91-118
c: ... II "
III :r .. .
.. . n ~
.
~ - < .
:r it . ~
~!.~.:
... ~ ~ s
~ - 5 t
_i-.....
!5 - ....
r:..-
N::~!
N"t..
s:: = .., f
.... - ID
!l .., f
~!h
.. <...
... -
...nn
0-81-
. " .
...
. :.
.. - ...
. ..
a .., _
!> ... .
-"'1
r ~ iI
. - -
r,:
! . .
! r!
. <
.., ~ .
1...::
-Q.
:r...
. - ...
i It ~
.. I
'-'I'l'Y OF CAMPBELL
D!:.PT. OF PUBLIC WORJtS
7ij North Firwt St.
Caw~ball, CA '5008
(408) 866-2150
9/-//8
ENCROACHMENT PERMIT
(fer werkinq in the
public ri9bt-ot-vay)
L'- I,'} I /'
lallUed _J /7'- / '/1
Jlenit up1ru in 12 1108.
Permit Ho.
t. fila
Appl1caUon Da~e -? // '/' / '~/
Application expir.. in 6 110..
APPLICATlOJf - Appl1ca~ion 18 tulraby _de fer a Plml1c Works PeZ'tli t in accordance wi t.b Clulpbell
llunicipal Coda, lection 11.04. (Application expiru in , IIOnt.tul if! pera1t,not ~led)
:.;:.;7,/"'l . . ./.-, ~ / '\
A. Work addna. or tract t 'j '7 ~ -of j .' J'?~' -! ph
ut:lli ty 1:nnc:b location
B. .aau-. of varkl r20.f{,:w.~ S t Of UA-' K' OVl t'",.,.,. CA/'~ i( Af?J//IPlfc-ff
c. Atuc:b fiva (5) copi_ of a drawill9 ebowinq t.ba location, extent and diaansiona of t.ba work
'l'ba drawin9 eball ebow t.ba nlation of t.ba propo.ed work to ex18tinq .urface and underqrouneS
iaproveaeftu. 1fben approYed by tIla City EnCJinear, .aid draw1nCJ beCOMa a part of t.b1a penlit.
D. 'l'be ~eral Condi~icma for all pera1u are l1ated on t.be nvarae aida. Special Prodaiona tor
t.b18 permit an li~ below. railura to abida by t.baaa conditions and prov18ions MY ruult
in job ebut-down and/or fortaiau-. of rait.bful Perforaanca Bonda and c:aeb dapoaiu. (S_
Genaral COnditiona 1 and 2).
E. An application f_ ~ aCCCll8pafty thia appl1cation. 'l'bis
.... of Applicant 0A (L '( Qu Mo'r
Addrua -:2 '(0<) ~
Is thi. work bein9 dona by t.ba property owner at t.ba1r own naidanca?
CoJIplata and atuch Worar.' Cmlpanaation and COntractor Infonation fame.
'!'ba Applicant/Permittee benby aCJnU by affixinq t.ba1r aiCJftatura to this 'per1lit to bold t.ba City
of
campbell, ita officare, aCJanta and -.ploy... frea, aafa and barala.. f~ any cla1a or d..-nd for
claaaq_ naultinq from tIla vark CDYarad by this permit.
The Applicant/Paraittaa bereby acJcnowladqa. that thay bava raaeS and uneSaretaneS both tha front and
back of thi. ~Z'tIit, and t.tuIt t.bay will inform thair contra arC.) of t.ba infonatiJi'
ACCEPTZD G All- 'r ~ At11 "2. .!.. ~ / C? (
Applicant (Paraitt_) print/a Data ' ,
NOTES: ALL waD SBALL CDIfJPOJUI Ifl'l'II 'l'BE A'l'TAaIED, APPRDVZD PLUtS AlII) ALL APPLICABLE CAKPBELL
STANDARD DRAWIHQS AND CONDI'nOllS.
