88-227
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CITY O)'CUPBliLL
OBP1'. 01' PUBLIC WOlUtS
7r .ortb I'irst st.
C..pbell, CA '5008
(408) 8"-2150
BNCROACHHBN'r PBRMIT
(for workinq in th.
publio rigb~-of-W.y)
Issu.d Ci{( b ~ cP J
P.rait exp r.s n 12 aos.
Perait 110.
a:iJ-z.z7
X-Ref. fUe
Applioation Date ~!r{f~
Applio.tion exp res n' aos.
APPLICATIOII - Applioation is hereby aade for. Public Works Perait in aooordance with C..pbell
Muaioip.l COde, S.otion 11.0.. (Applio.tion expires in , aonths if p.rait not pull.d)
A.
Work address or tr.ot .
193 REX CIRCLE
N/A
(C:ornpr
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of ~11n'borr:7
Avp
^' RI"Y
utility trenoh loo.tion
lIature of workz Curb & Gutter Removal and Drivewav Approach
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non-refundable. :
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C.
Attaoh five (5) oopies of a dr.wing Showing the loo.tion, eztent and diaensions of the work
The dr.wing shall show the relation of the propos.d work to existing surf.ce and underground
iaprov...nts. Wh.n .pproved by th. City Enqin..r, s.id dr.winq becoa.s . p.rt of this p.rait.
D.
The aener.l Conditions for .11 p.raits are listed on the reverse sid.. Bpeoi.l Provisions for
this p.rait are list.d b.low. F.ilur. to abide by th... condition. and prov!~ioD. aay r..ult
in job shut-doWJl and/or forfeiture of I'a!thful Perforaance Bon'ds and cash':4apodta. (Be.
a.neral Conditions 1 and 2).
t E.
AD .pplio.tion fee aust .oooapany this .pplio.tion.
Th18 18
.... of Applioant LLOYD C. BARRETT
Addre.. 19 3 REX CIRCLE
CAMPB
Is this work be~ng done by the property OWJler .t their OWJl residenoe? ~yes
_no
Coaplete and .tt.oh Workers' Coapens.tion and Contr.otor Infora.tion forae.
The Applioant/Peraittee hereby .qrees by .ffiKing th.ir
of
C..pbell, its offioers, .gents and ..ployees free, s.fe
d...ges re.ulting froa the work oovered by thi. perait.
.iqn.ture to this perait to hold the City
and h.rales. froa any ol.ia or d..and for
h.ve re.d and under.t.nd botb the front and
ontr.oto (D) of the infora .tion.~
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D.te
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HO'l'SBz ALL WOU: SBALL COHl'ORH WID '1'IlB AftACllBD, APPROVBD PLAlrS AHD ALL APPLICABLE CUPBBLL
BTAHDAItD DRAWIIIGB AHD COHDITIOIIB.
DS COftRAC'l'OR HUBT UVB DIB PSRMI'1' AHD APPROVBD PUIIB AHD HUS'1' DET WID '1'IlB P.W. I.BPECTOR ON
'l'IIB SI'1'S AT LBA8T no DAYS BEFORB B'1'ARTIHa wou.
VOTICE HUST BE aIVBH TO PUBLIC 'MOlUtS AT ~UT U ROUas BEFORB RB8'1'ARTIIIG AllY wou.
open out for vnderqround in.tallation8.. Hiniaua out.. aay be .llowed
for oonneotion. or explor.tion hole.. suoa out. !ust b. specifio.llY .ppro~.d by the
In.peotor.
p.v..ent aay be out for UDdergroun4 in.tall.tion. and su.t be re.tored in aooordanoe with
the Utility Trenoh Re.toration St~dard ~r.wing.
Work to be .tated by . lioen.ed Land 8urveyor or Civil Enqine.r and two (2) oopie. of the
out .heet. sent to tbe Publio Work oeptartaent before .tarting work.
Tile hour. of work are lialted to outDide tile hour. of 7-' .... and 3-' p... for any work
.ffeoting . tr.ffio lane.
SPECIAL PROVISIONS
~ 1. .Str.et .h.ll not be
_2.
_3.
_t.
_5.
B'1'AHDARD
PERMIT APPLICA'tIOII I'BE
(R-l)
e'35.00)
flO.OO
flOO.OO
(100' OP SHG. E8'1'.)
(., OP BOlIO, '500 KIll)
PLAIr CBBCK DEP08I'1'
BOlIO FOR I'AI'l'BFUL PBRI'ORKAHCE
CASH DEPOSIT ('ZOO.OO)
PUll CDCK ,
nwQ~xa ~ en 01' I'.P. BOlIO, '35 KIll)
n....a !1 tJ1. ~
or C t e
q-\lb-~
D.t.
APPROVED POR
fz PWPBRMI'1'
aevis.d 8/88
AKOVN'r DCBI" HO.
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ENCROACHMENT PERMIT ISSUANCE CHECK LIST
Encroachment Permi t No. flF - ~ ).--J
City of Campbell
Department of Public Works
~ Applicant section complete
~ Applicant signature and date
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::>~~ V Five sets of improvement plans submitted
p.,
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~----------------------------------------------------------------------
v
Permit Application fee $50.00 ($35.00 for R-l Homeowner),
paid. Receipt number
-
Plan check deposit, $500.00 (waived for R-l Homeowner),
paid. Receipt number
Bond for faithful performance, 100% of City Engineer's
estimate, (waived for R-l Homeowner), supplied or paid.
