ENC2006-00099CITY OF CAMPBELL R-1 NO FEE ENCROACHMENT PERMIT Permit No ~ ~' ~ ~'`~~ - O ~O G)~
DEPT. OF PUBLIC WORKS X-Ref. File
70 North First St. (Non-engineered work within the public right-of--way) Application Date ~ /
Campbell, CA 95008 ($5,000 maximum value of work) 2 -7 /v~
(408) 866-2150 G / / Application Expiration Date ///
Fax (408) 376-0958 ISSUED ~~ I~ ii
APN~U~ `~~~~~ll~
Permit Expiration Date ~ ~ U
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 is,~~s~~ued.)
A. Work address ~ L ~ ~''~'I' K ~'~ V ~? ~ ~ '~"~
B. Nature of Work f~~N1pV ~ ~ ~~~~ ~ _ pfd K ~-[~ ~ ~ ~ _ R-~,~4h ~ ~+V~E~-t 5 ° 1J
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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 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. 3~~ ~~ ~ S ~
1 ~ ~~-
NAME OF APPLICANT \ 1 ~~ ~~1~ / TELEPHONE ~~ ~ ~'~~-'
L (Z .. L~ C~ `a1
ADDRESS ~~Z~ ~~ print_n,~ ~ ~ ~`/"~~'~ t- r ! ~ C ~;
E-MAIL ADDRESS i't Yt - Cr ` ~t~ E'er(- ~ -' ~~.
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 ~ad and understand both the front and back of this permit, and that they will inform their
contractor(s) of the information.
ACCEPTED ~- ~'~ --~ G' 2 j 1 ~~
.~ {Applicant/Permittee) (Sign) Date
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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 a[ 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 NO.
SECURITY FOR FAITHFUL PERFORMANCE (100% OF NG. EST.) $
APPROVED FOR ISSUANCE C Z'J/G~
for City E gineer Date
Permit Expires 6 Months After Date of Issuance.
J:\forms\rl ermit "'
Revised 1. 0.04 ~( v\ \w \\,~
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California State Automobi sociation
Inter-Insurance Bureau
Homeowners Policy Declarations
~~; vdl? .ors- ~~--,1G<-
See Important Notices on Reverse
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For questions or changes call: 1-800-922-8228
AMENDED RENEWAL Pa
f 01
e 01
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g
MEMBERSHIP NUMBER HOMEOWNERS PO LICV NUMBER
PREMIUM DIFFERENCE- $0,00 ~ 201-24-86-3 Hp- 05-23-94-4
NAMED INSURED AND MAILING ADDRESS ~
~~I~Ill~l~l~~lll~~lt 1~11~111~'I~III~III~~III~~II~I~I~~II~11~1~ ~ FRO M ;12:01 A.M. Standard Time at the
LEE JEFREY M/JENNY W ~ ~ address of the Named Insured,
o but not prior to the time
626 PARKHURST DR LL applied for or, if this is a
9-25-2005
CAMPBELL CA 95008-3711 ? Your
replacement Declarations, not
POIICy
rior to the tim
} p
e coverage
U Period : change was requested.
J
To 12:01 A.M. Standard Time at the
a 9-25-2006 address of the Named Insured.
ALT: PREMIUM TO BE PAID BY'. PRIMARY SECONDARY
LOCATION HOME . 408-496-7438 I NSURED X
of 626 PARKHURST DR
INSURED
PROPERTY CAMPBELL CA 95008-3711 MAI
L DO REP DO REP NO. SP INST TERR PROT PREM GRP PROCESS DATE
CLASS
45 06 386 200 25 2 62 08-26-2005
COVERAGES AND LIMITS OF LIABILITY: Insurance is provided only with respect to the following coverages for which a specific
limit of liability is shown, subject to all conditions of this policy. The limit of liability for this structure (Coverage A -Dwelling)
is based on an estimate of the cost to rebuild your home, including an approximate cost for labor and materials in your area, and
specific information that you have provided about your home. SECTION II
SECTION I E F
A B C D PERSONAL LIABILITY MEDICAL PAYMENTS TO OTHERS
OTHER PERSONAL (Personal Injury 8 Property Damage)
DWELLING STRUCTURES PROPERTY LOSS OF USE EACH OCCURRENCE EACH PERSON EACH ACCIDENT
S 321,800 S 32,300 S 161,000 S 64,500 S 1,000,000 S 1,000 S 25,000
SECTION I ONLY:
YOUR SECTION I COVERAGE LIMITS HAVE BEEN CHANGED TO REFLECT CHANGES IN
CONSTRUCTION COSTS AND OTHER MATTERS AFFECTING REPLACEMENT COSTS.
SECTION II: ADDITIONAL RESIDENCE PREMISES, IF ANY, LOCATED: (Number, Street, City, State)
NUMBER FORMS AND ENDORSEMENTS MADE PART OF THIS POLICY AT TIME OF ISSUE
BUILDING CODE UPGRADE COVERAGE - $25,000
THIS POLICY DOES NOT PROVIDE EARTHQUAKE COVERAGE
HO-3 HOMEOWNERS POLICY - SPECIAL FORM - $1000 DEDUCTIBLE.
438 BFUNS LENDER'S LOSS PAYABLE ENDORSEMENT.
HO-28 LIMITED HOME REPLACEMENT COST ENDORSEMENT - 150% OF COV A
HO-48 APPURTENANT STRUCTURES.
ADDL LIMIT OF LIABILITY $35,000,00
HO-60 $1000 DEDUCTIBLE,
HO-90 WORKERS' COMPENSATION & EMPLOYERS' LIABILITY - CA.
PRIVATE RESIDENCE EMPLOYEES - CLASS 0910.
MORTGAGE SERVICING COMPANY/ MORTGAGEE
FIRST HORIZON HOME LNS
ITS SUCCESSORS/OR ASSIGNS
PO BOX 7481
SPRINGFIELD OH 45501
SECOND MORTGAGEE
FIRST HORIZON HM LN CORP
ISAOA
PO BOX 7481
SPRINGFIELD OH 45501
AUTOMATIC RENEWAL This policy will be renewed
FIRST MORTGAGEE NAME IF OTHER THAN MTG. SVC, CO. aUlOmatlCally SUb)eCt t0 the premiums, rules and forms
in effect for each succeeding policy period. If our rules
do not allow this policy to be renewed, we will give
DISCOUNTS/BENEFITS APPLIED. y0U written notice as required by law.
10°,6 FIRElBURGLAR ALARM TOTAL BALANCE
10750904
(OVER)
POOC00
1ST MORTGAGE LOAN NO.
0040438582
2ND MORTGAGE LOAN NO.
0054976212
PREMIUMS
INCL
88.00
-332.00
INCL
BASIC POLICY PREMIUM
g 1,170,00
ADDITIONAL PREMIUM
$ -244.00
TOTAL POLICY PREMIUM
g 926.00
S $0.00
g 926,00
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 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 barricades 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.
10. 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.
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.
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 ensuriy~ that all those providing services under the applicant are aware of and understand al] of the
above conditions. '" /
~- ~231~
Aoplic nt Date
J:\forms\rlpermit
Revised 1.20.04