87-160
Issued
Penni~ exp~res ~n .lL inths.
Permit No. e1- L l.l})
X-Ref. file ~ t""" b (g (, )
Application J?ate !>- (I.J.'E 7
exp~res ~n .! s.
CITY OF CA! lPSZT.L
DEFT. OF PUBL1C vORKS
70 North F;.rst St.
Car.1( .. ~1l, CA 95008
(403) 866-2150
PUBLIC WJRKS PERMIT
IIor worK~ng ~n ~e
public right-of-way)
APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell
l1unicipal Code, section 11.04.
A.
v.brk address or tract # I 4 [; .
Utility trench location I{ c4
Nature of work: f?p/J11('VC '-lArfd V'€f{tt u, :z. ~ ( d V~~Fi.L/'~/ 0..71 >-€...' c-h_
Attach three (3) copies of a drawing showing the location, extent and dimensions of the work
The drawing shall snow the relation of the proposed work to existing surface and underground
improve.nents. tr......en approved by the City Engineer, said drawing becomes a part of this permit.
St" LA', (r~tl
~
B.
C.
D. The General Conditions for all permits are listed on the reverse side. special provisions for
this pennit are listed below. Failure to abide by these conditions and provisions may result
in job shut-down and/or forfeiture of Faithful Performance Bonds and cash deposits. (See
General Conditions 1 and 2).
E. An application fee of $35 must accccnpany this application. This is non-refundable.
"'-C>e of ^'r'i=t~~A,I'~~ ("~ T.,.,-" ~--lliZr
Address 20 ~ ~ 3__~ ~-*~~_t'f)/l1J) C(__
Is this work being done by the property owner at their own residence? --yes .p;...no
Complete attached Workers' Ccxnpensation and COntractor forms.
The Applicant/Permittee hereby agrees by affixing their signature to this pennit to hold the City of
Ca.":'lpbe11, its officers, agents and employees free, safe and harmless from any claim or delnand for
damages resulting from the work covered Dy this permit.
The ApplicantjPenlittee hereby cknO\y1edges that they have read and understand both the front and
back of th.s EFnnit, and that ey wil ;a.nform their contractor(s) of the information.
ACCEPTED )~L -- -e> \-)~-~:q-
ppln ee e
NarES : AI.L \lORY.. SHALL CONFORH ~'ITH THE ATTAOIED, APPROVED PLANS AND AI.L APPLICABLE ~n>BELL STANDARD
DRA\\L.~S AND a)NDITIo.~S.
THE CONTRACTOR ~1UST HAVE THIS PERrITT AND APPROVED PLANS AND HUST MEET WIT'rl THE P.vl. mSPECTOR O~l THJ:
SITE AT LEhST T\D DAYS BEFOlU: STA.ttTIl~ \IORK.
NOTICE HUST Br:: GIVDl TO PUBLIC IDRKS AT LEAST 24 HOURS BEFORE RESTARTn;G ANY \IORI<.
S?ECIAL PROVISIONS
1. Street shall not be open cut for underground installations. Minimum cuts may be allQ\oled
for connections or exploration holes. Such cuts must be specifically approved by the
Inspector.
2. PaveIllent may be cut for underground installations and must be restored in accordance
with the Ut1lity Trench Restoration Standard Drawing.
3. vork to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of
the cut sheets sent to the Public Works Dept. before starting work.
v--
4. The hours of work are limited to outside the hours of 7-9 a.m. and
work affecting a traffic lane.
. J r ~. jJ Ii ,~-\ ~ d., /
5. IA.. \' (_ 5ya;,..-'U(Q ,.t:-i!_. ...vV'-Lr(,/,f../U,1 - 71~ t.-rJ el .:;;..A-,
I, {' 'I .!' ,,[- tJ l.y.......-lr.r ft(L~ j ,
, ,
3-6 p.m. for any
,'-'
Amount
Receipt No. ~
/:2 7Yt,
I /2/f~9 5/1:J'1'f'1
.
PERHIT APPLICATICX; FEE
BO.'ID FOR FAITHFUL PERFORMANCE
CASH DEPOSIT REY;2UIRED (4\ of bond, $ 500 min.)