'l'BE CON'l'RAC'l'OR MUS'l' BAVE ftlS nRIIl'1' AND APPIwY'ZD PLUS AlII) IIUST IID"1' 1Il'l'Il 'l'BE P... DlSPEC'1'OR ON
'l'BE SI'l'I: Nr LEAS'1' '1'IfO MYS uroa S'1'AJt'.fIIIG 1fOIIE.
IIOTlCE MUST a GIVDf 'l'O PUBLIC WORD It!t LUS'1' 24 BOURS BUDD JU:STAR'rDG AllY 1fOU.
SPECIAL PROVYSIOHS
_1.
Straet shall not be open cat for undarCJroUnd inatallationa. Kiniaua cuu _y be allowed
for connactiona or uplontion bola. Such cuts lIU.t be .DIIciticallv aanroved bv the
In.D.~or.
pav_ent MY be cat for anda1'qrOUDd 1utallations and ~ be restored in accordance wit.b
t.ba Utility '1'nnCb ltutoration StanclarcS Dnwillfl.
Work to be atalclld by a licen.eeS Land sunayor or Civil EnCJ1naar and two (2) copi_ of t.ba
cut ebaau aant to tile PlmUc Work Daptartaant bafon at&rtincJ vark.
'l'ba boura of work an l1a1ted to outside tile boura of 7-' .... and 3-6 p... for any work
affact1nq a traffic lana.
_2.
_3.
_4.
_5.
'11-1 ,
S'l'AHDARD
D~P!' RD..
AMOtJJI'l'
PDKl'1' APPLICATION P'D ("0.00) $100.00 $ /c:5c:~ ccj
PLAIf CBECJt DEPOSIT $!I00. 00 ( $_ 62:- Q, 0zJ
BOND POR FAI'1'Bn1L PERFORllUCE (lOOt OF ENG. U'1'.) ~ 3 -:J.o 6 ,(.-:()
CASH DEPOSIT ($200.00) (n OF IIOHD, '500 KIJf) $
PLAIf CBECJt . INSPEc:'l'ION l"D _, ($0 - $100,000 10" . 22 tj.lCb
$100,000 - '500,000 It, S!I00,~ and ~.. n, .$100 KIll)
APPROVED !'OR lSstWfCE "'P.r7~L..:-z'-<-j
City ineer
(SIZ c:7DD snE)
7.,1:')7 ~-
;2,,-5 '7 h
t:::/).
....:1,-C;) .:jL~S;-
-<;"- 2- .9/
Datat.-
x
I
I
I
I
I
t-3
o
tx:l
~
n
o
:s:
"0
t'i
t!j
;.,3
t!j
o
tx:l
t<
~
"0
'\:l
t'i
H
n
~
:z:
;.,3
I
I
I
I
I
I
'X
I
I
I
I
I
t-3
o
tx:l
~
n
,:)
..
""
'--0
t'i
tIj
;.,3
l1j
v
tx:l
:<
n
H
:-3
:<
TO:
City Clerk
PUBLIC WORKS FILE NO,
C// -/1 ~
Please collect & receipt
for the following monies:
35-3396
ACCT ITEM AMOUNT RECEIPT NO
3372
3521
3521
3521
Project Revenues (specify project)
Public Works Excavation Permit Fees:
Application Fee
Plan Check Deposit
Faithful Performance (Cash) Deposit
R-1:
($50)
Other:
($100)
($500)
(100% of)
(ENGR. EST)
(4% of FPB)
($500 min.)
$
. <76 25'57
/'c7o ':;"-
~()o '..!- 2J557t.,>
5'
3372
3373
3373
3373
3373
3373
3372
3372
3372
3372
3372
3395
3370
3380
3510
Other Cash Deposit (specify)
($200)
Plan Check & Inspection Fee ($0 - $100,000 10%;
$100,000 - $500,0009%; $500,000 and above 7%; $100 min.)
