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ENC2004-00133 of . c � t June 27, 2007 0 R C H A�� Roman Knop CITY OF CAMPBELL 261 17'Ave Public Works Department San Francisco, CA 94121 Re: 213 Rincon Ave. EP 04-0133, Tract Map 9604 Monumentation Cash Security—Third Request Dear Mr. Knop: This is a third request to the letter sent on 1/30/07. According to the City's records, a $7,000 security is still being retained for setting the survey monuments for the above- referenced Tract Map 9604. Please provide us with a letter from your land surveyor that states: (a) all monumentation has been completed in accordance with the Subdivision Map Act Section 66495, and the prepared Tract Map 9604, (b) that he has been paid for his services, and (c) that he has set easily identifiable/verifiable markers at the monumentation locations (i.e. above ground construction stakes and/or flags). Upon written request for refund of the security by the party who posted it, the staff will check the site to verify that the monuments have been set. When the monumentation has been completed, the staff will arrange to have your security released. According to recorded Tract Map 9604, monuments should have been set on or before October 1, 2006. Please respond within two (2) weeks of receiving this letter. Contact me at (408) 866- 2166 if you have any questions. Sincerely, L<! I Ed Arango,P.E. Associate Civil Engineer cc: LD File/ (213 Rincon Ave.) H. Alfredo Vasquez, SMP Engineers, 1534 Carob Lane Los Altos, CA 94024 70 North First Street • Campbell, California 95008-1436 1 TEL 408-866.2150 • FAX 408.376.0958 1 TDD 408.866.2790 MRR-21-2008 00:47 From: To:376095e Pa9e:2-2 FRAM :SMP ENGINEERS FAX NO. :650-941-8755 Mc. 21 2008 07:47AM P1 SMP 1 EVE March 19,2007 City of Campbell Building Department 70 North First Street Campbell,CA 95008 Attn:Deparanent of land Development Re; Three-New Townhome Development 243,245 and 247West Rincon Avenue Campbell,CA 95008 Final Corner Monuments Certlflente This letter is to certify that SN4P Engineers has set the final property comer monuments in accordance with the recorded Parcel Map,Book 787 of Maps,at Pages 36 and 37,Santa Clare County records and the Certificate of Correction dated January 2007, All the engineering and surveying fees associated with this project have bccaa paid in full by the owner.There are no outstanding invoices in this account, If you have any questions regarding this matter,please contact me at your convenience. Sincerely, QRoeusro,� Saoid F=avi SMP ENGINEERS a t&5M4 R.C.E.52724 M Carob Laaa is altos �lidpraie,14014 331.041.8155 P 11541.1155 E a tYw.3lapen�iaetra,easa r NCH I' CITY OF CAMPBELL Public Works Department TRANSMITTAL June 7,2007 From The Desk Of.- Sue Fontaine Mr. Hadi Ghafouri Executive Assistant 13810 Via Alto Court (408) 866-2776 Saratoga, CA 95070 e-mail: suef@cityofcampbell.com Re: 243,245 and 247 W. Rincon Ave. Enclosed for your records please find a copy of a recorded Certificate of Correction in connection with your property at 243, 245 and 247 W. Rincon Avenue. Sue Fontaine6i Executive Assistant Enclosure 701Nr)rti, F•11.q ')tree' C..amphell. California `.15008.1.49h TU 4011-86i,.2150 VAN -105.376.0958 Tun.408,866.2790 Recording Requested by and When Recorded, Return to: City of Campbell City Clerk's Office 70 North First Street Campbell, CA 95008 (SPACE ABOVE THIS LINE FOR RECORDER'S USE) CERTIFICATE OF CORRECTION The subdivision known as 243,245 and 247 W. Rincon Ave. recorded in the Office of the Santa Clara County Recorder in Book 787 of Maps,Page(s) 36-37 ,is hereby corrected in accordance with Chapter 3,Article 7,Sections 66469 through 66472.1 of the Subdivision Map Act as follows: 1. Character and locations of certain monuments were changed. The true location and character of the monuments set are indicated on the attached Exhibit A. The fee owners of the real property affected by this correction on the date of recording of the original recorded map are Hadi and Barbara Ghafouri. ENGINEER/SURVEYOR CERTIFICATE Prepared By: ..� ' R.E. No. 30442 Printed Name: Alberto Masso Expiration Date 03/31/08 Date Prepared: January 23,2007 CITY ENGINEER CERTIFICATE This document has been approved by the City of Campbell. &OJ—V4- 3—i3-07 ichelle Quinney,P.E.,City Engine6lDate RCE 44144(Exp.6/30/2007) r' I am satisfie at the within lot line adjustment and certificate of correction are tech '�' `o r 17 a14 -C Cyrud`Kianpo1.0c> veyor Date c LLS.7515,.-E ' s 12/31/07 a U No. 7515 J ; Exp. 3i c- = r r V l OF ORCH g0.o. CITY of CAMPBELL Public Works Department September 5, 2007 H. Alfredo Vasquez SMP Engineers 1534 Carob Lane Los Altos, CA 94024 Re: 243 Rincon Ave rH •7 g7 36,/-37 EP 2004-0013)($ 04 Monumentation Cash Security Dear Mr. Vasquez: This letter is a follow up to our conversation on 9/5/07. According to the City's records, a $ 000 cash security bond is still being retained for setting the survey monuments for the ab ve-referenced TradA4apzOWT I have verified that the monuments have been set. Please provide us with a letter that states: (a) all monumentation has been completed in accordance with the Subdivision Map Act Section 66495, and the prepared Tract Map 9604, and (b) that you have been paid for your services. Upon receiving the letter,the staff will arrange to have the security released. Please respond within two (2) weeks of receiving this letter. Contact me at (408) 866- 2163 or Ed Arango at(408) 866-2166 if you have any questions. Sincerely, William Lai cc: LD File/(243 Rincon Ave.) Hadi Ghafouri 13810 Via Alto Court Saratoga, CA 95070 70 North First Street • Campbell, California 95008.1436 • ITt. 408-866.2150 FAX 408.376.0958 TIT 408.866.]790 of J= oRCH ARC CITY OF CAMPBELL January 30, 2007 Public Works Department Roman Knop 261 17' Ave San Francisco, CA 94121 Re: 213 Rincon Ave. EP 04-0133, Tract Map 9604 Monumentation Cash Security—Second Request Dear Mr. Knop: This is a second request to the letter sent on 10/3/06. According to the City's records, a $7,000 security is still being retained for setting the survey monuments for the above- referenced Tract Map 9604. Please provide us with a letter from your land surveyor that states: (a) all monumentation has been completed in accordance with the Subdivision Map Act Section 66495, and the prepared Tract Map 9604, (b) that he has been paid for his services, and (c) that he has set easily identifiable/verifiable markers at the monumentation locations (i.e. above ground construction stakes and/or flags). Upon written request for refund of the security by the party who posted it, the staff will check the site to verify that the monuments have been set. When the monumentation has been completed, the staff will arrange to have your security released. Please respond within two (2) weeks of receiving this letter. Contact me at (408) 866- 2166 if you have any questions. Sincerely, Ed Arango, P.E. Associate Civil Engineer cc LIB`-Frle/�(21�3�Rincot-Ave:) H. Alfredo Vasquez, SMP Engineers, 1534 Carob Lane Los Altos, CA 94024 70 North First Street ° Campbell, California 95008-1436 ^ TEL 408-866.215.0 ° PAX 408.376.0958 ° TDD 408.866.2790 I OF C � u � October 3, 2006 i OR CH ARC Roman Knop 261 17"Ave CITY OF CAMPBELL San Francisco, CA 94121 Public Works Department Re: 213 Rincon Ave. EP 04-0133, Tract Map 9604 Monumentation Cash Security Dear Mr. Knop: According to the City's records, a$7,000 assignment security bond is still being retained for setting the survey monuments for the above-referenced Tract Map 9604. Please provide us with a letter from your land surveyor that states: (a) all monumentation has been completed in accordance with the Subdivision Map Act Section 66495, and the prepared Tract Map 9604, (b) that-he has been paid for his services, and (c) that he has set easily identifiable markers at the monumentation locations (i.e. construction stakes and/or flags). Upon written request for refund of the security by the party who posted it, the staff will check the site to verify that the monuments have been set. When the monumentation has been completed, the staff will arrange to have your security released by the City Council. According to recorded Tract Map 9604, monuments should have been set on or before October 1st, 2006 Please respond within two (2) weeks of receiving this letter. Contact me at (408) 866- 2166 if you have any questions. Sincerely, C Ed Arango, P.E. Associate Civil Engineer cc LD F;1e/2(213=Rincon-Aue:) H. Alfredo Vasquez-O, SMP Engineers, 1534 Carob Lane Los Altos, CA 94024 70 North First Street ° Campbell, California 95008-1436 • TEL 408-866.2150 • FAX 408.376.0958 ^ TDD 408.866.2790 MRR-21-2008 00:47 From: To:3760958 Page:2,2 FROM :SMP ENGINEERS FAX NO. :650-941-8755 MF 21 2008 07:47AM P1 . qS M.P 1 INEE bS MaMh 19,2007 City of Campbell Building Department 70 North First Street CampbeU,CA 95008 Attn:Department of Land Development Re: Three-N.ew Townhome Development 2439 245 and 247 West Aincon Avenue Campb4 CA 95008 Final Corner Monuments Certifleate This letter is to certify that SMP Engineers,has set the funaI property comer monuments in accordanoc with the recorded Parcel Map,Book 787 of Maps,at pages 36 and 37,Sean Clara County records and tw Certificate of Correction dated-January W, A11 the engineering and surveying fees associated with this project bane bean paid in full by the owner.There are no outstanding invoices in this account. If you have any questions regarding this matter,please contact me at your convenience. �6 QQ,oRUSl4, Saeid Razavi • SMP ENGINEERS a No.5M4 R.C.E.52724 ,a -i34 Carob Liao is Alms ?Ailprais, 3�.8i1.@956 P • h19.941.i155f _. +law-sapan�iaeera.ia� • .. r MY OF CAMPBELL Public Works Department TRANSMITTAL June 7,2007 From The Desk Of.- Sue Fontaine Mr. Hadi Ghafouri Executive Assistant 13810 Via Alto Court - (408) 866-2776 Saratoga, CA 95070 e-mail: suef@acityofeampbell.com Re: 243, 245 and 247 W. Rincon Ave. Enclosed for your records please find a copy of a recorded Certificate of Correction in connection with your property at 243, 245 and 247 W. Rincon Avenue. I ; Sue Fontairi ' Executive Assistant Enclosure 70 f` ordi hr o Sircc! r..ampocll. California 9.500R-143i; -11.1 40R-8(,o.i 150 A;. 108.376.0958 TUI� 408.806.2790 Recording Requested by and When Recorded, Return to: City of Campbell City Clerk's Office 70 North First Street Campbell, CA 95008 (SPACE ABOVE THIS LINE FOR RECORDER'S-USE) CERTIFICATE OF CORRECTION The subdivision known as 243,245 and 247 W. Rincon Ave. recorded in the Office of the Santa Clara County Recorder in Book 787 of Maps,Page(s) 36-37 ,is hereby corrected in accordance with Chapter 3,Article 7,Sections 66469 through 66472.1 of the Subdivision Map Act as follows: 1. Character and locations of certain monuments were changed.The true location and character of the monuments set are indicated on the attached Exhibit A. The fee owners of the real property affected by this correction on the date of recording of the original recorded map are Hadi and Barbara Ghafouri. ENGINEER/SURVEYOR CERTIFICATE Prepared By: �� e1r".. /�}/°��' R.E. No. 30442 Printed Name:' Alberto Masso --' Expiration Date 03/31/08 Date Prepared: January 23.2007 CITY ENGINEER CERTIFICATE This document has been approved by the City of Campbell. r 3—/3 07 ichelle Quinney,P.E.,City Enginql4vDate RCE 44144(Exp.6/30/2007) r I am satisfi at the within lot line adjustment and certificate of correction are tech �oir,� �o s ' -% R) Cyrua`Kianpo 'C' veyor LLS.7515,:E s 12/31/07 V off.. No.75 i 5 Exp. 03i A = OF ' C44 OR CH A0.' CITY OF CAMPBELL . Public Works Department September 5, 2007 H. Alfredo Vasquez SMP Engineers 1534 Carob Lane Los Altos, CA 94024 Re: 243 Rincon Ave y ��•'� •7 1 7 36�3 7 EP 2004-0013X,Tr 04 Monumentation Cash Security Dear Mr. Vasquez: This letter is a follow up to our conversation on 9/5/07. According to the City's records, a $ ,000 cash security bond is still being retained for setting the survey monuments for the ab ve-referenced Trad=Uap4kWT I have verified that the monuments have been set. Please provide us with a letter that states: (a) all monumentation has been completed in accordance with the Subdivision Map Act Section 66495, and the prepared Tract Map 9604, and (b) that you have been paid for your services. Upon receiving the letter,the staff will arrange to have the security released. Please respond within two (2) weeks of receiving this letter.. Contact me at (408) 866-" 216.3 or Ed Arango at(408) 866-2166 if you have any questions. Sincerely, William Lai cc: LD File/(243 Rincon Ave.) Hadi Ghafouri 13810 Via Alto Court Saratoga, CA 95070 70 North First Street Campbell, California 95008-1436 TEL. 408-866.2150 FAX 408.376,0958 TDO 408.866.2790 May 19 2015 11:55AM Y OUR , OGO A NO. 4083760958 NO. OTHER FACSIMILE rSTA/TTIME USAGE MODE .PAGES RESULT 01 14159010028 May 19 11:53AN 01'34 SND 03 OK TO TURN OFF REP,( PRESS 'Menu' 404 THEN SELECT OF� i For support, visit/ •tp Center model KX-FL421). r' i f , -o _ ... DATE(MMIDDmI - ` k om CERTIFICk ,,E OF LIABILITY INSM.;�-,NCE 8/11/2006 PRODUCER BONAFIDE INSURANCE SERVICES INC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION P O BOX 591478 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE;POLICIES BELOW. SAN FRANCISCO CA 94159 INSURERS AFFORDING COVERAGF_ ..