ENC2009-00012Print Form
CITY OF CAMPBELL R-1 NO FEE ENCROACHMENT PERMIT Permit No. ~~" r-_ ~ GG 1 V~12
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 _.-ill !~~__
Campbell, CA 95008 -1 Application Expiration.~~~.~~~~
Ph. (408) 866-2150 ISSUED: _ l I ~ i ~~~ _ _ Date _
Fx. (408) 376-0958 Permit Expiration Date: (~? ~~ (t~ 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: 1148 E Campbell Ave
e. Nature of work: .Replace existing broken sidewake and gutter that collects dirty water from the nearby restaurant
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: Himanshu Vaishnav Telephone: 408/626-0165
Address: 1 148 E Campbell Ave, Campbell, CA 95008
E-Mail Address: vaishnav@yahoo.com
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 acknow,Jedgestkjat they have read and understand both the front and back of this permit, and that they will inform their
contractor(s) of the informatio~t:`
-~
ACCEPTED: ~--, ~l`/ Z ~ ~'l~ ~`'~ ------- I j l / l `~ ~ -
- ~ (Ap~plican±tlPermittee) (Sign) Date
i J °°
NOTES: All work shall conform with 1~he 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 Seciion 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.
STANDARD AMOUNT RECEIPT NO.
SECURITY FOR FAITHFUL PERFORMANCE (100% Of Engr's Est.} $- L'~' ~~' ____ ~ 144~fi
APPROVED FOR ISSUANCE:
for City Engineer
i~7~1;,
Date`
Permit Expires 6 Months after Date of Issuance.
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Ref undnb~e l~ep~si~- Check Re4ues~
To: Finance Director
Check Payable To: Himanshu Vaishnav
Address -Line 1: 1148 E. Campbell Ave
Line 2:
City: Campbell State: CA Zip: 95008
Description: Refund Fee
Account Number: 101.2203 Amount: $500.00
Account Number: Amount:
Account Number: 101.540.7448 Amount:
(Finance Dept only) Interest Earned (Finance Dept only)
Total Payable: $500.00 (Exact Amount)
Purpose: Refund Faithful Perfornance Security on 1148 E. Campbell Avenue.
Voucher #:
Receipt #: 214041
Requested by: -~-'
Syed Wahidi;'
Approved by: ~ ~ ~ ~ '
Michelle-Quinney
Finance Dept Only:
Verified by:
Approved by:
Mail As Is:
Needed By;
Return To:
Permit #: ENC2009-00012
Date: 01/27/09
Title: PW Inspector Date: .12/17/2008
Title: City Engineer Date: 12/17/2008
Title: Accounting Clerk II Date:
Title: Accountant Date:
Special Instructions For Handling Check
Mail in Attached Envelope: Interim Check:
Joanne D'Ambrosia
(Name)
Other:
Public Works/City Hall
(Department)
f/n: Forms/excel/chkreq - Revised 05/00
PUBLIC WORI:S DEPARTMENT LANG DEVE`~OPMERT ~. TRAFFI ; RECEfF"
ITQ: City Clerk
i
Effective Juiv 1. 200E
PUBLIC WORKS FILE NC3.
~~ ~ ?Go`~ - GU~~12
I t l i r3 i -" ,, win o
I
Please collect & receipt for the following monies: !'KUt'tK I Y AUUKtSJ f 1 -T t. ~ '"~ I` 11 ~ 't ~-~-
ACCT. ITEM
LAND DEVELOPMENT AMOUNT
47221 Encroachment Permit Application Fee
Non-Utility Encroachment Permit ($310.00
Minor Encroachment Permit <sto.ooo ($140.00)
R-1 First Permit (No Fee) Subsequent <io.ooo ($135.00 I
2203 Plan Check Deposit 2% of Engineer's Estimate ($500.00 min)
4722 Grading & Drainage Plan Review
Single Family Lot ($210.00
Site < 10.000 s.f. ($625.00
Site > 10,000 s.f. < Acre ($835.00)
Site > 1 Acre ($1.250.00)
Plan Check & Inspection Fee Non-Utility)
