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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.
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_5.
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AMDmI'I'
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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
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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
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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.
.~
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.~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
- $
- $
- $
- $
- $
- $
- $
- $
- $
- $
- $