ENC2009-00001i
Print Form
CITY OF CAMPBELL R-1 NO FEE ENCROACHMENT PERMIT Permit No. ~L 2a0~ - OiGO ~
DEPT. OF PUBLIC WORKS (Non-engineered work within the public right-of--way) X-Ref File
70 North First Street ($10,000.00 maximum value of work) Application Date o
Campbell, CA 95008 Application Expiration
Ph. (408) 866-2150. ISSUED: ~ 7 G ~ Date S o ,
Fx. (408) 376-0958 Permit Expiration Date: I '7 Io APN /~,~`.',
APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04.
(Application expires in 6 months if the permit is not issued.)
A. Work Address: ~ ~ j.,^~ ~7~'C 1~ ~~
B. Nature of Work: ~ I /h~i~~ )~-l
~- _ __ ~( ~
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C. Attach three (3) copies of a drawing showing the location, extent and dimensions of the work. The drawing shall show the relation of
the proposed work to existing improvements. When approved by the City Engineer, said drawing become a part of this permit.
D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit
Conditions listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and
provisions may result in job shutdown and/or forfeiture of Faithful Performance securities.
NAME OF APPLICANT:
~ Tele hone:
Address: ~ b ~. ~ 7~ ~('i ,°r~ _ ~'~- ~ --~/ e 1.~ _ C,~ _ _ 7..~U(5
E-Mail Address: __rr ~ -rr`
U/1 f t ,STr~ e.___ N-' ~C$Pv~. !' C.K'i. l/~ CGYh.,
__. _ .
The Applicant hereby confirms that this work is being done by the property owner/applicant at their own residence.
The Applicant hereby agrees by affixing their signature to this permit to hold the City of Campbell, City of Campbell Redevelopment Agency, 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 hereby acknowledges that they have read and understand both the front and back of this permit, and that they will inform their
contractor(s) of the inform i n.c ~
ACCEPTED: ~ ~
(Applicant/Permittee) (Sign) Date
NOTES: All work shall conform with the attached approved plans and all applicable Campbell Standard Details and Conditions and applicable
insurance requirements.
The Contractor must have this permit and approved plans and must arrange to meet with the Public Works Inspector at the site at least two days
before starting work. Notice must be given to Public Works at least 24 hours before restarting any work.
Per Section 4215 of the Government Code this permit is not valid for excavations until Underground Service Alert (USA) has been notified and the
inquiry identification number (Ticket No.) has been entered hereon. USA Phone: 1-800-227-2600. Ticket No.:
Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all
damages arising out of the design, installation or condition of private improvements in the public right-of--way.
SPECIAL PROVISIONS
1. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right-of--Way, which shall be
recorded.
2.
3.
STANDARD AMOUNT RECEIPT N0.
SECURITY FOR FAITHFUL PERFORMANCE (100% Of Engr's Est.) $-~~-
APPROVED FOR ISSUANCE: I~ 7/D ~
for City Engineer Date
Permit Expires 6 Months after Date of Issuance.
~~
GENERAL PERMIT CONDITIONS
1. Payment of a security to insure faithful performance and completion of the work is required. This security is refundable upon
completion of the work and written acceptance by the City.
2. A one-year maintenance period for all work is required. Such period will begin on date of acceptance by the Ciry. It is the applicant's
responsibility to remove and replace unacceptable improvements within the one-year maintenance period.
3. Refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City.
4. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be
made in writing to the Permittee.
5. Maintain safe pedestrian and vehicular crossings and free access to private driveways, fire hydrants and water valves.
6. Replace as directed by the City Engineer any damaged or removed improvements in accordance with City Standards and
Specifications at the sole expense of the Permittee.
7. Sawcut for all PCC and AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements.
8. Adequate signing arid barricading is required on the job site. Failure to provide such signing and barricading as specified by the City
Engineer may result in the City's providing such signing and barricades and charging the cost to the Permittee.
9. The Contractor or Permittee will have a supervisory respresentative available for contact on the project at all times during
construction.
10. This permit shall be kept at the site of work and must be shown to any authorized representatives of the City of Campbell or any
law enforcement officer upon demand.
11. No storage of materials or equipment will be allowed near the edge of pavement, within the traveled way, or within the shoulderline,
which would create a hazardous condition to the public.
12. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other
work for which a separate permit may be required, nor does it relieve the Permittee of any obligation to obtain any other permit
required bylaw.
13. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other
public agency.
14. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon.
15. Prior approval of inspector is required for any work done after normal working hours, on weekends or holidays and may require
reimbursement of inspection costs at the current overtime rate.
16. Call back (call out) due to emergencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum
charge per occurrence.
17. If the public interest requires a modification of, or a departure from, the plans and specifications, the City shall have the authority to
require or approve any modification or departure and to specify the manner in which the same is to be made for City-owned or
maintained facilities.
18. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the
municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by
the Santa Clara Valley Urban Runoff Pollution Prevention Program.
Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand ail of the above
Applicant
Q,~ Q
Date
J:\FORMS\Templates\Encroachment Permits\R-1 No fee Encroachment Permit STATIC form2.pdf
Rev. 4/08
Jan 05 09 12:11p Nielsen 4083700954
Allstate insurance Company
RENEwJaL
Deluxe Plus Homeowners
Policy Declare#ions
Semmary
p.2
RECE~~ED
SAN ~ ., `~~~~:~
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JiiAMED ENSURED{S} YOUR ALLSTATE AGENT IS: CONTACT YOUR A6ENIT AT:
Eric W Nielsen Mbh Ins & i~vn Svcs {209} 472-8585
Christlne Nielsen 8907 Thornton Rd Di
1633 Adrian Dr Stockton CA 95209
Campbell CA 95008-5102
ruusf NUItIBEH POLICY PERIOD PREIAIUM PERI00
0 6717051203134 Begins on Mar. 30, 2006 Mar. 30, 2008 to Mar. 30, 2009
at 12:01 a.m. Pacific Time at 12:Oi a.m. Paa6c Time
and continues until cancelled
LOCATION OF PROPERTY INSURED
1633 Adrian Or, Campbell, CA 95009-5142
WORT6A6ff
• COUNTRYWIDE HOME LOANS INC iTS SCRS BJOR
ASSIGNEES ATiNJA
PO BX 961206 Ftvrx 22 Fort Worth TX 761 fii-0206 Loam /`0618057T0
Tote! Premium for the Premium Period (your brli mill be mailed sep8rate/y)
Premium for Property Insured $1.495.00
tutn~ -
i1.495.00
See the Important PaymetN and Coverage httormation section for details about payment options and
installment fees.
n~iui~umn~ai~iunuNwxii~u -_ _,
Jan 05 09 12:11p Nielsen
Allstate Insurance Company
Yalky Number. D 6T 170512 03Fig Your Agerd: Mbh Ina & Fla Sacs (209) 472-8685
For Premium Period Beginning: Nlar. 8D, 2008
POLICY COVERAGES AND LIMITS OF L1A811.IT'Y
COVERAGE AND APPLICABLE DEflUC716LES LIMITS OF LU-BILi7Y
(See Pokicy for Applicable Term, CondNans and 6rclusions)
Owekling Protection -with Building 5tructu~e Reimbursement Extended Omits $369,707
• $500 All Peril Deductible Applies
Other Structures Protection
• $500 All Peril Deductible Applies
$36,971
Personal Property Protection -Reimbursement Provision S277,281
• $500 All Peril Deductible Applies
Additional Living Expense Refer to Policy
Family Liability Protection $300,000 each occurrence
Guest Medical Protection $1,000 each person
Building Codes Refer to Policy
Workers' Compensation and Employers' Liability Statutoryl5ee Form
Coverage for Residence Employees
The limit of liability fior this structure (Ooverage A-Dwelling Protection) is based on an estimate of the cost to
rebuild your home, including an approximate cost for tabor and materials in your area, and specific information
thatyou have provided about your home.
This policy does not cover earth movement including earthquake
You have elected not to purchase a CEA earthquake policy
DI$COUaTS Your premium reflects Ehe following discounts on applicable coverage(s):
Claim Frae 15 °A
Protective Device Rate Applied
RATIiVG 111FORMATION
The dv~elling is of Frame construction end i5 occupied by 1 family
408700954 p.3
wama~imaW Page 2
F•nary 7, 2eDr iA°AROU
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