97-137
CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First 51.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
ENCROACHMENT PERMIT
(for working within the
public right-of-way)
Issued 3/J.1 / 97 /)l~
Permit expires in 12 months r
'lPermit No. 97 -J ~ 1
~eI. file
Application Date j/d--I /77
Application expires in 6 months
APPUCA TION _ Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code. Section 11.04. (Application expires in 6 months
if the permit is not issued. Application Fee is non-refundable.)
A. Work address or tract # ::5 iJz 0 e . Ca rn phvll A V <-
Utility treneh location te.",-\v--", \ Av L
B. NatUre of worle '5.; d z.."\.JJCl. , K rt:.-w-. ;:, v a \ ~.,... "Se.r LI .' L..t:--. V {> '1 (a 6J_
C. Attach four (4) copies of an engineered plans showing the location and extent of the work, and four (4) copies of the preliminary Engineer's EstimaIC of worle. The
plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer, said plan becomes a pan of
this permit.
D. All worle shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions listed on the reverse
side; and the Special Provisions for this permit. listed below. Failure to abide by these conditions and provisions may result in job shut-down and/or forfeiture of Faithful
Performance Sureties and cash deposits. (See General Permit Conditions I and 2.)
E. THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AT THE SITE AND MUST NOTIFY THE PUBLIC WORKS DEPARTMENT AT
LEAST TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
NameofAPPlicanr--::J, ~SCA"",'- \ \ a, CoII.Jr. r.o, Telephone4re qL~.2..13~
':--.. (priq! name)
Address 3,-\1#8 \<.a~5~c\ Dr. -Ss. qs(L.\ 24 HOUR EMERGENCY TELEPHONENO.YO~ S2-\-S~S~f~
Is this worle being done by the property owner at their own residence?
Yes
K No
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell. its officers, agents and employees free, safe and harmless from
any claim or demand for damages resulting from the work covered by this permit.
The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the
"'''''''''''''. /J /J ~
Accepted ~
/ (Applicant/Permittee) (sign)
'S/2-1/97
. Date
SPECIAL PROVISIONS
Street shall not be open cut for underground installations. Minimum cuts !!!!y be allowed for connections or exploration hoIes. Such cuts mav be soecificallv
lIDoroved bv the Insoector orior to cutting.
Pavement may be Cut for underground installations and must be restored in accordance with theVtilityTrenchRestoratlonStandardDeIlIils, Method' A'Badcfill,
unless otherwise approved by Inspector.
Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public WorksDepanmcnt before starting work.
Per Section 4215 of the Government Code this permit is not valid for excavations until UndergroundServiceAlen(USA) has been notified and the inquiry
identiflcation number has been ~red hereon. USA Phone I~8QO.227~2600. USA TICKET N .
'& -0 tJ t"",)6- -;?1tkS7' rt4Z I 'M f.,
_1.
_2.
=f
Ls.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
:rng
AMOUNT
SXJ.5'.J
S':;>~-
S .~
S "-00.-/
S .JIG ~
3)11 7
RECEIP'I' NO.
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFO
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & INSPECTION F
/0(;757
/60'11:>(;.
APPROVED FOR ISSUANCE
1(jC) rfO
)6Q c;
City of Campbell - Refundable Depos..; Check Request
Interim Check Required:
To: Finance Director
Return Check to:
Please Issue Check
Payable to:
Address - Line 1:
Department:
Jay Escamilla Construction
Line 2:
3468 Ramstad Drive
City:
San Jose
State: CA
Zip: 95127 .