(4415)522-5944 INSURED INSURER A; ProBuilders Speci V Insurance Co, RRG Romlkon,Inc. INSURER rj. I-InGoln General Insurance Company 261 17th avenue INSURER C; — San Francisco,CA 94121 INSURER0: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TIME POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REOUIREMENT, 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 SU8.IECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER Y DATE MMIDDEN1 0 EXPIRATION LIMITS _EACHnccuaRENeE a_ 1,000,000 GENERAL LIABILITY X COMMFRCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) 'S _50,000 _ CLAIMS MADE 191 OCCUR MED EXP(Any onA Per±,en) 5,000 A X 3500 PU Deductible COM 5008023 1116/2006 1116/2007 PERSONAL&ADVINJUR_Y 1,0001666 -- GENERAL AGGIREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMP/OP AGO I 1,000,000 X PdLICY PRO LOC Y AUTOMOBILE,LIABILITY COMBINED SINGLE LIMIT � 1,000,000 X ANY AUTO (Ea Soritlent) ALL OWNED AUTOS BODILY INJURY B 9CHEDUI.FD AUTOS 63221445102 8/1612006 8116/2007 {Per parson) _ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per Accidrvrlt) PROPERTY DAMAGE S, (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT _$ ANY AUTO OTHER THAN F.A ACc s. AUTO ONLY: AGG I. PXCESS LIABILITY REEACH OCCURRENCE I. OCCUR CLAIMS MADE E AGGGATE $ _— _ AUG 1 6 206 DEDUCTIBLE 9' — _ RETENTION $ P1.1Bpp w wz9' WG B'I'A'I OTH- WORKERS COMPENSATION AND ION TDRY LIM1Ts EMPLOYERS'LIABILITY E.L.EACH ACCIDENT I� E.L.DISFA$F-EA EMPLOYEE I ^ E.L.DISEASE-POLICY LIMIT I5 OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS See Supplemental Information Page(s) CERTIFICATE HOLDER ADDITIONAL INSURED;INSURERI.MER,. CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED•POLTCIES BE CANCELLED BFu"ORE THE EXPIRATION CITY CAMPBELL DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL—30 DAYS WRITTEN ATTN- DEPT OF PUBLIC WORKS NOTICE TO THE CERTIFICATE HOL13FR NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 70 NORTH FIRST STREET IMPOSE No OBLTGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED RE NTATIVE CAMPBEI,L CA 95008 ACORD 25-S(7197) 0 ACORD CORPORATION 1988 LM:LPW v1,8,$cn 011Ero6.14;48 by UaerNeme LP:LPw v1,9.8 on 811 B- :40 by U?nrName) PF v1.0.1 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statemen; on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does ir, affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. AUG 1 6 zoos Puw ACORD 25-8(7197) LM:LPW v1.9.B on Memo-14:43 by ueemame LP;LPW vl,9,8 vn 9116100.14;43 by WaMame PF AM ................. PRODU R 41� �94 APPLICANT(Frost Named lftmmd) PH-N A*lj....................( 1J . ................. (N 130........ ..................... ................ SONAFIDE ......................... INSURANCE SERVICES INC Romkon, Inc. P 0 BOX 591478 1261 17th avenue San Francisco,CA 94121 BAN FRANCISCO CA 94159 -..-........................ ........... . ..... CO... ..................... ...... ...................................................................................................... EFFECTIVE DATEPIRATION DATR CLAN MOM 1.10—T! ]_ IP ..........I.............. ... ......................... A a"E"N"C'Y C U'9*T0'M'E'R 6" . ......................... .......... .......... COUNTRUMSER: UUA I IU 41VCAt"-W(Exrf,0*lVRzlAULjE;.By 10 days written notice for non-payment of premium. PERMIT#: rzNC2004-00133 WORK SITE:213 W.RINCON AVENUE, CAMPBELL ALL WORK IN PUBLIC RIGHT-OF-WAY.CITY OF CAMI, BELL, CITY OF CAMPBELL REDEVOLOPMENT AGENCY,THE COUNTY OF SANTA CLARA ITS OFFICERS,EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSURED AS RESPECTS LIABILITY PER Rl 010 IWORK COMP.EXEMPT vel) AUG 2006 PY04i AbX7jjWV?a to &7)jQ0%r A LPW A0.8 on 8116/08-14:43 by IjaerNallAA LPG.LPW 0.9.8 an 8MG106-14!43 by UwNsma J CITY OF C:tMPBELL E )ACHMENT PERMIT Pern' �� -�00 4-0 0/ g,-o DEPT. OF PUBLIC WORKS (t:. .._rking within the public X-RL_.:,� 70 North First St. right-of-way) Campbell,CA 95008 Application Date (408)866-2150 Issued Application Expiration Date 101WO Fax(408)376-0958 Permit Expiration Date r' APN APPLICATION—Application is hereby made for a Public Works Permit in accordance 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# Utility trench location 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 0 M A, fJ `'�� Telephone ,�v i (P� CIS + ER Address �^ ! 5 a 24-2.) EMERGENCY TELEPHONE NO. E-Mail Address 1C(L1 M��U 0",p<,JfJ '� vA-fl OJ0 • W P I Is this work being done by the property owners at their own residence? Yes J No 1 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 information. 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 condition of any private improvements in,the•pnllic right- -way. Accepted % ©y h Q b (Applicant Permittee) (sign) Date ra { iyli 1 tiLl/P i Contractor (Print Name) Date ' { r _ � �rground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may ; I "� ��J lector rior to cuttin . + sU ,nd installations and must be restored in accordance with the Standard Details Trench Restoration Method — ?Inspector. �ad Surveyor or Civil Engineer and two(2)copies of the cut sheets sent to the Public Works Department i �JJ it Code this permit is not valid for excavations until Underground Service Alert(USA)has been notified and V O 'as been entered hereon. USA Phone 1-800-227-2600. USA TICKET NO. i tier shall execute an Agreement for Private Improvements in the Public Right-of-Way,which shall be J ii �✓�� ` � it �'OR CURRENT FEES AMQUN RECEIPT NO. �$ ` 4 s�33 �NCE/LABOR&MATERIALS $ CD I �� $� �7 0 AYrKU v Po rwi •ou ... 0 b For City Engineer Date Permit Expires 12 Months After Date of Issuance j I i r 1 \f'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 of 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. 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,bus stops,fire hydrants and water valves. 6. 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. 7. The 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. 8. 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. 9. Sawcut for all PCC or AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements. 10. 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. 11. 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. 12. Compaction testing of subgrade,base rock,and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 13. 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. 14. 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. 15. 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, ' 16. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 17. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 18, 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. 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. 20. 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. 21. Permittee must provide advance notification to all.parties that may be affected by the permit activities. Notification shall be reviewed by City prior to distribution and include dates of work and a contact name and phone number. 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 Contractor (Print Name) Date forms\P-perm ev. 11/9/05 CITY OF CAMPBELL ENCROACHMENT PERMIT Permit NoI'i'tj G 0 DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File 70 North First St. right-of-way) Campbell,CA 95008 Application Date �— (408)866-2150 Issued Application Expiration Fax(408)376-0958 Permit Expiration Date APN APPLICATION—Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code,Section 1 .04. (Application expires in 12 months if the permit is not issued. Application Fee is non-refundable.)J A.Work address or tract# '_ Q ' bf> Utility trench location B.Nature of work C' C.Attach four(4)copies of an engineered plan showing the location and extent o/bk ,and four(4)c ies of the preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surfaderground i rovements. 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 DPubIt orks Construction;the General Permit Conditions listed on the reverse side;and the Special Provisions for this permit,listed below. Failue b hese conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. (See Gei onditions 1 and 2.) E.The Contractor must have this permit and approved plans at the site and must Public Works Department at least two days before starting work. Notice must be given to Public Works at least 24 hours before restarting any w �(Name of Applicant �� Telephone u (print name) Address � 1 10 24-HOUR EMERGENCY TELEPHONE NO.Q E-Mail Address Is this work being done by the property owners at their own residen ? Yes No The Applicant/Permittee hereby agrees by affixing their signat 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 fr the work covered by this permit. The Applicant/Permittee hereby acknowledges that they ve read and understand both the front and back of this permit,and they will inform their contractor(s)of the informatio Applicant is advise t upon issuance of this permit, property owner,or property owner's successors,shall be responsible for any and all damages arisi out of the condition any private improvements in the public right-of-way. n Accepted 0 ,Vf (Applicant Permittee) (sign) Date Contractor (Print Name) Date SPECIAL PROVISIONS _I. Street shall not be open t for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be s ecifrcall a rov b the Inspector prior to cutting. _2. Pavement may be cu or underground installations and must be restored in accordance with the Utility Restoration Standard Details Method "A"Backfill,unles otherwise approved by Inspector. _3. Work to be stake by a licensed Land Surveyor or Civil Engineer and two(2)copies of the cut sheets sent to the Public Works Department before startinifintifi ork. 4. Per Section of the Government Code this permit is not valid for excavations until Underground Service Alert(USA)has been notified and the inquiry cation number has been entered hereon. USA Phone 1-800-227-2600. USA TICKET NO. 5. Prior to a work,the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way,which shall be recorde . 6. SEE PUBIAC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO. PER APPLICATION FEE $ PLA CHECK DEPOSIT $ SE URITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ C NSTRUCTION CASH DEPOSIT $ PLAN CHECK&INSPECTION FEE $ APPROVED FOR ISSUANCE For City Engineer Date Permit Expires 12 Months After Date of Issuance J:\forms\pwperm Revised 1.20.04 GENERAL PERMIT CONDITIONS 1. A Construction Cash Deposit is required. Charges will be made against this deposit if there is an•erriergency 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 of 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. 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,bus stops,fire hydrants and water valves. 6. 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. 7. The 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. 8. 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. 9. Sawcut for all PCC or AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements. 10. 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. 11. 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. 12. Compaction testing of subgrade,base rock,and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 13. 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. 14. 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: 15. 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. 16. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 17. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 18. 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. 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. 20. 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. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above conditions. ApplicafT_ Date Contractor (Print Name) Date J:\forms\pwperm Revised 1.20.04 1/29/2007 4:33PM Payment History For Case#: ENC2004-00133 4 IkeCQNde(1 1 ee 1D 1Deseri'taon T3 P p Fees- Paid DateU'a�d Clwec #. RuedY Drae H►sto APP 200406281347466400 Encroachment Application 260.00 260.00 6/22/2004 1044 168156 JD 0.00 Fee PCDP 200406281348112460 Plan Check Deposit 500.00 500.00 6/22/2004 1044 168156 JD 0.00 P01 200505240937318900 Non-Util Plan Ck/Insp to 1,146.27 1,146.27 5/19/2005 02088794 177053 JD 0.00 $250K FlMTM 200505240938025300 Parcel Map Fees-5 or More 3,365.00 3,365.00 5/19/2005 02088794 177053 JD 0.00 Lots Piwi 200505240944595900 Park Ded Fee<6 Units 18,139.00 18,139.00 5/19/2005 02088794 177053 JD 0.00 SDB 200505240946318260 Storm Drain Fee- 825.00 825.00 5/19/2005 02088794 177053 JD 0.00 Multi-Fam PCDR 200506091644408900 Plan Check Deposit Refund -500.00 �`=- � `� �'Z� � -500.00 APP 200608141545062180 Encroachment Application 125.00 125.00 8/11/2006 CHARGE 189338 JD 0.00 Fee /It CASH 2O0608141545275150 Construction Cash Deposit 500.00 500.00 8/11/2006 CHARGE 189339 JD 0.00 CASH 2O0701251435054690 Refund-Construction -500.00 -500.00 1/25//2007 1 189339 JD 0.00 Cash Dep CA-�n d'& Total Fees:$23,860.27 Paid:$24,360.27 TOTAL REMAINING DUE: $(500.00) Page 1 of 1 CasePaymentHistory..rpt to i Refundable Deposit Check Request To: Finance Director Check Payable To: Roman Knop Address-Line 1: 261-17th Avenue Line 2: City: San Francisco- State: CA Zip: 94121 - Description: Refund Deposit Account Number: 101.2203 Amount: $500.00 Account Number: Amount: Account Number: 101.640.7448 Amount: (Finance Dept only) Interest Earned (Finance Dept only) Total Payable: $500.00 (Exact Amount) Purpose: Refund of Construction Cash Deposit on 213 W. Rincon Avenue.. Voucher#: Permit#: ENC2004-00133 Receipt#: 189339 Date: 08/11/06 Requested by: Title: 4.b=CiMME49 Date: 1/29/2007 Syed ahidi Approved by: Title: City Engineer Date: 1/29/2007 Michelle Quinney Finance Dept Only: Verified by: - Title: Accounting Clerk II Date: Approved by: Title: Accountant Date: Special Instructions For Handling Check Mail As Is: Mail in Attached Envelope: Interim Check: Needed By: Return To: Joanne D'Ambrosia Pl k lic Works/City Hall (Name) (Department) Other: fin:Forms/excel/chkreq - Revised 05/00 y PUBLIC WORKS DEPARTMENT RECEIPT - Effective July 16,2006 TO:City Clark PUBLIC WORKS FILE NO. /'``� 2oo 4- G o` 133 PROPERTY ADDRESS Please collect&receipt for the following monies: ACCT. 7rEMc.. .� ...' ,;'�. =..,: AMO ENCROACHMENT PERMIT 4722 Application Fee G Q z�(7 Non-Utility Encroachment Permit ($275,00) 5.0 G ( A t r}(:&1✓J•V Minor Encroachment Permit<$6 000 ($126,00) - - R-1 First Permit No Fee Subsa cent $125,00 Utility Encroachment Permit Arterial/Collector Street $650,00 ' Residential Street/Other Areas $300,00 2203 Plan Check Deposit 2%of Engineer's Estimate 5500 min 2203 Faithful Performance Security FPS 100%of ENGR.EST. 2203 Labor and Materiels Security 100%of ENOR.EST. 2203 Monumentation Security 100%of ENGR-EST. • Q/�1(� 2203 Cash De Daft 4%of En r.Est $500 minl$10,000 max Plan Cheek 8 Inspection Fee(Nan-Utility) 4722 Engr.Est.