ENC2018-00087 &Z. ®kCAIl
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CITY ®F CAMPBELL
Public Works Department
July 1, 2019
Mr. Tom Hernandez
2217 Central Park Dr.
Campbell, CA 95008
SUBJECT: PERMIT NO. ENC 2018-00087
2217 Central Park Dr., Campbell, CA
FINAL INSPECTION AND ACCEPTANCE
Dear Tom:
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 ONE YEAR MAINTENANCE
ACCEPTANCE LETTER
Encroachment Permit # ENC2018-00087
Property Address 2217 Central Park Dr.
Date of Final Inspection: 6/18/19
On File: Bonds CD Cash
Faithful Performance Labor and Material $
Construction ZDeb released: $
Other overdleased (Description):
Processed by:
Ad finis for
Reviewed by:.
ector
Reviewed by:
Land Development Engineer
J:UoAnnaT\Deposit refunds\CHECKLISTS\Central Park2216.doe(Rev. 10/11)
Encroachment Permit Final Sign Off
Encroachment Permit#
Address: `22-t 7 Q,,ub ----L r�✓I� -. 'j�V
Date of Final Inspection and Acceptance:
Inspected by: <S'yj
OK to release deposits: 100% v 75%
Comments:
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•CkCHARO•
CITY OF CAMPBELL
Public Works Department
June 18, 2018
Mr. Tom Hernandez
2217 Central Park Dr. 'rf ,
Campbell, CA-95008
SUBJECT: PERMIT NO. -ENC 2018-00087
2217 Central:Park Dr.,Campbell, CA
FINAL INSPECTION AND ACCEPTANCE
Dear Tom:
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 June 18, 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.
If you have any questions, please call me at(408) 866-2165.
Sincerely,
Syed Wahidi
Public Works Inspector
Cc: Inspector/Suspense Files6
Permit File ENC2018-00087
70 North First Street • Campbell, California 95008-1436 TEL 408.866.2150 • FAX 408..376.0958 TDD 408.866.2790
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Print Form
CITY OF CAMPBELL R-1 ENCROACHMENT PERMIT Permit No.
DEPT.OF PUBLIC WORKS X-Ref File
(Non-engineered work within the public right-of--way)
70 North First Street ($10,000.00 maximum value of work) Application Date i t
Campbell,CA 95008 / Application Expiration
Ph.(408)866-2150 ISSUED: 11
/ (e Date 0IJ /y
Fx.(408)376-0958 Permit Expiration Date: �t / APN `t 1 Z_7D"l 05(Q
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:
B. Nature of Work:
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: �' ; Telephone:
.... _� f /x, - .......
Address: -
2 . ' fir -----
E-Mail Address:
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. J l
ACCEPTED:
(A icant/Per rttee) $j Date
NOTES: All work shall conform with the attached approved plans and all applicable Campbell Standard Details and Conditions and applicable
insurance requirements.
The Contractor must have this permit and approved plans and must arrange to meet with the Public Works Inspector at the site at least two days
before starting work. Notice must be given to Public Works at least 24 hours before restarting any work.
Per Section 4216 of the Government Code this permit is not valid for excavations until Underground Service Alert(USA)has been notified and the
inquiry identification number(Ticket No.)has been entered hereon. USA Phone: 1-800-227-2600. Ticket No.::
Applicant is advised that upon issuance of this permit,property owner,or property owner's successors,shall be responsible for any and all
damages arising out of the design,installation or condition of private improvements in the public right-of-way.
SPECIAL PROVISIONS
1. Prior to any work,the property owner shall execute an Agreement-for Private Improvements in the Public Right-of-Way,which shall be
recorded.
2.
3.
STANDARD AMOUNT RECEIPT NO.
