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ENC2016-00084
Joy Francois From: Arash Moradi <arash@urban-corp.com> Sent: Wednesday, September 19, 2018 8:25 AM To: Roger Storz Cc: JoAnna Thomason; Joy Francois Subject: Re: Campbell - 1443 Harriet Ave - ENC2016-00084 WARNING: This email originated from an external sender! Hi Roger, I hope you're doing great. Thanks so much for checking on the address. I moved to Dallas about a month ago for work. This is my new address: Arash Moradi 10407 Shadow Bend Dr Dallas, TX 75230 Thanks again! Arash Moradi EVP of Development and Acquisitions 650.444.1933 URBAN CORP 15400 Winchester Blvd #37 Los Gatos, CA 95030 urban-corp.com On Sep 19, 2018, at 10:06 AM, Roger Storz <rogersq..-` o�pbell.com> wrote: Good Morning Arash, The one year warranty period for your frontage improvements is complete. What address would you like us to use when sending you the check.for the remaining 25% of your faithful performance deposit? Regards, <image002.png>Roger Storz, PE Senior Civil Engineer City of Campbell I Public Works Department 70 N. First Street I Campbell, CA 95008 www.cityofcanipbell.com 1 408.866.2190 1 Ref undable Deposit Check Request To: Finance Director _ Check. Payable To: Arash Moradi . y'eedberry •Lane Address - Linel : Line 2`. j �94043 City: Mt-iey� O{� State: GA—�. Zip: S Description: ENC2016-00084 Account Number: 101.2203 Amount: $7,437.50 Account Number: 101..2203. Amount: Account Number: , 101.540.7448 Amount: •(Finance•Dept only) Interest Earned � (Finance'Dept only), Total Payable: (4act Amount) ' (l �ra1C- a-0\ 0,�LC30�y Purpose: Remaining 25% of FPS i Permit,#: ENC2016-00084..: Receipt* 265166 Dafe:"- 811/2016, Receipt_#: Date: Date: Requested by: . Title: -Inspector Syed Wahidi Approved by: Title: Sr. Engineet- Date: Roger'S 117 Finance Dept -Only: Verified by: Title:. Accounting.•Clerk.11: Date: Approved by: Title: Accountant Date: - Special Instructions For..H' d.]"n :Check . Mali As Is:. Mail In Attached envelope:., interim t.;necK:, Needed By: „ Return To: JoAnne Thomason Public Works (Name) f� (Department)' Other: 71e� ck to JoAnne" ~ t 1 '- pF C4 • G''CHAVo CITY OF CAMPBELL Public Works Department October 9, 2017 Arash Moradi 2215 Woodberry Lane Mt View, CA 95008 SUBJECT: PERMIT NO. ENC 2016-00084 1443 Harriet Ave. FINAL INSPECTION AND ACCEPTANCE Dear Arash: The City of Campbell has made a final inspection of subject Public Works improvements and finds the work to be acceptable and in conformance with City standards. Accordingly, the City Engineer accepts the improvements. _- --- - The one year maintenance period stated in the permit begins asrof September 13, 2017. _) The permittee is responsible for the repair and/or replacement kany de.£ect-i-ve work or failures that occur within one year. The City will inspect the improvements within one year and notify you, in writing, whether or not any repairs are required. 75% of your Faithful Security Deposit in the amount of $22,312.50, your Construction Cash Deposit for $1,190.00 and your Plan Check Deposit for $500.00 are enclosed._ The remaining 25% of your security deposit will be returned after the one-year maintenance period is. up. If you have any questions, please call me at (408) 866-2165. Sincerely, l Sy ahidi Public Works Inspector Cc: Inspector /Suspense Files Permit File ENC2016-00084 70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAX 408.376.0958 • TDD 408.866.2790 • Ck CHARD - -. .. CITY of CAMPBELL Public Works Department October-1, 2018 Arash Moradi 10407 Shadow Bend Dr. Dallas, TX 75230 SUBJECT: PERMIT NO. ENC 2016-00084 1443 Harriet Ave., Campbell, CA 95008 MAINTENNACE INSPECTION AND ACCEPTANCE Dear Arash: The City of Campbell has made the final inspection of the subject Public Works improvements and finds that no remedial work is required. Your warranty requirements and any surety, therefore, are hereby released. The remaining 25% of your Faithful Security Deposit refund is enclosed. FJ Syed Wahidi Public Works Inspector 70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAX 408.376.0958 • TDD 408.866.2790 PnntForm I / CITY OF CAMPBELL ENCROACHMENT PERMIT t No—��' DEPT. OF PUBLIC WORKS (for working within the public X-Ref. File 70 North First Street ri ht of -way) Application Date Za Campbell, CA95008 Application Ex iration Date Ph. (408) 866-2150 Issued APN Fx. (408) 376-0958 Permit Expiration Date APPLICATION - Application is hereby made for a Public Works Permit in acco an 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.: :0 Utility Trench Location: �( 7 B. Nature of Work: 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: 1 aS M� rn �) Telephone: _._...._............._�..._..............