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91-117 ~ .. . ,. :r Jr .# . n ., " 'J.-~~ ~f:'.. ... S! i 8-5:; w..... 5-~ ....- t:::j!t. . - N n f ~ = ., :;;: - 'I i i! I ..,., .. C" r:fti . n I ft' . >> ..-.. . .. f ., - .. . :-"'1 r!! If: . . ! I! ~ i · 1..= -0. r=_ "151 I I CITY OF CAMPIlELL DEPT. OF PUIlLIC WOIUtS ,~ North First St. :a.pbell , CA flOOI (401) 1"-2150 nlc:ROACHMENT P!:RMIT (for workinq in tn. public ri9bt-of-vay) !awed .;1-//3/9/ I'U'ait expuu 111 12 __. Perait Ito. ql- / I 7 , X-Ref. file ApplicaUon Da~e ~ - I c2 - q ( Application expirea 1ft 6 110.. APPLICATION - ApplicaUon 18 benby _de for a Public: Worb Perai~ 1D .ccorduc:e witb -..phell llunicipal COde, 8ection 11.04. (Application exp1ra8 in 6 .mt.bs if peZ1lit not pu.1led) A. Work ~ or U1u:t . ~q i-/ A Wi" / ..J-o /oj Bllld .CL/vtlbite.. CA. /" .. .i~J. vtllit:y u.ncb locaUon .. .atun af worJu 10 k'~j"Vwt. rMh'o":' l'"f JI....~hl,(JH-\'K.. .H;. RkflA<E. LDAfE-f!. /"";',..;c. c. Attacb fiv. (5) CIOpi. of a drawin9 novin9 tbe loca~ion, mctlUlt and cUaenaiana of tile work fte drawin9 aball abow tba nlation at tbe propoaed work ~ uiat1ft9 aurtaca aDd andU'fl'OWlct 1apra'V.-nta. Dan .pproved by tIUI cJ.t:y EnCJiftaer, .aid drawiDCJ becOllU a part of ~ pera1t. D. fte CIUIeral CCmdJ.Uana for all penita an l18~ed on tba revel'M 81M. 'pacial Prcw18iana for thi. perait an lined belov. P.UIIn b) abide by th..e ccmcUUona and pra'Visiona _y reault in jOb ahut-dovn and/or forfeitun of Faithful Perforaanc:a 80nda and cub dapollita. (S.. General COnd1tiana 1 ad 2). .. An .pplication f.. -.t .oec.pany tb1a application. t'hia 18 acm-ntandable. .... of Appl1cam: .A OI/At0( E. d pll'l.iuh ;4 'l'elepbaDaa e/~) ?''ii-3/9 () A4drM.~'() GOK ~/I~ Irr..;IC~ (1/+,/ i (lit. t7ij.:r8't- III thi. work bein9 done by tba property owner .t tbeir CNIl rM1dIUIoe? --:'1M ~ CD1Ipla~. and attacb WorJtan' ea.pena.tion aDd contractor lnfomation fane. ft. Appl1cant/Paraittaa banby avnea by .ff1xift; tb.ir aiCJD&t1In ~ tbis'paZ1lit b) bDld tb. City ot ClUIpball, ita offic:ers, .91U1ta and .-ploy... fna, ..f. and baral.. frat any c:1.1a or daaand for duaq.. naul~1nv fraa tbe work c:ovand by tbis panJ.t. ft. Appllcant/Peraittee bereby acknovled9.. t tiler bav. nact and uncS.rstancS bDtb tbe front and = tbis pan.1~, ,;i6- t.bst tbey will 1IIfo air :n~~c.) of tba 1nfO~~:ni2_ 't I plicant CPara1t Dau 1IO'1'ZS: ALL WORlt aBA1.1. COKFOJIK W1'1'B 'DIE AftACBZD, APPItDVZD PLUS UD ALL APPLICAIILI CAIIPBZLL I'l'AHDARD DRAWINGS AlII) CIOIfDrrma. 