95-270
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C1'l'Y OP CAIIPBELL
DZPl'. OP PUBLIC 1IOJUtS
10 North Pirat St.
caapball, CA '5008
(408) 866-2150
k
~ 110. 10- a. 70
GIIIIBIl U\iUlr.uw a-l
.JO 1I'n DCROACIDmII'l' PmIIIft'
(for worlt1n9 vithin the
public rlpt-of-way) Z-"f. file
($3,500 _viif- va1~f work) "/-"'17 /.J~
J _ _ ~ ApplicaUoa Date / t:::::^- - '7 v
I..ued 0 '11
. 0/' Application apina 1D 3 _.
APPLICATION - Application 1. hereby ..d. for a Public WOrka Pezs1t: iD accordaftCle with CUlpbell
llunicipal COd., S.ction 11.04. (Application expina 1D 6 .cmtba if the puait 18 not 18.,*,)
A. Work addre.. ~9~ HARRJ:so4/ At---G. CAA1rBJ;LL .cA, 95(:;;.08-
8. Nature of work: AJ<:I/I"1,/ k~",- i~II,'n7' ').UQ"Y't~rr"
C. Attach thr.e (3) copie. of a draw1nq uov1nq the location, extent aDd daenaiona of the work.
'!'b. draving 8ball DOW the relation of the prapoHCl work to exiat:1D9 iIIp~. When
approved by the city Engineer, .aid dravin9 bec:oae. a part of thi. puait.
D. All work aIlall confora to the City'. General con41tiona, Standard conatnct:1on Prov1aiona aftd
Standard Conatruction Detail. for Public .orb Conatruction, fte GeDeral ..nit CDIlditiona
li.ted on the rever.e .ide, and Special Prov1a1ona for th1a puait, l1at:ed belovo I'ailure to
abide by th... conditiona and prov1aiona ..y reault 1D job Dut-dolm aDdIor forfeitare of
I'd thful "fforunce Surety. ...... f 6 4 - J.. 760
.... of Applicant rI. E. ftlepboaa~ '3 ?9-/~g8'
Addr...
Complete and attach Workera' Coapenaation aDd contractor
'1'he Applicant/Permittee bereby a91"". by affix1nq their .iqnat:ure to th1a penit to bold the City of
Campbell, ita officera, .genta and aploy... free, ..fe and banIl... fftIII any cla1a or deuDd for
damage. re.ulting frea the work covered by thi. pera1t.
'!'b. Applicant/Permitt.. h.reby acknowledg.. that they have read aftd underatand both the front aftd
."ack O~f thia permi~. and that they will infont their contractor(.) of the iDfonaation.
ACCEPTED~~~ //-c:l. 7- 9'S
./ pl t ( ~ e~ print/.ign Date
/ I?I?/~ b-/Y-j%.
NOTES: ALL WOIUt SHALL co~ WZ'l'B 'l'BE A'1"1'ACIIED, APPlW~ PLUfS AlII) ALL APPLICABLE CAIIPDLL
STANDARD DETAILS AND CONDITIONS.
THE CONTRACTOR MOST HAVE THIS PERKIT AND APPROVED PLUS AlII) JlUST AlUWlGE '1'0 IIDT 1II'1'B '1'BE ....
INSPECTOR AT THE SITE AT LEAST TWO DAYS BEPORE STAR'l'IlfG 1IORJt.
NOT.1CE JlUST BE GIVEN '1'0 PUBLIC 1IOJUtS AT LEAST 24 BOOItS IIEPORE l1ZSTARTIHG AIR WOlUt.
SPECIAL PROVIS~O~
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PLA=c; C;;;;JAI~usr:~ ~~ U~~~
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J 0;'1) $/~ .
1'.<1:)" 5JY:;.
SURE'l'Y lOR PAI'l'BPUL
APPROVED lOR ISstJANCZ
!I'l'AJIDARD
&IIamI'l'
D~ RO.
93~b3
6-/0- ~6
Date
100t ,. BIIG. ~.)
.. 100. 0 0
f: R1 PERMIT
..,,1aed 6/92
ina 6 .mt:ba after the date of ta---.
