88-273
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TO: City Clerk
PUBLIC WORKS FILE NO. ~~-4-"~
:t Vl.:
($ 50)
'( 500)
(4% of FPB)
($500 min.)
(7'1., of FPB)
($ 35 min.)
Other Cash Depos i t (spec i fy) tu .L\EU ala. ~t1t.H"'U'-
Peb-\-Ob-~ u~ I?:.c"-.:. l:.:)
Project Plans & Specifications ($10)
General Conditions, Standard Provisions &
Details ($10 or $I/page)
"No Parking" signs ($I/ea. or $25/100
Work Area Traffic Control Handbook (S5)
Traffic Flow Hap (SIO)
Traffic Data Services $ O/hr. + material
Ma Revisions to Map Companies $10
Co ies of En ineerin Maps & Plans
Fire Hydrant Maintenance ~195/ea.
Please collect & receipt
for the following monies:
ACCT.
----
35-3396
3372
3521
3521
(specify project)
PeJLm,u Fe.u:
R-l :
($35)
(Cash) Depos i t
($200)
3372
Plan Check & Inspection Fee
f\ 3521
b)
J373
3373
3372 Tentative Parcel Map Fil ing Fee ($350)
3372 Final Parcel Map Fil ing Fee ($300)
3372 Tentative Tract Map Filing Fee ($400)
3372 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 Spl it ($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-I ieu Fee per Unit ($1,132)
3380 Publ ic Works Special Projects
3510 Postage
TOTAL
NAME
ADDRESS
PHONE
AMOUIJT
$
1;. "",::>G( Cl C!> . ~
$~q d!;J. 60
ZIP
FOR
C I TV CLERK
OlLY
(~Jee<)
RECEIPT NO.
~ () 8g 9
39 u(j
/
~.
. /:L ~$
'C~
~ PAID
RECE 'VED BY
DATE' I;;l.
July, 1987
TO: City Clerk
PUBLIC WORKS FILE NO. ~ce.,.-~..,~
Please collect & receipt
for the following monies:
ACCT.
-_.-
35-)396
3372
3521
3521
project )
p~'U~,{;t e~:
R-7 :
(S'35)
(S200)
:t. VL:
($ 50)
~ 500)
(4% of FPB)
($500 min.)
(7'70 of FPB)
($ 35 min.)
(Cash) Depos it
~13372
3521
Plan Check & Inspection Fee
Other Cash Deposit (specify)
1373
3373
Project
Gene ra I
&
3372 Tentative Parcel Map Fil ing Fee ($350)
3372 Final Parcel Map Fil ing Fee ($300)
3372 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 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-I ieu Fee per Unit ($1,132)
3380 Public Works Special Projects
3510 Postage
TOTAL
NAME
PHONE
AMOUNT
$
1t.cse:.c>, c::'O
c:;I. ""2..,~. CJo 0
$ (''l~r60
ADDRESS
ZIP
FOR
C I TV CLERK
ClNLY
RECEIPT NO. ::2-0 <g gCj (f---l-a'JlLd ,e~c )
-'
AMC)lWolT PA I D 7 7 :3. .-r:s
RECE I VED BY <:74-
DATE/:2 'l:;2- 22
July, 1987
City of Campbell
Department of Public Works
~ Applicant section complete
ENCROACHMENT PERMIT ISSUANCE CHECK LIST
Encroachment Permit No. g g -;2 Zi.
..
E-<
H
ciii
Ztil
HA.
~cx:
_0
et:~
25 v/ Plan check deposit, $500.00 (waived for R-I Homeowner),
Q ~ paid. Receipt number / j' / ::<..
~16 .
~j1-------~::~:_::::_:~-~:~:::~:_~~:~:_:~~::::~-----_..---..----.-
V Applicant signature and date
,,/ Permit Application fee $50.00 ($35.00 for R-l Homeowner),
paid. Receipt number /1 /;J.
Bond for faithful performance, lOOt of City Engineer's
estimate, (waived for R-l Homeowner), supplied or paid.
