ENC2000-00056CITY OF C33/IPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
ENCROACHMENT PERMIT
(for working within the
public right-of-way)
Issued ~' ~-~ag-- tgf
Application Date
_n Fax (408) 376-0958 Permit expires in 12 months~//~ Application expires in 6 months
p4,- . '-r
L~' '[qJ~ ~PPLICATION - A~li~on ~ hereby ~e for a ~blic Wor~ ~t in ~r~ wi~ C~II Municip~ C~e, S~on 11.~. (AppliCon exp~ ~ 6 mn~ ' ~ d ~ ~ ~ ~t ~su~. Appli~ion F~ ~ ~n~le.)
A. Work ~d~s or ~ . ~ ~ '-
Util~ ~ l~ion
/
C. A~h f~ (4) ~i~ of m engin~ pl~ showing ~e I~on ~ exit of ~e wo~, ~ f~r (4) ~pi~ of ~e p~l~ Eng~'s ~ of wo~. ~e
p~ s~l show ~e rel~on of ~e pro~s~ work m ex~ting suff~ md uM~nd ~rove~m. ~en ~p~v~ by ~e Ci~ Eng--, ~d p~ ~ a p~ of
D. All wo~ sh~l ~nfo~ to ~e Ci~ of C~tl S~d S~ifl~iom md ~ls for ~blic Wor~ Co~on: ~e Ge~ ~t Co~ifiom I~ on ~e r~e~e
side; md ~e Sp~ Provisio~ for ~is pe~it, 1~ ~low. F~lure m ~ide by ~e ~nditio~ md prov~io~ ~y ~ult in j~ shut~own ~or foffeim~ of F~I
Peffo~ Sur~i~ md ~h d~osim. (S~ G~ P~it Condifio~ 1 ~ 2.)
E. T~ CO~OR MUST ~VE T~S PE~ AND APPROVED P~NS AT THE S~ ~ MUST NO~ T~ P~LIC WO~ DEPAR~ AT
~T ~0 DAYS BEFO~ STATING WO~. NO~CE MUST BE GIVEN TO P~LIC WO~ AT L~ST 24 HO~ BEFO~ ~NG ~ WO~.
h ~ wo~ ~ng ~ by ~e prope~ owner a ~eir own r~iden~? Y~ ~ No
~e Appii~ffpe~ hereby agr~ by ~fixEg ~eir sig~re to ~h ~it to hold ~e Ci~ of C~II, im offi~, ~en~ ~d e~loy~ f~, ~e ~ ~s from
~y cl~m or de~ for ~g~ r~ulting from ~e work ~ver~ by ~ ~t.
The Appli~~hereby ~knowl~g~ ~ ~ey Mve r~ md u~d ~ ~e front md b~k of ~h ~it, md ~ will info~ ~ek ~s) of ~e
' / ' (Appli~P~) (sign) ? D~
/
SPECIAL PROVISIONS
~1. Street shall not be open cut for underground installations. Minimum cum ma~ b~ allowed for corm~tions or exploration holes, Such cuts may be mpe~Afieally
approved by the Inspector prior m cutting.
Pavement may be cut for underground installatiom and must tm restored in accordance with the Utility Trench Restoration Smmlard D~aih. Meuhod 'A' Bat:kill1,
unless otherwise approved by Inspecu)r.
Work to be staked by a licensed Land Surveyor or Civil Engineer and two (:2) copies of tim cut sheets scm ~o the Public Works l~parrmem I~fore starting' work
Per Section 4215 of ~he Government Code this perm'a is not valid for ~xcavations umil Underground Service Alert (USA) has been no6fied and ~ inquiry
identific~u, ion number has been entered hereon. USA Phone 1-800-227-2600. USA TICKET NO.
PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCEYLABOR & MATERIALS
AMOUNT
,.
~ -~'//~
Date
RECEIPT NO.
:\forms\pwperm2Yrev.6/96
..DEFT, OF PUBLIC WORKS (for working ~itbin the : X'l~f... '~
70 North Fu'~t St. public right-of-way) , ~' , ; · .
Campbell, CA 9~008
(408) 866-2150 Issued ~---~=~-'2_~i~i~ Application Dat~
F~ (408) 376-0958 Permit expires in ~2 mont~ Application expires in 6 mon~ ·
APPLICATION - Application is he~'~y mad~ for · Public Works ~ B ~ w~ C~I M~ C~. S~ H.~. (~i~ ~ ~ 6 m~
~ ~ ~ ~ ~ ~. A~l~on F~ ~ ~~lc.)
p~ ~ ~w ~ ~on of ~c p~ wo~ ~ ~ ~ ~ ~ ~~- ~ ~ ~ ~ C~ ~, ~ P~ ~ a ~ of
~ ~ w~ ~g don~ by ~e p~ ow~ ~ ~cir own ~id~? Y~ No
S~C~L ~O~lSlON~ :.' .-' .' '-. '.- ':': :.. '. '. v'.". ' '.: "-':.]' ~"~" ':%:'?:'-:?..:":":"::[:[-"~'~'[?~ '~'' ' ':-: '
~ .~ ~~ ~y I~r. - ' .:' .... .:". ......... ' :'" '"' '~'~'':~'':'" '~' .:i .... :. ........ ':' :' .;' · ".~ ..
SEE FU~IC WOR~ FEE $CHEDLq..E FOR CURRENT FEES
PERMIT APPLICATION
H. AN C/~CK DEPOSIT
~C~ FOR P~
CO~U~ON ~H DE~5~
~ ~& ~SPE~ON
APPROVED FOR I.q~UANC'E
3. IKE~JND of the cash deposit bxisnce ~nd re'fund °r cancdlati°n °f the F~'l~ul Perf°rmanca Surety will be initia~d bY ~ ~ ~ ~ ~
work ~ tbe C~.
4. TI~I~in=eMUSTREQUEST~ WR'rr~o ~finalinspec~°n~4 accaptnnce°fthew°rk~°ncomplati°n' Accept~bylhaCityw~]bemada
6. A COlqST~UCTION TRAF~C CONTROL PLAN and a CONSTRUCTION SCH]~)ULE is requi~nd for all ~ closuxes, detours a~d su~t dOmrU.
This phn nmst be ~ and APPROVED prior z) any lane closures.
7. 'Fno CONSTRUCTION TRAFFIC CONTROL PLAN shall conform with the C. alu'ans Mam~ of TmT~c Conl~is for Comuuctiou and lvlainnnnnoe
Work Zom~ d~md 1990, available at ~ Tn~~-c control aquipmcnt shall include Type II f{,,~,in_, ar~ ~ if required.
8. ~ ~ IC32qD ~ ~'~g~ or removed exist~ impmvemonn, incl-,~_- plantinf.
g. Sawcut for all PC¢ or AC removals. All PCC removals ~nn be m n~L-est scoremark znd sbzll be doweled ~ existinf impmvenmau.
10. OVERTIM~ ]]qSPECTION P~ will be chzrged qainst the cash deposit for inspec~on required outside the hours of 8.'00 a.m. ~ 4:00. p.m.
I~. SATURDAY I~TSPECTiON$ must be ar~nged in advance. San~day inspection ttm~ is ~hn~ed at the cttt~nt overtone ra~ with ~ ~ hour
n~nimum. Advance payment for the estm3~ad mnc is required. ·
12. Ad~iuate signing and lighted BAR~ICADI]qG is required on the job sit~. Failur~ to provide such si~ and ban-ic3din~ may nesult in thc City's
tentin~ such signing and ban~cades and cha~ing thc cost (including nil l~x)r and ~) a~inat th~ cash deposit.
13. Com~ testing of subF'ade, base rock, end asphalt concrm~ by Pennit~e is REQUIRED unless otherwise stand by thc ~ Eng~n~r.
14. The Contractor or Permit~e will have a SUPERVISORY R]~A~ av~lable for conner on the project at'all timas dur~ comuuct~n.
Conuactor or P~rminae s~ll provide a phon~ number at which they can be contacu=d outs~le d~ hours of 8:00 a.ne. to 4:00 p.m.
15. No STORAGE of mater~ls or equipment will be allowed na~r thc edge of l~Vemcnt, tl~ t~veled.way, or within t~c simulderline which wotlld cr~tt~
e haza~dons condition to the public.
16. This permit s~ll not be construed as authori~tion for excavation and gTading on private propert~ ADJACENT u) the work. or any other work for
which a scparat~ permit may be required, nor does it relieve the Pcrmittee of any obliga~on to obt~n any od~r permit ~ by l~w.
1'/. This pern~t does NOT RELEASE thc Pern~ncc from any liabilities connin~d in od~r ag~-eme~ts or contracts with the City snd any od~r public
agency.
1~. This.pen~ is NOT TRAN~LE. Work must be performed by the Pern~in~ or ~ designated agent or contra~or as spoch~d tha~on-
19. CALL BACK (c~ll out~ due to emergencies rei,,a~ling this permit, shall be at the currant overtin~ ra~ with a tl~ee (3) hour _m~i,mm~ c~a~e per
20. Pm'suznt to Chaptar 14.02 of the Campbell ]vlunicipal Code, applicant shall not c~use m be disc~ed an~ ma~rixl into the E-miL'~pa] storm drain
s~s~n otber than s~orm water. Applic3nt shah adhere to the EEST MANAGE}AENT PRACTI.CES est3blish~ by thc Sama ~ Vsi]ey Nonpeint Souza
Pollution Conuol Progrzm.
si~ll be responsible for ensuring that all thos~ providing services under fha applicant a~. awa~ of and undcmand all of tbe above conditions.
ENCROACHMENT PERMIT NO. ENC 2000-00056
SPECIAL PROVISION NO. 5
Special Provision No. 5 for Encroachment Permit No. ENC 2000-00056 consists of, but is not
limited to: Removal and disposal of approximately 119 L.F. of Structural Soundwall,
including structural posts, hardware and reinforced concrete foundations to 24 inch below
sidewalk grade, including backfill and compaction of topsoil material to sidewalk grade,
including traffic control and cleanup. The soundwall materials are shown on the plans for
Project 75-2, Loop Street Improvements, Phase II, dated April 11, 1977. Protect and/or repair
or replace any damaged street improvements.
