ENC2011-00050Print Form
CITY OF CAMPBELL R-1 ENCROACHMENT PERMIT Permit No. ~~~~ ~~ ~ -~ t'~7
DEPT.OF PUBLIC WORKS (Non-engineered work within the public right-of-way) X-Ref File
70 North First Street ($10,000.00 maximum value of work) Application Date
Campbell, CA 95008 ( ~ Application Expiration
Ph. (408) 866-2150 ISSUED: Date
Fx. (408) 376-0958 Permit Expiration Date: ~~ APN ,Z7 ~/ - ~~ ~ O/ ~/
APPLICATION -Application is hereby made for a Public Works Permit in acc rdance with Campbell Municipal Code, Section 11.04.
(Application expires in 6 months ifthe permit is not issued.)
A. Work Address: ~ ~ ~ f ~ ~-~/,~~f j~~~ ~ ~-7
B. Nature of Work: ~ ~~6.V~C~ 1~.~~~~ ~ ~~e IC. ~J~ C~~ ~ ~~~~~~~ ~~~~'~~ ~
C. Attach three (3) copies of a drawing showing the location, xtent and d ensions of the ork. The drawing shall show the relation of
the proposed work to existing improvements. When approved by the Ciry Engineer, said drawing become 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: ~i~Y1 r~ ~p ~~ ~ Telephone: ~~ ~~_~ //~/~
Address:
X 218 ~/Y/s~/~ eve-
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:
(Applicant/Permittee) (Sign)
_~l~_
Date
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 AMOUNT RECEIPT NO.
SECURITY FOR FAITHFUL PERFORMANCE ~ (100% Of Engr's Est.) $ ~
R-1 PERMIT FEE ~~~iC~l/ V~ j $ /
APPROVED FOR ISSUANCE: 1 ~ r ~ ~
for ity Engineer Date
Permit Expires 6 Months after Date of Issuance.
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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 and 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 respresentativesvailable 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 representatives ofthe 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 maybe required, nor does it relieve the Permittee of any obligation to obtain any other permit
required bylaw.
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.
17. 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.
18. 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 ensuring that all those providing services under the applicant are aware of and understand all of the above
conditions.
Applicant
X16-~ ~~~
Date
J:\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf
Rev. 3/10
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~~
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~a: Campbell City Halt
Attn: Danis
Fa~c 408-376-0958
Phone:
Re:
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260 W. Hamilton Ave, Ste A, Campbell, Ca 95008
Teie (408) 370-9100 Fax (408? 370-2909
Fromm Kim Stidham
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ED
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Pages: 7 including cover
Date: 5J17/2011
Client: Ann Lee
Per your request, please find attached evidence of insurance far the above customer.
Thank you,
Kim Stidham
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Allstate Insurance Company
RENEWAL
Deluxe Plus Homeowners
Policy Declarations
Summary
NAMED INSUREDS) YOUR ALLSTATE AGENT IS: CONTACT YOUR AGENT AT:
Ann Lee Katherine K Oswald (408} 370-9100
298 Harrison Ave 260 W Hamilton Ave,,#A
Campbell GA 95008-9410 Campbell CA 95008
POLICY NllMBER POLICY PERIOfl PREMIUM PERIOD
d 34 873126 06!09 Begins on June 9, 2010 June 9, 2010 to June 9, 2011
at 12:01 a.m. Pacific Time at 12:01 a.m. Pacific T1me
and continues until cancelled
LOCATION OF PROPERTY INSURED
298 Harrison Ave, Campbell, CA 95008-1410
Total Premium for the Premium Period (Your bi1J wiN ire marled separately)
~.~~.~~ -
Premium for Property Insured $529.00
TOTAL 5529.00
See the lmporlaol Payment and Coverage Information section for details about payment options and
installment fees.
IVU~~IliWU11117111uIIIIPIIIilllnlul~llltllllllll . ~ _...
