ENC2017-00298 Encroachment Permit Final Sign Off
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Encroachment Permit# � ?
Address: Lt �
Date of Final Inspection and Acceptance:
2
Inspected by:
OK to release deposits:. 100% ✓ 75.%
Comments:
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•�kCHARO•
CITY OF CAMPBELL
Public Works Department
March 4, 2019
Ms. Sharon Korat
1421 Sharp Ave.
Campbell; CA 95008
SUBJECT: PERMIT NO. ENC 2017-00298
1421 Sharp Ave., Campbell, CA
FINAL INSPECTION AND ACCEPTANCE
Dear Sharon:
The City of Campbell has made the final inspection of the subject Public Works
improvements and finds that no remedial work is required.
Your warranty requirements and any surety,therefore, are hereby released.
Sincerely,
Syed Wahidi
Public works Inspector
70 North First Street Campbell, California 95008-1436 TEL 408.866.2150 • FAX 408.376.0958 TDD 408.866.2790
p4 C9'�!
�Al '�S+
. •0RCHABV
CI'I Y of C"PBELL
Public Works Department
February 27, 2018
Ms. Sharon Korat
1421 Sharp Ave.
Campbell, CA 95008
SUBJECT: PERMIT NO. ENC 2017-00298
1421 Sharp Ave.
FINAL INSPECTION AND ACCEPTANCE
Dear Sharon:
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 February 7, 2018. The
permittee is responsible for the repair and/or replacement of any defective work or
failures that occur within one year. The City will inspect the improvements within one
year and notify you, in writing, whether or not any repairs are required.
Your Faithful Security Deposit in the amount of$2,000.00 is enclosed.
If you have any questions,"please call me at(408) 866-21615.
Sincerely,
Syed Wahidi
Public Works Inspector
Cc: Inspector/Suspense Files
Permit File ENC2017-00298
70 North First Street • Campbell, California 95008-1436 TEL 408.866.2150 • FAx 408.376.0958 •TDB 408.866.2790
i' l I _...�.. -'
-- ------- ---- - - - ----- - -- - 11
CITY OF CAMPBELL I`\ VENDOR No. 100147911 CHECK No. 266651
101 2203 CR022218' 2,000.00 1421 SHARP AVE
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10014791 SHARON KORAT \
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11 CHECK DATE ' , CHECK NO j '
s W1~iTi3 FARGO HANK N A 24
42Q MONTaoMERx STREkT iaio 02�26�18 266651
F, t� PO NORTH FIRST STREET
~ � CA
" MPBEL# CALIFO"RNIA 95008 '
cs
FRANC 4
�. ,PAY THE SUM} OF TWb THOUSANA DOLLARS .& ZEFtp CENTS mil
To s TxE S HARONr KORAT
ORDER 1421 SHARP (A 4
IS
F1i CAMPBELL CA'' 95 0 08
ii■ 2666�5 ��I' ��: L 2 100� 248�:� �4 Lr2i8`'S 5�, 5i' ..
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jF *See Reverse Side For Easy Opening Instructions*
- I -- - ----------- - - ----- ------- --- ----- - - --
CITY OF CAMPBELL � I
1 70 NORTH FIRST STREET
CAMPBELL, CALIFORNIA 95008
I
i I t I
I
I � I
SHARON KORAT i-
1421 SHARP AVE.
i CAMPBELL CA 95008
I
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i
Refundable Deposit Check Request
To: Finance Director
Check Payable To: Sharon Korat
Address- Line 1: 1421 Sharp Ave.
Line 2:
I
City: Campbell State: CA Zip: 96008 E
i
Description: 1421 Sharp Ave.
Account Number: 101.2203 Amount: $2,000.00 I
Account Number: 101.2203 Amount:
I
Account Number: 101.640.7448 Amount: ;
(Finance Dept only) Interest Earned (Finance Dept only)
i
Total Payable: (Exact Amount) I
Purpose: Deposit Refund !
