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ENC2018-00045 ®V C4 U o U�tCHAR�• CITY ®F CAMPBE L Public Works Department April 10, 2019 Kerry Depold I I I I Bent Dr. Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2018-00045 1111 Bent Dr., Campbell, CA FINAL INSPECTION AND ACCEPTANCE Dear Kerry: 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 TEL 408.866.2150 • FAX 408.376.0958 TDD 408.866,2790 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2018-00045 Name: Kerry Depold Property Address: 1111 Bent Dr. Date of Final Inspection: On File: Bonds CD Cash Faithful Performance: $ A Labor and Material: $ Construction Cash Deposit to be released: $ Other overdue deposits to be released (Description): l300/0 �\eN.0 Ae Sy�� (A :� Processed by: G� A inistrator Reviewed by: Inspector Reviewed by: Land Development Engineer J:UoAnnaT\Deposit refunds\CHECKLISTS\l Checklist-Final Acceptance.doc(Rev. 10/11) Encroachment Permit Final Sign Off Encroachment Permit# Address: Date of Final Inspection and Acceptance: ! �� q Inspected by: w OK to release deposits: 100% 75% Comments: / 1 i OF C4, •CkCHAR4• . . . . CITY of CAMPBELL Public Works Department May 16,2018 Kerry Depold 1111 Bent Dr. Campbell, CA 95008 SUBJECT:_ PERMIT NO. ENC 2018-00045 1111 Bent Dr., Campbell, CA FINAL INSPECTION AND ACCEPTANCE Dear Kerry: . 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 April 23, 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) 866-2165. Sincerely, Syed Wahidi Public Works Inspector Cc: Inspector/Suspense Files Permit File ENC2018-00045 70 North First Street • Campbell, California 95008-1436 TEL 408.866.2150 FAX 408.376.0958 TDD 408.866.2790 01P Cg4A �� ..v., •CkCHAR�• '. CITY or CAMPBELL Public Works Department May 16,2018, Kerry Depold 1111 Bent Dr. Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2018-00045 1111 Bent Dr., Campbell, CA FINAL INSPECTION AND ACCEPTANCE Dear Kerry: 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'Apri123, 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) 866-2165. Sincerely; Syed Wahidi Public Works Inspector Cc: Inspector/Suspense Files Permit File ENC2018-00045 70 North First Street • Campbell, California 95008-1436 TEL 408.866.2150 .FAX 408.576.0958 TDD 408.866.2790 ..................................... ........................................ ..................... ........................... ......................................! ;. ..................................... .................................... ... ................. ---------- -- --- - ------- ----------- -------- -- CITY OF CAMPBELL VENDOR NO. 10014884 CHECK NO. 267780 ............ .......... 101 2203 CRO50418 2,000.00 ENC2018-00045 10014884 KERRY DEPOLD "4 CHECK' ATE, CHECK NO 'BANK, N A � 0,17GqMER� STREET 11 121014/ 2677&0 FIRST STREET 94104 CALIFORNIACALIFORNIA950 08 '0 Am6u&.T - F, v T -j,0;�D.AYS o iz, 'D THE SUM: OF "'M I PAY T TWO DOLLARS. ZERO -'CENTS E 70 E,�TH ,-.,,KERRY'.DEPOLD ORDER 1111 BENT. DR' .................. 51 CA, 9 0 81'."': CAMPBELL II 2'6 7 �44 2, 4 ....• ...... • •-------• --------------------------------------- . ......... . ...... .. . ........... ............. ...... ....................... .................................... .............. .................. .......... ............... ................................ ............................ .................................... *See Reverse Side For Easy Op6ning Instructions* - --------------------- ------ - ---- --- -------------- - -------------------------------------------- i CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 KERRY DEPOLD 1111 BENT DR. CAMPBELL CA 95008 Encroachment Permit Final Sign Off Encroachment Permit# C 2� i� -ooc LI . Address DP— Date of Final Inspection and Acceptance: Inspected by: Sties OK to release deposits: 100% ✓ 75% Comments.- !c, i Ref undi ible Deposit Check Request To: Finance�Dir..ector l 6heck'Payable To-- Kerry Depold Addres's- Line 1:, 1111,Bent Dr. Line 2: - City:, Campbell State: CA Zip: 950.08 Description. 411 Merit Dr./ENC2018-00045 i Account Number:- 101.2203 Amount: $2,000.00 Account Number: 101`.220.3' Amount: Account Number:- 101'.540.7448 Amount: (Finance Dept only) Interest Earned (Finance Dept only) I Total Payable: (Exact Amount) fl Purpose: FPS refund Permit ENC2018-00045 Receipt.#: 274:100+ 'Date: 317/2018 Receipt M. Date: I Requested,by: Title: Inspector, Date: 4fz4 i Syed Wahidi - Approved by: Title: Sr. Engineer Date: Ly2 '8 Roger Stori i Finance Dept Only: { Verified by: Title: Accounting Clerk II Date: Approved by. Title: Accountant Date: Special Instructions ,For .Handling. Check Mail AS'IS':, mall in Attacneci Envelope: interim unecK: Needed By: Return To': JoAnna Thomason Public Works. (Name) (Department) Other: Please return check to JOAnna CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2018-00045 Name: Kerry Depold Property Address: 1111 Bent Dr. Date of Final Inspection: On File: Bonds CD Cash Faithful Performance: $ 2,000.00 Labor and Material: $ Construction Cash Deposit to be released: $ Other overdue deposits to be released (Description): Processed by: Adn16 si Kator Reviewed by: Inspector `f - Reviewed by: VY� Land Development Engineer JAJoAnnaT\Deposit refunds\CHECKLISTS\Bent I I 1 l.doc(Rev. 10/11) rint Form CITY OF CAIU PBELL R 1 ENCROACHMENT P ERMT Permit No. T=N c ?o cc,c-IfS DEPT,OF PUBLIC WORKS (Non-engineered work within the public right-of-way) X-Ref File 70 North First Street ($10,000.00 maximum value of work) Application pate Campbell,CA95000 Application Expiration 0 d Ph.