91-121
IS ~ · ~
5:i~~
.
Ii;!
...5!i
1- s t
'. . .. -
5 - ...
. .. -
t:i:.
. -
IV" ..
~: f
"-'I
J ! f
ij~i
:t .. ~ I
r=ft""
. ~: t
. .
..-..
. lr
f .. -
.. .
~"'1
f!i
Ii;
II!
~ i ·
I..:
-Q.
r~..
Illt
M I
CITY OF CAMPIlELL
DEPT. OF !'DilLIe WOIUtS
70 \'tOI."th :tint St.
~~ll, CA '5008
(.08) 8"-2150
q/-(c:/
ENCROACHl'1nl'T PnMIT
(for vork1nq in the
public ri9ht-of-vay) X-a.f. file
1881led .d< /i it./ '1/ ApplicaUon Date ,J/J.5/ 1/
hza1t exp1zwa in 12 _. ApplicaUon expiru 111 , .,..
APPLICA'1'1011 - ApplicaUon 18 bU'8by _d. for a Public Norb PeraU 111 accordance vi~ ~l
lIUnicipal COd., a.c:tion U.O.. (ApplicaUon expiru iD , ~tha 1f perait not pulled)
PeraU 110.
A. Nark addran or tract .
531 N. Central Avenue, Campbell, Ca.
vt.Ult;y b'encb loaaUon
a. .atun at work: Remove & replace two (2) Ci ty approaches
c. Attach fiv. (5) oopi_ of a dravi.n9 --iD9 the location, extent and lUaerwicma ot the work
fte dnv1n9 aball a_ ~a nlation at ~a propo.ed work 1:0 ex18t1D9 aurtace aM UlldU'lJZ'OWlIS
1IIpnw-.nta. When appZ"D'Md by the C1t;y EnCJiDeer, ..id dnvi.n9 I:Ieco.ea a part at thb pera1t.
D. fte Ceneral COndiUcma tor all peraita an l18ted on the r.vel'H aide. Special Prgv18icma for
~ia penUt an liated bel_. ".ilure to abide by ~e.e condiUorw and pnwiaions _y ruult
iD job abut-d~ and/or forf.itun at Faithful Perforaance Banda aM cuh dapoalta. (S..
General COnd1Ucma 1 &Del Z).
B. All .pplication f.. aft aocc.pany thb application. 'l'h1a 18 DOn-nfundable.
...otAppl1aant TERRY CONCRETE, INC. '1'elepbDne: 723-5100
~. P.O. Box 18824, San Jose, Ca. 95158
18 thi. work be1n9 dona by the propert;y GVMZ' at ~eir ~ ns1dence? -Ye8 Lno
COJIplate and attach Norltan' ea.penaation and COntractor InforaaUon foras.
fte Applicant/Paraittea bU'8by alJfteS by .ffixiD9 ~eir .iCJft&tun to ~ia' perait to bold the Clty
at
Cupbell, ita oftlcan, avanta and .-ploy... fne, .afa anlS haral_. fJ'Da any claill or d-..M for
daaaCJ" nsul tin9 fl"Oll tha work c:avared by th1a pera1t.
fte Applicant/Peralttea hereby ackn_ledCJa. that ~ay ha_ read .nd understand both the frDnt and
back of thi. perait, and that thay will intora thair conU'ac:tor(.) at tha intorastion.
ACCEP'l'ED faiF J~st:;J,KI! Feb. 25. 1991
Applicant (Peraitue) print/.19ft Data
NO'1'ZS: ALL WOD 8BALL CONPORK V1'1'B 'DIE AftACBZI), APPItOVZD PLUfS AIID ALL APPLICULI CUlPBZLL
STANDARD DltAWINCS AND CIClIfD1'nmlS.
'1'11! COII'l'RAC'1'OJt IIDft 8ft BI8 I'DIa'1' UD APPIb."yEl) PLUS &lID ImI'1' IID'l' 1Il'l'Il '1'11! .... DSPECTCIR OR
'DIE sm I{I LI:U'I' 'ftIO laYS IIU'QIlE 8DIl'Z'DIG 1IaB.
IIO'l'ICZ 1IDS'1' D GIVDI 'I'D PUBLIC 1IOIlD AT LDft 2. IIOUItS DPOD: IIESDR'1'1IIG AllY ~.
S~~YAL PROVYSYDRS
_1.
st:reet aball not be open Gat tor und&rCJZ'OUftlS 1natallaUOIIlI. lUniaua ClUta _y be alloncS
for connectlO11l1 or explonticm bol... Sucb ClUta III1ft ba SDecifieal1v alftlrav~ bY the
t".DIlet:er.
pav_ant _y be Gat for andarqround iMtallaUcma and -.t be nstored iD accordanoa vi~
~a vt.U1t;y 'l'nnch JtM1:onticm Standard Dr'aw!n9.
