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1707 Hurst Ave ENCROACHMI 'ERMIT ISSUANCE CHECK LIST(INT ►L USE ONLY) City of Campbell Encroachment rermit No.ENC-40!2`00 l )-1 Department of Public Works Tract No. 201Z—o:� Address: /701 h4,lzsr vs`"aF ITEMS REQUIRED FOR PERMIT APPLICATION: 1. \�,_ Encroachment Permit Application complete,with applicant signature and date(front and back) 2. Permit Application Fee paid$ -Receipt Number&Date 3. n1 Plan Check Deposit Paid(2%of Engineer's Estimate,$500 min)$ Receipt Number 4. rJ JA Grading Plan Review Fee paid$ -Receipt Number&Date 5. City Engineer's Estimate Completed and Submitted 6. Four(4)Sets of Street Improvement Plans 7. Four(4)Sets of Grading and Drainage Plans S. s` Check Lists(Grading and Drainage, Street Improvement) ITEMS REQUIRED PRIOR TO PUBLIC WORK CLEARANCE FOR BUILDING PERMITS 9. Plan Check&Inspection Fee:Engineer's Estimate(EE)=$ ;if EE is<$250,000,then fee is 14%of EE. If EE>$250,000,fee is Actual Cost+20%. $35,000 minimum deposit. Amount$ Receipt No. &Date 10. X Security for Faithful Performance and Labor.and Materials, 100.%each of Engineer's Estimate,sup lied or paid. Amount$ %00 Form Receipt No. &Date IZ 2,g9Y Z 11.+ Security for Monumentation Amount$ Receipt No. &Date 12.tj Construction Emergency Cash Deposit: 4%of Engineer's Estimate. ($500 minimum,$10,000 maximum) Amount$ Receipt No. &Date 13. Storm Drainage Area Fee Amount$390,Off Receipt No. &Date 14. 1J N Street Improvement Agreement signed and notarized(proof of ownership submitted) 15.4 Right of Way Documents Completed and Fees Paid. 16._tA All other Public Works requirements listed in the Conditions of Approval of the development. 17. Other Fees,Payments,Deposits Amount$ Receipt No. &Date 18. SWPPP+NOI 19. C3 Certification 20.bJA Covenant Agreement 21.0-Geotech Letter 22. Storm Water Management Plan ITEMS REQUIRED PRIOR TO ISSUANCE OF ENCROACHMENT PERMIT: 23. Contractor's signature added to the permit application(front and back) 24. Contractor's City of Campbell Business License# 25. Worker's Compensation Insurance Information Sheet received from Contractor. 26. Certificate of Insurance with Additional Insured's Endorsement received from Applicant or Contractor. 27. One"4ar-sot and six(6)or less sets of off-site plans signed by engineer,stamped APPROVED FOR CONSTRUCTION. Contractor, Inspector PW Superintendent(Service Center) EP File LD File _Signals&Lighting Supervisor(Service Center) 28. Permit signed by City Engineer. 29. INITIATE CHECK REQUEST FOR PLAN CHECK DEPOSIT REFUND WHEN ALL OF THE ABOVE ITEMS ARE COMPLETE,PERMIT MAY BE ISSUED. Issuer:Initial and date and file with permit J:\FORMS\Templates\Land Development\Street Improvements\Encroachment Permit Issuance Cheeldist.doc(Rev.07/11) Print'Fr m`l . CITY OF CAMPBELL R-1 ENCROACHMENT PERMIT Permit No. ZolZ.- ©U 12,1 DEPT.OF PUBLIC WORKS (Non-engineered work within the public right-of-way) X-Ref File (6L,6 2612 --06-3 70 North First Street ($10,000.00 maximum value of work) Application Date r5-/Iq 12 Campbell,CA 95008 Application Expiration Ph.(408)866-2150 ISSUED: 19 ' Date Z_ 7� 1 Fx.