<$250,000 (13%of ENGR,EST.) - 2203 En ,Est. >$250,000. (Deposit 8%of En r,EstJ$30,000 min)" 4722 utllt <$100,000 Minimum Charge Per Location ($250.00) ) Conduits/Pipsh...up to 500 Fast ($2.25/t) Above 600 Linear Feet ($1.361ft) Manhcf..(..It./Et.. (5725.001ea) Pole Set/Removal ($125.00/ee) Street Tree Plantin emoval $145.00 '- 2203 Utility>$100,000 Actual Cost+20%" ' 4760 Storage Container Permit. $125.00 4760 Pro act Plane&Specifications Pro act No. 4760 Standard S esific.tie..&Details (Sl/Pg$15.50/Bk - 4760 Copies of Engineering Maps&Plans Aerial plot 24'x 36' $54.00 Aerial Print a 1/2'x 11 $26.00 Aerial Search Fee $25.00 Maps and Plans 24'x 38' $12.00 4722 Penalties:Failure to restore public improvements $100/0e1ender Da Muni Code Sec.11.34.010 - 4722 Penalties:Failure to..rr-t unsela conditlons $100/0alendar Da 4722 Work Without Permits 4Tlmes Appli.abl.Fee LAND DEVELOPMENT 4722 Lot Line Adjustment 3900.00 _ 4722 Parcel Ma 4Lots or Less $3,400.00+$7511m) 4722 Fine,Tract Me 5 or More Lots $4,200.00+$1 DOAot 4722 Certff,..te of Compliance $660.00 4722 Certificate of Correction $40D.00 - - - 4722 Orading&Drainage Plan Review Single Family Lot $200.00 Site<10,000 elf. $600.00 Site>10,000 s.f.<Aere $800.00 Site>1 Acre $1,200.00 4722 Note Fee er signature) $10,00 4722 Vacation of Public Street.&Easements $2,200,00 4722 Assessment Segregation or Reapportionment First Split ($725.00) Each Additional Lot. $200.00 4721 Storm Drainage Area Fee Per Aere (R-1$2120.00) (Multi-pee$2,385.00) All Other$2,860.00 .4920 Parkland Dadlcation Fee 75%26%Due Upon Cart.of O.ou ne 511.74241 postage _. TRAFFIC - 4728 Intersection Turn Counts Two-Hour Count $76.60 4728 Intersection Turn Counts a.m.or p.m.peaks) $160.00 4728 Traffic Flow Map(Daily Traffic Volumes $32.00 4728 Cam belt Traffic Model Full Scope Assessment Actual 4728 Campbell Traffic Model Reduced Scope Assessment Actual 4728 Signal Timing Information $621111r 4271 Truck Permits $16.00/er trip) OTHER 4728 No Parking Signs $1/each or$26/100 - ` , �' TOTAL g 6245 ��C NAME OF APPLICANT NAME OF FAVOR �,` PHONE /�, ' ADDRESS ` , k 6• ZIP '.•Actual Cost Plus 211%Overhead Non-Intarest bearin do FOR : CITY CLERK RECEIVED BY ONLY Q� Data-. 'Recel t0 d For,Plam.Checicand-Cosh Deposits,.send yellow cop t i a ,. - - "'S ! - . ) Data!Inl '' .. ... ,,. ,d,,, .. j:\formsVeceipt form 06.07.x15 ' . . . . . , �A� CITY T CAMPBELL. G . A•vsl� «q§ BY: JANN qma ROMAN IO#3 DATE: 08d1A6 -® REGISTER DATE: mal±6 TIME: %;9:7 y . . ¥kQI+ kOtJ Om & ARW FILINGS 225.00 » . ---------- qqL Ro $125..00 �I R«qD: $125.00 CHANGE: Mo . ` i' PUBLIC W( )EPARTMENT RECEIPT Effective July 1,2004 } •°'�4 TO:City Clerk" _ -' PUBLIC WORKS FILENO. PROPERTY ADDRESS Please collect&receipt for the following monies �e=c s,` - a��; R "`�"��.� a.� � � •1"st.�a.��k '"��_� �, ��,''�s ��`� °�„maAintOUltIT ��, ENCROACHMENT PERMIT 4722 Application Fee - Non-Utility Encroachment Permit (5268.00) . Minor Encroachment Permit<$5,000 ($59.00) - '" - "1I=1'FisCPerrnit(No Fee)Subsequent ($125.00) Utility Encroachment Permit Arterial/Collector Street ($515.00) Residential Stmet/Other Areas (5283.00) 22031 Plan Check Deposit 2%or Engineer's Estimate (5500 min) 22031 Faithful Performance Security(FPS) (100%of ENGR.M.) ' 22031 Labor and Materials Security (100%af-ENGR.FS.) 2203 Mona ent ti-Security (100%or ENGR.ESr.) 2203 Cash Deposit (4%of En r.Est)($5W mIn/510.000 max) �'--` Plan Check&Inspection Fee(Non-Utility) t46 . 4 Engr:FsL L$250,000 (13%of LTIGR.ESTJ l 220. Engr.Est. >$250,000 (Deposil8%of Fngr.EstJS30r000 min)** 4722 Utllity<$100,000 • Minimum Charge Per location ($180.00) Canduits/PipeOnes up to 500 Feet ($225/R) Above 500Linger Feet ($135/t) Manholedyaults/Etc. ($125.00/ca) " Pole Set/Rcmoval ($125.001m) Street Tree Planting/Removal ($129.00/ca) 220.1 Utility>S100,000 Actual Cast+20%•• 'd760 Storage Container Permit ($125.00) 4760 Project Plans&Specification - Project No. - 47601 Standard Speeificatians&Details ($I/Pg$1550AIk) 4`1601 Copies of Engineering Maps&Plans Aerial Pool 24"x 36" (55200) Aerial Print 8 12"x I l" (521.00) .. Maps and Plans 24"x'6" ($8.00) . 4722: Penalties:Failure to restore public Improvements ($100/Calendar Day) Mani c e.s ett u.oto) 4722 Penalties:Fullum to correct unsafe conditions (SI00/Colendur Day) - 4722 Work Without Permits (4 Times Applicable Fee) LAND DEVELOPMENT ' 4 lot Lie Adlustmenl ($775.00) A2 Parcel Ma (4 lots or I—) (S2Ao0.W+S354a0 4722 Final Tract Ma (5 or Mom lots) (S3,1AU.M1+5354ot) "A722 Certificate of Compliance (5613.00) 4722 Certificate of Cometlon (5376.00) d722 Notary Fee(per signature) (S10.00) 47221 Vacation of Public Streets&Easements (52,116o.1n(I) 4722 A—ssmem Segregation nr Reapportionment First Split (5675.00) _ Each Additional Lot (S200J10) " 472 Storm Drainage Area Fee Per Acre (R-I$2,060)' .&-C? (Multi-Res,$2,318) '(All Other,$2,575) •4929 Parkinnd Dedication Fee(75%25%Due Upon Cert.of Occupancy) 511. 24 Postage TRAFFIC 4728 Intersection Turn Counts(T—Hour Count) ($74.25) ' 4728 Intersection Tom Couma(a.m.or pm.peaks) ($145.00) 4728 Traffic Flow Map(Daily Tmfrm Volumes) (531.00) 4728 Campbell Tmme Model(Full Scope Aa—nt) (Actual) d728 Campbell Traffic Model(Reduced Scope Asssesmrent) (Actual) 4728 Signal Timing Information ($Mir) 4271 Truck Permits (S16.0tt/per trip) - 4728 No Parking Signs - (SII[acbor$25/100) OTHER ✓J TOTAL 9 S NAME OFAPPLICANT NAMEOFPAYOR a &� PHONE ADDRESS - .:- ©l Irk;j? *-*Actual Cost Pins 20%Overhead(Non-Interest bearing deposit) FOR T, + i7S'S w�� 'u-,Pr q 1i*+4. s > #' x'd �e 1' �y i7' ,4 ;'`a v'�m 9il g CITY CLERK � Ftl 'y`� 7ny - !•fib .t, gli.�." li•'., ONLYIlk- !i" ;` ^'_ sa. la'�I`u��-�Ww till J� � d a a I M e 'e. •rsx•. [ ��q ��C i.'`"I h'°YI'�14 -�3.4�:5•PI� p �' � I -., ..ice ��ne� _ e5 A,oy Yil�al-� ��'xvr�4 ��`� �.,�.r' s 7'��'�•a �r f�� t^p t- '�".�.cfir'��rd,'s :�� =�uc MEMO „ jMormiVeceipt f-04-05 rev.11/9104 ..____ _.. f•.._ ._. 1 _. .'11E ._6 ir. 53 Ft TENDERED-- .__ 74775-27 Refundable Deposit Check Request To: Finance Director Check Payable To: South Bay Development Address-Line 1: c/o Akbar Abdollahi Line 2: 3131 S.Bascom Avenue,Suite 110 City: Campbell State: CA Zip: 95008- Description: Refund Deposit Account Number: 101.2203 Amount: $500.00 Account Number: Amount: Account Number 101.540.7448 Amount: (Finance Dept only) Interest Earned (Finance Dept only) Total Payable: $500.00 (Exact Amount) Purpose: Refund of Plan Check Deposit on 213.W.'Rincon Avenue. Voucher#: Permit#: ENC2004-00133 Receipt#: 168156 Date: 06/22/04 Requested by: l//Llit Title: Sr.Civil Engineer Date:. 5/24/2005 AI 'tI'an Approved by: Title: City Engineer Date:. 5/24/2005 Mid elle Quinney Finance Dept Only: Verified by: Title: Accounting Clerk II Date: Approved by: Title: Accountant Date: Special Instructions For Handling Check Mail As Is: Mail in Attached Envelope: Interim Check: Needed By: Return To: Joanne D'Ambrosia Public Works/City Hall (Name) (Department) Other: Yn:Forms/excel/chkreq - Revised 05/00 PUBLIC WORKS DEPARTMENT RECEIPT Effective July 1,2003 TO: City Clerk PUBLIC WORKS FILE NO. f/�v ��V✓ ``V�� !1`�"''�� PROPERTY ADDRESS �I �. Riata,t. Ave Please collect&receipt for the following monies: AMOUNT 435.535.4921 Project Revenue(specify ro ect) w $ ENCROACHMENT PERMIT 4722 Application Fee Non-Utility Encroachment Permit ($260.00) - �U Minor Encroachment Permit<$5,000 ($57.00) R-1 First Permit(No Fee) Subsequent ($120.00) Utility Encroachment Permit Arterial/Collector Street ($500.00) Residential Street/Other Areas ($275.00) 2203 Plan Check Deposit-2%of ENGR.EST. ($500 min) G7 - 2203 Faithful Performance Security(FPS) (100%of ENGR.EST.) 2203 Labor and Materials Security (100%of ENGR.EST.) 2203 Monumentation Security (100%of ENGR.EST.) 2203 Cash Deposit (4%of ENGR.EST.)($500 min/$10,000 max) 2203 Labor and Material Security (100%of ENGR.EST.) Plan Check&Inspection Fee(Non-Utility) 4722 Engr.Est.<$250,000 (13%of ENGR.EST.) 2033 Ea r.Est.>$250,(Deposit 8%of ENGR.EST./$30,000 min.)-- 4722 utility<$100,000 (8%) Minimum Charge Per Location ($180.00) Conduits/Pipelines up to 500 Feet ($2.25/ft) Above 500 Linear Feet ($1.35/ft) Manholes/Vaults/Etc. ($125.00/ea) Pole Set/Removal ($125.00/ea) Street Tree Planting/Removal ($125.00 ea) 2203 Utility>$100,000 Actual Cost+20%•• 4760 Project Plans&Specifications Project No. 4760 Standard Specifications&Details ($I/Pg$15.00/11k) 4760 Copies of Engineering Maps&Plans Aerial Plot 24"x 36" ($50.00) Aerial Print 8 1/2"x 11" ($20.00) Ma s and Plans 24"x 38" ($7.75) 4722 Penalties:Failure to restore public im roveme($100/Calendar Da7u4—i Coae s.c.11.34.010) 47221 Penalties: Failure to correct unsafe conditfont($100/Calendar Day) LAND DEVELOPMENT 4722 Lot Line Adjustment ($750.00) 4722 Parcel Ma (4 Lots or Less) ($2,400.00+$35/lot) 4722 Final Tract Ma (5 or More Lots) ($3,200.00+$35/lot) 4722 Certificate of Compliance ($595.00) 4722 Certificate of Correction ($365.00) 4722 Notary Fee(per sf nature) ($10.00) 4722 Vacation of Public Streets&Easements ######## 4722 Assessment Segregation or Reapportionment First Split ($655.00) Each Additional Lot ($200.o0) 4721 Storm Drainage Area Fee Per Acre (R-1,$2.000) (Multi-Res,$2,250) (All Other,$2,500) 4920 Parkland Dedication Fee(75%/25%Due Upon Cert.of Occupancy) 511.7424 Postage TRAFFIC 4728 Intersection Turn Counts(Two-Hour Count) $72.50) 4728 Intersection Turn Counts(a.m.or p.m.peaks)($145.00) 4728 Traffic Flow Ma (Daily Traffic Volumes) ($30,00) 4728 Campbell Traffic Model(Full Scope Assessmen(Actual) 4728 Campbell Traffic Model(Reduced Scope Assess(Actual) 4271 Truck Permits ($16.00/ ertri ) 4728 No Parking Signs ($1/each or$25/100) OTHER All ao [�/�Jpj ^++�r� n TOTAL $ NAME OF APPLICANT f'1 { ►- „ V1(/i'IC,t ` 1 NAME OF PAY0. F f @pi `I PHONE !ice�•• ADDRESS ../1 1 - I V ZIP V7 **Actual Cost Plus 20%Overhead Non-Interest bearing deposit) FOR y c '. v ^'' CITY CLERK ONLY "i _ ._, � ..J{ ��,f'i=&• � I�� - r, D For P1aniCheek andtCash Deposits send yellow copy.to'FInance' .. _ _ j:\forms\receipt form 03-04 411/04 CITY OF i'-'AMr sis i 6, CA RECUD " ,n t rim:.s 50 P.Y DEVELOPMENT -rr.nt.:rvn DIFE, -.�n rnr. - ili i�Hi,�, tiiiiL� iiii tLi'✓� ' REGISTER DATE1 =rn .w Llllr)iiii -- Roll: OAK _.... . _. [ iL_..._ OA v REEF -5 POSITS -101.2203 TiOTr'•.i DUE! $7:0.00 4 CHECK PAID: ail"+"+i,•.U4 CHECK NO; 1044 TENDERED; MOM CHARGE:• r c Val Page 1 of 1 Joanne D' Ambrosia From: Edward Arango �L- Sent: Monday, January 29, 2007 8:22 AM > y�J° L" To: Joanne D'Ambrosia; William Lai , Cc: Syed Wahidi Subject: RE: ENC2004-00133/213 Rincon Please hold off on monumentation release. We have not received any confirmation from the surveyor that he has set the monuments. Will, please send another letter to the survery and owner letting them know what we need and that it's our 2nd request. Thanks, Ed From: Joanne D'Ambrosia Sent: Thursday, January 25, 2007 2:49 PM To: Edward Arango Cc: Syed Wahidi Subject: ENC2004-00133/213 Rincon Syed is placing the above permit into maintenance but I stopped things when I saw he was releasing a $7,000.00 assignment of CD that Roman Knof had put up as a monumentation surety. I checked with Will and he said we have received nothing for release of the monumentation. This was a file of Al's in which he took in a bond for monumentation. Can you confirm that we should hold off on refunding the monumentation? Joanne 1/29/2007 Page 1 of 1 Joanne D'Ambrosia From: Joanne D'Ambrosia Sent: Thursday, January 25, 2007 2:51 PM To: Jan Hemsley Subject: FW: CDs on ENC2005-00133 Things have changed and we are not going to release the$7,000 cd assignment either now. Please only give me one of the $8,187.63 assignments. Joanne From: Joanne D'Ambrosia Sent: Thursday,January 25, 2007 9:19 AM To: Jan Hemsley Subject: CDs on ENC2005-00133 I need to remove two of the three CD Assignments we have in the vault on 213 W. Rincon Ave/Roman Knop/ENC2004-00133 to return to the applicant. I need to remove the one for$7,000 and either one of the$8,187.63 CDs. One of the$8,187.63 cds should stay in the vault. Thanks, Joanne D'Ambrosia PW Department x2701 1/25/2007 Permit 2004-00133 Certificate of Deposit#5890936627 $8,187.63 Certificate of Deposit#5890936619 $7000.00 Certificate of Deposit#5890936635 $8,187.63 Wells Fargo Bank, Laurel Village 213 W. Rincon Avenue Roman Knop Permit 2004-00218 Bond for Labor and Material$5,000 Bond for Faithful Performance$5,000 . 375 Budd Avenue (Morgan Park—Budd Side) Cingular Wireless Travelers Casualty and Surety Company(Bond#104370959 &104370960) Permit 2004-00218 Bond for Labor&Material $5,000 Bond for Faithful Performance$5,000 375 Budd Avenue(Morgan Park—Budd Side—Cellular Tree Site) Pacific Bell Wireless Travelers Casualty& Surety Company(Bond#104439553 and 104439552) Permit 2005-00014 Bond for Labor&Material $126,000 Bond for Faithful Performance $126,000 121-13 3 Kennedy Avenue Cullen.DeMattei Development Nationwide Mutual Insurance Co. Permit 2005-00035 Bond for Faithful Performance $225,000 Bond for Labor&Material $225,000 Kilmer Park LPA 16201-16239 E. Mozart Avenue Insurance Company of the West Permit 2005-00039 Bond for Labor&Material $90,468.69' Bond for Faithful Performance$90,468.69 Pinn Brothers 1815 S. Bascom Avenue Developers Surety&Indemnity Co.. 2 MOY-17-2005 TUE 04,32 PM RE/MAX PROPERTIES WEST FAX NO. 408 37( 941U r, u3 ASIitC;f+lllENT AHD RSCBIPT OF MEE. 9T CERTIMATE P.K. Permit Ws ENC2004-00133 TO I.ITY OF CAMPEEI.L, 70 H. FIRST 61'It13LyT TR or DEV cArpis , cALxroxHIA 95008 (408) 866-2150 mac• 21 W.-"-Li nnQo Ave,e 2 1wm/We are the ova@z(B) o a, ps►viag8• a co at 1 4- U at its branch office at lid Calif �a, lave tmen cs:rtificate No. 61101,' in the names a and having s present balance of $ I hereby grant.