( )860-2150 ISSUED: 3 / i a _ Pate Fx.4400)3*6-0954 Permit Expiration Date: .317 -I - .. APN -J56 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 1111 Bent Drive,Campbell B. Nature of Work: Relocate driveway and driveway approach /A 131At-Dr-N 01 ) Y)WY ^P n9 , 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: Kerry Pepold Telephone: 081799.4432 Address; 1111 Beat Drive,Campbell E-Mail Address: depold@yahoo.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 Information. Xt�l ACCEPTED: �G1ta�v� (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 4216 of the Government Code this permit is not valid for excavations until Underground Service Alert(USA)has been noted and the inquiry identification number(Tickpt 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 this 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 tight-of-Way,which shall be recorded. tr+ lr?0yfa_(f-- 11u`P)2V1-M10J G;IL t�1�ti`ISi' i5 S+.r�Ncr) Cu (N�7f� P.V�s INTZ,011r�7 J STANDARD - AMOUNT RECEiPTNO. SECURITY FOR FAITIAFUL PERFORMANCE (10096 Of Enges Est.) s 200 C 2 74-1 G v ' R-1 PERMIT FEE $ APPROVED FpItISSUANCE: �� .. for City ngineer Date Permit Expires 6 Months after Date of Issuance. GaE# IRAL PERMIT C®NDMON5 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 wilt 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 scorernark 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 forcontact 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. iVo storage of materials or equipment will be allowed near the edge of pavement,within the traveled way,or within the shouiderline, 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. Gall back(call out)due to emergencies regarding this permit shall be at the current overtime rate with a three(3)hour minimum charge per occurrence. 18. If the public interest requires a modification of,or a departure from,the plans and specifications,the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made for City-owned or maintained facilities. 19. Pursuant to Chapter 14,02 of the Campbell Municipal Code,applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMERT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. Applicant shall be responsible for ensuring that 9 those providiricnervices,under the applicant are aware of and understand all of the above conditions. -� )L)tlwu�' 64, 11 Applicant Date J:\F,ORMS\Templates\Encroachment Permits\R-1 Encro'chment Permit STATIC form2,pdf Rev.OV14 1 Steve Benzing Architect _—_—_—_ PROPERTY LINE G-I'985 12403 Fredericksburg - PCP. w Y Saratoga callf0rnla EF,FROOM v2 BEDROOM vB LLYJN!@ FAMILY 510E— —S-D•I LOmI 40H Has 132E ' O r- SIDE� ail Stove®Berlxarchcom n-T•a. iD e.a-. F it.u e la e. - "Ipr:n WobsltO:l Ber:zare h�com i I VIEW AC I -- & e e ec KITCHEN - I METER w/New Do AMP PANEL Z J A NDR I xI5TN6 5 N6lP STORYcfl I } M-B;DROOM � _____ 3 I/2 BATH O I HbApSpR'iDe%MAR FIN FLR I a _ •,•Hove lel uiADe W a= •"' "" �i I INSTALL- VAARS ASI - oI ErEL L" CITY (L-G-VJ I � PROPOSED O a• °'I ADDITION 11� PQ1VJ� ®® EXISTING FLOOR PLAN I ' NORTH I 6ORA�bE� i ! i /k�i -►"'f2� I aCp V ® 0/•� IT RY SANA ___ __ _ I EXISTING FLOOR PLAN 6 V �-�I 517E PLAN w � I NE RIVENAY ____ _ I Addition® a It—tlom to residence at: ��OOO `� I I I IIII Eent Dr. �� I 1 I Campbell,CA I �.p� for: Y� ( 1C PROPERTY LINE'13.00' r _ Kerry 6 Joanne Depold 11i�� V 517E NOTES CLOSE IN(E) T80 Stirling Dr. 0& '^� GRI Y _i_ � Milpitas,GA 46,Il� P NEW DRIVEWAY WILL COMPLY WITH CAMPBELL M/NICIPAL CODE SECTION e 2UD.0 U1)WHICH STATES PARKINS SPACES AND MANEWJERINb AREA _ W DRIVEWAY APPROACH TO BE SHALL Be PAVED AND PERMANENTLY MAINTAINED WITH ASP-HALT, \, CONSTRUCT@ PER CITY D /{• � /�,$ ��e.yyy� CONCR@TE OR OTHER ALL-W@ATHER SVRPACIN6. B T D I C� V STD.DETAIL D-14.7 �� ® -/�'J• CAMPBPIL MJN(CIPAL CODE SECTION 21.76A30(B)REQUIRES PROM YARD AN @NCROACHMENT PERMIT PORM REVISIONS- d� Y TO BE LANDSCAPED 4 CMC 21.15,070 ATATE5 PAVINS CONNOT EXCEED THE PUBLIC WO-5 EDEPT.M T B@ 10�{Ury'15120�fi¢II{QASE 50%OP THE FRONT YARD. OBTAIN@D BEPOR@ MAKIN6 ANY Y DRIVE— LANDSCAPING WILL BQ INSTALLED TO R@FLAG@ THE @%ISTIN6 9/6/IT-PLAN CHECK T5MOM I TI'r 5 TO THERic DRIVEWAY NZA LANDS', To BeBE SHA.REMOVE O4 War •••VRI MA Y 4 SIINGDE ROPE BE PLACED IN THE AREA B@TYR@N THE NEW CUTS IN THE PUBLIC RISHT OF WAY RESPONSE � a `Ab Y- DRIVEWAY SIDE PROPERTY LINE SQUARE fb Y 4 2 FRONT YARD PAVED AREA- PROPOSED SITE P NORTH A,p PROW -457 of A{� FRONT WALK.NEW PATIO-911 If APN:288-06-03 SCALE I/B• I'-O• ®Q Of .••SWJAR@ RD POOTASE OF FRONT YA LANDSCAPED AREA- OWNER: ® 2240 MiNJS T65•14TT(65%) KERRY 6 NNE DEPOLD SIZE OF STRUCTURES. 780 ST N6 AVE EX15T'6 ADD PROPOSED MIL P 5,GA RESIDENCE q0® x n A N�iN G� Dwy FIRST FLOOR '75455 45'7 2192 date: 2/6/11 NOT (iYPJ®✓• �`�G7/� 'W ONIN6: REBI 6ARA6E 485 O 485 Scale: NOTED �• /� �^ USE: RESIDENTIAL RESIDENCE w/6ARAGE 2220 a5'7 26TI<3T93 ' r•`T-1'�4"�L.