(408)376-0958 Permit Expiration Date: 411 APN z U � APPLICATION-Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code,Section 11.04. (Application expires in 6 months if the permit is not issued.) A. Work Address: 1707 HURST AVE,CAMPBELL CA-95125 B. Nature of Work: SIDEWALK AND GUTTER REPAIRS C. Attach three(3)copies of a drawing showing the location,extent and dimensions of the work. The drawing shall show the relation of the proposed work to existing improvements. When approved by the City Engineer,said drawing become a part of this permit. D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction;the General Permit Conditions listed on the reverse side;and the Special Provisions for this permit,listed below. Failure to abide by these conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance securities. NAME OF APPLICANT: DAVID CHRISTIE Telephone: 1.4082043710 Address: F70 RST AVE,CAMPBELL CA 95125 E-Mail Address: D.CHRISTIE@SLEEPWORLD.COM The Applicant hereby confirms that this work is being done by the property owner/applicant at their own residence. The Applicant hereby agrees by affixing their signature to this permit to hold the City of Campbell,City of Campbell Redevelopment Agency,its officers,agents,and employees free,safe and harmless from any claim or demand for damages resulting from the work covered by this permit. The Applicant hereby acknowledges that they have read and understand both the front and back of this permit,and that they will inform their contractor(s)of the jnformation. ACCEPTED: = '' _ �- sb/"✓ (Applicant/Permittee) (Sign) Date NOTES: All work shall conform with the attached approved plans and all applicable Campbell Standard Details and Conditions and applicable insurance requirements. The Contractor must have this permit and approved plans and must arrange to meet with the Public Works Inspector at the site at least two days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work. Per Section 4215 of the Government Code this permit is not valid for excavations until Underground Service Alert(US as been notified and the inquiry identification number(Ticket No.)has been entered hereon. USA Phone: 1-800-227-2600. Ticket No.: Applicant is advised that upon issuance of this permit,property owner,or property owner's successors,shall be responsible for any and all damages arising out of the design,installation or condition of private improvements in the public right-of-way. SPECIIA1- R&V&QN 1. Prior to any work,the proper y r-shall-execute an Agreement for Private Improvements in the Public Right-of-Way,which shall be recorded. 2. 3. STANDARD AMOUNT RECEIPT NO. SECURITY FOR FAITHFUL PERFORMANCE (100%Of Engr's Est.) $ 011 qO • 0 j ' LIW(S0'f/ 5 I R-1 PERMIT FEE $ 1� /1 Ce APPROVED FOR ISSUANCE: II -11� l I for City Engineer Date Permit Expires 6 Months after Date of Issuance. GENERAL PERMIT CONDITIONS 1. Payment of a security to insure faithful performance and completion of the work is required. This security is refundable upon completion of the work and written acceptance by the City. 2. A one-year maintenance period for all work is required. Such period will begin on date of acceptance by the City. It is the applicant's responsibility to remove and replace unacceptable improvements within the one-year maintenance period. 3. Refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. 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,fire hydrants and water valves. 6. 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. 7. Sawcut for all PCC and AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements. 8. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading as specified by the City Engineer may result in the City's providing such signing and barricades and charging the cost to the Permittee. 9. The Contractor or Permittee will have a supervisory respresentative available for contact on the project at all times during construction. 