-4_______................._.................---------------.........-------------.__.._.../.....__......._...__._..._......._...._. Address: 1 2 -1 S_ E-Mail Address: 14 Lam . Mau,�,-�-i�ln �✓ �✓ � ��1 � 4 o y 3 Leh; 24-HOUR EMERGENCY PHONE NUMBER: dl/1L • / Is this work being done by the property owners at their own residence? r YES NO 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 informationApplica"-- n�is^a sect that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all5lamages arising out oftM condition of any private improvements in the public right-of-way. , Accepted: nt (sign) 03-fc (Print Name) Date SPECIAL PROVISIONS: 1. Street shall not be open cut for unde ground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be specifically approved by the Inspector 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. X4. 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 has been entered hereon. USA Phone: 1-800-227-2600. USATICKET 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 PERMIT APPLICATION FEE PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS CONSTRUCTION CASH DEPOSIT PLAN CHECK & INSPECTION FEE EMERGENCY PERMIT FEE AMOUNT $ 00 $ C)o $ 0 60 $ , U;0 $ RECEIPT NO. 7L3?f 0 100 APPROVED FOR ISSUANCE For City Engineer Permit Expires 12 Months After Date of Issuance ` 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. Submit project schedule 10 (ten) 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, bus stops, fire hydrants, and water valves. 7. 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. 8. 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. 9. 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. 10. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements. 11. 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. 12. Adequate signing and barricading is required on the job 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. 13. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 14. 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. 15. 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. 16. 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. 17. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 18. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 19. 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. 20. 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. 21. 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. 22. 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 responsi ensuring that all those providing services under the applicant are aware and understand all of the above conditions. zR 16 Appli Date: Contractor (Print Nale) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev. 02/14 CR100217 10014588 NAVAl PROPERTIES . .................. ... . . ........ : ............. ------- - -------- ------ -- ------- ---------------- --------------------------------------------------- - k10014588 CHECK NO. 264668 MEMO i AND YOU CAN SEE A HEXAGON -SHAPED TRUE WATERMARK WHEN HELDTO THE LIGHT -Y 7 --------------------------------------------------------------- ----- -------------- ----------- ------------ --- ------------ ---------------------------------------- -- ---------- --- -- ---------- ------------------ I N. - ............ . ........... ...... . ... . .. . ........ .... ...... ........... . ..... . .... . . ................ ...... . ........ ...... . ......... .... . ....... . .......... . . ............... . .. ........ ... ........ ....... .... .. . ............ ............ .................... . . ........ ... .............. . ........ . ..... ......... . .... ....... . *See Reverse Side For Easy Opening Instructions.* -------------- - --------- --- ------- - -------------------------- ------------- - CITY OF CAMPBELL 70 NORTH FIRST -STREET CAMPBELL, CALIFORNIA-95008 NAVAI PROPERTIES 2215 WOODBERRY LANE MOUNTAIN VIEW CA 94043 ...................................... ............ .................... ..... .. . . . ....... . . .... . .. .. .......... .................................. ........... ..................... .. . . ... .. ... . .. ... .. . .. ......... ........................ CITY OF CAMPBELL VENDOR NO. 10014587 C.H*CK NO. 269990' LHLLiiS 1A z u 14 M FA ATITJ :1 :0 In I A Ila folk I I 1: 1:1 a I IN 0111,413 INVA [oil] 619.11 11:11A 1:1 Rumn ol 1:1 WEI I 3will 110 *A MEMO o Wn EWA A ffill Alif/A N :I GITY:i0f. 11' 24 ... ........ -94 1 STRFET, 2:210-� 1 0 -NOR- N STREET �-i, '.. �P T CHECK NO 72 64 (;A T �7. FIRST , "`4 ?,4104 Ll FOR NJA 95008 ZC 'koI N -:bF 'TWE tkhl�:: THO �;�.FIVE HUNDRED TWO DOLLAR- N T Y,'� W' CENTS .70 T,�iE,,," �S H "MORAD I'-., ORDER, 2215'W6615B,ERRY �_,LANE OUNTAIN�;'VfEW!t AS 94043 F4"3_ At • WON lKmjljljj6j�q - --- -- ________ -_____ -------------- ----------------------------- -------------- --------------------------- ------------------------------------------ -------------------------------------------------------------- r . ---------- - - --- - --- - - - ..................... ..... ..... ......................... ....... . .... . ....... . ......... ... ............ ......... ..................... .................. . *See Reverse Side For Easy Opening lnstr"u'ctions* -------------------------------------------------------------------------------- ----------------------------- ------------ - --- -------- --- ----- CITY OF CAMPBELL •{O NORTH FIRST STREET �CAMPBELL, CALIFORNIA 95008 ABASH MORADI 2215 WOQDBERRY LANE MOUNTAIN VIEW CA 94043 PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1, 2015 TO: Finance PUBLIC WORKS FILE NO. ENC2016-00084 PROPERTY ADDRESS 1443 Harriet Avenue Please collect & receipt for the following monies: _ AMOUNT c ACCT, -- . ]TEM' LAND -DEVELOPMENT - ' - 4722 Encroachment Permit ApplicatiQla Fee Non -Utility Encroachment -Permit Major >_$10 000 $395.00 Minor Encroachment Permit <$to,000 $225.00 Initial R-1 Permit N/C - Subsequent R-1 Permits within Two Year Period $225.00 Inspection Fee Minimum Charge per Location $390.00 Street Tree P[anti n /Removal N/C 2203 $500 per Tree Planting Deposit Required) $500.00/tree 22031 Plan Check Deposit 2% of Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Grading & Drainage Plan Review Single Famil Lot $275.00 Site < 10,000 s.f. $825.00 Site ? 10,000 s.f. < 0.5 Acre $1 105.00 Site >_ 0.5 Acre $1,655.00 4722 NPDES Review C3 Requirements For protects not required to submit numeric sizinq $160.00 For projects required to submit numeric sizing Impervious Area 10,000 S . Ft to 1 Acre $690.00 Impervious Area 1 Acre or more $900.00 4722 For projects sent to Consultant for review Consultant Cost +20% 4722 Additional treatment facilities $300 ea Plan Check & Inspection Fee(Non-Utility) 4722 En r. Est. < $250,000 14% of Engineer's Estimate $4,165.00 4722. En r. Est. >_$250,000 and :5$500 000 $35 000 + 8% of Engineers Estimate 4722 En r. Est. >$500,000 $55 000 + 7% of Engineers Estimate 2203' Emergency Cash Deposit 4% of Engr. Est.* ($500 min/$10,000 Max) $1,190.00 2203 Faithful Performance Security (FPS) 100% of ENGR. EST.* $29,750.00 2203 Labor and Materials Security 100% of ENGR. EST.* 4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00 $657.00 (Multi -Res $2 385.00) All Other $2 650.00 4722 Parcel Ma 4 Lots or Less $3 930.00 + $85/lot 4722 Final Tract Map (5 or More Lots) $4 775.00 + $116/lot 2203 Monumentation Securit 100% of Cit 's Monumentation Estimate 4920 Parkland Dedication Fee(Remaining 25% will be Due Upon Cert. of Occupancy) 4722 Lot Line Ad'ustment $1 856.00 4722 Vacation of Public Streets & Easements $2 480.00 4722 Certificate of Compliance $1 840.00 4722 Certificate of Correction $550.00 4722 Document Recording Fees $15.00/first page $3 ea. Additional 4722 Private Improvement in Public ROW $50.00 4722 Approved Plan Revision Fee $100/sheet 4722 Appeal Filing Fee $200.00 4722 Notary Fee(per signature $10.00 4722 Assessment Segregation or Reapportionment First Split $877.00 Each Additional Lot $275.00 511.7424. MISCELLANEOUS Postage *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $35,762.00 NAME OF APPLICANT �u ��bl Vu c ='"" :G .. 1 -4 NAME OF PAYOR PHONE ADDRESS ZIP FOR RECEIVED,B CITY CLERK ONLY Date Receipt # J:LLar�dCevW�an Check Comments\1-Spsif Nq--Active Prq-mPmgressWertiet A— 144aFeeslF—A. CITY OF CAMPBELL RECVD BY: CASHIER O1O03265166 PAY8R� ARASH MORADI T0DAY`S DATE; 08/31/16 REGIST[R DATE. O8/O1/16 TIME: OO.00 DESCRIPTION 'AMOUNT OUST ID-ENC2016-000-i-84 EWGR 8 SUBDIV FILING F $41165.00 CUST ID:EME8G CASH DEP REF DEPOSIT - 131 $1,190.00. OUST !.