Project Plans & Specifications ($10)
General Conditions, Standard Provisions & Details ($10 or $1/page)
"No Parking" signs ($lIea. 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 Reapp'ortionment
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
~. 't{..-1.
I
TOTAL
~JLatt.d'T
NAME OF APPLICANT
/ c-"O
$ (.??o6 -
ADDRESS
FOR
CITY CLERK
ONLY
PHONE
ZIP
RECEIVED BY
DATE
war>>
h~ t::.. ,'.c=,~
lL~"
~ -
t- LLJ :.) !
CiTY CLEKt\'S OfFiCE
TO:
City Clerk
PUBLIC WORKS FILE NO,
LJI-/ld
ACCT ITEM AMOUNT RECEIPT NO
Please collect & receipt
for the following monies:
3372
3521
3521
Project Revenues (specify project)
Public Works Excavation Permit Fees:
Application Fee
Plan Check Deposit
Faithful Performance (Cash) Deposit
R-1:
($50)
Other:
($100)
($500)
(100% of)
(ENGR. EST)
(4% of FPB)
($500 min,)
$
00 ;}...j 4- 5'" f)
-? 7i.j ~
<---
35-3396
3521
Other Cash Deposit (specify)
($200)
3372 Plan Check & Inspection Fee ($0 - $100,000 10%;
$100,000 - $500,000 9%; $500,000 and above 7%; $100 min.)
3373 Project Plans & Specifications ($10)
3373 General Conditions, Standard Provisions & Details ($10 or $1/page)
3373 "No Parking" signs ($lIea, or $25/100)
3373 Work Area Traffic Control Handbook ($5)
3373 Copies of Engineering Maps & Plans ($.50/sq.ft.)
3372 Final Parcel Map Filing Fee ($450 + $20 per lot)
3372 Final Tract Map Filing Fee ($500 + $20 per lot)
3372 Lot Line Adjustment Fee/Certificate of Compliance ($400)
3372 Vacation of Public Streets and Easements ($500)
3372 Assessment Segregation or Reapportionment
First Split ($500)
Each Additional Lot ($150)
3395 Park Dedication In-lieu Fee per Unit ($4,548)
3370 storm Drainage Area Fee
3380 Public Works Special Projects
3510 Postage
TOTAL
rOC
$ 7 Zc..; ,-
NAME OF APPLICANT Ga.ry R Qu..a i1 0-+
ADDRESS :2..'-f05 Ca.rnro.se AcJe. . s. :s-
;
PHONE
9 6- L 3 0
ZIP
FOR
CITY CLERK
ONLY
RECEIVED BY ;'- ,
DATE S-/ 3/ Cj /
, ,
E-l
H
~~
ZPLI
HP-l
~
;]~
~
P=:
OZ
~O
H
ClE-l
PLI,:C
P=:U
HH
O....:l
OP-l
~P-l
P=:,:C
~E-l
ZH
~~
PLIPL1
PLIP-l
Z
H~
~Z
ZH
~Cl
....:l
~H
0:::>
CQ
~
UP=:
ZO
,:C~
:::>
U)P=:
Cl)PL1
HE-l
E-l
P=:PL1
0....:1
~
PLI
ClU
~Z
~~
:::>,:C
OPLI
~....:I
P=:U
E-l
PLIH
~~
,:CPLI
:::>P-l
CI)
CI)CI)
H~
P=:
ll:0
O~
~
U
ClH
~....:I
P=:CQ
H:::>
:::>P-l
o
PLI~
P=:O
ENCROACHMENT PERMIT ISSUANCE .CK LIST
C"
City of Campbell Encroachment Permit No.l/ -// F
Department of Public Works
~Applicant section complete
~Applicant signature and date
~Permit Application fee $10.0,:00.-<$50.00 for R-l Homeowner),
paid. Receipt number .255 /:.J
)(. / Plan check deposit, $500.00 (waived for R-l Homeowner),
paid. Receipt number ;;2,55 7(
~Five sets of improvement plans submitted
---------------------------------------------------------------------------
~Bond for faithful performance, 100% of City Engineer's
estimate, (waived for R-l Homeowner), supplied or paid.