�� BUILT IN 1959 (E)FRONT PORCH 80 drawn by: SMB SIZE OF LOT: 6030 5f NEW FRONT PATIO I55 jab no. 1,700 MAX FA.R.: 45%=5613.5 If LOT COVERASE 291213212 ccNy-•msC7 Nt-:w L79-lV00j`f' MAX LOT GOVERA6E-.40=3212 sf sheet A- 0P 4 shts Date: 11/27/2017 To: KERRY DEPOLD 780 STIRLING DR MILPITAS, CA 95035-7505 CFR ITIMATE OF INSURANCE New Hampshire: This certificate is issued as a matter of information only and confers no rights upon the certificate holder. This certificate does not amend,extend,or after the coverage,terms, exclusions, and conditions afforded by the policy or policies referenced herein. All Other States: 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, terms,exclusions, conditions, or other provisions afforded by the policy referenced herein. In the event the policy is cancelled prior to the expiration date, notice will be delivered in accordance with the policy provisions. POLICYHOLDER: KERRY DEPOLD POLICY NUMBER: EFFECTIVE DATE: EXPIRATION DATE: 381-5000158612-01 12/01/2017 12/01/2018 ISSUED BY: Foremost Insurance Company Grand Rapids, (Michigan NAIC#11185 POLICY TYPE: UNIT COVERED(MH ONLY): SERIAL NUMBER(MH ONLY): Dwelling LOCATION ADDRESS: 1111 BENT DR, CAMPBELL, CA 95008-3603 ADDITIONAL INTEREST#1: LOAN NUMBER: ADDITIONAL INTEREST 92: LOAN NUMBER: Coverage Limit For Flood Verification-Check if applicable: Dwelling .......... $ $360,294 ❑ This document serves as verification that the policy listed includes the peril of flood. Liability: ❑ CPL ❑LL ® PL ❑CGL (TX).. $ $500,000 For Golf Cart Liability Verification: Medical Payments.......................... $ $500 All States: The referenced policy is not a motor Deductible: $5,000 vehicle liability policy and will not meet your state's financial responsibility laws for operation Total Annual Premium: $2,851.00 of a motor vehicle on public highways. North Carolina: Per the terms of the policy, golf cart liability coverage only applies if the golf cart is used for golfing. Texas: if the golf cart is used in connection with farming activities,there is no coverage per the terms of the policy. To obtain additional policy information,please contact: Agent Flame: JAMES HAWKINS INSURANCE AGENCY INC, FARMERS INSURANCE GROUP Telephone Number:800-528-6868 r Certificates issued LA Dept. of lns. Cert. of Ins. Assigned LDI No. Date fmm/yearl ouisiana: LDI COI N/A N/A 745144 04/11 PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1,2017 TO: Finance PUBLIC WORKS FILE NO. C_ C60 PROPERTY ADDRESS Please collect&receipt for the following monies: t 4722 1 Encroachment Permit AppliEdt—ion 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 2203 Plan Check Deposit 2%of Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 47221 Gradinq&Drainage Plan Review Single Family Lot $295.00 Site<10,000 s.f. $885.00 Site 10,000 s.f. <0.5 Acre $1,185.00 Site 0.5 Acre $1,772.00 4722 NPDES Review(C3 Requirements) For projects not required to submit numeric sizing $175.00 For projects required to submit numeric sizing Im ervious Area 10,000 Sq. Ft to I Acre $740.00 Impervious Area.I Acre or more $965.00 4722 For proffects sent to Consultant for review Consultant Cost+20% 4722 Additional treatment facilities $315 ea — Plan Check&Inspection Fee(Non-UtilitV) 4722 Engr. Est. <$250,000 .14%of Engineer's Estimate 4722 Enqr. Est. 2:$250,000 and 5$500,000 $35,000.00+8%of Engineers Estimate 4722 Enqr. Est. >$5D0,000 $55,000.00+7%of Engineers Estimate 2203 Efnergencv Cash Deposit 4%of Enqr. Est.*($500 min/$1 0,000 Max) 2203 Faithful Performance Security(FPS) 100%of ENGR. EST.* 2203 Labor and Materials SecuritV 100%of ENGR. EST.* 4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00 (Multi-Res$2,385.00) (All Other$2,650.00) 4722 Parcel Map(4 Lots or Less) $4,200.00+$90/lot 4722 Final Tract Map(5 or More Lots) $5,115.00+$124/lot 2203 Monumentation Security 100% of City'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 42 Approved Plan Revision Fee $1001sheet 4722 Appeal Filing Fee $200.00 730.4924 Notice of Improvement Obligation Payment 472-2 Assessment begregation or Reapportionment First Split $940.00 Each Additional Lot $295.00 511.7-424 Postage 7 t7 L _Other(Please Speci ) *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL 2--c 00 AME OF APPLICANT AME OF PAYOR ri u, PHONE 40q 72�1- tM2- ADDRESS ZIP IWAa) FOR 4, CITY CLERK ONLY `_P"CAMP, - LLi N Syed Wahidi From: Kerry Depold <kdepold@yahoo.com> Sent: Wednesday, February 28, 2018 1:06 PM To: Roger Storz; Syed Wahidi Cc: 'tom.mancuso@muktec.com';John Burchfiel;Tom Mancuso Subject: Re: 111 Bent Thanks Syed, I will be in touch with Roger about this. Regards,Kerry On Monday, February 26, 2018, 11:46:31 AM PST, Syed Wahidi <SyedW(a-cityofcampbell.com>wrote: Hi Kerry, We can issue you an R-1(no fee) permit fort his work. If you want to install pavers all the way to curb, then for encroaching it into public right of way, you will be required to sign an agreement called "Private improvement in Public Right of Way" and Roger can help preparing it. Permit requirements are: -1 permit application - Sketch (already submitted, I will fine tune it) - Private improvement agreement (Roger will help) - $2000 refundable security deposit - Copy of homeowner's insurance policy - Contractor shall possess C-8 license `- .OV CAS� Syed Wahidi V Public Works Inspector City of Campbell Public Works Department •��CHA�� 1 70 N. First Street I Campbell, CA 95008 www.cityofcampbell.com 1408.866.2165 From: Roger Storz Sent: Thursday, February 22, 2018 8:01 AM To: Kerry Depold; Syed Wahidi Subject: Re: Drawing for R-1 Encroachment Permit(1111 Bent Drive) Hi Kerry, Since we don't know if sidewalk will eventually be required in your neighborhood, there is no neighborhood plan exempting your street from sidewalks and sidewalk is the City Standard, you need to construct the driveway per the detail. You can install pavers between the driveway as shown in the detail and your garage, however the driveway as shown in the detail needs to be constructed with standard concrete. Syed can explain the specifics when you meet at your house. Regards, Roger Storz From: Kerry Depold <kdepoldCcD-yahoo.com> Sent: Wednesday, February 21, 2018 9:15 PM Subject: Re: RE: Drawing for R-1 Encroachment Permit(1111 Bent Drive) To: Roger Storz<rogers(acityofcampbell.com> Hi Roger, I was looking at the detail that you sent me, and I realized that there are two differences: 1) The street we live on used to be in the county and there are no sidewalks. 