:=::o~7:s::;~:. ;;1.f~,~')
'f5i-~g~neer
$ 35.00
$ J. J (JC1 ,(){)
$ <;' Clf}.oO
$ :1../7,06
W'.&~' PK.:./
/.2.7Y~ /
Y~/1
t:.e
I)
Vft(,--i (8 I
{:PWPERI'UT
Reviseci 3/87
.'MIII!RL V
PENOYER
NeLMs
Ref. No.
JQCSON
KJltUCIR
COMEZ
TELEPHONE
CALL
RECORD
DATE :2./~ / a ~
C PLACED CALL
[!t"'RECEIVED CALL
TIME II~ 11-. M.
.flt6.JEC! PE~MIT ....,- 1&0 I J+t. ~(')AlNY$IJ:>E
J..."I '^ '1 oS", Y a-t! tr
NAME
.et' k""""L"Y'I'j ".f t+;~k..wu~ ~ -M ..l~..Ju~.../ CD.
COMPANY
OF C of'C SPOKE WITH
In.. V~ M: l" ..J1t! t!.J S
NAME
.35'~.. 2."72..',
TELEPHONE NO.
ITEM DISCUSSED/ ",CTION REQUIRED JI.~ ~c..t:;; vt',.} -I--h~ +;.in..... 1 "VI.<~C!..-I,.tl!!!J.YJ
,
'~~Y" hUT ~LJf- rhl"". d".p~~i 1- (/~~s ~1V1..J-. b.t::,Hd) /I "TJ,,'t!!!..
t!J1~~J-. /".., +-J1I'~ is. ~^'~ "" +- d-l- - ": ~g '7 II ~~ (i~, 8.2.5": "7~. .,...
) as
.. :z..,~. ~ iVtokV'ft!'!.5"'1-J WLI 4;. 4P-.9V"bV<f!!d d.r +hI!'" 12..!~/ t!Du..YI~ I
WI...'_+:,,,..,J f Wn~ ~sh"4 b'j 1,/r2. ""Ju~.. ~~rj" wa..<
:S~ + +c 4-1 S" Hi r": INI b"... c.-I-. .; Sd. V'I.fn c". J.I " J ~J" ; ~}" j~~
-Ht~ h6HfJ"- t!>f +J,<<!!. aa./I't!Y"s eJt'- Ddl""..J.y.~y:",< h,~I-h~V'.
,
Jf,- $"'61..1 Jd YI '-I- ht1 V,- 9n~VJ t-J"t!" tr.J" 'i!..ck..
bd.. V~ /J1,. cJ.t:J, loS t ~~rl JJ-.. aJNV:I. 1ft LLJ~~_ lOa.. .-I-.III~n5..
,
Err,'c~.. is ~6~ JJY'6 r),~Jr t Ii II~<. 4..+ ...J-J1"t!- J-I.; cIc.~d.yj t!.1-.
add V"t:::S.15 II ])a Vi!... t ~~Y"+ t::(re ~o Ibn9'v- p4. Y'+",'t!!!.v":!!. ..
Dt:J... vl:- 'S u ". W2 i :s GS +-hd...T EY"" c- 00 ~ ~ '< ~b~Y"4'f- J,-
I :i:.
~. _. . .
Ylt'" ~ k.d AAIJd- t-h.. i'M~ #t"- :J ~ St!:VI+ .Jr.". h j ~ Add Y'r!!.SS .
. 14V'~ d"J:::O,", Y. ""'tal +J.,. Cia --;p.......-<; h/~ -t w; N 1,<1 ><dIe
.Jv.", 014 +0 9.e-t h;$ ;""Dne.., hAG, J, j WI:5~/of..
DISTRIB~I~: . J CONTINUED:
VYES .
o NO
Ref. No.
,TELEPHONE
CALL
RECORD
DATE
C PLACED CALL
IB"'RECEIVED CALL
TIME
PROJECT PEIt/tllJT 8"7-it.O
ly'^ ~ s.,. 'P .eV-
NAME
OF
OF C of'C SPOKE WITH
NAME
COMPANY TELEPHONE NO.
ITEM DISCUSSED/ A.CTION REQUIRED A1~,,+- ad.. ..;J,f!!,. ""~S- wt41",+. htU1d
,
f~J.bulJ bl!!. ~",.f- +0
J I t!!../k.,,,.. ~ p" ()" &.w
l'1/ lj)lI"d ; J't'J .J.c l'14- V~
-:tJ.. t"'.
d-dd ~Jj,tC
Il~ ~.... -N,.", ~"'IIM; 1-
,
as,,+s. AlbYt-k
,
"L/ /~D ,!,.1~
:S"~~..,n q,S"0.3o.