Finance Use Onlv
Description:
Refundable Deposit
Amount Payable:
$500.00
(Exact Amount)
Interest Earned
Account Number:
101.2203
101.540.7448
Purpose:
Refund faithful performance surety
Voucher #:
Permit #: 97-137
Date: 3/21/97
Title: Public Works Inspector Date: 04/10/98
Title: City Engineer Date: 04/10/98
Title: Account Clerk II Date:
Title: Date:
Requested by:
Receipt #:
Approved by:
Verified by:
Approved by:
Special Instructions For Handling Check
Mail As Is:
xx
Mail in Attached Envelope:
Other:
fln: S:/excel/chkreq - Revised 1/98
To: Accounts Receivable
Please Issue Check
Payable to:
Address - Line I:
Line 2:
City:
Description:
Amount Payable:
Account Number:
ate and Receipt No:
Permit No:
Purpose:
Requested by:
Cit )f Campbell - Che,-_. R~uest
Jay Escamilla Construction
14hR Ramstad Drive
S;:J n ,Tase
State: CA
Zip: 9 512 7
REFUNDABLE DEPOSIT
Finance Only.:
INTEREST EARNED
$2.000.00
101.2203
101.540.7448
3/21/97 #100759 & #100760
97-137
Refund of Cash Deposit and $1,500 of Faithful Performance
Surety.
Rahprt- Phi llips t/'-""?~
....
Title: Proiect Inspector Date: 4/4/97
Approved by: jI'
kChelle
FINANCE ONI.. V:
Verified by:
Approved by:
Mail As Is:
Return To:
(NAME)
Other:
rev: 3/25/95
(,2Ulnney
TItl~ City Engineer
Date:
Title:
Date:
Title:
Date:
Special Instructions For Handlillg Check
xx
Mail in Attached Envelope:
(Department)
'UBLlC WORKS DEPARTMENT RECEIPT
Effecti,'c July I, 1996
TO: City Cler\; PUBLIC WORKS FILE NO. 97 ~ ) 3 '7
PROPERTY ADDRESS 3~o 6.r.- D Kr-J Me
no. .".
ACer, ITEM .... ....
I .~.vv,' ............
43l.l3l.4921 Project Rcvenu~ (specify projcc:t) S
ENCROACHMENT PERMIT
4722 Application Fee
Non-Utility Encroachment Permit (S22l)
R-I First Permit (No Fee), Subsequent PennitiYr (StoO)
Utility Encroachment Pennit
Arterial/Collcc:tor Street (S32l)
Residential Street/Other Areas (S22l) :::J ~.'1
22113 Plan Check Deposit - 2% of ENGR. EST. (SllUlmin) .
( 22031) Faithful Performance Security (FPS) (IIUI\I.ofENGR.EST.) . c;J..O()u
22113 Labor and Materials Security (IIID';' ofENGR. EST.) .
V'~~ Monumentation Security (I()(~/.ofENGR.EST.) . "'Il" IX mu:::-
Cash Deposit (4%ofENGR.EST.)(S'OO minIS I lJ,OOO max) . '''){) 0 -
~ '" -- Plan Check & Inspection Fee (Non-Utility)
4722 Engr.Est. < S2'O,OOO (12\1. of ENGR. EST.)
.. 22113 Engr.Est.>S2'O,OOO (Deposit 8% of ENGR. EST.1S30.(H)() min.)" .
4722 Utility < SIOO.()()O
Minimum Charge Per Location (SI211) ;;L I /I ---'
ConduitslPipclines up to '00 Feet (SI.611/fi)
Above SOO Feet (SI.IO/fi.)
ManholesNaultsIEtc. (SlOl/04)
Pole ScllRemoval (SlOl/04)
Street Tree PlantinglRemoval (SlOlltrce)
.. 22113 Utility> SIUO.!"H) Actual Cost + 20-;' .. .