2)We are planning on using pavers for the driveway portion, instead of concrete. Is there a different detail that we reference on the permit drawing? One that more accurately reflects our situation? Thanks, Kerry Depold 2 k On Thursday, February 15, 2018, 9:38:26 AM PST, Roger Storz <rogers(Q-cityofcampbell.com>wrote: Good Morning Kerry, Yes, this plan with a couple of dimensions added will work fine. Please make sure to include the attached detail for the driveway. I would also suggest that you and your contractor contact our Public Works Inspector Syed Wahidi, 408-425-4704 cell, to review your proposed work in front of your house. Syed can explain to your contractor exactly what will be required and when your contractor should be calling for inspections. It's a little extra time at the beginning, but it really helps make sure everyone is on the same page and that we avoid any surprises. Regards, .0V*C4j40 Roger Storz, PE v Senior Civil Engineer City of Campbell Public Works Department �+CHARO' 70 N. First Street Campbell, CA 95008 www.cityofcampbell.com J 408.866.2190 From: Kerry Depold fmailto:kdepoldCaD-yahoo.coml Sent: Thursday, February 15, 2018 9:19 AM To: Roger Storz Subject: Drawing for R-1 Encroachment Permit Hi Roger, I am the owner of 1111 Bent Drive. I have a remodeling project underway that will require the relocation of the driveway. You had a brief look at this project when I applied for the building permit(The building department asked me to have you review the project before they would act on it). FYI the building permit number is BLD2017-00898. 3 I am preparing to submit the owner-occupied R-1 encroachment permit application, and have a question. about the drawing that needs to accompany it. Is the attached document, perhaps with some dimensions added, sufficient for this simple relocation of the curb cut? If not, what other information is required. Thanks, Kerry Depold 408/799-4432 Cell 4 Syed Wahidi From: Syed Wahidi Sent: Monday, February 26, 2018 11:46 AM To: Roger Storz; Kerry Depold Cc: 'tom.mancuso@muktec.com';John Burchfiel Subject: I 1 614 Bent rive Hi Kerry, We can issue you an R-1(no fee) permit fort his work. If you want to install pavers all the way to curb,then for encroaching it into public right of way,you will be required to sign an agreement called "Private improvement in Public Right of Way" and Roger can help preparing it. Permit requirements are: R-1 permit application Sketch (already submitted, I will fine tune it) Private improvement agreement(Roger will help) $2000 refundable security deposit Copy of homeowner's insurance policy Contractor shall possess C-8 license 0�•CA,$,�� Syed Wahidi Public Works Inspector U r City of Campbell I Public Works Department o o 70 N. First Street I Campbell,CA 95008 www.citvofcamnhell.com 1408,866,2165 •CRCHA1ti� From: Roger Storz Sent: Thursday, February 22, 2018 8:01 AM To: Kerry Depold; Syed Wahidi Subject: Re: Drawing for R-1 Encroachment Permit(1111 Bent Drive) Hi Kerry, Since we don't know if sidewalk will eventually be required in your neighborhood, there is no neighborhood plan exempting your street from sidewalks and sidewalk is the City Standard, you need to construct the driveway per the detail. You can install pavers between the driveway as shown in the detail and your garage, however the driveway as shown in the detail needs to be constructed with standard concrete. Syed can explain the specifics when you meet at your house. Regards, Roger Storz From: Kerry Depold <lcdepold yahoo.com> Sent: Wednesday, February 21, 2018 9:15 PM Subject: Re: RE: Drawing for R-1 Encroachment Permit (1111 Bent Drive) To: Roger Storz<rogers@cityofcampbell.com> Hi Roger, 1 t _ I was looking at the detail that you sent me, and I realized that there are two differences: 1) The street we live on used to be in the county and there are no sidewalks. 2) We are planning on using pavers for the driveway portion,instead of concrete. Is there a different detail that we reference on the permit drawing? One that more accurately reflects our situation? Thanks, Kerry Depold On Thursday, February 15, 2018, 9:38:26 AM PST, Roger Storz <ro ers cityofcampbell.com>wrote: Good Morning Kerry, Yes, this plan with a couple of dimensions added will work fine. Please make sure to include the attached detail for the driveway. I would also suggest that you and your contractor contact our Public Works Inspector Syed Wahidi, 408-425-4704 cell, to review your proposed work in front of your house. Syed can explain to your contractor exactly what will be required and when your contractor should be calling for inspections. It's a little extra time at the beginning, but it really helps make sure everyone is on the same page and that we avoid any surprises. Regards, .,av-CA`,t,,,, Roger Storz, PE �c Senior Civil Engineer 0 City of Campbell I Public Works Department xOkc liA4�� 70 N. First Street I Campbell, CA 95008 www.cityofcampbell.com 1408.866.2190 From: Kerry Depold [mailto:kdepold(c)-yahoo.com] Sent: Thursday, February 15, 2018 9:19 AM To: Roger Storz Subject: Drawing for R-1 Encroachment Permit 2 Hi Roger, I am the owner of 1111 Bent Drive. I have a remodeling project underway that will require the relocation of the driveway. You had a brief look at this project when I applied for the building permit(The building department asked