ENC2018-00149 �P5 P
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CITY ®P CAMPBELL
Public Works Department
August 5, 2018
John Lewis
1279 E. Campbell Ave.
Campbell, CA 95008
SUBJECT: PERMIT NO. ENC 2018-00149
1279 E. Campbell Ave., Campbell, CA
FINAL INSPECTION AND ACCEPTANCE
Dear John:
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.
If you have any questions, please call me at (408) 866-2165.
Sincerely,
Syed Wahidi
Public Works Inspector
70 Nortb.First Street Campbell, California 95008 • TEL 408.866.2150 . PAX 408.376.0958 . TDD 408.866,2790
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Encroachnient Permit Final Sign Off
Encroachment Permit# � � 2d1 oc, 41
Address: CAMPB&A-L—
Date of Final Inspection and Acceptance:
Inspected by:
OK to release deposits: 100% " 75%
Comments:
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CITY OF CAMPBELL
Public Works Department
August 15, 2018
John Lewis
1279 E. Campbell Ave.
Campbell,.CA 95008
SUBJECT: PERMIT NO. ENC 2018-00149
1279 E. Campbell Ave., Campbell, CA
FINAL INSPECTION AND ACCEPTANCE
Dear John:
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 July 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 Performance Deposit in the amount of$1,000.00 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 ENC2018-00149
70 North First Street • Campbell, California 95008-1436 TEL 408.866.2150 FAX 408.376.0958 TDD 408.866.2790
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CITY OF CAMPBELL VENDOR NO. 10015071 C ECK NO. 269305
Account..,.. .; Purchase:Order. . .,,'..Inuarce'Number:: Amount .: Descri ton,:*, ..:. .........
101 2203 CR080718 1,000.00 1279 E CAMPBELL AVE/
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*See Reverse-Side For Easy Opening Instructions*
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CITY OF CAMPBELL ',)
70 NORTH FIRST STREET
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CAMPBELL, CALTFORNIA 95008
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JOHN LEWIS
1279 E CAMPBELL AVE
CAMPBELL CA 95008
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Refundable Deposit Check Request
To: Finance-Director
-Check Payable To: John_Lewis.
Address- Line 1: 1279 E: Campbell Ave: . i
Line 2:
City: Campbell. State: CA Zip: 95008
Description: 1279 E..CampbeliAve.
Account Number: 101-.2203. Amount: $1,000.00
Account Number:'- 1'01.2203 'Amount:
_ Account Number: 101.540,.7448 _ Amount: ,
(Finance Dept only) Interest.Earned (Finance Dept only) ?
Total Payable: ���( �� (Exact.Amount)
Purpose: FPS"refund
Permit#.:.- ENC a.QA 00 VLk�
Receipt*: 275689 ; Date,:; .. 6/7/201±8 ,
Receipt.#: Date:
Requested by: Title;. Inspector Dafe: � /LrQ f
Syed Wahid'i
Approved by Title: ` Sr-Engineer Date: . (�
Roger-Storz
Finance Dept Only: i
Versified by: Title: Accounting Clerkal Date:
Approved by: Title: Accountant Date: -
Special Instructions For Hand.l:ihq, check , -
maii P1S IS: Mawin_Attacfiea Envelope, . interirn,t necK
- . Needed By:
r Return > JoAnna Thomason Public Works
Other: Please return:,check to.JoAnna
CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
CLEARANCE FOR FINAL INSPECTION
AND ACCEPTANCE LETTER
Encroachment Permit#: ENC 2018-00149
Name: John Lewis
Property Address: 1279 E. Campbell Ave.
Date of Final Inspection:
On File: Bonds CD Cash
Faithful Performance: $ 1,000.00
Labor and Material: $
Construction Cash Deposit to be released: $
Other overdue deposits to be released (Description):
Processed by:
A inistr or 1 D
Reviewed by:
Inspector
Reviewed by:
Land Development Engineer 1
J:VoAnna'Meposit refunds\CHECKLISTS\1 Checklist-Final Acceptance.doc(Rev. 10/11)
Encroachment Permit Final Sign Off
Encroachment Permit# wc `- lt; GG I Lo
Address:
Date of Final Inspection and Acceptance: /23 (l,5
Inspected by: s /
OK to release deposits: 100% 75.%
Comments:
�Rrint"Forth
CITY OF CAMPBELL R-1 ENCROACHMENT PERMIT Permit No.
