Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
ENC2012-00123
Print Form CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No 2r/'~ ~ CSI z ~ DEPT. OF PUBLIC WORKS (for working within the public X-Ref. File 70 North First Street ri ht- f-way) Application Date ~,' ~ 7- ~%) L Campbell, CA 95008 ~ sue- ~ Application ExpiratiocntDate Ph. (408)866-2150 Issued / ` APN ~,~ _ GCS UAL, Fx. (408) 376-0958 ___~/~~~fj /l? Permit Expiration Date !! // » APPLICATION -Application is hereby made for a Public Works Permit in accordan e with Campbell Municipal Code, Section 11.04. (Application expires in six (6) months if the permit is not issued. Application Fee isnon-refundable.) A. Work Address or Tract No.: ~ ~~ ~ C~/I-~~S Utility Trench Location: B. Nature of Work: ~~~ C. Attach four (4) copies of an engineered plan showing the location acid extent of the work, and four (4) copies of the preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer, said plan 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 Sureties and cash deposits, (See General Permit Conditions 1 and 2.) E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work. Name of Applicant ( C.-- Telephone: ~ ~ ~; ~ _ ~ , ~~~"~ / ~ a (/ /q Address: V?/ -~ i ~?~il'r- ~G (...-t~vy~ ~ T ~ ~ if~-,`~ ~ <r'. 7~ ~~~~ E-Mail Address: ~~~ , r r 2 ~ I ~ G~<vf ~ ?~ MERGENCY PHONE NUMBER: ~h' ~ _ ~ y Cx'~' Is this work being done byvthe property owners at their own residence? ~ YES ~ NO The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers, agents, and employees free, safe and harmless from any claim or demand f~tFam~ges resulting from the work covered by this permit. The Applicant/Permittee I contractor(s) of the info responsible for any all Accepted: ~~ y acknov~edges tFi t they have read and understand both the front and back of this permit, and they will inform their on. Appli ant is a vised that upon issuance of this permit, property owner, or property owner's successors, shall be g s arisin~,out oft e condition of any private improvements in the public right-of-way. ~-~~ (Applicant Permittee) (sign) (Contractor) (Print Name) Date Date iSPECIAL PROVISIONS: 1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts ma e ~pecifically~poroved by the Inspector prior to cutting. 2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A",unless otherwise approved by the Engineer. 3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public Works Department before starting work. 4. 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 has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO. 5. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be recorded. 6. Public Notification Requirements: SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO. PERMIT APPLICATION FEE 5 PLAN CHECK DEPOSIT 5 SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS 5 (~Ui CONSTRUCTION CASH DEPOSIT 5 ~ ~ 4 ~ Z y PLAN CHECK & INSPECTION FEE S_ - ,_y EMERGENCY PERMIT FEE ~'/II~j - 5 .SO~~ 7 U t-t ~ 7 `~ APPROVED FOR ISSUANCE For City Engineer Permit Expires 12 Months Aker Date of Issuance GENERAL PERMIT CONDITIONS I . A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency call-out, overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. 3. Refund or the cash deposit balance and 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, bus stops, fire hydrants, and water valves. 6. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures, detours, and street closures. This plan must be reviewed and approved prior to any lane closures. 7. A Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated 1990, available at Caltrans. Traffic control equipment shall include Type II flashing arrow signs if required. 8. 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. 9. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements. 10. 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. 11. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost (including all labor and materials) against the cash deposit. 12. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 13. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m. 14. No storage of materials or equipment will be allowed near the edge of pavement, the traveled way, or within the shoulderline which would create a hazardous condition to the public. 15. 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 maybe required, nor does it relieve the Permittee of any obligation to obtain any other permit required bylaw. 16. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 17. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 18. Call back (call out) due to emeregencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence. 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. 20. 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. 21. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and phone number. Applicant shall be res~afisible for~gnsuring that all those providing services under the applicant are aware and understand all of the above conditions. /~ -/d Appl 1 ~i~ ~, Contractor (Print Name) Date: 0 ~j' D ~ Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev. 09/10 ~~ O~ CA~A~ ~ r U r' 0 0 a ; 9~ G~ ~RCHAgO Transmittal Name: nna Thomason Title: (~u~ce Assistant City of Campbell Department of Public Works 70 North First Street Campbell, CA 95008 Phone: (408) 866-2701 Fax: (408)376-0958 E-Mail: Joannat@cityofcampbell.com To: Wade Ng Date: July 1, 2013 Re: Refund of Construction Deposits. Permit ENC 2012-00123 ^ Urgent ^ For Review ^ Please Comment ^ Please Reply ^ For Information & Use Enclosed please fmd a check in the amount of $5,375.00 representing 75% your Faithful Security Deposit and your Construction Cash Deposit in the amount of $500.00 for the Encroachment Permit referenced above. -you, JoAntaa Thorii~son Office Assistant cc: Project File No. ENC2012-00123 J:UoAnnallDeposit refunds\CHECK REQUESTS\Ck Transmittals\Use this.DOC (Rev. 03/08) CITY OF CAMPBELL vENDOR No . 10 01218 5 CHECK N0. 242184 Account Purchase Orcler Invoice Number Amount Descri lion 101 2203 CR062513 5,375.00 DEPOSIT REFUND OF'C`Ut~, CITY OF CAMPBELL wEnLS'Fa CHECK DATE CHECK NO. RCO saNx, N.A. 11-24 ~~• ~t~' 70 NORTH FIRST STREET 420 MONTGOMERY STREET izio 07/01/13 242184 - , C: ~_' CAMPBELL, CALIFORNIA 95008 sAN eRaxcxsco, ca 94104 °,. ~ AMOUNT ~ *****5 , 375. 00* ~' '~ ~. • ~ ~Rr~IAR~ VOID AFTER 90 DAYS ~' n D: PAY THE SUM OF FIVE THOUSAND, THREE HUNDRED SEVENTY FIVE DOLLARS W! & ZERO CENTS t TO THE WADE NG / v ORDER 261 CHRISTOPHER AVE Z/ / //~~ " of L ' y ~! CAMPBELL CA 95008 ~I'242L84u^ i:L2100024B~: 4L2~8554LSu^ CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 WADE NG 261 CHRISTOPHER AVE CAMPBELL CA 95008 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR ONE YEAR MAINTENANCE ACCEPTANCE LETTER Encroachment Permit # ENC2012-00123 Property Address: 261 Christopher Ave., Campbell CA 95008 Date of Final Inspection: On File: ^ Bonds ^ CD ^ Cash SC Faithful Performance $ (75% of Deposit) $ 4,875. 00 ^ Labor and Material $ Construction Cash Deposit to be released: $ 0 .00 ^ Other overdue deposits to be released (Description): Processed by: Administrator Reviewed by: Inspector Reviewed by: < Land Development Engineer J:UoAnnaT\Deposit refunds\CHECKLISTS\Checklist -1 yr maint.doc (Rev. 10/11) ~1Y•CA~71 ti ~~ U ~'. •"~<crinR~~ CITY of CAMPBELL Public Works Department June 20, 2013 Mr. Wade Ng 261 Christopher Ave. Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2012-00123 261 Christopher Ave. FINAL INSPECTION AND ACCEPTANCE Dear Mr. Ng: 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 failures 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. The Construction Cash Deposit of $500.00, and 75% of the Faithful Security deposit in the amount of $4,875.00 plus any interest due, is now being processed and will be sent to you under separate cover. If you have any questions, please call me at (408) 866-2165. Sincerely, Syed Wahidi Public works Inspector Cc: Inspector/Permit File Suspense File -11 Months 7Cr North First Srreer Campbell, California 95008-1423 ~ret 408.806.2150 enx 408.376.0958 1'~~ 408.866.2790 ~~~~ I h C' C~ ~~ ~.G ~J~ r~; ~~7 ~~~~ ~~,I ~ fp ~c ~,~~ ~' X12 sc~ t'~ `' ~~~" h ~P SI ~U ~ ~' ~-, ~ ~M J,~.J~? (~-,: , r~-~',P /C' ~'a ~.±c'~ , C/~..C~ (',+ ;.~I' ~..t..s' ~i`1 f ~,~, 4 f, / 1~ _ ~ , ~~ f O~ CAM ~~ A~c~ ~ ~ U r a o ~ ~ s ~ F G. O ~,CH ARO Transmittal Name: JoAnna Thomason Title: Office Assistant City of Campbell Department of Public Works 70 North First Street Campbell, CA 95008 Phone: (408) 866-2701 Fax: (408) 376-0958 E-Mail: Joannat(~cityofcampbell.com To: Wade Ng Date: July 7, 2014 Re: Refund of Construction Deposit. Permit ENC 2012-00123 ^ Urgent ^ For Review ^ Please Comment ^ Please Reply ^ For Information & Use Enclosed please find a check in the amount of $1,625.00 representing the remaining 25% your Faithfiil Security Deposit for the Encroachment Permit referenced above. Office cc: Project File No. ENC2012-00123 J:WoAnnaT\Deposit refunds\CHECK REQUESTS\Ck Transmittals\Christopher Ave.261.NgB.DOC (Rev. 03/08) CITY OF CAMPBELL vENDOR NO . 10 01218 5 CHECK NO. 247218 Account 101 2203 PurchaseOrder InvorceNumber CR061614 Amount 1,625.00 Descri xion 25a FPS RE1'UftN IW12185 WADENG c ~n CHECK DATE CHECK N0. os •~n.nr , CITY Or CAMPBELL W :~~a FARG~ BANK, N.A. 11-24 ~ 1~ 0 MONTGOMERY STREET 1210 • 0 7~ 0 7~ 14 2 4 7 2 1 8 ~C 70 NORTH FIRST STREET r, FreANCxsco, cA 9aloa ~~ L r CAMPBELL, CALIFORNIA 95008 625. 00* AMOUNT ~ *****l ~ 0 o ;, , ~'. ~`' C> VOID AFTER 90 DAYS ~. °kruaRp D. ~ PAY THE SUM OF ONE THOUSAND, SIX HUNDRED TWENTY FIVE DOLLARS c~ : ~' m; r ZERO CENTS ` E- TO THE WADE NG ~~~l~ ~~~ ~~ ~ ~~~- oxnER 261 CHRISTOPHER AVE v ~ "" " oF CAMPBELL CA 9 5 0 0 8 /~OYL~9~ n'24?2L811' ~:~2L000248~: 4L2~8554L511' f I CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 WADE NG 261 CHRISTOPHER AVE CAMPBELL CA 95008 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR ONE YEAR MAINTENANCE ACCEPTANCE LETTER Encroachment Permit # 2012-00123 Property Address: 261 Christopher Ave. Date of Final Inspection: 6/ 13/ 14 On File: ~ Bonds ^ CD ^ Cash Faithful Performance $1625.00 ~ Labor and Material $ ^ Construction Cash Deposit to be released: $ ~ Other overdue deposits to be released (Description): f Processed by: •, .,' ,. ~ U A inistrator \ Reviewed by: ~_- - Inspector Reviewed by: ~ ~ ~ ~ Z ~~ Land Development Engineer J: VoAnnaT\Deposit refunds\CHECKLISTS\Christopher261 #2.NG.doc (Rev. 10/ 11) l Y • C.,9 ~1 ~~ ~~ '~ V r' "~l~r~nhr. CITY of CAMPBELL Public Works Deparnnent June 25, 2014 Mr. Wade Ng 261 Christopher Ave. Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2012-00123 261 CHRISTOPHER AVE. ONE YEAR MAINTENNACE INSPECTION AND ACCEPTANCE Dear Mr. Ng: The City of Campbell has made the final one year maintenance inspection of the subject Public Works improvements and finds that no remedial work is required. Your warranty requirements and any surety, therefore, are hereby released. The remaining 25% of the Faithful Performance Security Deposit in the amount of $1,625.00 is now being processed and will be returned to you under separate cover. Sincerely, `. ___ ~~ Syed Wahidi Public works Inspector Cc: Permit #ENC 2012-00123 70 Noah First Srreer Campbell, California 95008-1423 rF.i. 408.8(i6.Z] 50 rnx 408.376.0958 'ri~o 408.866.2790 Ref undnble Deposit Check Request To: Finance Director Check Payable To: Address -Line 1: Line 2: City: Description: Account Number: Account Number: Account Number: (Finance Dept only) Total Payable: ade N '~' \ ~U I W g 261 Christopher Ave. Campbell State: CA Zip: 95008 25% FPS Return ENC2012-00123 