4722 Street Tree Planting/Removal Pennit (Sllll)
47611 Project Plans & Specifications Project No.
4760 Standanl Specifications & Details (SllPg S12lBook)
4760 Copies of Engineering Maps &: Plans (S.lll/'q.fi.)
4722 Penalties: Failure to restore public improvements (SIIXl/Calendar Day)
(Muni Code Section 11.34.010)
4722 Penalties: Failure to correct unsafe conditions (SIOn/Calendar Day)
LAND DEVELOPMENT
4722 Lot Line Adjustment (SSml)
4722 Parcel Map (4 Lots or Less) (SI.1l611 + S2llLo,)
4722 rmal Tract Map (S or More Lots) (S 1.3811 + S2SILot)
4722 Certificate of Compliance (Sl(KI)
4722 Certificate of COlTC(tion (S3(KI)
4722 Vacation of Public Streets &: Easements (Sllll)
4722 Assessment Segregation or Reapportionment
First Split (Sllll)
Each Additional Lot (SI711)
4721 Storm Drainage Area Fee Per Acre (R-I.S2.II(XI)
(Multi-Res. S2,2lll)
(All Other. S2.lIXl)
4920 Parkland Dedication Fee
4965 Postage
TRAFFIC
4728 Intersection Turn Counts (Two-Hour Count) (S60)
4728 Intersection Turn Counts (a.m. or p.m. peaks) (SI2l)
4728 Traffic Flow Map (Daily Traffic Volumes) (S27)
4728 Campbell Traffic Model (Full Scope Assessment) (S2.2l11)
4728 Campbell Traffic Model (Reduced Scope Assessment) (S7411)
4271 Truck Permits (S3l/lrip)
4728 No Parking Signs (SI/each or S2SIll}O)
OTHER
TOTAL S:{ q '3 ~ ~
NAME OF APPLICANT Lti 'Y ~5c4W1JLLA GAJ c;rfU-Aq1aN
NAME OF PA YOR JA"1 65 c...4 M J J.L4 GJ/V 5ff2 , PHONE qa~./ c;J-j-~7?y
ADDRESS 3 Ifb P /d:-ff1 S t-4JJ /Jr. 5'J ZIP 95'Jd /
.. Actual Cost Plus 2'''/0 Overhe::ld (Non-Interest bearing deposit)
J-- (r;,fUECIIGAi
f~ acd#
+~(""!J~ /
;W
J/;.lt/77
FOR
CITY CLERK
ONLY
Date
, ItCEIVED
HAR21_
GITV CLERK'S OFFICE
. For Pl.im ChecK.iJnd Cash Deposits, send yellow copy to Fmance;
h:\rccfrm4(cxc)mp(rev 1/2/97)
037F.ll CERTIFICATE 01<' Ii' ,RANCE.
35RBO - 33RR
Agent 2189
AFO 153
This is to certifY that:
State Fann Mutual Automobile Insurance Company , of Bloomington,
Illinois has coverage in force as shown below for the named insured. Ifthe coverage is changed or terminated we will give Ie
days written notice to:
CITY OF CAMPBELL, CITY OF
CAMPBELL REDEVELOPMENT AGENCV,
ITS
OFFICERS, EMP AND VOLUNTEERS
70 N 1ST ST
CAMPBELL CA 95008-1436
8}':
1f1. -4,'1:"
'//r s- ,f: ,Jt::-
l'l . ,t, ''''l,l'\ff...
.C\ <::IV, _0 (;:j~f'~':>.<f I/<
VLi U (~'> "~~
~"lJ\l . t~,! f'S- ul!b
VO ri/- '..1D '74
(<tOO \S'~ 1'(: If. ..AI ~c~
') B..ia:;.q ~ O~!Gl)t
"<O>a rs,<,>
Description of Vehicle: 1997
CHEVROLET
IGCEK14W8VZ180609
LIABILITY - COVERAGE A
Limits of Liability
Bodily Injury
each person each accident
Property Damage
each accident
Bodily Injury and Property Damage
Single Limit
$
$
$
$ 1000000
each accident
ro
~ This Certificate of Insurance does not change the coverage provided by the described policy.
m
o
tIl
~ Named Insured JAY ESCAMILLA CONSTRUCTION
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Effective Date AUG 29 1997
12:01 A.M. Standard TinIe
~~~~~SiJ.
t' \ c\~~ent
Countersigned ,~\S , I \
B~ \{ .~~/~m)
AUthO~epresentative
Policy Number V30 SOSS-C08-0SF
6037F.1l
~~.::liiil*;~<~II~~ii.'lirl~llf.dil..i"fii
::::i:ASTOCKCOMpAAYWfTHHOMSOFFICESiNBLOOMINGTONFhJUNOfS .....