(DB emma 8mB)
Wt() rl<
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UJI.-hJ J n Su.rA-iLf!.L.., L::' ,~ 'p )tt.c..u ·
rncryacto rour (bns~. 725 ;; C1~ 5J
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To: Accounts Receivable
Please Issue Check
Payable to:
Address - Line 1:
Line 2:
City:
Description:
Amount Payable:
Account Number:
ate and Receipt No:
Permit No:
Purpose:
Ci~ _ )f Campbell - Chec~_ ReJIuest
Ronald E. Bristol
392 Harrison
Campbell
State: CA Zip: 9 5 0 0 8
REFUNDABLE DEPOSIT
$700.00
Finance Only:
INTEREST EARNED
101.2203
6/10/96 #93863
95-270
101.540.7448
Refund Faithful Performance Surety.
Requested by: Title: Public Works InspecDate: 4/28/9
Approved by: Title: City Enqineer D~:~
FINANCE ONLY:
Verified by: Title: Date: ,
I
Approved by: Title: Date:
Mail As Is:
Return To:
Other:
rev: 3/25/95
Special Instructions For Handling Check
xx
Mail in Attached Envelope:
(NAME)
(Department)
TO: City Clerk
PUBLIC WORKS DEPARTMENT RECEIPT
Effective July 1, 1995
PUBLIC WORKS FILE NO. 97 - d, 7 (j
312. /./Nw5u"J
PROPERTY ADDRESS
Please collect & receipt for the following monies:
ACCT. m:M
435.535.4921 Pro'ect Revenue (s
i ENCROACHMENT PERMIT
I 4722 Application Fee
, Non-Utility Encroachment Permit ($225)
I R-1 First Permit (No Fee), Subsequent Permit/Yr ($100)
Utility Encroachment Permit
'I Arterial/Collector Street
Residential Street/Other Areas
2203 Plan Check De os it
2203 Faithful Performance Suret (FPS)
2203 Monumentation Suret
2203 Cash De os it
2203 Labor and Material Suret
Plan Check & Inspection Fee (Non-Utility)
Engr.Est. < $250,000
Engr.Est. > $250,000
$100.000
Conduits/Pipelines up to 500 Feet
Above 500 Feet
Manholes/Vaults/Etc
AMUUNT
!$
($325)
($225)
($500)
(100% of ENGR.EST.)
(100% of ENGR.EST.)
(4% of FPS)($500 min.)
(100% of ENGR. EST.)
i
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700.0 C)
~
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4722
2203
4722 Utility <
(12% of ENGR. EST.)
(Deposit 15% of ENGR. EST.)"
r
4920
4966
TRAFFIC
4728
4728
4728
4728
4728
4271
4728
(Multi Res. $2.2 )
iAiI-6ther, $2,500)
Parkland Dedication Fee (75%/25% Due U on Cert. of Occu anc )
Posta e
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Pole Set/Removal ($105/ea)
Minimum Charge Per Location ($120)
Street Tree Plantinll/Removal ($105/tree)
.. 2203 Utilitv > $100 000 (Deoosit 15% IIf ENGR. EST.)"
4760 Proiect Plans & Snecifications Proiect No.
4760 Standard Soecificatillns & Details ($1/PII $12/Book)
4760 Copies of Enllineerinll Mans & Plans ($.50/sq.ft.)
4722 Penalties: Failure to restore oublic imorovements ($1 DO/Calendar Dav)
(Muni Code Section 11.34.010)
4722 Penalties: Failure to correct unsafe conditions ($100/Calendar Dav)
LAND DEVELOPMENT
4722 Lot Line Adiustment ($500)
4722 Parcel Mao (4 Lots or Less) ($1.060 + $25/Lotl
4722 Final Tract Man (5 or More Lotsl ($1 380 + $25/Lot)
4722 Certificate of Comoliance ($400)
4722 Certificate of Correction ($300)
4722 Vacation of Public Streets & Easements ($550)
4722 Assessment Segregation or Reapportionment
I First Split ($550)
I Each Additional Lot ($170)
472 Storm Drainage Area Fee Per Acre (R-1, $2,000)
- , 50
($1.60/ft.) (MIN. $105)
($1.10/ft.)
($105/ea)
I
OTHER
($60)
($125)
TOTAL
<10.l>o
6rJ fc.
NAME OF PAYOR
ADDRESS
mR
errY CLERK
ONLY
h:\recfrm3.wk3(mp)rev.1/9/96
RECEIVED
JUN 1 01996
CITY CLERK'S OFFICE'
...................................... ........................................................