101.2203 Amount: $1,625.00 Amount: 101.540.7448 Amount: _ Interest Earned $1,625.00 (Exact Amount) (Finance Dept only) Purpose: Remaining 25% Refund of FPS Voucher #: Permit #: ENC2012-00123 Receipt #: 244728 Date: 9/5/2012 Requested by: Title: PW Inspector Date: Syed W hidi Approved by: ~ Title: City Engineer Date: ~ ~ 1 Michelle Quinney Finance Dept Only: Verified by: Approved by: Title: Accounting Clerk II Date: Title: Accountant Date: Species Instructions For Mail As Is: ~~"~ Mail in Attached Envelope: Returr~~To: JoAnna Thomason (Name) ther: andlinQ Check Check: ;ded By: Public Works (Department) f/n: Forms/excel/chkreq - Revised OS/00 `1~•CA~f ~ ~~ V r CITY of CAMPBELL Public Works Department %, June 20, 2013 Mr. Wade Ng 261 Christopher Ave. Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2012-00123 261 Christopher Ave. FINAL INSPECTION AND ACCEPTANCE Dear Mr. Ng: 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 failures 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. The Construction Cash Deposit of $500.00, and 75% of the Faithful Security deposit in the amount of $4,875.00 plus any interest due, is now being processed and will be sent to you under separate cover. If you have any questions, please call me at (408) 866-2165. Sincerely, Syed Wahidi Public works Inspector Ca Inspector/Permit File Suspense File -11 Months 70 1~lorrh Pirst Street Campbell, Ca(iEornia 95008-1423 ~i~F=t 408.866.2150 rwx 408.376.0958 Tn~ 408.866.2790 To: Finance Director Check Payable To: Address -Line 1: Line 2: City: Description Account Number: Account Number: Account Number: (Finance Dept only) Total Payable: Ref undnble Deposit Check Request ~ ~~~~ Wade Ng 261 Christopher Ave. Campbell State: CA Zip: 95008 Deposit Refunds 101.2203 Amount: $5,375.00 Amount: 101.540.7448 Amount: Interest Earned $5,375.00 (Exact Amount) (Finance Dept only) Purpose: Refund 75% of FPS ($4,875.00) and Emergency Cash Deposit ($500.00) Voucher #: Permit #: ENC2012-00123 Receipt #: 244728 Date: 9/5/2012 Requested by: -----~"'`-" Title: PW Inspector Date: ~ v~C 13 Syed ahidi ~t Approved by: Title: ~/_~ 1 ~ I Dater ?~ ~~ Finance Dept Only: Verified by: Approved by: S eci~ alGl it As Is: Return o: i Other: Title: Accounting Clerk II Date: Title: Accountant Date: ructions For H Mail in Attached Envelope: JoAnna Thomason (Name) Interim Check: Check Needed By: Public Works (Department) f/n: Forms/excel/chkreq - Revised O5/00 PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1, 2012 TO: City Clerk PUBLIC WORKS FILE NO. 7~1 Z - UUI z 3 PROPERTY ADDRESS Please collect & recei t for the followin monies: ACCT. ITEM AMOUNT __ LAND DEVELOPMENT 4 ncroac ment ermlt Icatlon e~ Non-Utilit Encroachment Permit Ma'or >_$10 000 $370.00 Minor Encroachment Permit <$io,ooo $210.00 Initial R-1 Permit N/C N ~ Subse uent R-1 Permits within Two Year Period $205.00 Street Tree Plantin /Removal N/C 2203 $500 er Tree Plantin De osit Re uired $500.00/tree 2203 Plan Check De osit 2°/D of En ineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Gradin & Draina a Plan Review Sin le Famil Lot $260.00 Site < 10 000 s.f. $780.00 Site ? 10 000 s.f. < 0.5 Acre $1 040.00 Site ? 0.5 Acre $1 560.00 4722 NPDES Review C3 Re uirements For projects not required to submit numeric sizinq $150.00 For protects required to submit numeric sizinq Im envious Area 10 000 S . Ft to 1 Acre $650.00 Im envious Area 1 Acre or more $850.00 Plan Check & Ins ection Fee Non-Utilit 4722 En r. Est. u to $250 000 14°/D of En ineer's Estimate "2203 En r. Est. >_$250 000 Actual cost +20% Admin Overhead Min $35 000 De osit ' 2203 Emer enc Cash De osit 4°/D of En r. Est.' $500 min/$10 000 Max ~vU.Qo 2203 Faithful Performance Securi FPS 100°/D of ENGR. EST." cC~'a 2203 Labor and Materials Securit 100% 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 Ma 4 Lots or Less $3 700.00 + $80/lot 4722 Final