. ,
,~J,;eJ" ls hi.:$ add~<:s.
DISTRIBUTION:
CONTINUED:
o YES'
erNO
r
CITY OF CAMPBEll
b
\~
... v' \ \/::1-
.\-\ ~ ~v i,~"
1>'\ C \. ... t}
. ~V ~"t. :oV
" i: , \,,"'\ " i:? J/.)r- '"
Public Works I....... ,I',. t( '--
-( l.t' \) \) f. \....-'
~00 j>- ~ '"
o 'i\~-S f'.o~;.}j'
\l f'" r-.{I"' 't,:c '" 'J
Hickman-Michael Co. (l~ <~v (t\
Robert C. Hickman - ~y --9 .L..
P.O. Box 35645 L//1:>'" ~/bnt-~'-' CA/
Monte Sereno, CA 95030 ~'
f ~() "
STREET
95008
7zz~~
II/f/II
~'
70 NORTH FIRST
CAMPBELL. CALIFORNIA
(408) 866.2100
Department:
October 10, 1988
WIMBEi;~ Y
HANDLING
HELMS
RETl.'RN TO
DISCARD
VAlKENAAR
DIAZ
fiLE
RE:
Final Inspection and Acceptance
Permit No.: 87-160
Location: 146 Sunnyside
Maintenance Bond Amount: $775.00
MANLEY
PENOYER
CASE
We have made a Final Inspection of subject public works construction and
find it acceptable and in conformance with City standards. Accordingly,
the work is hereby accepted subject to the one-year maintenance
requirement indicated below.
You are responsible for the maintenance, repair and/or replacement of all
work done should any failures occur within one (1) year of this date. To
guarantee this, you must either post a maintenance bond in the amount
indicated above, or maintain your existing faithful performance bond. If
you post a separate maintenance bond, your current bond will be released
by separate action.
We will inspect the work in one year and advise you whether or not
maintenance is needed.
Please feel free to call the undersigned if you have any questions.
Inspector
, ~ . ;
1 "q
! '
GE:sd
~ .; i" ,
I: i
1: '.
cc: Suspense -, 1 year
Publi~i,Wo.~ks
;: I,
., ~ .-.....
..- '. :"','\."~' .... "-'-l:.'~','l' ;t: '~:. (l.L~(;.;.,i:'.:
" ~- , \ '.'.,.... ..! I,: "./,.. I ,A ,-U.. ,.'1oU . '. ','
, '" '.' . ". ..' ,:;",''''''., "l"I(,' ....1'. '."..".1 .1',
'::,:\ <.' 1;'\~i,'t:1 I I :<(0/;1' ii, '
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..1. ,: f' 1: I it: V"'" '" ,
, - .....:~',;::f;::~~~~~~~;;~?~;;;W+~X,..
':11
. "
(
CITY OF CAMPBEll
Department: Public Works
-
WIMBERL Y
HElMS
70 NORTH FIRST STREET
CAMPBELL, CALIFORNIA 95008
(408) 866-2100
FAX # (408) 379-2572
September 6, 1991
Mr. Dave Michaels
P. O. Box 35645
Monte Sereno, CA 95030
SUBJECT: ONE YEAR MAINTENANCE ACCEPTANCE
PERMIT NO. 87-160
LOCATION: 146 SUNNYSIDE
Dear Mr. Michaels:
We have made a one year maintenance inspection of subject
public works improvements and find that no maintenance is
required.
Your cash maintenance bond will be refunded under separate
cover after we hear from you. Please call me so we can
arrange your refund.
Sincerely,
Sal Duckworth-Lanzo
Senior civil Engineer
SDL:djr
F:87-160
REFUNDABLE DEPOSIT
CHECK REOUEST
TO: SANDY TERPKO
ACCOUNTS RECEIVABLE
Please issue check payable to:
Hickman Michael Co.
