96-140
CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
ENCROACHMENT PERMIT
(for working within the
public righ cOf-wat
Issued 3 I t; 11 t;
Permit expires in 12 mos.
lit No,
A .,ef. File
Cl0--/ Llo
Application Date~ (2) I tt b
Application expires in 6 mos.
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 Application Fee is non-refundable).
A. Work address or tract # \ 'S~ DE 1-1- Av E. . ( A-M p~ CL..-l.-
Utility trench location 5~ E .
{ ..... A'.
B. Nature of work INSTAl....-l..-- ~",(.O)C. .;>0 L..r-. OJ::. ~ SA+.!. ~L.J:>",
C:>Sw~
C. Attach four (4) copies of engineered plans showing the location and extent of the work, and four (4) copies of the preliminary Engineer's
Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by
the City Engineer, said plans become a part of thi~ 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 shut-<iown and/or forfeiture of Faithful Perfonnance Sureties and cash deposits. (See General Permit Conditions 1 and 2.)
E. THE CONTRACTOR MUST HAVE TillS PERMIT AND APPROVED PLANS AT THE SITE AND MUST NOTIFY THE PUBLIC WORKS
DEPARTMENT AT LEAST TWO DAYS BEFORE STARTING WORK. NOTIC~ MUST BE GWEN TO PUBLIC WORKS AT LEA~T 24 HOURS
BEFORE RESTARTING ANY WORK. GrtJ ~.'" <3 5'It5/ffL)~ fLIAI'A/IAlG <! tAJt:d, c:r-Nn~ S'ft - ~F9- 7/0S
Name of Applicant/Permittee~T \I t\U-& Y ~'1"M\ OrJ D, SoT tC..\ c::... ..,- Telephone 378- 2Jfo7
c;S;coe
Address_'oo c. SV"J,JYOAt:::-S 1nJ2-. . L.~. (,4
Is this work being done by the property owner at their own residence? >< Yes'
No
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, 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/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their
contractor(s) of the information:
~tJ TO'( ::::3-Itsw.V$~'{ ~",' (. -', . ~ ~
(Applicant/Permittee)
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SEE PAGE 12
PUBLIC WORKS DEPARTMENT RECEIPT
Effective July 1, 1995
PU'L1C WORKS FILE NO. 9& - ~C
PROPERTY ADDRESS J 3 '!-If J I k.
monies:
AMDI1NT
$
I
I
($325) I ~.:l ';) .0 <>
($225)
($500) ~
(FPS) (100% of ENGR.EST.) ~
(100% of ENGR.EST.) .
(4% of FPS)($500 min.)
(100% of ENGR. EST.) I.
I
I
(12% of ENGR. EST.) I
(De os it 15% of ENGR. EST.)"
.;J.)6 . () ()
TO: City Clerk
ActT~
220
220
220
220
2203
472J
2203
4722
Utilit <
220
476
476
476
472
472
jor "^,_. i
I
(0..." .II.... r:e /0 r- i
I
($1.60/ft.)
($1.10/ft.)
($105/ea)
($105/ea)
($120)
($105/tree)
(De osit 15% of ENGR. EST.)"
Pro'ect No.
($1/P $12/Book)
($.50/s .ft.)
($100/Calendar Da
($500)
($1,060 + $25/Lot)
($1 380 + $25/Lot)
($400)
($300)
($550)
($550)
($170)
(R-1, $2,000)
(Multi-Res, $2,250)
(All Other, $2,500)
on Cert. of Occu anc )
492
496
TRAFFIC
472
472
472
472
472
427
472
OTHER
NAME OF APPLICANT
NAME OF PAYOR
ADDRESS
.. Actual Cost Plus 20% Overhead (Non-Interest bearin
I:-~~
($60)
($125)
TOTAL
$ 5'3 >'.00
)r;; 4P7- 11'~-
J-If~
CITY CLERIC
roR
ONLY
Itca:ipt,:
<A,\i-tC'\
Date/Initials
"ECEIVED
MAR 1 8 1996
CITY CLERK'S OFFICE
"For Plan Check and Cash Deposits, send yellow copy to Finance.
