ENC2017-00213 Encroachment Permit Final Sign Off
Encroachment Permit# f-44C 9-o17 - 7=G2i3
Address:
Date of Final Inspection and Acceptance:
Inspected by:
OK to release deposits: 100% 75/0
Comments:
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CITY OF CBELL
Public Works Department
November 27, 2017
William Horbaly
199 Bland Ave.
Campbell, CA 95008.
SUBJECT: PERMIT NO. ENC 2017-00213
199 Bland Ave., Campbell CA
FINAL INSPECTION AND ACCEPTANCE
Dear William:
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 as of November 9, 2017.
The permittee is responsible for the repair and/or replacement of any defective 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.
Your Faithful Security Deposit in the amount of$500.00 is enclosed..
.If you have any questions,please call me at(408) 866-2165.
Sincerely,
Syed Wahidi
Public Works Inspector
Cc: Inspector/Suspense Files
Permit File ENC2017-00213
70 North First Street Campbell, California 95008-1436 TEL 408.866.2150 • FAX 408.376.0958 TDD 408.866.2790
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CITY of CAMPBELL
Public Works Department
November 8, 2018
William Horbaly
199 Bland Ave.
Campbell,.CA 95008
SUBJECT: PERMIT NO. ENC 2017-00213
199 Bland Ave., Campbell, CA
FINAL INSPECTION AND ACCEPTANCE
Dear William:
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.
Sincerely,
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
V
Print Form
CITY OF CAMPBELL R-1 ENCROACHMENT PERMIT Permit No. [:0 2e 17-00243
DEPT.OF PUBLIC WORKS X-Ref File
(Non-engineered work within the public right-of-way)
70 North First Street ($10,000.00 maximum value of work) Applicationbate 1
Campbell,CA 95008 ` Application Expiration,
Ph.(408)866-2150 ISSUED: 1 Date 3 13
.117
Fx.(408)376-0958 Permit Expiration Date: It'IAPN Z
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: C( I-A
N D /-\1/C- .
B. Nature of Work: 12ll PLACE CXtST .� T W, P&x
l G"1 �-�'E iNl-ft-1 CA,t''tMeR CCa,T`( -Zo 9SK0-vL C-)GIST
C. Attach three(3)copies of a drawing showing the location,extent and dimensions of the work. The drawing shall show the relation of ` izur—
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: / / Telephone: _ f_ ...
ddress:
Mail.Address: t ,
�..
The Applicant hereby confirms that this work is b ing done bythe pro�erty 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 pd understand both the front and back of this permit,and that they will inform their
contractor(s)of the inform ti n. 2 f
ACCEPTED: / N
(Applicant/Pe ittee) (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 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 r
recorded. `
2. M
3.
STANDARD AMOUNT RECEIPT NO.
SECURITY FOR FAITHFUL PERFORMANCE (100%Of Engr's Est.) $ t5OC9
R-1 PERMIT FEE $�
APPROVED FOR ISSUANCE � � \ 34 U
forCi b Engineer ate
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.
S. 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.
is. 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 roster. ,Applicant shall adhere to the REST MANAGEMENT PRACTICES established by
the Santa Clara Valley Urban Runoff Pollution Prevention Program.
Applicant shall be respon ible or ensuring that all those providing services under the applicant are aware of and understand all if the above
condi 11 .
Applicant_ uat
J:\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf
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PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT
Effective July 1,2017
TO: Finance PUBLIC WORKS FILE NO. IL-4A 2-e L7—Go 2Q'j
PROPERTY ADDRESS 'C( I3 Vv i7 v
Please collect&receipt for the following monies:
ACCT. ITEM AMOUNT
LAND DEVELOPMENT.
4722 Encroachment Permit Application Fee
Non-Utility Encroachment Permit Major>$10 000 $425.00
Minor Encroachment Permit<sio,000 $240.00
Initial R-1 Permit N/C
Subse uent R-1 Permits within Two Year Period $240.00
Inspection Fee Minimum Charge per Location $420.00
Street Tree Plantinq/Removal N/C
-2203 ($500 per Tree Plantinq Deposit Required) $500.00/tree
2203 Plan Check Deposit 2%of Engineer's Estimate $500.00 min
Utility and R-1 Permits no deposit required
47221 Gradinq&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 protects 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 En r. Est. <$250 000 14%of Engineer's Estimate
4722 Enqr. Est. >_$250 000 and<_$500,000 $35 000.00+8%of Engineers Estimate
4722 En r. Est. >$500 000 $55 000.00+7%of Engineers Estimate
2203 Emergencv Cash Deposit 4% of En r. Est.*($500 min/$10,000 Max
2203 Faithful Performance Security FPS 100%of ENGR. EST.* Sao
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 Parcel Map(4 Lots or Less) $4 200.00+$90/lot
4722 Final Tract Map 5 or More Lots) $5,115.00+$124/lot
2203 Monumentation Security 100%of Ci '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 Private Improvement in Public ROW $100.00
4722 Approved Plan Revision Fee $100/sheet
4722 Appeal Filing Fee $200.00
730.4924 Notice of Improvement Obligation Payment
4727 ssessment Segregation or Heapportionment
First Split $940.00
Each Additional Lot $295.00
511.7424 Postage
MISCELLANEOUS_ , .
