1129 AudreyDate: August 9, 2000
TRANSMITTAL FROM THE PUBLIC WORKS DEPARTMENT
TO; Rami Karimi
1129 Audrey Avenue
FROM:
Campbell, CA 95008
Marlene Pomeroy, Department Secretary
SUBJECT:
1129 Audrey Avenue
We are fo~varding the following:
Copy of recorded Deferred Street Improvement Agreement
for your records.
Marlene Pcmeroy, Secre%ary
TO ~,E RL~ORD~D \¥ffflOU' '~:~
SECTION 610-'~ GO', fh .~.~ E ~, -ODE,
AT THE P, EOU~gT ¢>~ CI~Y OF CA"JP3~'I L
Recording Requested By:
City of Campbell
And When Recorded Return To:
City Clerk
City of Campbell
70 N. First Street
Campbell, CA 95008
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DOCUMENT: 15307972
· 0015~07972~
BRENDA DAVIS
SANTA CLARA COUNTY RECORDER
Recorded at the request of
City
Titles:l / Pages: 7
Fees .... * No Fees
Taxes...
Copies..
AMT PAID
RDE ~ 006
7/12/2000
3:30 PM
DEFERRED STREET IMPROVEMENT AGREEMENT
THIS AGREEMENT, (identified as BLD 2000-613) made and entered into this
/~, ~4 day of ~4c~ , 20 ~ , by and between RAMI KARIMI, A
SINGLE MAN c/ hereinafter referred to as "Owner," and the CITY OF CAMPBELL, a
municipal corporation of the County of Santa Clara, State of California, hereinafter referred to
as "City."
WHEREAS, City granted conditional approval of Building Permit 2000-613 upon that
certain real property described in Grant Deed recorded April 27, 2000, and filed as Document
15228188 in the office of the County Recorder, County of Santa Clara, State of California,
which property is hereinafter referred to as "said real property" and commonly known as
1129 Audrey Avenue;
: WHEREAS, compliance with the terms and conditions of this 'agreement are conditions
to the final approval of above described application to construct a single-family residence;
NOW, THEREFORE, IN CONSIDERATION OF THE ABOVE-MENTIONED
APPROVAL, it is hereby agreed as follows:
(1) Owner shall provide, constp-~ct and/or insm!l at his own proper cost and
expense, public street improvements within 12 months from the date when owners or their
successors are notified to do so by the City Engineer.
(2) All of said improvements shall be constructed and/or installed within 12 months
from the date that Owners, or their successors, are notified by said City Engineer to do so;
provided however, that in the computation of said twelve-month period, delays due to or
caused by acts of God, viz., unusually inclement weather, major strikes, and other delay
beyond the control of Owners shall be excluded.
It is expressly understood and agreed to that if Owner shall fail to complete the work
required by this Agreement within the said 12 month period, the City, after giving ten (10)
days written notice thereof to Owner, or his successors, may construct and/or install said
improvements and recover the full cost and expense thereof from owner, or his successors.
It is further expressly understood that the purpose of this agreement is to defer
construction of the above-mentioned improvements until some future date more conducive to
the overall needs of the City of Campbell. In keeping with this understanding-, the right of the
City to give any of the notices specified herein in Section (2) of this Agreement to install such
improvements, or to require construction or installation of such improvements, or to install
such improvements itself and recover the costs thereof shall not be barred by the passage of
time or delay by the City, but shall remain open and enforceable indefinitely and forever. It is
also understood that the passage of time or any delay caused by the City shall not relieve the
Owners, or their successors, from performance under this Agreement, but that the Owners,
and their successors, shall remain bound indefinitely and forever. Any increased construction
or preparation costs caused as the result of the passage of time shall be the responsibility of the
Owners, and their successors.
Nothing herein shall be deemed to prohibit construction of said improvements prior to
notice by the City Engineer to construct or install such improvements, provided that prior to
such installation, all of the provisions of Section (3) shall be satisfied.