me to have you review the project before they would act on it). FYI the building permit number is BLD2017-00898. I am preparing to submit the owner-occupied R-1 encroachment permit application, and have a question. about the drawing that needs to accompany it. Is the attached document, perhaps with some dimensions added, sufficient for this simple relocation of the curb cut? If not, what other information is required. Thanks, Kerry Depold 408/799-4432 Cell 3 Syed Wahidi From: Roger Storz Sent: Thursday, February 22, 2018 8:01 AM To: Kerry Depold; Syed Wahidi Subject: Re: Drawing for R-1 Encroachment Permit (1111 Bent Drive) Hi Kerry, Since we don't know if sidewalk will eventually be required in your neighborhood, there is no neighborhood plan exempting your street from sidewalks and sidewalk is the City Standard, you need to construct the driveway per the detail. You can install pavers between the driveway as shown in the detail and your garage, however the driveway as shown in the detail needs to be constructed with standard concrete. Syed can explain the specifics when you meet at your house. Regards, Roger Storz From: Kerry Depold <kdepo�,yahoo.com> Sent: Wednesday, February 21, 2018 9:15 PM Subject: Re: RE: Drawing for R-1 Encroachment Permit(1111 Bent Drive) To: Roger Storz<ro ers@cit oy fcampbell.com> Hi Roger, I was looking at the detail that you sent me, and I realized that there are two differences: 1) The street we live on used to be in the county and there are no sidewalks. 2) We are planning on using pavers for the driveway portion,instead of concrete. Is there a different detail that we reference on the permit drawing? One that more accurately reflects our situation? Thanks, Kerry Depold On Thursday, February 15, 2018, 9:38:26 AM PST, Roger Storz <rogers ancityofcampbell.com>wrote: Good Morning Kerry, Yes, this plan with a couple of dimensions added will work fine. Please make sure to include the attached detail for the driveway. I would also suggest that you and your contractor contact our Public Works Inspector Syed Wahidi, 408-425-4704 cell, to review your proposed work in front of your house. Syed can explain to your contractor exactly what will be required and when your contractor should be calling for inspections. It's a little extra time at the beginning, but it really helps make sure everyone is on the same page and that we avoid any surprises. i v -- Regards, ov•C° 1ti Roger Storz, PE A eta Senior Civil Engineer e 0 City Public Works Department A ,. Y of Campbell p � p o*ce+x0-" 70 N. First Street Campbell, CA 95008 www.cityofcampbell.com 1408.866.2190 From: Kerry Depold [mailto:kdepold(a-yahoo.com] Sent: Thursday, February 15, 2018 9:19 AM To: Roger Storz Subject: Drawing for R-1 Encroachment Permit Hi Roger, I am the owner of 1111 Bent Drive. I have a remodeling project underway that will require the relocation of the driveway. You had a brief look at this project when I applied for the building permit (The building department asked me to have you review the project before they would act on it). FYI the building permit number is BLD2017-00898. I am preparing to submit the owner-occupied R-1 encroachment permit application, and have a question. about the drawing that needs to accompany it. Is the attached document, perhaps with some dimensions added, sufficient for this simple relocation of the curb cut? If not, what other information is required. Thanks, Kerry Depold 408/799-4432 Cell 2 r' i s 1 i n Syed Wahidi From: Roger Storz Sent: Friday, March 02, 2018 10:56 AM To: 'Kerry Depold'; Syed Wahidi Cc: 'tom.mancuso@muktec.com';John Burchfiel;Tom Mancuso Subject: RE 1111 'Bent K'"Iw Attachments: Bent 111 .pdf Hi Kerry, As we discussed on the phone, please find attached an Agreement for Private Improvements in the Public Right-of-Way for you and your Wife to sign and have your signatures notarized. Please return the signed and notarized original document to me or Syed for us to complete the issuance of your encroachment permit. I went ahead and assigned an Encroachment Permit Number of ENC2018-00045 to facilitate the preparation of this agreement. Here is a link to our encroachment permit application form that still needs to be filled out and submitted to Syed: http://www.ci.campbell.ca.us/DocumentCenter/View/401 " Regards, Roger From: Kerry Depold [mailto:kdepold@yahoo.com] Sent: Wednesday, February 28, 2018 1:06 PM To: Roger Storz; Syed Wahidi Cc: 'tom.mancuso@muktec.com'; John Burchfiel; Tom Mancuso Subject: Re: 1111 Bent Drive Thanks Syed, I will be in touch with Roger about this. Regards,Kerry On Monday, February 26, 2018, 11:46:31 AM PST, Syed Wahidi <SvedW cityofcampbell.com>wrote: Hi Kerry, We can issue you an R-1(no fee) permit fort his work. If you want to install pavers all the way to curb, then for encroaching it into public right of way, you will be required to sign an agreement called "Private improvement in Public Right of Way" and Roger can help preparing it. Permit requirements are: R-1 permit application i G - Sketch (already submitted, I will fine tune it) Private improvement agreement (Roger will help) $2000 refundable security deposit Copy of homeowner's insurance policy Contractor shall possess C-8 license CAA Syed Wahidi Public Works Inspector e0 City of Campbell I Public Works Department " c,r4nti' 70 N, First Street I Campbell, CA 95008 www.cityofcampbell.com 1408.866.2165 From: Roger Storz Sent: Thursday, February 22, 2018 8:01 AM To: Kerry Depold; Syed Wahidi Subject: Re: Drawing for R-1 Encroachment Permit(1111 Bent Drive) Hi