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 Date
Campbell,CA 95008 - Application
Expiration/7�G
Ph.(408)866-2150 ISSUED: 9
Fx.(408)376-0958 Permit Expiration Date: 7 ( APN S•t 4 Z
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: L..Z 7.. C._ . � • � ..1..6�!— ley r
B. Nature of Work: �S7At _ T\&;_q (Z) !ice I 2LI Lid 1� R11
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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: (11 Telephone: L
Address: Nam, [ (� �y,•�j tof f
-7y -------- — _ T
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 acknowle at th ave d an rstand both the front and back of this permit,and that they will inform their
C contractor(s)of the inform ' n.
ACCEPTED:
pp icant/Per 'ttee) (Sign) ` Date
G
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.- T F't—S Ski"L�L (31 GY Coct A"_ -t-g7 PR-i-P T- 1N-C,,-CAttATjo v
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STANDARD AMOUNT RECEIPT NO.
SECURITY FOR FAITHFUL PERFORMANCE (100%Of Engr's Est.) $ 1000 7 �
R-1 PERMIT FEE $
APPROVED FOR ISSUANCE:
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 scommark 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 ofiany 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 Cla Valley Urban Runoff Pollution Prev tion Program.
Applicant sh be sponsible for ensuring t I those prov di g services under the applicant are aware of and understand all of the above
conditio
Appl' - t Date
J:\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf
Rev.02/14
PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT
T.0: Finance Effective July 1,2017 FILE NO. -CC,I L( T
PUBLIC WORKS
PROPERTY ADDRESS W79 /SLk!:
Please collect&receipt for the following monies:
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4722 1 Encroachment Permit Application Fee
20Non-Utility Encroachment Permit Major 410,000 $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 Plantinq/Removal - N/C
203 ($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�:I 0j000 s.f. <0.5 Acre $1,185.00
Site Z:0.5 Acre $1,772.00
4722 NPIDES Review(C3 Requirements)
- For projects not required to submit numeric sizing $175.00
For projects required to submit numeric sizing
Impervious Area 10,000 Sq. Ft to 1 Acre $740.00
Impervious Area I Acre or more $965.00
4722 For proiects sent to Consultant for review Consultant Cost+20%
4722 Additional treatment'facilitie-s $315 ea
Plan Check&Inspection Fee (Non-.UtilitV)
4722 Engr.Est. <$250X0 .14%of'Engineer's Estimate
4722 Enqr. Est.?$250,000 and 5$500,0D0 $35,000.00+8%of Engineers Estimate
4722 Enqr. Est. >$500,000 $55,000.00+7%of Engineers Estimate
1 2203 Emergency Cash Deposit 4% of En. r. Est.*($500 min/si 0,000 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 $2,420.00
(Multi-Res$2,385.D0)
(All Other$2,650.00)
4722 Parcel Map(4 Lots orLes $4,200.00+$90/10it
4722 Final Tract'Mar)(5 or More Lots) .$5;115.00+$124/lot
2203 Monumeritation Securitv 100% of City's Monumentation Estimate
e.
4920 Pafkland Dedication F e(75%/25% Due Upon Cart. of Occuparic )
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.-D0
4722 Document Recording Fees $15.00/first page$3 ea.Additional
4722 Private Improvement in Public ROW $100.00
4722 Approved Plan Revision Fee $1001sheet
4722 Appeal Filing Fee $200.00
730:4924 Notice of Improvement Obligation Payment
=-As-sessment begregation or Reapportionment
First Split $940.00
Each Additional Lot $295.00
511.74241 Postage
7,
Other(Please Specity)
*Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL
NAME OF APPLICANT J eJ)L_ L
NAME OF PAYOR L PHONE
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ADDRESS Q77F EC4,,,tell Nhfi6,�y
ZIP
FOR RI
CITY CLERK LL
ONLY
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:1G] AIG Private Client Group
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AIG Property Casualty Company
(Name of issuing company)
Automobile Declarations Page ns Page is
Your Declarations Page shows at a glance the coverage you have and your premium. Your attachedtio
art for
your policy. Please read your Policy carefully, including your Declarations Page and any
description of your coverage.
Policy Number: Policy Period: 05/09/2017 - 05/09/2018
Po 0Number 1 18 At 12:01 A.M. standard time at mail address below
P li 0 Insured and Mailing Address: Agency Name, Address, Phone # & Code:
Name
John Lewis Wells Fargo Ins Svc USA, Inc
Jessica Lewis 45 Fremont St, 8th Floor
1279 E Campbell San Francisco, CA 94105
Campbell, CA 95008
(650) 413-4200 0060599
"YOU WILL BE BILLED SEPARATELY FOR ANY PREMIUM DUE".