Other(Please peci )
*Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $ �j0C)
NAME OF APPLICANT (L(,t L,�-f — 1.
NAME OF PAYOR PHON5
ADDRESS ZIP
FOR RECEIVED BY. IV OF�j
CITY CLERK —II
ONLY Date Receipt#
J'TORMS\Templa
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CITY OF CAMPBELL
n `=: ', _ REC1Ii BY: CASHIER , OO2r13.8
PAYOR: WILLIAM HORBALY
TODAY"S HATE: 09 13JI17
n i REGISTER DATE: 09/13/17 TIMU O0.00 �
DESCRIPTION AMOUNT
7 CUST ID:ENC2017--00213
REF DEPOSIT - 1O1 $500,00 '
----------------
TOTAL DUE: $500.00 _
TENDERED: $500.00
CRANK.- $.00
CHEECK .L $500.0O
.Refundable Deposit Check Request
To:. Finance Director
Check Payable To, William Horbaly.
Address Line 1: 199 Bland Ave.
Line 2:
City: Campbell State: CA Zip:`95008
Description: ENC2017=00213
Account Number: - 101.2203 Amount: $500.00 ,
Account Number: 101.220a _ Amount:
Account Number: 101.540.7448 Amount:
(Finance Dept only) Interest Earned (Finance Dept only)
Total Payable: (Exact Amount)
Purpose: 199 Bland Ave deposit refund.
Permit#: ENC2017-00213
Receipt* 271398, Date: 9/13/2017
Receipt#: Date:
Title: Ins ector, Date: 1 JA
Requested by: - ,- p
Syed Wahid,i
Approved by: ?A
,. Title, Sr..Engineer Date:
Roger`Stolz
Finance Dept Only:
Verified by: Title: Accounting Clerk,ll Date.
Approvedby: Title: Accountant Date:
Special Lnstructiom For Handl ing Check
man As is mall in AttaChed.Envelope interim t;neCK: ,
Needed By:
Return To JoAnna Thomason Public Works
(Name) (Department)
Other: Please return check to JoAnna
CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
CLEARANCE FOR FINAL INSPECTION
AND ACCEPTANCE LETTER
Encroachment Permit#: ENC 2013-00127
Name: William Horbaly
Property Address: 199 Bland Ave., Campbell CA
Date of Final Inspection:
On File: Bonds CD Cash
Faithful Performance: $ 500.00
Labor and Material: $
Construction Cash Deposit to be released: $
Other overdue deposits to be released (Description):
Processed by:
Administrator
Reviewed by:
:ctor
Reviewed by: ,3
La d Development Engineer
JAJoAnnaT\Deposit refunds\CHECKLISTS\Bland 199.doe(Rev. 10/11)
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CITY OF CAMPBELL VENDOR NO. 10012333 CHECK NO. 265421
Account . Purchase.Qzder InvorceNu+nber.; . . "Amount... Deseri`teon .. :>
101 2203 CRI12017 500.00 ENC2017-00213
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10012333 - WILLIAM HORBALY
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O' 4t CITY 4F CAIVIPBEI.L w1 r; FARGO BANK,"N.A. .- "11-24 CHECK ATE CHECK NO D
I I CAMPBELt;:CALIFO.RNIA 95008 y 420 MONTGOMERY STREET lzla 11/27/17^( 265421 it `
7i7 NOl `WFIRST STREET
' SAN FRANCISCO CA 94104
o •o . ,-' AMOUNT �F ******`*,500� 00*�o� ,�,
-
ORrjp40'4 ` VOID AFTER 90 DAYS' 0
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I PAY THE SUM OF FIVE HUNDRED DOLLARS & ZERO CENTS ) / I
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To
ORDTHE -VVIL'LIAM.HORBALY
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1 r } CAMPBELL CA 95008
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*See Reverse Side For Easy Opening lnstrUctions*
- -
CITY OF CAMPBELL
70 NORTH FIRST STREET r
CAMPBELL, CALIFORNIA 95008
WILLIAM HORBALY
199 BLAND AVE
CAMPBELL CA 95008
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CITY of CAPBELL
Public Works Department
November 27, 2017
William Horbaly
199 Bland Ave.
Campbell,-CA `95008
SUBJECT: PERMIT NO. ENC 2017-00213
199 Bland Ave., Campbell CA
FINAL INSPECTION AND ACCEPTANCE
Dear William:
The City of Campbell hasmade 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 as of November 9, 2017.
The permittee is responsible for the repair and/or replacement of any defective 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.
Your Faithful Security:Deposit in the amount of$500.00 is enclosed.
If you have any questions,please call me at (408) 866-2165.
Sincerely,
Syed Wahidi .
Public Works Inspector
Cc: Inspector/Suspense Files -
Permit File ENC2017-00213
70 North First Street • Campbell, California 95008-1436 •TEL 408.866.2150 •FAx 408.376.0958 TDD 408.866.2790