(3) Owner, or his successors, shall cause to be prepared at his cost and expense
improvement plans for the construction and/or installation of said improvements prior to such
construction or installation. Said plans shall be prepared by a civil engineer registered by the
State of California and submitted to the City Engineer for examination and approval.
All of said improvements shall be constructed and/or installed in accordance with those
plans approved by the City Engineer and shall be made under the supervision and inspection
and to the satisfaction of the City Engineer. Said construction and/or installation shall be in
accordance with the existing ordinances and resolutions of the City of Campbell and to all
plans, specifications, standards, sizes, lines and grades approved by the City Engineer, and all
State and County statutes applicable thereto. Upon completion and acceptance of the
improvements by City, Owner, or his successors, shall provide reproducible as-built plans to
the City Engineer.
(4) The construction work of the improvements embraced by this Agreement shall
be done in accordance with the specifications of the City of Campbell and West Valley
Sanitation District, where indicated.
(5) Prior to approval of the plans by the City Engineer pursuant to Section (3) of
this Agreement, Owner, or his successors, shall pay to the City for examination of
improvement plans, field inspection of construction of improvements and all necessary
expenses incurred by City in connection with said improvements, a sum to be determined when
said plans are submitted in accordance with the rules in effect at that time.
2
(6) Owner, or his successors, shall file with City, prior to commencing work,
surety, acceptable to City, to ensure full and faithful performance of the construction of all the
aforementioned improvement work, excluding sanitary sewers and water distribution system.
Said surety shall guarantee that Owner, and his successors, will correct any defects which may
appear in said improvement work within one (1) year from the date of acceptance of the work
by City and pay for any damage to other work resulting from the construction thereof, as well
as pay the cost of all labor and materials involved. This surety shall remain in effect until one
(1) year after date of final acceptance of said improvements by City. Said surety amount may
be reduced by the City Engineer after the date of final acceptance to not less than twenty-five
(25) percent of its full value.
(7) Upon final release of said surety by City, the obligations of Owner, and his
successors, contained in this Agreement shall be considered null and void.
(8) When called upon by City to do so, Owner, or his successors, will execute a
petition for the formation of any special assessment district created pursuant to any special
assessment act as provided in the Streets and Highways Code of the State of California created
for the purpose of constructing and/or installing any or all of said improvements.
(9) Owner, or his successors, shall participate in and become a part of any special
assessment district as described in paragraph (8) of this Agreement.
It is expressly understood that any obligations of Owner, or his successors, contained in
this Agreement that are accomplished to the satisfaction of said City Engineer by said special
assessment district shall be considered null and void.
(10) Owner, or his successors, shall make such deposits or file such bonds and enter
intc~ such agreement as required by West Valley Sanitation District to ensure the installation of
a sanitary sewage system to serve said real property, and Owner, or his successors, shall file
with City, upon execution of this Agreement, a letter from said Sanitation District stating that
Owner, or his successors, have made such deposits or filed such bonds and entered into such
agreements.
(11) Owner, or his successors, shall pay to Pacific Gas and Electric Company any
and all fees required for installation of underground wiring circuit to all electroliers within said
real property when Owner, or his successors, is notified by either the City Engineer or the
Pacific Gas and Electric Company that said fees are due and payable. Owner's, and his
successors', obligations under this section shall not be relieved by delay or the passage of time,
but shall remain binding indefinitely and forever.
(12) Owner, or his successors, shall make such deposits or file such bonds and enter
into such agreement as required by San Jose Water Company when called upon to do so to
ensure that installation of a water distribution system to serve said real property, including fire
hydrant. Owner's, and his successors', obligations under this section shall not be relieved by
delay or the passage of time, but shall bind Owner and successors indefinitely and forever.