"2203 Engr. Est. >$250,000 (Actual Cost + 20% min. $30.000 Deposit
4722 Engr. Est. <$250,000 (13°~0 of ENGR. EST.
2203 Emergency Construction Cash Deposit 4°io of Engr. Est ($500 min/$10,000 max
2203 Faithful Performance Security (FPS) 100°~0 of ENGR. EST. SC.~O
2203 Labor and Materials Security (100°~0 of ENGR. EST.)
4721' Storm Drainage Area Fee Per Acre (R-1 $2,120.00)
(Multi-Res $2,385.00)
(All Other $2,650.00)
4722 Parcel Map 4 Lots or Less ($3,500.00 + $78/lot
4722 Final Tract Map 5 or More Lots) ($4,300.00 + $105/lot)
2203 Monumentation Security 100% of ENGR. EST.)
4920 Parkland Dedication Fee 75%/25°ro Due Upon Cert. of Occupancy) I
4722 Lot Line Adjustment $930.00
4722 Vacation of Public Streets & Easements ($2.200.00
4722 Certificate of Compliance ($675.00) _
4722 Certificate of Correction ($415.00 ~
4722 ' Appeal Filing Fee ($105.00
4722 Notary Fee per signature $10.00
4722 Assessment Segregation or Reapportionment
First Split
($735.00) ~
Each Additional Lot ($200.00
511.7424
TRAFFIC
4728 Postage
Intersection Turn Counts (Two-Hour Count)
($80.00) '~
4728 Intersection Turn Counts (a.m. or p.m. peaks) ($155.00) I
4728 Traffic Flow Map Daily Traffic Volumes) ($33.00)
4728 Signal Timing Information $64.75/Hr
4271 Truck Permits x$15.00/per trip) ~
4728 No Parking Signs
MISCELLANEOUS ($1/each or $25/100)
Other (Please Specify)
4722 Street Tree Planting/Removal Permit ($150.00 + $500 deposit)
`Engineer's Estimate shall be as approved by the City Engineer.
NAME OF APPLICANT ~• (~ ,~ I' ;t ~ - .. ~' ` ~'
TOTAL
`:~ ~~l ~~ / ---
$ ~~ C~ ~.
NAME OF PAYOR .. '~ _C PHONE ~ -
ADDRESS ~
i L. ~' - L 7 ~ ~ ~ IP
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"Actual Cost Plus 20°~6 Overhead (Non-Interest bearing deposit) ' " ~' ."
FOR RECEIVED BY ~~'"'~
ITV CLERK
ONLY t '? ~
~~' '7~ z >? ._ .
Date ~ {j~ Receipt # 1 `T~' `"
;
.;
"`For Plan Ch eck and Cash Deposits, send yellow copy to Finance.
te/ nitials j
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STK# 6i; 276i
~'~I~
c~ ' Newport InsurancE Company
~INSURANCEGROU?
P.O. Bol 25140 • Santa Ana. CA 92799-5140
PA~'MENT NO'I'1CL:
Date oi'Notice: OS-U4-20Ut;
Police 'Term: 06-22-2008- 06-22-2UU9
Mail To:
2zo-2zo
HIMANSHU VAISHNAV AND DARSHANA
1 148 E CAMPBELL AVE
CAMPBELL, CA 95008
Covered Property:
1 148 E CAMPBELL AVE
CAMPBELL, CA 95008
For Customer Service Call: (800) 894-0976
For Claims Call; (888) 768-2096
Policy Number Company Program
THN 000300833 Newport Insurance Company Preferred
Agent:
21ST CENTURY INS SERVICES, INC
SERVICED BY COUNTRYWIDE INS
SV
994 FLOWER GLEN
SIMI VALLEY, CA 93065
Invoice #
2889611
Payor
Insured
Payment Plan Method of Payment ~ Due Date Premium Balance Payment Amount
Insured Bill -Annual ~~~ Direct Bill 06-22-2008 $926.00 { $926.00,
Payment ~ '~..~,__ . -
If payment is not received by 06-22-2008 your policy will cancel due to non- payment of
premium
IF YOU HAVE ALREADY MADE YOUR PAYMENT, PLEASE DISREGARD THIS NOTICE
Keep for your Records
Picric ,~.CtaG1', and re~lii, t1;lS S: ctleII wau `y'ell; Ci~CCi:.
DO NOT STAPLE. Do not mail cash or other correspondence i" t `'
~% ~~=;~7
Do not return this section
Policy Number: THN 000300833
Invoice Number: 288961 I
Make checks payable to: Named lnsured•
Newport Insurance Company HIMANSHU VAISHNAV AND
DARSHANA Due Date 06-22-2008
PLEASE DO NOT SEND CASH Method of Payment ~ Direct Bill
PaymentAmount ~ $926.00
Insured Bill -Annual Payment Newport Insurance Company
PO Box 10439 Amount Paid
~
Van Nuys, CA 91410-0439
Date of Notice: May 4, 2008
~I~~~nn~~~~n~~n~~~~n~~~un~n~n~~~~i~u~~~n~
INSURED COPY
200814000300833220109190000926007
kt=NEWAL
t'~
Balboa
'"'u"""" `"°°' Newport Insurance Company
P.O. Box 25140 • Santa Ana. CA 92799-5 l 40
HOMEOWNERS POLICY DECLARATIONS
Mail To:
367 - 6789
HIMANSHU VAISHNAV AND DARSHANA
1148 E CAMPBELL AVE
CAMPBELL, CA 95008
Covered Property:
1148 E CAMPBELL AVE
CAMPBELL, CA 95008
Named Insured:
HIMANSHU VAISHNAV AND
DARSHANA
1148 E CAMPBELL AVE
CAMPBELL, CA 95008
Agent:
21ST CENTURY INS SERVICES, INC
SERVICED BY COUNTRYWIDE INS
SV
994 FLOWER GLEN
SIMI VALLEY, CA 93065
Agent Code: 614502
Customer Services provided by Countrywide Insurance Services on behalf of your Agent. For Customer Service, call
Countrywide Insurance Services: (800) 894-0976.