H:\permits\2000-56specprov5(mp)
CITY OF C.~viPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
ENCROACHM~ PERMIT
(for working within
public right-of-way)
Issued
Permit expires in 12 months
X-Ref. file
Application Dat~
Application expires in 6 months
APPLICATION - Application is her~y made for a Public Works P~mit in ac,,eor~x~ wi~ Campbell Municipal Co~, Seo. inn 1 l.Oa,. (Application ex~in~ in 6 momh$
if thc permit ~ a~ Bsu~. Applicon F~ a ~m~l~.)
Ufili~ ~ l~on
C. A~ t~r (4) ~i~ of m ~gin~ p~ showing ~c I~on ~ ~ of ~c wo~, ~ f~r (4) ~i~ of ~ p~ ~'s ~ of wo~. ~e
p~ s~l show ~e ~l~on of ~e pro~s~ work ~ ~x~ ~ ~ u~M ~v~. ~ ~mv~ by ~ C~ ~, ~ p~ ~ a p~ of
~ p~it.
D. ~1 wo& s~l ~o~ to ~e Ci~ of C~ll S~d S~ifi~om ~ ~ for ~bl~ Wo~ Come,on;
sMe; ~ ~e Sp<~ ~ovisiom for ~ pe~it, 1~ ~low. F~lu~ m ~i~ by ~e ~fiom
P~o~ Sumi~ ~d ~h d~osi~. (S~ G~e~ P~t CoOl,om I ~ 2.)
E. ~ CO~CT~UST ~VE ~S PE~ ~ APPRO~ P~S AT ~ S~ ~ MU~ NO~ ~ P~C WO~ DEP~ AT
L~O DA~BEF~ STATING WO~. NO~CE MUST BE G~ TO P~LIC WO~ AT ~T 2~ HO~ B~O~ ~~G ~ WO~.
Is ~ work ~ing done by ~e p~p~ owner ~ ~eir own ~id~? Y~ No
~ App[i~a~i~ her~y ~ by ~C=ing ~e~ sig~re m ~ ~t m hold ~e Ci~ of C~beil,
~y c~ or de~d for ~g~ r~ul~ng from ~e work ~ver~ by ~ p~t.
T
A / ~ ~- (Appli~ff~) (sign) ' ~-~ ~*~/ ~ ~ D~ '
SPECIAL PROVISIONS '
j~l. Str=t shatl not be open cut for underground installations. Minimum cuts may be ailowot f~r co _m~___'_.om or eqaloration hol~s. Such cuts may be s]~eif',mllv
approved by the Impector prior to curling. · ·
~2. Pavement may be cut for underground installalions and mu.mt be' r.'~mrext in ar. cordar~ with thc Utility Tremh R~toradort Stamtard D~am'ls. M~thod 'A' Backfill,
unless otherwise approved by Impeemr. : · · ·
3. Work to be stak~ by a licemed ~ Surveyor or CDil En~ and two ~) r.~pi~s of tl~ cut slm~ts ssm ua the PubFsc Worl~ l~a~a~nt l:~t'or~ sl~ wor~
~/4. Per Section 42 I$ of t~: Goverrcncnt C-~-e rJ:~ Pertrfit is n°t valid f°r ~cavati°n$ ~til UncL'TSt°und ~ ~ ~) ~ ~ ~ ~ ~ ~
identiFr--~UOn number has beea entered hel'~an..USA Pho~' 1-800-227-26~0_. . ~ ~,,~CK~ NO. ,
Sk-~ PUBLIC WORKS FEE SCHEDLq..E FOR CURR~NT FEES
PERMIT APPLICATION FEE
PI=AN CHECK DEPOSIT
SECURITY FOR FAITI-LFUL PERFORMANCE/LABOR & MATERIALS
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & INSPECTION FEE
AMOUNT
APPROVED FOR ISSUANCE
for CkT Engm~er
Dm.,.
i: fformsxpwperm2d rev.0/96
/~ GEN]//RAL PI~RMIT CONDITIOt'''
I. A CONSTRUCTION CASH DEPOSIT is required. Charges will be made against this deposit if there is an emergency can-out, overtime inspection
or when City ordered bamcading is required. Any such costs in excess of the deposit will be billed to the Permitme.
2. A ONE-YEAR MAINTENANCE PERIOD AND SURETY are required. Such pe~od will begin on date of vfl/tten acceptance by the City.
3. REI:UND of the cash deposit balance and refund or cancellation of the Faitlxful Performance Surety will be initiated by the wr/ttea ara:elYaI~ of the
work by the City.
4. The Permittee MUST REQUEST IN WRITING a final inspection and acceptance of the work upon completion. Accepunce by the City w~l be made
in writing m thc Perm/me.
$. MAINTAIN safe pedestmn and vehicular crossings and f3~e access m private dr/vewlys, bus stops, fu~ hydrants and water vtlves.
6. A CONSTRUCTION TRAE:IC CONTROL PLAN and a CONSTRUCTION SCHEDULE is required for all lane closures, demurs and suect closures.
This plan mast be REVIEW'ED and APPROVED pr/or to any la. ne closures.
'/. The CONSTRUCT]ON TI~C CONTROL PL,~ e, h21! coi:Lt'Orol With the ~AJlzan.q ]~ of Traffic Controls for Consm~ction and
Work Zones, dated 1990, available at Caltrans. Tra.r'fic contwl equipment ,.hull include Type 11 flushing alTOW S;/Lr]~S if rei[uired.
8. REPLACE IN KIND any damaged or removed existing impwvements, il~ludlng planting.
SI. Sawcnt for 211 PCC or AC removals. Ali PCC removals qh211 be to nem'est scoremark and shall be doweled to exisl/ng impwvements.
10. OVERTIM~ INSPECTION PILEM2UM will be charged against the ~ deposit for inspection required outside the hours of 8:00 ~t.m. to 4:00 p.m.
at thc current overtime rate, minimum one hour charge.
I I. SATURDAY INSPECTIONS must be ananged in advance. Saturday inspection fin~ is charged at the current overtime rate with a three hour
minimum. Advance payment for the estimated time is requh-ed.
12. Adequate signing and lighted BARRICADING is required on the job site. Fa/lure to pwvide such sign/rig and barricading may result in the City's
renting such signing and barricades and charging the cost (including all hbor and materiah) against the cash deposit.
1:3. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is REQUIRED un]ess otherwise stated by the City Engineer.
14. The Conwacmr or Permittee will have a SUPERVISORY P,.EPILESENTATIV~ available for contact on the project at all times dm/rig conslruction.
Cont~cmr or Perrmt~c shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m.
15. No STORAGE of materials or equipment will be allowed near the edge of pavement, thc traveled way, or With/n thc shouldefline which would create
a hazardous condition to the public.
16. This permit shall not be construed as authorization for excavation and grading on private property AD]'ACENT to the work. or any other work for
which a separate permit may be required, nor does it relieve the Perm/tree of any obligation to obnm any other permit required by hw.
17. This permit does NOT 1LELEASE ~c Permittee from any liabilities contained in other agreements or conwact3 with the City and any other public
agency.
I8. This permit is NOT TRANSFERRA.BLE. Work must be performed by the Permittee or his designated agent or contractor as specified thereon.
19. CALL BACK (call out) due to emergencies regarding this permit, shall be at thc current overt/me rate with a three (:3) hour ,,~i,lnmm dm'ge per
OCCBH~nce.
20. Pursuant to Chapter 14.02 of the Caznpbell Municipal Code, applicant _~hnll not cause to be discharged any material into the municipal storm drain
system other than storm water. Applicant shall adhere to the BE,ST MANAGEMENT PRACTI.CES established by the Santa Clara Valley Nonpoint Source
Pollution Control Program.
,,_..shall be responsible for ensuring that all those providing s~rvices under the applicant are aware of and understand all of the above conditions.
- Applicant ~- ~/_,~ .'~- f,~/-~..& .~ Date
j:\fonm\pwperm2 6196
0
o
0
o
0
0
0
0
0
PUt ¥ORKS DEPARTMENT RECEIPT
.ecfive August I, 2000
Please ~ol cc[ & receipt for the following monies:
ENCROACItMENT PERMIT
4722 Application Fee
Non-Utility Encroachment Permit ($245.001
Mirror Encroachment Permit < $5,000 ($50.00)
R-1 First Permit (No Fee) Subsequent Permit/Yr /$110)
Utility Encroachment Permit
Arterial/Collector Street ($355.00)
Residential Street/Other Area~ ($245.00)
2203 Plan Check Deposit - 2 % of ENGR. EST. ($500 raint
2203 Faithful Perfo .... Security IFPS) {100% of ENGR.EST.)
2203 Labor and Materials Security (100% of ENGR. EST.)
2203 Monumentation Security (100% of ENGR.EST.)
2203 Cash Deposit (4% of ENGR.EST.)($500 rain/S10,000 max)
2203 Labor and Material Security (100% of ENGR. EST.)
P,an Check ,as ct,on Fee on-Ut,,it,
4722 Engr. Est.< $250,000 (12% of ENGR. EST.)
** 2203 Engr. Est.>$250~000 (Deposit 8% of ENGR. EST./$30,O00 min.)**
4722 Utility < $100~000 {8%)
Minimum Charge Per Location
Conduits/Pipelinns up to 500 Feet /$2.00)
Above 500 Linear Feet {$1.25)
Manholes/Vaults/Etc. ($I 15.00/ea)
Pole Set/Removal ($115.00/ea)
Street Tree Planting/Removal ($115.00/tree)
*. 2203 Utility > $100~000 Actual Cost + 20% **
4722 Street Tree Planting/Removal Permit iS 115.00)
4760 Proiect Plans & Specifications Proiect No.
4760 Standard Specifications & Details ($1/Pg $12.50/Bk)
4760 Copies of Engineering Maps & Plans
Aerial Plot 24' x 36' ($45)
Aerial Print 8 1/2' x 11'
Maps and Plans 24' x 36'
4722 Penalties: Eaiiure to restore public improvements ($100/Calendar Day) [Mum Code Sec.ll.34.010~
47221 Penalties: Failure to correct uasafe conditions ($100/Calendar Day)
LAND DEVELOPMENT
4722 Lot Line Adiustment (S600.00)
4722 Parcel Map (4 Lots or Less) ($1,170 + $25/Lot)
4722 Final Tract Map (5 or More Lots) ($l~510 + $25/LOt)
4722 Certificate of Compliance ($545.00)
4722] Certificate of Correction ($330.00)
47221 Notary Fee (per signature) ($10.00)
47221 Vacation of Public Streets & Easements ($600.00)
4722 Assessment Segregation or Reapportionment
First Split ($600.00)
Each Additional LOt ($I85.00)
4721 Storm Drainage Area Fee Per Acre (R-I~ $2~000)
(Multi-Res~ $2~250)
492(1 Parkland Dedication Fee (75%/25% Due Upon Cert. of Occupancy)
4965 Postage
TRAFFIC
4728 Intersection Turn Counts {Two-Hour Count) ($65.50)
4728 Intersecpon Turn Counts (a.m. or p.m. peaks) ($136.50)
4728 Traffic Flow Map (Daily Traffic Volumes) ($29.50)
4728 Campbell Traffic Model (Full Scope Assessment) ($2,460.00)
4728 Campbell Traffic Model (Reduced Scope Assessment) ($810.00)
4271 Truck Permits ($32.00/rnd trip)
4728 No Parking Signs (SI/each or $25/100)
OTItER
TOTAL
**Actual Cost Plus 20% Overhead (Non-Interest bearing deposit)
h:\forms\receiptform00-01 .xls rev 7-17-00 (mp)
To: Finance Director
Check Payable To:
Address - Line 1:
Line 2:
City:
Description:
Account Number:
Account Number:
Account Number:
(Finance Dept only)
Total Payable:
Purpose:
Refundable Deposit Check Request
Network Fundin~l Associates, Inc.