ADDL I NTEREST COPY
NAMED INSURED AND MAILING ADDRESS
2602-F153
ESCAMILLA, JAY
DBA JAY ESCAMILLA CONSTRUCTION
3468 RAMSTAD DR
SAN JOSE CA 95127-4313
COV A -INFLATION COVERAGE INDEX: N/A
CONTRACTORS POLICY - SPECIAL FORM 3 COV B - CONSUMER PRICE INDEX: 158.3
Automatic Renewal - If the Policy Period IS shown as 12 months this policy will be renewed automatically subject
to the premiums, rules and forms in effect for each succeeding policy period. If this policy is terminated, we will
give you and the Mortgagee/Lienholder written notice in compliance with the policy provisions or as required by law.
POLICY PERIOD: 1 YEAR
EFFECTIVE DATE: 02/15/97
EXPIRATION DATE: 02/15/98
NAMED INSURED:
INDIVIDUAL
THE POLICY PERIOD BEGINS AND ENDS AT 12:01 AM
STANDARD TIME AT THE PREMISES LOCATION
LOCATION OF COVERED PREMISES:
3468 RAMSTAD DR
SAN JOSE CA 95127-4313
COVERAGES AND PROPERTY
SECTION I
A BUILDINGS-
B BUSINESS PERSONAL
PROPERTY -
LIMITS OF
INSURANCE
$ EXCLUDED
$ 11,200
SECTION II
L BUSINESS LIABILITY $
M MEDICAL PAYMENTS $
PRODUCTS-COMPLETED OPERATIONS $
(PCO) AGGREGATE
GENERALAGGREGATE(OTHERTHANPCO) $
1,000,000
5,000
2,000,000
2,000,000
DEDUCTIBLES - SECTION I
$ 250 BASIC
THE SECTION I DEDUCTIBLE WILL BE APPLIED
TO EACH OCCURRENCE AND WILL BE DEDUCTED
FROM THE AMOUNT OF LOSS. OTHER DEDUCTIBLES
MAY APPLY--REFER TO YOUR POLICY.
FORMS, OPTIONS, AND ENDORSEMENTS
SPECIAL FORM 3
AMENDATORY ENDORSEMENT
TREE DEBRIS REMOVAL
POLICY ENDORSEMENT
POLICY ENDORSEMENT CONTRACTORS
BLANK ENDORSEMENT
ADDITIONAL INSURED
LOSS OF INCOME ENDORSEMENT
INLAND MARINE SUPPLEMENTAL
DEDUCTIBLES - SECTION II
PROPERTY DAMAGE LIABILITY
$ 250 PER CLAIM
TOTAL ESTIMATED PREMIUM $
5,049.00
FP-6100
FE-6205
FE-6451
FE-6506.1
FE-6467
FE-7315.1
FE-6324
FE-6306.1
FE-4299.3
DISCOUNT(S) APPLIED
RENEWAL YEAR YEARS IN BUSINESS
Other Limits and Exclusions May Apply - Refer to Your Policy
PREPARED
03/10/97
FP-8051.1 C
(08/93) TH
COUNTE SI t\1ED
BY ENT
WILSON, SHIRLEY
408-736-5100
YOUR POLICY CONSISTS OF THIS PAGE, ANY ENDORSEMENTS
AND THE POLICY FORM. PLEASE KEEP THESE TOGETHER.
(F0115C) 555-7011.1 Rev. 12-91 Printed in U.S.A
CERTIFICATE OF INSURANCE
This certifies that [K] STATE FARM ~ AND CASUAL TV COMPANY, Bloomington, Illinois
D STATE FARM GENERAL INSURANCE COMPANY, Bloomington, Illinois
insures the following policyholder for the coverages indicated below:
ESCAMILLA, JAY (AN IND)
Name of policyholder (DBA) JAY ESCAMILLA CONSTRUCTION
2602-Fl53
Address of policyholder
3468 RAMSTAD DR
SAN JOSE CA 95l27-43l3
Location of operations
Description of operations
The policies listed below have been issued to the policyholder for the policy periods shown. The insurance described in these policies is subject to all the terms,
exclusions, and conditions of those policies. The limits of liability shown may have been reduced by any paid claims.