__trangfer-a.wA_.Qe+.-.-.--A�-iaccouat, said investment certificate, said balance (incli i thereon), and all other rights in connection the:rewith to i Ci see, for a`good and valuable consideration, re-:eipt of WX for the purpose of insuring construction described as 1 its associated with development of 5-Unit �sion at 213 W. Rincon Ave. I :,ave phY61c: �of said' investaellt certificate and duplicate of Sc1 thI9 AsB nai iger, (�(�Q 7 Klee. i I :nddrstand t 'roe said account any tams an his signature alone up.n presentat -___,,.- -ate Januer. I also understand that I may not vithdraw from said account unless I.present a .signed release from the assignee. The issuer of the certificate assumes no responsibility for the conduct of the assignee and may, act an the signature of the assignee witimut further inquiry. . r euted on S 2 '1�at said office of the i -- s sign Assignor print sign Y\M1�^ - -Jusigaor print. AC.ICNOWLEDGEMM BY ISSUER Isisuar aYfirar that there are no other holds cm vubject account, that subject monies are available, and that the above described assignment has base noted on the Records of said .is i luer.. Da':e L7 Hy ATTACS Anthoz_ze#Isignat NOTARY Title: - INSTRUCTIONS TO ASSIMM 711:ase sign below for signature identification and as acknowledgment of your notice of Actignment. Return this Assignment and Receipt to the issuer at its address above. Re':ain one copy of this Assignment and Receipt for your films. _ City of Campbell De :e: . Ir�5C?wS� Sy RELFABB BY ASSIGNEE SlAd assignee hereby releases and relinquishes all his right, tittle and internist in and , tc, said account, said investment certificate, said balance and all other rights in cci inaction therewith, City of Campbell Da,:e: nX SUBSCRIBED AND SWORN T BEFORE'ME RElIECCA THIS L.VOIGT DAY OF 20 ( _ Commbsion*1559395 r N otary Pubic•Coukx a Son Francisco Cwnty MY Comm.Expies Mcr 15.2009 NOTARY USLIC • 5890936635 • o lime Account Receipt/Disclosure MET name Wells Farqo Bank, N.A. Time Account number Date opened Term of Time Account 5890936635 05/18/2005 -12 . months days Maturity date Interest rate Fixed rate Variable rate Annual percentage yield Your Time Account will mature on 05/18/2006 2.52 X 2.56 Interest will be paid EVERY 01 MONTHS AND AT WITHDRAWAL e method of interest payment will e _ BY ADDING TO PRINCIPAL Renewability Taxpayer Identification Number(TIN) YOU WILL AUTOMATICALLY RENEW MY TIME ACCOUNT AT MATURITY UNLESS I NOTIFY YOU OTHERWISE 611-30-7507 The Bank.is opening the above described Time Account for your deposit of EIGHT THOUSAND ONE HUNDRED EIGHTY SEVEN AND 63/100 - g Your name and address ROMAN KNOP PAYABLE TO CITY OF CAMPBELL 261 17TH AVE SAN FRANCISCO CA 941212310 05/18/2005 15:13 CD099 04351 Bank# 00114 This is a receipt.It need not be presented at the time you obtain payment from the Bank. W60168(11104 83975J)Time Accounts 0 PM 27 2005 06:48 FRUM:RKRRF'It 65b5y5b 565 i u:1q15a rbbel[ r, tILIY-17-2005 TUE 04:32 PM RE_ ", PROPERTIES WEST FAX NO. 408 9410 P. 03 ABI;rGNKw AND RSCBIPT OF nMSTKM =TInCATE P.N. Permit tic. FNr9-QQ4-00133 To :ITY OP CAMpBELL, 70 N. FIRST MTXXT TR or DEv�"66 Cu'ea E=J CALMRNIA 95008 (406) 066-2150 LOC. 211:��nn AA— I mu/We are the owner t s) of at savingip account at at its branch office at LL-t K &,. , C if is, investment, cerrtificate No. �)Nl the es o U and having a present balance of $ I '°----`- - -- - -I assign said account, said iaVestisnt certificatsr 2414 hs ;Mhich accrues thereon) , and all other rights in conneotioa th PBELL, assignee, for a good and valuable Consideration, re cknowledged, for the putpose of insuring construe i de ;t Improvements associated with developm nt o Unit iouse subdivision t 213 W. Rincon Ave. � �j�Y I toriftcation of said investment certificate and duplicate of th to said assignee. I I in withdraw from said account any tics on his signature alone np�..j acaeptSuOA of"a Mritte» or4er to the issuer_ I also understand that I may not rithdriw from said account unless I present a signed release from the assignee. The issuer of the certificate assumes no responsibility for the Conduct of the assignee and on,,,, act on the signature of the assignee without further inquiry. LxL.cuted on �� , ' � at said office of the er. sign Assignor print p . sign �-"� �1-dJ �r/�► Assignor print ACKNOWLEDGEKENT SY ISSUER Isiiuer affirms that there are no other holds on subject account, that subject ==Lee are available, and that the above described assigment has been noted on the Records of said is i suer. DA':e i1TTAC8 Authorized gnature NOTARY Title; ,P INSTRUCTIONS To ASSIMM P]i:ase sign below for signature identification and as acknowledgement of your notice of Assignment. Return this Assignment and Receipt to the issuer at its address above. Rt-:ain one eapy of this Assignment and iteceipt for your filers. Mt of lI REMSE BY A8$JrxNSR Eli,Ld assignee hereby releases and relinquishes all. hie right, title sad iatergst in and to said account, said investment certificate, said balance and all other rights in cc.inecti*n therewith. Ci q:!!A7 SUBSCRIBEDANDSWORNT BEFORE'ME THtSDAY OF�^ !��, LeMV, i�ECCA1.VOIaT ui 20 Con"W*n*1 ba9395( CaWOMICSch honebco CCU* Comm.EVkM Mat 18.2009 NOTARY PUBLIC 5890936627 t� Time Account Receipt/Disclosure Bank name Wells Fargo Bank, N.A. Time Account number _ Date opened Term of Time Account 5890936627 05/18/2005 12 months days atunty date Interest rate Fixed rate Variable rate Annual percentage yield . Your Time Account will mature on 05/18/2006 2.52 X 2.56 Interest will be paid EVERY 01 MONTHS AND AT WITHDRAWAL e method ot interest payment will e BY ADDING TO PRINCIPAL Renewability _ Taxpayer Identification Number(TIN) YOU WILL AUTOMATICALLY RENEW MY TIME ACCOUNT AT MATURITY UNLESS I NOTIFY YOU OTHERWISE 611-30-7507 The Bank is opening the above described Time Account for your deposit of EIGHT THOUSAND ONE HUNDRED EIGHTY SEVEN AND 63/100 $ ****$8,187.63 Your name and address ROMAN KNOP PAYABLE TO CITY OF CAMPBELL 261 17TH AVE SAN FRANCISCO CA 941212310 05/18/2005 15:01 CDO99 04351 Bank# 00114 This is a receipt.It need not be presented at the time you obtain payment from the Bank. W60168(11/04 83975J)Time Accounts n J A irbT-C�`C✓JE'JJ uo•"o r INUI I.ni%rmi 1� MAY-17-2005 TUE 04:32 PM I PROPERTIES WEST FAX NO. 408 3" 9410 P. 03 AS11EGNMM AND RBCSIPT Or MESTKW I ifICATE P.w. permit L__ FNC2004-00133 ._ 10 aZTY OF CAMpzELL, 70 M. FIRST STREET TR or DEV CM!:PBML, CALIFORNIA 95008 (4081 1B66-21.50 Loc. 14ka/We are the owner(s) of -a savin gV le/r,077 t Cat k �.._ -) at its branch offi.ceat C CSC i%� r, \6 if r ia, laves ` f-� s�e:rtifiGate No,. � the es o U and having a present balance of $ I .heraby grant, transfer and assign said account, said investment certificate, said ha;tance (including interest Whieh aacraea thereon), and all other rights in connection therewith to the CITY OF Cl"BELL, assignee, for a good and valuable consideration, re.:eipt of which is hereby acknowledged, for the purpose of insuring eonstrua i de.:ssribed as follows: Street Improvements associated with developm nt o Unit Townhouse Subdivision t 213 W. Rincon Ave. � a ,(elv Y ::ave FkTxically delivered verification of said investment certificate and duplicate of th6s Assignment and Receipt to said assignee. I %nderstand that assignee can withdraw from said account any tiara on his signature alone yap,,u presentation of a written ordex to the issuer_ I-also understand that I may not vlthd>r•av from said account unless ,I present a signed release from the assilpes. The i®Luer of the certificate assumes no responsibility for the conduct of the assignee and suag' Act on the signsture of the assignee without farther inquiry. ExG cured on �at said office of the signs As3sigssoz print sign 4 N �U'�► _ Assignor print *MOWLEDGEKEHT BY ISSUER Isiluar affirms that there are no other holds on subject account, that subject nonles are av+silable, and that the above described assignment has been "tad an the Records of said 2 isi6uer. c-� De,:e c>' Hy+; ATTACH Authorized gnature M=ARY Title: Ibi6'PtiUCTIONS M ASSIGi Pli:ase sign below for signature identification and as acknowledgement of your notice of 1►sr,signment. Return this Aesxigsm:ent and Receipt to the issuer at its address above. Rs,;ain one copy of this Assignment and Receipt for your files. CA of dam 11 BY r, ltRIMSE By ASSIMIM So.Ld assignee hereby releases and relinquishes all his right, title and interest in and tc, said account, said investment certificate, said balance and all other rights in cc,antetion therewith. city of Campbell BY SUBSCRIBED AND SWO�97 E ME THIS n _DAY OF20 C SCCA 1. w L c sR 1619b -CWogk San Proneb w Cosily V Expkw(War lb, 4N0 ARY PUBLIC ` 5890936627 Time Account Receipt/Disclosure an name Wells Fargo Bank, N.A. Time Account number _ Date opened Term of Time Account 5890936627, 05/18/2005 12 months days Maturity date Interest rate Fixed rate Variable rate Annual percentage yield Your Time Account will mature on 05/18/2006 2.52 X 2.56 Interest will be paid EVERY 01 MONTHS AND AT WITHDRAWAL e me ad at interest paymen wi e BY ADDING TO PRINCIPAL c Renewability Taxpayer IdentificatIon Number(TIN) YOU WILL AUTOMATICALLY RENEW MY TIME ACCOUNT AT MATURITY UNLESS I NOTIFY YOU OTHERWISE 611-30-7507 The Bank is opening the above described Time Account for your deposit of EIGHT THOUSAND ONE HUNDRED EIGHTY SEVEN AND 63/100 $ ****$8,187.63 Your name and address ROMAN KNOP PAYABLE TO CITY OF CAMPBELL 261 WTH AVE SAN FRANCISCO CK.941212310 05/18/2006 15:01 CD099 04351 Bank# 00114 This is a receipt.It need not be presented at the time you obtain payment from the Bank. . W60168(11104 63975J)Time Accounts , 0 rg ,n MAY-17-2005 TUE 04:32 PM RE/HAX PROPERTIES WEST ?PX.NU. yuts iri e4iu Ut![GNbIM AND REGBIPT OF INVE�IT CERTIFICATE P.K. persit �oiiTO ^.ITY OF CAMPBELL, 70 N. FZ BT> z TR or erm CAsspBELL, CALIFORNIA 95008 (�O6i $66�Z150 Loc. 213 W. kRic I iha/We are the owner(s) f a savin s secs tat at its branct of e at L call rn' investment ce:r tificate the names of. and having a present balance of $ Z I hereby grant, transfer a L 4 investwwt certificate, said balance (including interes sad all other rights is connection tht!rewith to the CITY 01P ( �GL' ' ""67A�tj�od &na valuable consideration, re,:eipt of which is hereN pose of insuring construction de.cribed as follows: St SU ated with development .of 5-Unit Tc �^ 13 W. Rincon Ave. // 4 oil 041 611 AZ741;vi I ::Ave physically deliver) �f � estsent certificate and duplica�te_of th6s Assignment and Rscei I %nderstand that assigns' Count any time on bis signature alone up n.preaentation of a written order to tJn�iaxuaz_ I also understand that I .may not vithdraw from said account unless I present a signed release from the assignee. The i®tuer of the certificate assumes no responsibility for the conduct of the assignee and an!,, act an the signature of the assignee witbouz further inquiry. Ex1�cuted of Z , , at said office of the sign Assignor print sign all�41-fll j Assignor Print ACKNOWLEXEHM ar issars Isisues affirms that there are no other holds on subject account, that subject monies are a,gailable, and that the above described asaigmnent has been noted an the Records of said is(suer. 7 Authorized S ture NOTARY Titla: 2 /' ACKNOWLEDGRKENT INSTRUCTUMS TO ASSIGN Pliiase sign below for signature identification and as acknowledgesent of your notice of Actignment. Return this Assignment and Receipt to the issuer at its address above. Rsgain one copy of this Assignment and Receipt for your files. :e: City De '- � �' RPSYASE BY ASSIGNEE - SCLd assignee hereby releases and relinquishes all his right, title and interest in and U1 said account, said investw=t certificate, said balance and all other rights in ccl anectian therewith. City of Campbell Dt.=e: BY SUBSCRIBED"BLIC E T THIS�� Canninlon#1 No my heft-coMbrtYo San Ranobco Courdy MV Comm.Es{p U Mar 1& N 5890936619 Time Account Receipt/Disclosure 7en name Wells Farqo Bank, N.A. Time Account number Date opened Term of Time Account 5890936619 05/18/2005 12 months days Maturity date Interest rate Fixed rate Variable rate Annual percentage yield Your Time Account will mature on 05/18/2006 2.52 X 2.56 Interest will be paid EVERY 01 MONTHS AND AT WITHDRAWAL e metriod or interest payment will e BY ADDING TO PRINCIPAL c Renewability Taxpayer Identification Number(TIN) YOU WILL AUTOMATICALLY RENEW MY TIME ACCOUNT AT MATURITY UNLESS I NOTIFY YOU OTHERWISE 611-30-7507 The Bank is opening the above described Time Account for your deposit of SEVEN THOUSAND AND 0/100 g ****$7,000.00 Your name and address ROMAN KNOP PAYABLE TO CITYOF CAMPBELL 261 17TH AVE SAN FRANCISCO CA 941212310 05/18/2005 14:55 CD099 04351 Bank# 00114 This is a receipt.It need not be presented at the time you obtain payment from the Bank. W60168(11/04 8397")Time Accounts 0 CITY OF CAMPBELL F DACHMENT PERMIT Perm, _ Y*l,f Cis �L� DEPT. OF PUBLIC.WORKS ( Irking within the public X-Rt e 70 North First St. ngnt-of--way) Campbell,CA 95008 d 1 ' Application Date (408)866-2150 Issued U ( 6 Application Expiration Date 1 U Fax(408)376-0958 - _ Permit Expiration Date r' APN APPLICATION—Application is hereby made for a Public Works Permit in accordance 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# ffO ( U " A LJ Utility trench location 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 I 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 restartingany work. / Name of Applicant M A, Telephone (print name) � Address 24-HOUR EMERGENCY TELEPHONE NO. E-Mai I Address A- t,) 'f—� U A-n 6 i W� Is this work being done by the property owners at their own residence? Yes V 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 batb_the.front and back of this permit,and.they.will inform their contractor(s)of the information. 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 condition of any private improvements in,the-pul ii.c right- -way. Accepted � !