Permit M ENC2017-00298 1
Receipt M 272838 Date: 12/13/2017 +
Receipt M. Date:
Requested by`' Title: Inspector Date:
Syed Wahidi
Approved by: Title: Sr. Engineer Date2 fS 11
Roger Storz
Finance Dept On j
Verifi b Title: Accounting Clerk Date: !I
A ed by: Title: Accountant D e:
I
i
5 cial' Instructions For Handling Ch ck I
II AS IS: mail in Attacnea Envelope: interim uneCK
Needed By:
I
R turn To: JoAnna-Thomason Public Works
(Name) (Departmen
ther: Please return check to JoAnna
CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
CLEARANCE FOR FINAL INSPECTION
AND ACCEPTANCE LETTER
Encroachment Permit#: ENC 2017-00298
Name: Sharon Korat
Property Address: 1421 Sharp Ave., Campbell CA
Date of Final Inspection:
On File: Bonds CD Cash
Labor and Material:
Construction Cash Deposit to be released:
Faithful Security Deposit: 2,000.00
Other overdue deposits to be released (Description):
Emergency Cash Deposit:
Plan Check Deposit: $
Processed by: L (Z
A inistrator
Reviewed by: `7 T 3/6
Inspector
Reviewed by:
Land Development Engineer
J:\JoAnna'Meposit refunds\CHECKLISTS\Sharp 142 Ldoc(Rev. 10/11)
PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT
Effective July 1,2017
TO: Finance PUBLIC WORKS FILE NO. .��%, 20 7-GCS 2q
PROPERTY ADDRESS ` 21 SL( k2p
Please collect&receipt for the following monies:
ACCT ITEM e MOUNT:"
LA'Nb'DEVELOPMENT;:., _..: -
4722 1 Encroachment Permit Application Fee
Non-Utility Encroachment Permit Major>_$10 000 $425.00
Minor Encroachment Permit<sio,000 $240.00
Initial R-1 Permit N/C
Subsequent R-1 Permits within Two Year Period $240.00
Inspection Fee Minimum Charge per Location $420.00
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 $295.00
Site< 10 000 s.f. $885.00
Site>_ 10,000 s.f. <0.5 Acre $1,185.00
Site_>0.5 Acre $1 772.00
4722 NPDES Review C3 Requirements)
For protects not required to submit numeric sizing $175.00
For projects required to submit numeric sizing
Impervious Area 10,000 S . Ft to 1 Acre $740.00
Impervious Area 1 Acre or more $965.00
4722 For projects sent to Consultant for review Consultant Cost+20%
4722 Additional treatment facilities $315 ea
Plan Check& Inspection-Fee(Non-Utility)
4722 Enqr. Est. <$250 000 14%of Engineers Estimate
4722 Enqr. Est. >-$250,000 and s$500,000 $35 000.00+8%of Engineers Estimate
4722 En r. Est. >$5D0 000 $55 000.00+7%of Engineers Estimate
2203 Emergency Cash Deposit 4%of Enqr. Est.*($500 min/$10,000 Max
2203 Faithful Performance Security FPS 100%of ENGR. EST.*
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)
47221 Parcel Map(4 Lots or Less) $4,200.00+$90/1ot
47221 Final Tract Map(5 or More Lots) $5 115.00+$124/lot
2203 Monumentation Securitv 100% of Cit 's Monumentation Estimate
4920 Parkland Dedication Fee(75%/25% Due Upon Cert. of Occupancy)
4722 Lot Line Adjustment(Includes Certificate of Compliance) $1,990.00
4722 Vacation of Public Streets& Easements $2,700.00
4722 Certificate of Compliance $1,970.00
4722 Certificate of Correction $590.00
4722 Document Recording Fees $15.00/first page$3 ea.Additional
4722 Private Improvement in Public ROW $100.00
4722 Approved Plan Revision Fee $100/sheet
�4722 Appeal Filing Fee $200.00
Notice of Improvement Obligation Payment
Assessment Segregation or Reapportionment
First Split $940.00
Each Additional Lot $295.00
511.74241 Postage
MISCELLANEOUS' - -
Other(Please Specify) Liu T k:a?as ITUu
*Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL Gc,
NAME OF APPLICANT hay-a r-CL
NAME OF PAYOR ka trc o(-C,_+ PHONE go(7 -C
ADDRESS 14 Z k A Je- •'T" !ZIP 5o Ug
FOR RECEI, ED BY:_
CITY CLERK
ONLY Date Recei tZY
1
J'VORMS17-1a
Encroachment Permit Final Sign Off
Encroachment Permit# C
Address: 11f21 '5(,VW A\Jr
Date of Final Inspection and Acceptance: 2,17�'1�
Inspected by:
OK to release deposits: 100% V 75%
Comments:
f .