-3-
(13) Any easement and right-of-way within or without said real property necessary
for the completion of the improvements shown upon aforesaid improvement plans shall be
acquired by Owner, or his successors, at his own cost and expense. It is provided, however,
that in the event eminent domain proceedings are required for the purpose of securing said
easement and right-of-way, Owner, or his successors, shall deposit or cause-to be deposited
with City a sum covering the reasonable market value of the land proposed to be taken and to
be included in said sum shall be a reasonable allowance for severance damages, if any. It is
further provided that in addition thereto such sums as may be required for legal fees and costs,
engineering and other incidental costs shall be deposited with the City.
(14) Owner, or his successors, shall carry out any and all negotiations with all
interested parties and shall perform or cause to be performed at his own cost and expense and
to the satisfaction of the City Engineer any and all work required to abandon, remove, raise,
lower, relocate and otherwise modify irrigation line or lines within the boundary of said real
property.
(15) To the fullest extent permitted by law, Owner, and his successors, shall
indemnify, defend and hold the City of Campbell, the City of Campbell Redevelopment
Agency, and its agents, employees, attorneys, officers, officials, and assignees harmless from
any and all claims, damages, losses and expenses, including, but not limited to, attorneys'
fees, arising out of, or resulting from any negligent or intentional act or omission (including
misconduct) of said Owner, or his successors, or any subcontractor, or anyone directly or
indirectly employed by him, or anyone for whose acts any of them may be liable in the course
of performance of this Agreement.
~ The Owner, and his successors, shall also indemnify, defend and hold the City of
Campbell, and its agents, attorneys, employees, officers, officials, and assignees harmless
against and from any and all claims, demands, liabilities, losses, lawsuits, judgments,
damages, costs and expenses (including, but not limited to, attorneys' fees and court costs,
whether incurred at trial, appellate or administrative levels) which the City of Campbell may
incur or suffer, or to which the City of Campbell may be subjected resulting from the failure of
Owner, or his successors, or his agents, employees, subcontractors, or anyone performing
services under him, to fulfill any of the obligations imposed under this Agreement.
(16) It is acknowledged that the provisions of this Agreement constitute covenants for
the improvement of the subject real property for the mutual benefit of Owner's property,
commonly known as 1129 Audrey Avenue and the City's property, commonly described as
Audrey Avenue where it adjoins Owner's property. These covenants shall be considered to
affect rights in the above-described real properties, and shall be binding on the heirs, assigns,
successors, and grantees of Owner to said real property.
(17) Nothing contained herein shall be construed to transfer any unvested interests in
real or personal property for purposes of the rule against perpetuities.
-4-
(18) In the event that Owner, or his successors, should breach any of the terms,
conditions, or covenants of this Agreement, the City shall be entitled to recover, in addition to
any other relief available in law or equity, all costs incurred in attempting to obtain
enforcement of the Agreement, or compensation for such breach. These costs shall include
reasonable attorneys' fees and court costs.
(19) This is the entire Agreement between the parties and there are no
representations, agreements, arrangements, or understandings that are not fully expressed
herein.
(20) This Agreement can be executed in counterparts by the parties hereto, and as so
executed shall consist of one agreement, binding on all the parties.
IN WITNESS WHEREOF, said City has caused its name to be affixed by its Public
Works Director and City Clerk, who are duly authorized by Ordinance 1951 adopted
September 2, 1997, and said Owner has caused his name to be affixed the day and year first
above written.
RAMI KARIMI, A~ SINGLE MAN,
RAMI KARIMI
Anne Bybee, City Clerk
(Notary Acknowledgment for above
signator(ies) MUST be attached)
Rol~er~ kass [
Public Works Director
(Attach Notary Acknowledgment
for all parties)
h: agr\ 1129audreyimplater(mp)
STATE OF CALIFORNIA
COUNTY OF SANTA CLARA
On ,~ ~- /~ .9o~c-~ before me, //~/~',~
personally appeared ~4;,gYZ
(Notary Public)
-personally ~w~ to me-(or proved to me on the basis of satisfactory evidence) to be the person(s}
whose name(~) is/are subscribed to the within instrument and acknowledged to me that he/she/they
executed the same in his/her4thcdr authorized capacity(-ies-), and that by his/-her4th~r signamre(-~) on the
instrument, the person(~, or the entity upon behalf of which the person(z) acted, executed the
instrument.