Kerry, Since we don't know if sidewalk will eventually be.required in your neighborhood, there is no neighborhood plan exempting your street from sidewalks and sidewalk is the City Standard, you need to construct the driveway per the detail. You can install pavers between the driveway as shown in the detail and your garage, however the driveway as shown in the detail needs to be constructed with standard concrete. Syed can explain the specifics when you meet at your house. Regards, Roger Storz From: Kerry Depold <kdepold yahoo.com> Sent: Wednesday, February 21, 2018 9:15 PM Subject: Re: RE: Drawing for R-1 Encroachment Permit(1111 Bent Drive) To: Roger Storz <rogers(@cityofcamgbell.com> Hi Roger, 2 I was looking at the detail that you sent me, and I realized that there are two differences: 1) The street we live on used to be in the county and there are no sidewalks. 2)We are planning on using pavers for the driveway portion, instead of concrete. Is there a different detail that we reference on the permit drawing? One that more accurately reflects our situation? Thanks, Kerry Depold On Thursday, February 15, 2018, 9:38:26 AM PST, Roger Storz <rogersfa cityofcampbell.com>wrote: Good Morning Kerry, - Yes, this plan with a couple of dimensions added will work fine. Please make sure to include the attached detail for the driveway. I would also suggest that you and your contractor contact our Public Works Inspector Syed Wahidi, 408-425-4704 cell, to review your proposed work in front of your house. Syed can explain to your contractor exactly what will be required and when your contractor should be calling for inspections. It's a little extra time at the beginning, but it really helps make sure everyone is on the same page and that we avoid any surprises. Regards, .jV-C"tAjt, Roger Storz, PE 11114 046 'Senior Civil Engineer 0 0 City of Campbell Public Works Department , . 70 N. First Street Campbell, CA 95008 www.citvofcampbell.com 1408.866.2190 3 From: Kerry Depold [mailto:kdepold(Qyahoo.com] Sent: Thursday, February 15, 2018 9:19 AM To: Roger Storz Subject: Drawing for R-1 Encroachment Permit Hi Roger, I am the owner of 1111 Bent Drive. I have a remodeling project underway that will require the relocation of the driveway. You had a brief look at this project when I applied for the building permit(The building department asked me to have you review the project before they would act on it). FYI the building permit number is BLD2017-00898. I am preparing to submit the owner-occupied R-1 encroachment permit application, and have a question. about the drawing that needs to accompany it. Is the attached document, perhaps with some dimensions added, sufficient for this simple relocation of the curb cut? If not, what other information is required. Thanks, Kerry Depold 408/799-4432 Cell 4 TO BE RECORDED WITHOUT FEE 23335909 SECTION 6103 GOVERNMENT CODE Regina A 1 comendras AT THE REQUEST OF CITY OF CAMPBELL Santa Clara Count yy - Clerk-Recorder 03/13/2018 08:11 AM Recording Requested By: ) CONFORMED COPY Citof Campbell Copy of document recorded. y P ) Has not been compared with original. 70 North First Street ) Campbell, CA 95008-1423 ) After Recording Return To: ) City Clerk ) City of Campbell ) 70 North First Street ) Campbell, CA 9.5008-1423 ) APN: 288-06-035 (Space Above for Recorder's Use Only) Address:1111 Bent Drive,Campbell,CA 95008 AGREEMENT FOR PRIVATE IMPROVEMENTS . IN THE PUBLIC RIGHT-OF-WAY In consideration for granting permission to construct improvements in the public right-of-way, Kerry M. Depold and Joanne Depold, husband and wife, as community property with right of survivorship (property owner) enters into this Agreement with the City of Campbell. The improvements contemplated under this permit are for the benefit of that certain real property described in the Grant Deed recorded on September 26, 2016, Document number 23441907, recorded in the Office of the County Recorder, County of Santa Clara, State of California, and commonly known as 1111 Bent Drive, Campbell, CA. The City of Campbell grants such permission to install non-standard.driveway improvements under Encroachment Permit No. 2018-00045. All conditions of Encroachment Permit No. 2018-00045 remain in full force and effect. The property owner shall be solely responsible for maintaining the improvements in a good and safe condition at all times; and the property owner shall indemnify, defend, and hold harmless the City of Campbell, its officers, officials, agents, volunteers, employees and attorneys from any and all claims, actions, losses, liabilities and costs. (including reasonably incurred attorney's fees) arising out of or connected with, or alleged to arise out of or be connected with the installation, design or condition of the improvements, except for any claims, actions, losses, liabilities and costs proximately caused by the sole negligence or willful misconduct of the City of Campbell, its officers, officials, agents, volunteers, employees or attorneys. This provision is intended to be the disl ositive of all rights of indemnity and contribution between the parties, and property owner waives and releases any and all rights to indemnity or contribution from the City of Campbell, in law or equity, arising out of, or connected with any and all. claims, actions, losses, liabilities and costs (including reasonably incurred attorney's fees) for which property owner is obligated under this paragraph to provide indemnity or defense to the City of Campbell, its officers, officials, volunteers, employees or