Print Form
CITY OF CAMPBELL R-1 ENCROACHMENT PERMIT Permit No. 'EN C'1017-0.-2JR
DEPT.OF PUBLIC WORKS (Non-engineered wort:within the public right-of-way) X-Ref File
70 North First Street ($10,000.00 maximum value of work) Application Date 2- 13 l
Campbell,CA 95008 Application Expiration I
Ph.(408)866-21.50 ISSUED: Z �3 17 Date G )3 I
Fx.(408)376-0958 Permit Expiration Date: 3 APN
APPLICATION-Application is hereby made fora 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: 1\1 1 /-�R(' CT
B. Nature of Work: C'G�S7rLUC t N. I" Lv\qA-( DWY AfP12cAC-kl
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: S Telephone: 9 G 3, 8 06 7
�'1 Q v G ti'1 o I^ P Ceti (�
Address: l l o..........
'r._. .
E-Mail.Address: Ko r6z L+1 Un @ Gt�idO� co I�
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
contractors)of the informati n.
ACCEPTED: ;'�CL�t. �'�- �d� ,� ' A3
(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 leasttwo days
before starting work. Notice must be given to Public Works at least 24 hours before restarting any work.
.Per Section 4216 of the Government Code this permit is not valid for excavations until Underground Service Alert(USA)has been notified and the
inquiry identification number(Ticket No.)has been entered hereon. USA Phone: 1-800-227-2600. Ticket No.:
Applicant is advised that upon issuance of this permit,property owner,or property owner's successors,shall be responsible for any and all
damages arising out of the design,installation or condition of private improvements in the public right-of-way.
SPECIAL PROVISIONS
1. Prior to any work,the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way,which shall be
recorded.
2. _ 1CL/A5"S C-8 Cl!WTfZ/-\cZ1.1?__ 56-rLL l7 el
3.
STANDARD AMOUNT RECEIPT NO.
SECURITY FOR FAITHFUL PERFORMANCE (100%Of Engr's Est.) $ 20co 2 72 e38_
R-1 PERMIT FEE P(� $
APPROVED FC R!SSUP,(!CE: -.-._.__._.`�. —� �I� �f` -7
for.City,Engineer Date
GENERAL PERROT CONDITIONS
1. Payment of a security to insure faithful performance and completion of the work is required. This security is refundable upon
completion of,the work and written acceptance by the City.
2. A one-year maintenance period for all work is required. Such period will begin on date of acceptance by the City. It is the applicant's
responsibility to remove and replace unacceptable improvements within the one-year maintenance period.
3. Refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City.
4. Submit project schedule 10 days prior to proposed start of work.Special provisions may be required for work within City facilities
and downtown Campbell.
5. The Permittee must request in writing a final inspection and acceptance of the work_upon completion. Acceptance by the City will be
made in writing to the Permittee.
6. Maintain safe pedestrian and vehicular crossings and free access to private driveways,fire hydrants and water valves.
7. Replace as directed by the City Engineer any damaged or removed improvements in accordance with City Standards and
Specifications at the sole expense of the Permittee.
8. Sawcut for all PCC and AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements.
9. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading as specified by the City
Engineer may result in the City s providing such signing and barricades and charging the cost to the Permittee.
10. The Contractor or Permittee will have a supervisory respresentative available for contact on the project at all times during
construction.