10. This permit shall be kept at the site of work and must be shown to any authorized representatives of the City of Campbell or any law enforcement officer upon demand. 11. No storage of materials or equipment will be allowed near the edge of pavement,within the traveled way,or within the shoulderline, which would create a hazardous condition to the public. 12. 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. 13. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 14. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 15. 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. 16. 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. 17. 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. 18. Pursuant to Chapter 14.02 of the Campbell Municipal Code,applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above conditions. Applicant Date J:\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf Rev.3/10 PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1,2012 TO: City Clerk PUBLIC WORKS FILE NO. PROPERTY ADDRESS U s — Please collect&receipt fo.....I i..Ir the followingmonies ACCT. ;ITEM ,I:,i z:s,., 1��, AMOUNT ..; in ... ,.._, I,:1 1:;n,:4-.7 LAND DEVELOPMENT., ,-' 4722 Encroachment Permit Application Fee Non-Utility Encroachment Permit Major>_$10 000 $370.00 Minor Encroachment Permit<sio,000 $210.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $205.00 Street Tree Planting/Removal N/C 2203 $500 per Tree Planting Deposit Required) $500.00/tree 22031 Plan Check Deposit 2%of Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Gradinq&Drainage Plan Review Single Family Lot $260.00 Site< 10,000 s.f. $780.00 Site>_ 10,000 s.f. <0.5 Acre $1 040.00 Site>_0.5 Acre $1 560.00 4722 NPDES Review C3 Requirements) For projects not required to submit numeric sizing $150.00 For projects required to submit numeric sizing Im ervious Area 10,000 S . Ft to 1 Acre $650.00 Impervious Area 1 Acre or more $850.00 Plan Check& Inspection Fee(Non-Utility) 4722 En r. Est. up to$250 000 14%of Engineer's Estimate **2203 En r. Est. >_$250 000 Actual cost+20%Admin Overhead Min$35 000 Deposit) 2203 Emergency Cash Deposit 4%of En r. Est.* $500 minl$10 000 Max 2203 Faithful Performance Security FPS 100%of ENGR. EST.* 96 CEO,C)C7 2203 Labor and Materials Security 100%of ENGR. EST.* 4721 Storm Drainage Area Fee Per Acre R-1 $2 120.00 (Multi-Res$2 385.00) All Other$2 650.00 4722 Parcel Ma 4 Lots or Less $3 700.00+$80/lot 4722 Final Tract Ma 5 or More Lots $4 500.00+$110/lot 2203 Monumentation Security 100%of ENGR.EST. 4920 Parkland Dedication Fee 75%/25% Due Upon Cert. of Occupancy) 4722 Lot Line Ad'ustment Includes Certificate of Compliance) $1 750.00 4722 Vacation of Public Streets&Easements $2 340.00 4722 Certificate of Compliance $1 765.00 4722 Certificate of Correction $520.00 4722 Appeal Filing Fee $200.00 4722 Notary Fee (per signature) $10.00 4722 Assessment Segregation or Reapportionment First Split $830.00 Each Additional Lot $260.00 511.7424 Postage MISCELLANEOUS' . ... h- Other Please S eci *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. **Actual Cost Plus 20%Overhead(Non-Interest bearing deposit) TOTAL $ Q, 0 NAME OF APPLICANT NAME OF PAYOR C f- �.t S'J r L� PHONE ADDRESS I'-4 1~I vWL j—7 zip . Y k FOR RECEIVED BIY." Recei t CITY CLERK? ONLY Date `j # - �O �, fix.: y 3` .. ... .. ,.e .. ... .. .. . r.. >. Date/.initials J:IFORMS\TemD?atesWdminlst,ati,e\Rec,!,t Form Land Oeve10 ,,112-13 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT ENGINEERING DIVISION Prepared By: Roland Neufeld ENGINEER'S`ESTIMATE FOR t ' LAND`DEUELOPIVIENT PROJECTS IS Date: 08/07/12 For File No:2012-00547 Site Address: 1707 Hurst Avenue ENC. No. ITEM UNIT PRICES FOR PROJECT AMOUNT NO. DESCRIPTION QTY UNIT <$250 K > $250 K $AMOUNT I. DEMOLITION/CLEARING 1 SAWCUT P.C.C. (UP TO 6") 84 LF $6.10 $49 $ 512.40 2 P.C.C. REMOVAL 236 SF $4.00 $ A9 $ 944.00 3 CURB AND GUTTER REMOVAL 59 LF $7.05 $345 $ 415.95 II. CONCRETE IMPROVEMENTS $ - 4 SIDEWALK 236 SF $12.00 $8 99 $ 2,832.00 5 CURB AND GUTTER 59 LF $45.00 $35.00 $ 2,655.00 SUBTOTAL $ 7,359.35 PREPARED BY: 10% MOBILIZATION, CONSTRUCTION TRAFFIC CONTROL/PHASING, REVIEWED BY: CONSTRUCTION STAKING CONSTRUCTION TESTING $ 735.94 APPROVED BY: 10% CONTINGENCY $ 735.94 10% SECURITY ENFORCEMENT $ 735.94 TOTAL FAITHFUL PERFORMANCE SECURITY $ 9,567.16 USE THIS AMOUNT FOR SECURITY $ 9,600.00 J:\LandDev\Form\SI\EngEst Page 1 of 1 ,r�F1717Hwst Avenue,C lifamia United Stalrs r f r , Ow W ARM M71151 . r i 1 ,.:....5 7�.-, � .az r:�»sv.:r.+R• s s'�• -„a'`-' a� x �- a.,.-.. 1 �� ie`_'.x-,. 7 H , "?1MR"R+"^ '"r ~+�ew".u:o ^i 4."as:. 'q? a'tr i " P a ,:r:. V.: r. c� \ Y .�4. ii: w t� r s �"�':`* 1 '`C^ t �h ` / * Vtt.'y","` n','_, k �:S,,F•4�a S y, s a7's - r � t f i a. � 5� � a, S"...r .�- r tom.. t t r. 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S+cT4 ' .. �FS'���'S�21i�1n -'�t�;� �11,� ry, 3t�,, 3 v -F•y1a * � � �ek��r �flT.wrx-x' ,�,�a7f t�r� '✓`�w ��r,�a �'�-��,r". ss IJ'ry.t t � IN T � _ 4.�•� 2 t F rf.i_ -N U } ,7�iq y try r 'W $'�i'f +��6'�$''^�*��U� t shy y'U }e��•e'(����`� 4�'S-� i aa�.�'q'� - �'3fiJ ..� � "r Y r'•J�o � -kri,� 4 .. �� � 9! i�� ^r � �ti sk ,�- d >y $ A r,,h1M^Ri.� .yM, w�1ntC •2.,.d{ SP� .� b �$a - rC ..]•. t1Y�a��� �,u%����`���'ay"'�a.�.�.��Su e +r.-N ye a .33 Y �5 ffil ;,. S 5'+f "�,�. n r�,%i e rt� tz�,,:•k'S'�.e fir+'-�z�`r n x i �F '.f'k, '+tNs'&c,1� rd�, fi �y' �'�r�' „fit �a•��" we r".r^*eY�'`.»,� st a sW'3^rr+r x 7."n3"c^ lf' t+`x ri x. ..a'f f r rah •*r�'1 yq+t.. `' �' s��� �� � � SAC l $�� mr"'•�•3;�'�i. �5�ep?.."Ty_�-' "na iy,+y'-,k tP Yf"�Y�'��,"�'�FFS�.t���� k,�.�' ; i i s+ �f fi i'[ tfii' [E C(-�s '1• �'', }.r -"�"T X � -1 `(i�" &b"c''v f-1� ! u, �r a,.��'� -�"r G ' v-i. ,y.��,� t,r�cr�, `� PERMIT APPLICATION PERMIT 5L-1'7 CITY OF CAMPBELL-BUILDING DIVISION DATE: Zj BUILDING ADDRESS: i -7 SOW JUN 2 0 2012 PERMIT TYPE: BUILDING ELECTRICAL PLUMBING jk MECHANICAI�--- DEMOLITION SIGN * GRADING OTHER DESCRIPTION OF WORK: (N)SFD RES.ADD REM (N) COMM. DEMO SIGNS VALUATION OWNER'S NAME: (._t�4 41,127 OL/ 7-05- PHONE#: /A. 71 ADDRESS: r 7 6'�'t K CITY: ZIP: APPLICANT'S NAME: PHONE#: ADDRESS: CITY: ZIP: CONTRACTOR'S NAME: e5wZO LICENSE# CONTACT PERSON: PHONE#: ADDRESS: CITY: ZIP: ARCHITECT/ENG NAME: CONTACT PERSON: PHONE#: ADDRESS: CITY: HAZARDOUS MATERIALS: USED ON SITE: YES NO STORED ON SITE: YES NO (For use or storage of hazardous materials,provide a HazMat Information Statement to the Fire Dept.Hazardous Materials Specialist for review and comment. "' FIRE SPRINKLE RED: YES NO API` 4 ld Development Information shf Prepared by: APN: 2 �Z 2 Date: P 2 9' 12 Address: 1"►07 ov rst A vz. Lot size:'N 7 (SF) If this project is part of a larger development(new subdivision, new townhomes) or commercial development, skip A through D. A. Existing building area(SF): 1003 B. Proposed addition area(SF): -7 S 76 C. Total area w/addition(A+B): j -7 51 D. Percent increase(B/A): (if less than 50%, stop research) Tract or Parcel Map (circle one): y o15 Date recorded: g~ 11 - 1 C N (Tract#or book&page) Any found records of