/ L Q tl/A"Ll (ApplicantPermittee) (sign) Date Contractor (Print Name) Date SPECIAL PROVISIONS 1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be specifically approved by the Inspector prior to cuttine. 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 Inspector. 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. 4. 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 has been entered hereon. USA Phone I-800-227-2600. USA TICKET 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 AM RECEIPT NO. PERMIT APPLICATION FEE � �$ PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ Cif CONSTRUCTION CASH DEPOSIT. $ PLAN CHECK&INSPECTION FEE p$ 27 APPROVED FOR ISSUANCE 8 0 For City Engineer Date 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 of 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. 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,bus stops,fire hydrants and water valves. 6. 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. - 7. The 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. 8. 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. 9. Sawcut for all PCC or AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements. 10. 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. 11. 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. 12. Compaction testing of subgrade,base rock,and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 13. 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. 14. 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. 15. 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. 16. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 17. This permit is not transferable. Work must be performed by the Permittee.or his designated agent or contractor as specified thereon. 18. 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. 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. 20. 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. 21. Permittee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by City prior to distribution and include dates of work and a contact name and phone number. 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 V Date Contractor (Print Name) Date Aforms\pwperm Rev. 11/9/05 � �. BONA.FIDF INSURANCE HRVICCS,INC. 471 Fulton Stregt,San Francisco CA94-102 Tal:415 522 5944•fan 415 522 5949 Email:info99771oquote.com www.87710quote.wm RECEIVED AUG 14 2006 PUBLIC ftx WpgKS ADMINI3TIRk56N Tkc Joanne D' Ambrosia From: Eugene Kharakh uses: Incl. cover) Rhone Gate: 08111/2006 Re. Romkon Inc. cc: ❑Urgent ❑ For Roview ❑Please Comment x Please Reply ❑Please Recycle MESSAGE: Please be advised that the Insurance Company is unable to actually issue a Primary wording endorsement. The insurance company has applied for their rating, but is not currently rated, They are not admitted but are licensed to do business in California. Thank you, n harakh Eugene Karahk - From: Elisa Wu [ewu@commodoreins.com] Sent: Friday,August 11,2006 1:51 PM To: Eugene Karahk Subject: demotech rating Hi Eugene, Please see attached. ProEuilders is rated "A"with demotech and the reinsures are rated with AM best. If you have any questions or concerns, feel free to contact me. Thanks, Elisa Commodore Insurance Services RECEIVED 2000 Powell St.#1005 r\! Emeryville, CA. 94608 Tel: 510-89"513 A U G 14 2006 Fax' 510-899-6913 ewu a7cammodoreins.com PUBLIC!ryPF ADMINf3Tpq M 8/11/2006 Southwestern Casualty FroBuilders Specialty Insurance Company insurance Company, RRG 73-726.Alessandro Drive 73-726 Alessandro Drive Suite 200 Suite 200 Palm Desert,CA 92.260 Patin Desert,C.A. 92260 760/836-0155 760/836-0155 Financial Stability Rating., Finand2l Stab lflty Rating" After a rigorous,quantitative analysis,the Company was After a rigorous,quantitative analysis,the Company was assigned a 2004 Financial Stability Rating'"of: assigtled a 2004 Financial Stability)itatingt'of Am � Demotech,Inc. Demotech,Inc, rimincial Stability Ttadttit' FtndnClal suability Rming' Based on the Demotech review of statutory financial Based on the Demotech review of statutory financial statements, this Financial Stability Ratine representsg statements, this Financial Stability Ratinag represents our opinion of the Company's ability to meet its financial our opinion of the Company's ability to street its financial obligations over the next year. obligations over the next year. The data to develop our ratings is obtained from The data to develop our ratings is obtained from statutory financial statements. Some of the items statutory financial statements. Sonic of the items reviewed include: reviewed include. Total Garrett Assets Total Assets Total Currant Assets Tolial Assets Total Current Liabilities Total Liabilities Total Current Liabilities Total Liabilities Working Capital Surplus 'Working Capital Surplus Total Revenue Not Income Total Revenue Net Income Receivables Total FXpenses Receivables Total.Expenses Administrative Expenses Leverage Ratios Administrative Expenses Leverage Ratios Dermtechl;Financial Stability Rating s'e are: Dernotech's Financial Stability Ratings'are: A"(Unsurpassed) S (Substantial) A"(Unsurpassed) S (Substantial) A (Unsurpassed) M(Moderate) A'(Unsurpassed) M(Moderate) A (Exceptional) L (Licensed) A (Exceptional) L (Licensed) The distinction between A" and A' tray be related to The distinction between A" and A' may be related to the magnitude of policyholders'surplus,market share the magnitude of policyholders'surplus,market share or national presence. or national presence. The Company's Vi,nnnciat Stability Rnting:,O expires on or The Company's Flauncial Stsbillty Ratin;l'°expires on or before May 31,2005. Information must be aontirmed by beloire May 31,2005, Information mutt be confirmed by contricting Dcmotech,Inc,ar by visiting Demoteeh's web titer svxv�rdcntateelt.enm. contacting DemoteClt.Int.or by visiting pemntecli's ivclt site,w.v►v.detnatectt.com, RECE1 y 5) AUG 14 Z006 PUBLIC WORKS ADMUSTRATION INSURANCE REQUIREMENTS CHECKLIST Permit# �c_,, oo� -� �� 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 tD work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggre ate limit. iP, Policy expiration date 4 '7 (l Automotive Liability: Ue-- "Any Auto" checked on certificate $1,000,000 per accident for odily injury and property damage k C Policy expiration date (0 ®� Workers' Compensation and Employer's Liability nL,�i ❑ Waiver of Subrogation clause �Jc �M ❑ $1,000,000 per accident for bodily injury or disease �s c ,� ❑_ Policy expiration date Course of Construction (if required in Special Provisions) � ❑ Completed value of the project �S ❑ Policy expiration date t �j Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement The City, the City of Campbell Redevelopment Agency, its officers, employees and volunteers are named as additional insured. CQ)��11--1 ❑ The insurance coverage afforded to the Additional Insured is primary insurance. _❑ Cancellation area of certificate edited to delete "endeavor to" and '`but failure to mail � �TG' agents o rep such resentatives". preslenmpoeS ono obligation or liability of any kind upon the company� its r� S� ❑ Workers' Compensation Insurance Sheet Submitted ❑ For General Contractors -{ ❑ For Developer or Owner Or Acceptability of Insurer(s) PG �,�L , lir' --7 ❑ Insurer(s) has curreCAI. Best ating_o- A.VII and is authorized to transact business in the State ia. rrf-n` +L Insurance Certificate Reviewe C� ��'�EJ �� 0 J , a, Initials ate Copy of Insurance Certificate placed in tickler file for month of expiration. j:\forms\inscklst(rev 11/99) f MEMORANDUM CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT O: Jesse Takahashi, Finance Director DATE: August 14, 2006 FROM: Michelle Quinney, Cit Engineer,Pub iior s Department RECEiVE AUG 14 2006 SUBJECT: Evidence of Insurance FINANCE DEPT. The following company/individual has submitted evidence of insurance coverage to us which does not meet our minimum City insurance requirements in the following aiEIE& CRIV ED Company/Individual: Romkon, Inc. AUG 1 80 2006 Work Address: 213 W. Rincon Avenue Permit No./Project No: ENC2004-00133 ADMPU IN1 wows pj 1. General Liabilitv — Meets our requirements EXCEPT insurance company is not able to A provide endorsement showing insurance coverage afforded to the additional insured (the City) is primary insurance and unable to edit the cancellation clause area to delete unacceptable wording. v Insurer, ProBuilders Specialty Insurance Company, is not rated under A.M. Best Rating program. They are still in the application process to get a rating. The showed us that they had an "A" rating with another insurance rating service name ema c' They are licensed with the State of California to do insurance business in the e7. 2. Automobile Liabilitv— Have provided no automobile liability insurance as feel it is not necessary in this case. 3. Workers' Compensation—Have signed our Certificate of Exemption that states they have ,f no employees and are therefore exempt from workers' compensation law. 4. Other-N/A A copy of the insurance certificate, plus endorsements, is attached for your reference. Please let us know as soon as possible whether we may accept this insurance without any changes. We are really in a rush on this one as the applicant is very anxious to have things in order. If you have any questions, please contact Joanne D'Ambrosia in our department at ext. 2701. H Aword\miscltrs\insmemo6 d) Page 1 of 1 Joanne D' Ambrosia From: Joanne D'Ambrosia Sent: Wednesday, August 16, 2006 5:02 PM To: Syed Wahidi Cc: Michelle Quinney; Alan Hom Subject: Romkon Insurance/ENC2004-00133/213 W. Rincon I just received a phone call from Jesse in Finance and after he heard the size of the scope of the job, that they had provided us with an additional insured clause, and after he checked Demotech rating service (in place of AM Best) he agreed that the risk was so small that it was ok for us to accept Romkon's insurance "as-is". Since is 4:55, 1 can call the insurance agent in the morning and maybe you can call Roman (the contractor), Syed. The insurance agent called me a little while ago to plead his case again and tell me that his insured (Roman)will be leaving on a trip this Sunday. Joanne 8/16/2006 Page 1 of 1 Joanne D' Ambrosia From: Joanne D'Ambrosia Sent: Wednesday, August 16, 2006 4:02 PM To: Jesse Takahashi Subject: FW: Insurance Review for Romkon Jesse - We have just received auto liability with "any auto" checked from the insurance agent on this permit but they have still need a ruling from you on whether we can accept a non-AM Best rated insurance company (rated through Demotech) and go without a "primary" clause. The insurance agent keeps calliing us to see if we are going to accept his insurance. Joanne From: Joanne D' Ambrosia Sent: Wednesday, August 16, 2006 1:02 PM To: Jesse Takahashi Subject: Insurance Review for Romkon I know you probably have a load of things to catch up on from your absence but the insurance agent on the permit for 213 W. Rincon about which I sent you a memo on 8/14/006 has been calling us constantly to see if it has been approved by our Risk Manager. He didn't call for a couple days because we told him you were out of town but he just called again looking for an answer. Apparently, the insured is going out of the country on a trip and is trying to clear things up before he leaves. Thanks, Joanne D'Ambrosia PW Department x2701 8/17/2006 Page 1 of 2 Joanne D' Ambrosia From: Syed Wahidi Sent: Monday, August 14, 2006 12:03 PM To: Michelle Quinney;Alan Hom; Joanne D'Ambrosia; Marlene Pomeroy Cc: Alberto Oxonian; Edward Arango; Lisa Petersen Subject: RE: 213 W Rincon Joanne, I have informed Mr. Romkon that we will be forwarding the insurance to the Risk Manager for review and will let him know once we hear from him but he should not expect it to happen very soon although we will request the Risk Manager to expedite. Mr. Romkon seems to have toned down today and he apologized for yelling last Friday. Syed From: Michelle Quinney Sent: Monday, August 14, 2006 10:17 AM To: Alan Hom; Syed Wahidi; Joanne D' Ambrosia; Marlene Pomeroy Cc: Alberto Oxonian; Edward Arango; Lisa Petersen Subject: RE: 213 W Rincon Actually I don't have the ability (or knowledge) to waive insurance conditions either. If an applicant wishes to propose different levels of insurance coverage, we need that in writing from them,.. then we forward this request to our Risk Manager(Finance). They in turn send this request to ABAG (our insurance advisors)who will either agree or reject the proposal. This process takes quite some time, but we are willing to submit any requsts for alternate coverage for consideration...we try to expedite the process as much as possible, but it is mostly out of our hands as Finance and ABAG are the deciding entities and we can't control their schedules. From: Alan Hom Sent: Friday, August 11, 2006 1:54 PM To: Syed Wahidi; Joanne D' Ambrosia; Marlene Pomeroy Cc: Michelle Quinney; Alberto Oxonian Subject: RE: 213 W Rincon Michelle, Syed has told Mr Romkon we do not have the authority to waive any conditions of the insurance requirement. Syed advised him that if he wishes to address those conditions, he will have to speak to the City Engineer. Congratulations, you're it and welcome back. Alan Hom Senior Public Works Inspector City of Campbell 70 N First Street Campbell, CA 95008 Phone (408)866-2168 FAX (408)376-0958 e-mail: Alanh@cityofcampbell.com From: Syed Wahidi Sent: Friday, August 11, 2006 1:50 PM To: Joanne D' Ambrosia; Marlene Pomeroy 8/14/2006 Page 2 of 2 Cc: Michelle Quinney; Alan Hom; Alberto _.