WITNESS my hand and official seal.
(This area for notarial seal)
-6-
STATE OF CALIFORNIA
COUNTY OF SANTA CLARA
(Notary bLic) ..._._/
personalty k~wn to me ~r p.'m'cd m ,'z~m2:tmqmm~~evid~n~) to be the person(s)_ whose
subscnbed tn. the with/n /nstnrmeut and acknowledged to me that he/st~Cfi~y executed th~ same in
attlhoriz~ capaci .~ies), and that by ~ si~mre(~ on th~ instnm~, tlm person(SO, or the enfily upen behalf
of which the person(~) acted, execut~ the instrument.
WITNESS my hand and official seal
(Th/s area for notarial seal)
PL _,~C WORKS DEPARTMENT RECEIPT
Effective August 1, 1999
TO: City Clerk PUBLIC WORKS FILE NO.
Please collect & receipt for the following mon us - ·
~i~ ! i ii i !!~ i i~iCii~ii!~ i i:~:~:~:i:~:i:~:~:!:!:~:~::: :~:~ ................................................................................................................................................................................... ~ ...........
~i35.535.4921 ................................................ ] Prolect: ................. Revenue:':':':':':':':':':':':':':':':':':':':':':'(specify pr~iect}:.:.:-:.:-:-:-:.:-:.:.:.:.:.:.:.:-:-:.:::.::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::i:i:i:i:i:i:!:!:!:!:!:~:i:i:i:~:i:i:~:!:!:!:!:
ENCROACHMENT PERMIT
4722 Application Fee
Non-Utility Encroachment Permit ($236.25}
Minor Encroachment Permit < $5~000 ($50.00)
R-I First Permit (No Fee) Subsequent PermiffYr ($105)
Utility Encroachment Permit
Arterial/Collector Street ($341.25)
Residential StreeffOthet Areas ($236.25}
2203 Plan Check Deposit - 2% of ENGR. EST. ($500 rain}
2203 Faithful Performance Security (FPS} 000% of ENGR.EST.}
2203 Labor and Materials Security (100 % of ENGR. EST.) *
2203 Monumentation Security (100% of ENGR.EST.)
2203 Cash Deposit (4% of ENGR.EST.){$500 miniS10,000 max) *
2203 Labor and Material Security (100% of ENGR. EST.) *
Plan Check & Inspection Fee (Non-Utility)
4722 Engr. Est.< $250,000 (12% of ENGR. EST.)
'- 2203 Engr. Est. > $250,000 (Deposit 8% of ENGR. EST.I$30,000 min.)*=
4722 Utility < $100~000 (8%)
Minimum Charge Per Location ($126)
Conduits/Pip~lines up to 500 Feet ($1.75/ft}
Above 500 Linear Feet ($1.15/ft)
Manholes/Vaults/Etc. ($1 lO.25/ea)
Pole Set/Removal ($1 i0.25/ea)
Street Tree Planting/Removal ($110.25/tree)