-,,:FAITHFUL PERF REF DEPOSIT - 101 $29,?5D.00 OUST lD:1443 HARRIET AVE STORM D8AIN FEES FN 2 $657.8O -__--__--_--- TUTAL DUE: $35,762.00 TENDERED: $35;762.01-'i CKANGEt $.00 $35,762,OO REF NUM; 165948 �\\ INSURANCE REQUIREMENTS CHECKLIST Permit # CIP Project # Consultant/Contractor: i `t��e, = The following insurance is required of all consultants/contractors working in the of Campbell public right-of-way. Insurance -certificates must be accepted by City staff before w rk can begin. These insurance requirements apply to work being performed under an Encroach ent Permit and work being performed .under contract for Capital Improvement Projects. Limits Commercia General Liability for bodily, personal injury and property damage: �( $1,000,00 er occurrence, and ❑ $1,000,000 gen all aggregate limit applying separa y to the project, or o $2,000,000 general gregate limit. V, Policy expiration date t Automotive Liability: IN e ❑ "Any Auto" checked on certifica� //� o $1,000,000 per accident for bodily i1�j .ry and property damage ❑ Policy expiration date Workers' Compensation and Emplov6r's Liability" ❑ Waiver of Subrogation clause �Qe ❑ $1,000,000 per accident for bodily injury or disease ❑ Policy expiration date \ Course of truction (if req ed in Special Provisions) ❑ Compl e value of the roject ❑ Poli; expira ton d Additional Insured E dorsement: ❑ The City, its officers, employees and volunteers are named as additional insured. (Reference Pr?Ject Location/Permit Number) ❑ The insu nce coverage afforded to the Additional Insured is primary insurance. ���7Cancellation ea: ❑ Cancella fon area of certificate edited to delete "endeavor to" and "but failure to mail such notice all impose no obligation or liabilityof an kind up on the companV, its agents or re res ntatives". OR should say: ❑ Should any of the above described policies be cancelled before the expiration date thereof, ✓% notice will be delivered in accordance with the policy provisions. ❑ Workers' Compensation Insurance Sheet Submitted ❑ For General Contractor ❑ For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 1 Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: �Ly �� �� NAIC # Rating: Authorized in CA: Name: NAIC # Rating: Authorized in CA: Name: NAIC # Rating: Authorized in CA: Name: NAIC # Rating: Authorized in CA: ❑ Campbell Business License # Expiration: ❑ Contractors License # Class: Expiration: Insurance Certificate Reviewed Initials Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 o ACORD- CERTIFICATE OF LIABILITY INSURANCE DATE(MMlDnm) 04/12/17 PRODUCER Ali Danesh 1610 Blossom Hill Rd #8 San Jose CA 951248 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE Tel 408 2417641 Fax 408 445 0105 Email: adanesh@farmersagent.com INSURED INSURERA: SECURITY NATIONAL INSURANCE COMPANY INSURERB: a-® ABLE PAVING & GRADING INSURER°: aa- 942 RUNNYMEDE ST INSURER D: PALO ALTO CA 94303 INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLITCY EXPIRATIONLIR E (MMt0DfYY1 LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 FIRE DAMAGE (Arty one fire) $ 100 000 u COMMERCIAL GENERAL LIABILITY A CLAIMS MADE OCCUR NA114958401 03/01 /17 03101 / 18 MED EXP (Any one person) $ 5 000 PERSONAL & ADV INJURY $ 1 ,000,000 GENERAL AGGREGATE $ 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMPIOP AGG $ 1 ,000,000 POLICY PRO- LOC AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMB (Ea aaldent) $ BODILY INJURY (Perperson) $ ' ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE (Per accident) $ ' GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ' ANY AUTO $ AUTOONLY: AGG EXCESS LIABILrTY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY TWORSLATUS IEH- E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTSPECIAL PROVISIONS f`FRTIFICATP Hf11 TIFrR I X I Annnnnmm INCI roPn• INR,IoFo, P n- rAN:^1=1 I ATITVd ARASH MORADI 1443 HARRI ET AVE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR To MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL CAMBELL CA 95008 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE AL Urlu Za-s (ItUly OACURD CURPOHATION 1988 r --'77"`11 6o ,Oqc— V KU �" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 04/26/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, ANDTHE