Amount $ 3;2. CC' C:~ Form <:"i~" 1. D. # ?"9/ 9"1 - C 3/c""i
~ ~Cash Deposit: 4% of FP bond, $500 min. ($200 for R-I
Homeowner), paid."
Amount $52) c."'::- Receipt No. ?- S-::5-76
______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-:ljHomeowner) pa~d. 7 0'. / _-
Amount $ 2. ,,-. '1, c>c' Rece~pt No. '-' C Y .~( -5
~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)
~Permit signed for City Engineer
WHEN ALL OF THE ABOVE ITEMS ARE COMPLETE, PERMIT MAY BE ISSUED
Issuer: Initial and date and file with permit
UPON ISSUANCE, INITIATE CHECK REQUEST FOR PLAN CHECK DEPOSIT REFUND
f:pmtcklst (Mise forms) 7/90
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.
WORKERS' COMPENSATION INSURANCE INFORMATION
Name of Contractor/Applicant c,oa....O D tJ ~ o-\.-"-w-e"l\ 3' fl.
One of the following must be on file with the Public Works Department:
A Certificate of Consent to Self-insure issued by
the Director of Industrial Relations; QR
~A Certificate of Workers' Compensation Insurance
Insurance Co.! ~~f ~~ f\\\A-fu14-1 Tv'I<;;,:"ul.4+llIC"<:",
Policy No.We; I 062 Expiration date
G fl.,()~ .
q/91 ; QR
, ,
.......................................................................... .
This Certificate of Exemption from the Workers' 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 employ any person in any manner so as to become subject
to the "orke;!' Co,?nsat~~ "! Cal~Jf"ia.
~igned ~ ~ Date :2-/:1-0/11
NOTICE TO CONTRACTOR/APPLICANT: 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 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 Workers' Compensation Insurance.
Name of Contractor G Telephone 2'12-- 0.5:"00
Address
State Contractor License No.:S~~q~'
City Business License No.
Expiration Date
Will do the following types of work:
_____underground ~P.C. concrete
_____A.C. paving _____electrical
.
_____other (specify)
f:PERMINFO
REV. 8/88
CITY OF CAKPIlEL.
..-, :3
Address'-;! '/
.:r: ..<) t5- ('..- "." "" . /' )
CITY ENGINEER'S CONSTRUCTION COST ESTIKATE
Surface Construction
Cleering & Grubbing
Sawcut Concrete
Cone rate aeaoval
Curb & Gutter aaaoval
Inlot Drain with Pipe
Curb " Gutter
Sidewalk
Driveway Approach
Handicap a-p
Ex tt'\lded Curb
aarricacle
Street Excavation
AC Pave.ent
Adjust Kenhole to Grade
Adjust Handbole to Grade
KonUlHnt lox v/KOtNIHnt
Street Tree (15-cellon)
Pave.ent Striping ($100 .in)
Pave_nt Le&enda ($100 .in)
Stop, Street Name or Other Sign
Pave.ent Kerkera
Pave.ent Key Cut
LuIIp SUIIl Eniaate
/3' U @ $ 4.00
;::.. '/ d SF @ 3.00
/8 loF @ 5,00
EA@ 600,00
/2' U@ 14.00
,.f __.....L ) SF @ 4.00
; < ,.
