88-217
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that they have read and understand both the front and t
ra their contractor(s) of the inforaation. !
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<(- - j>O ,- 8' 0 -=--
CXTY OF CAKPBBLL
DBPT. OF PUBLXC WORD
70 Morth lirat It.
Caapbell, CA 15008
(408) 8"-2150
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8
2
Permit 110.
BNCROACHMEHT PBRMXT
(for vorkinq in the
public riqht-of-.aYI
Issued ~.3 {fl$
perait rea' n 12 acs.
I-aef. file
Application Date cF'
Application exp
A'P~CATIOM - Applic.tion ia hereby ..de for . Public Works Perait in .ccordance with Caapbell
Municipal Code, lection 11.0.. (Application expires in , .onths if perait not pulled)
A.
Work .ddress 01' tract .
IY ~S
A--....l~
(O~f~~U
t:- I c:... "'"^
B.
utility trench loc.tion
lI.ture \ 0-- ----j... sea: P I. ~
,
Attac five (5 opies of a dravinq showinq the location, extent and di.ensions of the work
The d s .11 ahow the relation of the proposed work to eXistinq surf.ce .nd underqround
i.prov..ents. Wben approved by tbe City Bnqineer, said drawinq beco.es a part of tbie perait.
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D.
Tbe General Conditions for all peraits are listed on tbe reverse side. Ipecial .rovisions for
this perait are listed below. Failure to abide by these conditions and provisions .ay re.ult
in job Shut-down and/or forfeiture of Faitbful Perforaance Bonds and caab deposits. (lee
General Conditions 1 and 2).
B. AD .pplication fee .uat .ccompany tbia applic.tion. Tbis is non-refundable.
lI..e cf Applicant Go-...... +~ e: 0 f (L \ \ ~ Telephone:
Addre.. I ~ <? S-- P I "- """" J4 v e.. C 0- --.. f k, e II (' -=I.....
Is tbis work beinq done by the property owner .t their cwn residence7 ~yes ___no
Co.plete and attacb Workers' Co.pensation and Contractor Inforaation foras.
Tbe Applicant/Peraittee bereby aqrees by affixinq tbeir
of
C..pbell, its Officers, aqents and ..ployees free, safe
d...qea reaultinq fro. tbe work covered by this permit.
siqnature to tbi. perait to bold tbe City
and h.raless fro. any clai. or d..and for
ACCBPTBD
qn GA......-l-L-. R ~ 0 fe \<:- Date
IIOTB81 ALL WOU lBALL COIllOIlK nTH TBB AftACIIBD, APPROVED PLAII8 AIID ALL APPLICABLE C>>IPBBLL
ITAIIDAIlD DRAWIIIGI AIID COIlOITIOIII.
THB COIITRACTOR XUIT DVE THII PBRMIT AIID APPROVED PLAIII AIID KUIT KBBT WXTH THB P.W. IIISPBCTOR 011
THB SUB AT LBAST no DAYI BBFORB ITDTXIIG WOU.
IIOTICB MUIT BB GIVBM 'fO PUBLIC WORD AT LBAST U B01JR8 BBroRB RBITDTXIIG AllY WOU.
IPBCIAL PROVIIIOIIS
_1. . Street sh.ll not be open cut for underqround inst.ll.tions. Xini.ua cuta ..y be .llowed
for cODaections 01' explor.tion boles. Sucb cuta .ust be specificallY approved by tbe
Inspector.
_2. p.v..ent..y be cut for underqround installations and .ust be restored in .ccordance with
tbe Utility Trencb Restoration Itandard Drawinq.
_3. Work to be ataked by . licensed Land surveyor or Civil Bnqineer and two (2) copies of tbe
cut abeeta aent to tbe Public Work oaptartaent before atartinq work.
_.. Tbe bours of work are lialted to outaide the bours of 7-1 .... and 3-6 p... for any work
affectinq . tr.ffic lane.
_5.
PBIlKXT APPLXCATIOII FBB
(R-1)
(t35.00)
8TAllDARD
AHOUllT
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IBCBIPT NO.
207S-~
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r~$k
oate
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$500.00
(100' OF BIIG. B8T.)
(., OF BOlIO, $500 MXII)
PLAII CHICK DBP08IT
,
$
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BOlIO roR FAITBrUL PBUOIlKAllCB
-
CAlK DBPOSIT
('ZOO.OO)
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,
PLAII CHBCK ,
,......,...... 4" o. .... ...... ,.. KI.,
l:88UUlCB ? ~
for I'
APPROVED FOR
f 1 "PERMIT
aevised 8/88
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TO: City Clerk
PUBLI C \-JORKS FI LE NO. c?cf- 2 / 7
Please collect & receipt
for the following monies:
,CCT.
-----
35-3 96
(specify pro'ect)
PVU!/-<.-t eu:
R-l :
($'35)
Depos i t
3372 Plan Check & Inspection Fee
3521 Other Cash Deposit (specify)
J373
3373
Project
Gene ra I
&
3372 Tentative Parcel Map Fil ing Fee ($350)
3372 Final Parcel Hap Fil ing Fee ($300)
72 Tentative Tract Map Fil ing Fee ($400)
}372 Final Tract Ma 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 Envi ronmental Assessment:..