Work to be ataUd by . l1canaed Land sunayor or Clv11 ZncJ1nHr and Do (2) CIOpi.. of ~a
cut aHta MIlt 1:0 the Public Nark Daptaralent betore atar't1nlJ work.
fta houn at work an liaited to outaiU the boun at 7-' .... &Del 3-. p... for allY wrk
.ttactinCJ . tzaft1c laDe.
_2.
_3.
-..
_5.
nt-l'
S'l'1RDUD
lmt!rTP'l' 1m.
-") --- j( '"
r...t .,L)< ...:J ,;L~
AJIODIIlp
I'DKI'1' APPLICATIOR nz (SSO.OO)
PI.oAM CllEClt DIPOS%'1'
IIOIID FOR FAITB7CL PDPORIWICZ
CASH DEPOS%'1' (S200.00)
. flY- ,e V
G 6-C16.()O
. ~/~,)" U, c)<.:)
.
. 46s:. oc'
-;c; - ':>
2.S . J '::0
nOO.OO
tsoo.oo
c2 f.;--g .::5 ~.::'
;;:'_<)ySZ
U'1' . )
1100,000 - '500,000 It,
APPROVZD lOR ISSUANCZ
;:).. -27-'1/
Date
(BIZ c:aat 8DZ)
I
I
I
I
I
8
o
tIl
~
(J
o
3:
'i:l
t"i
t%j
8
t%j
1:1
tIl
t<
:l:>'
'i:l
"0
t"i
1-1
(J
>'
Z
1-3
I
I
I
I
I
I
I
I
I
I
I
1-3
o
tIl
~
(J
o
~
'"'0
t"i
t!j
8
l:>:1
v
tXl
:<:
(J
1-1
:-3
:.<:
(
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
\h!I~,ARr:-PLY r:'."Li\;,.rn;,~,1
J I \ J L I \ _I,_~_!)_'~_" <l:._~~~_l_~'~_1 ,
~ , - I i- r \
I~~>:~\:~----i~l-'.~. --.--:.1
r---- ,.- -------, -.---, --
I -, i .'.iJl.
! _ ,\ j r, , ';,
r;--------~.----.-.------ - I,
In !j' II.: ;" ~ .1' I I: ,I ;-
_ \J ..,.. ,- I I. ,L_
Department:
Public Works
April 2, 1992
Mrs. Consuelo F. Dasalla
531 N. Central Avenue
Campbell, CA 95008
SUBJECT: ONE YEAR MAINTENANCE INSPECTION
PROJECT NO.: 91-121
Dear Mrs. Consuela Dasalla:
We have made a one (1) year maintenance inspection of subject
public works improvements and find that no maintenance is required.
Your maintenance requirements are hereby released.
your cash deposit of $1,162.50 plus any interest.
Sincerely,
Enclosed is
Sal Duckworth-Lanzo
Senior Civil Engineer
SDL/bg
f:91-121
(JD) wp
CITY Of CAMPBELL
BANK OF AMERICA
CAMPBElL OFFICE
125 E. CAMPBEll AVE.
CAMPBEll. CA. 95008
11-35
1210
No.
30277
70 NORTH FIRST STREET
CAMPBELL, CALIFORNIA 95008
DATE
05/05/1992
.CHECK NO.
30277
AMOUNT
$1,247.64
CONSUELO F. DASALLA
531 N. CENTRAL AVENUE
CAMPBELL CA 95008
SIGNATURE
ONE THOUSAND TWO HUNDRED FORTY SEVEN AND
PAY TO
THE
ORDER
OF
ri;'l\'"iY\'\"\\<"'\' II I 11/1''''///'''
':..,'....,....~',..:,'.t......I. \..... 1 .' ~' I I I / / ,. /'1
:.,,!i~~-~~ .1/1/,".
_~ ,\-" ..~ -I
'" ,
"1')'-;'--..-;-:"-::>;';'7;/;/). ')'1' I' i """\'\"\'\" I' Ijil
11///-:';;)/" .~~.-- / )/#/11' "d'"',,,,',','
((I//I~ 1.\\,1\1\\\\ ,\
,I! I tPt~? :e,e-',',,\:,,\\
\\\\\\, ",'1 It ,',. V~.. /...~~~,.~//'/.,.'
11-010 27711- I: ~ 2 ~OOO 1581: 0 g ~ g 1"180 200"-
DETAIL PURCHASE ORDER #
05/05/1992 Check # 30277
INVOICE IF DESCRIPTION AMOUNT
VENDOR .007 CONSUELO F. DASALLA
001.00.905.0000.4662
001.05.540.0000.4448
REFUNDABLE DEPOSIT
INTEREST EARNED
1,162.~
85. -
~ -/1J
/Jd
. TOTAL
1,247.t
CITY OF CAMPBEll
PUBLIC YORKS ENCROACHMENT PERMIT/PROJECT
INSPECTION REPORT
DATE: 4-'-2- -92..