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Allstate Insurance Company
Policy Number: 034 873126 Ofi/09 Your Agent: Katherine K Oswald (408) 370.9108
For Premium Period Beginning: June 9, 2010
POLICY COVERAGES AND LIMITS OF LIABILITY
CDVERAGE AND APPLICABLE DEDUCTIBLES LIMITS OF LIABILITY
(See Po icy for Applicable Terms, Conditions and Exclusions)
Dwelling Protection -with Building Structure Reimbursement Extended Limits $274,693
• $1,000 All Peril Deductible Applies
Other Structures Protection $30,626
• $1,ODil All Peri! Deductible Applies
Personal Property Protection -Reimbursement Provision $206,020
• $1,DDD All Peril Deductible Applies
Additional Living Expense Refer to Policy
Family Liability Protection $100,000 each occurrence
Cuesi Medical Protection $1,000 each person
Building Codes Refer to Policy
Workers' Compensation and Employers' Liabilibj Statutory/See Form
Coverage for Residence Employees
The limit of liability for this structure (Coverage A-Dwelling Protection) 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.
This policy does not cover earth movement including earthquake
You have elected not to purchase a CEA earthquake policy
DISCOUNTS Yeur premium reflects the followp/ing discounts on applicable coverage{s):
55 and Retired 1t? /D Claim Free 15 °/°
Protective Device Rate Applied
RATING INFORMATION
The dwelling is of Frame construction and is occupied by 1 family
nm~~so4~sm Page 2
Fp°I,9, 20,0 .".SWDRBD
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Allstate Insurance Company
Policy Number: 0 34 873126 D6J09 Your AgenC Ralherlne K Osurald 140e137D•9100
For Premium Pericd Oeginning: June 9, 2010
Your Policy Documents
Your Homeowners policy consists of this Policy Declarations and the documents listed below. Please keep these together,
- Deluxe Plus Homeotivners Policy form AP337
-Amendment of Policy Provisiens farm AP425
- Deluxe Plus Homeowners Amend End. Corm AP4486-t
- CA Deluxe Plus Amendatory Endorsement form AP2236
- Domestic 1Norkers' Camp & Errp Liability APt127
- Bldg. Struct. Reimb. Ext. Limits End. form AP445
- California Sid Fire Policy Prou. End form AP1862-1
- Calitornia Amendatory Endorsement form AP29-4
Important Payment and Coverage Information
Coverage A - Oatelling Protection includes an approximate increase of $4,924 due to the Property Insurance
Adjustment provision using the h7arshall Swift Boeckh Publications Building Cost Index. Coverage C -Personal Property
Protection adjusted accordingly.
Please note: This is not a request far payment. Your biEl wiil be mailed separately.
Payment Options -Choose the payment option that best meets your needs. Ycur bill 'Hill be sent to you shortly
and will contain more details about these options.
Dption 1 -You can pay your premium in full. The "To Pay In Full" amount will be shown on your bill.
Option 2 -You can pay the Minimum Amount Due shown on your bill. ff you choose this option: you will be
sent a bill each month and the Minimum Amount Due will include a $3.50 installment fee for each monthly
payment (the monthly installment fee is $1.40 far the A1151ate Easy Pay Plan).
Option 3 -You can pay less than the full amount but more than the Minimum Amount Due. You tivill be charged
a $3.50 installment fee each time you choose this payment option (the monthly installment fee is $1.00 for the
Allstate Easy Pay Plan).
Please note that the Allstate Easy Pay Plan allows you to have your insurance payments automatically deducted
from your checking or savings account.
IN WITNESS WHEREOF, Atlslate has caused this policy to be signed by two of its officers at Northbrook,
Illinois, and if required by state law, this policy shall not he binding unless countersigned on the Policy
Declarations by an authorized agent of AlEstafe.
~-s~~--
Thomas J, Wilson
President
~- ~~~
Mary J. McGinn
Secretary
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Allstate Insurance Company
Policy Number: 0 34 873126 06(09 Your Agent: Ka87erlne K Oswald (4081370.9100
for Premium Period beginning: Jurte 9, 2010
Important Notice
lnfarrnatian about Your Dwelling and Your Coverage A -Dwelling Protection
Limits
Thank you for being an Allstate customer.
For your convenience, we're providing you the following information about the estimated cost to replace your
home and your related Coverage A -Dwelling Protection liability limits. Please review it and let us know it you
have any questions or concerns.
The estimated cost to replace your home
Allstate has determined that the estimated cost to replace your home is: $274,693
The estimated replacement cost of your home is the minimum amount for which we will insure your home.
YourGoverage A- Dwelling Protection Liability Limits
The enclosed Policy Declarations shows the liability limits that are applicable to the Coverage A - bevelling
Protection of your homeowners insurance policy. Your Coverage A limits reflect our estimated replacement cost,
which is based on data that was available to us when we made this estimate. (This data is described further
below.} Please keep in mind that one cannot know the actual amount it will cost to replace your home until after
a covered total loss has occurred.