Storm Drain Area fee previously paid? Yes ❑ (provide info below) Nog (Fee initiated for residential subdivisions 4 8/15/55; all developments 5/16/60) Date paid (file#&address or LID �� Storm Drain Area fee: , 1 V4 Xarea in acres) (fee/acre) Any found records of building permits in last five years?Yes[ (provide info below)No ❑ Was permit issued? Yes J�§(provide info below)No ❑ uP9ra de LC(-VrXCA r low Zoly-- 00750 Nature of Work: -Wl"- �vrn�(�i $ l�vLtS permit Number:d(_Q ;Z o/o -bb q L/3 Within STANP? Yes ❑ No)4 (check one) STANP Requirements: Curb ❑ Gutter❑ Sidewalk❑ Rolled curb ❑ None❑ NA9 Existing improvements present? Curb ❑ Gutter ❑ Sidewalk ❑ (check all that apply) Sidewalk dimension(BOW to FOW): l Park strip dimension(FOW to BOC): Driveway dimension(s): 'q D/W ADA compliant? Yes X No ❑ Street light info: JP� older pole galvanized pole ❑ Water meter and sewer cleanout info: Street ROW half width(CL to PL): aL 3 (� Date that street had been resurfaced: Electrical panel relocation? Yes ❑ No NA ❑ Provide details and attach pictures (8.5xl 1), assessors map (l lxl7) and aerial map (8.5 x 11.): J:\LandDev\Land Develop Information Sheets\AB Info sheet Template.doc AAA Northem Wifornitt A "BjQd UtahHomeowners Policy Declarations insurance Exchange. _.. PO 30a 22 1.UA.3-'ic A i 9o2 - :].1 See Important Notices on Reverse For question s ar Changes cell: I.M-922-8229 Renew4l Page 01 n, 01 �� � \, Membership Number Horneclwrlers Policy Number ._,� 'O'r'�a.i irk:•a�i a �s I•.ta I,,c nc�cras ..... .....................31 ...... ....... HO-WA-12-05-6, .. ................... V�\\ 1'f'I�tlltlE�fll�lll�I.,IrII�t Et!'EI'(ll„E„I�„f r�rlle( Pr'�f 12:0 i A,K Pacific 8tunoary Time.but rQt prior to the CHRISTIE DAVID CHRISTIE SHERI tirre applied for o",it this:s 1707 HURST.AVE 8,04 20, a replacement Ueclarat;otie. SA-N 1OSE CA 95121,5515 Your not oriorto the time otivarape P01ic chenfle was requested. y Period To $-04-2013 11:DlA.M. Paoific:Standard'rirne r it Premium to be paid by. Frimay Sooancory 1707 HURST AVE �am4, 408-204.3710 1 St Moftgagee X rf CAMPBELL CA 951-25 {r.Ain+.d Covbrgggg and Limits of Inriurance: Insuranc;a 1S pruv!dal 1Gr trier 101I0'rutrrq covetaf os only Oan o Nnif is ahown. The firnit rrf Iol tniv siwowr: (t avpragtj A C?v`refling' ry ilasFC oq ein e.1tM)atf. of tf)e GOSt to ratlu!ld ycur 1`10mr3,,rgluc 09 art ur'F.rroxir sots cost foe Iaber and mat§rla:S •n your er%l. artd 8pcclfic lift.r a'ien 'that you ria" providr d eba'ft your home. Section i tEltftction 11 Oth r Fers0n8f personaf Liability Medea Payments to OVers -1veF;x� Stturlurrns P caerty Loss of USP, EPerstrti:frqury 8 P-operty Darrega: Eaoh Occurrence Eacl,fytrsbr 1 Each Accldnrl; 400,200 5 ; 40,1C0 : gO,zOQ $, . $0,,1,0U $. i,Ut70000 $ 1,00C F 25;000 . .. section 1 Qnly' "Mr$(•t ttt,,r)1 Loverag+,Limits htrlu o4 er.r,'h:ingr->l to rP.ffect cnanyt;�in POOCOO <n+�lrLcf,on costs anO Cethi v rhnttv-,affecting replacement co5t5. '.".'."....... , ..• .... ':sf tNortga8a Lotin fop s2Ct{prl tf; Addlttona!riesloencK r'rttir.IsK�;i fir,IQ(xatQC:iNt.rTrtJar,Sheet.city,stBlrl A341$5140F3 and 141UrWaPO Loaf)No This policy dplos not provide ExrritpuMn Insurance. .. ......... . .............. Thin of%Gy-dues• ot.pravide,F'lood Insurancg: ft$r?.iiumrz . 