63 North First Street
Campbell
Refund Deposit
101.2203 Amount:
Amount:
101.540.7448 Amount:
Interest Earned
$1,100.00
State: CA
Zip: 95008
(Exact Amount)
$1,100.00
(Finance Dept only)
Refund Faithful Performance Security Deposit
Voucher #:
Permit #: ENC2000-00056
Receipt #:
Requested by:
Approved by:
Finance Dept Only:
Verified by:
136110
Date: 12/19/2000
Title: PW Inspector Date: 12/0912002
Title: City Engineer Date: 12/09/2002
Title: Accounting Clerk II Date:
Approved by:
Title: Accountant Date:
Specicd ]:nstructions For Hondlinq Check
Mail As Is:
Mall in Attached Envelope:~
Interim Check:
Needed By:
Return To:
Joanne D'Ambrosia
(Name)
Public Works/City Hall
(Department)
Other:
f/n: Forms/excel/chkreq Revised 05/00
To: Finance Director
Check Payable To:
Address - Line 1:
Line 2:
City:
Description:
Account Number:
Account Number:
Account Number:
(Finance Dept only)
Total Payable:
Purpose:
Refundable beposit Check Request
Network Funding Associates, Inc.
30 Tait Avenue
Los Gatos State: CA
Refund Deposit
101.2203 Amount:
- Amount:
101.540.7448 Amount:
Interest Earned
Zip: 95030
Voucher #:
Receipt #: 136110
Requested bY: S~e~A~
Approved by:
M ~'h-el'l'e-'Q'~n ney
Finance Dept Only:
Verified by:
Approved by:
$3,916.00
(Finance Dept only)
11/08/2001
11/08/2001
~~'~ ~ (Exact Amount)
Refund Construction Cash Deposit ($616.00) and
Faithful Performance Security Deposit/$3,300.00)('-/5~/o~
Permit #: ENC2000-00056
Date: 12/19/2001
Title: PW Inspector Date:
Title: City Engineer Date:
Title: Accounting Clerk II Date:
Title: Accountant Date:
Mail As Is:
Return To:
Special :[nstructions For Handling Check
X Mail in Attached Envelope: Interim Check:
Needed By:
Other:
(Name)
(Department)
f/n: Forms/excel/chkreq Revised 05/00
To: Finance Director
Check Payable To:
Address - Line 1:
Line 2:
City:
Description:
Account Number:
Account Number:
Account Number:
(Finance Dept only)
Total Payable:
Purpose:
Refundable Deposit Check Request
Roger Cummings
63 North First Street
Campbell State: CA Zip: 95008
Refund Deposit
101.2203 Amount: $2,750.00
Amount:
101.540.7448 Amount:
Interest Earned
$2,750.00
(Exact Amount)
Refund Faithful Performance Security Deposit
(Finance Dept only)
Voucher #:
Permit #: ENC2000-00056
Receipt #: 130311
Requested by:Sy~~
Approved by:
Mi~helle Qu~ey
Finance Dept Only:
Vedfied by:
Date: 05/03/2000
Title: PW Inspector Date: 12/09/2002
Title: City En~lineer Date: 12/09/2002
Title:
Accountin~l Clerk II Date:
Approved by: Title: Accountant Date:
Special ]:nstructions For Handling Check
Mail As Is:
Mall In Attached Envelope: ~
Interim Check:
Needed By:
Return To:
Jeanne D'Ambrosia
(Name)
Public Works/City Hall
(Department)
Other:
f/n: Forms/excel/chkreq - Revised 05/00
To: Finance Director
Check Payable To:
Address - Line 1:
Line 2:
City:
Description:
Account Number:
Account Number:
Account Number:
(Finance Dept only)
Total Payable:
Purpose:
Refundable Deposit Check Request
Roger'D. Cummin~ls
30 Tait Avenue
Los Gatos
State: CA
Zip: 95030
Refund of Deposits
101.2203
Amount:
$8,250.00
Amount:
101.540.7448
Interest Earned
Amount:
(Finance Dept only)
$8,250.00 (Exa= Amount)
Refund Faithful Performance Security Deposit
Voucher #:
Permit #: ENC2000-00056A
Receipt #:
Requested by:
Approved by:
Finance Dept Only:
Verified by:
130311
Sye~
Date: 05/03/2000
Title: PW Inspector Date:
Title: City Engineer Date:
Title: Accountin~l Clerk II Date:
11/08/2001
11/08/2001
Approved by: Title: Accountant Date:
Special :l:nstructions For' Handling Check
Mail As Is:
X Mail in Attached Envelope: Interim Check:
Needed By:
Return To:
Other:
(Name)
(Department)
f/n: Forms/excel/chkreq Revised 05/00
City of Campbell - Refundable Deposit Check Request.
To: Finance Director
Check Payable To: Roger 'Cummings
Address - Line 1:
Line 2: 30 Tait Avenue
City: Los Gatos
Description: Refund Deposit
Total Payable: $ 5 0 0 L 0 0
Account Number: 101.2 2 0 3
Account Number:
Account Number: 101.540.7448
(Finance Dept only) Interest Earned
Purpose: Refund of Cash Deposit
State: CA Zip: 95030
(Exact Amount)
Amount: $ 5 0 0.0 0
Amount:
Amount:
(Finance Dept only)
Voucher #:
Receipt#: -' 1303!?/ / /,
Requested by:~~~/~/ Title:
Lym5 P ei%oyejf
Verified by: Title:
Permit #: ENC2000-00056
Date: 5/3/2000
Land Dev. Eng. Date: 1/2/2091
Land Dev. Eng. Date: 1/2/2001
Accounting Clerk II Date:
Special Instructions For Handling .Check
Mail As Is:
Return To:
XX
Mail in Attached Envelope:
(Name)
Interim Check:
Needed By:
(Department)
Other:
f/n: Forms/excel/chkreq Revised 02/00
P,_ ~ WORKS DEPARTMENT RECEIPT
Effective August 1, 1999
TO: City Clerk PUBLIC WORKS PILE NO.
PROPERTY ADDRESS
Plem collect & receipt for the following monies:
;~'~i~'~;;~'i 1 u;;i;;~ ~;u;;'~;"(;~i~'~;;i;;~i .................................................................................................................................................
ESCRO~C~ENT PE~IT
4~2 Appli~tion F~
Non-Utilit~ E~r~hment Permit ($236.25)
Minor Emr~hment Permit < ~,~
R-t Fi~t Permit (No F~) Sub~quent PemiffYr ($105)
Utility E~r~hment Permit
Arzrml/Coll~tor S~et {$341.25}
R~identia[ S~O~er Ar~ ($236.~)
2203 Plan Ch<k ~p~it - 2 · of ENGR. ~. ($5~ rain)
2203 Faithful Performa~ Security {FPS) (1~% of ENGR.~T.)
2203 ~r and Material~ S~urity (1~% of ENGR.
2203 Monumenmion S~uri~ (1~ of ENGR.EST.)
2203~ ~bor and Material S<urity (1~ of ENGR. ~T.)
Plan Ch~k & lm~tion F~ {Non-Utili~)
4722 Engr. Est.< $250,~ (12% of ENGR. ~.)
· * 2203 Engr. Est.>$250,~ (~sit 85 of ENGR. EST./$30,~ min.}**
4722 Utilit~ < $1~,~
Minimum C~ge Per ~tion ($126)
Co~uiB/Pi~li~a up to 5~ F~t ($1.75/~)
A~ve 5~ Lin~ F~t ($1.15/ft)
Manholes/VaulB/E~. ($110.25/~}
Pole SeffRemoval ($1 lO.25/ea)
Strut Tree Planting/Removal ($I 10.25/~)
· - 2203 Utili~ > $1~,~ Actual Cost + 20~
4722 Street T~e Planting/Removal Permit ($110.25)
47~ Pro~t Plato & S~ifi~tiom Pro~t No.
47~ S~nd~d S~ifi~tio~ & D~ils ($1/Pg $12.50~k)
47~ Copies of Engi~ring Maps & Pla~
Aerial Plot 24' x 36'
Aerial ~int 8 I/2' x 11'
Maps and Plans 24' x 36"
4722 Penalties: Failure to restore public improvemen~ ($1~/Calen~ Day)
4722 Penalties: Faiture to co~<t u~fe eo~itio~ ($1~/Calend~ Day)
~ DE~LOP~NT
4722 ~t Line Ad{ustment (~.50}
4722 Pardi M~ {4 ~ or ~} ($1,125 + $25/~t)
4722 Fi~{ T~t M~ {5 or More ~} ($I,450 + $25/~t)
4~2 Cenificam of Compiia~
4~2 Cenifi~te of Correction ($315)
4~2 No~ F~ (~r sig~tu~) ($10)
4722 V~tion of Public Str~ & ~men~ ($5~.50)
4~2~ Assessment Segregation or R~p~rtionment
First Split ($5~.50)
~eh Additional ~t ($178.50)
4721 Storm Drainage Am F~ Per Acre (R-I, $2,~)
(Multi-Res, $2,250)
(All O~er, $2,5~)
4~0 Parkland Dedication Fee (75%~% Due U~n Cert. of ~cupancy)
4~5 Postage
~AmC
4728 Inter~ction Turn Counu (Tw~Hour Count) ($63)
4~8 Inte~tion Turn Coun~ {a.m. or p.m. ~} ($131.25)
4728 T~ffic Flow M~ {Daily Traffic Volume) ($28.35}
4728 Campbell Traffic M~el (Full Sc~ A~sment} ($2,362.50}
4728 Camp~ll T~ffic M~e{ {R~ed S~ As~sment}
4271 Truck Permi~ ($36.75/~ip}
4728 No P~king Sig~ ($1/~ch or $25/1~)
O~R
· *Actual Cost Pl~ 20% Overhea~ (Non-lnter~t ~ing de,itl ....