.-................................... .......................................................
......................................................,
.....................................................
.....................................................
...... .l. .....1' l.i:~Ii,. .:..:tl~II#.:I..I:'=::A.
> .ft..... . .I!9Il"g'IJs.t1l
PRODUCER
....................................................................................................
...................................................................................................
..... ............................................................................................
................................................................................................
:1.11111'11111,
.........................................................................................
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................................................................................. ISSUEO~ (OMjwg
.........................................
................................................................................. ..... -f
............................ f 2
MULTI UNIT INSURANCE SERVICES
852 NORTHPORT DRIVE SUITE #5
WEST SACRAMENTO CA 95691
.. 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
MORADO FOUR CONSTRUCTION
725-C EAST JULIAN ST.
SAN JOSE CA 95112
COMPANY A
LETlER
COMPANY 8
LETlER
COMPANY C
LETlER
COMPANY D
LETlER
E
FIRST FINANCIAL INSURANCE COMPANY
INSURED
flECEJVE.D
JUN241996
'-
qDMINISTRATlON
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOlWlTHSTANDING 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.
GENERAL LIABILITY
10/18/9
LIMITS
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DAlE (MMIDDIYY)
9G411407
10/18/9
GENERAL AGGREGAlE
PRODUCTS-COMP/oP AGG.
PERSONAL & ADV. INJURY
EACH OCCURRENCE
FIRE DAMAGE (Anyone fire)
MED. EXPENSE (Anyone
COMBINED SINGLE
LIMIT
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE
OCCUR.
OWNER'S & CONTRACTOR'S PROT.
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
GARAGE LIABILITY
BODILY INJURY
(Per person)
BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
EACH OCCURRENCE
AGGREGAlE
AND
EMPLOYERS' LIABILITY
STATUTORY LIMITS
EACH ACCIDENT
DISEASE - POLICY LIMIT
DISEASE - EACH EMPLOYEE
WORKER'S COMPENSATION
OTHER
DESCRIPTION OF OPERATIONSlLOCATIONSlVEHICLESlSPECIAL ITEMS
THE ABOVE RISK PERFORMS INTERIOR TRIM INSTALLATION AND INSTALLS CUSTOM RAILING
AND HANDLES. THEY ALSO INSTALL MOLDING AND DOORS.
ADDITIONAL INSURED
CITY OF CAMPBELL
DEPT OF PULBLIC WORKS
70 NORTHFOLK RD.
CAMPBELL
. ...........................,.,...,....:.:......:...<<..))wcetLitior,f)i<<...................,...,............... ..... .
... ..........................................
. ....-.--- ... .----- ...
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL -=uL- 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.
.............................................................
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................................................
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..................................
. . . . . . .. .............. ..
c.~ij:ij"6Ati:H~!ii.ji)..
CA 95008
@jMiMVj;i~=''''::5cl11i
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..............................................................-----.......,
.......................9.... ..00.. ......RI)..........C...OR..... .p...OU........no.. .....N......1.18O... ... ........
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::::::::::::::::::::::.....:...:.......:.....:..:........:::::.....:.............:::...:.:............:..;...:.......:...::::;..:........:...::;:::::::
WORKERS' COMPENSATION INSURANCE INFORMATION
The following workers' compensation insurance information is required for all
Contractors and Subcontractors. One of the following items for each Contractor and
Subcontractor must be submitted prior to execution of a Public Works contract.
CONTRACTOR'S WORKERS' COMPENSATION INFORMATION:
Name of Contractor lBOf.~ ~ ~
o A Certificate of Consent to Self-Insure issued by the Director of Industrial Relations;
.oR
o A Certificate of Workers' Compensation Insurance
Insurance Co.
Policy No.
Expiration Date
;.QR
o A signed Certificate of Exemption from the Workers' Compensation laws as printed
below.
CERTIFICATE OF EXEMPTION
I certify that in the performance of the work for this contract, I shall not employ any
person in a manner so as to become subject to the Workers' Compensation Laws of
CalifOrnUL/]/
Signed . ~- / y- /C-
Title
NOTICE TO CONTRACfOR/SUBCONlRACfOR: 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 the Contract will
be cancelled
a:workcomp( contract doc:. disk)