0asic policy Prerni Jm 1,212.00 ^'Mft`::3nr! pz .7:hrS�rpE,.g d1',:•nN C`I.SSt1P. lameoirrers Pol'fty - spec;al form 31GOO Deductible Lendcr'S Oss P yAb'le RnrlorsemQnt• ,41,q BRjNS), Lilritep Home kep`la.ame:rt Cost mdcrsemer.t - 150% of Cav A (1f0-28;- tncl, FrNp'laceinenc value E•idDrsement persojRl property (HO-29), 200.00 $1000 Deductir'le (Ho-60,;, 34S,00 Sc:hed:,leu per50na1 Properly rlto••61), 0-1 ,ewe,"• L i rni C S 5 8,800 145.G'0 tM1urhe'r5' Co:1iPeri54t'ion & Ettployers' L'iab'ility - CA (Ii0-90). Pl'iv,ce aesldence Er,pTayers - [lrss U9'lp. Incl. 501..E;Mj C13(1A ViDgNde Limit 11.00,DSQ.4i] t]lseounts/ftnefiti Applied: i X'a n;r,E'.sg!a:Ala m TOka;policy Prernittrn r.....,,r•::va�rr 'F:[-•:.,,�;,c K f.zlt,.eo Vi t'L_i P'IRGO MNK NA I;AOA I>0 ai x 10051, N.,)RE,�,CE SC ,9S02 AtrloritaGc Renewal This pvllcy vill be.tenewad Prpf MpVr'gae Name A ernyr rna^ Mtg. Svc. 40. r,Ldprt,.abaally,1`10W�."Ver,11 our rulr=a K•rufilbit we will give You va it-e vi lien notice. Total Balance t 1 6.bu a GEICO GEICO GENERAL INSURANCE COMPANY / Washington DC VERIFICATION OF COVERAGE (SEE BELOW UNDER CAUTIONARY NOTE) INSURED Policy Number: 4220115986 Effective Date: 02-2 7-13 VINCENZO MARIO AND TIFFANY Expiration Date:08-27-13 ALICIA TACOMINI Registered State:CALIFORNIA 2015 TRUMAR IN GILROY, CA 95020-901 To whom it may concern: This letter is to verify that we have issued the policyholder coverage under the above policy number for the dates indicated in the effec- tive and expiration date fields for the vehicle listed. This should serve as proof that the below mentioned vehicle meats or exceeds the financial responsibility requirement for your state. This verification of coverage does not amend,extend or alter the coverage afforded by this policy. Vehicle Year: 2008 Make: FORD Model: F-250 VIN:IFTSW21R18ED81890 COVERAGES LIMITS DEDUCTIBLES BODILY INJURY LIABILITY $300,000/$500,000 - PROPERTY DAMAGE LIABILITY $100,000 UNINSURED &UNDERINSURED MOTORISTS $300,000/$500,000 COMPREHENSIVE $500 DED COLLISION $500 DED/WAIVER EMERGENCY ROAD SERVICE NON-DED RENTAL REIMBURSEMENT $50/DAY-$1500 MAX ,X_Lienholder _Additional Insured Interested Party UNKNOWN Additional Information: Issued 04/02/2013 If you have any additional questions,please call 1-800-841-3000. CAU17ONARYNOTE:THE CURRENT COVERAGES,LIMITS,AND DEDUCTIBLES MAYDWnR FROM THE COVERAGES,LIMITS,AND DEDUCTIBLES IN EFFECT AT OTHER TIMES DURING THE POLICYPERIOD.THIS VERIFICATION OF COVERAGE REFLECTS THE COVERAGES,LIMITS AND DEDUCTIBLES AS OF THE ISSUED DATE OF THIS DOCUMENT WHICH IS SHOWN UNDER"ADDITIONAL INFORMATION"OR IFAN ISSUED DATE IS NOT SHOWN,THE DATE OF TMS FACSMME. U-3310-07 IACOM-1 OP ID: EW CERTIFI;..�.-1TE OF LIABILITY INSL.`ANCE F DATE(MMID12YY) 08/21/ THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A state `.' this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). '11� CONTACT PRODUCER 916-630-8643 NAME: Powers and Company PHONE -- _ FAX Insurance Agents and Brokers 800-.783-0083�/yNo Ext: _�G (Alc,No): P. Box 6 E-MAIL ADDRESS:_ Roseville,CAA 95 95661-9043 — P_ �y. P_ - INS RLFWj,T14rFFsOf{DING COVERAGE NAIC# INSURER A:Financial Pacific Est 31453_ — INSURED lacomini Construction Co.Inc. INSURERS:Benchmark Insurance Co t01) 41394 2035 Trumer Lane --- - --- - Gilroy, CA 95020 wsuRERc:__ INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I ' ­ AEOL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A _X_ COMMERCIAL GENERAL LIABILITY X SCP5006798 08/23/11 08123/12. DAMAGE TO RENTED PREMISES Ea occurrence $ 100,000 CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 _G_EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 PRO- I POLICY T LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED F SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVE CST5002170 11/14/11 11/14/12 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N/A — (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Certificate holder is included as an Additional Insured under Commercial General Liability policy per endorsement BP0407 attached.