h:\recfrm3.wk3(mp)rev.1/9/96
ql~) )4J
/3LJ'iJ j..l( ((J
CERTIFIC~TE OF INSURANCE. CSR DH 03/18/96
I PRODUCER - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
I INB Insurance Services Corp. CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
1 I DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE I
1 P.O. Box 699 1 POLICIES BELOW. I
I Los Ga tos , CA 1-- - ___n_u u -----nun -- u - un -- - -- - u u n ----- -- uun -- __uu___ -- ----I
I 95031- 1 COMPANIES AFFORDING COVERAGE I
1 PHONE408-395-7900 I I
1-----------------------------------------------------1---------------------------------------------------------------------------1
I INSURED I COMPANY LETTER A CNA Insurance Companies I
I 1---------------------------------------------------------------------------1
a~~i~~~~rn Plumbing i -=~~~~ - ~~::~~-~- - - - - - - - __n_un______ - - - - a -E--c- 1: - r - - - - - - - - - --- --I
~~h~~~8Kle Road #28 i _:;:~:;-~m-mm-mm---nmMmn:'n:y'-~nm-'
i-~;~~~-~;;;;;-~---------------------------------~I1~~j)-~fl----------
> COVERAGES <=======================================================================================~~'~;~~=~v=================
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED~~g~ P~LICY
PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT wITn~f~T TO
WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO
ALL TERMS, EXCLUSIONS, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE
POLICY NUMBER
---------------------------------------------------------------------------------------------------------------------------------
LIMITS
POLICY EFF I POLICY EXP I
DATE I DATE I
--------------------------- ---------------1--------------1----------------------------------
I 1 GENERAL AGGREGATE 12, 000, 00 OJ
I 1-------------------1--------------1
01/06/96 101/06/97 IPROD-COMP/OP AGG. 12,000,0001
I I ------------------1--------------1
I IPERS. & ADV. INJURY 11 ,000,0001
I 1-------------------1--------------1
I 1 EACH OCCURRENCE 11 , 0 0 0 , 0 0 01
1 1-------------------1--------------1
I I FIRE DAMAGE I I
I I (ANY ONE FIRE) 150,000 I
I I ------------------1--------------1
I IMED. EXPENSE I I
I I (ANY ONE PERSON) 15,000 1
------------------------------- --------------------------- ---------------1--------------1-------------------1--------------1
AUTOMOBILE LIAB I I COMB, SINGLE LIMIT 11,000,0001
I 1-------------------1--------------1
01/06/96 101/06/97 IBODILY INJURY I I
I 1 (PER PERSON) 1 I
I 1-------------------1--------------1
1 I BODILY INJURY I 1
I I (PER ACCIDENT) I 1
I 1-------------------1--------------1
I IPROPERTY DAMAGE 1 1
------------------------------- --------------------------- ---------------1--------------1-------------------1--------------1
1 lEACH OCCURRENCE I 1
I 1-------------------1--------------1
I I AGGREGATE I 1
------------------------------- --------------------------- ---------------1--------------1-------------------1--------------1
I I ISTATUTORY LIMITS I I
I lEACH ACCIDENT I 1
I I DISEASE-POL. LIMIT I I
I IDISEASE-EACH EMP. I I
------------------------------- --------------------------- --------------- --------------1----------------------------------1
I 1
1 I
I I
---------------------------------------------------------------------------------------------------------------------------------1
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS I
I
I
I
col
LTRI
---1-------------------------------
I GENERAL LIABILITY
A IX] COMMERCIAL GEN LIABILITY
1044317669
[ ] CLAIMS MADE
[Xl OCC.
OWNERS'S & CONTRACTOR'S
PROTECTIVE
[ ]
[ 1
A []
[ ]
rX1
rX1
[XJ
[ ]
[ ]
10443176725
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
GARAGE LIABILITY
EXCESS LIABILITY
[ 1 UMBRELLA FORM
[ 1 OTHER THAN UMBRELLA FORM
WORKERS' COMP
AND
EMPLOYERS' LIAB
OTHER
(30 day notice of cancellation/10 day notice for non payment of premium)
Additional Insured per attached CG 20 10 11 85 endorsement.