11. This permit shall be kept at the site of work and must be shown to any authorized representatives of the City of Campbell or any
law enforcement officer upon demand.
12. No storage of materials or equipment will be allowed near the edge of pavement,within the traveled way,or within the shoulderline,
which would create a hazardous condition to the public.
13. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other
work for which a separate permit may be required,nor does it relieve the Permittee of any obligation to obtain any other permit
required by law.
14. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other
public agency.
15. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon.
16. Prior approval of inspector is required for any work done after normal working hours,on weekends or holidays and may require
reimbursement of inspection costs at the current overtime rate.
17. Call back(call out)due to emergencies regarding this permit shall be at the current overtime rate with a three(3)hour minimum
charge per occurrence.
18. If the public interest requires a modification of,or a departure from,the plans and specifications,the City shall have the authority to
require or approve any modification or departure and to specify the manner in which the same is to be made for City-owned or
maintained facilities.
19. Pursuant to Chapter 14.02 of the Campbell Municipal Code,applicant shall not cause to be discharged any material into the
mi inirinal ctnrm drain cwgern ntho than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by
_.r......,.... I_._, rp..__.._shall _..-
the Santa Clara Valley Urban Runoff Pollution Prevention Program.
Applicant shall e responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above
conditions.
Ch.eh. -�j 6Z.�- /�• /�� moo/,
Appi/nt. Date
J:\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf
GENERAL PERROT CONDITIONS
1. Payment of a security to insure faithful performance and completion of the work is required. This security is refundable upon
completion of.the work and written acceptance by the City.
2. A one-year maintenance period for all work is required. Such period will begin on date of acceptance by the City. It is the applicant's
responsibility to remove and replace unacceptable improvements within the one-year maintenance period.
3. Refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City.
4. Submit project schedule 10 days prior to proposed start of work.Special provisions may be required for work within City facilities
and downtown Campbell.
5. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be
made in writing to the Permittee.
6. _ Maintain safe pedestrian and vehicular crossings and free access to private driveways,fire hydrants and water valves.
7. Replace as directed bythe City Engineer any damaged or removed improvements in accordance with City Standards and
Specifications at the sole expense of the Permittee:
8. Sawcut for all PCC and AC removals. All PCC removals shall be to,nearest scoremark and shall be doweled to existing improvements.
9. Adequate signing and barricading is required on thejob site. Failure to provide such signing and barricading as specified bythe City
Engineer may result in the City's providing such signing and barricades and charging the cost to the Permittee.
10. The Contractor or Permittee will have a supervisory respresentative available for contact on the project at all times during
construction.
11. This permit shall be kept at the site of work and must be shown to any authorised representatives of the City of Campbell or any
law enforcement officer upon demand.
12, No storage of materials or equipment will be allowed near the edge of pavement,within the traveled way,or within the shoulderline,
which would create a hazardous condition to the public.
13. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other
work for which a separate permit may be required,nor does it relieve the Permittee of any obligation to obtain any other permit
required by law.
14. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other
public agency.
15. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon.
16. Prior approval of inspector is required for any work done after normal working hours,on weekends or holidays and may require
reimbursement of inspection costs at the current overtime rate.
17. Call back(call out)due to emergencies regarding this permit shall be at the current overtime rate with a three(3)hour minimum
charge per occurrence.
18. If the public interest requires a modification of,or a departure from,the plans and specifications,the City shall have the authority to
require or approve any modification or departure and to specify the manner in which the same is to be made for City-owned or
maintained facilities.
19. Pursuant to Chapter 14.02 of the Campbell Municipal Code,applicant shall not cause to be discharged any material into the
njuni�iCnal ctnrm drain cyctn other than storm water. Arnpli�artt shall adhere to the REST MANAGEMENT PRArTlCES ect�hlished by
the Santa Clara Valley Urban Runoff Pollution Prevention Program.
Applicant shal e responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above
conditions. X
/G�ce-�.