CERTIFICATE HOLDER. IMPORTANT: Ifthe certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or beendorsed. If SUBROGATION IS WAIVED, subjectto theterms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: ALI DANESH ALI DANESH PHONE FAX 1610 BLOSSOM HILL RD # 8 (A/C, NO, EXT): 408 241 7641 (A/C, No): 408 445 0105 MAIL ADDRESS: ADANESH@FARMERSAGENT.COM A SAN JOSE CA 95124 INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURERA: SECURITY NATIONAL INSURANCE COMPANY 19879 INSURER B: ABLE PAVING $ GRADING 942 RUNNYMEDE ST INSURER C: INSURER D: PALO ALTO CA 94303 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALLTHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDTL INSD SUBR WVD POLICYNUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE x OCCUR DAMAGE TO PREMISES (Ea Occ(Ea OccED urrence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV 1 NJURY $ 1,000,000 A NA114958401 03/01/2017 03/01/2018 GEN'L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 1,000,000 POLICY ❑ PROJECT LOC PRODUCTS-COMP/OPAGG $ 1,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ ANYAUTO BODILY INJURY (Per accident) $ OWNEDAUTOS SCHEDULED ONLY AUTOS HIRED AUTOS NON -OWNED ONLY AUTOSONLY PROPERTY DAMAGE (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY PER STATUTE OTHER $ ANY PROPRIETOR/PARTNER/ Y/N EXECUTIVE OFFICER/MEMBER N/A E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE EXCLUDED? (Mandatory in NH) E.L. DISEASE -POLICY LIMIT $ Il'yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if morespace is required) CITY OF CAMPBELL, ITS OFFICERS, EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSURED. THE INSURANCE COVERAGE AFFORDED TO THE ADDITIONAL INSURED IS PRIMARY INSURANCE. ALL WORK IN THE PUBLIC RIGHT-OF-WAY. REFERENCE PROJECT LOCATION: 1443 HARRIET AVE CAMPBELL CA 95008 PERMIT# ENC 2016-0084 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITY OF CAMPBELL DATE THEREOF NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 70 N. FIRST ST AUTHORIZED REPRESENTATIVE ALI DANESH ACORD 25 (2016/03) 31-1769 11-15 @1988-2015 ACORD CORPORATION. All Rights Reserved The ACORD name and logo are registered marks of ACORD AAAMC01 OP ID: MR AC'�RO" CERTIFICATE OF LIABILITY INSURANCE (MM DATE IDD/YYYY) 05/01/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Mitchell & Mitchell-Lic0620650 250 Bel Marin Keys Blvd, Bid E Novato, CA 94949 Boardwalk Insurance Services CONTANAME: Maritza Moreno PHONE FAX A/c Ne E:t :510-487-9379(AC, No): 415-883-7762 E-MAIL ess: mmoreno@mitchellandmitchell.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Security National Insurance Co INSURED AAA Meca Construction INSURERS: Infinity Insurance Angel Gomez INSURER c : State Compensation Ins. Fund 35076 1129 South 6th Street San Jose, CA 95112 INSURERD: 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 NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR D POLICY NUMBER MM ICYEFF /YYYY MM ICYEXP /YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADEFX] OCCUR X NA107413203 01/25/2017 01/25/2018 DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY PRO- F—] ❑ LOC PRODUCTS -COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ S ANY AUTO 504-61004-9623-001 01/22/2017 01/22/2018 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Peraccident $ X NON -OWNED X HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAR CLAIMS -MADE DED I I RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN 9068663-16 08/16/2016 08/16/2017 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N / A E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Job: 1443 Harriet AV9, Campbell CA All work in public right-of-way. City of Campbell, its officers, employees and volunteers are named additional insured as respects liability per policy c' form 49-01080711 ��q �0�� — Q C)C) b l7 a.11 111 L9d\1-0i L•lMR■,a� 9]\CL�7a„GII L.,r City of Campbell Public Works Department 70 N. 1st Street Campbell, CA 96008 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY BLANKET ADDITIONAL INSUREDS - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Policy Number: NA107413203 Endorsement Effective: 1/25/2017 12:01 a.m. Named Insured Countersigned y: ANGEL GOMEZ , DBA: A A A MECA CONSTRUCTION r SCHEDULE , m poerson o°O� o°rgOai> R c 'Et the named insured is obligated by virtue of a written contract or agreement to provide insurance such