attorneys. The City, in its sole discretion, may revoke the rights granted under Encroachment Permit No. ENC2018-00045 and remove the improvements installed under Encroachment Permit No. ENC2018- 00045 at any time, without liability to the property owner, or require that the improvements be removed, and property owner shall have no right to compensation from City,in any form. In the event that Owner fails to reimburse the City for the costs of removing the improvement ("default") as required by this Agreement, the City shall have and may execute the absolute right, at the City's option and without demand or notice to Owner, to claim and impose a lien, attached.as Exhibit A and incorporated herein by this reference ("Lien"), on said real property (also referred to herein as "Collateral"). City's failure to exercise this option will not constitute a waiver of the right to exercise it in the event of any subsequent default. (a) Amount of Lien: The Lien shall be for the entire amounts then owing under this Agreement. (b) Recordation: City is authorized to record the Lien in the appropriate Recorder's Offce(s). (c) City shall have full authority to perforn all acts and things that City may consider necessary or advisable to impose, maintain and enforce the Lien, (d) Debtors' Warranty: OWNERS WARRAN T that they are the owners of the Collateral and Owners have the right to make this Lien Agreement. (e) Debtors Covenants: Owners agree: q - (i) To pay City all amounts payable pursuant to this Agreement on or before the due date-when due and payable, and to perform all terms of this Agreement; (ii) To defend the Collateral against claims and demands of all persons and entities; (iii) To keep the Collateral in good condition; to perform other acts that may be necessary to preserve the Collateral and protect the Collateral against unreasonable loss and all hazards, and; (iv) To immediately notify the City in writing when Owners.become aware of any event that substantially affects the value of the Collateral, or the rights and remedies of City in relation to the Collateral. (f) Prohibitions: Without the prior written consent of the City, Owners will not permit any liens or security interests (other than the City's Lien) to attach to the Collateral; permit the Collateral to be levied on under legal .process; dispose of the Collateral; or permit anything to be done that may impair the value of the Collateral or of the Lien, which is the.subject of this Agreement. (g) Notices: Any notice, demand or request required hereunder, or by law, shall be given in writing(at the addresses set forth below) by any of the following means: (a) personal service; (b) facsimile; (c) overnight courier or delivery service; or (d) registered or certified, first class U.S. mail, return receipt requested. J:\LandDev\Forms\2.AGREEMENTS-PIA SIA DEF SIA Maintenance Reimbursement DevelopmentTrivate Improvements Agreements in ROW'".Word Document\Bent I I I l.docx Page 2 of 5 Property owner agrees to maintain homeowners or general liability insurance with a limit of at least$100,000 for damages arising from the installation, design or condition,of the improvements. This provision shall run with the land and be binding on the property owner's successors. Executed this day of 2018. Kerry M. Depold and Joanne Depold, husband and wife, as community property with right of survivorship I erry . Depold J nne Depold (Attach Notary Acknowledgment For All Parties) CITY OF CAMPBELL, 'a municipal Corporation Todd Capurso Public Works Director, City of Campbell ATTEST: Wendy o d, City Clerk J:\LandDev\Forms\2.AGREEMENTS-PIA SIA DEF SIA Maintenance Reimbursement Development\Private improvements Agreements in ROW\Word Document\Bent 111 l.doex Page J of 5 t� 1 CALIFORNIA ALL"- PURPOSE CERTIFICATE OF ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California . } County of SPA ,ra C\Xn,-N } On VwLL, 5, "Die before me, Rtz�4,V=0 COOM, tv��c ere insert ti name and e o e o cer personally appeared kbIVCr M. !moo y�-P0,D who proved to me on the basis of satisfactory evidence to be the person(ewhose name@)is/@�D subscribed to the within instrument and acknowledged to me that he/she/t egexecuted the same in his/her/ el authorized capacity le ), and that by his/her/tt -signatureQ on the instrument the persor(D, or the entity upon behalf of which the persorcted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNES y ha d official seal. FERNANDOCROCE Notary Public—California Santa Clara County Commisslcn 9 2223476 _ My Comm.Expires Dac 24,2021 Notary Public Signature (Notary Public Seal) 0 ADDITIONAL OPTIONAL INFORMATION INSTRUCTIONS FOR COMPLETING THIS FORM Thisform complies with current California statutes regarding notary wording and, DESCRIPTION OF THE ATTACHED DOCUMENT ifneedecl should be completed and attached to the document.Acknowledgments from other states may be completed.for documents being-sent to that state so long as the wording does not require the California notary to violate California notary law. (Ttle or description of attached document) • State and County information must be the State and County where the document signer(s)personally appeared before the notary public for acknowledgment. • Date of notarization must be the date that the signer(s)personally appeared which (Title or description of attached document continued) must also be the same date the acknowledgment is completed. • The notary public must print his or her name as it appears within his or her Number of Pages Document Date commission followed by a comma and