—Subject to company approval.RE: carpentry work at 1707 Hurst Ave,Campbell,CA CERTIFICATE HOLDER CANCELLATION CITYOFC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of Campbell ACCORDANCE WITH THE POLICY PROVISIONS. 70 N. 1st Campbell, CA 95008 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD MEMORANDUM CITY OF CAMPBELL TO: Bill Bruckart,Building Official DATE: 07/12/2012 FROM: Roland Neufeld,Project Engineer (408) 866-2155 Ed Arango, Associate Engineer(408) 866-2166 SUBJECT: BUILDING PERMIT APPLICATION Site Address: 1707 Hurst Avenue For File No(s): 2012-00547 Project Description: Enlarge living room, add new master bed&bathroom suite Applicant: David Christie PUBLIC WORKS DEPARTMENT CONDITIONS OF APPROVAL 1. Plan Lines: Prior to issuance of any grading or building permits for the site, the applicant shall provide a plan layout showing the correct street dimensions (dimension widths of entire street and dimension fiom property line to centerline of roadway), and existing street improvement dimensions (sidewalk, curb, gutter, etc) and other relevant information in the public right of way. 2. Storm Drain Area Fee: Prior to issuance of any grading or building permits for the site, the applicant shall pay the required Storm Drain Area fee, currently set at $2,120 per net acre, which is $390.08 (set for R-1 land use). 3. Street Improvements: Prior to issuance of any.grading or building permits for the site, the applicant shall execute a street improvement agreement, cause plans for public street improvements to be prepared by a registered civil engineer, pay various fees and deposits, post security and provide insurance necessary to obtain an encroachment permit for construction of the standard public street improvements, as required by the City Engineer. The plans shall include the following, unless otherwise approved by the City Engineer: a. Show location of all existing utilities within the new and existing public right of way. b. Removal of existing damaged concrete, sidewalk, curb and gutter. c. Installation of City standard curb, gutter, sidewalk and ADA compliant driveway approach. d. Installation of asphalt concrete overlay per street pavement restoration plan for utility installation and/or abandonment, as required by the City Engineer. e. Installation of traffic control, stripes and signs. f. Construction of conforms to existing public and private improvements, as necessary. J:\LandDev\Conditions\Bldg\Hurst 1707.DOC Page 1 of 3 1707 Hurst Avenue 4. Utilities: All on-site utilities shall be installed underground per Section 21.18.140 of the Campbell Municipal Code for any new or remodeled buildings or additions. Applicant shall comply with all plan submittals, permitting, and fee requirements of the serving utility companies. 5. Water Meter(s) and Sewer Cleanout(s) Proposed water meter(s) and sewer cleanout(s) shall be relocated or installed on private property behind the public right-of-way line. 6. Utility Coordination Plan: Prior to issuance of building permits for the site, the applicant shall submit a utility coordination plan and schedule for approval by the City Engineer for installation and/or abandonment of all utilities. The plan shall clearly show the location and size of all existing utilities and the associated main lines; indicate which utilities and services are to remain; which utilities and services are to be abandoned, and where new utilities and services will be installed. Joint trenches for new utilities shall be used whenever possible. 