Tract Ma 5 or More Lots $4 500.00 + $110/lot 2203 Monumentation Securit 100°/D of ENGR. EST. 4920 Parkland Dedication Fee 75°/D/25% Due U on Cert. of Occu anc 4722 Lot Line Ad ustment Includes Certificate of Com liance $1 750.00 4722 Vacation of Public Streets & Easements $2 340.00 4722 Certificate of Com liance $1 765.00 4722 Certificate of Correction $520.00 4722 A eat Filin Fee $200.00 4722 Nota Fee er si nature $10.00 4722 Assessment Segregation or Reapportionment First Split $830.00 Each Additional Lot $260.00 511.7424 Postage MI 'CELLAN E if __ Other Please S eci 'Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. "Actual Cost Plus 20% Overhead (Non-Interest bearing deposit) TOTAL $ ~p0,0C~ NAME OF APPLICANT I ~ PHONE NAME OF PAYOR / ADDRESS ~~ I ~~t v t ~ ~ '? ~? " ZIP G7 C, / -~ FOR RECEIVED CITY CLERK ONLY Date _ _ ~ ~~ Recei t # Date! Initials J'.~FORMS\TSmplatesWtlministrative\Recaipt Form lantl Development 12-13 PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1, 2012 ~ TO: City Clerk PUBLIC WORKS FILE NO. Z ~ 12 ` ~ ~Z PROPERTY ADDRESS ~ - I / i <.~ - n~~ Please collect & recei t for the followin monies: -ACCT. ITEM AMOUNT LAND``DEVELOPMENT - 4 2 - - ncroac ment ermlt Ication ee Non-Utilit Encroachment Permit Ma~or?$10 000 $370.00 Minor Encroachment Permit <$io,ooo $210.00 Initial R-1 Permit N/C Subse uent R-1 Permits within Two Year Period $205.00 Street Tree Plantin /Removal N/C 2203 $500 er Tree Plantin De osit Re uired $500.00/tree 2203 Plan Check De osit 2°/D of En ineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Gradin & Draina a Plan Review Sin le Famil Lot $260.00 Site < 10 000 s.f. $780.00 Site ? 10 000 s.f. < 0.5 Acre $1 040.00 Site ? 0.5 Acre $1 560.00 4722 NPDES Review C3 Re uirements For projects not required to submit numeric sizing $150.00 For protects required to submit numeric sizing Im ervious Area 10 000 S . Ft to 1 Acre $650.00 Im ervious Area 1 Acre or more $850.00 Plan Check & Ins ection Fee Non-Utilit 4722 En r. Est. u to $250 000 14% of En ineer's Estimate "*2203 En r. Est. >_$250 000 Actual cost +20% Admin Overhead Min $35 000 De osit 2203 Emer enc Cash De osit 4% of En r. Est.* $500 min/$10 000 Max 2203 Faithful Performance Securit FPS 100% of ENGR. EST.* 2203 Labor and Materials Securit 100% 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 Ma 4 Lots or Less $3 700.00 + $80/lot 4722 Final Tract Ma 5 or More Lots $4 500.00 + $110/lot 2203 Monumentation Securit 100% of ENGR. EST. 4920 Parkland Dedication Fee 75°/D/25°/D Due U on Cert. of Occu anc 4722 Lot Line Ad'ustment Includes Certificate of Com Hance $1 750.00 4722 Vacation of Public Streets & Easements $2 340.00 4722 Certificate of Com Hance $1 765.00 4722 Certificate of Correction $520.00 4722 A eat Filin Fee $200.00 4722 Nota Fee er si nature $10.00 4722 Assessment Segregation or Reapportionment First Split $830.00 Each Additional Lot $260.00 511.7424 Postage MI5 ELLANE U Other Please S eci 'Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. _ "Actual Cost Plus 20% Over ad (Non-Interestt bearing deposit)] TOTAL $ ~.~~~ , NAME OF APPLICANT ~~'~~' +~{ ~ 1,~ NAME OF PAYOR,..:~+'-~ - PHONE ~9 7 - y ~~ ~ ~~ ADDRESS ~ ~] ~ ~f~~/~ ~~~ # ~T ZIP c~ ~2`- FOR RECEIVED BY .` W~-~, ~~ ~~. ~ ~~ _~ CITY CLERK ONLY _ 'J Date ~ Recei t # Z~~~ ~ a f ~ f~ "~; - ~ : ~- ~.: t ~ . . , , Dates tnitia~s' J:IFORMS1TemplalesUtlminiaValiveVtecaipt Form Lantl Development 12-13 EXPRE-2 OP ID: GH '~'~`j"~ CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDDlYYW) 08122/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER 916-369-8793 Brocklnsurance A enc NAME: g y Lic. OE48158 888-243-0928 PHONE qfC No Ext : A1C No 9700 Business Park Dr. Ste 100 E-MAIL Sacramento CA 95827 ADDRESS: , Daniel E. Brock fNSURER(S) AFFORDING COVERAGE NAIC N wsuRER A : Lan d m a rk Am erica n 33138 INSURED Art8~CarlCorporation E INSURERS: xpress