88-233
CI~ or CAKPBELr"
J)BP'1'. O~ PUB7.Ll.: . '1:::0.3
10 ~o.. ~b l'i..II'; .....
Campbell, CA ~500.
(40.) _"-1150
PUBLIC WORKS PERMIT
(for workin~ in the
public riVht-of-W~)
%"\le4 ~9 /fS
~....~t ezp r.. ill 11 .0..
perait .0. 88- 233
S-Ref. fU. PS'- I s-t:)
application Date 'U28/f?,15
application asp e. ~n 6 .0..
APPLlCATI0. _ application i. her.by .a4e for. PUblio work. perait in .ccor4ance with campbell
~cipal c04e, sectiOD 11.0.. (applicatioD ezpir.. iD , .0Dth. if p.~t Dot pull.a)
a.
.ork dare.. or tract' f-, h 0 \~ ( fA (2 Ie. 1/1 U G u~; IV! P 13 61...-1-
DtUit, treDch 10catioD 11 Pp(~X. 10' FIZ()/LA. t-D66 of PFII)(' NG/lJ/.
..tur. of worklll)}SmLL 701-. F t:- 6" 5Arum1J2V SFttJt::'Z (1PV~) f-N9/lJi-fOL/; IV/mllV
Attach fi~. (I) copie. of . 4rawin~ .howin~ the loc.tion, extent an4 4laen.ioD. of the work
The arawiD~ .hall .how the r.lation of the propo.ea work to .zi.tiD~ .urfac. ana un4er~rouna
!apr~_eDU' Oen .pprove4 by the cit, ED~ine.r, .aia 4rawinv beco.e. . part of thi. p.rait.
The GeDeral con41tion. for all p.rait. are li.t.4 OD the r.ver.. .ia.. sp.cial p~~i.ion. for
tbi. perait are li.te4 below. I'ailur. to abi4e by tbe.e con~ition. ana provi.ion. .a, r..ult
:LD ~ob .hut-down aDd/or forfaitare of I'aithful perforaanca Bond. and cuh 4epoll1t8. (.aa
GeDeral conti tioDS " u4 2).
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C.
D.
B. aD .pplicatioD f.. .ut .ccoapu, tbi. applicatioD. Thill i. Don-r.fun4abla.
.... of applicutdVtST IJHUt.y 5i1J1.;;m77fJ/V D/Sl72-ICr TelephoDel '57'6-;2'11..-' 7
aUre.. / DO E.. <,;; U I1J IV ,,'(J 0 r.:.... ~ j (lJi/l.I; fllY:,f....c
x. tbi. work baiDV dODa by tba propart, own.r at th.ir own r..i4anc.' ---,a. ~ no
coaplat. aD4 .ttacb workar.' COap.D..tiOD ua CODtractor %DforaatioD foraa.
The applicant/paraittaa bereby acknowla4~e. tbat tbey ba~e raaa u4 un4er.tand botb tbe froDt an4
.... Dr ",,0 ~,...~..~... .... will 'or... ...i. ..........,., .r ... iOr.....,..~ '. .
aCCZP'l'ZD "lfWi'riJ., ~CZi ,/j . 'A / /;;z 8 /"1 g
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.OTEal aLL WOJUt 8HaLL COHl'OJUl WIft 'I'D a,"ACUD, apPROVED PLUt8 &lID aLL UPLICULB CAKPBBLL
''1'AHDaRD DRA.I1108 UD COIIDITI0.8.
'ftIB COftRACTOR W8T un DU pZJlX%'f UD APPaovBD PLUt. &lID XU8'1' Dft WI9 'I'D .... D8PIC'l'OR O.
'I'D Sl'f. AT LBUT ftO DaYI .IFO" STDTIIIG trOD.
IIO'l'%CB XU_T .. GIVBJI ~ PUBLIC WOaD a'f LIWI'1' U BOU1t8 '.1'0" ".'fU'1'DG U'Y Gaz.
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8PECIAL PROVIII01I8
_1.
.tr..t .ball not be opaD aut for 1Uldervroun4 in.tall.tioD.. KlDiaua out. ..y be allow.4
for conn.ction 01' asploratioD bola.. .ucb aut. .u.t be .Ileciflcally .llllro~.4 bY tba
In.pector.
pavement .a, be aut for 1Ul4arqrouna iD.tallaUoDS ua n.t be :ra.torea iD .ccor4ance w1 tb
tb. uti11t, 'francb ...toratioD standar4 DrawiDg.
work to be .tak.a b, a licaD..a LaDd s~e,or 01' C1~il Inv1Daar ana two (I) oopia. of tba
aut .b.et. ..Dt to tbe Publio .ork Deptartaent bafor. .tartiDv work.
TIl. hour. of work ara l1aitaa to out.1a. tha bour. of 1-' .... u4 J-' p... for u, work
affactlDi a traff1c lane.
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8D1IDaRD
'10.00
'500.00
(100' OF DG. U'f.)
(4' 01' BOW, '500 IIDI)
(,SI.DO)
wnxn UPLIQU9 ...