SECURITY FOR FAITHFUL PERFORMANCE (100°/ f Engr's Est.) $ C
R-1 PERMIT FEE i
T
APPROVED FOR ISSUANCE: A", Pf
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. 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 ofany 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
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. /
A licant Dat
J.\FORMS\TemP fates\Encroachment erP mits\R-1 Encroachment Permit STATIC form2.pdf
Rev.02/14
-- Billing Statement
E= Insurance,.
A Liberty Mutual Company 9-W
PERSONAL IYSUW4CE.PARTNER Due Date - 01/12/18
Amount Due $740.15
Account Number 7117-2742993
TOMMY HERNANDEZ Statement Date 12/18/17
® MARIA B HERNANDEZ HUSBAND&WIFE
Account Activity - Contact Us
Date Description Amount ,
12/18/16 Previous account balance $682.15 INTEGRA INSURANCE SERVICES INC
01/09/17 Payment received-Thank you! 682.15- Agent Telephone (408)354-3030
11/13/17 Renewal Home policy OA2742993 740.1.5
effective 01/12/18- 01112119 24-Hour Claims 1-800-332-3226
12/18/17 Account balance $740.15 Make a Payment www.safeco.com.
or1-888-723-3260
Billing Detail
Description Bill Plan, Account Balance Amount Due
Home policy 0A2742993 effective 01/12/18-01/12/19 Full Pay $740.15 $740.15
2217 CENTRAL PARK DR.
SAFECO Insurance Company of America
- TOTAL $.740.15 $740.15
If you want to change your billing plan.please call 1-408-354-3030 or visit www.safeco.com. For billing and .
M°me\
payment options see the back of this notice.
Managing Your Policy is Easy Online I Create your,account today at www.safeco.eom/on➢ine
+f Sign up for paperless billing and/or enroll in automatic payments beginning with your next bill
J Access policy and billing documents, make changes, and track.claims 24/7
3189/006785 ACV954 3189 4 ® Please fold,detach at perforation and return bottom portion with your payment in the enclosed envelope.
ozz '
Your payment is due in our office by: 01/12/18
SAFECOINSURANCE A
Account Number .Account Balance Amount Due
•
INTEGRA INSURANCE SERVICES INCfNC 1� /
14107 WINCHESTER BLVD STE V l l v 7117-2742993 $740.15 $740.15
LOS GATOS, CA 95032-1836
Save time and money! Complete the form on the AmPa'nnt
m
reverse side for automatic payments:
Pleas e: ake check payable to:
II'lllllllllllLl'I°11°111111°III°II111°Illlllllllllllllllllll°'I yyy`'-`�`f (p'�
fi{iil II IIII IIIIIIIII III I,Ill IIII lllill ll
014636 1 AB 0.4003189/014636/006785 050 01 ACV954 y, -
TOMMY HERNANDEZ " 'of I11°IIII°IIIlIeLnOI°I1111°II"I'II"I'I'I'lIIIIIIII®IIII➢IIII'I
MARIA B HERNANDEZ HUSBAND&WIFE Eta !
f r 0021967980121
2217 CENTRAL PARK DR i t' SAFECO INSURANCE
CAMPBELL CA 95008-4933 PO BOX 66542
ST LOUIS,MO 63166-6542
02196798D127 90 0711727429939 00000152758 022 000"0074015 00-00074015 0
1 Billing 6-Month 12-Month Billing
J'fn Policy Policy' Frequency
�'Il The.full premium is paid at the beginning of the term with no installment fee
6-Month Policy'2 installments approximately 2-months.apart
12-Month. Policy:2 installments approximately 5 months apart
4 installments at approximately 60 day intervals
�1`vperitlaltr �' Monthly installments for the policy term
Other Payment Methods Payment Application .
-1' You rnay, change your payment method by visiting o Payments will be-applied to the Amount Due-. If youpay
wvvkf.€s<afieco.com or by contacting your agent, more than the. Amount Due, we will credit the overpay-
Automatic Deduction payments are deducted from your menf-to-your next bill. To have some'or all of.a payment
chc;r it ig or savings account. To choose this payment applied in another way, please contact your agent.
miethod, complete the authorization form below and Payments or credits received will be applied to your•
ri-,turn it with your check or visit www,safeco.com. account and may be used .to `pay other balances due.