Amount $ ~qC'6 f-i'::J Form 1. D. #
Cash Deposit: 4' of FP bond, $500 min. ($200 for R-l
Homeowner), paid.
Amount $ ~ .60 Receipt No.
Plan Check & Inspection fee of 7' of FP bond, $35.00 min.,
(waived for R-l Homeowner) paid.
Amount $ -z...:1~. c:>L:!leceipt 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.
-----------------------------------.---------------------------------------
E-<
~H
J~
~ til
:>A.
f}
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~~
~ 0
)~
..
U
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~ ai
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~Vorker's comp and Contractor's Information received for
Contractor (see Information Sheet for Encroachment Permits)
v' 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 Publie Works Permit number and property
address on plans)
Permit signed for City Engineer
WEN AU. 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 CAlCPIEU., CITY IMCIIIED' I CDlfmUCT101l COST UTIKATE
AMr... ~ -c:.. <<:::;;... ?.;... L c::.. ~ \;,-..\
,url.e. ee~.~rue~te~
'.ralt IID.'C'&--'l..-\'~
(,,~~
by_....te \""2....q-~~
Clurbl& . Cr\Ibbill& I.IaIp 1_ latiaate - I
I8IfCWt C4mcrlt. "S.D u, I ".00 - . .....1.,..()C)-
c:.r.c...te Ieaoval ~e. IFf S.OO - . \C>~O -
~ . Outtu Ieaoval 1.-0 U, 5.00 - . \00-
IDIot l>ra11l with Pipe lA' 600.00 . .
Ourb . Cu~ter ,-n !.Ff 14.00 - . ~~o-
'ldewalk 4<:>0 IF , '.00 - . \ ~ctlO-
I>rl_.' Appro.ch IF' 5.50 . I
lIaNlic.p ...., .., 4ClCl.00 - .
IanuAa' ~ u, '.50 - .
..nlca.... U, SO.OO - .
'UMt ..~.tl_ ,- .F)a(.0.10)al.....) - .
"'t~ 1- If)aClO.JO)al.....) - .
"jut IItIIlhol. te ClI'elIa .., S15.00 - .
".1 \18 t 1IaNIho1e te Grella IAt 275.00 - .
-'-lIt loa wIN-lit lA' 100.00 - .
'ttee~ Tr.. (U...11_) lA, SOO .00 . .
'~t .crt,lll& (1100 8111) ut 0.65 - .
'_lIt .......... (1100 81n) lA' 40.00 . .
I~, Itnet __ or Other 111'\ lA' 120.00 - .
'_nt ..run lA' 15.00 - .
'~t a.e, CY~ !.F' 10.00 - .
- .
. .
lur'fac. "coul ... . .~'1..~-
"jlln I. ala.: ".CSSO,OOO ... 20\, ".>1100,000 _uact lOt (. . .J . CD~-
.rr..t: U.ttt:lft.
a..cuIUer
1t.I., 2,000.00
u , 10.00
u , 2.00
.. , 200.00
....It
~cor, pall'
Nl loa
.~III~ lM>.t.....
12- .. 15. ICP
11. . l1e ICP
u,
u,
60.00
70.00
'Cl'Mt Ialec
14' 1,100.00
1t.I.' 2,400.00
It.I. , 'SO.OO
.....11
..... . Ilacor .....1.
- .
- .
. .
- .
- .
- .
.
. .
- .
- .
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.'_._t-..t
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~ :Dahg- Idl;)/:.~~S
r
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' 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
Note that all contractors must have current City of Campbell Business
License, State Contractor's Licens~~nd Workers' Compensation Insurance.