Appl4nt_ Date
:\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf
APN: 414-33-043 REVISIONS BY
PLAN CHECK ZONED: R-1-6 " AV ___ _ __ �c 12-6-16 1
Q
T r m, c,Y 7�a� PLAN CHECK
LOT 512E. 10.M S.F. J% 1-9-17 Z02
CLRTNER z
EXISTING HOUSE 910 S.F. E s*'"�pp1' 3
20a CHANGE 31577
ADOMON: A�SF.
,$ H s LOS � "'�� n W A
aCHANGE 315-17
TOTAL HOUSE
[ENDA AY
NEW GARAGE 424 S.F. q�Lgbgi�" fa `�q ors o,F 0R�' cclRatE V!
NEW PORCHES: 354 S.F.
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LOT ON.ALLOWED: 10.M X.40=4209 S.F. =F a Fy WILLESTER AV AV
PROPOSED. 2,966=2Z8% •. c 6 cq9 MIA OR 2000 ¢ S
Q e o���
F.&F-ALLOWED•. 10,673X.45=4,802 S.F. REtlGtxc RN
PROPOSED. Z612=24.5% SELLEY AY E gg s .,ao t� CAdNE.N 6
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CT
i3YN a a.t�` " mi�E. PAR
TYPE OF CONSTRUCTION:VB s 3 �p1 ow m e
�o nw e 87
OCCUPANCY GROUP:K-3,U
THIS PROJECT SHALL COMPLY WITH 2O13 CBC,CRC,CMC,CPC,
LEG CFC,CAL GREEN,CAL ENERGY CODE,AND LOCAL ORD.
51TE DATA VICINITY MAP
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PLANNING FINAL REQUIRED. r �
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THE NEW LANDSCAPING/INDICATED ON� 1E PLAN W
MUST 6E IN5TALLED/I"RIOR TO FINAL IN 13ECTION. . W N
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SIDEWALK
MiyJ
SG� SIDEWALK
R MECHANICAL
SEPARATOR CONSTRUCTION
JOINT
SIDEWALK a WEAKENED
SEE NOTE 5 PLANE JOINT
OR CUT JOINT
SIDEWALK 0 API 1/8„DWIDE,
25
WEAKENED PLANE JOINT
OR CUT JOINT 1/8" WIDE,
2" DEEP 2�0
1
3/4
S=""
PER FOOT 5/8„ r 1„R
a.a..
1/2" R
R 9 —0"
(7' 0" MIN)
4'-6" 4'—6" 2'—0"
(3'-0" MIN) (4'-0" MIN)
6"
+10% MAX
SLOPE = 1/ 4" PER FT.
CONFORM
al iiii
—6� MAX
8 6" CLASS •A CONCRETE, TYP. ` ' :, 6"
6•' CLASS 2 AGGREGATE BASE, TYP. DOWEL �
NOTES SECTION A—A
1. WHEN THE DRIVEWAY IS NOT POURED AT THE SAME TIME AS THE CURB AND GUTTER, 12" OF NO. 4 REBAR AT 4'
INTERVALS SHALL BE INSTALLED AS SHOWN (REBARS TO BE BENT DOWN AND COVERED UNTIL USED).
2. SCORE MARKS SHALL NOT EXCEED 4'-0" O.C., AND USE MECHANICAL SEPARATOR AT EVERY OTHER SCORE MARK.
3. DRIVEWAY APPROACHES (EXCEPT SINGLE FAMILY) SHALL HAVE A 6"X6"X10/10 WELDED WIRE FABRIC 3" ABOVE
BOTTOM OF CONCRETE.
4• DOWEL ALL NEW CONCRETE IMPROVEMENTS TO EXISTING CONCRETE IMPROVEMENTS.
5. IN AREAS WHERE THE DISTANCE BETWEEN THE NEW AND EXISTING DRIVEWAYS IS LESS THAN 16 FEET FROM THE
BACK OF THE DRIVEWAYS, THE SIDEWALK SHALL NOT TRANSITION, THE SIDEWALK SHALL CONTINUE AT AN EQUAL
DISTANCE FROM THE FACE OF CURB TO THE PROPERTIES RIGHT OF WAY OR AS DETERMINED BY THE ENGINEER.