'fD CONTRACTOR IlUI'l' BAft '1'IIDI PaIIII'1' AKD APPI..""I.D PLAIIS UD IIDI'l' IIEI:f Wl'l'II 'fD P... DlSPEC!OR 011 '1'BE am A't LEU'l' 'l'IfO ~y. BJ'OD ftAIr1'DIG .-&. IIO'l'ICZ 1IOS'1' D GIVaf 'l'O PUBLIC 1IODI U IoBAI'l' 24 IIOOItS urou IIZIDaTDIG an 1IaB. SPEeIAL PROVYSIONS _1. strae~ aha11 not be open oat for uncIarlJrOUnc! inftallatiana. lUna. cuta -y be allowed for connactiana or exploration bDl.. 8ucb c:uU .ust. be _eifiea.l1v amlftlYad bv tbe tft.!)8et:~ . pav_ant _y be oat for ucIarc;rounc! 1uta11aUona aDd -.1: be rM~nd 1D aocordaJIaa witb tal. Utilit:y 'l'rancb ...tetration St.andarcS Dnw1n9. Work b) be aUJuId by . licenaed LaDeS surveyor or CivU KnlJ1naar and ao (2) oapi_ of tbe cut abe.ta ~ ~ tIUI Public work Deptu1:aUlt bafon Rarting work. ft. hours ot work an 11a1~ b) outaida tbe boUn of ,... .... ad J-I p... for any wrk .ff.~ . traffic laDe. _2. _3. _4. _5. "-1. , ......1mUD AMDmI'I' . C;;;(J $ /&-0.- . . $ $ n~JIII!'tm. .;2Z:; ~ /7) PDKI'1' APPLICA'l'ION PI:! PUll CBZa DZPOS1'1' (UO.OO) $100.00 $SOO.OO IOND lOR FAI'1"BFtJ1. ~CI (loot or DIG. ZS'1'.) CASH DZPOSrr (1200.00) (n or IDIID, $500 lID) PUll c:BEa , IIISPEC'l'IOII PI:! ($0 - $100,000 lOt, $100,000 - 1500,000 ,t, '50~'0 and aboVa 7t, '1~0 lID) APftCVZD FOR ISSUAlfCZ /" _ ~ ~~ fo C1~ Sn91Her I (.:E ODD m:E) a 4-v;J ;?_C;SI<j :1/ /-)/ c; / I Oate I I I I I ~ o tl:l ~ (J o 3: "0 t-t t1j ~ t1j C tl:l to< ~ 'i:1 "0 t-t H (J ;Xl' z ~ I I I I I I I I I I I ~ o tl:l ~ (J .:) "t '" t-t tIj ~ l:t:l o tl:l :<: (J H :-:3 :< .r z o I- o ,/ ~ )..) <..J 12~ c ~ ~\.J V> ,"i!~ c:.2 . ~ t Q. => .. t; VI c: ~ e ::) './\ [- ..9 J G ()J '--' c) VJ c ifj d~ -L) ". ,.~ ) \~ , K ,) .~ " ' ~ (',) \) ~> /2 v ~ .\) C' ~ .~ ;~ ~ :~ ~, \~ ~ \ ~ '0~.J ~, \~ .j " 'J ~ ~ 'J "..l \ ~ '~~\~\'~ ~ .... v, ' " J I "'"'-. ....... 3' -.., I ~C)~ ri1.. ,-, . v u} 0 .~;.~' 0= /. '"..... r- ..:.:...- (j ~ ~ J j c:L c& Jl r.. N ':,. ,~/\ ..,....':~)I " ;;Y.. ~ " ., .. '" ( o ~ . ~ i ~rj -+oJ ~.~ I'" {' ..c::.:; '-} r- t;"tI v_.. Q) i.~ L.l_ ~ 1$ '0."- U ,,_ '" :::Jl 0-......-.-.. v' V 01:: () ~ ..,.l 0 ..,~ 3 ') ..... ~~ -"" I') ...' I C{i -:r () [,- <: .- <t ~ .1 'b 3 --.,' U .0 ::J CL LJ_ r~_ ,...( ...... " "', ,... ~ C' .J<.,! ,l- ~.~ ~ ~ ,.,. "r.~/ w... .. ~ . ' . / f, J' t. .J ~ \\:- ~ ~ ti \~ ' {D _ ~~ ~ --- ":::t V) N \:C- ...... =, '. , Coo II 55" '--- /-"-/ I ...L. , r ~ ~ ( · " : 0). " , - . ' . ." 0. t ... _ ~ (If .. .. .... "" 'j' -./".J- ~ J J I. 0- \ :J 0 'f,lj ~ c ,/ 0-- \ 0---- -1 (' -, :: - ~ I _______L:J- 1, ,\,") ',-, ;; .--, ~ - / t !- . ~11 j ;': j l~ -Z J .~ ~ [j ,..., 1 ( .....'./ ;" .~ , '....I ~. 0 k ,"I .-) \,.1 cYU" rJ r;J II l ~ --- 1 ~ ....- \ ....--- .