POLICY PERIOD
POLICY NUMBER TYPE OF INSURANCE Effective Date I Expiration Date
Comprehensive I
;-his'i~;~r~~~~ i~ci~de-s~ - D - . p~~d~~f!:e~~~~~~~~ 'OperaUons' . - - - . - - J - - - - - - - . - - . . . .
D Contractual Liability
~ Underground Hazard Coverage
Personal Injury
Advertising Injury
D Explosion Hazard Coverage
D Collapse Hazard Coverage
D General Aggregate Limit applies to each project
D
LIMITS OF LIABILITY
(at beginning of policy period)
BODILY INJURY AND
PROPERTY DAMAGE
Each Occurrence $
General Aggregate $
Products. Completed $
Operations Aggregate
EXCESS LIABILITY
D Umbrella
D Other
POLICY PERIOD
Effective Date Ex iration Date
BODILY INJURY AND PROPERTY DAMAGE
(Combined Single Limit)
97-GB-7l55-6
Workers' Compensation
and Employers Liability
Each Occurrence $
Aggregate $
Part 1 STATUTORY
lO/22/96 10/22/97 Part 2 BODILY INJURY
Each Accident $ l,OOO,OOO
Disease Each Employee $ l,OOO,OOO
Disease - Policy Limit $ l,OOO,OOO
POLICY NUMBER
TYPE OF INSURANCE
POLICY PERIOD
Effective Date Expiration Date
LIMITS OF LIABILITY
(at beginning of policy period)
PUBLIC WORKS
If any of the described policies are canceled before its
expiration date, StateZ{m ~ill try to mail a written notice to
the certificate holder [) days before cancellation. If
\
however, we fail to mail such notice, no obligation or liability
w;II be ;mpored 00 St,te F,"" o/'f ',eo"'" ".presenta-.
tives. 1 u. L~~-
b -ilf7
Name and Address of Certificate Holder
THE CITY, THE
REDEVOLOPMENT
VOLUNTEERS
ATTN: DEPT OF
70 FIRST ST
CAMPBELL CA
CITY OF CAMPBELL
AGENCY ITS OFFICERS, EMPLOYEES AND
Title
95008
558-994 a.2 Rev. 12.91 Printed in U.S.A.
:tie D:~/ Pi S;. ~
TH Policy No. 97-GA-2400-9
EFF: 03/14/97
FE-6324
(7/88)
ADDITIONAL INSURED ENDORSEMENT
Owners, Lessees or Contractors (Form B)
STAll FAaM
A
INSU."NCI
.
Policy No.: 97-GA-2400-9
Named Insured:
ESCAMILLA, JAY
Name of Person or Organization: THE CITY, THE CITY OF CAMPBELL REDEVELOPMENT
AGENCY, ITS OFFICERS, EMPLOYEES & VOLUNTEERS
ATTN: DEPT OF PUBLIC WORKS
70 N FIRST ST
CAMPBELL CA 95008
WHO IS AN INSURED, under SECTION II DESIGNATION OF INSURED, is amended to include as an insured
the person or organization shown above, but only with respect to liability arising out of your work for that insured
by or for you.
FE-6324
(7/88)
Printed in U.S.A.
TH Policy No. 97-GA-2400-9
2602
FE-7417.1
(12/90)
STATE FARM FIRE AND CASUALTY COMPANY, BLOOMINGTON, ILLINOIS
CHANGE AND ATTACHING CLAUSE ENDORSEMENT
This endorsement effective 03/14/97 , the effective hour being the same as that designated in
the policy to which this endorsement is attached, forms a part of Policy No. 97-GA-2400-9 issued to
ESCAMILLA, JAY
Loan No.