then your title(notary public). • Print the name(s) of document signer(s)who personally appear at the time of notarization. CAPACITY CLAIMED BY THE SIGNER • Indicate the correct singular or plural forms by crossing off incorrect forms(i.e. he/she/the} is/are)or circling-the correct forms.Failure to correctly indicate this ❑ Individual (S) information may lead to rejection of document recording. ❑ Corporate Officer e The notary seal impression must be clear and photographically reproducible. Impression must not cover text or lines.If seal impression smudges,re-seal if a (Title) sufficient area permits,otherwise complete a different acknowledgment form. • Signature of the notary public must match the signature on file with the office of El Partner(S) the county clerk. ❑ Attorney-in-Fact Additional information is not required but could help to ensure this ❑ Trustee(s) acknowledgment is not misused or attached to a different document. Other Indicate title or type of attached document,number ofpages and date. ❑ Indicate the capacity claimed by the signer.If the claimed capacity is a corporate officer,indicate the title(i.e.CEO,CFO,Secretary). 2ol 5`:'e,siem. Securely attach this document to the signed document with a staple. CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§1189 A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is-attached,and not the truthfulness,accuracy,or validity of that document. State of Calif rniaUyarCounty of ) On: c- before me, &�, �a Date . Here Insert Name and Title of t e Officer personally appeared Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the erson4 whose name(4 dAre subscribed to the within instrument and acknowl ged to me that e/ /t* executed the same in is /thfeir authorized capacity(i ),and that.by i� '/the.Wsignature on-the instrument the person or the entity upon behalf of which the person(%acted, executed the instrument. certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. -ANOREA SANDERS, Commission#t 2078910 z -p Notary.Pubiic California Z Signature . � z Santa Clara_County Sign a of Notary Public M Comm:i:x`ires'A 1T2018 Place Notary Seal Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document:�ri i ti i &03 Document Date: ,3�$$� zi Number of Pages: Signer(s) 6ther Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: Signer's Name: ❑Corporate Officer — Title(s): ❑Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑General ❑ Partner — ❑ Limited ❑General ❑ Individual ❑Attorney in Fact ❑ Individual El Attorney in Fact ❑Trustee ❑Guardian or Conservator ❑Trustee ❑Guardian or Conservator ❑ Other: ❑ Other: Signer Is Representing: Signer Is Representing: 02014 National Notary Association •www.NationaiNotary.org • 1-800-US NOTARY(1-800-876-6827) Item#5907 Exhibit A Recording Requested By: ) City of Campbell ) When Recorded Mail To: ) City Cleric ) City of Campbell ) 70 N. First Street ) Campbell,'CA 95008 ) APN: Space above this line for Recorder's use only Address: CLAIM OF LIEN I, Todd Capurso,.Public Works Director for the City of Campbell, a California Municipal Corporation ("City"), do hefeby certify: A. On or about 20_, ("Debtors") executed an Agreement for Private Improvement with the City of Campbell ("Agreement"). B. The Agreement was recorded in the Santa Clara County Recorder's.Office on or about 20_Document Number C. The Agreement allowed the Debtor's to provide, construct, and/or install certain private improvements in front of their property at Campbell, California, at their own costs and expense. Pursuant to the terms of the Agreement, the Debtors expressly agreed that-if they failed to comply the work the Agreement, the City was authorized to remove said improvements and recover the full cost and expense thereof from the Debtors or their successors. D. The Debtors did not remove the improvements after being notified to do so. Therefore, the City removed said improvements. E. In , 20 , the City informed the Debtors about the improvements that would be removed pursuant to the Agreement. F. The City subsequently completed the work. On or about 20_, the City sent the Debtors an invoice for said work in the amount of$ 7:\LandDev\Forms\2.AGREEMENTS-PIA SIA DEF SIA Maintenance Reimbursement Development\Private Improvements Agreements in ROW\Word Document\Bent I I I I.doex Page 4 of 5 G. Pursuant to the terms of the Agreement, the Debtors expressly agreed that the City is authorized to, at the City's option and without demand or notice to the Debtors, immediately claim and impose a lien on the real property commonly known as , Campbell, California, APN Number , 'for the entire amounts then owing under, or incurred pursuant to,the Agreement, including without limitation, the entire unpaid principal amount. WHEREFORE, the City of Campbell, A California municipal corporation, pursuant to the Agreement, hereby claims a lien upon the work of improvement and the land upon which it is situated, namely, the real .property commonly known as Campbell, California, APN Number in the amount of $ and said amount shall constitute a lien against said property until paid in full. IN WITNESS WHEREOF the City of Campbell, California, a California Municipal Corporation, has duly authorized the undersigned to execute this instrument in its name. Dated: By: for the CITY OF CAMPBELL, a California municipal corporation (Notary Acknowledgement Required for Signatures) J:\LandDev\Forms\2.AGREEMENTS-PIA SIA DEF SIA Maintenance Reimbursement Development\Private Improvements Agreements in ROW"..Word Document\Bent I I I I.docx Page 5 of 5