)% Overhea~ (N. Iring deposit~ .... ~
crrv CLERK ::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
J :;::: :i:;::: :;:i*: :i*i:::;:i:i:: :i ...................... !:::...: ~~i:i:: :!: :~:i:: :i:!:i:iiii~i~i~i' .:~i~i~i' ~ :i~i~r~ '. ..... · ........ ~ j
TODAY'S ~TE: 05/03/00
~E~!STER ~ATE: 05!05!00
01000130511
To: Finance Director
Please Issue Check
Payable to:
Address - Line 1:
Line 2:
City:
Ci_ty of Campbell - Check Request
Interim Check Required:
Return Check to:
Department:
~o_< ~,4-7'-o,5., ~ c).5'O.70 State: CA
Zip: 95008
Description:
Amount Payable:
Account Number:
/'4, -
~-;I¢1~: -'~"0 0, 0 ~2> (Exact Amount)
I01, 750,
Purpose:
Requested by:
Approved by:
Tide:
Tide: d.,q-~dj> 2>~v'. ~R. Date:
/~. zO, b/,,(~-r,c/q Date:
Special Instructions For Handling Check
Mail As Is:
Mail in Attached Envelope:
Other:
fin: S:/excel/chkreqRevised 1198
07/' ¢3/2P_81 11:86 4¢Je22G1702 MC~, CONCRETE
INVOICE
MCR CONCREL £
4942 Scarlet% Way San Jose, CA 95111
T (408) 281.3345 F (408) 226.1702
Lic # 7,12251
DATE'
July
RECEIVED
JUL 1 2 2001
2 U GL.;C, w~RKS
Ai3MINi~TRATIO~
1 1. 2001
BILL TO:
Michael W. Springs
92 Fourth Street, Suite 8
P.O. Box 1126
San Juan Bautista, Ca
95045
D_e.%cr_~xtloj~ Concrete work done for the city of Campbell, at the corner of
Civic Center Dr. and 63 First st.
1. Demolition of the corner barrier
2. Demolition of the sidewalk--g48 sr.
3. Grading and compaction
4. Handicap ramp
5. Replace sidewalk--g48 sL
6. Removal of the old concrete and Install new driveway
$ 600.00'~
$ 2,133 /
$ 1,070 /#8~532-
$ 700 ~
$ 4,029_./
,,,,/o r- 7-0 E,,< CE-E D '-~,¢, 5'00
ITOTAL $1 1,232]
,AMOUNT DUE .........
WORKER'S COMPENSATION INSURANCE INFORMATION
The following worker's compensation insurance information is required for all Applicants and
Contractors. One of the following items for each Applicant and Contractor must be submitted
prior to working under a Public Works permit or contract.
WORKERS' COMPENSATION INFORMATION:
Name of Contractor/Applicant ~.~~~,~~
A Certificate of Consent to Self-Insure issued by the Director of Industrial Relations; OR
A Certificate of Workers' Compensation Insurance'
Insurance Co.
Policy No. Expiration Date ; OR
A signed Certificate of Exemption from the Workers' Compensation laws as printed
below.
CERTIYICATE OF EXEMPTION
I certify that in the performance of the work for this contract, I shall not employ.any
person in a manner so as to become subject to the Workers' Compensation Laws of
California.
Signed ~'~/:/_,~~~ / Date
NOTICE TO APPLICANT/CONTRACTOR: If after signing this Certificate of
Exemption, you should become subject to the Workers' Compensation provision of the
Labor Code, you must forthwith comply with such provisions or the Permit or Contract
will be cancelled or revoked.
j:\forms\workcomp(rev6/96)
WORKER'S COMPENSATION INSURANCE INFORMATIOY
The following worker's compensation insurance information is required for all Applicants and
Contractors. One of the following items for each Applicant and Contractor must be submitted
prior to working under a Public Works permit or contract.
WORKERS' COMPENSATION INFORMATION:
A Certificate of Consent to Self-Insure issued by the Director of Industrial Relations; OR
[] A Certificate of Workers' Compensation Insurance
Insurance Co.
Policy No. Expiration Date ; OR
A signed Certificate of Exemption from the Workers' Compensation laws as printed
below.
CERTIFICATE OF EXEMPTION
I certify that in the performance of the work for this contract, I shall not employ.any
person in a m.~mne~so as to become subject to the Workers' Compensation Laws of
Califo~a~
Title
NOTICE TO APPLICANT/CONTRACTOR: If after signing this Certificate of
Exemption, you should become subject to the Workers' Compensation pt'ovision of the
Labor Code, you must forthwith comply with such provisions Or the Permit or Contract
will be cancelled or revoked.
j:\forms\workcomp(rev6/96)
ACORD.
PRODUCER
FRO Insurance Brokers, Inc.
6130 Stoneridge Mall Rd, #100
Pleasanton CA 94588
Phone~ 925-460-6222 Fax=925-460-9484
INSURED
CERTIFICA' -- OF LIABILITY INSUPJ = I DATE,..'OD
~''~PRIN-1 06/20/01
THIS CERTIFICATE IS ISSUED AS A MA~ER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVE~GE AFFORDED BY THE POLICIES BELOW.
Springs. Construction
ic~aeA Sp;}~s o~a:
· U. ~OX
San Juan Bautista CA 95405
INSURERS AFFORDING COVERAGE
INSURER A:
INSURER B:
INSURER C:
INSURER D:
INSURER E:
General Security Insurance Co.
Acceptance Indemnity Ins. Co.
I1
COVE~GES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIO CLAIMS.
INSR [ FOLICY EFFECTIVE POLICY EXPIRATION
LTR TYPE OF INSU~NCE POLICY N UMBER ~ DATE {M~D~) DATE {M~O~) UMITS
GENE~L L~BILI~ ~CH ~URRE~E $1 · 000 · 000
A X COMM;RClAL~ENEP~LLIAmUTY 22T.24003995 02/04/01 02/04/02 ;IRE O^MA~E {~ one me) $ 100, 000
J CU~lUS MA~ ~ occu, u;o ExP (A.~ o~, ~,~.) s 5,0 0 0
PERBONAL &ADV INJURY $ 1,000,000
GENERALAGGRE~TE $ 2, 000,000
GE~LAGGRE~TELIMIT~PLIESPER: PRO~CTS-CO~P~G $ 1· 000 · 000
PRO-
-~ POLICY ~ JECT ~LOC
AUTOMOBILE UABILITY COMB,NED SINGLE LiMiT $
ANY AUTO , (Fn accidenl)
__ ALL OWNED AUTOS BODILY iNJURY
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INdURY
-- NON.OWNED AUTOS (Per aecide~l)
__ PROPERTY DAMAGE i $
(Per accident)
GARAGE UABlUTY AUTO ONLY - EA ACCIDENT $
__~ ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
__~ occu. L_I C~'MSMADE , A,~,REC_.,,TE s
$
~ DEDUCTIBLE j $
RETENTION $ i
WORKERS COMPENSATION ANDI X IWCTORY8 fAf U-LiMiTS J )!OTH'ER
EMPLOYERS' LIABILITY
B FW99984131 j 02/04/01 02/04/02 E.L. EACH ACCIDENT $ 1000000
I E.L DISEASE- EA EMPLOYEE[ S 10 0 0 0 0 0
EL.. DISEASE - POUCY LIMIT ,iS 1000000
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
All California locations and operations. License#343841. Cancellation ~or
non payment of premium is ten (10) days·
CERTIFICATE HOLDER f N J ADDITIONAL INSURED; INSURER LETTER: --
CANCELLA~ON
City of Campbell
Bldg. Dept.
Attn: Joanne
70 N. First St.
Campbell CA 95008
CAMPBEL
ACORD 25-S (7197)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ~PI~T~N
DATE THEREOF, THE ISS~NG INSURER ~LL EN D~VOR TO ~L 30 DAYS WRi~EN
NOTICE TO THE CERTIFICATE HOLDER N~ED TO THE LE~, BUT FAILURE TO BO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR
PRESENTATIVES. ~ ~
- ~ ~ ~ - ~ACORD CORPO~TION 1988
ACORO. i CERTIFIC/ TE OF LIABILITY INSURANC'E DATE (MM/DD/YY)MAY8 00
~'RODUCER THIS CERTIFICATE IS ISSUEL. AS A MATTER OF INFORMATION
CCIS INSURANCE SERVICES ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
2291 W. MARCH LANE, SUITE 201A HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
STOCKTON CA95207 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PHONE: 209-477-3262
FAX: 209-477-3654 COMPANIES AFFORDING COV~R~E.,,~
COMPANY
Agency Lis#: 0B97936 A CREDIT GENERAL INSURANCE COMPANY""' ~ ~'' I V E D
INSURED COMPANY MAY 1 0 2000
M W SPRINGS CONSTRUCTION B
P.O. BOX 1126 COMPANY PUBLIC
SAN JUAN BAUTISTA CA 95405 C ADMINISTRAT!oNWORKS
COMPANY -
D
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO
WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO
ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YY) DATE (MMIDD/YY) ~ LIMITS
GENERAL LIABILITY ART001 5139 APR 10 00 APR 10 01 GENERAL AGGREGATE $ 1,000,000
OMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $ 1,000,000
CLAIMS MADE ~ OCCUR PERSONAL & ADV INJURY $ 1,000,000
A X [OWNER'S & CONTRACTOR'S PROm EACH OCCURRENCE $ 1,0~00,000
FIRE DAMAGE (Any One Fire)$ 50,000
MED. EXP (Any One Person) $ 500
AUTOMOBILE LIABILITY ~ COMBINED SINGLE LIMIT $
IANY AUTO
ALL OWNED AUTOS BODILY INJURY
-- (Per person) $
] SCHEDULED AUTOS I
I HIRED AUTOS ! BODILY INJURY
---1 ; (Per accident) $
tNON'OWNED AUTOS i
~ I
I PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM ~ , $
WORKERS COMPENSATION AND 17&S.v~,.*.,:,¥-;~ I I~"
EMPLOYERS' LIABILITY EACH ACCIDENT $
THE PROPRIETOPJ ~ INCL DISEASE-POLICY LIMIT $
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL DISEASE-EACH EMPLOYEE $
OTHER:
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED AS PER ATTACHED CG2010. '10 DAY NOTICE FOR NONPAYMENT, 30 DAYS
ALL OTHER. THIS CERTIFICATE IS A REVISION AND SUPERSEDES ALL OTHERS PREVIOUSLY ISSUED. RE: ALL CALIFORNIA OPERATIONS
CERTIFICATE HOLDER CANCELLATION
CITY OF CAMPBELL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL MAIL '30 DAYS WRITTEN
PUBLIC WORKS DEPARTMENT NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.