Address:
Line 1:
P. O. Box 35645
Line 2:
City :
Monte Sereno
State: ~ Zip:95030
Description: Refundable Denosit
Exact Amount Payable: 5775 .00
Account Number: 905 .4662
PERMIT NO:
87-160
LOCATION:
146 Sunnyside
DATE AND NO. OF RECEIPT: 5/15/87 receipt #12759
PURPOSE:
refund cash maintenance bond
Requested by: S.Duckworth-Lanzo Title:Sr.Civi1 Enqr Date:
Approved by: D.Wimber1y Title:Dir Pub Wks Date:
Verified by:
Accounts Receivable
Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as is
xx
Mail in attached envelope
Return to:
(Department)
(Name)
Other:
04/18/91
CITY OF CAMPBEll
PUBLIC WORKS INSPECTION REPORT
DATE:
7//5/ q / PERMIT/PROJECT NO.: ~7--/00
, .
TRACT NO.
ADDRESS:
Iq(p
;t;>
.5(lnntj<;)a~
A~.
TYPE OF WORK: STREET:.A- STORM:
SANITARY:
ELEC:
P.C.C. :
PARKWAY:
OTHER:
[] PRELIMINARY INSPECTION WITH DEFICIENCY LIST
[] FINAL INSPECTION WITH DEFICIENCY LIST
[] FINAL INSPECTION ACCEPTANCE
SIGNED PLANS ? YES
NO
COUNCIL ACTION? YES
NO
CHARGES AGAINST DEPOSIT? YES
NO
OVERTIME:
HRS. @ $
PER HOUR = S
EQUIPMENT RENTAL: TYPE:
AMOUNT: $
DATE:
/
/
REASON:
TOTAL CHARGES:$
[] ONE YEAR MAINTENANCE WITH DEFICIENCY LIST
~ ONE YEAR MAINTENANCE ACCEPTANCE
MCIDR
) .
REFUNDABLE DEPOSIT
CHECK REQUEST
TO:' FINANCE DIRECTOR
CITY OF CAMPBELL
Please issue check payable tQ:
Hickman .. Michael Co.
(30 spaces)
(30 spaces)
(30 spaces)
State: ~ Zip: 95062
(2) (10 spaces)
(24 spaces)
Addres$ :
Line 1:
415 Hickman Court
Line 2:
Ci ty :
Santa Cruz
(20 spaces)
Description:
Refundable Deposit
'I
, ;
Exact Amount Payable:
Account Number:
$2,325.00
001.00.905.0000.4662
PURPOSE:
l
Release of cash deposit for Excavation Permit No. 87-160 less
25% being retained for a 1 year maintenance bond. See receipt #12759
dated 5/15/87.
Requested by:
. Appr~ve,d by:
Verif1~d by:
, i' ,
~ '@ Title: P.W. Inspector
,Dol~~~ ~Tltle: P.w'. Director
+ Accounts Receivable
Date: 11/9/88
Date: 11/9/88
Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
.. Mail as is
x
Mail in ~ttache~ envelope
,( ,
Return to:
(Department)
(Name)
Other:
, (
08/24/88
1M~~
fostad
/"-z, I rz..
,
z.. 5'"<:/""1. ,-t; , YJ~
("2,.-'"2., -z..'" 1--/
C? r~ 1" ~< k:' r . J" 7 t
/ C../ ,'~.'..')
Permit No.
);= 1-/~b
Applicant
INFORMATION SHEET FOR PUBLIC WORKS PERMITS
A separate form must be completed for the applicant and each contractor that will
work under this permit.
CONTRACTORS INFORMATION
Note that all contractors must have current City of Campbell Business License,
State Contractor's License and Workers' Compensation Insurance.
-M\c.t:-~ ~ Vhlcha.~1 ~O.
Name of contractor..R.D~f-t- ~elePhone '3~~.d-7d.7
Address_BO ~ ~))( 3564-S rYt:f\i-e X-YE::Y\a 0t\ CJtS-03o
State Contractor License NO.~~ \'73~City Business License No.
will do the following types of work:
_____underground
P.C. concrete
A.C. paving
electrical
Y-other 'SpeCifYI-d.JciI/.QLl.:n.~ ~ ch
WORKERS' COMPENSATION INFORMATION
City Council policy requires the following information be submitted by the
applicant and any contractors prior to the issuance of a permit.
Name of (Applicant) or (Contractor) ~\(J::::_J{YY.J....Y\ -- yYllcJr1a..~...-'{ ~O.
One of the following must be on file with the Public Works or Building Department
(indicate one) :
Certificate of consent to self-insure issued by the Director of
Industrial Relations; or
Certificate of Workers' Compensation Insurance
Insurance Co. Policy No.