as is afforded by this policy. Location: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) A. Section II — Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only to the extent that the person or organization shown in the Schedule is held liable for your acts or omissions arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions This insurance does not apply to "bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the. additional insured(s) at the site of the covered operations has been completed; or (2) That portion of "your work'.' out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. The words "you" and "your" refer to the Named Insured shown in the Declarations. D. "Your work" means work or operations performed by you or on your behalf; and materials, parts or equipment furnished in connection with such work or operations. Primary Wording If required by written contract or agreement: Such insurance as is afforded by this policy shall be primary insurance, and any insurance or self-insurance maintained by the above additional insured(s) shall be excess of the insurance afforded to the named insured and shall not contribute to it. Waiver of Subrogation If required by written contract or agreement: We waive any right of recovery we may have against an entity that is an additional insured per the terms of this endorsement because of payments we make for injury or damage arising out of "your work" done under a contract with that person or organization. 49-0108 07 11 May Include Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 1 Used with permission ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION 9068663-16 RENEWAL NF PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE MAY 2, .2017 AT 12.01 A.M. AND EXPIRING AUGUST 16, 2017 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME AAAllECA CONSTRUCTION 1129 S 6TH ST SAN JOSE, CA 95112 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF CAMPBELL PUBLIC WORKS DEPT. WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, AAAMECA CONSTRUCTION IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: MAY 4, 2017 AUTHORIZED REPRESENT IVE PRESIDENT AND CEO SCIF FORM 10217 (REV.7-2014) 2570 OLD DP 217 4 INSURANCE REQUIREMENTS CHECKLIST �^- Permit # C— �� —ab� L -bon CIP Project # The following insurance is required of all contractors working in. the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: 74— $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or 4 $2,000,000 general aggregate limit. Policy expiration date Automotive Liability: Any Auto checked on certificate 7a $1,000,000 per accident for bodily injury and property damage fir --Policy expiration date Z �� Workers' Compensation and Employer's Liability ❑ Waiver of Subrogation clause >61 $1,000,000 per accident for bodily injury or disease y Policy expiration date l Course of Construction (if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement (Description of Operations Area) The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location & Permit Number) The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation Area: ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR Should Read \\Honouliuli.cityhall.ci.campbell.ca.us.local\Profile_Data$\loannat\Desktop\Insurance Requirements Checklist.doc (Rev 03/13) Page 1 of 2 Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. I Name: Sifc. 1 NAIC # �� Rating: 2)IV Authorized in CA: Name: '_t_ASd - NAIC # ZZZating: >�, Authorized in CA: Name: NAIC # Rating: Authorized in CA: Name: NAIC # Rating: Authorized in CA: i �'� ❑ Campbell Business License #_ Contractors License # Insurance Certificate Reviewed OZ`k p60 1 --"—'Class: Initials Expiration: \�t�x `�' _ Expiration: 3( C 1 D to W Copy of Insurance Certificate placed in tickler file one month prior to expiration. \\Honouliuli.cityhall.ci.campbell.ca.us.local\Profile_Data$\ oannat\Desktop\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 ENCROACHMENT PERMIT ISSUANCE CHECK LIST City of Campbell Encroachment Permit No. ENC 2016-00084 Department of Public Works Tract No. N/A Address i14Harriet Avenue 43 ITEMS REQUIRED FOR PERMIT APPLICATION: 1. ® Encroachment Permit Application complete, with applicant signature and date (front and back) 2. ® Permit Application Fee paid $395:00' - Receipt Number & Date263710 `- 4/29l16 3. ® Plan Check Deposit Paid (2% of