-2' .-' ~ ~ ~t -:r ( >- o o t-- --~ t~ ./~ (__J l .- \() I 1\ I' ,~----' .......J t- " / /- --..----. ; . 1\ i\ I, \ 1\\\\\. ' u ~ ~.J \ "J j :r J 0 J ,.., ~ L) I ~ .~ ... ;> \f) . ) ,) '0 , (~! " ~ i . ~' , y ~ .-; ':>- f'J 1;- .":< ,; '-;.. i- '1\ IH ~ ~ ~ TO: City Clerk PUBLIC WORKS FILE NO. 9/ -//7 35-3396 ACCT ITEM AMOUNT RECEIPT NO Please collect & receipt for the following monies: 3372 3521 3521 3521 Project Revenues (specify project) Public Works Excavation Permit Fees: Application Fee Plan Check Deposit Faithful Performance (Cash) Deposit $ c'-) :J.S5/3 /~- 3<jfq .).. ~S I R-1: ($50) Other: ($100) ($500) (100% of) (ENGR. ESn (4% of FPB) ($500 min.) Other Cash Deposit (specify) ($200) 3372 If NAME OF APPLICANT ADDRESS FOR CITY CLERK ONLY 3373 3373 3373 3373 3373 3372 3372 3372 3372 3372 3395 3370 3380 3510 Plan Check & Inspection Fee ($0 - $100,000 10%; $100,000 - $500,000 9%; $500,000 and above 7%; $100 min.) Project Plans & Specifications ($10) General Conditions, Standard Provisions & Details ($10 or $1/page) "No Parking" signs ($1Iea. or $25/100) Work Area Traffic Control Handbook ($5) Copies of Engineering Maps & Plans ($.50/sq.ft.) Final Parcel Map Filing Fee ($450 + $20 per lot) Final Tract Map Filing Fee ($500 + $20 per lot) Lot Line Adjustment Fee/Certificate of Compliance ($400) Vacation of Public Streets and Easements ($500) Assessment Segregation or Reapportionment First Split ($500) Each Additional Lot ($150) Park Dedication In-lieu Fee per Unit ($4,548) Storm Drai rage Area Fee Public Works Special Projects Postage TOTAL $ 1-:7 ij ~o /~::'7 .- PHONE ZIP RECEIVED BY % DATE ')... J J ~ / 9/ , I "" 8 H t?~ Ztil Ho.. l:': ~~ ~ ~ OZ ~O H Q8 tilld; ~U HH 0.....:1 00.. rilo.. ex:1d; t?8 ZH ~~ riltil rilo.. Z Ht? t?Z ZH rilQ .....:I ~H 00 lXl til uex: ZO <~ o tf.lex: tf.ltil H8 8 ~~ 0.....:1 ~ til QU rilZ ~~ Old; O~ til.....:l ~U 8 rilH ~~ <til 00.. tf.l tf.ltf.l H~ ex: ~o O~ fz.4 U QH ril.....:l ~lXl HO 00.. o til~ ~o ENCROACHMENT PERKIT ISSUANCE ""'U:CK LIST City of Campbell Encroachment Permit No.9/-/17 Department of Public Works ~ Applicant section complete ~Applicant signature and date ~permit Application fee $100.00 ($50.00 for R-l Homeowner), paid. Receipt number-2::r5-f ~ ~~/l Plan check deposit, $500.00 (waived for R-l Homeowner), paid. Receipt number V Five sets of improvement plans submitted --------------------------------------------------------------------------- A14 Bond for faithful performance, 100% of City Engineer's estimate, (waived for R-1 Homeowner), supplied or paid. Amount $ Form I.D. # ~;.4 Cash Deposit: 