> CERTIFICATE HOLDER <===============================> CANCELLATION <============================================================
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX-
PIRATION DATE THEREOF, THE ISSUING COMPANY WILL ~ MAIL 3 0
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.~
CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 N. 1ST STREET
CAMPBELL, CA
I 95008
I_ACORD 25-S (7/90)
=------------------------------~.---~-.-----------~--- -----------.-. ---------
: AUTHORIZED REPRESENTATIVE ~h~ ' -4
INB Insurance Services, Corp. /~
(11-85)
POLICY NUMBER: 104/....17669
THIS ENDORSEMENT CkANGES THE POLICY, PLEASE READ IT CAREFULLY.
CG 20 10 11 85
ADDITIONAL _I~SURED-OWNERS, LESSEES OR CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
,
Name of Person or Organization:
CITY OF CAMPBELL
DEFT. OF PUBLIC WORKS
70 N. 1ST STREET
CAMPBELL, CA 95008
(If no entry appears above, information required to-complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
SCHEDULE JOB: 1344 DELL A\~., CAMPBELL, CA
PERMIT II 96-140
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.
The City, its officers, employees and volunteers are to be covered as insureds
as respects: liability arising out of activities performed by or on behalf of
the Contractor, products and completed operations of the Contractor, premises
owned, occupied or used by the Contractor, or automobiles owned, leased, hired
or borrowed by the Contractor. This coverage shall be primary and any coverage
carried by additional insured shall be excess insurance only.
The Contractor's insurance coverage shall be primary insurance as respects the
City, its officers, officials, -employees and volunteers. Any insurance 'or self-
insurance maintained by the City, its officers, officials, employees or volunteers
shall be excess of the Contractor's insurance and shall not contribute with it.
...
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~,-l..clkoor;,"'r
OAUTHENTICO
~-:.:::~~\~
Copyright, Insurance Services Office. Inc., 1984
MAR-19-96 WED 00:36 STREAMLINE PLUMBING
510 489 3801
p". ~_L_~
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WEST VALLEY SANITATION DISTRICT
OF SANTA CLARA COUNTY
SERVING RESIDENTS OF
CITY OF CAMPBELL
TOWN OF LOS GA TOS
CITY OF MONTE SERENO
CITY OF SARA TOGA
UNINCORPORA TED AREA
100 East Sunnyoaks Avenue
Campbell, California 95008
Telephone (408) 378-2407
April 1, 1996
(96-/0
Mr. Randy Westfall
Department of Public Works
City of Campbell
70 North First Street
Campbell, CA 95008
RE: 1344 Dell Avenue
Dear Randy:
The district will not pay for the $565.23 for the 11.5 hours of overtime between March 21 and
March 22. Please forward your bill to the contractor, Streamline Plumbing and Underground
Construction.
Very truly yours,
eid
4/ J--;V, -r.a.c-Ov ...i,.j.L rf. fA,,; ~ f.,!. 4-. wV(1) w:/( 11- Ik ~~ 4t
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~./, "J-..{j f. 2'../0"" ;v.-' CIU"'-W l'"ut!<..1'<- ,.14 Cj.Vfff
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"'1/4 /1" Ik- :,,;/~ ;;;- ~,;,tJ. C"^fr",f'JJ(J/
Co::: : M Q - r'f..t
(FORMERLY COUNTY SANITATION DISTRICT NO, 4)
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"eH A"O'
CITY OF CAMPBELL
Public Works Department
March 25,1996
Mr. Don Toy
West Valley Sanitation District
100 E. Sunnyoaks Ave.
Campbell, CA 95008
Subject: Permit #96-140
Backcharge for Overtime Inspection
Dear Mr. Toy:
As you may be aware, Streamline Plumbing and Underground
Construction experienced difficult~es while excavating for t~e new
sewer lateral for 1344 Dell Ave. on 3-21-96. This letter is to
inform you that we'll be adding a billing for overtime inspection
on the subject permit to our next quarterly billing.
Overtime inspection, at the hourly rate of $49.15, was required for
8.5 hours on 3-21-96, and 3 hours on 3-22-96. Therefore, a total
of $565.23 will be added to the next quarterly billing.
If you have any questions, or need further information, please call
me at 866-2165.