Engineer's Estimate, $500 min) $500.00 #Receipt Number 263710 = 4/29/16 4. ❑ Grading Plan Review Fee paid — N/A 5. ® City Engineer's Estimate Completed and Submitted 6. ® Four (4) Sets of Street Improvement Plans 7. ❑ Four (4) Sets of Grading and Drainage Plans 8. ® Check Lists (Grading and Drainage, Street Improvement) ITEMS REQUIRED PRIOR TO PUBLIC WORK CLEARANCE FOR BUILDING PERMITS 9. ® Plan Check & Inspection Fee: Engineer's Estimate (EE) = $2qY750:00; if EE is <$250,000, then fee is 14% of EE. If EE > $250,000, fee is Actual Cost + 20%. $35,000 minimum deposit. Amount $4.165.00. Receipt No. & Date 265i56 & 8/1/15 10. ® Security for Faithful Performance and Labor and Materials, 100% each of Engineer's Estimate, supplied or paid. Amount $29.750 W. Form Gash Receipt No. & Date NJ— 6',& 8/1/16 11. ❑ Security for Monumentation Amount $�M Receipt No. & Date I" 12. ® Construction Emergency Cash Deposit: 4% of Engineer's Estimate. ($500 minimum, $10,000 maximum) Amount $1.190 60 Receipt No. & Date 265166`&*8/1/16 13. ® Storm Drainage Area Fee — $'657.0� 14. ® Street Improvement Agreement signed and notarized (proof of ownership submitted) 15. ❑ Parcel Map recorded — N/A 16. ® All other Public Works requirements listed in the Conditions of Approval of the development. ❑ PG&E App (SL) ITEMS REQUIRED PRIOR TO ISSUANCE OF ENCROACHMENT PERMIT: 23. ❑ Contractor's signature added to the permit application (front and back) 24. ❑ Contractor's City of Campbell Business License #° '- 25. ❑ Worker's Compensation Insurance Information Sheet received from Contractor. 26. ❑ Certificate of Insurance with Additional Insured's Endorsement received from Applicant or Contractor. 27. ❑ One mylar set and six (6) or less sets of off -site plans signed by engineer, stamped APPROVED FOR CONSTRUCTION. ® Contractor, ® Inspector ❑ City Arborist (Service Center) ® EP File ® LD File ❑ Signals & Lighting Supervisor (Service Center) 28. ❑ Permit signed by City Engineer. 29. ❑ INITIATE CHECK REQUEST FOR PLAN CHECK DEPOSIT REFUND WHEN ALL OF THE ABOVE ITEMS ARE COMPLETE, PERMIT MAY BE ISSUED. Issuer: Initial and date and file with permit Documentl (Rev.07/11) Encroachment Permit Final Sign Off Encroachment Permit Address: 14`f Date of Final Inspection and Acceptance: Inspected by: '7w OK to release deposits: 100% 75% V Comments: 7 �� ' 00 vv C�& Oeoos C 1(-b - �es- �DO PUBLIC WORKS DEPARTMENT LAND DEVELOPM'11-41- Effective July 1, 2015 TO: Finance PUBLIC WORKS FILE NO. ENC2016-00084 PROPERTY ADDRESS 1443 Harriet Avenue Please collect & receipt for the following monies: ACCT ;ITEM AMOUNT LAN D-DEVELOPMENT• 4722 Encroachment Permit is mon Fee Non -Utility Encroachmeht Permit Major >_$10,000 $395.00 $395.00 Minor Encroachment Permit <sio,000 $225.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $225.00 Inspection Fee Minimum Charge per Location $390.00 Street Tree Planting/Removal N/C 2203 $500 per Tree Planting Deposit Required) $500.00/tree 22031 Plan Check Deposit 2% of Engineer's Estimate $500.00 min $500.00 Utility and R-1 Permits no deposit required 4722 Grading & Drainage Plan Review Single Family Lot $275.00 Site < 10,000 s.f. $825.00 Site >_ 10,000 s.f. < 0.5 Acre $1 105.00 Site >_ 0.5 Acre $1 NPDES Review C3 Requirements) For projects not required to submit numeric sizing $1 For projects required to submit numeric sizing Impervious Area 10,000 S . Ft to 1 Acre $6 Impervious Area 1 Acre or more $9 For proeects sent to Consultant for review Cc Additional treatment facilities $3 Plan Check & Inspection Fee(Non-Utility) En r. Est. < $250,000 14 En r. Est. >_$250,000 and :5$500,000 $3:I Q1 En r. Est. >$500,000 $5: Emergency Cash Deposit 40/c Faithful Performance Security FPS 10( Labor and Materials Security 10( iz!=?J'? �?" =o Storm Drainage Area Fee Per Acre R-1 F;-•;vISTE„ P A T F_ 04,_-r;`"... ii�i Gf! s' All n.''�_.'