4% of FP bond, $500 min. ($200 for R-1 Homeowner), paid. Amount $ Receipt No. ~Plan Check & Inspection fee of 10% of F.P. Bond for amounts of $0 - $100,000; 9% for $100,000 - $500,000; 7% for $500,000 and above; $100 min. (waived for R-l ~meowner) paid. Amount $ .3 'f~ Receipt No. 2-S--~-/ r.f ~Worker's compensation information received for Applicant (see Information Sheet for Encroachment Permits) _____All other Public Works requirements listed in the Conditions of Approval of the development. ................................... ----------------- ---- --.... -- -------- ------.. -- --..-.. -- --.......... ~Worker's comp and Contractor's Information received for Contractor (see Information Sheet for Encroachment Permits) ~Certificate of Insurance with Additional Insured's Endorsement received from Contractor (see General Summary of Insurance Requirements for Encroachment Permits) ~-Three sets of off-site plans, stamped APPROVED (Tract or Development and Public Works Permit number and property address on plans) v/ Permit signed for City Engineer WHEN ALL OF THE ABOY~I ITEMS ARE COMPLETE, PERMIT KAY BE ISSUED Issuer: Initial--/TQ and date 2--/ I ~ / L; / and file with permit ~ I (,' }lIe; UPON ISSUANCE, INITIATE CHECK REQUEST FOR PLAN CHECK DEPOSIT REFUND f:pmteklst (Mise forms) 7/90 ill-- /1 ;~~~......... .:-: ~~~~ ::::........ ..:-..:....:-..$.........:-:... .. ..:-:.:.:-:-....~.::.:..:...:.:.....;.:...::::;.... TSM Ins Agents & Brokers POBox 3469 Modesto, CA 95353 ISSUE DATE (MMIDOiYV) 02/13/91 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. COMPANIES AFFORDING COVERAGE PRODUCER ~~NY A American States Ins Co ~~~NY B Fairmont Ins Co INSURED Advanced Plumbing P.O. Box 2172 Union City, CA 94587 ~~~NY C ~~~NY 0 COMPANY E LETTER 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. ' CO LTR TYPE OF INSURANCE POUCY NUMBER POllCY EFFEC11VE POlICY EXPIRATION uwrs DATE (MM/DDNY) DATE (MMIDDNY) GENERAL AGGREGATE $ 600,000 PRODUCTS-COMPIOP AGG. $ 600,000 01CC531503 12101/91 12/01/92 PERSONAL & ADV. INJURY $ 300,000 EACH OCCURRENCE $ 300,000 FIRE DAMAGE (Any one fire) S 50,000 MED. EXPENSE (Any one poorson $ 5,000 GENERAL UABlUTY X COMMERCiAl GENERAL LIABILITY A CLAIMS MADEW OCCUR. OWNER'S & CONTRACTOR'S PROT EXCESS UABlUTY COMBINED SiNGlE S LIMIT BODILY INJURY S (Perpoo~) BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ EACH OCCURRENCE S AGGREGATE S AUTOMOBILE UABlUTY ANY AUTO AlL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS GARAGE LIABILITY OTHER THAN UMBRELLA FORM ~~~ffrIlt{tt~rftfI~lttttrrrtrmrrttrrttt~tfftfltttr . . ... ..... B