Concrete Breaking 8~ Cutting INSURER C P.O. Box 103 INSURER D San Martin, CA 95046 INSURER E INSURER F I.VVtKAIitJ CERTIFICATE NUMBER• REVISION NUMBER• THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS , EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY X LHA135662 10105111 10!05112 PREMISES Ea occurrence $ 50,D00 CLAIMS-MADE ~ OCCUR MED EXP (Any one person) $ Excluded PERSONAL & ADV INJURY $ 1 000 000 , , GENERAL AGGREGATE $ 2 000 000 , , GEN'L AGGREGATE LIMIT APPLIES PER'. PR PRODUCTS- COMPlOP AGG $ 2,000,000 O- POLICY X T LOC $ AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per person) $ AUTOS AUTOS NON OWN BODILY INJURY (Per accident) $ HIRED AUTOS - ED AUTOS PROPERTY DAMAGE $ Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y ! N ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERfMEMBER EXCLUDED? ^ N f A E.L. EACH ACCIDENT $ (Mandatory In NH) If yes describe untler E.L. DISEASE - EA EMPLOYEE $ , DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $ DESCRIPTION OF OPERATIONS f LOCATIONS! VEHICLES (Attach ACORD 701, Additional Rsmarks Schstlule, If more space Ic required) Jobsite: 261 Christopher Ave. Campbell, CA (home). THE CITY OF CAMPBELL, ITS OFFICERS, EMPLOYEES AND VOLUNTEERS ARE NAMED ADDITIONAL INSURED PER TTACHED IN REGARDS TO GL ON PRIMARY BASIS. CITY OF CAMPBELL 70 N 1ST STREET CAMPBELL, CA 95008 CITYCAM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 {2010!05) v ly~tl-[uiu ALVKU cUKPUKATION. Ail rights reserved. The ACORD name and logo are registered marks of ACORD ~+~ EXPRE-3 OP ID: GH ACORO' ~ CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 08!24!12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S-, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(Ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certtficate holder in Ifeu of such endorsements . PRODUCER 916-364-7380 NAME: Sierra Oak Insurance Services 916-364-7381 Lic# OC97528 PHONE AIC No E# : A1C No 9700 Business Park Dr. Ste 105 EMAIL ADDRESS: Sacramento, CA 95827 Dora Brock INSURER(S) AFFORDING COVERAGE NAIC >r INSURERA:GOIden Ea le Insurance Cor 10836 INSURED Art 8~ Carl Corp INSURERS: Everest National Insurance CO 10120 Express Concrete Breaking 8~ INSURERC: Cutting P O Box 103 INSURER D . . San Martin, CA 95046 INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDrrION OF ANY CONTRACT OR OTHER DOCUMENT WrrH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE POLICY NUMBER MM1DDlYYY MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ A A COMMERCIAL GENERAL LIABILITY PREMISES Ea occu« ence $ CLAIMS-MADE ~ OCCUR MED EXP (Any one Derson) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS- COMPIOP AGG $ POLICY PROT- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1 DDO,DOD $ r A ANY AUTO BA8801163 tD/D2H1 1D/Q2l12 BODILY INJURY (Per person) $ ALL OWNED AUTOS X SCHEDULED AUTOS BODILY INJURY (Per accident) $ X X NON-OWNED T^DAMAGE Pe aER $ HIRED AUTOS AUTOS d UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY X WCSTATU- OTH- I Y 1 N B ANY PROPRIETORlPARTNERIEXECUTIVE X 7600009221121 05/01112 05!01/13 E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED9 ~ NIA 1 ~OO D00 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE , , $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS! LOCATIONS 1 VEWCLES (Attach ACORD 101, Additional Remarkc Schedule, if moro space is required) Jobsite: 261 Christopher Ave. Campbell, CA (home).Waiver of subrogation in favor of THE CITY OF CAMPBELL, ITS OFFICERS, EMPLOYEES AND VOLUNTEERS applies to WC. lv~~ ~~~~ ~' '~ L SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF CAMPBELL ACCORDANCE WITH THE POLICY PROVISIONS. 