�t•1•..1 Iat?, ., ,.,,_;, Parcel Ma 4 Lots or Less $3 Final Tract Ma 5 or More Lots $4,' ENCIR=??iF!IE 1,' 1-1UMb_ i Monumentation Security 10C Parkland Dedication Fee(Remaining 25%will be Due UPC e__ - Lot Line Adjustment $1 ! L` t'= t `' - ` J t " Q. ' Vacation of Public Streets & Easements $2,, "--`-` ---' ---- Certificate of Compliance $1 f TOT A ":`:r = j' ` 00 Certificate of Correction $55 - Document RecordingFees T`-f? '`_t' ?" not: -w. $15 i..._� Private Improvement in Public ROW $50 "'),'"-'-` Approved Plan Revision Fee $101 `•I'1 "14. P.D. -'°1 Appeal Filing Fee $201 f;;_;= ?uri 3L Notary Fee(per signature) $10. Assessment Segregation or Reapportionment First Split $87; Each Additional Lot $27E,.uu 4722 4722 4722 4722 4722 4722 2203 2203 2203 4721 4722 4722 2203 4920 4722 4722 4722 4722 4722 4722 4722 4722 4722 4722 5117424 MISCELLANEOUS- Postage ' *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $895.00 NAME OF APPLICANT v _ c NAME OF PAYOR PHONE ADDRESS % V vo- ,`61 , ti i U,� ZIP ( Lj FOR a f RECEIVED BY','' CITY CLERK ONLY J- ✓ Date , J1Lentl0eN. Check Canme %I-Sp.fk: Projeft-A— Project,n Progre 1He Aye. 1"3\F—%F—x , .- , - � _- - - -7 1 1-1 -.,- .: - ��,,_,��,11� `,-� , _�;,:, ". I . -., -, �_ .. - �. -,. ". I '. ,�' '- ., .��,_-.. .i, � . , , �: - , �� : '. . . - , - I - , - - :� I .. , _ , . - , . ..., . 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I 1 . , ., . ,_� Z� - I ;_ , . . . ,� CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2016-00084 Name: Arash Moradi Property Address: 1443 Harriet Ave. Date of Final Inspection: On File: Bonds CD Cash Xantlsf-u1° e orm°ance: 'W29%749r00jq,,5,%=$2 9,19TO5011W Labor and Material: $ ARSE tructlon -sh o > si= to be rel sed: 1'070WOW Other overdue deposits to be released (Description): �a Ch a euas�t5�00..0.0� Processed by: �l z 1 Ad inistrator Reviewed by: -9/2g�n Reviewed by: Inspector 01 I/M lil Land Development Engineer JAJoAnnaT\Deposit refunds\CHECKLISTS\Harrietl443.doc (Rev. 10/11) KELLY'S CONCRETE & BUILDING MATERIALS, INC. 44300 Old Warm Springs Blvd. Fremont, CA 94538 (510)656-2368 WARNING IRRITATING TO THE SKIN AND EYES Contains Portland Cement. Wear Rubber Boots and Gloves. PROLONGED CONTACT MAY CAUSE BURNS. Avoid Con- tact With Eyes and Prolonged Contact With Skin. In Case of Contact With Skin or Eyes, Flush Thoroughly With Water. If Irritation Persists, Get Medical Attention. KEEP CHILDREN AWAY SOLD TO: 7W f I )Wy /`Al,n/ U-4- j/ --Y7 1-t-1 5 I G- WEIGHMASTER'S CERTIFICATE THIS IS TO CERTIFY that the following described commodity was weighed, measured, or counted by a weighmaster, whose signature is on this certifi- cate, who is a recognized authority of accuracy, as prescribed by Chapter 7 (commencing with Section 12700) of Division 5 of the California Business ,and Professions Code, administered by the Division of Measurement I17 PROPERTY DAMAGE RELEASE (TO BE SIGNED IF DELIVERY TO BE MADE INSIDE CURB LINE.) Dear Customer - The driver of this truck is presenting this RELEASE to you for your signature is of the opinion that the size and weight of his truck may possibly cause damage to the premises and/or adjacent property if he places the material in this load where you desire it. It is our wish to help you in every way that we can, but in order to do this the driver is requesting that you sign the RELEASE relieving him and KELI-Y'S CONCRETE from any responsibility from any damage that may occur to the premises and/or adjacent property, buildings, sidewalk, driveways, curbs, etc. by the delivery of this material, and that you also agree to help him remove mud from the wheels of his vehicle so that he will not litter the public street. Further, as additional consideration, the undersigned agrees to indemnify and hold harmless the driver of this truck and KELLY'S CONCRETE for any and all damage to the premises and/or adjacent property which may be claimed by anyone to have arisen out of delivery of this order. . Interest and Attorney's fees: Customer agrees to pay interest at the rate of 12 % Annum or at the highest rate permitted by law, whichever is lesser upon all delinquent accounts, and further agrees to pay upon demand, all reasonable collection cost and attorney's fees incurred in collection of this account or in enforcing any of the terms of this agreement. WATER ADDED ON JOB AUTHORIZED BY J r GALS. X�- TRUCK NO. CUBICYARDS MIX NUMBER ACCOUNT NO. SLUMP (INCHES) RODUCT DESCRIPTION DATE CALCIUM PTS. LAMP BLACKIYARD KELLY'S CONCRETE - WEIGHMASTER DRIVER'S NAME LOAD NO. ACCOUNT/MIX TOTAL DELAY EXPLANATION/CYLINDER FINISH UNLOADING ARRIVE PLANT r TESTSTAKEN �J COMMENTS: ARRIVE JOB LEAVE PLANT TOTAL TIME ON JOB TOTAL DEL. MINS. CODE AMOUNT PRICE C.O.D.AMOUNT 1-7 DELIVERY TAX BALANCE DUE %'r SUBTOTAL STAND BY TOTAL 1 ^Ar%TAP%- ki— �± E11F'I�jlj�; .. 1 Ott♦III l"a WK. 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