". -' ,- SF @ 5.50
IA@ 400.00
U@ '.50
loF@ SO.OO
EA@ 375.00
EA@ 275.00
EA@ 600,00
EA@ 300.00
LF@ 0,65
EA@ 40,00
EA@ 120.00
EA@ 15.00
loF@ 10,00
7/ '"8
:mit No. . f ---/ ."1 f~
'. I
byL.I< date "- . 2.::'
S~reet Lilfhtinlf
Adjust for aize: .S"<$30,OOO add 20', .S.>$100.000 aubtract 10' (+ or -) $
Electrol1er
Conduit
Conductor. pair
Pull lox
Stan Dr.ina~e
12- or 15" acp
18' or 21" aep
Street Inlet
Manhole
Ireak & Enter Manhole
~
~~ S'"
~~'V'~ ,Ci A
L ",", :: ,4
r ~-<..
revl..d 6/88
f/con-eoat-est
- $
$
- $
SF)x($O,10)x<-.) - $
SF)x($0.30)x<-") - $
- $
- $
- $
- $
- $
- $
- $
- $
- $
- $
- $
$;;?-Sy.
Surface Subtotal
"S"
- $
o:.:~... ("C" "!",-, .;:- ~
5Z.,,,.)
- $
_ $ -7,:/ (/'0,)
_ $ ?C,,;~
- $
- $
- $
_...,....j.w--
",,/ Fc',.'. )
- $
;( i:~ C; . ;;~ )
. .
_.
...-:- - ~
~.: ,j
If'
. (;)(.j
.!
'Ct
~
l'
:=
'"
i
b
~
.~
I
I ~:' '1, : -,1- "... QA rcp ,XI ~T m
" A' , .., '1CA1
': ~',' -. · f '
, '" . I
i.",: : 'I ..
;j.," ~'.II I' ...
l:1 "
i I .:, '. . '\,'
l~ji~i -l.r
~ Ii' . _ .....~.......
I':i ~.~
!:; fj4/"i ,.....
I i1 .., i
I . . I
II I t:1
I I'"
II . I
1 II .0 . ,/
I . i
II " .. ,I
I II II).,. I
I i I ..' :
I . 'C I
I II ,,' I
I II i."
I' I, ~
II :. i
I li I,. I
I j I I. '. ' I
I II :~. ~ -d A:> <- ..- -/'/'
I ..; r'r 1" /-,of I > I. ..:... y
I I: :...' I
o # I
i I .' 'I
i
:1 '. ~'
. . ,I
. , . ,.1
II
II
II
~ II
II
~ I II
~ II
I II
1t
~ I 1.1
I I II
~
CD II
I II
\ . ,
I .
} ,0.
, . ,
.J' .
, ~
.. ~
\ \'
,. .
. ,
, "
" \ 'C
1
,;of...( T~il.~~ I ~r:
,
I.
I
-0
c
0-
-
-.
(j
~,
P
-0
--0
;0
~ 0
o <
"""Com
g () " -. 0
;.t en C
II.. ~
-. ~ "
g.~ '"U 0 0
~I ~ -+. ::0
Q. 3 0
~. r ;:+ 0> 0
if z 3 0
C! 'I. 0 "'0 Z
fi' g ~
=;0
~:' C
()
-I
-
o
z
,
,
""-
"
~\
(
CITY OF CAMPBELL
70 NORTH FIRST STREET
C AMP BEL L, C A L I FOR N I A 9 5 0 0 8
(408) 866-2100
FAX # (408) 379-2572
Department:
Public Works
September 29, 1992
Mr. Gary Quandt
2405 Camrose Avenue
San Jose, CA 95130
SUBJECT: ONE YEAR MAINTENANCE INSPECTION, ACCEPTANCE
PERMIT NO. 91-118
LOCATION: 99 SOUTH SECOND STREET
MAINTENANCE SURETY: BANK OF AMERICA - CD
Dear Mr. Quandt:
We have made the final one (1) year maintenance inspection of subject Public Works
improvements and find the work acceptable.
Your maintenance requirements and any surety, therefore, are hereby released.
Sincerely,
H~:t:'~.:J;
Public Works Inspector
J.~Q:djr
cc: File # 91-118
f:91-118
ASSIGNMENT AND RECEIPT OF INVESTMENT CERTIFICATE
TO CITY Of CAMPBELL, 70 N. fIRST STREET
Co\!.rPDELL, CALIFORNIA 95008 (408) 866-2150
P.w. Permit No.