Ca CITY OF CAMPBELL REV. DATE BY SCALE:
°F kjD�� PUBLIC WORKS DEPARTMENT Retrofit Residential N.T.S.
°tea;a r DRAWN BY: ➢G DATE 1D/9/99
Driveway Attached DETAIL
°•D�°' CHECKED BY: DATE Sidewalk
NO.
APPROVED BY: ���1(�L%C� Sidewalk Detail y� D _ 1
�kCH ARC MICHELLE QUINWEY
CITY ENGINEER
AAA Northern California,
Nevada&Utah Homeowners Policy Declarations
Insurance Exchange
PO Box 22221,Oakland CA 94623-2221 See Important Notices on Reverse
For questions or changes call: 1-800-922-8228
Renewal Page 01 of 01
Membership Number Homeowners Policy Number
844-22-04-1 HO-37-46-93-0
Named Insured and Mailing Address
From E 12:01 A.M.Pacific Standard
Time,but not prior to the
KORAT EDUARD BENNO KORAT SHARON M E time applied for or,if this is
1421 SHARP AVE 6-14-2017 a replacement Declarations,
CAMPBELL CA 95008-6753 Your not prior to the time coverage
Policy change was requested.
Period To
6-14-2018 12:01 A.M. Pacific Standard Time.
s.
Alt: _408_341_5748 Premium to be .paid by: Primary, Secondary
Location 1421 SHARP AVE Home: 408-371-9748 Insured X
of CAMPBELL CA 95008-6753
Insured
Property For office 045 045 0 000 April 20,2017
use oNy
Coverages and Limits of Insurance: Insurance is provided for the following coverages only when a limit is shown. The limit
of liability for this structure (Coverage A-Dwelling) is based on an estimate of the cost to rebuild your home,including an
approximate cost for labor and materials in your area, and specific Information that you have provided about your home.
Section I Section 11
A B C D E F
Other Personal Personal Liability Medical Payments to Others
Dwelling Structures Property Loss of Use (Personal Injury&Property Damage)
Each Occurrence Each Person Each Accident
$ 308,300 $ 31,700 $ 231,300 $ 123 500 $ 1,000,000 $ 1,000 $ 25,000
Section I Only:
Your Section I Coverage Limits have been changed to reflect changes in PO0000
Construction costs and other matters affecting replacement costs. 1st Mortgage Loan No.
Section 11: Additional Residence Premises if any located:(Number,Street,City,State) 000030010852
2nd Mortgage Loan No.
3000971387
This policy does not provide Earthquake Insurance.
This policv does not provide Flood Insurance. Premiums
Basic Policy Premium 977.00
Forms and Endorsements made part of-this policy at time of issue.
Homeowners Policy - special form - $3000 Deductible (HO-3).
Name Change Endorsement (60 1000 12 13)
Lender's Loss Payable Endorsement (438 BFUNS).
Limited Home Replacement Cost Endorsement - 150% Of Cov A (HO-28). incl.
Replacement value Endorsement Personal Property (HO-29). 183.00
$3000 Deductible (HO-79). 386.00
Workers' Compensation & Employers' Liability - CA (HO-90).
Private Residence Employees - Class 0910. Incl.
Building Code Upgrade Limit - $77,075.00
Discounts/Benefits Applied: AAA Membership Total Policy Premium
Mortgage Servicing Company/Mortgagee Second Mortgagee $ 774.00
US BANK NATIONAL ASSOCIATION US BANK,NA
ISAOA INSURANCE CENTER
PO BOX 1551 PO BOX 200027
SPRINGFIELD OH 45501 KENNESAW GA 30156
Automatic Renewal This policy will be renewed
First Mortgagee Name if other than Mtg. Svc. Co. automatically;however,if our rules prohibit renewal,
we will give you advance written notice.
Total Balance $ 774.00
1075 0815 (Over)