ENC2017-00299Print Form
CITY OF CAMPBELL R-1 ENCROACHMENT PERMIT Permit No. ZO 1 —00 `
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 I2-e! �/ r
Campbell, CA 95008 Application Expiration
Ph. (408) 866-2150 ISSUED: �^ Z� 1.7 Date zee
Fx. (408) 376-0458 Permit Expiration Date:p`�T APN
APPLICATION -Application is hereby made fora Public Works Permit in accordance with Campbell Municipal Code, Section 11.04.
(Application expires in 6 months if the permit is not issued.)
A. Work Address: 1 ✓_
B. Nature of Work:
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 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: �7,1 e� Telephone:
Address:
............ .
E-Mail. Address: J .
d....... _.__. ........
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)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 leasttwo days
before starting work. Notice must be given to Public Works at least 24 hours before restarting any work.
Per Section 4216 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.. '
X 2. flan-P 'mt n)reuiatA &g- -b Cu -1 le c�5
3
STANDARD AMOUN
SECURITY FOR FAITHFUL PERFORMANCE (100% Of Engr's Est.) $ A
R-1 PERMIT FEE � $
APPROVED GRIP ISSUANCE:
for City Engineer
,I PT NO.
7
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. Submit project schedule 10 days prior to proposed start of work. Special provisions may be required for work within City facilities
and downtown Campbell.
5. 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.
6. Maintain safe pedestrian and vehicular crossings and free access to private driveways, fire hydrants and water valves.
7. 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.
8. Sawcut for all PCC and AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements.
9. 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.
10. The Contractor or Permittee will have a supervisory respresentative available for contact on the project at all times during
construction.
11. This permit shall be kept at the site of work and must be shown to any authorized representatives of the City of Campbell or any
law enforcement officer upon demand.
12. 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.
13. 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.
14. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other
public agency.
15. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon.
16. 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.
17. 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
mi �niCipal ctnrm drain cy stem other than storm water Applicant shall adhere to the BEST MANAGEMENT PRACT!CES establishers 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_ Date
J:\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf
Rev- 02/14
AAA Insurance Homeowners Policy Declarations o
underwritten by CSAA Insurance Exchange
"Insurance PO Box 22221 Oakland, CA 94623-2221 (800) 922-8228
Amended Effective: 10/10/2017
For questions or changes call: (800) 922-8228
Named Insured and Mailing Address Policy Number: CAH3-207337970
l°III®°I�1°°1111�1°1'Illlnl'IIIII'I'IIIIIII°III'IIIeIIIIIIneI®I
KRISHNA MANDAVA
PADMAJA MANDAVA
30 CARLYN AVE
CAMPBELL, CA 95008-1914
Agency Information
JEFFREY VENABLE
888 S 2000 E
CLEARFIELD, UT 84015
(555) 555-5555
Insured Location
30 CARLYN AVE
CAMPBELL, CA 95008
Description of Property
Membership Number: 429005-10230185-12
12:01 A.M. Standard Time,
but not prior to the time
1 ,
From:
applied for or, if this is a
10/10/2017
; replacement Declarations,
f(p
! not prior to the time coverage
- r :
change was requested.
`
To:
! 12:01 A.M. Standard Time.
'
10/10/2018
Notice Date: 09/27/2017
Home Phone #: (408) 638-7526
Business Phone #: (408) 746-5415
Named Insured(s)
KRISHNA MANDAVA
PADMAJA MANDAVA
Premium to be paid by: The Mandava Family Trust
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+ � C?cpupaC��y,{).. �
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�a ,,. ,
,�ons4ruc(ic�n ,Type.. �
:ti..3` , t�
� o#�a�1y �' �
1940
Frame
Owner Occupied
1-Single Family
Coverages and Limits of Insurance: Insurance is provided for the following coverages only when a limit is shown. 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.
`r.�i�
Dwelling
Other
Personal
Loss of Use
Personal Liability
Medical Payments to Others
Structures
Property
Each Occurrence
Each Person
Each Accident
$537,056
$53,706
$402,792
$214,822
$500,000
$1,000
$25,000
$2,000 (In case of loss under Section I, we cover only that part of the loss over the deductible)
This policy does not provide Earthquake Insurance.
This policy does not provide Flood Insurance.
Forms and Endorsements
61 2000 CA 10012010 (CA 7/2015) Homeowners Policy Special Form
Included T
438BFUNS
Lenders Loss Payable
Included
HO-28 01 05
Limited Home Replacement Cost
Included
HO-77 12 07
$2,000 Deductible
-$452.00
HO-90 10 86
Workers' Compensation and Employers' Liability Insurance
Included
HO 04 10 06 10
Additional Interests - Residence Premises
Included
HO-29 08 05
Replacement Value - Personal Property
$278.00
_
Basic Policy Premium:
$1,209.00
Endorsements Premium:
-$170.00
Seismic Safety Fee:
$0.15
Total Policy Premium: 1 $1,039.15
1075 09012015 Page 1 of 2
Discounts Information
AAA Membership Discount $60.00
� Multi -policy Discount $151.00
Discounts applied to your account may be removed if you become ineligible for the discount. Total Discount Savings
Removal of the discount may occur at renewal or at midterm. $211.00
nstie, i..Fe.e.4
NtYler.and Acdres x� r
i _ r' Mn n Sri-'. , r 3,:
Lgar�Nurnber
1. Mortgagee/Lender
WELLS FARGO BANK, N.A., #936 ITS SUCCESSORS A
0512637562
PO BOX 100515FLORENCE, SC 29502
2. Additional Interest
THE MANDAVA FAMILY TRUST
30 CARLYN AVECAMPBELL, CA 95008
1075 09012015 Page 2 of 2