· * 2203 Utility > S100.000 Actual Cost + 20% *-
4722 Street Tree Planting/Removal Permit ($110.25)
4760 Proiect Plans & Specifications Pro}ect No.
4760 Standard Specifications & Details ($1/Pg $12.50/Bk)
4760 Copies of Engineering Maps & Plans
[ Aerial Plot 24' x 36' ($42}
[ Aerial Print 8 I/2' x 1 l · ($I5}
I Maps and Plans 24' x 36' ($5)
4722 Penalties: Failure to restore public improvements ($ I00/Calendar Day) {Muni C~e Sec. I 1.34.010~
4722 Penalties: Failure to correct unsafe conditions ($100/Caleva:lar Day}
LAND DEVELOPMENT
4722 Lot Line Adiustment ($577.50}
4722 Parcel Map (4 Lots or Less) ($1,125 + $25/Lot)
4.722 Final Tract Map (5 or More Lots) ($L450 + $25/Lot}
4722 Certificate of Compliance ($525}
4722 Certificate of Correction ($315)
4.~2 Notary Fee (per signature) ($I0)
4722 Vacation of Public Streets & Easements ($577.50}
472-2 Assessment Segregation or Reapportionment
First Split ($577.50)
~ ..- .~ Each Additional Lot ($178.50)
~ ~ Storm Drainage Area Fee Per Acre (R-l, $2,000) ,~ ~.~,~ --
(Multi-Res, $2.250}
(All Other, $2~500)
492.0 Parkland Dedication Fee/75 %/25 % Due Upon Cert. of Occupancy)
4965 Postage
TRAFFIC
4728{ Intersection Turn Counts (Two-Hour Count) ($63)
47281 Intersection Turn Counts (a.m. or p.m. peaks) ($131.25)
4728 Traffic Flow Map (Daily Traffic Volumes) ($28.35)
4728 Campbell Traffic Model (Full Scope Assessment} ($2.362.50)
4728 Campbell Traffic Model (Reduced Scope Assessment} ($777)
4271 Truck Perm,s ($36.75/trip)
4728 No Parking Signs (SI/each or $25/100)
OTHER
TOTAL
NAME OF APPLICANT
NAMEOFPAYOR ~------~
PHONE
^ DRESS z,P
· *Actual Cnst Plus 20 % Overhead IN/ rest bearing d it} RECEIVED
h:\forms\ecfrm4.xls rev. 7/13/99 (mp)
CiTY OF CAMPBELL~ CA
~ g ! h": l.tg,r ·
PUBLIC WORKS - ENGINEERING DIVISION .................. MEMORANDUM
TO:
FROM:
SUBJECT:
DATE:
Bob Kass, Public Works Director
Bill Helms, Land Development Manager
I
· Harold Housley, Land Development Engih~ee
STREET IMPROVEMENT AGREEMENT
Attached please find the signed and notarized copies of the street improvement agreements for
//'.~v/~~,/./ /9:ffl/tg. for your signature.
-(Address)
This agreement was required as a condition of approval for
was approved by ·
, which
City Council Resolution No. on
Planning Commission Resolution No. on
Community Development Director on
This agreement requires the improvements to be installed:
Public Works Department/Land Development Section on
Within 12 months from the date of the agreement and the required bonds have been
submitted.
Within 12 months from the date notified by the City Engineer to install the required
improvements.
j :h-nq\ld\agrmemo (1/4/00)
MEMORANDUM
TO:
FROM:
~// cfm o~ c.mvs~u Ptmuc worsts r~,,~~
Bill Bruckart DATE: ~ --~--~~~
Build~g Official / [ %~ ~ ~~ ~~
./~/ Site Ad.ess: ~ ~f~G-~,- - - C~
H~old Housley, L. D. Enginee~l~ Check Nmber:
Chuck Oomez, Assist~r Eng~r File No(s):
:TI-lIS DEPARTM2Eb~T HAS NO OBJECTION TO ISSU~N'CE OF GRADING,
D1L-k~'AGE, OR BLTLDING PERzMITS FOR TIKE ABOVE REFERENCED PLAN
CI-IE CK N-U~IBER.
BY: DATE:
I.CON-DITIONS OF A.PPROVAL )~RE SL.'~I3IA.~I~D BELOW FOR CLEARANCE OF[
BUILDING PE1LMIT(S) TO CONSTRUCT A ,.NEW RESIDENTL~L STRUCTURE OR
I
.UN' .a~DDITION OR )~LTE1L-kTION THAT ADDS 50% OR MORE. SQUARE FEET OF
STRUCTL-RAL COX/ERAGE (SECTION 11.24.182).