Categorical Exemption cost
Ne ative Declaration
3370 Storm Drainage Area Fee per Acre Multi-Res"
$2,060; all other, $2,250)
3395 Park Dedication 11'l-lieu Fee per Unit ($1,132)
3380 Public Works Special Projects
3510 Postage
NAME
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JY A ~;;
TOTAL
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PHONE ,3 7 'i - /GY 7
) 2. / a /J E Lee
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L.---
AMOUln
$
3s~-
200
$
r--
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(,_(' ,;; /'L'~ <\4-(>,,-,---'- ~,
ZIP
~..f, ) 7 of)
f '
ADDRESS
FOR
C I TV CLERK
a-lLY
RECE IPT NO.
d-.-O 7 ~~
., .---00
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AMOl.I'iT PAID
RECE I VED BY
DATE'
July, 1987
~O ___ .__ _ O_'___.h.._
PUBLIC WORKS INSPECTION REPORT
JAte /~,;j-z--4~ Permit or Project No. .88 ~ 2/?
, ,.
Address /48S": 'EZ4ii1
~pe of work; Street Storm SAnitAry ElectricAl
Other (describe) M-A::.t:.WI'l1'/
..-/
[JPRELIMINARY INSPECTION WITH DEFICIENCY LIST (attAched)
[JFINAL lNSPECTION WITH DEFICIENCY LIST (AttAched)
~ INSPE~ION - ACCEPT~
. Signed plans? , Y <...JL-J (If signed, Council AcceptAnce.)
ChArges agAinst deposit? y
Overtime I hrs. @ $
DAte 5 reAsonl
~
.
$
BArricAde rentAl (Attach invoice)? y
Date , reAsonl
C0
$-
.-
Other?
$
$
$
· Refund $
Total chArges deducted from deposita
(Cash Deposit $ less chArges $
ck. req.)
[JONE YEAR MAINTENANCE WITH DEFICIENCY LIST (AttAChed)
o ONE YEAR MAINTENANCE - ACCEPTANCE
(ReleAse'maintenAnce bond. Check Request if CAsh.)
Engineer
.~~
CITY OF CAMPBELL
Permit No.
Applicant
INFORMATION SHEET FOR ENCROACHMENT 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
.....~....................................................................
. .
. .
: 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 Wo rs' mpensation Laws of California.
Date
g.- ,30 -S8'
Signed
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
REV. 8/88
CITY OF CAMPBEll
70 NORTH FIRST STREET
CAMPBELL. CALIFORNIA 95008
(408) 866-2100
Department: Public Works
December 13, 1988
Mr. Garth Riopelle
1485 Elam Ave.
Campbell, CA 95008
RE: Final Inspection and Acceptance
Permit No.: 88-217
Location: 1485 Elam Ave.
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 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
mainten~nce is needed.
Please feel free to call me if you have any questions.
Sincerely,
Gregg Eaton
Public Works Inspector
GE/sd
cc: SUsp~nse ~ 1 Year
.':0\)/,'(1
PUBLIC WORKS INSPECTION REPORT
Date /Z:~f:~~ Permit or Project No. ,88 - 2/?
Address /485"-' El4/i1
Type of work: Street Storm Sanitary Electrical
Other (describe) m,e~",,/
.-./
[JPRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached)
[JFINAL INSPECTION WITH DEFICIENCY LIST (attached)
~ INSPE~TION - ACCEPT~
Signed plans? y ~ (If signed, Council Acceptance.)
Charges Against deposit? y
OVertime; hra. @ $
Date" reason:
~
.
$
Barricade rental (attach invoice)? Y
Date " reason:
C0
$
...
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
(ReleaBe'maintenance bond. Check Request if cash.)
Engineer
(W
TO: C i".:y C I e rk '
PUBLI C ~JORKS FI LE NO. J cf'- 2 / 7
Please collect & receipt
for the following monies:
"'--"1CCT.
35-J -6--
Depos it
R-1 :
($'35)
3372
3521
J373
3373
Plan Check & Inspection Fee
Other Cash Deposit (specify)
&
3372
1372
72
'j372
3372
3372
3372
3372
Tentative Parcel Map Fil ing Fee ($350)
Final Parcel Ma Fil in Fee ($300)
Tentative Tract Map Fil ing Fee $ 00
Final Tract Ma Fil in Fee ($350)
Lot Line Ad.ustment Fee/Certificate of Com I iance
Vacation of Publ ic Streets and Easements
Assessment Segregation or Reapportionment
First Spl it ($500)
Each Additional Lot ($150)
Environmental Assessment:'
Categorical Exemption cost
Ne ative Declaration
Storm Drainage Area Fee per Acre Multi-Res..
$2.060; all other. $2.250)
Park Dedication 11'l-lieu Fee per Unit ($1.132)
Public Works Special Projects
Pos tage
3370
J395
3380
3510
AMOUtn
$
3 :;;- -
20<:0
r--
.)
TOTAL
atJ.-~ n IcJ PELce- tJ9-/-3-.5
NAME: 'f ' / PHONE
(j / 'T d:r g~~- c::; ~
ADDRESS c:'v~$
23
$
379~/oY/
/<)Uocr
ZIP
FOR
C I TV CLERK
C1NLY
RECE IPT NO.
~CJ 7 ~-g-'
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~
'7/-3/. ~r
AMOI.JIIT PAID
RECE: J VED BY
DATE'
July. 1987