70 NORTH FIRST STREET
CAMPBELL, CA 95008-1436
AUTHORIZED REPRESENTATIVE
Attention:
ACORD 25-S (1195) Certificate # 11990 .CYNTHIA ARCHULETA
POLICY NUMBER: ART001 5139 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED-OWNERS, LESSEES OR
CONTRACTORS (Form B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY
Name of Person or Organization;
SCHEDULE
CITY OF CAMPBELL, ITS OFFICERS AND EMPLOYEES
PUBLIC WORKS DEPARTMENT
70 NORTH FIRST STREET
CAMPBELL, CA 95008-1436
(If no entry appears above, information required to complete this endorsement will be shown in the
Declarations as applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization
shown in the Schedule, but only with respect to liability arising out of "your work' for that insured by
or for you
CG 20 10 11 85
Copyright. Insurance Services Office, Inc., 1984
Certificate # 11990
Prod: 040430
Prod Name: COAST AUTOIGILROY
Prod Phone: (408) 842-1990
Prod Addr: 401 E. lOTH STREET SUITE #2
Fax: (408) 842-7633 Prod City/St/Zip: GILROY CA 95020
Zap #: 00AE3B
Zap Day: 05/03/2000
Zap Time: 15:25PST
Policy,: 001349512-00
PLEASE COMPLETE FOR ALL PERSONS UNDER AGE 15 AND OLDER, LICENSED OR NOT, WHO RESIDE WITH THE APPLICANT,
AND ANY OTHER DRIVERS OF THE VEHICLE(S) ON THIS APPLICATION.
Named Insured - Mailing Address
MICHAEL W. SPRINGS
P O BOX 1126
SAN JUAN BAUTISTA
Garaging Address (If Different)
301 SEVENTH ST
SAN JUAN BAUTISTA
Do you Own your home?
["] APARTMENT
CA 95045
CA 95045
r~Yes,No
[] CONDO · HOUSE [] MOBILEHOME
Effective Date Time Term
05/03/2000 03:25P 12 mos.
Home Phone: Work Phone:
(831) 623-4783 (831) 623-2193
FR Filing Information:
Type: Name Filing if
First Name I Middle Name I Last Name Applicant A,qe DOB Gender Status SSN # Spouse
Yrs State Valid License Number First Licensed Veh Prin/Occa Occupation
37 CA M0889192 08/24/1961 1 PRIN EMPLOYED ........
ACCIDENTS AND CONVICTIONS WITHIN THE PAST 36 MONTHS {GIVE COMPLETE INFORMATION ON ALL OPERATORS AND/OR MEMBERS OF HOUSEHOLD)
INSURED MUST PROVIDE PROOF OF NOT-AT-FAULT ACC.
Driver Incident Inc Date I Driver Incident Inc Date
1 -MICHAEL FAILURE TO STOP 11/2011997 1-MICHAEL FAILURE TO APPEAR 11120/1997
COMMERCIAL, BUSINESS, PROFESSIONAL, USE EXCLUSION ENDORSEMENT (FORM #01552 R0489)
(Must be signed for all Pickups, Vans, and Utility Vehicles regardless of Profession, and on all Named-driver Non-owner Policies.)
DOES NOT APPLY IF THE VEHICLE HAS BEEN IDENTIFIED FOR ARTISAN USE AND APPROPRIATE PREMIUM HAS BEEN PAID.
In consideration of the premium charged, it is agreed that this policy is amended as follows:
It is hereby understood and agreed that insurance afforded by this policy, or any renewal thereof, shall not apply when any insured person is using a vehicle in the operation of any
business (self-owned or as an employee). Furthermore, coverage shall not apply when any vehicle is owned or leased by a business (single proprietorship, partnership or
corporation) or regularly used in that business. Coverage shall not accrue to the benefit of any insured or any other party including but not limited to a third party claimant(s). Farm
use of any pickup or van shall not, for the purposes of this endorsement, qualify as business use.
· .~ .. : .::.. ::: ::. :: :!!!:i!:~:i~ Date:
Applicant's Signature: ~ ~-' ~' . ~
Rev.:l 1/5/98 - INF270CA
' ZapApp ~o:00AE3B
CALIFORNIA AU- SURANCE APPLICATION Applicant: N ,EL WAYNE SPRINGS Page 2 of 8
DESCRIPTION OF THE AUTOMOBILE(S)
# Yr Make Model V.I.N. ACV Purch Date New/Used
1 1994 (:;MC C1500 1GTEC14ZORZ509316 11165 12/31/1996 NEW
5
LOSS PAYEE - (FINANCIAL INSTITUTION ONLY~ ADDITIONAL INSURED
PRIMUS AUTOMOTIVE P O BOX 7555 SPRINGFIELD OH 45501 E] Yes III No
Annu. ] Usage Rate/Band I Points Veh Veh Discount/
Miles Odometer B/PNV LI PD Class LI PD Symbol A,qe Credits Surchar,qe
18000 208000 W 165165 1 1 P01 0
Coverage and Limits of Liability
Covera,qe Applies Only Where Premium is Indicated
Coverages Premiums
$ 50000 Occur
$ 20000 Occur
$ 2000 Pers
$ 50000 Occur
$ 3500 Occur
NONE
Liab-BI $ 25000/ Pers
Liab-Property Damage
Medical Expense
UMBI $ 25000~ Pets
UMPD ACV or MAX
Comp Ded 1:$500 2: 3:
Coil Ded '1:$500 2: 3:
Collision Deductible Waiver
Special Equipment Coverage
Towing
Rental
Accd Death Limit
Waiver of Glass Deductible
Waiver of Mandatory Arbitration
Total Vehicle Premium:
Veh I
246.00
102.00
102.00
128.00
0.00
196.00
236.OO
22.00
0.00
0.00
$ 0.00
$ 0.00
$ 0.00
$ 0.00
$ 1032.00
~
Down Payment to be SWEPT
Pay Period Months: 10
137.00
Total Premium, All Vehicles:$
FR Filing Fee:$
CIGA Surcharge: $
Policy Fee: $
1032.00
000
0.00
25.00
Total Policy Premium: $
1057.00
Rev.:l 1/5/98 - INF270CA
iii ACORn. CEiR IiEICA...ci!O!F!!!EtABI!LIT::¥!i!INSUIL.
..................... ..........~~~.~............................~.~..............................~.....~....~.~~..~..~.~.......................~..........~...............~.......~.~....................~ ......... ................. 04/27/00 .
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
FRO Insurance Brokers, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
6130 Stoneridge Mall Rd, #100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Pleasanton CA 94588 COMPANIES AFFORDING COVERAGE
COMPANY
PhoneNo, 925-460-6222 FaxNo. 925-460-9484 A Credit General Insuran~
Co.
mchaeZ M W S rings Springs Cons tion a a, COMPANY C
P. O. Box 1126 COMPANY
San Juan Bautista CA 95405 D ~WIIvi~._I4,,Olct~,,,...
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQtJIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I POLICY EFFECTIVE I POLICY EXPIRATION I
co PEOF,NSURANCE PO',CY.UMBER L,M,TS
LTR DATE (MM/DD/YY) ' DATE (MI'vl/DDy~"K)
GENERAL LIABILITY GENERAL AGGREGATE $ 1 · 000, 000
A X COMMERCIAL GENERAL LIABILITY ART0015139 04/10/00 04/10/01 PRODUCTS-COMP/OPAGG $ 1· 000, 000
:;;::;: CLAIMS MADE OCCUR PERSONAL & ADV INJURY $1,000,000
X OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $ 1, 000,000
FIRE DAMAGE (Any one fire) $ 50 · 000
MED EXP (Any one person) $ 500
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO
__ ALL OWNED AUTOS BODILY INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY: '.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'.'
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM $
WC STA'rU- OTH-
EMPLOYERS' LIABILITY
EL EACH ACCIDENT $
THE PROPRIETOPJ [--'--] iNCL EL DISEASE - POLICY LIMIT $
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL EL DISEASE. EA EMPLOYEE $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
Job.' 63 North_First Street. License #343841. Cancellation for
Non-Payment o~ Premium is Ten (10) days.
CAMPBEL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL ~ MAIL
City of Campbell 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Public Works Department .......
70 North First Street ...............................
Campbell CA 95008-1436 _~ .................................. ~. .....
:A~R~:!25;~S:~(~1~95):!:!:i:i:i:!:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:!:i:i:i:i:i:!:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:::i:i:i~~!:~!:i:i~~I!~N:i1i~88i:i
;925 460 9494
..~"~~ ....... 04/2?/00
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
FRO Insurance Brokers, ThC. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
613 0 Stoneric~ge Mall Rd, #100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
l~l~asanton CA 94588 COMPANIES AFFORDING COVERAGE
COMPANY
~me~. 925-460-6222 FaxNq. 925-460-9484 A Credit General Insurance .... Co.
iNSU RED COMPANY
M&chael Springs dba: C
o. co, ^Ny APR 2 7 [lO0
San Juan Bautista CA 95405 D
?1o
N
INDICATED. NOTWffHSTANDING ANY REQUIREMENT, TERM OR CONDmON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS -
CERTIFICATE MAy B~ ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLK;lES DESCRIBED HEREIN L~ SUBJECT TO ALL THE TERMS,
EXCLUSK)NS AND CONDITIONS OF SUCH POLICIES. UMITS SHOWN MAY HAVE B~EN REDUCED BY PAJD CLAIMS.