YOUR POLICY IS CHANGED AS FOLLOWS:
THE LIMITS OF LIABILITY, PROPERTY DESCRIPTION AND PREMIUMS ARE CHANGED AS FOLLOWS:
LIMITS OF LIABILITY
PROPERTY AND COVERAGES
PROPERTY DESCRIPTION
LOSS DEDUCTIBLES APPLICABLE: $
NO CHANGE IN PREMIUM: x
CHANGE IN PREMIUM: 0 INCREASE 0 DECREASE
INFLATION COVERAGE INDEX
ENDORSEMENT PREMIUM:
$
FULL TERM PREMIUM FOR ENDORSEMENT: $
The following Form Numbers are attached to and
form a part of your policy.
FE-6324
(EFF: 03/14/97 THRU 03/24/97 ONLY)
ADD the interests of the following:
The following Form Numbers are voided and no longer form a part
of your policy.
VOID the interests of the following:
Agent ~411Zif4( ~~\-J
FE-7417.1
(12/90)
CERTIFICATE OF INSURANCE
This certifies that ~ STATE FARM, ..: AND CASUALTY COMPANY, Bloomington, Illinois
D STATE FARM GENERAL INSURANCE COMPANY, Bloomington, Illinois
insures the following policyholder for the coverages indicated below:
ESCAMILLA, JAY
Name of policyholder DBA JAY ESCAMILLA CONSTRUCITON
TH
2602
Address of policyholder
3468 RAMSTAD DR
SAN JOSE CA 95127-4313
Location of operations
SAME
Description of operations
The policies listed below have been issued to the policyholder for the policy periods shown. The insurance described in these policies is subject to all the terms,
exclusions, and conditions of those policies. The limits of liability shown may have been reduced by any paid claims.
POLICY NUMBER TYPE OF INSURANCE POLICY PERIOD LIMITS OF LIABILITY
Effective Date 1 Expiration Date (at beginning of policy period)
Comprehensive 1 BODILY INJURY AND
i-his -i~~~r~~~~ i~ci~cie~~ . ~ - - prod~~rt:e~~~~I~~~~ -operations' . . . . . . . J . . . . . . . . . . . . . . PROPERTY DAMAGE
~ Contractual Liability
~ Underground Hazard Coverage Each Occurrence $
Personal Injury
Advertising Injury General Aggregate $
D Explosion Hazard Coverage
D Collapse Hazard Coverage Products. Completed $
D General Aggregate Limit applies to each project Operations Aggregate
R
EXCESS LIABILITY POLICY PERIOD BODILY INJURY AND PROPERTY DAMAGE
Effective Date I Expiration Date (Combined Single Limit)
B Umbrella 1 Each Occurrence $
Other 1 Aggregate $
1 Part 1 STATUTORY
Workers' Compensation Part 2 BODILY INJURY
and Employers Liability 1 Each Accident $
1
1 Disease Each Employee $
1 Disease. Policy Limit $
POLICY NUMBER TYPE OF INSURANCE POLICY PERIOD LIMITS OF LIABILITY
Effective Date Expiration Date (at beginning of policy period)
CONTRACTORS 02/15/97 I $1,000,000 (EACH OCCURRENCE)
97-GA-2400-9 ~~TT~," 102/15/98 ~? nnn nnn (
1
I
I
Name and Address of Certificate Holder
THE CITY, THE CITY OF CAMPBELL REDEVELOPMENT AGENCY,
ITS OFFICERS, EMPLOYEES & VOLUNTEERS
ATTN: DEPT OF PUBLIC WORKS
70 N FIRST ST
CAMPBELL CA 95008
If any of the described policies are canceled before its
expiration date, State Farm will try to mail a written notice to
the certificate holder 30 days before cancellation. If
however, we fail to mail such notice, no obligation or Iiapility
will be imposed on State Farm or its agents or representa.
tives. (J).,
Agent's Code Stamp
558.994 a.2 Rev. 12-91 Printed in U.S.A.
