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X51-0896 p.3
Print Form
CITY OF CAMPB1:Ll H-1 ENCt?OACHMEf~I' PicRMIT Permit No. ~/fit -~I - ~6ti~3
DEPT. OF Pl3BLIC N1flRKS (titan-engineered work within the public right-of-way} X-Ref File -.~-~
7o Nortfi First Street tS t0A00.00 maximum value of warki Application Date x;,21 i (
Cerrspbell, CA 95448 ~ /C I' I Appiicat3on Expiration /( i
Rh. (a0i3) s66-zt54 E55UED: / Date ~, f
Fx. (4481376-4958 Perr.~it Expiration Date: ~ APN ~~ - y 7 ~ V~ -~l
APPlICATiON - Application is hereby made for a Ptablic Works permit in accordance vrith Cam pbeii Municipal Code, Section 11.04.
(gpplication expires in 5 monti~s if the permit 1s net issued,)
A. Work Address:
$. Nature of Wotk:
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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 become a part ofthis permit.
+~, Ali work she!! conform to the City of Campbelt Standard Specifrcations and Details for Public Works Construction; the General Permit
Conditions listed on the reverse side; and the SFeclal Provisions for this permit, listed below. Faklure to abide by these ronditions and
provisions may result in job shutdown and/ar forfeiture of faithful Performance securities.
L
NAf~IIEOF APPLICANT: ~` ~ ~ ~~ ~ ~ ~ ~ ~ ~ r ~ S Telephone: ~ 7 ~ G ~ ~ ~ t ^ ~ ~; 3
Address: ` J ~ t7
E-Mail Address: ~ ~a Gr~.+{p
The Applicant hereby confirms thatthis work is being done by the property owner/applicant at their awn residence.
The Applicant hereby agrees by afbxing their signature to this permit to hold the Ciry of Campbell, City of Campbell Redevelopment Agency, its
officers, agents, and employees Eree, 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 urtderstar:d both the front and back of this permit, and that they will inform their
contractor(sj of the information. ,y ~~ f,?J
1~, a.~ c~ cYll..e X i,.t Gt~ ~~ 3 7 l;v
ACCEPTED: _~. `~" Cl T Dade
(Aoolr ~ nt/Permittee} (Sign)
NOTES: All work shall ton form with the attached approved plans and ail applirabfe Campbell Standard Details and Conditions and applicable
insurance requirements.
She Contractor must stave this permit and approved plans and must arrange to meet wltis the Public Vlrorks inspector at the sate at least two days
before starting work. hlotite must be given ao Public Works at least 20. hours before restarting any work.
Per Section x215 of the Government Cade this permit is not valid for excavations until Underground Service Alert (USA) has been notified and ihF
inquiry identification num!}er [Ticket No.) has been entered hereon. USA Phone: I-840-227-2600. Ticke[ No..
Applcant is advised that upon issuance of. this permit property owner, ar propery owners successors, shall be responsible for any and all
damages arising out of the desig n, insialiation or condition of private improvements in the public right-of-way.
SPECIAL PROVI510NS
7. Prior to any work, the property owner shall execute an Agreement far Private Improvements in the Public flight-of--Way, which steal 1:e
recorded.
2.
3.
STANDARD AMOUNT RECEIPT NO.
SECURITY FC?R FAITNFUi. PEHFOIiMANICE (1 U096 Of Engr's Est.) 5~.-...-~-
IR-i PERM3TFE>: - S
II ?~~I I t ^_
~APPRtiJVED i'C-R {55t1ANCE: ~ -- for City Engineer Dace
Permit Fxpires 6 Months after Date of Issuance.
RECEIVE
MAR -8 2~~`~
`h ~; in'i.~~ iii
PUBL(C WORKS
Mar 08 11 03;48p lukkyme 751-0896 p.4
6~f~HRAL PERMf7 C~h1D1T14j~ES
1. Payment of a security to insure faithful perr"orrnance ants completion of the work is required. This security is refundable upon
cam pietion of the work and wzi?ten aueptance by the City.
7.. A one-year maintenance period far al! work is required. Such period wil! 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 wiii be ini;fated by the written acceptance of the work ley the CEty.
4. T:~e Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City wlEl be
made in writing to the Perm it[ee.
5. Maintain sar'e pedestrian and vehicular Crossings and free aaess to private driveways, fire hydrants and water valves.
5. 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.
Sawcut for aiE PCC and AC removals. Alt PCC removals shall be to nearest scoremark and shall be doweled to existing improvements.
