4662
ACCOUNT #905.4443
PURPOSE:
RELEASE OF CASH DEPOSIT AND PERMIT APPLICATION FEE~ MR. CANTRELL',S
ADDRESS IS NOT IN CAMPBELL CITY LIMITS THEREFORE HE DOES NOT NEED A
CAMPBELL EXCAVATION PERMIT (#88-196). SEE RECEIPT #20223 DATED 8/1/88.
Requested by: D. Valkenaar
Approved by: D. Wimberly
Verified by:
Title: Assoc. Civi I Engr. Date: 9/8/88
Title: P. W. Di rector Date: 9/8/88
Accounts Receivable Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as i~
Mail in attached envelope
Return to:
(Name)
(Other.
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(Department)
I '
08/24/88
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RECEIPT
CITY OF CAMPBELL
CAMPBELL, CALIFORNIA
NAMF
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c.D---;e{/LL_~
ADDRESS
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;;;2 3~ 00
REVENUE ACCOUNT NO.
S 3 7 ~ t s !);;J.!
~372 '( :) S""2-r
~
FUND NUMBER
---
~~
o MONEY ORDER
o CASH
DATE
AMOUNT
II
THIS RECEIPT
MUST BE MACHINE
VALIDATED AND
SIGNED BELOW.
331'2-
3:S-2,..;.l e
35 0"
~~ 00
;;)- 26' t!:J6
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BY
CITY CLERK
20223
Thank You
CITY OF CAMPBELL
FINANCE DEPT.
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CITY OF CAMPBELL
70 NORTH FIRST
CAMPBELL, CALIFORNIA
(408) 866-2100
STREET
95008
Public Works
November 3, 1988
Department:
Mrs. Brenda Cantrell
3890 Buckna11 Rd.
Campbell, CA 95008
RE: Final Inspection and Acceptance
Permit No.: 88-196
Location: 3890 Buckna1l Rd.
Maintenance Bond Amount: Waived
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. 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
, ..
PUBLIC WORKS INSPECTION REPORT
JAte 10 ~8 . Permit or Project No.
Address /3 BCZ 0 ... - ~/CIU~ l.- L
, 89 .j9~
Type of work: Street Storm SanitAry Electrical
Other (describe) "'~I'ut'W7
[JPRELIMINARY INSPECTION WITH DEFICIENCY LIST (attAched)
[]FINAL INSPECTION WITH DEFICIENCY LIST (AttAched)
~AL INSPE~TION - ACCE~
Signed plAns? Y.~ (If signed, Council AcceptAnce.)
Charges agAinst deposit? Y
OVertime: hrs. @ $
DAte ~ reAson:
w
-
$
Barricade rental (attach invoice)?
Date ~ reAson:
y;(0
$
Other?
$
$
Total chArges deducted from deposit:
(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
i2)