Name of Contractor ~ (:~~ Telephone 557-t)Zt:TO
Address O"~/ ~_ _'-_'
State Contractor License No. 3081//3 City Business License No./-ff/W7Z,-L
Expiration Date
Will do the following types of work:
underground ~.C. concrete
_____A.C. paving _____electrical
.
other (specify)
f:PERMINFO
REV. 8/88
1Ate //~1
,
PUBLIC WORKS INSPECTION REPORT
Permit or Project No. . g~ -273
Address .~9ZS. s. ~.5lo~
Type of work; Street Storm SAni tAry
Other (describe) ;:1.~. C. uJo.e-;~
Electrical
o PRELIHINARl INSPECTION WITH DEFICIENCY LIST (attAChed)
[JFINAL INSPECTION WITH DEFICIENCY LIST (AttaChed)
~AL INSPECTION - ACCEPTANCE
Signed plans? Y ~ (If signed, Council AcceptAnce.)
Charges Against deposit? y
Overtime a brs. @ $
Date , reason;
@
/hr.
-
$
Barricade rental (attach invoice)? y
Date , reasona
@
$
Other?
$
$
Total charges deducted from deposita
(Cash Deposit $ leas charges $
$
- Refund $
o ONE YEAR MAINTENANCE WITH DEFICIENCY LIST (attached)
o ONE YEAR MAINTENANCE - ACCEPTANCE
(Releaae'maintenance bond. Check Request if cash.)
ck. req.)
Engineer
~
Inspector
REFUNDABLE DEPOSIT
CHECK REQUEST
TO: FINANCE DIRECTOR
CITY OF CAMPBELL
Please issue check payable to:
Tom Dodge Builders
Address:
Line 1:
851 McGlincey Lane
(30 spaces)
(30 spaces)
Line 2:
(30
spaces)
95008
(10 spaces)
City :
Campbell
(20 spaces)
State: CA Zip:
l2}
Description:
Cash Deposit Refund
(24 spaces)
Exact Amount Payable:
$9J,5.00
Account Number:
905.4662
PURPOSE:
Release of cash deposit for excavation permit #88-273.
See receipt #1825 dated 12/12/88.
Requested by:
-Approved by:
Verified by:
~ ~aton
D . c. W iJ!nb e r 1 y
Title: P. W. Inspector
Date:
1/8/90
Title: P. w. Director
Date:
Accounts Receivable
Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as is
x
Mail in attached envelope
Return to:
(Department)
(Name)
Other:
08/24/88
~{~'-~~,Jl--
(Y\,Y. ~~LC
REFUNDABLE DEPOSIT
CHECK REQUEST
TO: . FINANCE DIRECTOR
CITY OF CAMPBELL
!
Please issue ch~ck payable to:
Torn Dodge Builders
851 McGlincey Ln.
(30 spaces)
(30 spaces)
(30 spaces)
State: CA Zip: 95008
(2) (10 spaces) .
(24 spaces)
Address:
Line 1:
Line 2:
City :
Campbell
(20 spaces)
Description:
Cash Deposit Refund
Exact Amount Payable:
$500.00
Account Number:
001.00.905.0000.4662
PURPOSE:
Release of cash deposit for Excavation Permit No. 88-273.j
See receipt #20889 dated 12/12/88.
Reques~ed by.
Approved b
Verified by:
Title: P. W. Inspector
Date: 1/13/89
Don Wimberly
P.W. Director
Date: 1/13/89
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 ~",,\KS FILE NO. ~~--:z.,~
Please collect & receipt
for the following monies:
ACCT.
:5-) -6
3372
3521
) 3521
)}3372
3521
3373
3373
R-1 :
$'35)
Depos it
($200)
Plan Check & Inspection Fee
Other Cash Deposit (specify)
&
3372
3372
3372
3372
3372
3372
3372
3372
3370 Multi-Res.,
TOTAL
\ME
PHONE
AHOUUT
$
ctt.'-s~. oc:::>
<;It 4-'~. GO
$ ,-,~~oc::>
ZIP
lORESS
FCR
C I TV CLERK
~y
RECEIPT NO. ~o <g~? (Ho/Ji d R~c)
ANCI..M' PAID '7? 1. ~
RECE I VED IJY . 'Zf
DATE' /z -;::;1.- -;!i g
July, 1967
'.};i,"{~~~;~"., '~'~_,"',:<~~>,,~,_.:_,_."''' _" --J;
'~J;;"i:"'~l: 4'.- I~'H~:.J. ". \"
>'~'*':;~ '--:,:'....r..). ~"'{1.;>,-,.:'::;~,> ;;~ ,,,
:~' 'NTERIM CHECK
~~\ .