PERMIT/PROJECT NO.: :) i - / Z (
TRACT NO.
ADDRESS: 3-3i Ai, C-GNTI::JI-L PrVC
TYPE OF WORK: STREET:
STORM:
SANITARY:
SIGNALS
LIGHTING:
SIGNING:_
STRIPING: IRRIGATION:
P.C.C.: ~,/ PARKYAY:
PLANTING:
OTHER :
PRELIMINARY INSPECTION YITH DEFICIENCY LIST:
(Date)
FINAL INSPECTION AND ACCEPTANCE:
OVERTIME:
HRS. @ $
(Date)
..../
NO
NO ...-
NO ........-
NO
NO
PER HOUR - $
SIGNED PLANS?
COUNCIL ACTION?
C E ACTION?
FILE NOC?
YES_
YES_
YES_
YES_
CHARGES AGAINST DEPOSIT? YES_
EQUIPMENT RENTAL: TYPE:-
AMOUNT: $
DATE:
REASON:
TOTAL CHARGES:$
ONE YEAR MAINTENANCE YITH DEFICIENCY LIST
v
ONE YEAR MAINTENANCE ACCEPTANCE
fI, ) fl/o/<A\t"'/1
INSPECTOR
4 -Z.~92-
DATE
f:pw insp
9/91
REFUNDABLE DEPOSIT
CHECK REQUEST
TO: SANDY TERPKO
ACCOUNTS RECEIVABLE
Pl ease issue check payabl e to: Consuelo F. Dasalla
Address:
Line 1: 531 North Central Avenue
Line 2:
City: Campbell
State: ..cA.- Zip: 95008
Description: Ref Deposit/Permit No:
Exact Amount Payable: Sl.162.50
Account Number: 001.00.905.4662
INTEREST EARNED
001.05.540.4448
LOCATION: 91-121
DATE AND NO. OF RECEIPT:
2/28/91
#25952 ($4,650.00)
PURPOSE:
release of maintenance cash deposit
Requested by:
Approved by:
Verified by:
TitleP.W. Inspector
l7<ritle: Sr Civil Engr
City Englneer
Title:
Date: 4/,2/92
1/1/ L
Date: / /92
4/2/92
Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK: PLEASE PUT PERMIT NO. 91-121 ON CHECK
Mail as is
Mail in attached envelope
Return to:
Public Works
(Department)
Sal
(Name)
Other:
Rev 11/21/91
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
April 2, 1991
Ralph Jeschke
Terry Concrete, Inc.
P.O. Box 18824
San Jose, CA 95158
SUBJECT: FINAL INSPECTION AND ACCEPTANCE
PERKIT NO.: 91-121
lDCATION: 531 N. CENTRAL AVENUE
Dear Mr. Jeschke:
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.
We will retain 25% of your cash Faithful Performance Bond in the
amount of $1,162.50 as your maintenance bond. The remaining 75%,
$3,487.50, and the $500 plan check deposit will be refunded by a
separate action.
We will inspect the work in one year and advise you whether or not
maintenance is needed.
free to call me if you have any questions.
Si cerely,
~ Lo.
oeny \
vil Engineer \
GE:pm
cc: Suspense - 1 year
h:9l-l21
CITY OF CAMPBELL
WORKERS' COMPENSATION INSURANCE INFORMATION
Name of Contractor/Applicant
Terry Concrete, Inc.
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. S ta te Compensation Insurance Fund
Policy No. 650434-90 Expiration date 10-1-91; 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 Workers' Compensation Laws of California.
Signed
Date
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 Terry Concre te, Inc. Telephone 723-5100
Address P.O. Box 18824. San Jose. Ca. 95158
State Contractor License No. 257948
City Business License No.
Expiration Date
Will do the following types of work:
_____underground ~P.C. concrete _____A.C. paving _____electriea1
.
_____other (specify)
f:PERMINFO
REV. 8/88
CERTIFICATE OF INSURANCE
This is to certify that the policies of insurance listed belOW" have been issued to the
insured narred belOW" for the policy pericxi indicated notwithstanding any requirarent, tenn
or condition of any contract or other docunEIlt 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 & conditions of such policies. Limits shown may
have been roouoo:i by paid claims. This certificate does not arrmd, extend or alter the
coverage afforded by the {X)licies belOW".
Certificate Holder's Nane and Address:
CITY OF CAMPBELL
DEPAR'I'MENl' OF PUBLIC IDRKS
70 NORTH FIRST SIREET
CAMPBELL, CA 95008
Insured's Nane and Address:
TERRY CC>NCRm'E
P 0 OOX 18824
SAN JOSE, CA 95158
:JiB.mn:e in fart:e rnly far h=t'>>nrl:: .infu:at:B:l bt "X"
: RL.'RV : RDIY
: nHIIlG : tl'1'tI.:l1W
'~'117 I .......,.