__�iian Subject: 213 W Rincon FYI Developer Mr. Roman Romkon is very upset for not getting the permit issued for street improvements. Two weeks ago,we learned that he did curb &gutter demo/formwork without permit. Work was stopped and he was asked to get permit. He was out of town at that time and promised to take care of it as soon as he returns. He also told that he was under the assumption that the previous owner has got all the permits. Until this date, there are issues with his insurance which is lacking: -auto liability - insurance certificate not showing that insurance is"primary" - Insurance company is not rated as they have applied for rating. Joanne has repeatedly explained everything that is missing in insurance certificate to Roman's insurance company. Syed 8/14/2006 T-1 MEMORANDUM CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT TO: Jesse Takahashi,Finance Director DATE: August 14, 2006 9 FROM: Michelle Quinne Cit Engineer;Pubei�or s Department SUBJECT: Evidence of Insurance The following company/individual has .submitted evidence of insurance coverage to us which does not meet our minimum City insurance requirements in the following areas: Company/Individual: Romkon, Inc. Work Address: 213 W. Rincon Avenue Permit No./Project No: ENC2004-00133 1. General Liability — Meets our requirements EXCEPT insurance company is not able to provide endorsement showing insurance coverage afforded to the additional insured (the City) is Sri y insurance and unable to edit the cancellation clause area to delete unacceptable wording. Insurer, ProBuilders Specialty Insurance Company, is not rated under A.M. Best Ratin>7 program. They are still in the application process to get a rating. They showed us that they had an "A" rating with another insurance rating service named Demotech. They are licensed with the State of California to do insurance business in the state. 2. VAutomobile Liability— Have provided no automobile liability insurance as feel it is not necessary in this case. 3. Workers' Compensation—Have signed our Certificate of Exemption that states they have no employees and are therefore exempt from workers' compensation law. 4. Other-N/A A copy of the insurance certificate, plus endorsements, is attached for your reference. Please let us know as soon as possible whether we may accept this insurance without any changes. We are really in a rush on this one as the applicant is very anxious to have things in order. If you have any questions, please contact Joanne D'Ambrosia in our department at ext. 2701. H Aword\mi scltrs\in smemo0 d) FAX Date 8111106 Number of pages including cover sheet 9 TO: ATTN.- Greg FROM: Joanne D'Ambrosia Bonafide Insurance Services City of Campbell PO Box 591478 70 North First Street San Francisco, CA 94159 Campbell, CA 95008 Phone (415) 522-5944 Phone (408) 866-2701 Fax Phone (415) 522-5949 Fax Phone (408) 376-0958 CC: REMARKS: ❑ Urgent ❑ For your review ® Reply ASAP ❑ Please Comment Re: Insured: Romkon, Inc.. Permit#: ENC2004-00133 Work Site: 213 W. Rincon Avenue, Campbell AMENDED FAX We have received the certificate of insurance for general liability for work the above insured will be doing in the City of Campbell right-of-way. In order to meet our minimum insurance requirements we must ask that the following changes be made to the certificate. 1. These endorsements/changes need to be added/done: The City, the City of Campbell Redevelopment Agency, the County of Santa Clara, their agents, officers, attorneys, employees, officials and volunteers are named as additional insured. - The insurance coverage afforded to the Additional Insured is primary insurance. - The cancellation area of the certificate is to be 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". 2. We require auto liability in the amount of$1,000,000 per accident for bodily injury and property damage. The "any auto"box needs to be checked on the certificate under the auto liability section. 3. We also require Workers' Compensation and Employer's Liability in the amount of$1,000,000 per accident for bodily injury or disease. It must also include a waiver of subrogation clause. 4 he encroachment permit number and address as shown above are to be clearly stated on all insurance O documents. 5. Insurer(s) must have current A.M. Best Rating of AXII and authorized to transact business in the State of California. ProBuilders Specialty Insurance Co. has an NR-2 rating and we are unable to confirm that the company is authorized to do business in the State of California on the California Department of Insurance website. A copy of the certificate, as well as our insurance requirements, follows for your reference. You may forward the requested items to us by fax. Please call me if you have any questions. Thanks for your help. BONAFIDE INSURANCr•SERVICES,INC, 471 Fulton Street,San Francisco CA 94102 TeI:415 522 5944-rar.415.522 5949 Email.info@8771cKpote.com www,87710quote.COM ftx va Joanne D' Ambrosia From: Eugene Kharakh >Fm 40S 866 2701 Pages: 1 (Ind. cover) Phone Date: 08/11/2006 Re: Romkon Inc. Ce: ❑Urgent C1 For Review Ca Please Comment x Please Reply Cl Please Recycle (MESSAGE: Please be advised that the Insurance Company is unable to actually issue a Primary wording endorsement. The insurance company has applied for their rating, but is not currently rated. They are not admitted but are licensed to do business in California. Thank your, r. n harakh ATE ACORD,, CERTIFICAI .- OF LIABILITY INSUR_ _.4CE D8/11/2006 ' PRODUCER BONAFIDE INSURANCE SERVICES INC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION P O BOX 591478 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. SAN FRANCISCO CA 94159 (415) 522-5944 INSURERS AFFORDING COVERAGE INSURED INSURER A: ProBuilders Specialty Insurance Co, RRG Romkon, Inc. INSURER B: 261 17th avenue INSURERC: San Francisco, CA 94121 INSURER D: I I INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE MM/DD/YY DATE MM/DD/YY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire) $ 50,000 CLAIMS MADE ® OCCUR MED EXP(Any one person) $ 5,000 A X 3500 PD Deductible COM 5008023 1/16/2006 1/16/2007 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X POLICY IRO- AUTOMOBILE JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS APA (Per person) HIRED AUTOS _ _ BODILY INJURY $ NON-OWNED AUTOS !!�� (j (Per accident) AUG 14 2Q 6 PROPERTY DAMAGE p�+ (Per accident) $ GARAGE LIABILITY pa� a �+ AUTO ONLY-EA ACCIDENT $ ANY AUTO E!7➢ S� OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WC STATU- I OTH- WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 'I E L_DISEASF_-EA EMPLOYE $ E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS See Supplemental Information Page(s) CERTIFICATE HOLDER ADDITIONAL INSURED;INSURER LETTER: CANCELLATION SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITY CAMPBELL DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN ATTN: DEPT OF PUBLIC WORKS NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 7O NORTH I FIRST STREET IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON TH-1NSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE..-, CAMPBELL CA 95008 � ACORD 25-S(7/97) ©ACORD CORPORATION 1988 LM:LPW v1.9.8 on 8/11/06-10:14 by UserName LP:LPW v1 9.8 on 8111/06-10:14 by U rName ° PF v1.0.1 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25-S(7/97) LM:LP W A9.8 on 8/11/06-10:14 by UserName LP:LPW 0 9.8 on 8/11/06-10:14 by UserName PF A0.1 °-SUPPLEMENTAL INFORMATIOI AG I= FDATE(MM/DD/YY) 77 •_Y •. 3 ATTACki'TO',ACORD 25 S (7/97} 8/11/2006 PRODUCER PHONE 415 522 5944 APPLICANT(First Named Insured) .PHONE 1A/C No Ext)_.....__._............ ._......_�.. _........._ .. .. _.. SA/C Nq Ext).. ......__-............ BONAFIDE INSURANCE SERVICES INC Romkon, Inc. P O BOX 591478 261 17th avenue San Francisco, CA 94121 SAN FRANCISCO CA 94159 .... ._.._.._....__........................._.._................._..........__....._......., EFFECTIVE DATE EXPIRATION DATE CO/PLAN .........._..__.._...___..._...__.... .._._.._........................._ ..... ......._..._....................._........... ., CODE: z SUB CODE: __..._._. ... ........... ...._........ ..__.. .. ._..._ :_..__.... ......._ ....... .. ......... .._....................._._........._..............__.........._..................................................---... ..... .._. ....._... . ........._...... . . . AGENCY CUSTOMER ID POLICY NUMBER: ......... _...._.............._... _._.... ACCOUNT NUMBER: 10 days written notice for non-payment of premium. PERMIT# : ENC2004-00133 WORK SITE: 213 W. RINCON AVENUE, CAMPBELL ALL WORK IN PUBLIC RIGHT-OF-WAY. CITY OF CAMPBELL, CITY OF CAMPBELL REDEVOLOPMENT AGENCY, ITS OFFICERS EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSURED AS RESPECTS LIABILITY PER CG 2009 I I ,SUPQLEMENTAL INFORMATION PAGE, ATTACH TO ACORD 25=5(7/97),PFv1 0 1,, ©'PAPERFREE CORPORATION)1993 2004 _M:LPW 0.9.8 on 8/11/06-10:14 by UserName LP:LPW 0.9.8 on 8/11106-10:14 by UserName PF 0.9.8 INS NISMON 471 Fulton Strut,San Frandgw CA 94102 Ti3l.415 522 5944-Faxt 415 522 5949 I-mallt W008771oquoto,com www.8771OgUOtexnm Fax rdc Jjoanne a' Ambrosia From.. Eugene Kharakh Fax: 408 376 0958 Pages: 4(inch cover) Phone ante: 08111/2006 Rat Romkon Inc. CC: C]Urgent C] For Review ©Please Comment x Please Reply ❑please Recycle MESSAGE: Per our conversation, attached is the Cert. of Insurance for the permit . Please be advised that the endorsement will be forwarded within a few days. The cancellation area cannot be edited due due it being a legal document. Thank you, �� ne Kharakh is �� DaTE(MMIDOIYY) AC-DIM,, CERTIFICA OF LIABILITY INSUF ICE $11112006 PRODUCRR RONAFIDE INSURANCE SERVICES INC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION P O BOX 591478 ONLY AND CONFERS NO WOWS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. SAN FRANCISCO CA 94159 INSURERS AFFORDING COVERAGE (416522-5944 _ INSURED INSURER A: ProBuilders Special Insurance_Co,RRG Romkon, Inc. INSURER B: 291 17th avenue INSURER C: _ San Francisco,CA 94121 INSURER D! INSURER F;. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A$OVE 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 AFI=ORDED 13Y THE POLICIES DESCRIBED HEREIN 16 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ INSIRLTR TYP6oFINSURANCE POLICYNUMDERR DnTE MM VE DaTE MM/DD1YY)OLICY FXFIRXTM 41M1T5 EACH OCCURRENCE $ 1,000,0 00 GENERAL LIA131UTY X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one firm) $ 50,000 _ CLAIMS MADE LJ OCCUR MED EXP(Any one pemon) r $ 5,000 A X 3500 PD Deductible COM 5008023 1/1612006 1/1612007 PFRSONAL a ADV INJURY 2-_ 1,000,000 GENERAL AGGREGATE 9 _ 2,000,000 GEN'L AOOREGAT-LIMIT APPLIES PER; PRODUCTS;COMPIOP AGO, A 1,000,000 PRDX POLICY JEC LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea acrldent) ALL OWNED AUTOS BODILY INJURY $CHEDULEDAUTOS (Pnrpenan)HIRED AUTOS BODILY INJURY � NON-OWNED AUTOS (Per accldnn!) PROPERTY DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC 3_ AUTO ONLY: AGG EXCESS LIABILITY OCCURRENCE 3— OCCUR u C4AIMS MADE AGGREGATE B_ DEDUCTIBLE _ RETENTION ATU• I OTH- WORKERS COMPENSATION AND TORY LIMITS-„__ I qR EMPLOYERS'LIABILITY E,L,EACH ACCIDENT _$ E.L.DISEASE-EA EMPLOYE $ E,L,DISEASE-POLICY LIMIT 3 OTWRR DESCRIPTION OF OPERATIONS/LOCATION.9NEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS See Supplemental information Page(s) CERTIFICATE HOLDER ADDITIONAL INSURBD;INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITY CAMPBELL DATE THEREOP,THE ISSUING INSURER WILL ENDEAVOR TO MAIL_30 DAYS WRITTEN ATTN: DEPT OF PUBLIC WORKS NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 70 NORTH FIRST$k RFET IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON TH NSURER,ITS AGENTS OR REPRESENTATIVES. CAMPBELL CA 95008 AUTHORIZED REPRBSENTATn/F�y f + ACORD 25-S(7197) .� O ACORD CORPORATION 1988 LM:LPW VT.i3.8 on 8/11lCB-10:14 by UaerNeme LP:LPW u1.8.B on Sil l/08-10:141 by'} Name ! PF v1.0.1 t IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the poliey(ies) must be endorsed, A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. ACORD 2&S(7197) LM;LPW v1,9.0 an 0/1 1106-10:14 by UmNaMS LP:LPW v1.B.B on 811 1108-1 011,1 by UBarNEIMS PF v1.0.1 DATE JMMIDII Y) ... r� f�• r,nilr nrelAafiPno,l" s I. IIYfPolCN17: ' c 1 ue« 811112006 S rnvn+•.r:. V ai;N uA m a fdf r � � I f LiA....a.INOa E%tlbi :......_._._............................... 1 eU �- Q PRODUCEk ? APPLICANT IFIfBt Nnm�d Ineuratl 1C f..� ...r, P,.-A)...._...__..._...{415 522.,5944................. . --...._._....................._......._...__..._..._.__..._......_.... BONAFIDE INSURANCE SERVICES INC Romkon, Inc, P O BOX 591478 261 17th avenue San Francisco,CA 94121 SAN FRANCISCO CA 94169 .........._,.....•.......,......... _.__..._...._...._....._.............,.. ........................._....-........................................._....-......_........_..._.................:.... EFFECIIVE DATE � � XPIRATION DATE COIPI.AN CODE; sue cooE: _.__._.._._._..._._..._........ .........._..._.....___.._._.__._.........................................................., ......... ._.....-...._...._...._....... ........_..._....._...__...__....._..._................ AGENCY CUSTOMER 10 POLICY NUM9ER: .........................__.__............ . ..................................._... __..._.__._..._........._...... ........._.__..._...__.. ACCOUNTNUMOER; 10 days written notice for non-payment of premium. PERMIT# : ENC2004-00133 WORD SITE: 213 W. RINCON AVENUE,CAMPBELL ALL WORK IN PUBLIC RIGHT-OF-WAY. CITY OF CAMPBELL,CITY OF CAMPBELL REDEVOLOPMENT A+-11ENCY, ITS OFFICERS EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSURED AS RESPECTS LIABILITY PER CG 2009 LM:LPW V1.9.8 on 8111103-10:14 by UeerNsma LP;LPW OAS on$111/00-10:14 by UaRflamn PF Vl.V.A FAX Date 8110106 Number of pages including cover sheet 9 TO: ATTN. Greg FROM: Joanne D'Ambrosia Bonafide Insurance Services City of Campbell PO Box 591478 70 North First Street San Francisco, CA 94159 Campbell, CA 95008 Phone (415) 522-5944 Phone (408) 866-2701 Fax Phone '(415) 522-5949 Fax Phone (408) 376-0958 CC: REMARKS: ❑ Urgent ❑ For your review ® Reply ASAP ❑ Please Comment Re: Insured: Romkon, Inc.. Permit#: ENC2004-00133 Work Site: 213 W. Rincon Avenue, Campbell We have received the certificate of insurance for general liability for work the above insured will be doing in the City of Campbell right-of-way. In order to meet our minimum insurance requirements we must ask that the following changes be made to the certificate. `I. These endorsements/changes need to be added/done: -The City, the City of Campbell Redevelopment Agency, the County of Santa Clara, their agents, officers, attorneys, employees, officials and volunteers are named as additional insured. -The insurance coverage afforded to the Additional Insured is primary insurance. -The cancellation area of the certificate is to be 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". 