'.
,'li-'"
REQUESTEP
. " -",,;,"~'~~ . ),"~
'ItEFUNDABLE DEPOSIT
: PHECK REQUEST
'''i' "
1:
~' >~~:~;'::> \./' ;
951 MCGLINcEY LN.
'.f~ :. ,~.."
I: ~;">""\
~;~.. ..:~:~'~.,:~'~::;-
" '
. -"""';';':~~' ">>"'~7': .... /'~, :C,':';;>; ...,...;~~j~"
" CAMPBELl. "
~' . i~20 spaces)
';'~~l::-;.~: ~"i:~<:'-_:'~:',;_:':~'} ;'--;,~';> "',,~, ;"
CASH DEPOSIT REFUND
.J-'-'
~:.~' :~":~
','
, .
~~;~;:~:f~
DEPOSIT FOR EXCAVATION PERMIT NO. 88-273~ SEE RECEIPT
,:~'-,', ,lI.'~'- j "';.,rr:. ~
$3;;475. 00 .,.~ Y;f1f\~t:~~,1.:~l :.' i':>T
b,;, . ,.",.'
"001.00.905.0000.466'2 />
'(24 spaces)
, '~'~",r,:~
'" ;~'
~ <,:~',';.":~.;',-' :;~':.'--/~'
^. > ";~" :,'d,; ;
3900.00 LESS
,--;., ...c, _, ';' ~_:~;.~~,-"
-r - "':
975.00 FOR 1 YEAR MAINT: BOND
';)- ",;",
AIm'RECEIPT
DEPOSIT)
- ",
'/.}: :~i".;:,;; ;'~ ',"t,J./;"?,:. f;' ....;i . J~ ',>- ,/ '
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,..,. .. 'i..' ;1
~ i. ~~/ ' '''. -:;;" ../ ~ '."'.-','-..-;,;,: ,;';'.. ~ J ~ "
'1" '.
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Requested b~: ; G E N ~ ,j
by r1-
, , " '",.
Veriftedby: '.', .. "" .. ."",.'Y',:f't.'
~ i.'
~., ~ d ~i:;~~:\.~'/f~~:.'~, '
Title: p rW~ INSPE~ """Date; >:2/6/89
_ ;<-- ,.:t. { ''',..J'
Title:' ~.w .DIRECT6l:t''',.!
,j,
,.1;' ~
Return to:
. -~~~~r~~ ~~~;~-
li ". ~.
'.~-~_~j:;i~'
>~' ,-
,... ~-;J: ....
L
"~'
SPECIAL INSTRUCTIONS FORBANDLING CHECK:
i
\
,
~:~~;~':ttiN~;;~;r ~"
'X
~~i~\;'\
, (Department)
0," '..\Jli;,c,':/,
V'.f ,'"
,~ ",~
WOULD I:.IItE. CHECK al2/~/89
~:~:, .~,
, .'
. ~ "I., ,:. .
~:~~,_' ~.~: (' ., < d~:' ~\ >,,;'
';::~'.'\~...~,~,..,.'~..' .... .,.. l,
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REFUNDABLE DEPOSIT
CHECK REQUEST
TO: FINANCE DIRECTOR
CITY OF CAMPBELL
Please issue ch~ck payable to:
Tom Dodge Builders
851 McGlincey Ln.
(30 spaces)
(3() spaces)
(30 spaces)
State: CA Zip: 95008
(2) (10 spaces)
(24 spaces)
Address:
Line 1:
Line 2:
City :
Campbell
(20 spaces)
Description:
Cash Deposit Refund
Exact Amount Payable:
Account Number:
$500.00
001.00.905.0000.4662
PURPOSE:
Release of cash deposit for Excavation Permit No. 88-273.
