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ENC2018-00120CITY OF CAMPBELL DEPT. OF PUBLIC WORKS 70 North First Street Campbell, CA 95008 Ph. (408) 866-2150 Fx. (408) 376-0958 R-1 ENCROACHMENT PERMIT Permit No. -ICO.sC 2a($' (3G 12C� (Non -engineered work within the public right-of-way) X-Ref File ($10,,000.00 maximum value of work) Application Date 2 1 5 �23 /-� �/ Application Expiration�' ISSUED: � Date _ Permit Expiration Date: J 2 APN qj APPLICATION - Application is hereby made for a 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: I G OAVA 74 . � Cv�rr�ye�l Q A qgDD e Nature of Work:(�•(/�rIV. C. Attach three (3) copies of a drawing showing the location, extent and dimensions of the work. The drawing shall showthe relation of the proposed workto existing improvements. When approved bythe 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. h AME OF APPLICANT: Tele hone: 'Address: MO V\c lJi�lvA\/e. , Ca W k (CST q [J ov � . .......... - ............ ............. ._ _ -Mail Address: rnDt� __ .. .- - -- 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 th y will inform their 3 contractor(s) of the information. J ACCEPTED: �� (Applican ermittee) (Si 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 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. 2. 3. STANDARD AMOUNT RE IPTNO. SECURITY FOR FAITHFUL PERFORMANCE (100%Of Engr's Est.) $ 20d0 75337 R-1 PERMIT FEE $_ APPROVED FOR ISSUANCE: 3/1 for City Engineer Date Permit Expires 6 Months after Date of Issuance. J 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 ofiany 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 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 un1derpstand all of the above cond' ` I I 1 i Applicant Date J.\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf Rev. 02/14 .of C4,y �41 A� U �W � r' s •91?CHAR,D• - CITY OF CAMPBELL Public Works Department July 10, 2018 Shirley Iwagaki 1490 McBain Ave. - Campbell, CA 95008 Re: Deposit Refund for Permit ENC2018-00210 Dear Shirley, Please find enclosed the permit application fee refund for the cancelled permit referenced above. The application Was withdrawn; therefore, we are returning the application fee. Thank you, Syed Wahidi Inspector 70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAX 408.376.0958 • TDD 408.866.2790 Ref undnble Deposit .:Check :Request To Finance' ;Dlrecfor, Check Payable To Shirly Iwagaki , A . Address ve Linen ' City, : Campbell ..; State: CA Zip 95008 Description ENC2018 OQ120;` 1490 McBain Ave .. AccountNumber ,` 101 2.203 -Arno $2,000 00 Accounf;Number : 1011201,: `: : Amount: ~ Account,Number , 101 540:7448 -- Amount (F.mance Dept only) -Interest Earned (F.inanq Dept Total ;Payable (Exagt Amoun►).t: t Purpose FPS Deaoslt refund Af : Permit M, ENC201!8 00120 # Recel pt, . :..275337 .. :... D ate . 5/2'312018 Receipt:.# - Requested by—' Title inspector Date`:._ Syed Wahldi Approved by i Title Sr: Engineer Date: �J Roger Storz i Finance Dept Oniy ; Title Accounting C erk LI .." Date: = `. Approved .by : , Title Accountant Date: S ecal " Instru,c_:tions For Handlin =Check iVialjl' S is magi in AttaChea Envi iope, interifn t.heCK Needed . -. • Return Toy-, JoAnna, Thomason Public Works (Name) (Department) Other Please ;retu`rn check to:JoAnna - PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1, 2017 TO: Finance PUBLIC WORKS FILE NO. 6C 1 2-a PROPERTY ADDRESS I ut C_t�,A tN /*t Please collect & receipt for the following monies AMOUNT LAND_DEVELOPIVIENT ..>_ 4722 Encroachment Permit Application Fee Non -Utility Encroachment Permit Major 2$10 000 $425.00 Minor Encroachment Permit <gio,000 $240.00 Initial R-1 Permit N/C Subse uent R-1 Permits within Two Year Period $240.00 Inspection Fee Minimum Char e er Location $420.00 Street'Tree Plantinq/Removal N/C 2203 $500 per Tree Planting Deposit Required) $500.00/tree 2203 Plan Check Deposit 2% of Enqineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Grading & Drainage Plan Review Single Family Lot $295.00 Site < 10,000 s.f. $885.00 Site >_ 10,000 s.f. < 0.5 Acre $1 185.00 ` Site >_ 0.5 Acre $1 772.00 4722 NPDES Review C3 Requirements) For projects not required to submit numeric sizing $175.00 For projects required to submit numeric sizing Impervious Area 10 000 S . Ft to 1 Acre $740.00 Impervious Area 1 Acre or more $965.00 4722 For projects sent to Consultant for review Consultant Cost +20% 4722 Additional treatment facilities $315 ea Plan Check & Inspection-Fee(Non-Utility) 4722 4722 4722 En r. Est. < $250 000 14% of Engineer's Estimate Engr. Est. >1250,000 and 5$500,000 $35,000.00 + 8% of Engineers Estimate En r. Est. >$500 000 $55 000.00 + 7% of Engineers Estimate 2203 2203 Emer enc Cash Deposit 4% of Enqr. Est.' ($500 min/$10,000 Max Faithful Performance Security FPS 100% of ENGR. EST.' 20 2203 Labor and Materials Security 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 4722 2203 Parcel Map (4 Lots or Less) $4,200.00 + $90/10t Final Tract Map (5 or More Lots) $5 115.00 + $124/lot Monumentation Security 100% of Cit 's Monumentation Estimate 4920 Parkland Dedication Fee (75%/25% Due Upon Cert. of Occupancy) 4722 Lot Line Adjustment (Includes certificate of Compliance) $1,990.00 4722 Vacation of Public Streets & Easements $2,700.00 4722 Certificate of Compliance $1,970.00 4722 Certificate.of Correction $590.00 4722 Document Recording Fees $15.00/first page $3 ea. Additional 4722 4722 Private Improvement in Public ROW $100.00 Approved Plan Revision Fee $100/sheet 4722 Appeal Filing Fee $200.00 730.4924 Notice of Improvement Obligation Payment Assessment Segregation or Reapportionment First Split $940.00 Each Additional Lot $295.00 511.7424 MISCELLANEOUS Postage _77 Other (Please Specify) 'Engineer's Estimate shall be as approved by the City Engineer and i shall include all items of work. TOTAL $ 2000 NAME OF APPLICANT , i� �� —L1,v (`� Nf NAME OF PAYOR PHONE lay (ADDRESS FOR RECEIVED 1BY: �i„W _ ; ; - ' . CITY CLERK ONLY f t Date Receipt#. / -• Fl]RMG\Trmola ;. Homeowners Policy Declarations AAA Insurance underwritten by CSAA Insurance Exchange Insurance PO Box 22221 Oakland, CA 94623-2221 (800) 922-8228 Named Insured and Mailing Address II'll'lllllllllllllllll'I'llllll'I'll"IIIII1�11111�11��1��1�111� SHIRLEY M IWAGAKI 1490 MCBAIN AVE CAMPBELL, CA 95008-0729 Agency Information HOUSE AGENT LOS GATOS 15450 LOS GATOS BLVD STE 300 LOS GATOS, CA 95032 Insured Location 1490 MCBAIN AVE CAMPBELL, CA 95008 Dpnerintinn nf• Prnnerty Renewal For questions or changes call: (800) 922-8228 Policy Number:. CAH3-105112795 Membership Number: 429005-421151563-14 12:01 A.M. Standard Time, but not prior to the time From: applied for or, if this is a 02/16/2018 replacement Declarations, not prior to the time coverage I change was requested. To: : 12:01 A.M. Standard Time. 02/16/2019 Notice Date: 12/29/2017 Home Phone #: (408) 377-8896 Business Phone #: Named Insured(s) SHIRLEY M IWAGAKI Premium to be paid by: SHIRLEY IWAGAKI `YYR',BUllt�s ;. y Construction" Type.t t " �t4 gn,fi ' r• .�• t" sti, x #rofFamtlyllmts,w. .,Occupancy „ ," - - , 1960 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: • Sectional �. � � � � a' «� �.� �� ' Section 11� ' Dwelling Other Structures Personal Property Loss of Use Personal Liability Each Occurrence Medical Payments to Others Each Person Each Accident $743,800 $74,380 $558,000 $297,700 $500,000 $1,000 $25,000 Section I Only:Your Section I Coverage Limits have been changed to reflect changes in Construction costs and other matters affecting replacement costs. Deducttble` '`Sectlanl ,s �.'e@,^�,s� T�. "Kzx' .I:An� `qa fx.. .r $500 (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 ForrtiNumle�r�' 4 Forms andxEndorsemen#s lifladePart of th'isPallcy'',H� 61 2000 CA 10012010 (CA 7/2015) Homeowners Policy Special Form Included HO-28 01 05 Limited Home Replacement Cost Included HO-59 10 86 _ $500 Deductible-$191.00 HO-90 10 86 Workers' Compensation and Employers' Liability Insurance Included HO-29 08 05 Replacement Value - Personal Property $387.00 HO-70 12 02 Additional Residence Premises - Rented To Others (Section 11 only) $96.00 Basic Policy Premium: $1,212.00 Endorsements Premium: $296.00 Seismic Safety Fee: $0.15 Total Policy Premium: $1,508.15 1075 09012015 Page 1 of 2 Discounts Information ®isco nt Applied S'a�ing AAA Membership Discount $60.00 Multi -policy Discount $152.00 . Protective Devices Discount $119.00 Senior discount factor . $119.00.. . 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. $450.00 1075 09012015 Page 2 of 2