Expiration Date or
Certificate of Exemption from the workers' compensation laws
(sign certificate below).
CERTIFICATE OF EXEMPTION
I certify that in the performance of the work for which this permit is issued, I
shall not employ any person in any manner so as to become subject to the Workers'
Compensation Laws of California.
Signed ~^'--r( ~'-'<J~ _ Date 5::l!i-
'NOTICE TO APPLICANT; If, after making 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 this permit shall be deemed revoked.
~/ f :Continfo
~~7 Rev. 4/87
Page _____of
CONSTRUCTION COST ESTIMATE FOR PERMIT NO.
Street Tree (15 gallon)
Pavement Striping ($100 min)
Pavement Legends ($100 min) @
Stop.Street Name or Other Sign EA. @
Pavement Markers ~EA. @
Pavement Key Cut L L.F.@
Name & Address ;I~~
Surface Construction
Clearing and Grubbing
Sawcut Concrete
Concrete Removal
Curb & Gutter Removal
lnlot Drain with Pipe
Curb and Gutter
Sidewalk
Driveway Approach
Handicap RllIIIp
Extruded Curb
Barricade
Street Excavation
A.C. Pavement
Adjust Manhole to Grade
Adjust Handhole to Grade
Monument Box v Monument
Lump Sum EstilllAte
I r L.r. @ $ 4.00
Is8 s.r. @ 3.00
3.r' L.F. @ 5.00
~, EA. @ 500.00
~r L.F. @ 15.00
~ S.F. @ 3.50
..2~ ~) 5 . F. @ 5.50
EA. @ 1000.00
L.F. @ 6.00
L.F. @ 50.00
S.F.)x($0.15)x(___")
S.F.)x($0.45)x(___tt)
EA. @ 300.00
EA. @ 200.00
@ 500.00
@ 200.00
0.65
40.00
120.00
15.00
8.00
(
(
. $
· $ ~,O~
· $ L/7rfoo
· $ 17.$;"
- $
. $ 5'2S-#'Q
. $
. $ I;:J. 8,1, So
. $
. $ .-
. $
. $
. $
. $
. $
. $
. $
. $
. $
Surface Subtotal "S" · $.2S / S'. .("0
Adjust. for .he: S $30.000 add 20%. 5 $100.000 subtract 10% t 50,3,/ D
Street Lighting
Electrolier
Conduit
Conductor. pair
Pull Box
Storm Drainage
12" or 15" RCP
18" or 21" RCP
Street Inlet
Manhole
Break and Enter Manhole
s,[)1J D ~(D 0 IS- .'d..-
t::e f' ' ~," 0 0 0:1.-
;::~ :;"/7 u~
Revised 6/85
EA. @ 3000.00
!L'F.@12.00
L.F.@ 4.00
EA. @ 200.00
L.F.@ 60.00
3' L.F.@65.00
.. EA. @ 1800.00
EA. @ 2000.00
EA. @ 600.00
.$=t
. $
. $
. $
. $
· $ 1
. $\
· $----r-
. $-t-'
. $
TOTAL ESTIMATE
USE FOR BOND
. $
$ 3, t3/ g- . to c::>
$ _ <, / Of" C/O
PUBLIC WORKS INSPECTION REPORT
)ate I~~/* _ Permit or Project No.
Address ~ ~ _~,.I~
B7-/~6
Type of work:
Street Storm
Other (describe)
Sanitary Electrical
ttDA:, ~~ ~AA1.1l>..;k/.../
[JPRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached)
[JFINAL INSPECTION WITH DEFICIENCY LIST (attached)
G31f:INAL INSPECTION - ACCEPTANCE
Signed plam;? . Y ~ (If signed. Council acceptance.)
Charges against deposit? y
Overtime: hrs. @ $
Date 5 reason:
dD
/hr.
-
$
Barricade rental (attach invoice)?
Date , reason:
y
@
$
Other?
$
$
Total charges deducted from deposit:
(Cash Deposit $ less charges $
$
- Refund $
ck. req.)
[JONE YEAR MAINTENANCE WITH DEFICIENCY LIST (attached)
o ONE YEAR MAINTENANCE - ACCEPTANCE
(Release" maintenance bond. Check Request if cash.)
Engineer
rG?J
Inspector