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CITY OF CAMPI1ELl
70 NORTH FIRST STREET
C AMP BEL L, C A L I FOR N I A 9 5 0 0 8
(408) 866-2100
FAX # (408) 379-2572
Department:
March 9, 1990
J.H. Steffenson
1049 Dell Ave.
Campbell, CA 95008
Permit No.: 88-265
Location: 195 Sunnyoaks Ave.
Dear Mr. Steffenson:
We have made a one year maintenance inspection of subject public
works improvements and find that no maintenance is required.
By copy of this letter, we hereby release your maintenance bond.
Sincerely,
Carlos M. Jocson
A$sociate Civil Engineer
CMJ : sd
cc: Bond Co.
G. Eaton
/vrr1~t'1d
Date 'J~6~ Permit or Project No.
Address .?~5 _~~~"'047?-5
PUBLIC WORKS INSPECTION REPORT
1?:IJ -,U~
Type of work: Street Storm
Other (describe)
Sanitary Electrical
/?~/;~...,.~ ~~
[JPRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached)
[]FINAL INSPECTION WITH DEFICIENCY LIST (attached)
o FINAL INSPECTION - ACCEPTANCE
Signed plans? Y N (If signed. Council acceptance.)
Charges against deposit? y
Overtime: hrs. @ $
Date Ii reason:
N
/hr.
-
$
Barricade rental (attach invoice)? y N
Date Ii reason: $
Other? $
$
Total charges deducted from deposita $
(Cash Depo5it $ less charges $ - Refund $ ck. req.)
[JONE YEAR MAINTENANCE WITH DEFICIENCY LIST (attached)
~YEAR MAINTENANCE - ACCEPTANCE
(Release'maintenance bond. Check Request if CAsh.)
C- /~
~ineer
~
Inspector
r-
CITY OF CAMPBEll
70 NORTH FIRST STREET
CAMPBELL, CALIFORNIA 95008
(408) 866-2100
Department:
Public Works
February 28, 1989
J. H. Steffenson
1049 Dell Ave.
Campbell, CA 95008
RE: Final Inspection and Acceptance
Permit No.: 88-265
Location: 195 Sunnyoaks Ave.
Maintenance Bond Amount: $750.00
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
requi~ement 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, a maintenance bond in the amount indicated above is
required. We will be refunding the $500.00 Plan Check Deposit, $500.00
Cash Deposit and 75% of the $3,000.00 Faithful Performance Bond
($2,250.00) under a separate cover and we will retain 25% ($750.00) to
cover the maintenance bond.
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,
.
C:::Z~
Associate Civil Engineer
CMJ : sd
cc: G. Eaton, P.W. Inspector
Suspense - 1 year
PUBLIC WORKS INSPECTION REPORT
Date Zyh~tt
Address /1 S
Permit or Project No.
'~-u~
E~ .~tJj~,q-ICr5
~pe of work: Street Storm
Other (describe)
Sanitary Electrical
1'. c.. . c:... t-VO,a.I C-
o PRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached)
o FINAL INSPECTION WITH DEFICIENCY LIST (attached)
~AL INSPECTION - ACCEPT~~
Signed plans?_ Y ~(If signed, Council acceptance.)
Charges against deposit? y
OVertime: hrs. @ $
Date , reason:
~
-
$
Barricade rental (attach invoice)?
Date , reason:
C9
$
y
Other?
$
$
Total charges deducted from deposit:
(Cash Deposit $ less charges $
$
- Refund $
ck. req.)
DONE YEAR MAINTENANCE WITH DEFICIENCY LIST (attached)
o ONE YEAR MAINTENANCE - ACCEPTANCE
(Release'maintenance bond. Check Request if cash.)
~~~
1(L~
760~
REFUNDABLE DEPOSIT
CHECK REQUEST
TO: FINANCE DIRECTOR
CITY OF CAMPBELL
Please issue check payable to: J. H. Steffenson
(30 spaces)
(30 spaces)
(30 spaces)
State: CA Zip: 95008
(2) (10 spaces)
(24 spaces)
Address:
Line 1: 1049 Dell Ave.
Line 2:
City: Campbell
(20 spaces)
Description: Cash denosi t refund
Exact Amount Payable: $ 750.00
Account Number: 905.4662
PURPOSE:
Release of cash deposit for excavation permit 88-265. See receipt
no. 1351 on the date of 11/16/88.