~ maCK DBP08IT
BOW I'OR FA%'RI'DL PlUORDJICB
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(t100.00)
CUB DlP081'f
PlU%'f nz
un,onD I'OR XS.UOCB
(" 01' F... ~W, '31 IIDI)
for Ci~r~
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REFUNDABLE DEPOSIT
CHECK REQUEST
TO: FINANCE DII}ECTOR
CITY OF CAMPBELL
Please issue check payable to:
Roma Construction
(30 spaces)
(30 spaces)
(30 spaces)
State: CA Zip: 95051
(2) (10 spaces)
(24 spaces)
Address:
Line 1:
1552 Norman Ave.
Line 2:
City :
Santa Clara
(20 spaces)
Description:
Cash deposit refund
Exact Amount Payable:
$500.00
Account Number:
905-4662
Release of cash deposit for excavation permit 88-233. See receipt
PURPOSE:
NO. 0032 of ~ :1/c2-7/ Ft'.
Requested by:
Gregg Eaton
Title: P . W. Inspector
Date: 2/7/90
Approved by:
Bill Helms
Ti tle : Engr. Manager
Date:
Verified by:
Accounts Receivable
Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as is
x
Mail in attached envelope
Return to:
(Department)
(Name)
Other:
08/24/88
TO: City Clerk
PUBLIC WORKS FILE NO. ~[-233
Please collect & receipt
for the following monies:
AMOUNT
$
SlJ. t) 0
(Cash) Depos i t
($200)
Plan Check & Inspection Fee
.:3 s-' Co
'_H- 16'
.:5?JO.Oo
Other Cash Deposit
3373
3373
3372 Tentative Parcel Map Filing Fee ($350)
~172 Final Parcel Map Fil ing Fee ($300)
~372 Tentative Tract Map Fil ing Fee ($400)
J372 Final Tract Ma Fil in Fee ($350)
3372 Lot Line Adjustment Fee/Certificate of Compl iance
3372 Vacation of Publ ic Streets and Easements ($500)
3372 Assessment Segregation or Reapportionment
First Spl it ($500)
Each Additional Lot ($150)
3372 Envi ronmental Assessment:'
Categorical Exemption
Ne ative Declaration
3370 Storm Drainage Area Fee per Acre Multi-Res.,
$2,060; a II 0 the r, $2,250)
J395 Park Dedication In-lieu Fee per Unit ($1,132)
3380 Public Works Special Projects
3510 Postage
NAME
o IYJ It- &, A1 ~T'
1S-~2-- NOeMPrA1 Ave-
PHONE
$ ~f?;;tJ)'
'I~t -~~-7
I
ZIP 95CJ,s-/
TOTAL
ADDRESS
SL.
FOR
CITY CLERK
CI'lLY
RECEIPT NO.
ftJL3d-
Si~
LP
1.1;21/ff'
July, 1987
AMOUNT PAID
RECE J VED BY
DATE'
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' COMPEN~TION INSURANCE INFORMATION
Name of Contractor/Applicant !/.;4.(lLo {~lAl1-L-t>
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. ?:oc../F'1 c.... ea-,,,
Policy No.W.....v 1/0'10 . Expiration date fife? ; 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' 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
/{"
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Note that all contractors must have current City of Campbell Business
License, State Contractor's Li~e and Workers' Compensation Insurance.
Name of Contractor ..f2/LLo f 412-Lo Telephone '3.5 9 6s's:J
Address 176?r:- ~G)i-/~11..0~ /l- c!. ~s c;,.,oTD ~ CJo
State Contractor License No. l/Jz.-B6'6 City Business License NOrZ tj
Expiration Date~~ ,
w~o the following types of work:
underground _____P.C. concrete _____A.C. paving _____electrical
other (specify)
f:PERMINFO
REV. 8/88
(
...
SEP 28 '88 15:43 FL~MER COMP~NIES
P.2/2
oj
.
POLICY NUMBER:
PSP 107924
COMMERCIAL GENERAL LlAIIUTY
THIIINDORSIMENT CHANGIS THE POLICY. PLIASE RIAD IT CAREFULL v.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS (FORM B)
ThiS endorMment modifies in,url"ce prO'Wldtd under thl ronowln,:
COMMERCIAL GENERAL LIABILIty COVI,RAGE PAAT, '
ICMlDULI
N.IM of ",,,Oft or Or..n'nt\Oftt
- I .... , ,. ..............- ~- _........ ,,- --- ....' --- '" . -
~-.- .... ,....-..
~'.........- .....-~
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Chy of ClmDbeIJ anti It. respective offj~.rsf aRentS and employee.
(It no .ntr~ appear. .bov...."tormatior. required to comptete thl' tndo....."tftt wm b:.t .,",own In thl Decl.r.tlon,
.. ap~"ca~l. to th,s tndOr"Mttlt.) . ,
WHO IS AN INSURED (Section II) IS .",ended to ,.,elude II II' Insured the ptrtOft or o,.,,..I,.\lOft thow" In tht
Schedule. but only with respect to liability .rlslnl out of "your wo,"" for thlt "'lurid by or for you.
The City 0' ea~n and It I ,espec:tl\ie officers, ..eftt' and employees
ar. named II Iddi t lanai Insureds from Ind 'A&lnst any clalml. 10011lablllty,
cost Of expense .rlllnl out of or In any way connecled with th. con.tructlon
of the project. This ~aA. .hall _ primary a,.d .'W ccw.r... carried
by ,ddl,lonall"lurlld nit be excess IMUraftCl only.
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