As an Allstate policyholder, you decide the Lability limits that are applicable to your Coverage A -Dwelling
Protection. We only ask that your limits, at a minimum, equal our estimated replacement cost and do not exceed
the maximum coverage limitations we established.
Now we determined your replacement cost estimate?
Many factors can affect the cost to replace your home, including its age, size, and type of construction. So when
we estimate that cost, we consider construction data, such as labor and materials costs, that are available to us
at the time we make an estimate. We also base the estimate on characteristics of the home, which include
information that you provided to us. Please remember that you might have chosen to insure your home for a
higher amount than the estimated replacement cost shown above.
Note to customers renewing their policy
If you're abeut to renew your policy, you may find that your home's estimated replacement cost has changed
since the last time we communicated this information io you. This is because, at renewal, we use the home
characteristics that you provided to us to recalculate and update your home's estimated replacement cost. The
information about your home's characteristics is provided below.
If the information shown raelow requires any change or if you have any questions or concerns about the
information contained in this Important Notice, please contact your Allstate representative, or calf us at
1800-ALLSTATE ~.
DWELLING STYLE: 1.0 Story{s), 1 Family{s), Buifl 1940, Living Area 1500 sq. ft.
FOUNDATION: 30% Basement, 7Q°/° Crawlspace
ADDITIONS: Attached Structures --Screened Porch -Small (1}
Detached Structures -- Detached Garage - 2 Car (1)
Lb~ne~on uof Page 4
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Allsiate lasuranee Company
Policy Number: 0 34 8731 2 6 06103 Your Agent: Katharine K Oswald (408) 370.9100
Far Premium Perfod Beginning: June 9, 2010
Interior --kitchen -Basic (1)
Interior -- Full Bath -Basic (2)
Interior --Fireplace -Single (1}
DETAIL: Exterior Walls -- Stucco on Frame 100
Roofing --Asphalt/Fiberglass Shingle 100
Interior Partitions --Drywall 25 °o
Interior Partitions -- Plaster 'S °I°
Interior Partitions -- Less than 7 0 ft Wall Height 100 °!o
Heating & Ccoling --Heating -Gas 100 °b
SPECIAL FEATURES: Exterior --Atrium Doors (1)
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Allstate Insurance Company
Policy Mumber: 0 34 6731 26 06^04 Your Agent. Katherine K Osurald t408} 370-9100
For Premium Pericd Beginning: June 9, 2010
Adrtitional inlormation about Dwepin~ Protection limits
Your policy includes a feature called "Property Insurance Adjustment" (PIA). PIA reflects changes in construction
costs in your area that may have occurred during the policy period.
We would like you to know that your policy's PIA recently indicated that construction costs in your area have
increased. Based on this information, we have automatically increased your Coverage A - Dwelling Protection
Ii m its.
Again, it i5 ultimately your responsibility to consider whether the changes vie have made meet your insurance
needs and provide sufficient coverage in the event of a loss. For example, if you have done any remodeling to
your home chat has not been updated in our records, your home's replacement cost may be higher than our
current records indicate. In that case, you may want to increase your limits to reflect such Changes.
Conversely, there is a possibility that your new limits may provide coverage in excess of the actual replacement
cost of your home. For example, if you originally decided to insure your home at an amount that exceeded the
estimated replacement cost, you may grant to ca11 your Allstate representative to discuss your home's current
value and the possibility of lotivering your limits.
Consider the putentral impact an your CFA policy
Please note that, if ycu purchase a California Earthquake Authority {CEA) earthquake insurance policy, the
Coverage A -Dwelling limit under that policy will be the same amount as the Coverage A -Dwelling Protection
limit for your homeowners Insurance policy. Therefore, any change you decide to make to the Coverage A -
Dwelting Protection limit for your homeowners insurance pelicy vJill atso apply to the Coverage A -Dwelling
limit under your earthquake insurance policy,
Have questions? Please contact us
!f ycu have questions about the current estimated replacement cost of your home or about adjusting the
Coverage A -Dwelling Protection liability limit shoovn on the enclosed Policy Declarations, please contact your
Allstate representative at your earliest convenience. If you request a laver limit, you must agree in writing to a
new amount before sue can make any change to the limit.
Thank you for being an Allstate customer.
X72025
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