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ENC2011-00088CITY OF CAMPBELL ENCROACHMENT PERMIT DEPT. OF PUBLIC WORKS (for working within the public 70 North First Street right-of-way) Campbell, CA 95008 ~, ~ I Ph. (408) 866-2150 Issued Fx. (408) 376-0958 Q ~ I Z Permit Expiration Date t, Tom, Print Form Permit No r--~ ~ ~ I ~ - ~~~-~~ X-Ref. File _ Application Date _ I Application Expiration Date 11 APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable.) A. Work Address or Tract No.: ~ ~lt~ S ~ (~ C ~-~ ~~ ~~ Utility Trench Location: B. Nature of Work: ~'~ ~C~ `~~ ~ ~-tt`'~ L ( (7 i r?C (~ ~~ S 7 C. Attach four (4) copies of an engineered plan showing the location and 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: ~ Telephone: ~ ~ .~ ~ ~.vGi e ~ /~ ~ ~ ~ ~~ ~J y~ Address: I~yS ~~/f'/~~~'~~ ~y/ ~S~q~.J fcy~'' ~ ~ 9~/z ~j- E-Mail Address: 24-HOUR EMERGENCY PHONE NUMBER: ~~~ Is this work being done by the property owners at their own residence? ~` YES C" NO III 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 for damages resulting from the work covered by this permit. The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. 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 t~ conditio rivate improvements in the public right-of-way. ___---- --- .---~ Accepted: ,- ~ ~ ~ J ~ ~~r1// (Applicant Permittee) (sign) «, (Contractor) (Print Name) Date %/ SPECIAL PROVISIONS: 1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may bebe ~pecifically~poroved by the Ins ep CtOr 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 421 S 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: 7 SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT PERMIT APPLICATION FEE $ ~ .~C~ PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK & INSPECTION FEE $ ~C7 EMERGENCY PERMIT FEE $ APPROVED FOR ISSUANCE For City Engineer Permit Expires 12 Months After Date of Issuance RECEIPT NO. 236 2`~ 2 -`1 ~'l ~fi~~l Date f: ~ t -'1 ~ ~ i ~~, i `/ i_ GENERAL PERMIT CONDITIONS 1. 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 thejob 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 responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions. . _ ~rJ,. __ Applicant Date: Contractor (Print Name) ~ ~ /r Da e: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev. 09/10 TO: City Clerk PUBLIC WORKS DEPARTMENT LAND DEVELOPMEN I ~ I KArr~c rctctir i Effective July 1, 2011 ~ ~ ,~ ~ I ~ G ~~ ~~ PUBLIC WORKS FILE NO. PROPERTY ADDRESS ~ 7~{ ~ ~ ~ If~C E~ ~~~~ Please collect & recei t for the followin monies: ACCT. LAND DEVELOP ITEM MENT AMOUNT ncroac ment ermlt Icatlon ee Non-Utilit Encroachment Permit $360.00 Minor Encroachment Permit <~to,ooo $205.00 Initial R-1 Permit N/C Subse uent R-1 Permits within Two Year Period $200.00 Street Tree Plantin /Removal N/C 2203 $500 er Tree Plantin De osit Re uired $500.00/tree 2203 Plan Check De osit 2% 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 $255.00 Site < 10 000 s.f. $765.00 Site ? 10 000 s.f. < Acre $1 020.00 Site ? 