Sincerely,
f~ W~Stf
Public Works I
cc: Greg Martin, Streamline Plumbing & U/G, fax (510)489-3801
70 North First Street, Campbell. California 95008,1413 :rL 408.866,1150 . FAX 408.379,1571 ' TDD 408,866,1790
NEW PW FAX #:
AnQ_.~~r;._l\nr.:o
CITY OF CAMPBELL
FIELD ENGINEER'S DAILY REPORT
O*M~
PROJECT NO.
REPORT NO:
-/tfu
CONTRACTOR: 5f~~
DATE: 4-'1-;0
WEATHER: fCtr r
INSPECTOR: K. ~51fALL
ITEM
DESCRIPl'ION
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W<J~ If......
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PAGE: I
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WEST VALLEY SANITATION DISTRICT
OF SANTA CLARA COUNTY
SERVING RESIDENTS OF
CITY OF CAMPBELL
TOWN OF LOS GA TOS
CITY OF MONTE SERENO
CITY OF SARA TOGA
UNINCORPORA TED AREA
100 East Sunnyoaks Avenue
Campbell, California 95008
Telephone (408) 378-2407
April 1, 1996
(ii-/v
Mr. Randy Westfall
Department of Public Works
City of Campbell
70 North First Street
Campbell, CA 95008
RE: 1344 Dell Avenue
Dear Randy:
The district will not pay for the $565.23 for the 11.5 hours of overtime between March 21 and
March 22. Please forward your bill to the contractor, Streamline Plumbing and Underground
Construction.
Very truly yours,
eid
4/ J-1f, --(.a.,."" ..;".jL If. /(e;J ~ ?'!....... yJV!1) ",;:/; /j. Ik. dol"- J""'- .
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&//~.J2j An Jk..... :" ;1 U& ,t:'r tMA co. ki~~..11
C<. : M Q - P't.t
(FORMERL Y COUNTY SANITATION DISTRICT NO, 4)
CITY OF CAMPBELL
FIELD ENGINEER' S DAILY REPORT
13* ~. -
wv' s ~ ~
PROJECT NO. 9t - !fG
REPORT NO:
CONTRACTOR: )frMMA(i~ I)~~)~ Y!i1/0.
DATE: 5;). 9- CJ(p
WEATHER: ~; ('"
INSPECTOR: R. .v~51fALL
ITEM
Jtt1.ru
/1IJ I ffL.;
cc:
PAGE: I
OF I
CITY OF CAMPBELL
0* W
!;JVSfj
CONTRACTOR: J!1....(v II""",,~ iJ
PROJECT NO. 9b" - Ifk)
REPORT NO:
FIELD ENGINEER I S DAILY REPORT
DATE: 3. -".... 7~
WEATHER: !;lV
INSPECTOR: K. .v~5-rfALL
ITEM
DESCRIPTION
cc:
PAGE: /
OF I
CITY OF CAMPBELL
FIELD ENGINEER I S DAILY REPORT
(34-4- ~ .
V0V~fJ '
CONTRACTOR: 5htcu.J ~A.U f/....J, 1.":t'C/ G
PROJECT NO. q~,/ 11--0
REPORT NO:
DATE: 3 -).) - 9(P
WEATHER: fair
INSPECTOR: R. ~~51fA.LL
ITEM
DESCRIPTION
W'L
^ STREAMLINE PLUMBING
ill & UNDERGROUND CONSTRUCTION
Residential. Commercial. Industrial. Insurance. (i()\emment
~
~
Serving the Entire Bav A~ea II 'i II . 3 ~() I
(510) 489-7105 f!:tx. (1',-) TI ~
(408)924-0100
0\\ l1er
Greg Martin
Lie "672250
cc:
PAGE: /
OF I
CITY OF CAMPBELL
FIELD ENGINEER'S DAILY REPORT
/)4-lV ~l ~.
PROJECT NO. 9bv 0
REPORT NO: I
ITEM
CONTRACTOR: )-J./~I/MJ Pl~s,'r~
.k-v{ blo
DESCRIPTION
DATE: ~.).... 't~
WEATHER: \ /
1'1-1(
INSPECTOR: K. ~~51fALL
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PAGE: I
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