,d-to O~/ H~ ~
'rH Policy No. 97-GA-2400-0
2602
FE-7315.1
(12/90)
STATE FARM FIRE AND CASUALTY COMPANY, BLOOMINGTON, ILLINOIS
BLANK ENDORSEMENT
This endorsement effective , the effective hour being the same as that designated in
the policy to which this endorsement is attached, forms a part of Policy No. 97-GA-2400-0 issued to
ESCAMILLA, JAY
loan No.
o YOUR POLICY IS CHANGED AS FOllOWS:
1 Insured's Name
2 Insured's Address
3 Effective Date
4 Expiration Date
5
6
7
8
location
Construction
Mortgagee or Lienholder's Name
Mortgagee or Lienholder's Address
9 Other (Specify)
PRIMARY INSURANCE ENDORSEMENT
IT IS FURTHER UNDERSTOOD AND AGREED THAT THIS INSURANCE SHALL BE
PRIMARY AND NOT CONTRIBUTING WITH ANY OTHER INSURANCE IN EFFECT
FOR THE ADDITIONAL NAMED INSURED ONLY AS IT APPLIES TO THE NAMED
INSUREDS BUSINESS OPERATION.
HL48 END OF MANUSCRIPT ENDORSEMENT
CHANGE IN PREMIUM: 0 INCREASE 0 DECREASE
NO CHANGE IN PREMIUM: The following Form Numbers are attached to and form a
part of your policy.
ENDORSEMENT PREMIUM:
$
The following Form Numbers are voided and no longer
form a part of your policy.
FUll TERM PREMIUM FOR ENDORSEMENT: $
Agent
a, L~J~-)
*Minimum premium applies.
FE-7315.1
(12/90)
Printed in U.S.A.
. .<
!.
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CITY OF CAMPBELL
Public Works Department
April 10, 1998
Jay Escamilla Construction
3468 Ramstad Drive
San Jose, CA 95127
SUBJECT: PERMIT NO. 97-137
LOCATION: 360 E. Campbell Avenue
ONE YEAR MAINTENANCE INSPECTION - ACCEPTANCE
Dear Mr. Escamilla:
The City of Campbell has made the final one year maintenance inspection of subject Public
Works improvements and find that no remedial work is required.
Your warranty requirements and any surety, therefore, are hereby released.
Your warranty deposit of $500.00 plus any interest due, will be sent directly to you from our
Finance Department.
Alan Horn
Public Works Inspector
MQ/
cc: Permit 97-137
Public Works/Maintenance Division
H:\ WORD\PERMITS\97137 ACC(JD)
70 North First Street. Campbell, California 95008.1423 . TEL 408.866.2150 . FAX 408.376.0958 . TDD 408.866.2790
of'Ct...
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O.qCHA\l.U'
CITY OF CAMPBELL
Public Works Department
April 3, 1997
Jay Escamilla
Jay Escamilla Construction Company
3468 Ramstad Drive
San Jose, CA 95127
SUBJECT: PERMIT NO.97-137
LOCATION: 360 Campbell Avenue
FINAL INSPECTION AND ACCEPTANCE
Dear Mr. Escamilla:
The City of Campbell has made a final inspection of subject Public Works improvements and
finds the work to be acceptable and in conformance with City standards. Accordingly, the City
Engineer accepts the improvements.
The one year maintenance period stated in the permit begins as of the date of this acceptance
letter. The permittee is responsible for the repair and/or replacement of any defective work or
failures that occur within one year. The City will inspect the improvements within one year
and notify you, in writing, whether or not any repairs are required.
The City will continue to hold $500.00 of your $2,000.00 Faithful Performance Surety cash
deposit, receipt #100760, as your Maintenance Surety. Additionally, your cash deposit of
$500.00, plus any interest due, is now being processed and will be sent to you under separate
cover.
If you have any questions, please call me at (408) 866-2168.
~elY," ~
DL~tMlo/
Public Works Inspector
&b
cc: Suspense - 11 months
Permit #97-13 7
H'\ WORD\PERMITS\97137FIN(jd)
70 North First Street. Campbell, California 95008.1423 . TEL 408.866.2150 . FAX 408.376.0958 . TOO 408.866.2790
CITY OF CAMPBELL
FIELD ENGINEER'S DAILY REPORT
PROJECT NO.
q 7 - /37
REPORT NO:
''3 G () L:- C~""11' PIS L l
DATE: >.- z ~- q7
WEATHER: /".
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CONTRACTOR:
INSPECTOR:
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