See receipt #20889 dated 12/12/88.
Requested by:
Approved by:
Verified by:
Gregg Eaton
Title: P. W . Inspector
Date: 1/13/89
Don Wimberly
Title: P.W. Director
Date: 1/13/89
Accounts Receivable
Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail . as is
x
Mail in attached envelope
. Return to:
(Department)
(Name)
Other:
08/24/88
....,._-~.._--..-..._...___..~-.....~..__.lt.....__...._.""---',,,.._.....-..-.,.........."'.........____ "_~~~. ~
CITY OF CAMPBEll
70 NORTH FIRST
CAMPBELL, CALIFORNIA
(408) 866-2100
STREET
95008
Public Works
Department:
January 11, 1989
Tom Dodge Builders
851 McGlincey Ln.
Campbell, CA 95008
RE: Final Inspection and Acceptance
Permit No.: 88-273
Location: 3925 S. Bascom Ave.
Maintenance Bond Amount: $975.00
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
975t?()
PUBLIC WORKS INSPECTION REPORT
Date /44q Permit or Project No. ,g~ -27.3
, ...
Address ~~9ZS S. ~Sc.o~
Type of work: Street Storm Sanitary
Other (describe) fJ. C. C. uJo~{.,
[JPRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached)
Electrical
[J FINAL INSPECTION
~AL INSPECTION
Signed plansi?
WITH DEFICIENCY LIST (attached)
- ACCEPTANCE
Y ~ (If signed, Council acceptance.)
Charges against deposit? y
Overtime I hra. @ $
Date 5 reason:
(E)
/hr.
-
$
Barricade rental (attach invoice)? Y
Date 5 reason:
cv
$
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
~
Inspector
TO: City C Ie rk
PUBLI C WORKS FILE NO. f P ---.:-2 "7.3
Please collect & receipt
for the following monies:
ACCT.
--~---
35-3396
3372
3521
3521
project)
PeJu'1-U reM:
R-l :
($35)
($200)
:t elL:
($ 50)
'( 500)
(4% of FPB)
($500 min.)
(?'Iu of FPB)
($ 35 min.)
(Cash) Depos it
3372
Plan Check & Inspection Fee
3521 Other Cash Deposit (specify)
l373
3373
Project
General
&
3372 Tentative Parcel Map Fil ing Fee ($350)
3372 Final Parcel Map Fil in Fee ($300)
3372 Tentative Tract Map Fil ing Fee $ 00
)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-I ieu Fee per Unit ($1,132)
3380 Publ ic Works Special Projects
3510 Postage
TOTAL
NAME
--/f/))
PHONE
(L. t'-, (', t.'
"'../( ....) /'-.
/Jt. ( I L Of.: / )'J
AMourn
$
5" c: , CJ ()
~-<;uc ,C'C
ADDRESS
7.5/
j ).), (~LII~ (' eLl I /v
.
ZIP
~-.jC: c ,;.
.:')..:.'; - '/ - L~ ~) (' (
$
5 S- 03-E-
(i/) In I.
FOR
C I TV CLERK
QIlLY
RECEIPT NO.
AMOUNT PAID
RECE IVED BY
DATE'
July, 1987
f
"\
CITY OF CAMPBELL
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
Public Works
W,M8ERlYtf- n..--.: H:__. DUNG f. I
~~.. _~ .... .:,.l__tjl
!'\ ( .~ ;- I" ~
t::~:::~_.... 'd".! __.
KRI'~'-" . i
,> l';:l "; : I
.-..-... ,-....-..... -r-"1
PENOYEH i : .. i
__L ____",,____...L.._I
Department:
January 8, 1990
To~ Dodge Builders
851 McG1incey Ln.
Campbell, CA 95008
RE: One Year Maintenance Acceptance
Permit No.: 88-273
Location: 3925 S. Bascom Ave.