TR or DEV
Loc. 9c; ~ fi-
9/-//?
2-mL Vr~
,
=
co /) ~ Ll
I am/'ole are the owner( s) of a .....r1:~s "J-LfullL /) /7
at its branch office at (2 /) /Yl P I;)E: t.. L ,~l1fornia, Investment Certificate
No. in t he names of
and havin~ a present balance of $ 8~/"')~
I hereby Krant, transfer and assign said account, said Investment Certificate, said
balance (includin~ interest which accrues thereon), and all other rights in connection
therewith to the CITY OF CAMPBELL, assignee, for a good and valuable consideraeion,
receipe of which is hereby acknowl~dg~d, for the purpose of in~uring con5eruction
d~~cribed as follows:
I have h sically delivered said Investment Certificate and du licate of this Assi nment
and Receipt to said ass1~nee,
I understand that assignee can withdraw from said account any time on his signature alone
upon presentation of the Investment Certificate to the issuer. I also understand that I
may not withdraw from said accoune unless I present said Investment Certificate and the
si~nature of assi~nee approvin~ said withdrawal. The issuer of the certificate assumes
no responsibility for the conduce of the assignee and may act on the signature of the
assignee without further inquiry.
Executed on
, 19
at said office of the issuer.
Assignor
Assignor
ACKNOI..'I.EDGEHEnT BY ISSUER
Issuer affirms that there are no other holds on subject account, that subject monies are
available, and that the above described assignment has been noted on the Records of said
issuer.
Date
By
Authorized Signature
Title:
INSTRUCTIONS TO ASSIGNEE
Please sign below for signature identification and as acknowledgement of your notice of
Assi~nment and as receipt of said Investment Certificate. Return this Assignment and
Receipt to the issuer at its address above. Retain one copy of this Assignment and
::::'P'pfD your files. ~:,y 0JJ~JlJi~
RELEASE BY ASSICNEE
Said assignee hereby releases and relinquishes all his right, title and interest in and
to said account, said Investment Certificate, said balance and all Other rights in
connection therewith.
Date~
City ~ camPbe~ (
By ~ 1fi: tnS t'1
I /
CITY OF CAMPBEll
70 NORTH FIRST STREET
C AMP 8 ELL, C A L I FOR N I A 9 5 0 0 8
(408) 866-2100
FAX # (408) 379-2572
Department:
Public Works
July 18, 1991
Mr. Gary Quandt
2405 Camrose Avenue
San Jose, CA 95130
SUBJECT: FINAL INSPECTION AND ACCEPTANCE
PERMIT NO.: 91-118
LOCATION: 99 SOUTH SECOND STREET
Dear Mr. Quandt:
We have made a final inspection of subject Public Works
construction and find it acceptable and in conformance with
City standards. Accordingly, we will recommend the
acceptance of the work to the City Council. We will send a
copy of their resolution accepting the work upon their
approval of same.
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.
We will inspect the work in one (1) year and advise you
whether or not maintenance is needed.
We have received your maintenance bond in the amount of
$800.00 and hereby release your faithful performance bond.
Please feel free to call me if you have any questions.
pY~
Sal Duckworth-Lanzo
Senior Civil Engineer
SDL/AS:djr
cc: C. Case, Council Agenda
Bond Company
Suspense - 1 year
f:91-118
CITY OF CAMPBELL
PUBLIC WORKS INSPECTION REPORT
DATE: 1 / / g/ q I PERMIT/PROJECT NO.: q / - / / %
TRACT NO.
ADDRESS: qq 5,
;JiJi
5f{~
TYPE OF WORK:
STREET:X STORM:
SANITARY:
ELEC:
P.C.C.:
PARKWAY:
OTHER:
[] PRELIMINARY INSPECTION WITH DEFICIENCY LIST
[] FINAL INSPECTION WITH DEFICIENCY LIST
~ FINAL INSPECTION ACCEPTANCE
SIGNED PLANS ? YES
NOX
NOX
COUNCIL ACTION? YES
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
PRODUCER
Garland-Sturges & Co.
