ENC2004-00119CITY OF CAMPBELL R-1 NO FEE ENCROACHMENT PERMIT Permit No ~ ~~ ~ .~ G>C> ~~' Ll ~~~~
DEPT. OF PUBLIC WORKS X-Ref. File
70 North First St. (Non-engineered work within the public right-of-way) Application Date O
Campbell, CA 95008 ($5,000 maximum value of work)
(408) 866-2150 Application Expiration Date//`J~
Fax (408) 376-0958 ISSUED ~ / ~ ~ L/ p
APN ~~lf _ 13- ~p
Permit Expiration Date ~/ / // y
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
B. Nature of Work ~~/-~/~i~ I/%' G~7/t-~~G%Zl=~l_-= /~A/.~%~ ~Jl/~/L'/ / ! C ~.
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 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 APPLICANT ~f /t~G~N~ ~ ~~~~.~-~-~ TELEPHONE~~SCY~'.~ -~G"°~~
(print name)
ADDRESS C'~~'iGc~ ~T ~~G~1~/C/~ ~~ ~~- C% ~S~
E-MAIL ADDRESS
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 information. ,~/~ ~~
ACCEPTED -~%'t/ //~ C ~1-CZ- ~>~~~ ~/ l~ ~U
(Applicant/Permittee) (Sign)
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 AMO ,, ~ RECEIPT NO.
SECURITY FOR FAITHFUL PERFORMANCE (100% OF ENG. EST.)
~J ,
APPROVED FOR ISSUANCE ~ (./ LC4Ct v
for City Engineer '~ Date
ti
~ Permit Ex fires 6 Months After Date of Issuance.
J:\forms\rlpermit V i ~` ° ~
Revised 1.20.04 ~~~ ~~ ~ ~\~
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PROTECTOR PLUS DECLARATIONS
FIRE INSURANCE EXCHANGE, LOS ANGELES, CALIFORNIA HOMEOWNERS
Replaces all prior Declarations, if any
TRANSACTION TYPE:CHANGE IN MORTGAGEE AND~OR LOAN NUMBER
The Policy Period is effective (not prior to time applied for) at described residence premises.
POLICY NUMBER POL.IGY PERIOD POLICY EDIT{ON
ISSUING OFFICE:
FROM: TO: STANDARD TIME P . O . BOX 19 0 0
91997-63-31 05-21-2004 03-29-2005 12:01 A.M. 04 pLEASANTON, CA 94566
This policy will continue for successive policy periods, if: (1) we elect to continue this insurance, and (2) if you pay the renewal
premium for each successive policy period as required by our premiums, rules and forms then in effect.
INSURED'S NAME & MAILING ADDRESS: LOCATION OR DESCRIPTION OF RESIDENCE PREMISES:
(Same as mailing address unless otherwise stated.)
GERALD DONAGHY AND VINCENT MCCULLAGH
3656 W CURTIS DR
570 20TH AVENUE SACRAMENTO CA 95818
SAN FRNCSCO, CA 95818 -
94121-
DESCRIPTION OF PROPERTY
YEAR Of
CON5TRUGTION
OONSTRUGTION T/PE
FOOF TYPE NUMBER
OF.UNITS
DGGUP:4NCY
1926 FRAME ASPHALT COMPOSITION 001 OWNER
COVERAGES - We provide insurance only for those coverages indicated by a specific limit or other notation.
SECTION 1 - PRl7PERTY SECTION II -LIABILITY
'
ANNUAL
_
A- DWELLING OR B -SEPARATE E-PERSONAL D -LOSS OF E -PERSONAL F,MEDICAL PAY PREMIUM
M061C;E HOME (OTHER) STRUCTURES PROPERTY u$E LJABItITY T9 OTH&RS'
$320,000 $32,000 $240,000 $160,000 $300,000 $1,000 $1,705.21
Each Occurrence Each Person
ENDORSEMENTS
ENDORSEMENT EDITION' DESORIPTION
NUMBER NUMBER
CA015 lED ENDORSEMENT AMENDING SECTION II- LIABILITY,COV-PERSONAL L
E4040 lED ENDORSEMENT AMENDING SECTION II - EXCLUSION
E4207 lED EXCLUSION AMENDING SECTION II - LIABILITY
E6008 2ED AMENDING PERSONAL INJURY - PROTECTOR PLUS
E6044 3ED BUILDING ORDINANCE OR LAW COVERAGE ENDORSEMENT
E6047 2ED EXTENDED REPLACEMENT COST
E6179 lED AMENDING SECTION II - LIABILITY EXCLUSIONS
E6268 lED AMENDING DEBRIS REMOVAL COVERAGE AND POLLUTION EXCLUSION
H6106 lED SPECIAL LIMITS ON SPORTS CARDS
H6114 2ED AMEND SECTION I - LOSS NOT INSUR NB-SPF TP PTP
IMPORTANT NOTICE - ADDITIONAL ENDORSEMENTS SHOWN ON BACK
DISCOUNTS
50 PLUS, NON SMOKER, AND EXPERIENCE RATING PLAN DISCOUNTS HAVE BEEN APPLIED TO YOUR
POLICY.
DEDUCTIBLES POLICY ACTIVITY
$1 , 5 0 0 Deductible is applicable to covered losses under
Coverage A, B, C.
NONE
NONE
Previous Balance
Premium
Fees
ANY "TOTAL" BALANCE
Payments or Credits OR CREDIT $7.00 OR
LESS WILL BE APPLIED
TO YOUR NEXT BILLING.
BALANCES OVER $7.00
Total ARE DUE UPON RECEIPT.
This Declarations page is part of your policy. It supersedes and controls
anything to the contrary. It is otherwise subject to all other terms of the policy
AGENT: David F . Kelly
AGENT PHONE: (916) 631-9797 AGENT NUMBER: 95 33 376
Countersignature
i~~\/
Authorized Represents e
56-5279 1ST EDITION ,o-s~ (Continued on the Reverse Side) 05 - 24 - 2004 G-oz cez~s,,,
S ~ ~ ~~,
S~wMlNfgrW S~iw
Keep with your policy showing the same policy number as dais endorsement.
Effective ENDORSEMENT
Date: 05-21-2004 91997-63-31
Policy Number of the Company designated
ADDITIONAL ENDORSEMENT CONTINUED inlheDeclarafions
ENDORSEMENT EDITION DESCRIPTION
Ni7MBER NUMBER
258531 103 CA NOTICE OF INFORMATION PRACTICES
438BFU 542 LENDER'S LOSS PAYABLE ENDORSEMENT
This endorsement is part of your policy. It supersedes and controls ariydling to the contrary. It is od~erwise
subject to all od~er terms of die policy.
Countersigned
Authorized Repres tative
91-0052 ISTEDIiION 7-03
E0052101