1 Acre $1 530.00 Pla n 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% 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 $3 675.00 + $80/lot 4722 Final Tract Ma 5 or More Lots $4 490.00 + $108/lot * 2203 Monumentation Securi 100% of ENGR. EST. 4920 Parkland Dedication Fee 75%/25% Due U on Cert. of Occu anc 4722 Lot Line Ad~ustment Includes Certificate of Com fiance) $1 730.00 4722 Vacation of Public Streets & Easements $2 295.00 4722 Certificate of Com fiance $1 730.00 4722 Certificate of Correction $510.00 4722 A eal Filin Fee $200.00 4722 Nota Fee er si nature $10.00 4722 Assessment Segregation or Reapportionment First Split $815.00 Each Additional Lot $255.00 511.7424 TRAFFIC 4728 Postage Traffic Fiow Ma Dail Traffic Volumes $34.00 4728 Si nal Timin Information $72.00/Hr 4271 Truck Permits $16.00/ er tri 4728 No Parking Signs MISCELLANEOUS $1/each or $25/100 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 $ NAME OF APPLICANT ~~( ~ 1~1 ~ ~~CZI~C~~~ ~b"1 ~ 7 2 G NAME OF PAYOR ~ ~ PHON ~2 ~~~ ~ ~ ~ ~l ~ ADDRESS ~~(c~l ~ L!` , QS • ~~(7V~ ~C.`jC ~tS I Z ~ ZIP FOR RECEIV D BY CITY CLERK ONLY ~ ~ 'Date Z Recei t# C'! lj *For Plan Check and Cash Deposits, send yellow copy to Finance. ~' `'" "' `~'`` Date! Initials J'1FORMS\TemplalesWtlmin~elreliveWecaipl Fwm Lantl Devebpmenl Traffic 1112 SINGLE LANE AND CENTER TURN LANE CLOSURE , 5 LANE STREET I~G FT a~~ >~ aroa I I e ®e ® ®~ STREET NAME ~i/9,3l~frs ~ AfJ~ BETWEEN ('pn~OtrN A/c' AND 3~ POSTED SPEED ALL LENGTHS ARE MINIMUM DISTANCES UNLESS OTHERWISE NOTED PLACE SIGNS ON ALL SIDE WORK ®~ ZONE ®I ®_ I ®) ®I I I ® I 0® ®® ~ ti INDICATE NORTH DRAWING NOT TO SCALE DOWNSTREAM TAPER 100 FT per lane maximum VARIABLE AS NEEDED WORK SITE ADDRESS ~~ (~ FT BUFFER SPACE OPTIONAL ~(' FT=L MERGING TAPER FT=''/zL COL' FT STREETS, WITHIN THE ( I ~ I TRAFFIC CONTROL ZONE -~ I I bn FT FOR DIMENSIONS CONSULT I I CITY OF SALEM I I aosED "TEMPORARY TRAFFIC CONTROL ~~ SPACING TABLES" ~~'C> FT I I I I ROAD W W ~ ~ ~ Sight distance shall be maintained at all public and private intersections and driveways. If sight distance is not achievable, prior approval by the City Traffic Engineer is required to either restrict turn movements or use flaggers and shall include coordination with the affected property/business owner(s). (TCP REF) LC-105 ~ii~i of y.'.2,~ t: -._, ~rif"i> .t`~k Li ~~'~~: d ~'~ y c;i'1iI1,'FFk~teti rUllriY'S t+nlE: 1~li~~l? tip ~~ ~'! ,F: .. ::~ Hi7t~t~ ~Y }~ ~:~Z~' ~t S~Ft~tjlJ I'T~t~~i3 ~ -• .;+1ti~ a ~~i~jiTiJ ; ?~..t;ta F r; ~: r - ~~ ~U. G ~~ 3£i: i~;=i 5 ;~itri:HyS ~~ ~ 1~~, iJt~' Tt.t'~~I~~~it: x.ul! ~~~~/~> Mr. Gil Acosta Information Services Coordinator West Valley Sanitation District 100 E. Sunnyoaks Ave. Campbell, CA 95008 /~ , Subject: ~7~6 ~~,~,,~el~ ~,1~~-~Q, Plans submitted show the following sources of wastewater: 3~.•~daic Range 1 ~ ~ ~`~`~~3~ C~, .i Floor Drains No. / ~~ ~ Dishwasher _.. _ _ __ .. _____._ Garbage_Grinder _. __ _____ f Pot Sink s) No. / 3 ~~uli.Z"h,~:2~t.Q" Seating Capacity: ~© '~ _ /~ Floor Sinks No. ~~, ~~ C~-~ / Other REQUIREMENTS: !' ~ hp, ~ ~''~- n-~'.• 2 ~L;' Clarifier CEO Pound grease trap t~ ~' ~~ Gallon grease interceptor Gallon per minute power operated grease removal device No requirement This unit is to be plumbed to accept the wastewater flow from the items checked below: Wok Range Floor Drains No. Dishwasher Floor Sinks No. Garbage Grinder ;,/ Mop Sink (EMF) (/ ~~ Pot Sink(s) No. 1 ~./ Other _ colvrn~NTS: ~~// ~ ~~, Sincerely, ~ ~ ~ U ~h(,J ~+~--a. Enviro ntal Tnspec~o ngineer /;,~ '"f~~ cc: Plan check Unit, County Health Dept. n~Qa,,~U,~~ ~ ~ ~~r ,~ "' •~~ ~ ~t !