CO TYPE OF INSURANCE POUCY NUMBER POUCY EFFECTIVE POL~Y EXPIRATION LIMr[S
LTR ~ATE (MM/DO/YY) IiATE
I GENERAL L~Lr~ GENERAL AGGREGATE $1 · 000,000
~ X COMMERC~LGENERALLLABILITY ~0015139 04/10/00 04/10/01 PRODUCTS-COMP/OPAGG $1,000,000
X OWNERS & CONTRACTOR'S PROT EACH OCCURRENCE $ I, 000,000
FIRE DAMAGE (Any 0ne tim) $ ~0~000
MED EXP (Any 0ne pemon)$ 500
AUTOMOSILE UABIL~Y
COMBINED S~NGLE LIMIT
ANY AUTO
ALL OWNED AUTOS BODILY INJURY
, SCHEDULED AUTOS (Per
HIRED AUTOS BODILY INJURY $
I NON~)WNEDAUTOS (Per ac~de~t)
PROPERTY DAMAGE
GARAGE LD~BILITY AUTO ONLY - EA ACCIDENT
EACH ACCIDENT
AGGREGATE
~CESS ,~u~ EAC. OCCUR~CE $
UMBRELLA FORM AC',GREOATE S . .
omE~,T.AN u~.~u.~ ro~
WC STATU-
EMPLOYERS' LIABILITY EL EACH ACCIDENT $
THE PROPRIETOR/ ~ INCL EL DISEASE. POLrCY LIMIT $
P^RTNERS/E~ECL/TIVE
OFFIC~ ARE: EXCL i EL DISEASE - EA EMPLOYEE
OTH~
DESCRIPTION OF' OPERATIONS/I_OCATIONS.NEI~iCL -ES/SPECIN_ ITEMS
JOb= 63 ~ort-.b, First ~treet. ~.icasse #343843., C&acel:].&t:ios £or
~on-PaTment oE Pre~L~m :i.s ?e= (3.0)
i C~J~P'I=t ~'r' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCE]LLED BEFORE THE
, EXPIRATION DATE THEREOF, THE IS...'.'.'.'.'.'.'.'~JI NG COMPANY WILL ~ MAI[.
C~ l:70 f Ca~u--13he 1~ 3 0 DAYS WRI~FEN NOTICE TO THE CER1]FICATE HOLDER NAMED TO THE LEFT,
Pu331ic Works De~&rtm~nt -- , .... ~ ....... _
?0 North First ~treet .......................
FAX
TO:
Phone
Fax Phone
CC:
REMARKS:
Ronafi
FRO 1 surance Brokers, Inc.
6130 ~'toneridge Mall #I00
Please nton, CA 94588
(925) t60-6222
(925) t60-9484
[] Urgent [] For your review
I Date 4/2 7/00
I Number of pages including cover sheet
FROM:
doanne D'Ambrosia
City of Campbell
70 North First Street
Campbell, CA 95008
Phone
Fax Phone
(408)866-2701
(408)376-0958
Re: Insured: Michael
Permit No. ENC5
We have reviewed yot
you for responding so
you are only providing
specifically state that
Copies of the applical
of the original certific
for your help.
[] Reply ASAP [] Please Comment
Springs dba MW Springs Construction
000-00056/63 N. First Street
r edits to the certificate of insurance for the above referenced contractor. Thanks
:luickly. There is still one item, however, that we need added to the certificate. As
$1,000,000 general aggregate under general liability we require that the certificate
he insurance applies separately to 63 North First Street, which is the work address.
le section of our insurance requirements follow for your reference as well as a copy
~te that was submitted. Please call me if you have any questions. Agains, thanks
'PRODUCER .................................................................... YHiS 'CERTiFicATE' i'S 'lS~0~D AS A MATTER Of INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
FRO Insurance Brokers, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR
6130 Stoneridge Mall Rd , #100 ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW.
Pleasanton CA 94588 COMPANIES AFFORDING COVERAGE
COMPANY
A Credit General Insurance Co.
PhoneNo. 925-460-6222 Fax lo. 925-460-9484
INSURED COMPANY
B
M W Springs Construction COMPANY
Michael Springs dba: C
P. O. Box 1126 COMPANY
San Juan Bautista CA 95405 D
THIS IS TO CERTIFY THAT THE POLICIES ( )F INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY RE(; UIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PE ~TAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH =OLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
co I TYPE OF INSURANCE POLICY NUMBER I POLICY EFFECTIVE IPOLICY EXPIRATION LIMITS
LTR DATE (MM/DD/YY) DATE (MM/DD/YY)
GENERAL LIABILITY GENERAL AGGREGATE $ 1, 0 0 0, 0 0 0
A X COMMERCIAL GENERAL LIABILITY ART0015139 04/10/00 04/10/01 PRODUCTS-COMP/OPAGG $ l, 000,000
iii! [ CLAIMS MADE ~ OCCUR PERSONAL&ADVINJURY $ 1, 000,000
X OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $ 1 · 000 · 000
FIRE DAMAGE (Any one fire) $ 50·000
MED EXP (Any one person) $ 500
AUTOMOBILE LIABILITYANY AUTO ~tECEI COMBINED SINGLE UMIT $
(Per person) $
SCHEDULED AUTOSH,RED AUTOS
~UBLIc
(Per
NON-OWNED AUTOS
~N PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM $
WC STATU-I OTH-
EMPLOYERS' LIABILITY EL EACH ACCIDENT $
THE PROPRIETOPJ ~ INCL EL DISEASE - POLICY LIMIT $
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL EL DISEASE - Fca EMPLOYEE $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSN[ HICLES/SPECIAL ITEMS
Ail California Operati(~ns and Locations. License #343841. Cancellation for
Non-Payment of Premium is Ten (10) days
CAMPBEL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ~MAIL
City o f CampbelL 30 DaYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Public Works Department ~,1 ....
~ ~" ~ree~ .......... II In I~ir .....
?0
North
First
Campbell CA 950!08-1436
~E~RIZED REPRESE IATI E
RD 25 S ~1735 ................................................... ~~ .:~z..~'.~f. :~........~CORPORATiON '1'988' '
Policy Number:
THIS EN
This endorsemen
IRT0015139 Commercial General Liability
)ORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS (FORM B)
modifies insurance provided under the following: M W Springs Construction
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person ~r Organization:City of Campbell
Redevelopment
Agency
/
I It's Officers, Employees and Volunteers
I 70 North First Street
Campbell, CA 95008-1436
(If no entry appe~ trs above, information required to complete this endorsement will be shown in the
Declarations as a >plicable to this endorsement).
WHO IS AN IN~ URED (Section II) is amended to include as an insured the person or organization shown
in the Schedule, 1 ~ut only with respect to liability arising out of"your work" for that insured by or for you.
It is further agree~ that such insurance as is afforded by this policy for the benefit of the additional
insured(s) showr~ above shall be primary insurance but only as respects to any claims loss or liability
arising out of the operations of the named inusred or from occupancy maintenance or use of the premises
by the named insured and any insurance maintained by the additional insured(s) shall be non-contributory.
CG 20 10 11 85 Copyright, Insurance Services Office, Inc., 1984
CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
PHONE (408) 866-2150
FAX (408) 376-0958
FACSIMILE TRANSMITTAL SHEET
TO: FROM:
Ronald Joanne D'Ambrosia
COMPANY: DATE:
FRO Insm ance Brokers, Inc. 04/21/2000
FAX NUMBER: TOTAL NO. OF PAGES INCLUDING COVER:
(925) 460-9 ~84 8
PHONE NUMBER: SENDER'S REFERENCE NUMBER:
(925) 460-6222
RE: YOUR REFERENCE NUMBER:
[] Insurance~ertificate
URGENT I_1 FOR REVIEW
[] PLEASE COMMENT XPLEASE REPLY [] PLEASE RECYCLE
NOTES/COMMEN~S:
RE: Permit #ENC2000-00056/M W Springs Construction/63 N. First Street !
We have receiv
does not meet tl
the insurance c
cfa/1. We requi~
provide
applies se
~ 2. We requi~
employee
Thecertifi
coverage
ed a copy of insurance certificate for M W Springs Construction and find that it
~e City's insurance requirements. Copies of our insurance requirements as well as
ertificate follow for your reference. The main items that are missing include:
e $2,000,000 general aggregate under general liability. If the insured desires to
fly $1,000,000 coverage the certificate must specifically state that the insurance
~arately to the above-referenced project only.
· e that the City, the City of Campbell Redevelopment Agency, its officers,
and volunteers be named as additional insured on the certificate.
~ate needs to state or an endorsement needs to be attached showing the insurance
fforded the Additional Insured is primary insurance.
The cance[lation area of the certificate needs to be edited to delete "endeavor to" and "but
failure to ~n. ail such notice shall impose no obligation or liability of any kind upon the
company, xts agents or representatives".
Please fax a cop~, of the revised certificate to me for review. If you have any questions you may
contact me at (408) 866-2701 Thanks for your help in this matter.
!
70 NORTH FIRST STREET, CAMPBELL, CA 95008-1436
................................................. ~.~..~.~`..~`~..~.~...~...~...~..~..~.~.~...~..~.....~........... ... .... ..... .... ..... 04/11/0o
PRODUCER THIS CERTIFICATE IS ISSUED AS A MAI I~R OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
FRO Insurance Brokers, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
6130 Stoneridge Mall R~, #100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Pleasanton CA 94588 i COMPANIES AFFORDING COVERAGE
I COMPANY
PhoneNo. 925-460-6222 Fax o. 925-460-9484 A Credit General Insurance Co.