I u.A.".En.'O. I LZUI:I
I I
lX' t>n:::rm~;rnc::! 174- '
L'~~'~~ I t
:!: P.n:dJ::i:s - Cbrpleta:i Im:ai 759 (XXll' 04-04-90
(t:emt.ias
'Xl B3rs::ml arrl
'_I
k:lvert.isirq Injury
lEU<<I:"fiW SlBlIE
: RDIY
: J:'RI.I1ffIm.N
I .......,.
I LZUI:I
I
I
I
I
, 04-04-91
,
I
I
I
,
I
$I, (0), (0) :
I
I
$1,(0),00)\
$1,(0),00) I
I
I
I
I
$1,(0),00) :
$ 50,(0):
$ 5,(0):
I
I
anmEN:E :
I
I
I
I
t
,
,
I
I
I
$1,(0),00):
I
,
I
I
,
,
'Im: <F IRIHHE
mms <F LI1lHIInY
G:n3ral ~
P.o:rlx:ts-O:np
(t:emt.ias JlgJrBJile
:Eers. & k:lvert.isirq Injury
Erl1 0::0 IrlH09
kr:l ere Ier:s:n
cr 0:.g:mi2at.im
kr:l ere Eire
, 1nt ere Ier:s:n
<EiEPAL LIJ.\BILlTl
lX' ~;n=ll ~
I_I ~~
:xl Eire IBrEg3 I.Egll
lUlQ[BI[E LIJ.\BILlTl
:R: Cblpo::laBive R:n:m
I
I
,74- :
Im:ai 759 (0)2: 04-04-90
I I
I I
I I
I I
I I
I I
I I
I ,
1 ,
I I
I I
I I
, I
I I
I I
- I I
I 'T.~~, ~;rT\174- I
1_' ~ v.A'J:'=~""""'1 ,
arrl I~ I
- I ,
I , tm-r-l,...."",...".1 T' hi 1 '+'IT I I
I I J';U~ ;'If'! ,....1, I
- , I
I I
I I
, I
I I
I I
I I
I ,
I ,
Should any of the abJve described policies be cancelled. before the expiration date
thereof, the insurance canpany will enctea..,f(}r to mail 10 days written notice to the
certificate holder naned above, but failure t'O mail such notice shall impose no obligation
=::~== ~ e&._, ita ~tB or ~~ct2ll
~/R=st:rict.kns/~f'!l Itan
Ie: 531 N:RIH CENIRAL AVENE
I
I
I
,
: 04-04-91
I
I
I
I
I
I
I
I
I
I
Rrlily Injury
(Erl1 Ier:s:n)
Rrlily Injury
(Erl1 kI::id:nt)
~ IlIrEg9
Rrlily Injury arrl
I P~ty CJ:nbirej
I Rrlily Injury arrl ~W
: D:Ira;J3 O:x::.
l CJ:nbirej kg.
SImIJI(R{ LIMrIS
Rrlily Injury Erl1 kI::id:nt
btkI::id:nt $
Rrlily Injury R:il.i.qr LimLt
by"DilHBa $
Rrlily Injury Erl1 ~
bt~ $
'Xl o.-n:rl
'_I
'Xl Hi:ta::i
I_I
I X I N::n-OIllrl
1_'
EXE:B LIJ.\BILlTl
I-I Ud:J:ella R:n:m
I_I
I , CtlEr:"
I_I
:mmNmE lIIIIm. IRIHHE <IMJNl
mmNmE F.mE IRIHHE <IMJNl
<IIIIIIS, ano
0:::U1:t:EJ::s: at: S:m.J:l.::e, CA
rate O:rtifi.cate I5BB:l: 02-22-91
THIS ENDORSElmNT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
POLICY CHANGES Policy Change
Number
POLICY NUMBER
74 PR 506 759 0001
POLICY CHANGES
EFFECTIVE
2-22-91
COMPANY
NATIONWIDE INSURANCE CO.
NAMED INSURED
AUTHORIZED REPRESENTATIVE
TERRY CONCRETE
POBOX 18824
SAN JOSE, CA 95158
D.A. MCCLENAHAN INSURANCE
1046 W. TAYLOR ST. STE 102
SAN JOSE, CA 95126
COVERAGE PARTS AFFECTED
I
I
I
IGENERAL LIABILITY
CHANGES
I
lIT IS AGREED TO ADD ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS
I
FORM B ATTACHED BP-5
IL1201 11 85
ill.---t 4. JH. c eI.J
Authorized Representative Signature
POLICY NUMBER: 74-PR 506 759 0001 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED -- OWNERS, LESSEES OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person or Organization: CITY OF CAMPBELL, ITS RESPECTIVE OFFICERS,
AGENTS, AND EMPLOYEES
70 NORTH FIRST STREET
CAMPBELL, CA 95008
WHO IS AN INSURED (Section II) is amended to include as an insured the
Person or Organization in the Schedule, but this insurance with respect to
such Persons or Organizations applies only to the extent that such Persons
or Organizations are held liable for your acts or omissions arising out of
and in the course of operations performed for such Persons or Organizations
by you or your subcontractor.