2. We require auto liability in the amount of$1,000,000 per accident for bodily injury and property damage. The "any auto" box needs to be checked on the certificate under the auto liability section. 3. We also require Workers' Compensation and Employer's Liability in the amount of$1,000,000 per accident for bodily injury or disease. It must also include a waiver of subrogation clause. 4. ,The encroachment permit number and address as shown above are to be clearly stated on all insurance documents. A copy of the certificate, as well as our insurance requirements, follows for your reference. You may forward the requested items to us by fax. Please call me if you have any questions. Thanks for your help. ATE ,.ACGRID. CERTII=IC11 r f'E OF LIABILITY INBUI •,NCE D112312006 ) PRODUCER BONAFIDE INSURANCE SERVICES INC THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION P O BOX 591478 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. SAN FRANCISCO CA 94169 (4'18)622»5944 �-C5 522®�1 4'� INSURERS AFFORDING'COVERAGE -_ INSURED & ��S INSURER AP P_r_OBUilders Specialty Insurance Co, RRG Romkon,Inc. INSURER 0; _ 261 17th avenue INSURER C: San Francisco,CA 94121 INSURERO: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED 13FLOW 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 HEEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. L T TYPE OF INSURANCE POLICY NUMBER DATE MlD 6�TE MEXPIRATION OU T7 N LIMITS QFNFRAL LIABILITY EACH OCCURRENCE b 1,000,000 X COMMERCIAL.GENERAL LIABILITY FIRE DAMAGE(Anyone}Ire) F TJa,000 CLAIMS MADE ��OCCUR MFD EXP(Any one pere0n) S_ 5,000 A X 3500 PD Deductible COM 5008023 1/16/2006 1/1612007 PERSONAL BAOVINJURY $ 1.,000,000 OENERALAaGRF_GATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG X POLICY E FRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ee eccttlent) _� ALL OWNED AUTOS BODILY INJURY ffi SCHEDULED AUTOS (Pnr per!:en) _ HIRED AUTOS BODILY INJURY NQN•QWNED AUTOS (Per accident) 3 PROPERTY DAMAGE ) (Per acoldenL) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT_ 3 _ ANY AUTO - OTHER THAN EA ACC $ AUTO ONLY: AGO EXCESS MABIL,ITY EACH OCCURRENCE F_ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE REC a RETENTION $ $ ` WORKERS COMPENSATION ANDAUG' TORY LIMITS I QER EMPLOYERS'LIABILITY PUquC W®RK5 E.L.EACH ACCIDENT A0K41Nf TMTION E.L.DISEASE-EA EMPLOYE F _ -- E.L.DISEASE-POLICY LIMIT S OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS 10 days written notice for none payment of premium. Operations consist of new construction of single family and multi unit properties. CERTIFICATE HOLDER ADDITIONAL INSUREDI INSURER LETTER: CANCELLATION SHOULD ANYOF THE ABOVE DESCRIBED POLICIE&BE CANCELLAD BEFORE THE EXPIRATION Insured's Copy DATE THEREOF,THE ISSUING INSURER IMLI.EN@F.AVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,OUT FAILURE TO DO$0 SHALL, IMPOSE NO OBLIGATION OR LIABILITY OF AlfiKIND UPORTHE INSURER,ITS AAF.NTS OR REPRESENTATIVES, AUTHORIZED RESENTATIVE ACORD 29-S(7/97) o ACORD CORPORATION 1988 LM:LPW 0.0.8 on 8/1010G.14;04 by UmnrNRMR LP:LPW vl.9.8 on t1/10/ .14;04 by UAarNgrng PF V1,0.1 IMPORTANT, If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. ACORD 26-S(7197) LM:LPW vi.8.8 on 8110/08-14:04 by UeerName LP:LPW A9.6 on 01•10/00-14:04 by UaerNema PF v1.0.1 : Company Profiles Page 1 of 1 CompanyList For more information on any company, click the Company Name "Info" link. To view all companies in the same group, click the NAIC group number. Company Name State of NAIC NAIC Group Name Domicile Number Number Type PROBLTILDERS SPECIALTY INSURANCE COMPANY, DC Legal RRG, A RISK RETENTION GROUP Info Name Record 1 New Search Last Revised-June 20,2006 08:24 AM Copyright©California Department of Insurance http://interactive.web.insurance.ca.gov/webuser/idb_co_list$co_list_me.actionquery 8/11/2006 : Company Profiles Page 1 of 1 CompanyList For more information on any company, click the Company Name "Info" link. To view all companies in the same group, click the NAIC group number. Company Name State of NAIC NAIC Group Name Domicile Number Number 'Type LINCOLN GENERAL INSURANCE PA 33855 1326 Legal COMPANY Info Name Record 1 New Search Last Revised-June 20,2006 08:24 AM Copyright©California Department of Insurance http://interactive.web.insurance.ca.gov/webuser/idb_co_list$co_list_mc.actionquery 8/16/2006 Best's Rating Center- Search Results Page 1 <s -Page 1 of 1 +C r2A ter it View Ratings: Financial Strength Issuer Credit Securities Advanced Search Other Web Centers: Select One {a_� Search Results Page 1 of 1 1 Rated and non-Rated companies found, results sorted by Company Name Criteria Used: Company Name: Company names starting with ProBuilders Specialty Insurance To refine your search, please use our Advanced Search or view our Online Help for more information. New Search j ProBuilders Specialty Insurancl View results starting with: A B C D E F G H I J K L M N 0 P Q R S T U V W X Y Z Company Information Financial Strength Ratings Issuer Credit Ratings Outlook/ Outlook/ A. w AMB# + Company Name Rating Implication Long-Term Implication Short-Term T Domicile 75530 ProBuilders Specialty Insurance Co NR-2 Not US:District RRG Applicable Columbia (Property/Casualty-Insurance Company) ........................................................................................................................................................................... Note:Financial Strength Ratings as of 0811012006 03:03 PM E.S.T. Financial Strength Ratings (FSR)are sometimes assigned to Property/Casualty-A.M. Best Consolidated Groups. Please nc $ Life/Health -A.M. 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A.M.Best Worldwide Headquarters,Ambest Road,Oldwick,New Jersey,08858, U.S.A. http://www3.ambest.com/ratings/RatingsSearch.asp?AltSrc=9 8/10/2006 r� Best's Rating Center- Company Information for Lincoln General Insurance Company Page 1 of 2 Member Benefits Ratio Center , g f View Ratings:Financial Strength Issuer Credit Securities Advanced Search Other Web Centers:Select One Rating Methodology Industry Research. Ratings Def initi Lincoln General Insurance Company I%Print this pa Search Bests'Ratings (a member of Kingsway America Group) (view securities for related issuers) Assigned to companies that Financ all,5tren�tte A.M.Best#:03723 NAIC#:33855 FEIN#: 232023242 have,in our opinion,an Press Releases excellent ability to meet their DEST. Address:P.O. Box 3709 Phone:717-757-0000 ongoing obligations to 9 s A.&6611"enit Related Products ► York, PA 17402-0136 Fax:717-751-0165 policyholders. ="� ----�'` ----== Industry a Regional I Web:www.lincoingeneral.com Country Risk �— - Best's Ratings How to Get Rlsted Contact en Analyst Financial Strength Ratings View Definitions Issuer Credit Ratings View Definitions Rating:A-(Excellent) Long-Term: a- Financial Size Category:Vlll($100 million to$250 million) Outlook: Stable BestMark Outlook: Stable Action:Assigned • Action:Affirmed Date: March 28,2006 Insurers Effective Date: March 28,2006 Denotes Under Review Best's Ratings Reports and News Visit our NewsRoom for the latest news and press releases for this company and its A.M. Best Group. Best's Company Report-includes Best's Financial Strength Rating and rationale along with comprehensive analytical commentary,detailed business overview and key financial data. Report Revision Date: 04/05/2006 (represents the latest significant change). 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US Best's Insurance Expense Exhibit(IEE)-P/C, US Best's State/Line(Combined Lines)-P/C, US http://www3.ambest.com/ratings/FullProfile.asp?B1=0&AM 3Num=3723&A1tSrc=1&AltNum=&URATI... 8/16/2006 Best"s Rating Center- Company Information for Lincoln General Insurance Company Page 2 of 2 Customer Service I Product Support I Member Center I Contact Info I Careers About A.M. Best I Site Map I Privacy Policy I Security I Terms of Use I Legal & Licensing Copyright©2006 A.M.Best Company, Inc.All rights reserved. A.M.Best Worldwide Headquarters,Ambest Road,Oldwick,New Jersey,08858,U.S.A. http://Www3.ambest.com/ratings/FullProfile.asp?B1=0&AMBNum=3723&A1tSrc=1&A1tNum=&URATI... 8/16/2006 WORKERS' COMPENSATION INSURANCE INFORMATION The following workers' compensation insurance information is required for all Applicants and Contractors. One of the following items for each Applicant and Contractor must be submitted prior to working under a Public Works permit of contract. WORKERS' COMPENSATION INFORMATION: Name of Contractor/Applicant ❑ A Certificate of Consent to Self-Insure issued by the Director of Industrial Relations; OR ❑ A Certificate of Workers' Compensation Insurance Insurance Co. Policy No. Expiration Date ; OR A signed Certificate of Exemption from the Workers' Compensation laws as printed below. CERTIFICATE OF EXEMPTION I certify that in the performance of the work for this contract, I shall not employ any person in a manner so as to become subjec -t r ers' Compensation Laws of California. Signed — j Date 09A Title NOTICE TO APPLICANT/CONTRACTOR: If after signing this Certificate of Exemption, you should become subject to the Workers' Compensation provision of the Labor Code, you must forthwith comply with such provisions or the Permit or Contract will be cancelled or revoked. j A1anddev\forms\street improvements\workeomp(rev. 6/96) DISPLAY BUSINESS RECORDS: DISPLAY EXIT DISPLAY HISTORY RECORDS PENTAMATION---------------------------------------------------------- 08/11/06 BUSINESS 021508 ,�__RQI KON INC ' SERVICE 1799A SPCL TRAD BILLED PAID CURRENT 35.00 35.00 BILLED 05/01/2006 BILL REF 07/05 RENEWAL TAX 0.00 0.00 DUE 05/31/2006 LICENSE 1 PENALTY 0.00 0.00 PAID 07/_1_1/2006 INTEREST 0.00 0.00-EXPIRE:S.__05/31-/20.07 ADJUSTMENT 0.00 TOTAL 35.00 35.00 BALANCE 0.00 ------------------------------------------------------------------------------- SERVICE BILLING REF BILLED PAID DATE DESCRIPTION E-END/N-NEXT/R-REVIEW BUS/S-SERVICE/0-OWNER/V-REVIEW SCREEN L era e,Detail Page 1 of 2 California Home Friday,August 11,2006 com ...,...m.e....,..w....-e....._...sa,-......--3z„H o w..«.«.,`,...a.«.�...,.✓aa.;,... ,..:w.o».s...R.... �' +»� -a%i.!.._ .�...a 3 3 �'u_'..-< License Detail CALIFORNIA CONTRACTORS STATE LICENSE BOARD Contractor License # 620277 DISCLAIMER A license status check provides information taken from the CSLB license data base. Before relying on this information, you should be aware of the following limitations: . CSLB complaint disclosure is restricted by law (B&P 7124.6). If this entity is subject to public complaint disclosure, a link for complaint disclosure will appear below. Click on the link or button to obtain complaint and/or legal action information. . Per B&P 7071.17, only construction related civil judgments reported to the CSLB are disclosed. . Arbitrations are not listed unless the contractor fails to comply with the terms of the arbitration. . Due to workload, there may be relevant information that has not yet been entered onto the Board's license data base. Extract Date: 08/11/2006 * * * Business Information C'ROMKON-I N C 261 17TH AVENUE SAN FRANCISCO, CA 94121 Business Phone Number: (415) 516-5180 Entity: Corporation Issue Date: 05/18/1991 Reissue Date: 08/20/2001,,EXpire Date:_081.31/2007- * * * License Status * * * This license is current and active. All information below should be reviewed. * * * Classifications Class Description © GENERAL BUILDING CONTRACTOR * * * Bonding Information CONTRACTOR'S BOND: This license filed Contractor's Bond number 6329807 in the amount of $10,000 with the bonding company SURETY COMPANY OF THE PACIFIC. Effective Date: 01101/2004 Contractor's Bonding History_ http://www2.cslb.ca.gov/CSLB LIBRARY/License+Detail.asp?LicNum=620277 8/11/2006 LQkersepetail Page 2 of 2 BOND OF QUALIFYING INDIVIDUAL(1): The Responsible Managing Officer (RMO) ROMAN ABRAM KNOP certified that he/she owns 10 percent or more of the voting stock/equity of the corporation. A bond of qualifying individual is not required. Effective Date: 08/20/2001 * * * Workers Compensation Information This license is exempt from having workers compensation insurance; they certified that they have no employees at this time. Effective Date: 11/07/2003 Expire Date: None Workers Compensation History_ * * * Miscellaneous Information Date Description 08/20/2001 LICENSE REISSUED TO ANOTHER ENTITY 05/09/2002 CLASS C20 REMOVED Personnel listed on this license (current or disassociated) are listed on other licenses. Personnel List Other Licenses License Number Request Contractor Name Request Personnel Name Request Salesperson Request Salesperson Name Request ©2006 State of California.Conditions of Use Privacy Policy http://www2.cslb.ca.gov/CSLB LIBRARY/License+Detail.asp?LicNum=620277 8/11/2006 OF C ul _,r C}},' c'G ytDFC U t �J : C✓ 02 CH ARC t CITY OF CAMPBELL Public Works Department February 26, 2008 Mr. Roman Knop 261 — 17th Avenue San Francisco, CA 94121 Subject: Permit No. ENC2004-00133 Location: 213 W. Rincon Avenue One Year Maintenance Inspection—Acceptance Pear Mr. Knop: The City of Campbell has made the final one year maintenance inspection of subject Public Works improvements and find that no remedial work is required. Your warranty requirements and any surety, therefore, are hereby released. Enclosed please find your original