WORKER'S COioFENSA 110N AND EMPLOYERS' UABlUTY 80480857 09/04/90 09/04191 STATUTORY LIMiTS EACH ACCIDENT S DISEASE-POLICY LIMIT $ DISEASE-EACH EMPlOYEE S OTHER DESCRIPTION OF OPERATlONSILOCATlONSNEHlCLESlSPECIAL ITEMS CITY OF CAMPBELL & ITS RESPECTIVE OFFICERS, AGENTS, & EMPLOYEES ARE NAMED AD ADDITIONAL INSURED FROM & AGAINST ANY CLAIM, LOSS LIABILITY, COST OR EXPENSE ARISING OUT OF OR IN ANYWAY CONNECTED W/CONSTRUCTION OF PROJECT. :::;;;;;.:.... ....:::...:~~..~;~..:-rldS.~~~~~~~t.(.~t:;~N~~t.i.N~;. ..:...:...:.::....~Wi.._~~M~~~MliW~Hl@~@~~~ I:::t:::.::.::.::.:::\::: :~~I~~I:Y ~:T;~~~~F,DET~ERI~~~U~~~IC~~:~;AN~~L~LE~N~:AC:;R T~~ MAIL 1!L- DAYS WRmEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE ~~~~ LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR ~;;; LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. :;:;; AUTHOR D REPRESENTATIVE III ~ i_tt1''-I1 :;..: :.: mrii!@~fi~fi@~~~W!.M~Mt:~m~nnm~~~~~~~~~~~~~~~~~~~t~~~~WWtm@!.1tMM~\~M~~@~f~~~~wr~~~~~~~~~~~~~~~~*~~~~~~~d~~~~~~jt~~U@tl1WJtl~~~~tmM?t:~MWl!.;@1'-1_lg~mll1.(t; CITY OF CAMPBELL ATTN: DON KING 70 N. FIRST CAMPBELL, CA 95008 INSURED: Advanced Plumbing .~:::::::..~:::::::.:... .D..E. s.c.. RIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS. (Continued): THIS COVERAGE SHALL BE PRIMARY & ANY COVERAGE CARRIED BY ADDL INSD EXCESSIVE INSURANCE ONLY PER FORM CG20101185. .~ I :-: 1 ., I 1; .:: :~~ :[: ::: .~: ~~~ :. I :11 .;; ~~l ~ .~ :: , J .~~ :!! :~~ j: :; .~M~~~~MM~~~~ff~~~t@~w&m~~%f@$M~iillMl~m:M~~?mMM~~~~~~~~?~~~~WrufU~~T~~fM~~~~~M~?~MHf:!WM;M~~M1M~~~:MM~M~~WMtHi~~M?WM1M: ADVANCED PLUMBING, POLIry #OlCC531503 THIS ENDO. _MENT CHANGES THE POLICY. PLEASE REA.. . ( CAREFULLY. ~J ADDITIONAL INSURED - OWNERS, lESSEES OR CONTRACTORS (FORM B) CG 20 10 11 85 COMMERCIAL GENERAL LIABILITY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: CITY OF CAMPBELL & ITS RESPEcrIVE OFFICERS, AGENTS, & EMPLOYEES ATI'N: DON KING 70 N. FIRST 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.) 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. Copyright. Insurance Services Office. Inc, 1984 CITY OF CAMPBELL Permit No Applicant INFORMATION SHEET FOR ENCROACHMENT PERMITS A separate form must be completed for the applicant and each contractor that will work under this permit. YORKERS' COMPENSATION INSURANCE INFORMATION Name of Contractor/Applicant One of the following must be on file with the Public Yorks Department: _____ A Certificate of Consent to Self-insure issued.by the Director of Industrial Relations; 2R _____ A Certificate of Yorkers' Compensation Insurance Insurance