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DESCRIPTION OF YOUR COVERED AUTO(S):
S Y M B O L S AGREED
AUTO TER CMP COL LIB MEDPIP TYPE YEAR MAKE MODEL VIN VALUE CLASS
2 086 23 23 265 465 REG 2003 BMW M3 WBSBL93493JR24043 $12,786 A132TBN000
3 086 33 33 N/A N/A REG 2017 MAZDA CX-5 JM3KFADLBH0117944 $28,155 A130TBN000
4 086 48 48 NIA N/A REG 2017 MAZDA CX-09 JM3TCBDYSH0140073 $43,210 A199VBN000
COVERAGE IS ONLY PROVIDED WHERE A SPECIFIC PREMIUM CHARGE IS SHOWN
COVERAGE LIMITS OF LIABILITY AUTO 2 AUTO 3 AUTO 4
Bodily Injury: $250,000/$500,000 Per Person /Accident $242.00 $266.00 $217.00
Property Damage: $100,000 Per Accident $130.00 $160.00 $141.00
Medical Payment: m,000 Each Person $38.00 $39.00 $34.00
Uninsured Motorist BI: $250,000/$600,000 Per Person/Accident $38.00 $38.00 $32.00
Collision: $378.00 $360.00 $436.00
Less Auto Deductible: 2- $1,000 3-$1,000 4- $1,000
Waiver of Collision Deductible Auto(s) 2 3 4 $26.00 $26.00 $26.00
Other Than Collision: $84.00 $99.00 $127.00
Less Auto Deductible: 2- $500 3- $500 4- $500
Full Glass Coverage: Auto(s) 2 Comp 3 Comp 4 Comp
California Investigation Assessment: $1.00, $1.00
$1.00
California Consumer Services Assessment: $0.26 $0.26 $0.26
California Fraud Interdiction Assessment: $0.50 $0.50 $0.50
Total Annual Premium Per Auto: $937.76 $989.76 $1,014.76
Premium Subtotal this page: $2,942 28
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TOTAL FULL TERM PREMU $2,942.28
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AIG Property Casualty Campanv
({Name of issuing company) Endorse Effective:10/23/17
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PERSONAL EXCESS -LIABILITY DECLARATIONS PAGE i
Your Declarations Page shows at a glance the coverage you have and your premium. Your Declarations Page is part of your poli<
Please read your policy carefully, including your Declarations Page and any attached Endorsements, for a description of y!
coverage.
Policy Number Policy Period 05/09/2017 -05/09/2018
PCG 0058336994 At 12:01 A.M. standard time at your mailing address shown be
Name of Insured and Mailing Address Agency Name, Address, Phone # St Code
John Lewis Wells Fargo Ins Svc USA, Inc
Jessica Lewis 45 Fremont St, 8th Floor
12.79 E Campbell San Francisco, CA 94105
Campbell, CA 95008
(650) 413-4200 0050599
"YOU WILL BE BILLED SEPARATELY FOR ANY PREMIUM DUE".
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A. PERSONAL EXCESS LIABILITY COVERAGE LIMIT $2,000,000
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Excess Uninsured/Underinsured Motorist Limit $ 1,000,000
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B. LIMITED EMPLOYMENT PRACTICES LIABILITY LIMIT 1
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Annual Aggregate $ Not Applicable
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Per Wrongful Employment Act $ Not Applicable
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Deductible $ Not Applicable
C. LIMITED CHARITABLE BOARD DIRECTORS AND TRUSTEES i
LIABILITY COVERAGE
Annual Aggregate $ Not Applicable
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Per Wrongful Act $ Not Applicable
Required Underlying,Insurance Minimum Required Underlying Limits
1.Personal Liability, Homeowners or Bodily Injury/Property Damage $300,000 each occurrence I
Comprehensive Personal Liability Combined Single Limit
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2. Private Passenger Auto and Licensed Bodily Injury and Property Damage or $250,000 Bodily injury each person I
Rbcreational Vehicles $500.000 Bodily injury each accident !
g $300:000 each accident
damage each accidi
Combined Single Limit:
Uninsured/Underinsured Motorist Bodily Injury and Property Damage or $25.0,000 Bodily lly injury each person
$500,000 Bodily injury each accident
Combined Single Limit: $ 25,000 Property damage each accid
$300,000 each accident j
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PEL-DEC (03/06)