Requested by:
Gregg Eaton
Title: P. W. Inspector
Date:
Approved by:
Donald C. Wimberly
Title: P. \v. Director
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 C I e rk
~s-
PUBLIC WORKS FILE No.6cf- 2
Please collect & receipt
for the following monies:
Depos it
R-l :
(S'35)
3372
3521
@)
e1)
3373
3373
Plan Check & Inspection Fee
Other Cash Deposit (specify)
3372
3372
3372
)372
3372
3372
3372
3372
3370 Multi-Res.,
J395 Unit ($1,132)
3380 Public Works Special Projects
3510 Postage
AMOUNT
$
3Cl()O r--
2-10
~() 0
$ ~ 7 /0 -
]J 79'S-"2- Y )-----
9 ..roo ~
TOTAL
NAME .:J /1 fie f-.l-e",s(J~ 7~ g ~ ~
ADDRESS / tl Y 9' ~ ~ ~ ZIP
FOR
C I TV CLERK
ClNL Y
RECEIPT NO.
AtoIOU'lT PAID
1'3s1
311! 0 61)
'p /
I ~ 1(P/~ <{
RECE I VED BY
DATE
July, 1987
REFUNDABLE DEPOSIT
CHECK REQUEST
TO: FINANCE DIRECTOR
CITY OF CAMPBELL
Please issue check payable to:
J. H. Steffenson
(30 spaces)
Address:
Line 1:
1049 Dell Ave.
(30 spaces)
(30 spaces)
State: CA Zip: 95008
(2) (10 spaces)
(24 spaces)
Line 2:
City :
Campbell
(20 spaces)
Description:
Cash Deposit Refund
Exact Amount Payable:
$3,250.00
Account Number:
001.00.905.0000.4662
Release of cash deposit for excavation permit no. #88-265, receipt
PURPOSE:
# 1292 dated 11/11/88 ($500); cash deposit receipt #1353 dated 11/16/88
($500); and 75% of faithful performance bond receipt #1351 dated 11/16/88
retaining 25% ($750.00) for the maintenance bond.
f
Requested by:
Approved by:
Verified by:
Carlos Jocson
Title: Assoc. Civil Engr. Date: 2/18/89
Don Wimberly
Title:
P.W. Director
Date:
Accounts Receivable
Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as is
xx
Mail in attached envelope
-
Return to:
(Department)
(Name)
Other:
08/24/88
TO: City Clerk
PUBLI C WORKS FI LE NO. ? 9' - c:;2 ~ 6-
Please collect & receipt
for the following monies:
(specif
R-l :
(S'35)
Depos it
3372 Plan Check & Inspection Fee
3521 Other Cash Deposit (specify)
3373
3373 &
3372 Tentative Parcel Map Filing Fee ($350)
3372 Final Parcel Map Filing Fee ($300)
3372 Tentative Tract Map Filing Fee ($~OO)
3372 Final Tract Ma Fil in Fee ($350)
3372 Lot Line Ad'ustment Fee/Certificate of Com 1 iance
3372 Vacation of Public 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)
~395 Park Dedication In-lieu Fee per Unit ($1,132)
3380 Public Works Special Projects
3510 Postage
TOTAL
NAME --.7';"l S'TE:FF l=AJ S () ^--)
ADDRESS I I> L/ 1 Dc'LL AvE '
AMourn
$
~,CJ 0
S-t)~. 00
$
SSC,CJO
PHONE
379-5';; 1L'.s
~ .:S2J CJ g.
{!n} 6 L
ZIP
,.at
C I TV CLERK
CINL y
RECEIPT NO.
I '2r 9 -Z-
'o,-F5so 0.9
O-ht
/ / -/1' R )(
ANO'-M' PAID
RECE f VED BY
DAn
July, 1987
ENCROACHMENT PERMIT ISSUANCE CHECK LIST
City of Campbell Encroachment Permit No. ~g',-z.-b:;:
Department of Public Works
V
Applicant section complete
E-o
....
~~
Zt.:l
....Ilo
~a:
_0
a:l>..
021
l>..0
....
CE-o
~15
....~~ V Five sets of improvement plans submitted
Ilo
~cu
~----------------------------------------------------------------------
~ond for faithful performance, lOOt of City Engineer's
estimate, (waived for R-I Homeowner), supplied or paid.