Co. Policy No. Expiration date ;QR . " " " . . " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " This Certificate of Exemption from the Yorkers' Compensation laws printed below (certificate must be signed). CERTIFICATE OF EXEMPTION I certify that in the performance of the work for this permit, I shall not emP>6Y~ny person in any manner so as to become subject to the York~s' Compensation Laws of California. Signed L ;;4'7 I~ ~~- Date ~ - t'd- - q i l,'-/ NOTICE TO CONTRACTOR/APPLICANT: If, after signing this Certificate of Exemption, you should become subject to the Yorkers' Compensation provision of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. . . ..""""".. ......"""" ............................. ......."""" ....."" ...."".." CONTRACTORS INFORMATION Note that all contractors must have current City of Campbell Business License, State Contractor's License and Yorkers' Compensation Insurance. Name of Address TelePhone0/j~) F/?11- 3Jq() State Contractor License No. C -- 3(~ City Business License No. Expiration Date Yill do the following types of work: _____underground _____P.C. concrete _____A.C. paving _____electrical - _____other (specify) f:PERMINFO REV. 8/88 Surfaee Cons~ruetion Clearing 6 Grubbing ~ Sum Eaeiaaee - $ Sewcue Concreee /9 U@ $ 4.00 - $ Concrete Reaoval ~~ SF @ 3.00 - $ Curb 6 Gutter Reaoval U@ 5.00 - $ Inlot Drain viUl ripe EA@ 600.00 - $ Curb 6 Gutter U@ 14.00 - $ Sielawalk -Sx SF @ 4.00 - $ Driveway Approach SF @ 5.50 - $ Handicap a-p IA@ 400 .00 - $ Exeruded Curb U@ '.50 $ "rrica4e IS' SO.OO - $ Str.ee Ezcavaelon SF)a($0.10)aL----.) - $ AC Pavaaene SF)a($0.30)aL----.) - $ Adjuat Kanhola to Gra.se IA@ 375.00 - $ Adjusc Il&ncShole co Grade EA@ 275.00 - $ KonUlMnt loa w/Kcmuaent EA@ 600.00 - $ Streee Tr.e (lS-sallon) EA@ 300.00 - $ Pave.ent Striping ($100 .in) U@ 0.6S - $ Pavement Legends ($100 .in) EA@ 40.00 - $ Stop. Street Haae or OUler SiJn EA@ 120.00 - $ Paveaene Karker. EA@ 15.00 - $ Paveaene Key Cue U@ 10.00 - $ - $ - $ Surface S\!beoul .S' - $ CITY OF CAKPBl CITY ENGINEER'S CONSTRUCTION COST ESTIMATE Address araie No. by_claee 7& Ii' ,/ /.:> 2- Adjust for a1&e: .S'<$30,OOO ad4 20', .S'>$l00,ooo aubtract 10' (+ or -) $ S'treet Lill'htin.l. ElactroUer IA @ 2,000.00 Conduit U@ U@ Ea@ 10.00 2.00 200.00 Conductor. pair Pull lox StDY1II Draina.e 12- or IS. RCP u@ LF@ 60.00 lS" or 21' RCP 70.00 Street Inlet EA @ 1.600.00 lA' 2.400.00 Kanhole Ireek 6 Enter Kanhole IA@ 6S0.00 -sLf2- 1 / 0 -. - """',1 Z-u .~ ,. TOTAL ESTlHATE $ $ 3'12- USE FOR lORD reviaed 6/88 f/con.cose-ese - $ - $ - $ - $ - $ - $ - $ - $ - $ - $ - $