Rec,urrmg Credit Card payments are charged to the debit Contact your agent to receive a, refund check for any
card or credit card you specify. To choose this payment, policy credits.
rni tl=od; visit www.safeco.com. o All policies contributing to the amount due may be
o Autonlatic Deductions and Recurring Credit Card cancelled or expired.if the amount due is not paid, or is
paymen s. will continue, including at policy renewal, only partially paid.
unless you change your payment method. o Late payments may result in changes to future bills.for the
entire account. In sorne cases,.if a payment is received 20o .
1431.�r�a��if:�'�iur Account ore enfww.safeco:coni or more days after the due date, YOU, willbe billed for an
As a registered user, you can: amount equal to two installrn6nts on yaur,next bill
M,aike a payment with a check or a debit or credit card
Sign up for automatic deduction or recurring credit card Cancellation Procedures
- Update your bank, debit card or credit card information o If you need to cancel a policy, please contact your agent.
Change-your billing plan, payment method or due date Billing options may be limited for policies that are reissued
following a lapse in coverage. -
Fees o Unpaidtipremium on cancelled policies may be subject to
v The installment fee varies by payment method, state.and credit reporting.
pcii�::y type. See your policy Declarations page for
specific information about installment fees. Combined,Billing
e If we receive your payment after.the.due date, you may ® You may combine your Safeco personal insurance
be charged a late feet of'up to $15.00. Late payments policies on one. billing account.3 Your account will have
may affect your-.future. ,premiums; your,. coverage or one. due date; Chosen.by you..Each month any amounts _
continuation of your policy. due for each policy will be combined for oneamount due.
a If your payment is not honored b.y your bank,you may be o To add or remove any policies on a.billing account please
charged a returned item fee of up to$25.00. contact your agent.
1.Ncat all billing plans are available in all states or for all products. If the billing plan for a policy on the front of this notice is printed with a#sign, installments will be billed
aXr MI-:lely.3 months apart.Additional billing plans may be available in Florida.Contact your agent for more information. 2.Late fee exceptions in certain states forcertain
Products contact your agent for more information. 3.Except California Earthquake Authority policies,policies in Massachusetts and policies paid by a mortgage company.
OG-52 2E`:'0803
Automatic Deduction AuthorizMlon
I authoriE..e the::companies operated as Safeco Insurance(together,"Safeco")to initiate deductions from my bank account when payments are
due for my Safeco account.I authorize the•ilnancial institution("bank")listed on the enclosed check to accept the deductions initiated by
Safeco, i rnake this authorization subject to the following conditions:
4 Safeco may deduct payments from n,y bank account ON or AFTER the of the month.
Safeco must notify me about the amount of the first deduction and whenever the.deduction amount changes,
Refunds ma'y be credited to my bank account unless I specifically request payment by check at least 7 days beforehand.
i hi-vIve the right to terminate this payment option or change my payment option or bank information by notifying Safeco at least 7 days
prir.r 0 a scheduled deduction.
This authorization will remain in effect until it is revoked by me.
I u'sderstaind that I must make payments using another payment method until I receive my first Automatic Deduction notice.
I Linderstat d that I may be removed from the Automatic Deduction program and/or my insurance coverage may be canceled if there are not
sufficient fltnr s in my bank account or if Safeco cannot access my bank account.
1 att-esi t of I am authorized to sign checks drawn on the bank account listed on the enclosed check.
Sioned Date
Encroachment Permit Final Sign Off
Encroachment Permit# tom' I
Address: `2217 ��� Dv
Date of Final Inspection and Acceptance: G/It A6
Inspected by: �vj
OK to release deposits: 100% 75%
Comments:
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