Coverage provided to the Additional Insured under this endorsement is
primary, but only with respect to acts or omissions of the Named Insured.
Any other insurance maintained by the Additional Insured is deemed to be
excess.
RE: 531 N. CENTRAL AVENUE
NAME AND ADDRESS OF INSURED:
TERRY CONCRETE
POBOX 18824
SAN JOSE, CA 95158
BP - 5
D.A. MCCLENAHAN INS
TEL:408-298-9367
Feb 25,91
8:49 No.002 P.03
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
POLICY CHANGES Policy Change
Number
74 PR 506 759 0001
POLICY CHANGES
EFFECTIVE
2-22-91
POLICY NUMBER
COMPANY
NATIONWIDE INSURANCE CO.
AUTHORIZED REPRESENTATIVE
NAMED INSURED
D.A. MCCLENAHAN INSURANCE
1046 W. TAYLOR ST. STE 102
SAN JOSE, CA 95126
CHANGES
1
I
I'
&-t ~_ 'H}~r~-
Authorized Representative Signature
E-!
H
l'J~
ZriI
H~
~
~~
r.x.
p::;
OZ
r.x.O
H
08
riloe:t:
P::;u
HH
O~
O~
riI~
p::;oe:t:
l'JE-!
ZH
~~
riIri1
riI~
Z
Hl'J
l'JZ
ZH
ril0
~
~H
00
~
riI
UP::;
ZO
oe:t:r.x.
o
CJ)O::
CJ)ri1
HE-!
E-!
0::ri1
O~
r.x.
PLl
OU
rilZ
e1~
Ooe:t:
Oril
riI~
O::U
E-!
rilH
~~
oe:t:ri1
O~
CJ)
U)CJ)
H~
0::
P::;O
O~
r.x.
U
OH
rilH
P::;~
HO
O~
o
rilr.x.
0::0
ENCROACHMENT PERMIT ISSUANCE \ ,ex. LIST
City of Campbell
Department of Public Works
~Applicant section complete
~Applicant signature and date
Encroachment Permit No .9<
/
- (
~Permit Application fee $100.00 ($50.00 for R-l Homeowner),
paid. Receipt number ,2.5/:5 '.,)-
( ~Plan check deposit, $500.00 (waived for R-l Homeowner),
paid. Receipt number ~SX:3 3.
I ~Five sets of improvement plans submitted
- -l- - - - - - - - -;; - ~~~~ - ~~~ - ~~~. ~~:. ~.: - ~:~:~~:~:: :..- ~~~: - ~~ - ~~:~ - ~~:~.: ~::~: : - -- -- - -
estimate,_}~a~v~g for R-l ~~meowner), supplied or pa!d.
Amount $ 'Y&~ t:/'- Form ~H I~;t- 2.. ') q ,) ....
tit Ie f 'f-
_____Cash Deposit: 4% of FP bond, $500 min. ($200 for R-1
Homeowner) ~. /pa~d. Ft ~ _ , "
Amount $ ",'3 ~'O ~ Receipt No. J.:; r,3 ci.
/
~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-~_Jlomeowner) paid. ""'7
Amount $ "7"(:>J ,..:.0- Receipt No. L ') q c;2,
~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)
t~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: Initiald.6;and date 2-2-7-"'7 { and file with permit
--
UPON ISSUANCE, INITIATE CHECK REQUEST FOR PLAN CHECK DEPOSIT REFUND
f:pmtcklst (Mise forms) 7/90
CITY OF CAKPIEU., CITY ENCINEER' 5 CONSTRUCTION COST ESTIKATE
Addres. 5,3 / N, ~t:/l/)7;;,,4L /(:.h~.
Surf.~. Cons~ruction
Cloorina . Crubbina
Soveut Cone rot.
Coner.c:. a..oval
Curb . Cutt.r a..oval
Inlot Drain with Pip.
Curb . Cutter
Sidewalk
Drivoway Approach
Handie.p -..p
htrwSad Curb
"uieade
Stroat laeavation
AC 'ovo..nt
Adjust 1Canh0le co Grada
Adjust Handhole to Grad.