Street Lmr~rovements: Prior to issuance of any ~ading, drainage or building permits
for the site, the applicant shah cause plans for public Street Improvements to be
prepared Dy a registered civil engineer, pay fees, execute a street improvement
agreement, post secur/ty and provide imurance necessary to obtain an encroachment
permit for construction of the improvements, as required by the City Engineer. The
plans shall include ~e following:
~~-~_.-~Street knprovements an R-1/Minor Encroachment Permit: Prior to issuance of an
encroachment permit for construction of any public street improvements in the public
Right-of-Way the applicant shall cause plans to be prepared, post security, and provide
insurance, all as required by the City Engineer. .
Page I of 3 .
PI_AN CHECK NUMBER:
Unsecured Deferred Street Improvement A~eement: Prior to issuance of any grading,
drainage, or building permits for the site, the owner shall execute an unsecured street ..
improvement agreement for construction of street improvements.
Riaht-of-Wav for Public Street Purposes- Prior to issuance of any ~ading, drainage,
or building permits for the site, the applicant shall grant additional
Right-of-Way for Public Street Purposes along the
frontage(s) to accommodate
Applicant shall cause to be prepared all documents necessary to record dedication and
submit to the City for review
Public Service Easement: Prior to issuance of any ~ading, drainage, or building
permits for the site, the owner shall grant a
Public Service Easement on private property conti~ous with the public fight-of-way
along the
frontage. The applicant shall cause all documenm to be prepared by a registered civil
engineer/surveyor and submitted to the City for review and recordation.
Storm Drain Area Fee: Prior to issuance of any grading, drainage, or building permits
for the site, the applicant shall pay the required Storm Drain Area fee. The current fee
_ $ '"'2_.C~¢~.-,.~ ~C, per acre which is $ .~7'jZ7~--'-% ~ ~ .
Proof of Ownership: Prior to issuance of any grading, drainage, or building permits
for the site, the applicant shall provide a current preliminary title report, ~ant deed, or
other proof of ownership. ':
Utility Installation Plan: Prior to issuance of building permits, the applicant shall
submit a Utility Installation Plan and Schedule for approval by the City Engineer for
installation of any new utilities. Streets which have been resuffaced within the previous
5 years may require installation beneath pavement by boring'and jacking method and
will also require a pavement restoration plan for approval by the City Engineer prior to
any utility installation.
[,,AC,Legal Lot: The applicant shall provide documentation to ascertain that the tot was
legally created, or prepare a parcel map to create the parcel shown.
~'~~ite Plan: Prior to issuance of an encroachment permit, the applicant sba/1 provide a
complete and accurate Site Plan in accordance with the Plann/ng Division's checklist.
Page 2 of 3 :
PLAN CHECK ~ER:
cc: Alan Horn, PWD Inspector
j:\forms\bldgapp
Rev. 3/18/99
P_a_g_e_ _3_ _of_3 ................................................