7. Pavement Restoration: Based on the utility coordination plan, the applicant shall prepare a pavement restoration plan for approval by the City Engineer prior to any utility installation or abandonment. Streets that have been reconstructed or overlaid within the previous five years will require boring and jacking for all new utility installations. Hurst Avenue has not been reconstructed or overlaid in the last 5 years. The pavement restoration plan shall indicate how the street pavement shall be restored following the installation or abandonment of all utilities necessary for the project. 8. Utility Encroachment Permit: Separate permits for the installation of utilities to serve the development will be required (including water, sewer, gas, electric, etc.). Applicant shall apply for and pay all necessary fees for utility permits for sanitary sewer, gas, water, electric and all other utility work. 9. Additional Street Improvements: Should it be discovered after the approval process that new utility main lines, extra utility work or other work is required to service the development, and should those facilities or other work affect any public improvements, the City may add conditions to the developmeiit/proj ect/permit, at the discretion of the City Engineer, to restore pavement or other public improvements to the satisfaction of the City. 10. Stormwater Pollution Prevention Measures: Prior to issuance of any grading or building permits, the applicant shall comply with the National Pollution Discharge Elimination System (NPDES) permit requirements, Santa Clara Valley Water District requirements, and the Campbell Municipal Code regarding stormwater pollution prevention. The primary objectives are to improve the quality and reduce the quantity of stormwater runoff to the bay. Resources to achieve these objectives include Stormwater Best Management Practices Handbook for New Development and Redevelopment ("CA BMP Handbook") by the J:\LandDev\Conditions\Bldg\Hurst 1707.DOC Page 2 of 3 a . V 1707 Hurst Avenue California Stormwater Quality Association (CASQA), 2003; Start at the Source: A Design Guidance Manual for Stormwater Quality Protection ("Start at the Source") by the Bay Area Stormwater Management Agencies Association (BASMAA), 1999; and Using Site Design Techniques to Meet Development Standards for Stormwater Quality: A Companion Document to Start at the Source ("Using Site Design Techniques") by BASMAA, 2003. 11. Occupancy and Building Permit Final: Prior to allowing occupancy and/or final building pen-nit signoff for any and/or all buildings, the applicant shall have the required street improvements installed and accepted by the City, and the design engineer shall submit as- built drawings to the City. J:\LandDev\Conditions\Bldg\Hurst 1707.DOC Page 3 of 3 OFFICE OF C0L. fY ASSESSOR W S A N TA C L A R A COUP. � i' Y , CALIFORN IA � BOOK PAGE Cn 0 z 288 25 x p 3 LLJCr > } a >- w � I o pa W & 3 > p R.0.5. 45812 •w HVRST - r-' __;a - - - - - --- T�:Q' 776E /77/ �..._ AVE. 4 -O 4 N N 1647 1657 1667 1677 1687 _-6`9,7 .,, 1707 _1717 /767 R.O.S. 181-M-28 1779 1789 1803 1815 1831 M 4 3/ '206.68 55.04 59 1 59 1 59 1 59 1 59 59 59.1.:; �`59 59 -r,6.72 56.72 56.72 66.72 69 69 69 493E 67 /637 �? 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