1I0n-.nt aox w/Ko_nt
Stro.t tro. (15-aallon)
'av_nt Stdplna ($100 ain)
'av...nt Le,enda (Uoo .in)
Stop, Str..t .... or Other Slm
'ov...nt Marun
'av...nt K.y Cut
l.r.8Ip Sua 11 t 1lu te
;;'0- u @
'2 t./ D SF @
LIB u @
EA@
-:/6
/0
~'70
u@
SF @
SF @
$ 4.00
3.00
5.00
600.00
14.00
4.00
lA, 400.00
5.50
u , '.50
U , 50.00
SF)x($O.lO)x<--,-)
SF)x($0.30)x<--,-)
IA@ 375.00
lA' 275.00
lA' '00.00
lA' 300.00
LT@ 0.65
lA, 40.00
IA@ 120.00
IA@ 15.00
LT@ 10.00
'.nit No. eJ'/-/2/
7) b -:/' _. .,7 -"
by~date <;.. .;;..J -/i
- $
- $
- .
3CJO.o,; )
/0 Sf': (/0
720 .(;: '~I
_ . ;::. YQ,e ,j
$
t. _"'0_
_ $ I;':;' I .;. . 0-0
~;/" ,,"'.
_ $ ...... j t? v.. We' ?J
_ $ /., 4' qr.'~~,~ J
- $
- $ ~
\
- $ ~.
- . (.,
$ ~h
- .
I
- $ '.'. \
- . \1
- $ '/'. ,
- , -
- , \"\
.....
- $ 1',
- $
- .
- ,
- $
2' ORI
Surfae. Subtotal -5- . .-/, (/ L. . C)
Adjust for .1&.: -S.<$30,ooO add 20\, -S->$100,ooo aubtract lOt (+ or _) $ -7767 (j
Sua.!': U.ht:i".
&leeuol1er
Ccmdui t
Conductor, pair
Pull aox
.~D~ Draff'lA..
12- or 15- ac,
11- or 21- I.C,
Stn.t Ill10t
llallbole
Iroak . Intor KaDhol.
~e-c #6.r- () t)
I~/Wi.-;;;r .6 (.> ). C"
non.od 'III
f/eon-colc-.IC:
k,
~ /./ut
. u t
!
; ..,
2,000.00
10.00
2.00
200.00
@ 60.00
t 70.00
1.'00.00
2,400.00
650.00
TOTAL UTIIIAT! .
US! rea JOIn) .
-~~
- .
- .
-~
.
- $
#, (pC?.. ;:'0
~tl~ c:;- () . t;)
STATE
COMPENSATION
INSURANCE
FUND
P.O. BOX 807, SAN FRANCISCO, CA 94101-0807
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
FEBRUARY 22, 1991
POLICY NUMBER 0650434-9(,
CERTIFICATE EXPIRES: 10-01-91
r
CITY OF CAMPBELL
DEPT OF PUBLIC WORKS
70 N FIRST STREET
CAMPBELL, CA 95008
JOB: 531 N CE~TRAL AVE-CMfPRELL
L
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California
Insurance Commissioner to the employer named below for the policy period indicated.
~ 30
This pOlicy is not subject to cancellation by the Fund except upon tfirfi days' advance written notice to the employer.
30
We will also give you i~N days' advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the
policies listed herein. Notwithstanding any requirement. term, or condition of any contract or other document with
respect to which this certificate of insurance 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.
/f~
PRESIDENT
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDEI{S' NOTICE EFFECTIVE
10-01-90 IS ATTACHED TO AND FORMS A PART OF TliIS POLICY.
EMPLOYER
I"
TERRY CONCRETE, INC
POBOX 18824
SAN JOSE, CA 95158
L
selF 10262 (REV. 10-86)
COPY FOR INSURED'S FILE
OLD 262A
STATE
C:QM~.Na"'TlON
. NSURANel!
F.UND
P.O. BOX 807. SAN FRANCISCO, CA 94101.0807
CERTIFICATE OF WORKERS' COMPENSATION INSURANce
FEBRUARY 22, 1991 POLICY NUMBER;
CEATI'FICATE EXPIRES:
0650434-90
10-01-91
r
CITY OF CAMPBELL
DEfT OF ~UBLIC WORKS
70 N FIRST STREET
CAMPBELL, CA 95008
JOB; 531 N C!N~RAL AVE-CAMPBELL
L
This is to certify that we halle issued a valid Workers' Compensation insurance policy in a form approved by.the California
Insl,Irance Commissioner to the employer named below fqr the poliCY period indicated.
;._ 30
This p<<>1icy is not subject to cancellation by the Fund exc.ept upon tM days' advance written notice to the employer.
30
We will also gille you tEN days' advance notice should this pOlicy be cancelled prior to its normal expiration.
This certificate of insurance is not an ir:lsurance policy and does not amend, extend or alter the coverage afforded bv the
policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with
resp4lCt to which this certificate of insurance may be iS5ued or may pertain. the insurance afforded by the policies
described herein 15 subject to all the terms, exclusions and conditions of such policies.