06/15/00 THU 15:05 FAX 408+558+7779
Recording Requested by:
COlVlMONWEALTH LAND TEI'LE COM~'ANY
Escrow No.: 60730228-CAF
A.P.N. 406-24-015
WHEN RECORDED MAIL TO:
RAMI KARIMI
1129 AUDREY AVE
CAMPBELL, CA 95008
BAY RESIDENTIAL MTG
DOCUMENT; 15~. ~8
~002
Fees ?,@0
Taxes . 517 @@
Cop]es
AMT PAID 524 00
BRENDA DAVIS RDE ~ 0B6
SANTA CLARA COUNTY RECORDER 4/27/288~
Recorded aC the reques~ O~ 2:11 PM
Commonwealth Land Title
SPACE ABOVE T}~S LINE FORR. ECORDER'S USE
MAIL TAX STATEMENTS TO:
SAME AS ABOVE
The undersigned Grantor(s) declare(s) that the DOCUMENTARY
County Transfer Tax is: $ 517.00; City Tax ~s: $
x __ computed on full value of property conveyed; OR
__ computed on full value less value of liens and encumbrances
remaining at time of sale,
Unincorporated area: X CITY OF CAMPBELL, and
GRANT DEED
FOR A VALUABLE CONS1/)E1ZATION, reozipt of which is hereby acknowledged,
CLAIRI~ E. PODLISKA, EXECUTOR OF I~IE ESTATE OF JOHN THOMAS ODENHE/MER. DECF. ASED,
PURSUANT TO LETTERS TESTAlVIENTARY FILED NOVEMBER I, 1999, CASE NO. 1-99-PR145820 OF
THE SUPEILIOR COURT OF THE COUNTY OF SANTA CLARA, STATE OF CALIFORNIA
hereby (}RatdqT(S) to
RAM] KARIM], A SINGLE PJklq
all the foal property si~ated in thc CITY OF CAMPBELL, Count7 of Santa Clara, State of California, described as:
Lot 6, Block 3, Tract No. 329, filed August 27, 1946 in Book 11 of Maps, at Page(s) 40 and 41, Sallta Clara ~unty
Dated: April 18. 2000 '
STATE OF CALIFORNIA } ss
COUNTY OF
On ~~ L / ~1 ?O~ beforeme,
· e ~demi~e~ a No~ ~bIic ~ ~d for said Coun~ ~d
CLAIRE E. PODLISK~, EXECUTOR OF THE
ESTATE OF JOHN THOMAS ODENHEIMER,
DECEASED
personally known to me (or proved to me on the basis of
salisfactory evidence) to be the person(s) whose name(s)
~e subscribed to the within instrument and acknowledged
to mc that hcYsh.~thcy executed thu same in his/h~Tj;thcir
~thofized capacity(les), lind that by hi~hff. F~cir signature(s)
on the instrument the person(s), or the entity upon behalf of
which the person(s) acted, executed the instrument.
WITNESS~p{y hand and_~ffic~ seal.
/~.~.~.-~-~,,,/ ,..- ,.~.~.-_._ .....
Sig~tm'¢ of Notary Publf¢
-- ~~~ Comm. # 1214408
~ ~.~ NOT~¥ ~U~LtC. C~L!FORNq'
CTI~i.s ar~a for official notarial seal)
Form 3195-1 (Rev. 1-94)
MAIL STATEMENTS AS DIRECTED ABOVE
SHE~LA C~
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PUBLIC WORKS
PLAN REVIEW ROUTE SHEET
APPROVED /NO COMMENTS:
DATE:
APPROVED / CONDITIONS BELOW:
DA~ _
.: u'd ~ R 2000
NOTES:
[RETURN TO DARLEEN BECKER, BUILDING DMSION [
PERMIT APPLICATION
C1TY5uiLDiNGOF CAMPBELLDiviSiON ~ NO'.. ~)0 - &/~._ DATE: ~ - ~-{2~
D~O ~ ~~G
BUILDING ADDP. F_SS:
OWNER'S NAME:
ADDRESS:
APPLICANT'S NAME:
ADDRESS:
DESCRIPTION OF WORK: (RA) TI SIGN
CoN'rR~CI'OR:
COMPANY NAME:
CONTACT PERSON:
ADDRESS:
PHONE NO.:
DP. MO OTI~R
EIVED
COMPANY NAME:
CONTACT PERSON:
ADDRESS:
PHONE NO.:
HAZARDOUS MATT. RIALS:
U~e or storase of h~z~rdous materi&Is requires a H~z~rdous Materi~l~ Ir~ormation Statement
to be submitted to the Fire Dep~rtment for review ~nd comment at time of buildin$ permit
application, l:~ilure to provide the HM~$ will hold up buildin$ permit approv&l.
FIRE SPKINqCLEKED: YES ~