Amount $ Form I.D. #
~Applicant signature and date
V Permit Application fee $50,!:00 ($35.00 for R-I Homeowner), .
paid. Receipt number l.;l /' ;;J-'
~ Plan check deposit, $500.00 (waived for R-I Homeowner),
paid. Receipt number /:L 'j :t-
~ Cash Deposit: 4, of FP bond, $500 min. ($200 for R-I
Homeowner), paid. .
Amount $ Receipt No. /3 s-/
~ Plan Check & Inspection fee of 7' of FP bond, $35.00 min.,
(waived for R-I Homeowner) paid., ~
Amount $ Receipt No. /.J ~ I
~Worker's compensation information received for Applicant
(see Information Sheet for Encroachment Permits)
All other Public Works requiremenes listed in the
Conditions of Approval of the development.
~,
---------.-.---------------------------------------------------------------
E-o
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) 3:
...
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v/ Worker'. 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)
t/
Permit signed for City Engineer
WEN ALL OF THE ABOVE ITEMS ARE COMPLETE, PERMIT KAY BE ISSUED
Issuer: Initial and date and file with permit
UPON ISSUANCE, INITIATE CHECK REQUEST FOR PLAN CHECK DEPOSIT REFUND
8/88
permchklst
'" TYPE OF INSURANCE
POLICY EFFECTIVE
DATE (MMlOOIYY)
pOlIe EXPIRATION
OATE:,(MMlOOIYY)
"<'1
POLICY NUMBER.,,-
,GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
[!] OCCURRENCE
OWNER'S & CONTRACTORS PROTECTIVE
"
Renewal of
MP341342
~'~~
1j
101 J 5/88 I O,~1518 9
':A
~:'.,;~~.
.. '{
;'W..
N.:
';'~
!' ~,
".j...
.,",'
'.''''
',;>,-
;~;;~
OTHER THAN UMBRELLA FORM
WORKERS' COMPl:NSATlON
AND
EMPLOYERS' LIABILITY
'~
OTHER
, ',lj
.",~
\:'~
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/RESTRICTIONS/SPECIAL ITEMS
"":/\
holder is named as additional insured':~ith
Said insurance shall be primary. ~~
I
.,x,'i>:
CSL
BOOIL Y
INJURY
(PER PERSON) $
t BODILY
INJURY
tJc~oENn $
$
$
$
~,~i.. ~j-.,' I, . \.';,.:...' -::;;:~
/',.,>(EACH ACCIOENT};,,;;<~:.A.,
(DISEASE-POLICY LIMIT)
(DISEASE-EACH EMPLOYEE)
STATE
COMPENSATION
INSURANce
FUND
NOVEMBER 16,
P.O. BOX 807, SAN FRANCISCO, CA 94101-0807
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
1988 1049348
POLICY NUMBER: 1-1-89
CERTIFICATE EXPIRES:
88
I
CITY OF CAMPBELL
ATTN DON KING
75 N CENTRAL 'AVE
CAMPBELL
CA 95008
L
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California
Insurance Commissioner to the employer named below for the policy period indicated,
This policy is not subject to cancellation by the Fund except upon ten days' advance written notice to the employer,
We will also give you TEN days' advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the
policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with
respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policies
described herein is subject to all the terms, exclusions and conditions of such policies,
~~
PRESIDENT
EMPLOYER
I
RALPH W GILLIAN AND NICHOLAS SALAMIDE
. VALLEY CONCRETE & REDWOOD
2679 HOCKING WAY
SAN JOSE
CA 95124
L
SCI.F 10262 (REV. 10-86)
COPY FOR INSURED'S FILE
OLD 262A
CITY OF CAMPBEll
Permit No.
Applicant
fly -.;l t;, 5'
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~b\, ~ \ e~ e- t-l ~o <-.J ~-~ (\r, I i-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
.CJ "-.\ ~ \ Lg I N '-\OL"-~ o~~ f~<--
.~ A Certificatec~f Workers' Compensation Insurance
Insurance Co. ~~C<..-I ~ ~utJD
Policy No. I '62> 9, - Expiration date
S-/ <;(
; 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 ~.a-"/~I-" Date//-/v ,-f?;J-
(
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~,.~:f\ e~c\JSotJ-~~lYhI-I'CTelephone 3'10-S-;JY 5"
Address
State Contractor License No .<PR. D '39:, \;
City Business License No. j --D:2.-Y7';--L-
Expiration Date '?>J1J I / Z 9
. ,
Vi11 do the following types of work:
underground
P.C. concrete _____A.C. paving
electrical
other (specify)
f:PERMINFO
REV. 8/88
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