Amount $ Form I.D. #
~ Cash Deposit: 4% of FP bond, $500 min. ($200 for R-l
Homeowner), paidD
Amount $ ~ 00 t:::'-, Receipt No.
Plan Check & Inspection fee of 7% of FP bond, $35.00 min.,
(waived for R-l Homeowner) paid.
Amount $ Receipt No.
Worker's compensation information received for Applicant
(see Information Sheet for Encroachment Permits)
All other Public Works requirements listed in the
Conditions of Approval of the development.
---------------------- ------------- --... ---- ------............................................. ----- ---- ---
Worker's comp and Contractor's Information received for
Contractor (see Information Sheet for Encroachment Permits)
Certificate of Insurance with Additional Insured's
Endorsment received from Contractor (see General Summary of
Insurance Requirements for Encroachment Permits)
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 CHECK REQUEST FOR PLAN CHECK DEPOSIT REFUND
8/88
permchklst
CITY OF CAMPBELL
Permit No.
Applicant
fg -:;~1
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 LLOYD C. BARRETT
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' Co~pensation Laws of California.
Signed ft4j! t:~ r1~ Date r 0 /0?
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
TO: ' City Clerk
PUBLIC WORKS FILE NO. 8'J"zz'7
Please collect & receipt
for the following monies:
I"\~CT.
J5- 3396
3372
3521
3521
ITEM
Project Revenues (specify project)
Pubuc. ('JoJtfu Exc.ava.-uon PeJun,u: fe.M:
Appl i cat ion Fee
Plan Check Deposit
Faithful Performance (Cash) Deposit
R-l :
($'35)
($200)
OthVt:
($ 50)
'($500)
(4% of FPB)
($500 min.)
(7'7.- of FPB)
($ 35 min.)
3372
Plan Check & Inspection Fee
3521 Other Cash Deposit (specify)
3373
3373 &
3372 Tentative Parcel Map Fil ing Fee ($350)
~~72 Final Parcel Map Fil ing Fee ($300)
,2 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 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; all other, $2,250)
3395 Park Dedication In-lieu Fee per Unit ($1,132)
3380 Publ ic Works Special Projects
3510 Postage
TOTAL
.....E.ar P A; L 1fJ~
PHONE
AMOUNT
$
35. 0 0
~
2, " o.
$
2 3.r ..&-i)
ADDRESS
ZIP
FOR
C I TV CLERK
O>l1.Y
RECEIPT NO.
ooo~
d.-~~ op
am
q - 1'$ - f5~
~ PAID
RECE J VED BY
DATE
July, 1987
CITY OF CAMPBEll
70 NORTH FIRST STREET
CAMPBELL, CALIFORNIA 95008
(408) 866-2100
Department: Public Works
October 27, 1988
Mr. & Mrs. Lloyd Barrett
193 Rex Circle
Campbell, CA 95008
Dear Mr. & Mrs. Barrett:
We made an e~ror and will waive the Maintenance Bond requirement.
Enclosed please find your check for $50.00. Your cash deposit
refund of $200.00 will follow under a separate cover.
I apologize for any inconvenience this may have caused.
Sincerely,
Gregg Eaton
Public Works Inspector
GE/sd
cc: Suspense - 1 year
REFUNDABLE DEPOSIT
CHECK REQUEST
TO: FINANCE DIRECTOR
CITY OF CAMPBELL
Please issue check payable to: Lloyd C. Barrett
Description:
Ref. Dep. Permit 88-227
(30 spaces)
(30 spaces)
(30 spaces)
State: CA Zip: 95008
(2) (10 spaces)
(24 spaces)
Address:
Line 1: 193 Rex Circle.
Line 2:
City :
Campbell
(20 spaces)
Exact Amount Payable: $200.00
Account Number: 01446290500
PURPOSE:
Release of cash deposit for Excavation Permit No. 88-227.
See receipt #0005 dated 9/14/88.
Requested by: Gregg Eaton Title: P.W. Inspector Date: 10/27/88
Approved by: Don Wimberly jUe: P.W. Director Date: 10/27/88
Verified by: A counts Receivable Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as is
x
Mail in attached envelope
Return to:
(Department)
(Name)
Other:
08/24/88
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CITY OF CAMPBELL
70 NORTH FIRST
CAMPBELL, CALIFORNIA
(408) 866-2100
STREET
95008
Department:
Public Works
October 13, 1988
WtM!Eay HANDLING
HELMS RETliRN TO
V ALKENAAA DISCARD
DIAl fill
MANlEY
PfNOYfR
CAS!
Mr. Lloyd C. Barrett
193 Rex Circle
Campbell, CA 95008
RE: Final Inspection and Acceptance
Permit No.: 88-227
Location: 193 Rex Circle
Maintenance Bond Amount: $50.00
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
Date 10 /; ~tk~ Permit or Project No. '8~ - 2...Z-7
I ~ .
Address /t73 - /f'E,X C/:eeUE'
Type of work: Street Storm Sanitary Electrical
Other (describe) ,.2Nt!/i/Gf ~4'~-1
o PRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached)
o FINAL INSPECTION WITH DEFICIENCY LIST (attached)
~INAL INSPECTION - ACCEPTANCE
Signed plans'? y ~ (If signed, Council acceptance.)
Charges against deposit? y
Overtimez hrs. @ $
Date '.reason:
@
7hr.
-
$
Barricade rental (attach invoice)? y
Date , reason:
1E)
$
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
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