/f.~'.<
PRESIDENT
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE
10-01-90 IS ATTACHED TO AND FOaMS A PART OF THIS ~OLICY.
EMPL..OyltFl
,-
TERRY CONCRETE, INC
POBOX 18824
SAN JOSE, CA 95158
REFUNDABLE DEPOSIT
CHECK REQUEST
TO: FINANCE DIRECTOR
CITY OF CAMPBELL
Please issue check payable to: Consuela F. Dasalla
City:
Campbell
(20 spaces)
(30 spaces)
(30 spaces)
(30 spaces)
State: CA Zip: 95008
(2) (10 spaces)
Address:
Line 1: 531 N. Central Ave.
Line 2:
Description:
Cash Deposit Refund
(24 spaces)
Exact Amount Payable: $ 3,487 .50
Account Number: 001.00.905.0000.4662
PURPOSE: Release of 75% ($3,487.50) of cash deposit, 25% ($1,162.50)
beinq held for Maintenance Bond. See receipt #25952 ($4650.00) dated
2/28/91.
(Location - 531 N. Central Ave.) For excavation permit 91-121.
Requested by: Ted Thoeny
Title: Sr. Civil Engr. Date: 4/16/91
Approved by: Donald C. Wimberly
Title: P. W. Director
Date:
Verified by:
Accounts Receivable
Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as is
xxx
Mail in attached envelope
Return to:
(Department)
(Name)
Other:
08/24/88
TO:
City Clerk
PUBLIC WORKS FILE NO.
9/- 12 I
Please collect & receipt
for the following monies:
ACCT ITEM AMOUNT RECEIPT NO
35-3396 Project Revenues (specify project) $
Public Works Excavation Permit Fees: R-1: Other:
3372 Application Fee ($50) ($100)
3521 Plan Check Deposit ($500)
3521 Faithful Performance (Cash) Deposit (100% of) . . c.c>
(ENGR. EST) -i~52'-- ) ~ ). ~'
3521 Other Cash Deposit (specify) ($200) (4% of FPB)
($500 min.)
3372 Plan Check & Inspection Fee ($0 - $100,000 10%; i/'t,;.
/16.s- ./ ."
$100,000 - $500,0009%; $500,000 and above 7%; $100 min.) ; I ,
, ' .
3373 Project Plans & Specifications ($10)
3373 General Conditions, Standard Provisions & Details ($10 or $1/page)
3373 "No Parking" signs ($1Iea. 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 Drai rage Area Fee
3380 Public Works Special Projects
3510 Postage
TOTAL
NAME OF APPLlCANT(?e (~J.oJrltll' (" r Da~aLlCf
AD~~::L:~1 '1 ~;:,:'::yL 4Y~'1~4~bdt'
$ .5 ! 15't:S
PHONE
La- ZIP
~ L:. ....:~ ".,,, "
';,..':;;: i..
r C~~.J '1) ,.",
- ~.',
C~TY CLt{HrS OFfiCE
ji,'.',,..~ ~,..
'---;,-'\
I
)~,i]j~~j, . ~. . 't;~.:;
REFU~DABLIr DEPOSIT~.'",,~:{i>J~.Y .
... . ,- .I:~...'... '.
CHECK REQUEST::' ..$ii',L. .~. ...:Z,:".\
"""'(.,,,. _".,l _ , ..
"~',.
-; (-'~,
.
. ~" ',r
-----' j'
. .
'f ,~ .
.,
( .
TO: FINANCE DIRECTOR
CITY OF CAMPBELL
',.5~~!:~;~~,~::Wi;~~;'
Please issue check payable to:
Terrv
....,;.'4..>..: .,.;
.<~i:~~, ":'
(30 spaces)
(30 spaces)
(30 spaces)
95158
(10 spaces)
Address:
Line 1:. 1873
Line 2:
City: San
Description: Cash
(24 spaces)
Account Number:
$500.00 ,,{r':~~i~;~'"
001 . 00 . 905 . 0000 . 4:662
I
Exact Amount Payable:
PURPOSE: Release of cash
91-121. See
rprpip~ *25833 ($500.00) dated 2/25/91~ i
r'"
" .
"~'i
.L.~:'.;t
-"\~~:.;-,';J-'l,- .
,~! -~: ~
,," '':'' '.:.:-. H"-"-:'~
;,'~;<< 'j',,:."? .-/.:..~.
Requested by: Ted Thoenv
..,:....~ ..~.:;Al~:tt.~\~\..(.~...