888 Saratoga ave #21
San Jose, CA 95129
THIS CERTIFiCATE IS iSSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
NC ;:lIGHT:; UP<::N -:-iE ':E!'lT!F:CAT~"iCLOE". 'TrilS CERTIFICATE OCES NOT AMEND,
~XT~~O GR A.. 7ER 7:-iE SCVER,l.GE .~FFCROE:J 3Y THE POLICIES BELCW.
CaMP ANIES AFFORDING COVERAGE
INSURED
Gordon Bothwell Jr.
Concrete Construction
2185 Stone Ave
San Jose, CA 95125
SCMP ~,"(f A
_=i ;.:=:-'
COMP~NV B
:..ETTE?
COMP,A,'iV C
l...ETTE?
COMF"~lV D
LETIE~
i COMP.ANV E
I LETTE~
!
Industrial Indemnity
THIS IS TO CERTIFY THAT POliCIES OF INSURANCE LISTED BELOW HA VE SE!:N ISSUED TO THE INSUFlED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTrlE;; DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY
BE ISSUED OR MA Y PERTAIN, THE INSURANCE AFFORDED BY THE POLlCIES DESCRIBED HEREIN IS SUBJECT TO ALL 'THE TERMS, EXCLUSIONS. AND CONDI.
TIONS OF SUCH POLICIES.
TYP= CF INSURANC:::
"OL:C'! :Il(j\16E."
:lI:~:C'( ::::':~:\'E
].4 T~ ~.~~1, cc,'I'J':
:c:...':';' '.:\pl~;' -c.
:;.:~ \1\1/C2'-"'-"
_:A81l!TY liMITS IN THOUSANDS
i ~GGREGATE
GENERAL L!ABILlTY
'X~OMPClE;"E'JSiVE "ORM
X D'lEMISES,QPE'V\TiONS
.~ UNOE'lGROUNO
i . EXPLOSiON !. ::LAFSE -iADRD
:~"RODUC'S,COMPL:;EJ ~FE?X:CClS
~ CONTFAC7UAL
i-=-.
: X i ,NDEPENDENT :ONTFAC7CRS
!X 3AOAD .=CRM "~OPE."n JA~,1AGE
:r "E"SONAL~U;,gy
BC9079550
9-1-90
9-1-91
3C::Ji_ "
~t..'...;:;V
.3
$
=:c;CP~.=~1
:~~.~;'G=
-3
$
E~('~';iEeJ S 1000 $ 1000
:=~SCNAL ;,'lvUev $ 1000
',= ::=;c\. $
,..".'
........,...
:o.L!...JWNEO .:.Ui"CS ,P9!V ,:l,<lSS.
- 'L' ~\V"ECl 'J-~~ ('CTi-'E" -'"Al-II
'"---- ,..., - ..i~ I. -.... '\..~ ='RIV ,:Jw.ss. ,:
HIRE!) ~U"":S
:C,.