Certificate of Deposit in the amount of$8,187.63 which we are returning to you. For your information, there is still a ertificate of Deposit in the amount of$7,000 on file with this office. This represents a monumentation security. ou ave e previously notified by Ed Arango of our office of the steps necessary to complete the requirements for the release of this deposit. We urge you to complete these requirements so your file can be closed and your additional deposit returned to you. Sincerely, . Syed Wahidi I Public Works Inspector MQ Cc: Permit ENC 2004-00133 Public Works Maintenance Division 70 North First Street • Campbell, California 95008-1436 1 TEL 408-866.2150 FAX 408.376.0958 TDD 408.866.2790 ORCH PR9. CITY OF CAMPBELL January 30, 2007 Public Works Department Roman Knop 261 17'Ave San Francisco, CA 94121 Re: 213 Rincon Ave. -,jfflfff13Y3.)Tract Map 9604 Monumentation Cash Security—Second Request Dear Mr. Knop: This is a second request to the letter sent on 10/3/06. According to the City's records, a $7,000 security is still being retained for setting the survey monuments for the above- referenced Tract Map 9604. Please provide us with a letter from your land surveyor that states: (a) all monumentation has been completed in accordance with the Subdivision Map Act Section 66495, and the prepared Tract Map 9604, (b) that he has been paid for his services, and (c) that he has set easily identifiable/verifiable markers at the monumentation locations (i.e. above ground construction stakes and/or flags). Upon written request for refund of the security by the party who posted it, the staff will r check the site to verify that the monuments have been set. When the monumentation has been completed, the staff will arrange to have your security released. Please respond within two (2) weeks of receiving this letter. Contact me at (408) 866- 2166 if you have any questions. Sincerely, Ed Arango,P.E. Associate Civil Engineer cc: LD File/(213 Rincon Ave.) H. Alfredo Vasquez, SMP Engineers, 1534 Carob Lane Los Altos, CA 94024 70 North First Street • Campbell, California 95008-1 436 1 TEL 408-866.2150 e FAX 408.376.0958 TDD 408.866.2790 of ORCHAti'o CITY OF CAMPBELL Public Works Department January 29, 2007 Roman Knop 261-17'Avenue San Francisco, CA 94121 SUBJECT: PERMIT NO. ENC2004-00133 LOCATION: 213 W. Rincon Avenue, Campbell FINAL INSPECTION AND ACCEPTANCE Dear Mr. Knop: 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 October 8, 2006. 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 Construction Cash Deposit of$500.00, plus any interest due, is now being processed and will be sent to you under separate cover. At your request, the Faithful Performance Bond (Assignment and Receipt of Investment Certificate), in the amount of $8,187.63, will be kept in force for the duration of the one year maintenance period. The other Assignment, in the amounts of$8,187.63, is being returned to you. If you have any questions, please call me at (408) 866-2165. Since ely, Syed Wahidi ��Public Works Inspector IMQ� Enclosure cc: Suspense- 11 months from 10/8/06 PermiE#EN.C2004z0018.3-- Inspector File Wells Fargo Bank, 3431 California Street, San Francisco, CA 94118 h:\word\permits\2004_133 findd) 70 North First Street ° Campbell, California 95008-1436 ° TEL 408-866.2150 FAx 408.376.0958 TDD 408.866.2790 EN( LCHMENT PERMIT ISSUANCE CHECE ;T a City of Campbell Encroachment Permit No. ENC 204 'rc Department of Public Works Tract No. V7U� Address: Z I'3 in/�.S t I�+VI C��JI Ave ITEMS REQUIRED FOR PERMIT APPLICATION: 1 1. ti� Applicant section complete 2. Applicant signature and date(front and back) �j 1 3. 6)-22 OtPermit Application Fee$260.00 paid-Receipt Nur 4.0-2,2 d4 Engineer's Estimate Submitted 5.0 4-v4 Plan Check Deposit Paid(2%of Engineer's Estima 6. Fve Sets of Grading and Drainage Plans 7. V 7Fi<e Sets of Improvement Plans Submitted 8. ti✓ Check Lists ITEM�� Plan S REQUIRED PRIOR TO PUBLIC WORK CLEARANCE FOR BUILDING PERMITS 9,. i Check&Inspection Fee: If Engineer's Estimate<$250,000,then 4010 of Engineer's Estimate. If Engineer's Estimate >$250,000,then Actual Cost+20%. (Deposit of 8%of Engineer's Estimate required;$30,000 minimum deposit. Amount$ (wo.2'r Receipt No. oJos�:;> 10: Mpiecurity for Faithful Performance and Labor and Materials, 100%ea f ngin er' �g�i�orpaid.,11/ %mount$-13t .6 Form I.D.#________� 1 Iq L Security for Monumentation Amount$`ZWO ,CO Receipt No. 12. Construction Emergency Cash Deposit: 4%of Engineer's Estimate. ($500 minimum,Il0,00 maximum) g �9/,3 al/ Amount$_ Receipt No. 13J M Storm Drainage Area Fee Amount$ 00 Receipt No. O� 14. Right of Way Documents Completed and Fees Paid. ��► �c'iJ c m �-j�7a 15. Worker's Compensation Insurance Information Sheet Received for Applicant. jai ryh fpr, �j�ZL?p 16. All other Public Works requirements listed in the Conditions of Approval of the development. iJ,"` 6� 17. Other Fees,Payments,Deposits Amount$ Receipt No. `_ _-4,y ITEMS REQUIRED/ RIOR TO I - ANCE OF ENCROACHME T PERMIT• 9 c9 -7O 18. Contractor's signature added to the permit application(front and back) 19. Contractor's City of Campbell Business License # 20. Worker's Compensation Insurance Information Sheet received from Contractor. 21, Certificate of Insurance with Additional Insured's Endorsement received from Applicant or Contractor. 22. One mylar set and four blueline sets of off-site plans signed by licensed engineer,stamped APPROVED FOR CONSTRUCTION. 23. Permit signed by City Engineer. WHEN ALL OF THE ABOVE ITEMS ARE COMPLETE,PERMIT MAY BE ISSUED. .....j1sIIssu r: Initial and date and file with permit. W/ 7,Q}/'�7�r rnnrrw wT(� ,INITIATE CHECK REQUEST FOR PLAN CHECK DEPOSIT REFUND 1 /d4+ 1 j andDev\forms\streetimprovements\EP checklist rev. 1/20/04 I U � r ORCH ARC CITY OF CAMPBELL Public Works Department Date: February 12, 2007 TRANSMITTAL FROM THE PUBLIC WORKS DEPARTMENT TO: Mr. Roman Knof 261-17"'Avenue San Francisco CA 94121 FROM: Joanne M. D'Ambrosia, Office Specialist SUBJECT: 213 W. Rincon Avenue, Campbell, CA Encroachment Permit#ENC2004-00133 Enclosed is a check in the amount of$507.05, representing a refund of your construction cash deposit,plus accrued interest, in connection with the above property. Joanne M. D'Ambrosia Office Specialist Enclosure 70 North First Sheet Campbell, California 95008-1436 TEL 408-866.2150 FAX 408.376.0958 TDD 408.866.2790 CITY OF CAMPBELL WARRANT NO. CAMPBELL,CA 208262 ORGANIZATION I ACCOUNT PORCH.ORDER INVOICE NUMBER AMOUNT DESCRIPTION 101 2203 CRO129'20 }7 500.00 REFUND DEPOSIT 101 .540 7448 CRO1292007 7.05 INTEREST EARNED 00007523` ROMAN KNOF' REMITTANCE ADVICE-PLEASE DETACH BEFORE BANKING i C X. ..r 11-35 BANK OF AM ERICA WARR�NT NO pg M r }€ VOID AFTER 90 DAYS cAMPeEti oFFlce CA�VI 1z10 99 THE 0 N>:rain k r 2 F BELL zv �' 70 FORTH FIRST STREET w _... �0 6 AMPS �A.135008 • y��( L CAMPBELL,CALIFORNIA 95008 DATE r°�I v� - ' Y � AMOUNT 7117IC; k5t� Og PAY:, FIVE HUNDRE DOLLARS • 05 CENTS j SIGNATURE r ' � TO a I ROMAN I�NOP . t f ,S P rd ,�� W 4 1 t� fi 17TH� AVE SAha FRRNC I ScO CAS 941^1 t:. k ` �� ^1y I S's '�'Y Y "t?i" ♦ c• s F t �[1 "KtW YBWw�'�'►�► 7 3 ,�-�.k` ks .' t h �':8 _ ». srF' � ;y n+.?, y?;e+x• °§x`N v"-s r..:...Y oV ' y u 51 >a OR CH AR' CITY OF CAMPBELL Public Works Department Date: June 6, 2005 TRANSMITTAL FROM THE PUBLIC WORKS DEPARTMENT TO: South Bay Development c/o Akbar Abdollahi 3131 S. Bascom.Avenue, Suite 110 Campbell, CA 95008 FROM: Joanne M. D'Ambrosia, Senior Office Assistant SUBJECT: 213 W. Rincon Avenue, Campbell, CA Permit No. ENC2004-00133 Enclosed is a check in the amount of $506.96 representing a refund of the plan check " deposit, plus accrued interest, in connection with the above property. . i - Joanne M.D'Ambrosia Senior Office Assistant Enclosure 70 North First Street Campbell, California 95008-1436 TEL 408-866.2150 FAX 408.376.0958 TDD 408.866.2790 CITY OF CAMPBELL WARRANT NO. CAMPBELL,CA. 115128 101 . 22t 3 CR05242005 500.00 REFUND DEPOSIT 101 . 540 7448 CR05242005 6.96 INTEREST EARNED 0u0006058 SOUTH BAY DEVELOPMENT REMITTANCE ADVICE-PLEASE DETACH BEFORE BANKING F Cq VOID AFTER 90 DAYS 11-35 BANK OFAMERICA WARRANT NO. O Mp 1210 CAMPBELL OFFICE . ham. 111 CITY OF CAMPBELL 125 E.CAMPBELL AVE. r 70 NORTH FIRST STREET CAMPBELL,CA.950.08 115128 ? o CAMPBELL,CALIFORNIA 95008 DATE C)6/t16/��5 11.51'�$ OR CHA%O' AMOUNT PAY FIVE HUNDRED SIX DOLLARS & 96 CENTS TO SIGNATURE SOUTH BAY DEVELOPMENT C/O AKBAR ABDOLLAHIlip,-, 1=i StASCOM AVE STE 1 i 0 If _. v ; 'k� r ✓s �: CAMPBELL CA 95008 • )/ y Il' L 15 128115 1: 12 1000 3 581: 0 9 19 311,80 2000 4, OF C"N OR CHAR CITY OF cCAMPBE L Public Works Department TRANSMITTAL May 27, 2005 From The Desk Of.- Marlene Pomeroy Wells Fargo Bank Executive Assistant 3431 California Street (408) 866-2776 San Francisco, CA 94118 e-mail: marlenep@ci.campbell.ca.us Re: Assignment and Receipt of Investment Certificates Enclosed please find copies of Assignment and Receipt of Investment Certificates for your customer Roman Knop. The Assignments will remain in effect until such time as the Conditions of Approval and maintenance periods are satisfied with regard to Encroachment Permit ENC2004-00133 at 213 W. Rincon Avenue, Campbell. IIf you have any questions, please contact Alberto Oxonian, Senior Civil Engineer, at I (408)866-2162. I I ,I Marlene Pomeroy Executive Assistant ,I Enclosure 11 cc: Roman Knop, 261-17th Ave. , San Francisco 94121 I I I I .I 70 North First Street Campbell, California 95008-1436 TEL 408-866.2150 FAX 408.376.0958 TDD 408.866.2790 r v CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT ENGINEER'S COST ESTIMATE ADDRESS: 213 West Rincon Ave., Campbell CA Date: 6122/2004 ENCROACHMENT PERMIT NO. APPLICATION NO. ITEM No. DESCRIPTION 0,yt UNITS UNIT COST EXTENSION I SURFACE CONSTRUCTION 1 MOBILIZATION 0 LS $0.00 $0.00 2 CONSTRUCTION TRAFFIC 0 LS $0.00 $0.00 3 CONTROL/PHASING 0 LS $0.00 $0.00 4 CONSTRUCTION STAKING 0 LS $0,00 $0,00 it DEMOLITION/CLEARING 1 LS $1,052.20 $1,052.20 1 CLEARING AND GRUBBING 0 LS $0.50 $0.00 2 SAW CUT P.C.C,/AC(up to 6") 40 LF $4-W $164.00 ?L�••O� 3 P.C.C. REMOVAL 0 SY $30.00 $0.00 4 CURB AND GUTTER REMOVAL 0 LF $6.00 $0.00 5 MEDIAN REMOVAL 0 . SF $4.50 $0.00 6 DEMOLISH EXISTING INLET/PLUG RCP-S 0 EA $8.00 $0.00 III STORM DRAINAGE 1 12" R.C.P.(CLASS V) 0 LF $47.35 $0.00 2 15"R.C.P.(CLASSlil) 0 LF $65.00 $0.00 3 18"R.C.P.(CLASSIII) 0 LF $70.00 $0.00 4 24" R.C.P.(CLASS)II) 0 LF $80.00 $0.00 6 30" R.C.P.(CLASSIII) 0 LF $90,00 $0.00 6 T.V. INSPECTION(12") 0 LF $1.20 $0.00 7 STD. DRAINAGE INLET 0 EA $1,505200 $0.00 (C.C. DETAIL 9) 8 FLAT GRATE INLET 0 EA $1,400.00 $0.00 (C.C. DETAIL 6) 9 STANDARD MANHOLE 0 EA $2,000.00 $0.00 (C.S.J. DETAIL D-11) (INCLUDES FRAME&LID) 10 BREAK AND ENTER M.H./D.I. 0 EA $700.00 $0.00 11 CURB INLET 2 EA $800.00 $1,600.00 )I IV CONCRETEIMPROVEMENTS 1 SIDEWALK 200 SF 1" $1,350.00 Page 1 of 3 a13 FROM' : 'SMP COMPANY FAX NO. 408-2B7-8630 -Tun. 22 2004 04:04PM P2 o 2 DRIVEWAY APPROACH 90 SF LO g $702.00 C1,00 3 CURB AND GUTTER 40 LF T2 $1,180.00 (I(a� 4 VALLEY GUTTER 0 SF $12.50 $0.00 5 HANDICAP RAMP 0 EA $1.200.00 $0.00 6 TYPE B-1 CURB 0 LF $12.00 $0.00 7 TYPE Al-63 CURB 0 LF $40.00 $0.00 8 COBBLESTONE MEDIAN SURFACE 0 SF $50.00 $0.00 9 P.C.C. DRIVE WAY CONFORM 0 SF $64.00 $0.00 10 A.C. DRIVEWAY COFORM 0 SF $50.00 $0.00 V PAVEMENT 1 ASPHALT DIG OUT AND REPLACE 40 CF gyp,g0 $4-ff $164.00 2 PAVEMENT WEDGE CUT(6") 0 LF $5.00 $0.00 3 PAVEMENT GRINGING 0 SF $0.80 $0.00 4 PAVEMENT FABRIC(PETRO-MAT) 0 SY $2,30 $0.00 5 ASPHALT CONCRETE(TYPE A) 3 T 14.0 $ -O $173.70 6 AGGREGATE BASE 0 T $23.15 $0.00 7 SLURRY SEAL(TYPE II) 0 SF $0.07 $0.00 8 AC OVERLAY 0 T $52.00 $0.00 9 SLURRY SEAL(TYPE III) 0 SF $0.11 $0.00 VI TARFFIC SIGNALS/LIGHTS 1 DETECTOR LOOP(6' ROUND) 0 EA $450.00 $0.00 2 DETECTOR LOOP(5'X30') 0 EA $650.00 $0.00 3 DETECTOR LOOP(6'X50') 0 EA $900.00 $0.00 4 ELECTROLIER 0 EA $2.600.00 $0.00 6 11/2" RIGID CONDUIT 0 LF $9.00 $0.00 6 2" RIGID CONDUIT 0 LF $17.00 $0.00 7 CONDUITS 0 LF $ 0.70 $0.00 8 PULL BOX(NO. 31/2) 0 EA $ 300.00 $0.00 9 PULL BOX( NO. 5) 0 EA $ 400.00 $0.00 VII STRIPING AND SIGNS 1 REMOVE PAVEMENT MARKING(PAINT) 0 SF $2.50 $0.00 2 REMOVE PAVEMENT MARKING(THERMO) 0 SF $3.00 $0.00 3 REMOVE PAVEMENT STRIPING 0 LF $1.40 $0.00 4 STRIPING DETAIL 9 0 LF $1.35 $0.00 5 STRIPING DETAIL 29 0 LF $2.25 $0.00 6 STRIPING DETAIL 32 0 LF $2.40 $0.00 7 STRIPING DETAIL 37(THERMO) 0 LF $1.85 $0.00 8 STRIPING DETAIL 38(THERMO) 0 LF $2.50 $0.00 9 STRIPING DETAIL 39 0 LF $1.50 $0.00 10 STRIPING DETAIL 40 0 LF $2.20 $0.00 11 LIMIT LINE 0 LF $1.35 $0.00 12 CROSSWALK 0 LF $1.35 $0.00 13 PAVEMENT MARKING(PAINT) 0 SF $2.50 $0.00 14 PAVEMENT MARKING(THERMO) 0 SF $5.50 $0.00 15 PAVEMENT MARKING(NON-REFL.) 0 EA $4.50 $0.00 Page 2 of 3 2t3 'FROM' : 'SMP COMPANY FAX NO. 408-287-OG30 Jun. 22 2004 04:04PM P3 r ' 16 PAVEMENT MARKING(REFLECTIVE.) 0 EA $6.00 $0.00 17 TYPE K MARKER 0 EA $95.00 $0.00 18 TYPE N MARKER 0 EA $95.00 $0.00 19 SALVAGE ROAD SIGN 0 EA $85.00 $0.00 20 RELOCATE ROAD SIGN 0 EA $100.00 $0.00 21 INST. RD. SIGN ON EXIST. POLE 0 EA $200.00 $0.00 22 ROAD SIGN WITH POST 0 EA $300.00 $0.00 VIII LADNSCAPING 1 IRRIGATION, PLANTING WORK 0 EA $250.00 $0.00 2 PRUNE TREE ROOTS 0 EA $250.00 $0.00 3 TREE REMOVAL 0 LF $250.00 $0.00 4 ROOT BARRIER(12") 0 LF $250.00 $0.00 5 ROOT BARRIER(18") 0 LF $250.00 $0.00 6 STREET TREE(24"BOX) 1 EAAj,'3D �0 $250.00 A41,Wt 7 STREET TREE(36" BOX) 0 EA $590.00 $0.00 8 TOP SOIL BACK FILL 0 CY $250.00 $0.00 IX MISCELLANEOUS 1 PEDESTRIAN BARRIER 0 LF $75.00 $0.00 2 CHAIN LINK FENCE(6') 0 LF $15.00 $0-00 3 RAISE MISC. BOX TO GRADE 0 EA $300.00 $0.00 4 RAISE MANHOLE TO GRADE 0 EA $400.00 $0.00 5 INSTALL MONUMENT BOX 0 EA $450.00 $0.00 6 MEDIAN BACK FILL_ 0 CY $19.00 $0.00 SUBTOTAL 7M70 -f t44-3,3 D PREPARED BY: SMP COMPANY 10%SECURITY REVIEWED BY: ENFORCEMENT FEE TOTAL ESTIMATE FOR g 6 APPROVED BY: FAITHFUL PERFORMANCE f ° 3 SECURITY $7 49 p�Essle c ► .27 h E5 No.52724 � Exp.. 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