INSURED
COMPANY
B
M W Springs Constr~ction COMPANY
Michael Springs ~ba .. C
P. O. Box 1126 COMPANY
San Juan Bautista ."A 95405 D
:::::RA::::::::::::::::::::::::::::::::::::::::::::::::
THIS IS TO CERTIFY THAT THE POLICIES { F INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQ JIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PEI ~TAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH I )OLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
LTR DATE (MM/DD/YY) DATE (MM/DD/YY) LIMITS
GENERAL LIABILITY GENERAL AGGREGATE $ 1, 000, 000
A X COMMERCIAL GENERAL LIABILITY T 1% D 04/10/00 04/10/01 PRODUCTS-COMP/OPAGG $ 1, 000, 000
::': I CLAIMSMADE ~-~ OCCUR PERSONAL&ADVINJURY $ 1, 000, 000
__X OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $ 1 · 000 · 000
FIRE DAMAGE (Any one fire) $ 5 0, 0 0 0
MED EXP (Any one person) $ 5 0 0
AUTOMOBILE LIABILITY I
ANY AUTO COMBINED SINGLE LIMIT $
ALL OWNED AUTOS
BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS
BODILY INJURY
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY. EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE ! $
-~ UMBRELLA AGGREGATE $
FORM
! I ~ I HER 'FHAN UMBRELLA FORM I $
WORKERS COMPENSATION AND I WC STATU-
EMPLOYERS' LIABILITY . TORY LIMITS t OTH-
EL EACH ACCIDENT $
THE PROPRIETOR/ E~ INCL EL DISEASE- POLICY LIMIT $
PARTNERS/EXECUTIVE
OFFICERS ARE:I ] EXCL EL DISEASE- EA EMPLOYEE $
OTHER
DESCRIPTION OF OPERATIONSJLOCATIONSNEH CLES/SPECIAL ITEMS
All California OperatiozLs and Locations. License #343841. Cancellation for
Non-Payment of Premium .s Ten (10) days
ROGERCU SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WELL ENDEAVOR TO MAIL
3 0 DAYS WRI~'EN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Roger Cummings
30 Tai t Avenue BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
Los Gatos CA 9 5 0 3 0 OF ANY KIND UPON THE COMPANY. ITS AGENTS OR REPRESENTATIVES.
JOHN LIEN
ARCHITECT
· 196 College Avenue Phone (408) 395-3525
Los Gatos, California 95030 Fax (408) 395-4560
. '..' ;... '. ~"" '--' ? ':-: '~ ';':' -t ....
December 9, 2002
Roger Cummings
Network Funding A
63 North First Streel
Campbell, CA 9500
SUBJECT:
PER1
LOC
ONE
Dear Mr. Cumming:
The City of Campl
Works improvemen
Your warranty requi
Your remaining wl
directly to you from
Public Works Inspe
MQ k.~&,
cc: PermitENC2012
Public Works/}
CITY or CAMPBELL
Public Works Department
CAMPBELL
;sociates, Inc.
lit NO. ENC2000-00056 and ENC2000-00056A
~TION: 63 North First Street
YEAR MAINTENANCE INSPECTION - ACCEPTANCE
~.11 has made the final one-year maintenance inspection of subject Public
:s and find that no remedial work is required.
rements and any surety, therefore, are hereby released.
· ranty deposits of $2,750 and $1,100, plus any interest due, will be sent
our Finance Department.
:tor
D-00056
~aintenance Division
h:\word\permitsk2000_56acc(j d)
70 North First Street - Campbell, California 95OO8-1436 · TEL 408.866.2150 - FAX 408.376.0958 · TOD 408.866.2790
November 8, 2001
Roger Cummings
Network Funding As.,
30 Tait Avenue
Los Gatos, CA 95030
SUBJECT:
PER]~
LOC,
FINA
Dear Mr. Cummings:
The City of Campbel
work to be acceptable
improvements.
The one year mainten
CITY oF CAMPBELL
Public Works Department
ociates, Inc.
~T NO. ENC2000-00056 and ENC2000-00056A
kTION: 63 North First Street
L INSPECTION AND ACCEPTANCE
. has made a final inspection of subject Public Works improvements and finds the
and in conformance with City standards. Accordingly, the City Engineer accepts the
race period stated in the permit begins as of the date of this acceptance letter. The
permittee is responsil: le for the repair and/or replacement of any defective work or failures that occur
within one year. Th~ City will inspect the improvements within one year and notify you, in writing,
whether or not any repairs are required.
/
75%. of your Faithful Performance Surety (FPS) cash deposits of $11,000.00 and $4,400.00, plus any
~nterest due, are now I~eing processed and will be sent to you under separate cover. We will continue to
hold 25% of your FPS cash deposits as a maintenance surety. Additionally, your Construction Cash
Deposit of $616.00, lus any interest due, is now being processed and will also be sent to you under
separate cover.
If you have any questi
Sincerely,
Syed Wahidi
Public Works Inspecto]
cc: Suspense- 11 mo~
Perrmt #ENC200~
Inspector File
,ns, please call me at (408) 866-2165.
ths
-00056
h:\word~2000_00056fin(jd)
70 North First Street . C,~mpbell, California 95008-1423 - TEL 408.866.2150 · FAX 408.376.0958 - TDD 408.866.2790
STREET 15IPROVEMENT AND REIMBURSEMENT AGREEMENT
~-THIS ,ikGREEMENT, is made and entered into on the /dt~ day of
~/d,4 / 2001, by and between the City Council of the City of Campbell, a
municipal corppration of the County of Santa Clara, State of Califo ,r~,~a, herein,a~, er
referred to as "~2ity" and Roger Dean Cummings, hereinafter referred to as Developer'.
adopted Res&
to allow the cc
comer of Civic
street improven
WI-IEPd
barrier located
a part of the off
WHEPd
replacement of
agreed to recor
the traffic bani
ramp; and,
WI-IEPd
for the offsite sl
WHEPd
identified as E?
as ENC 2000-
aforesaid street
NOW,
parties hereto a
RECITALS
:.AS, the City Council of the City of' Campbell on March 21, 2000,
.tiori No. 9658 approving a Planned Development Permit (PLN 1999-22)
nversion of an existing residential use into an office use at the northwest
Center Drive and North First Street; and,
:.AS, a condition of approval of PLN 1999-22 required the installation of
lents associated with the converted use; and,
:.AS, Public Works Department staff determined that the metal traffic
>n the comer was no longer appropriate and desired to have it removed as
ite street improvements; and,
AS, the removal of the traffic barrier necessitated the removal and
:he adjacent sidewalk and pedestrian ramp; and,
:.AS, in discussions with the Developer, Public Works Department staff
amend to the City Council that the City contribute the cost of removal of
er. and removal and replacement of the adjacent sidewalk and pedestrian
iAS, Public Works Department staff has reviewed the contractual prices
reet improvements; and,
:.AS, the Developer has entered into a Street Improvement Agreement,
[C 2000-00056 Phase II, has obtained an Encroachment Permit, identified
56 Phase II, and has provided insurance and indemnity to cause the
improvements to be constructed.
'H2EREFORE, in consideration of each other's mutual promises, the
'ee as follows:
(1)
(2)
IN WI~
Public Works 12
adopted Septen
day and year fir:
Attest:
Bybee, ~k/
['he Developer shall remove the traffic barrier and remove and replace the
tdjacent sidewalk and pedestrian ramp in accordance with the approved
>fans and specifications for Encroachment Permit ENC 2000-56 Phase II.
Fhe City shall pay the actual cost of the traffic barrier removal and
[djacent sidewalk and pedestrian ramp removal and replacement in an
[mount not to exceed $8,500.00
2x/ESS WHEREOF, said City has caused its name to be affixed by its
)irector and City Clerk, who are duly authorized by Ordinance No. 1951
lber 2, 1997, and said Developer has caused his name to be affixed the
;t above written.
d_,. DEAN CUMMINGS, an
man, Developer
CITY OF CAMPBELL, a municipal
corporation of the State of California
~CROAC~ PERM1T ISSUANCE CHI~,~ LIST
City of Campbell Encroachment Permit
Department of ~blic Wor~ Tract No.
~MS ~Q~D FO PE~ ~PLICA~ON:
A[plicant section Complete
plicant signatur and date(front Md back)
Permit Applicafior Fee ~ paid - Receipt Number
j Engineer's Estima
i>"'"~Plan Check Depos
k~. Five Sets of Impro
ITEMS REQUIRED PRI(
~/~Plan Check & Insp
Estimate > $250,(
deposit).
e Submitted
Paid (2% of Engineer's Estimate, $500 min) Receipt Number
vement Plans Submitted
)R TO PUBLIC WORK CLEARANCE FOR BUll,DING PERMITS
:ction Fee: If Engineer's Estimate < $250,000, then 12% of Engineer's Estimate. If Engineer's
00, then Actual Cost + 20%. (Deposit of 8% of Engineer's Estimate required; 530,000 minimum
mount $ ,,/fff~-) Receipt No. /.:,,'5_ .~,/2~ .~ ~,,~
/.'""'/Security for Faithfl Performance and Labor and Mtaterials, 100% each of Engineer's Estimate, supplied or paid.
,,~'.".'///~Security for Monut aentation Amount $ Receipt No.
'~'/Construction E. r~ncy Cash Deposit: 4.% of Engkneer's Estimate. ($500 mimmum, $i0,000 maximum)
Amount $ Rece,pt
,
rm Drainage ,~r :a Fee Amount $ <~.ff2~ Receipt No.
Worker's Compens
'~AI1 other Public
Other Fees, Payme:
1TEMS RZQL'IRED PRIO
Contractor's signart
Worker's Compens:
Ce?.:.ficate of Insur:
xtion Insurance Information Sheet Received for Applicant.
~rlcs requirements listed [n the Conditions of Approval of the development.
zts, Deposits Amount S Receipt No.
R TO ISSUANCE OF ENCROACi-~i~,NT PERMIT:
re added to the permit application (front and back)
~tion Insurance Information Sheet received from Contractor.
nco with Additional Insur:d's Endorsement rec:ived item Applicant ar Can:mc:er.
__ One tartar set md t'gur blue,ins sets of off-fire ~lans signed by licensed eng:_nee:, staw. ued Y.?FR.Y.:ED FCR
CONS3XUCTiON.
Pe:~nit signed by Ci~ Engineer.
!
.,ssuer: ir2:iai ~"~"- i ~d date m-.d fil~ wi.:h permi:.
V/~UPON ISSUANCE INI ,ATE C C~REQUEST FOR PLAN CHECK DEPOSIT REFUND
v
CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
ENGINEER'S ESTIMATE
Address: 63 N. FIRST STREE' Date: 0410612000
ENCROACHMENT PERMIT NO. APPLICATION NO.