~-LC~ ` ~r~~.~ ~~~. ` ~~ ~ ~ ~ ~ ~-...~-~..'-t~... City of San Jose Environmental Services Department Watershed Protection Division San Jose City Hall 200 East Santa Clara Street, 7th Floor San Jose, CA 95113 Directions from Highway 680 South/280 North and 280 South: • Take Highway 87 North • Exit Santa Clara Street/Downtown San Jose • At the light, turn right onto Santa Clara Street heading east • Turn right on 6th Street • Look for the parking garage entrance on the right-hand side Directions from Highway 101 South: • Take Highway 87 South • Exit Julian Street/St. James Street • At the light, turn left onto Julian Street • Julian Street becomes East St. James Street • Turn right on 6th Street • Once you pass Santa Clara Street, look for the parking garage entrance on the right-hand side Parking Once at the City Hall Garage (Basement), park and take the elevator identified as "Tower", which will take you to the 1St Floor of the Office Tower. At 1St floor get off this elevator and take the elevators by the information desk to get to 7th floor to our Watershed Protection Reception Desk. Parking validation is available at the Reception Desk. GREASE REMOVAL DEVICE CERTIFICATION FORM I acknowledge the 6 grease trap/irE#e~ept~r being required for l ~ ~i O ° C.~.e~Qa.,c. ~.a.Q was sized based upon the plans and information I submitted to the E Watershed Protection group. I certify that the questionnaire submitted for the food service facility is accurate. I have read and . understand the regulation requiring the grease trap/interceptor be maintained in efficient operating condition by periodic removal of accumulated grease. I have read and understand the regulation prohibiting the use of chemicals to clean out the grease trap/grease interceptor. I agree to do the following to maintain the grease removal device. ~stablish routine cleaning of a grease trap or interceptor. ~rease traps must be cleaned monthly, or more frequently if needed to meet the discharge limit of 150 ppm of grease, oils and/or fats. b. Grease interceptors must be pumped out every three months, or more frequently if needed to meet the discharge limit of 150 ppm of grease, -_ -oils~rad/or-fat . _~___ ~2)~Size and location of grease removal device must be kept on site, along with cleaning schedule and cleaning instructions. ~ H log of grease trap cleaning, and/or copies of grease interceptor pumping cleaning and maintenance, must be maintained on site for at least three (3) years and made available for inspection and/or copies furnished upon request. acknowledge additional equipment and maintenance steps may be required, 1) if the information and plans, as submitted are changed, 2) the use of the site is changed, 3) and/or the grease trap/grease interceptor is not maintained as agreed to. I acknowledge that I will comply with the requirements of installing additional equipment and/or performing additional maintenance steps