For Claims Call: (888) 768-2096
Policy Number Company Program
THN 000300833 Newport Insurance Company Preferred
Policy Period
From: 06-22-08 To: 06-22-09
12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE RESIDENCE PREMISES
Coverages Limits of Liability Premium
Section I
Coverage A -Dwelling $364,000 $728.00
Coverage B -Other Structures $36,400
Coverage C -Personal Property $182,000
Coverage D -Loss of Use $72800
Section II
Coverage E -Personal Liability (each occurrence) $500,000 $33.00
Coverage F -Medical Payments (each person) $5,000 $13.00
INSURED COPY
H605E-OOE1104 Pagc 1 of 2
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Date: February 17, 2009
TRANSMITTAL FROM THE PUBLIC WORKS DEPARTMENT
TO: Himanshu Vaishnav
1148 E. Campbell Avenue
Campbell, CA 95008
FROM: Joanne M. D'Ambrosia, Office Specialist
RE: 1148 E. Campbell Avenue
Encroachment Permit #ENC2009-00012
Enclosed is a check in the amount of $500.00 representing a refund of your Faithful
Performance Security, plus accrued interest, in connection with the above property.
~~.~-h ~
~~
Joanne M. D'Ambrosia
Office Specialist
Enclosure
.~~ - iii ~ i. ._ run~~~x~~ a i;~~ni~, :: ~)tiili L; -13r, I'.CI-any, ~ ~~~ ..A`, il~. O.'!~1~n i.~..,~ IU, Sn~~. _,. ,.,
CITY OF CAMPBELL
Account
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VENDOR NO . 10 0 0 9 4 9 9 cxECl_ NO . ~ 2 016 4
AYriUUf1( ~PSCrl D11011 ~~
Purchase Order- Im~oice Nu~nher
COL ":i?hOM ~~~._ E2E? ~._,
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~x)yav~~ wMntism~ vni>n~ti'n~
CHECK DATE CHECK N0.
~~'~~r,, CITI" nF CAMPBELL t,ANK OF AMERICA 11-3s 02 / 16 / 0 9 22 0164
,
7Q NQR i H FIRST STREET
~'~ ~C CAMPBELL OFFICE
200 .rHE PRUNEYARn 1210
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-
CAMPBELL, CALIFORNIA 95008
" cAMpEEnL, cA 9s00e AMOUNT ~ *******500.00* ~!.
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~^ JCID AFTER 9C DP.YS O'
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PAY THE SUM OF FIVE HUNDRED DOLLARS & ZERO CENTS ~',
~.
~ro Tr;c ~ HIMANSHU VAISHNAV E'Il~~
~~zn~R 114 8 E CAMPBELL AVE
CAMPBELL CA 9 5 0 0 8 CYL~~
11' 2 20 L6411' ~: L 2 L000 3 58:000 6 2 2080 2 4 911'
~r~ i ~~r ~~s rsirac ~r~~truc~~®rs~%
CITY OF CAMPBELL
70 NORTH FIRST STREET
CAMPBELL, CALIFORNIA 95008
HIMANSHU VP_ISHNAV
1148 E CAMPBELL AVE
CAT~!PBELL CA 95008
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February 2, 2009 ~:ITh' «t~ (;1-~MP'BELL
!'iihlic V`(4n~lcs I?i~~»rtmri~t
l~imanshu Vaishnav
].148 E. Campbell Avenue
('ampbell, CA 95008
SUB7ECT: PERMIT NO. ENC2009-00012
LOCATION: 1148 E. Campbell Avenue, Campbell
FINAL INSPECTION AND ACCEPTANCE
Dear Mr. Vaishnav:
'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
faihires 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.
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 Dave any questions, please call me at (408) 866-2165
Sincerely,
Syed ahidi
Public Works Inspector
MQ ,E.
cc: Suspense - 11 months
Permit ~/ENC2009-0(}012
Inspector File
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