We have made a one year maintenance inspection of subject public
works improvements and find that no maintenance is required.
Your cash deposit refund of $975.00 will follow under separate cover.
Sincerely,
Carlos M. Jocson
Associate Civil Engineer
CMJ : sd
cc: G. Eaton
~
PUBLIC WORKS INSPECTION REPORT
Date /..p?o Permit or Project No.
Address ~?;?S' 5. d.45c..c- 4v.e:;-,
'88 -2-7 3
Type of work: Street StoXlD
Other (describe)
SanitAry
Electrical
(JPRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached)
(J FINAL INSPECTION WITH DEFICIENCY LIST (attached)
o FINAL INSPECTION - ACCEPTANCE
Signed plans? Y N (If signed, Council acceptAnce.)
Charges against deposit? Y
Overtime: brs. @ $
Date ~ re~lI.on:
N
/hr.
-
$
BArricade rentAl (attach invoice)?
Date ~ reason:
Y
N
$
Other?
$
$
Total chArges deducted from deposit:
(CAsh Deposit $ less charges $
$
- RefWld $
[JONE YEAR MAINTENANCE WITH DEFICIENCY LIST (attached)
~~ MAINTENANCE - ACCEPTANCE
(ReleAse'maintenance bond. Check Request if CAsh.)
,
7n~
I~r
/.~~
ck. req.)
At~t.III." CERTIRCATE OF INSURANCE
ISSUE DATE (MM/DDIYY)
I
PRODUCER
COMPRO Insurance Services
P.o. Box 611090
San Jose, CA 95161-1090
(408) 236-3000
12-8-88
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,
EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
COMPANIES AFFORDING COVERAGE
CODE
~~~~NY A
Continental Insurance Company
SUB-CODE
INSURED
~~~NY B
Thomas R. Dodge
Tom Dodge Builders
851 McGlincey Avenue
Campbell, CA 95008
~~~~NY C
~~~NY D
~~~~NY E
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION ALL LIMITS IN THOUSANDS
LTR DATE (MM/DDIYY) DATE (MM/DDIYY)
GENERAL LIABILITY GENERAL AGGREGATE $ 500
X COMMERCIAL GENERAL LIABILITY PRODUCTS.COMP/OPS AGGREGATE $ 500
A
CLAIMS MADE X OCCUR. PERSONAL & ADVERTISING INJURY $ 500
X OWNER'S & CONTRACTOR'S PROTo CLP5072431 1/1/88 1/1/89 * EACH OCCURRENCE $ 500
FIRE DAMAGE (Anyone fire) $ 50
MEDICAL EXPENSE (Anyone person) $ 5
AUTOMOBILE LIABILITY COMBINED
SINGLE $ 500
X ANY AUTO LIMIT
ALL OWNED AUTOS CLP5072431 1/1/88 1/1/89 * BODILY
INJURY $
A SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY
INJURY $
NON-OWNED AUTOS (Per accident)
GARAGE LIABILITY PROPERTY
DAMAGE $
EXCESS LIABILITY EACH AGGREGATE
OCCURRENCE
$ $
OTHER THAN UMBRELLA FORM
STATUTORY
WORKER'S COMPENSATION
$ 100 (EACH ACCIDENT)
A AND 93W838986288A 1/1/88 1/1/89 *
$ 500 (DISEASE-POLICY LIMIT)
EMPLOYERS' LIABILITY
$ 100 (DISEASE-EACH EMPLOYEE
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/RESTRICTIONS/SPECIAL ITEMS
* Renewal policies being processed for 1-1-89 to 1-1-90 policy term. Updates to be mailed.
All California Operations as respects work being done at 3925 So. Bascom Ave., Campbell, Cl
CERTIFICATE HOLDER
The City of Campbell
(Per Attached Document)
CANCELLATION
ACORD 25-S (3/88)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL -JG-- DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUT"D REPRESENTATIVE /~( /'
U71/lIj~ ~. t...c..>--=...S:onnie Flores
@ACORD CORPORATION 1988