if the Watershed Protection Group determines these measures are required., I will inform the Watershed Protection Group of any change in management or ownership. Signature: ~~ Title: ~ ._ M R ~v ~ ~ ~ Print Name: ~ ~ (~ ~ ~ ~•~ 4' ~ (. ~ ~ Date: n }~~ ~/ll Revised 10/03 ENVIRONMENTAL SERVICES DEPARTMENT (ESD) SAN JOSE/SANTA CLARA WATER POLLUTION CONTROL PLANT FOOD SERVICE FACILITY WASTEWATER DISCHARGE QUESTIONNAIRE * FOOD SERVICE FACILITY PLAN CHECKS ARE DONE BY APPOINTMENT ONLY CALL (408) 945-3000 FOR AN APPOINTMENT SEE BACK OF ATTACHMENT FOR PLAN CHECK LOCATION All restaurants or other food service facilities which discharge to the San Jose/Santa Clara Water Pollution Control Plant are required to complete a wastewater discharge questionnaire and submit it to the ESD Watershed Protection Group. Use current operating data, if available, or your best estimate based on similar types of businesses. Answer all questions: Please Print 1. Facility Name: ~ ~ U S~ ~ ~ ~-\- ~ ~ 2. Address: jT-S~ W i~1( ~P ~~ t'~' ~ ~`f ~~ C4,~k~u~ ~ CA ~~Q~~ 3. Facility Manager/Owner: ~ ~~, ~ ~~J o (3 ~~. ~ Facility Phone #: L~~ ~- SAS ~',~Y,S _ 4. Emergency Contact: o ~ ~ s Phone #: '~ Q ~~ ~ S 3 y ~ ~- 5. Building Owner: ~ F~1 ~, ~ ~ ~ ~ ~ p ~ }'f I ~ S 6. a. Type of facility (i.e. fast food, dinner house, etc.)(: P ~ V1 b. Type of food served: (~-~ 1 ~ ~ ~~1~ M~ ~ ~ `~ k } k4 1~1 ~'~ ~~, L h ~ ~C c. Is food prepared from scratch:~..~ / d. Food will be served on ~_disposable V washable dishes 7. a. Average number of employees: b. Days/hours of operation:~~~ - 1 G ~ ''" c. Seating Capacity ~ d. Busiest hours of day: 1..~-111 C~) ~ I~ I k~11 Q~ e. Maximum- number of meals served per hour: ,s f. Peak process discharge rate to sanitary sewer: Gal/hr. 8. Wastewater generating activities/points of discharge: (Check all that apply) ( )Cup/Glass Washer ('1) Pot Sink(s) # ()Dishwasher # of Compartments ~L/ (~ Floor Drain(s) # ~~~~ Sanitary (restrooms) (~ Floor Sink(s) # 3/~~ ()Self-cleaning Hoods ( )Garbage Can Cleaning ()Soup Vat ()Garbage Grinder ()Trash Compactor ()Grill Hood Cleaning (N~ (~ Vegetable Sink(s) # / ~NJ (~ Range(s) # 1 ~G ~t~tn.e.1~ Mop Sink j ~~P~ ( )Other ~1n 11„ SIG ~ `/C 1hl ~ . f^ _N Ca-+`~J l~~ 9. a. Dishwasher make/model #: /0~ 1 ~ Flow rate: b. Temperature range of dishwasher water: 140°F 10. a. Do you have a grease trap/interceptor installed: y eSeS b. Size and type of un c. Location: '(Provide a diagram showing grease trap/interceptor location) d. Distance from dishwasher (if applicable): ~ e. Frequency of maintenance: i1 ~ f. Grease hauler's name: ~ ~~ ~-(' ~ ~ ~~ Phone #: . 11. a: Do you use a renderer or tallow hauler: ~ S b. If yes, can you provide receipts: ~ ~-~ ~~~,~ c. If no, how do you dispose of your grease waste: 12. a. Is construction: _ new ~ remodel _ expansion b. If existing, when was facility established: I 13. What agency referred you to us: ~.J ~e s~ ~ ~ ~-~~ ~~~_~ c f e~~, ta1~ °I l S ~ ~'~ c~ 14. The information submitted in this questionnaire is accurate to the best of my knowledge and is based on check one): () Current opera ing data ~ Best estimate based on ~ ~-~- ~ a ~1 ~~ .