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ENC2006-00054CITY OF CAMPBELL R-111., FEE ENCROACHMENT PERMIT tN C 20 °G - oaa5t1 r .,.mit No DEPT. OF PUBLIC WORKS X-Ref. File 70 North First St. (Non-engineered work within the public right-of--way) Application Date 4 aG Campbell, CA 95008 ($5,000 maximum value of work) (408) 866-2150 /1~ ` / a Application Expiration Date ~ ti ~ Fax (408) 376-0958 ISSUED -T I ` ~ (~ 5 ~ 2~ - y~ APN ~ y ~ Q Permit Expiration Date v 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.) /~ G A. Work address _ ~ ~ 9 x'11 ~ p~/-4~Mt~QR H ~f2 ~ /-~ n'1 p ~~~ ~ ~. 9 sd U 0 B. Nature of Work RE~Ai'R DwY ~PP~~cN 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 [o existing improvements. When approved by the City Engineer, said drawing becomes 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 A P P LICANT T Q4 1 R 1 L' t tl f~ _ ~~ C C_ o R v e ~i TELEPHONE -3 ~ ~ ' ~ 7 9 ~ 7 / ADDRESS ! f q _ ~/. . L !4'Tj jvt 2 (print rime e e ~ b r b ~ ~ ~ ~ /~ ~ .J 0 Q f( E-MAIL ADDRESS N/~f The Applicant hereby confirms that [his 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 i~Snttnation. ACCEPTED ~~-oC (Stgn) /T 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 lmprovements in the Public Right-of-Way, which shall be recorded. 2. 3. STANDARD SECURITY FOR FAITHFUL PERFORMANCE (l00°rh OF E13P APPROVED FOR ISSU for City Engineer Permit Expires 6 Months After Date of Issuance. ~ a6 Date J:\forms\rlpermit Revised 1.20.04 _l~ ~y,~ `~ N ~ ~\ 1 AMOUNT RECEIPT NO. GENERAL PERMIT CONDITIONS 1. PaRyment 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 al] work is required. Such period will begin on date of acceptance by the City. 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 or AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements. 8. Adequate signing and 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 bamcades and charging the cost to the permittee. 9. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. ]0. This permit shall be kept at the site of work and must be shown to any authorized representative 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 by law. 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. ]4. 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. 18. 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. 19. 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 all of the above conditions. ~~ ~-i~-~ Date J:\forms\rlpermit Revised 1.20.04 Allstate insuran~- company RENEWAL Deluxe Plus Homeowners Policy Declarations summary - _ NAMEfl 1NSURED(S) YflttR ALLSTATE AGENT i1S: CONTACT YOUR AGENT AT: Patricia McCorvey Kenneth R Jackson (408) 247-7995 179 W Latimer Avenue 1713 E! Camino Real Campbell CA 96008-1106 Santa Clara CA 95050 POLICY NUMBER POLICY PffllflD PflEMiUM PERIOD 0 14 264594 06/12 Begins on June 12, 2005 June 12, 2005 to June 12, 2006 at 12:01 a.m. Pacific Time at 12:01 a.m. Pacific Time and continues until cancelled LOCATION OF PROPERTY INSURED 179 W Latmer Avenue, Campbell, CA 95008-i 106 MORT6AGEf(S) {Listed in order of precedence) • COUNTRYWIDE HOME LOANS INC ITS SCR5 ~/OR ASSIGNEES ATIMA PO BX 961206 Ftwx 22 Fort Worth TX 76161-0206 Loan/`Q22423385 + THE CIT GROUP ITS SUCCESSORS &/OR ASSIGNEES P 0 Box 7731 Springfield OH 45541-7731 Loan /` 16!4612 Tote! Premium f©r the Premium Period Your bil! will ba mailed separately) Premium for Property Insured $652.00 --- TOTAL i652,0A IIAIB~kAA~IIII111111A~@NAAAIIIIIINUI :.. Allstate Insurar-~a Company PoNey Number. 0 14264594 O6jt2 Your Agent: Kenneth R Jackson (408) 247.7995 for Premium Period Beginning: Jurta 12, 2005 POLICY COVERAGES AND LIMITS OF LIABILITY COVERAGE AND APPLICABLE DfDUCTiBLES (See Policy ror Apptfcaple Terms, Conditions and Exetusions) LIMITS OF LIABILITI' Dwelling Protection -with Building Structure Reimbursement Extended Limits • $500y All Peril Deductible Applies $234,662 -- ther Structures Protection -- • $500 All Peril Deductible Applies $23,466 Personal Property Protection -Reimbursement Provision - _- _• $500, Afi Peril Deductible Applies - ~`-_----- -- -- - $115,997 Additional living Expense --- -`----°--- _~---- -_-------- -- -. ---- Up To 12 Months amity Liability Protection ___ --~- ---- - -~- -- _ Guest Medical Protection $100,000 each occurrence ----y--- -__-.._ _ - Suifding Codes - $1,000 each person ~ -- -- - --_ _-~___ __.~---- --__ ---_--- ---`~-- - 2.'_-- Reter to Policy Workers' Compensation and Employers' liability - -------- - ~-- Coverage #or Residence Employees Statutory/See Form his policy does not cover earth movement including earthquake You have elected not to purchase a CEA earthquake policy DISCOUNTS Your premium reflects the following discounts on applicable coverage(sj: 55 and Retired i 0 ~° Home and Auto Claim Free 20 ~° 15 Protective Device Rate Applied RATING INFflRMATtflN The dwelling is of Frame construction and is occupied by 1 family ~:~~, ~ ~: ~~ Z