::: '~~'~::'l""
\~ON-CWNEJ .l.U;-CS
~qcP=.:::T't
JAMAGE
311 ="
CCM81NEeJ '
, EXCESS LIABILITY
h UMBRE' 'A ""-M
,I -- vCl
~ OTHER "'HAN JMBREL,-A FORM
~~t~~EeJ $
$
WORKERS' COMPENSATION
AND
EMPLOYERS' LIABILITY
ST ~ TUTORY
. OTHER i
IN LIEU OF CERTIFICATE ISSUED 2-20-91
AS RESPECTS: 99 S. 2nd St., Campbell,
I
DESCRIPTION OF OPERATIONS/LCCATIONSNEHICLES/SPECIAL ITEMS e
agents and employees are named as additional insureds from and
cost or expense arising out of or in any way co~nected
$
$
$
EACH ACC:OENn
iDISEASE,POLlCY L1Mtn
:DISEASE,EACH EMPLOYEE)
an ~ts respect~ve 0
against any claims,
the construction of
~cers,
loss liabil
tl:e project
t,,. ..,~-;,f. - '''..~''~... .. (~:) ~.~., ",:.t.;~
..' "; : if~~' ~:j{ ~T;;(:S;;:~:.:;;'~l;f:?r;~~,REOUEST
TO. "..,.flANDY TERPKO ~'l<'-' '. ....:.'-' "',::>
".j~~;j:ACCOUNTS RECEIVABLE > /t:f:Zi' I.,
.:~~:~:.> ~\':~'{::!~;~f~:~~~."::~<\~ :t~"..\:~:'.:1::~'-'<;' ~'::' 'J
Plea:Seis~ue check paY~le to:
'}.~.'~~'~ "." 'j~. :.~'..'~',~." <:\ .,',,:~:,~" b........
..;,.~ress' '..'- ","-to'...;.. :"-l"",!
~ hi.~,,:,,:~~.'- L1ne- 1:
....-
. "\.' ,.
\\,-.
.~.::i( ~:-~.\ .
'~,i
',:(,: "
.~~. \~
"'.
"'I;.: ~ ._,.-.....;.
...... .
:...':.
. ......~. ,.,..
::' ~):.~~ ~ ~-:.~;\;:~;(,.' .'
".:;
'", 7.~
.. --:~ ~~;
1'.'
..-rr....
-;-
- .....~-''i:...
.,
; ./~
"' ..... .~. f '~1'
J'.
:-..,~'. 1
,;.: ti"
Line 2:
.~ 2405
Camrose Avenue
~ :',:,~.~L .~t,.;
...
-:~~r
.' .
. ,
',...
.: .,
'"
. "
.." -, t '..
~.'"
State: -CA.. ZiP:C}J::j110
~:.~,~
.JoI ,~:. .;.4
.j.:-.....
"
- :~. ",
"City, .
~-.:.
;.~ .
San
.Tose
\......,
'.- "'oj;. _ ~ :.. /.....'__ . , ._. . I,t ./"',,1-,:
'~ .'~ t'!~2 ~~ .':: \~' ..: ~v!l -,..~ -'.~~:-~ ~'.: ; ..0'-~ .
'.' '1'~~~:;f:\Descr1ption' Refundable De'Dos1:t -
::', "'~S/~~:t'., "",:.,', ,."": . .'.. -" '!":. ,'i;'
:,~ Exact. Amount Payable: '/ S500. 00"
. -r. ....
,\;.~'
');1~ l",:'r;:"'~ ~'~~ J." ';'
c-
, ~.'~' '-~-:-
~.
~..:
~~
" ~. '_:
-!,:-. ,
,
J
\
> .
. ii .
.,
"
","'
. . _to _ .
I · 'Account Number:
~~.~~ .'
905.4662
~~j
,-;:\. f
-/:'.
PERMIT NO:
91-118
....
~,
J,...:,.
.;.:....i':y
~99
... ;'
LOCATION:
South
Se~nnd
Str~~t.
("~mphp11
:,-
DATE AND NO. OF RECEIPT:
. 2 /1 Ii 1c}1
.i^:
i2J::jli7fi
~"". ~~
PURPOSE:
.. r'
ReI'ease of ca!=lh
d~pn!=lit rnr pprmit iq1~'lA
Approved by:
Sr.' Civil EnqrDate: 7-18-91
't.
Requested by: Sal
D. W
Title: Dir. ,Pub Wks
Date: 7-18-91
Verified by:
Accounts Receivable
Date:
.. .
\
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
\,-.
'\'.
Hail as is
'-
Xy
Mail in attached envelope
Return to:
(Department)
(Name)
.^
'"
Other:
,
04/18/91
;z'Z Ie
,/)-
, jf- '-'<- "-