~ ~'~~ p ~V1S () Other: 15. Completed by: "~ ~ E ~. ~' ~.i O ~ L rc ~ Title: C~ : M ~ N a ~ i, ~ Date: ~' l~ Print Name: F~ l; ~ ~ ~~ ~3 (,C ~ Phone #: ~ o~ So S X 1 X S Additional Comments: ~R~ CERTIFIVATE OF LIABILITY INSURANCE OP ID sL °"~`"'""'°°"""'' 07 22 11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFOImED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTFIORIZED REPRESENTATIVE OR PRODUCER, AND THE CERT~ICATE HOLDER. e Is an res must to the temLS and conditions of the policy, certain policies may require an endorsement. A statement on this certiflcate does not cor-fer rkjhts to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: Bozzuto 6 Associates Insurance '''~•I'IO ~•IIOr One Almaden Blvd suite 810 ADDRESS: San Jose CA 95113 cusTOMERIDaK BURRP-1 Phone:800-989-8712 Fax:408-288-7130 INSURERISIAFFORDnioc~vt~rAOe NAICi INSURED INSURERA: Scottsdale insurance Corapany 41297 S6rM ineering, Inc. 1645 Almaden Road INSURER B: Qoldea Lagle Insaraace corp. --------------- -- -----------____.. 10836 _-.____-- San Jose CA 95125 INSURER C : tverest National insurance Co. 10120 INSURER D: Centu Sure aJ1 36951 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAKED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERI111 OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAMI, THE INSURANCE AFFORDED BY THE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDRIONS OF SUCH POLICIES. LAYNTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF MSURANCE ~ INSR POLICY NUMBER LIMBS GENERAL LIABILITY EACH OCCURRENCE $ 1 , OOO , OOO A X COMMERCIAL GENERALLIABILLIY BCSOO22943 08/31/10 08/31/11 PREMISES (Eaocwrrence) $ 100,000 CLAIMSMADE L=' OCCUR ~ MED EXP (Any one person) $ excluded PERSONAL & ADV INJURY s 1, 000 , 000 GENERAL AGGREGATE $ 2 , OOO , OOO i GEN'L AGGREGATE l1MR APPLIES PER: ; PRODUCTS - COMP/0P AGG $ 2 , OOO , OOO I POLICY X ~ LOC '~ $ AUT OMOBILE LIABILITY ~ ) NGIE LIMB COM BW ED 000 s1 000 B X ANY AUTO ~ BA6855735 07/22/11 07/22/12 ~ ~n t , , BODILY INJURY (Perperswr) S ~ ALL OWNED AUTOS I BODILY INJURY (Per a[xider~ $ ! SCHEDULED AUTOS I PROPERTY DAMAGE i HIRED AUTOS ~ [Per actdderrt) $ - -- -- NON-0WNED AUTOS ~ -_ - --- S - - F- - ~ - - --- - -- -- - - S A X uMBRELtALIAS X occuR XL30069227 08/31/10 08/31/11 EACIiOCCURRENCE s 5,000,000 EXCESS LIAB CLAIMS-MADE, AGGREGATE $ 5 , OOO , OOO ~ DEDUCTIBLE $ X RETENTION $ $ C AN KLat3 COMPENSATbN i D EMPLOYERS' LIABILITY 07 01 11 07 Ol 12 X TORY ~~ ER -'--"- ~ Y / N ANY PROPRIETOR/PARTNERfEXEC ~~ M / A E.L EACH ACCIDENT $ 1 , OOO , OOO i OFFICER/AAEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE- EA EMPLOYE $ 1 , OOO , OOO ff describe under DESCRIPTION OF OPERATIONS bebvr E.L. DISEASE -POLICY LIMB S 1 , OOO OOO D I Pollution ' i CCP687168 01/03/11 01/03/12 Pollution 1, 000 , 000 DESCRIPTION OF OPERATXIS /LOCATIONS /VEHICLES (Almeh ACORD 101, Additional Remarks Schedule, ff more space is regtNred) 7~c:; S. vJ i n c h cis ~e~- CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE A~VE DESCRIBED POLICIES BE CANCELLED BEFORE EVIDBNC THE EXPIRATION DATE TFIEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ****Evidence of Insurance***** wuTHOR1~DREPRESENTATTVE (~ j(Op8 ACQ~~DRATIl7N. Ali rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD 1MENGlNEER/NG V Credit Reference Sheet 1645 Almaden Rd. San Jose, CA 95125 Ph. (408) 279-8340 Fax (408) 287-2844 Ownership/Tax Info Corporation: Date Incorporated: 7-1-11 Federal Tax ID: 30-0692372 State Tax ID: Taxable No resale No. Contractors Info Contractor Lic # 902278 General A Expires 8-31-11 Bond Number: SC6077827 Bond Co.: Construction Services Name of Principal Officers Eric Burr President 108 Friaz Way Campbell, Ca. 95008 (408) 376-0402 Mark Burr Vice-Pres. 1645 Almaden Rd San Jose, Ca. 95125 (408) 275-0300 Banking/Finance/lease Information Financial Institution Address Account No Contact Phone Number Union Bank-Chkng 2007 Camden Ave, San Jose CA 6750013897 Johnny Yadegari 408 879-3306 Trade Reference Trade Reference Trade Reference Pace Supply Corix Bruce Barton 605 Laurelwood Rd 3750 Bassett St. 940 S. First St. Santa Clara, CA 95054 Santa Clara, Ca. 95054 San Jose, Ca. 95110 Phone: 408 550-8700 Phone: 408 988-3311 Phone: 408 292-1182 Attn. Rocky Attn: Nancy Attn: Carol Purchase Information Authorized Buyers -Officers. Refer to Eligible Employee list for wholesale/retaail supply accounts Purchase order is required to charge our account (call office). lob Name is required. Eligible employees must be identified by name/signature on invoice. The signature in this block must and will be construed to be from a Duly Authorized Representative of the buyer, and shall act as an authorization for release of Bank and Trade-Reference information. Name: Signature: Title: Date: Mark S Burr VM,e-President est Valle~r dankatlon Dis dct Issue Date: 7 ~I By. OFFICE HOURS & CONTACTS: 7:30 a.m. to 4:30 p.m. Monday thru Friday 100 E. Sunnyoaks Ave., Campbell, CA 95008 • Phone: (408) 378-2407 • Information Services Department LOCATION: APN ~~y--~ ~ -UC,~ ' Sewer Map Book Page Tract Lot Project Assmt Address/'7~t1: ,~«,~,~~:~ Jurisdiction ~Q~~, BUILDING TYPE: Single Family CondolTown House Multiple Dwelling Units Industrial Commercial ___L___ REMARKS:/N~1.s~~%/ ~~-y..r„f~ OLD PERMIT Nol~,r~/ j 3Sub No,C=~~Cr ~igG',rc~•ry gy~~~~ ~r ~'~'/ ,G% . ~+~,~ u ~,~.~. ~~ c.~f~=c-c`~iea~ Sewer Connection Permit ~`'"~ i~~'~~ ~~~- No:, ,39750 FEES: Connection $ rfJ Capacity- /~~2 ~~lG _ ~-- ~/ Processing ~ j~; ~.~_, Service Advance Total Due: $ (s3~ " '' Paid by Check No: /~ Hillside: Yes_ No INSTRUCTIONS: • Permit is invalid if not connected within 12 months of issue. • Do not connect until the main sewer is accepted by the District. • Obtain a building or plumbing permit from the Jurisdiction listed above. • Street encroachm nt permit is required from L • Keep 3' ra ius around cleanout clear of vegetation or obstruction. BACKFLOW PREVENTION: Field check required •-/`~ Elevation Basemer Check valve required: Yes No BUILDING SEWER CONNECTIONS: Total number of connections to this property:.__~__ 1. Lateral ID No. _//0~ I is located feet of property line, feet from main sewer and feet deep. Connection to Main Sewer~ZwFeet Upstream from DS MH •-~tJ~°~ ~~~ Upstream M.H . }~~~ ~~ Pipe Type List any additional connections on reverse side of this form. Original -Applicant Pink -Accounting Yellow -City/County Bldg. Inspector Card -District File