ITEM UNIT PRICES FOR PROJECT AMOUNT
NO. DESCRIPTION UNIT QTY < $30 K $30 K to $150 K > $150 K $ AMOUNT
I. SURFACE CONST~ UCTION
MOBILIZATION ! I LS $ 1,000.00 $ 1,750.00 $ 1,000.00
CONSTRUCTION T~ AFFIC
CONTROLCONTRO] dPHASING I LS $ 750.00 $ 1,750.00 $ 750.00
CONSTRUCTION S~ ~KING DS $ 500.00 $ 500.00
CONSTRUCTION TE STING LS $ 1,500.00 $ 1,500.00
Il. DEMOLITION/CLE, kRING
1. CLEARING & GRUB 31NG DS $2,000.00 $2,000.00
2. SAWCUT P.C.C./A.( .(UP TO 6') 133 LF $4.50 $3.00 $2.00 $ 598.50
3. P.C.C. REMOVAL 87 SY $30.00 $23.00 $10.00 $ 2,610.00
4. CURB AND GU'I-I'Eg REMOVAL LF $6.00 $3.00 $2.00
5. MEDIAN REMOVAL SF $4.50 $2.25 $1.25
6. DEMOLISH EXISTIN 3 INLET/PLUG RCP'S EA $300.00
[II. STORM DRAINAGE
1. 12' R.C.P. (CLASS V LF $60.00 $40.00 I $20.00
2. 15' R.C.P. (CLASS II ) LF $65.00 $48.00 $38.00
3. 18' R.C.P. (CLASS Iii) LF $70.00 $60.00 $52.00
4. ~4' R.C.P. (CLASS Iii ) LF $80.00 $68.00 $59.00
5. 30' R.C.P. (CLASS III) LF $90.00 $75.00 $65.00
6. T.V. INSPECTION (1; ') LF $1.20 $0.75 $0.60
7. STD. DRAINAGE iNL ET EA $1,600.00 ~ $1,300.00 $1,000.00
C.C. DETAIL 9)
8. FLAT GRATE INLET EA $1,400.00 $1,100.00 $900.00
C.C. DETAIL 6)
9. ;TANDARD MANHO] ,E EA $2,000.00 $1,600.00 $1,300.00
C.S.J. DETAIL D-Il)
INCLUDES FRAME ~: LID)
10. BREAK AND ENTER ~.H./D.I. EA $700.00 $550.00 $450.00
Page I
ITEM UNIT PRICES FOR PROJECT AMOUNT
NO. ~)ESCRIPTION UNIT QTY < $30 K $30 K to $150 K > $150 K $ AMOUNT
IV. CONCRISTE; IMPR£ VEMENTS
1. SIDEWALK 780 SF $6.50 $4.50 $2.75 $ 5,070.00
2. DRIVEWAY APPRO, iCH SF $7.50 $5.50 $3.75
3. CURB AND GU"I~I'E~ LF $22.00 $18.00 $15.00
4. VALLEY GUTFER SF $12.50 $10.00 $8.25
5. HANDICAP RAMP EA $1,200.00 $800.00 $700.00
6. TYPE B-I CURB LF $12.00 $9.50 $7.50
7. TYPE AI-B3 CURB LF $15.00 $12.00 $10.00
8. COBBLESTONE ME[ lAN SURFACE SF $12.00 $8.00 $5.00
9. P.C.C. DRIVEWAY ( ONFORM SF $7.00 $5.50 $4.50
I0. A.C. DRIVEWAY CO ~IFORM SF $4.50 $3.75 $3.O0
V. PAVEMENT
1. ASPHALT DIGOUT A ND REPLACE CF $2.00 $3.50 $2.50
2. PAVEMENT WEDGE CUT (63 LE $5.00 $2.50 $1.50
3. PAVEMENT GRINDII IG SF $0.80 $0.50 $0.35
4. PAVEMENT FABRIC '~PETRO-MAT) SY $2.00 $1.85 $1.50
5. ASPHALT CONCRE'E (TYPE A) T $80.00 $50.00 $35.00
(73.4)( 18)(0.33)(0.077.'
6. AGGREGATE BASE 0 :LASS 2) T $40.00 $20.00 $12.00
(73.4)(18)(0.92)(0.070)
7. SLURRY SEAL (TYPE II) SF $0.07 $0.06 $0.05
8. SLURRY SEAL (TYPE Ill) SF $0.11 $0.09 $0.07
VI. rRAFFIC SIGNALS/I IGHTS
1. DETECTOR LOOP (6' ROUND) EA $450.00 i $300.00 $250.00
2. DETECTOR LOOP (6' ~ 30') EA $650.00 $540.00 $440.00
3. DETECTOR LOOP (6' 50') EA $900.00 $750.00 $640.00
4. ELECTROLIER EA $2,600.00 $2,200.00: $1,800.00
5. I I/2' RIGID CONDUI [' LF $9.00 $7.00 $5.00
6. 2' RIGID CONDUIT ~ LF $17.00 $13.00 $10.00
7 CONDUCTOR LF $0.70 $0.55 $0.45
Page 2
ITEM UNIT PRICES FOR PROJECT AMOUNT
NO. )ESCRIPTION UNIT QTY < $30 K $30 K to $150 K > $150 K $ AMOUNT
8 PULL BOX (NO. 3 1/ !) EA $300.00 $240.00 $185.00
9 PULL BOX (NO. 5) EA $400.00 $350.00 $300.00
VII. STRIPING AND SIGi ~'S
1. REMOVE PVMT. M.a RKINGS (PAINT) SF $2.50 $1.50 $1.00
2. 'REMOVE PVMT. M.4 RKINGS (THERMO) SF $3.00 $2.00 $1.40
3. REMOVE PVMT STR PING LF $1.40 $0.80 $0.40
4. STRIPING DETAIL 9 LF $1.35 $0.85 $0.35
4.5 STRIPING DETAIL 22 LF $2.25 $1.65
5. STRIPING DETAIL 2§ LF $2.25 $1.65 $1.20
6. STRIPING DETAIL 32 LF $2.40 $1.75 $1.25
7. STRIPING DETAIL 37 (THERMO) LF $1.85 $1.50 $1.00
8. STRIPING DETAIL 38 (THERMO) LF $2.50 $1.85 $1.15
9. STRIPING DETAIL 39 LF $1.50 $0.85 $0.45
10. STRIPING DETAIL 40 LF $2.20 $1.70 $1.00
11. LIMIT LINE LF $1.35 $1.05 $0.90
12. CROSSWALK LF $1.35 $1.05 $0.90
13. PAVEMENT MARKINI }S (PAINT) SF $2.50 $1.90 $1.60
14. PAVEMENT MARKIN( }S (THERMO) SF $5.50 $3.80 $2.60
15. PAVEMENT MARKER (NON-REFL.) EA $4.50 $3.00 $2.20
16. PAVEMENT MARKER REFLECTIVE) EA $6.00 $4.15 $3.15
17. TYPE K MARKER EA $95.00 $80.00 $70.00
18. ]'YPE N MARKER EA $95.00 $80.00 $70.00
19. 5ALVAGE ROAD SIGN EA $85.00 $75.00 $65.00
20. RELOCATE ROAD SIG] ~' EA $I00.00 $85.00 $75.00
21. INST. RD. SIGN ON E~ IST. POLE EA $200.00 $145.00 $110.00
22. ROAD SIGN WITH PO! F EA $300.00 ' $240.00 $195.00
23 STANDARD BARRICAI3{E LF $15.00
I
Page 3
ITEM
NO.
VIII.
1.
2
3.
4.
5.
6.
7.
8.
X.
1.
2.
3.
4.
5.
6.
LANDSCAPING
IRRIGATION, PLAN~
PRUNE TREE ROOT
I'REE REMOVAL
ROOT BARRIER (12'
ROOT BARRIER (18'
STREET TREE (15 G/
STREET TREE (36' B,
TOP SOIL BACKFILL
MISCELLANEOUS
PEDESTRIAN BARRII
CHAIN LINK FENCE
RAISE MISC. BOX TC
)ESCRIPTION
RAISE MANHOLE TO
INSTALL MONUMEN
MEDIAN BACKFILL
'lNG WORK
~R
6')
GRADE
QTY
SF
EA
EA
LF
LF
EA
EA
CY
UNIT PRICES FOR PROJECT AMOUNT
< $30 K
UNIT
LF
LF
EA
$8.00
$125.00
$650.00
$20.00
$25.00
$450.00
$700.00
$20.OO
$75.00
$15.00
$3OO.00
$30 K to $150 K
$8.00
$100.00
$500.00
$10.00
$15.00
$325.00
$550.00
$20.OO
$60.00
$11.50
$200.00
> $150 K
$85.00
$400.00
$6.00
$10.00
$250.00
$400.00
$50.00
$9.25
$175.00
$ AMOUNT
PREPARED BY:
REVIEWED BY:
APPROVED BY:
GRADE
[' BOX
EA
EA
CY
$400.00
$450.00
$19.00
$275.00
$350.00
$17.00
$200.00
$300.00!
$15.50
SUBTOTAL
10% SECURITY ENFORCEMENT FEE
TOTAL ESTIMATE FOR FAITHFUL
PERFORMANCE SECURITY
$10,028.50
$ 1,002.85
$11,031.35
$11,000.00
*See Section 66499.4 of the Map Act.
h: \landdev\63 nfirstenges 6 mate4_O0, xls~ rip)
Page 4
June 8, 2000
Roger Cummin
30 Tait Avenue
Los Gatos, CA
Subject: Permit
Mr. Cummings
During the proc
contractor ran G
you are hereby:
specifications o
Caltrans #6 C~
the lid.
Your immediat~
call me at (408)
Yours truly,
Alan Hom
Public Works In
Cc file
CITY ol: CAMPBELL
Public Works Department
gs
95030
No. ENC 2000-00056, 63 N. First Street.
ess of your demolition work at the abovementioned address, your
ver the utility box lid and damaged it. Per the conditions of your permit,
ratified to replace the utility box lid to the city's fiber optic box. The
tthe lid is as follows:
isty N36 with the words "CAMPBELL COMMUNICATION" casted into
:ly response will be greatly appreciated. If you have any questions, please
866-2168.
spector
70 North First Street · Campbell, California 95008-1423 · TEL 408.866.2150 - VaX 4083760958 ' TDD 408.866.2790