70 N 1ST STREET AUTHORIZED REPRESENTATIVE CAMPBELL, CA 95008 CITYCAM OO 1988-20'10 AGORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD California (STATE) COMPANY NUMBER 10836 INSURANCE IDENTIFICATION CARD COMPANY ~ COMMERCIAL ~ PERSONAL Golden Eagle Insurance Corp. POLICY NUMBER BA8801163 YEAR MAKEfMODEL 1996 Zieman Trailer AGENCYfCOMPANY ISSUING CARD Sierra Oak Insurance Services Dora Brock 9700 Business Park Dr. Ste 105 Sacramento, CA 95827 916-364-7380 INSURED ~ Art and Carl Corporation P.O Box 103 San Martin, CA 95046 EFFECTIVE DATE EXPIRATION DATE 10102111 10!02112 VEHICLE IDENTIFICATION NUMBER 1ZCE24S25TZP19207 SEE IMPORTANT NOTICE ON REVERSE SIDE THIS CARD MUST BE KEPT IN THE INSURED VEHICLE AND PRESENTED UPON DEMAND IN CASE OF ACCIDENT: Report all accidents to your Agent/Company as soon as possible. Obtain the following information: 1. Name and address of each driver, passenger and witness. 2. Name of Insurance Company and policy number for each vehicle involved. THE FRONT OF THIS DOCUMENT CONTAINS AN ARTIFICIAL WATERMARK -HOLD AT AN ANGLE TO VIEW ACORD60 WM (2007103) ©ACORD CORPORATION 1993.2007. All rights reserved. EXPRE-3 GH LANDMARK AMERICAN INSURANCE COMPANY This Endorsement Changes The Policy. Please Read It Carefully. ADDITIONAL INSURED BLANKET- PRIMARY AND YOUR WORK This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM SCHEDULE Name of Person or Organization: Jobsite: 261 Christopher Ave. Campbell, CA (home). THE CITY OF CAMPBELL, ITS OFFICERS, EMPLOYEES AND VOLUNTEERS A. SECTION II -WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the SCHEDULE, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations; and/or "your work" defined for the additional insureds) designated above included in the "products-completed operations hazard". B. If you are required by a written contract to provide primary insurance, this policy shall be primary and SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance does not apply, but only with respect to coverage provided by this policy. This endorsement effective 10/5/2011 forms part of Policy Number LHA135662 issued to Art & Carl Corporation by Landmark American Insurance Company RSG 15017 1207 Includes copyrighted material of Insurance Services Office, Inc. 1984 (1185) with its permission NSURANCE REQUIREMENTS CHECKL' ~~V ~. ,~ ,~, CIP Project # The following insurance is required of all contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: $1,000,000 per occurrence, and ^ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggregate limit. ^ Policy expiration date 1~~ Aut otive Liability: ^ 'Any Auto" checked on certificate -- \~`~~ ~ ~ ~~'~~ca Cj~' ~ ~'~\~ ~- $1,000,000 per accident for bodily injury and property damage ^ Policy expiration date _ ~ ~~ 7~~ 2.~ --~- Workers' Compensation and Employer's Liability ^ Waiver of Subrogation clause $1,000,000 per accident for bodily injury or disease ^ Policy expiration date 1 Course of Construction (if required in Special Provisions) ^ Completed value of the project ^ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement ^ The City, its officers, employees and volunteers are named as additional insured. ^ The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: ^ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR should say: ^ Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. ^ Workers' Compensation Insurance Sheet Submitted ^ For General Contractor ^ For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 07/11) Page 1 Acceptability of Insurers ^ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. n Name: f • _~~>~~~~ ~c1S\~~~~ ~IVAIC # 1t; ~~ atin •~ ~/ g. ~ Authorized in CA: j Name: v ~ ~S~' ~~\ T S~, CG• NAIC # l~G Rating:~~-- )x~/ Authorized in CA: T . Name: L~c~~c~.yvlc,. ~. ~vy1Fv ~cc~~+NAIC # Rating: '~ ~`\\ Authorized in CA: ~/ Name: NAIC # Rating: Authorized in CA: Campbell Business license # ~{~ ~~~~ Lx~~ ~ \ .~ ( Insurance Certificate Reviewed -Z~-~Z_ Initials ^ Copy of Insurance Certificate placed in tickler file on Date prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 07/11) Page 2