R. Adequate signing and barricading is required an the job site. Failure to provide such signing and barricading as specified by the Cit•r
Engineer may result In the City`s providing such signing and barricades and charging the cost to the Permittee,
9. The Contractor or Permittee wiii have a supervisory respresentativeevailable farcontact on the project at all times aunng
construction.
10. This permit shall be kepi at the site of work and m ust be shown to any authorized representatives ofthe Ciry of Campbell or any
law enforcement offices upon demand.
', ' . h!o storage of materiels or equipment will be allowed near the edge of pavement, within the traveled way, or within theshouldedine,
which would create a hazardous condition to the public.
12. This permit shall not be construed as authorization for excavation ar,d grading a n private property ad}acentto the workor any other
work far which a separate permit may lee required, nor does it relieve the Permittee of any obligation to obtain any other permit
required by law.
i 3. This permit does not release the Permittee from any liabilities contained in othes agreements or contracts with the Ciry and any other
public agency.
tc. This permit is r.ot transferable. Work must be perrormed by the Permittee or his designated agent orrontractoras speafied thereon,
15. Prtor approvaE of inspector is requirea for any work done after normal wodcing hours, On weekends or holidays and may require
reimbursement of inspection Costs at the current overtime rate.
~ b. Cali back fcali out} due to emergencies regarding this permit shall he at the current overtime rate with a three (31 hour minimum
charge per occu rrence.
17. if the public i merest requires a modification of, ar a departure from, the plans and specifications, the City shall have the authority to
require or approve any modification or departure and Co specify the manner in which the same is to be made for Ciry-owned or
maintained facilities.
18. Ptrrsuant to Chapter 14.02of the Campbell Municipal Code, applicant shall not cause to 6e discharged any material into the
municipal storm drain system otfierthan storrr. water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by
the Santa Clara iJaltey Urban Runoff Palluiion Prevenvon Program.
Applicant shall be responsible far ensuring that all those providing services under the applicant are aware of and uncerstand all of the above
conditions.
r
Applicant
Date
J:\FCAMATempla:e5'.Entroa[hrnentPermrts\R-i EntroachrnentPerrnitSiATlCform2.pdf
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Mar 08 11 03:47p lukkyme - X51-0896
MEf~O CDPY
UNIGARD INSURANCE COh1PANY
P, O. BOx 90701 Bellevue, N/A. 980x$-0701
Policy No: 20080390 Issued: 0612 512 01 0
CR 01
p.2
Agent: SUNR RISK SERVICES OF CALIFORNIA INS SRK Policy Period:
Agent Phone No: (408) 510-5440 16135 PSAC SEE BACKIFOR PROPERTY/Lp1CATl0{V~S}
UNiGARD POLICYHOLDER 8 MAILING ADDRESS:
Protecting
Niargaral Adkins You C ~ ~
28205 Stonington Way Since 2005
Escondido CA 92026-6632
Dwelling Fire Renewal Statement
UNIGARD INSURANCE COMPANY is pleased to offer you a renewal of your
dwelling fire policy for an additional one year. The renewal premium
is $1 262.00. For your coverage to continue, we must receive a
minimum premium payment postmarked before 08/1 9120 1 0. I f we do not
receive this payment your policy w~11 expire on 081191201 0 at 12'.01
A.M. A Check or Money Order will be deemed a valid payment when
honored by the bank.
You may select one of the following four payment options.
(SEE REVERSE SIDE OF NOTICE FOR OPTIONAL PAYMENT DETAILS)
Amount
Oplion Method $1.282.00
A Full Payment: $ 432.33
B Budget Payment: $ 218.60
C Monthly Payment. $ 11fi.54
D Check-Saver Payment.
!f you elect Option B, your second payment will be glue on 1 1 12 812 01 0.
1 f you elect Option D, SIGN AND RETURN THE ENCLOSED AUTHORIZATION.
10D'T2 XE 1-91
ppLICY TtUMBER PREMIUM DUE BY
20080390 08!19!2010
Policy expires on Premium Due Date
unless Renewed by Premium Payment.
A Check or Money-Order will be deemed
payment when honored by the bank.
I f you have any questions about this
sEalement, p1Q7Se CtJiS18Cl your dgent. A Full Pay Pfan $1 ,282.00
or
t3 sucludlesa$5POOnservice charge}
C {Monthly Pay Plan $ 218.66
Includes $5.00 service charge)
D (Check-Saver Plan $ 116.54 0
0
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Please do nol wr11u Dai ow :his Ilea.
20060390620iG09070412$200040043233000021866604fl116546