Title: Sr~.. Civil Engr. Date: 4/16/91
Approved by: Bill Helms
~F- :.-:'~ ,~;. '; ~,~ ~:.~__ ." t'
Title: En'gr.:Manager Date:
Verified by: Account~' Receivab'le. Date:
;' ~,' ..:.~
-c,- .; ~:~ ":-;-':"'__~:"~})~~"-'::--i'~-:"
SPECIAL INSTRUCTIONS FOR HANDLING CHECK: .~h\~~2~.;~t\.~:,
~ , . .. }~~:::};~:~',~S::"'..
Mail as is xxx Mail m .att~ched envelope
:'
,.
Return to:
Other:
-,,\
(Department)
08/24/88
TO:
City Clerk
PUBLIC WORKS FILE NO.
9/- /2-1
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
$
.k. rc 25'83;),
&C> --
5''-'0 <-E!- .;l5A33
R-1:
($50)
Other:
($100)
($500)
(100% of)
(ENGR. EST)
(4% of FPB)
($500 min.)
Other Cash Deposit (specify)
($200)
3372
NAME OF APPLICANT
ADDRESS / If 7.-S
3373
3373
3373
3373
3373
3372
3372
3372
3372
3372
3395
3370
3380
3510
FOR
CITY CLERK
ONLY
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 ($1/9a. 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 Drainage Area Fee
Public Works Special Projects
Postage
TOTAL
<<ffr<./ 01'7 L~e Ie L~c_
17L ".;o~"? R~ ~&;I? Ips f'
I RECEIVED BY f-ra ce.--
2-26-9/
. DATE
$ ~OO,()V
'7 2 3 - S ./,;:f?cR. "
T ....~\:Jl1 IL:
ZIP ~/~-Jf..
-.- L) .J"
~:'~ LIJl;o...';"
PHONE
f)'-
I,; I V (" ru"" ._._
'... / ,. "'\K.(' I)'-".'~
.._<,. \ \) . ;-I'l\./t
tf5-336-lr 03-25-9'
~
GENERAL CHANGE ENDORSEMENT
This endorsement changes the policy. Please read it carefully.
It is agreed that the policy is changed as follows:
BP 1/5c
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED --
OWNERS, LESSEES OR CONTRACTORS
(FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
City of Campbell, Its Respective Officers, Agents and Employees
70 North First Street
Campbell, CA 95008
WHO IS AN INSURED (Section II) is amended to include as an insured the Persons or
Organizations in the Schedule, but this insurance with respect to such Persons or
Organizations applies only to the extent that such Persons or Organizations are held
liable for your acts or omissions arising out of and in the course of operations
performed for such Persons or Organizations by you or your subcontractor.
The following item shall be completed if this endorsement is not referred to by number in the policy to which this endorsement is attached.
Attached to and forming part of policy Effective at 12:01 A.M. on policy effective date This endorsement supersedes any prior
number: 74-PR506759-0001 or on 04 06 91 (whichever is later). endorsement numbered:
Mo. Day Year
This endorsement is executed by the company designated on the Declarations Page.
Issued to:
I
TERRY CONCRETE, INC. AND
JESCHKE CONCRETE CONSTRUCTION,
P.O. BOX 18824
SAN JOSE, CA 95158
Countersigned at:
Authorized Representative:
INC.
Cas. 2926-4-84
~ Concord, CA D. McClenahan 04-2433
PLEASE ATTACH THIS ENDORSEMENT TO YOUR POLICY AS IT CONSTITUTES AN IMPORTANT PART OF THE CONTRACT.
-.. - '-" , _,11.
b;4~ No.002 P.04
POLICY NUMBER: 74-PR 506 759 0001 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED -- OWNERS, LESSEES OR
CONTRACTORS (:tOb B)
This endorsement modifies insurance provided under the followingl
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person O~ Organization, CITY OF CAMPBELL, ITS RBSPBCTIVE OFPICERS,
AGENTS t AND EMPLOYERS
70 NORTH FIRST STREET
CAMPBELL, CA 95008
WHO IS AN INSURED (Section II) is amended to include as an insured the
Person or Organization in the Schedule, but this insurance with respect to
such Persons or Organizations applies only to the extent that such Persons
or Organizations are held liable for your acts or omissions arising out of
and in the course of operations performed for such Persons or Organizations
by you or your subcontractor.
Coverage provided to the Additional Insured under this endorsement 1s
primary, but only with respect to acts or omissions of the Named Insured.
Any other insurance maintained by the Additional Insured is deemed to be
excess.
RE: 531 N. CENTRAL AVENUE
NAME AND ADDRSSS OF INSURED I
TERRY CONCRETE
POBOX 18824
SAN JOSE, CA 95158
BP - 5
.
~ v !.107 r0r~ ~
@~ ;- ." "
'I, I H- I\J
'3 .J I ~ "-
I ! I
"\ I .1
I '""'"'
I
,/ i ~
@~ <-
( ... c: '-
r g -2 ~ J
) ... V
,.1 Q, i'. "
., -
--, ... ... - \
" <:
.c 0 t''''-
- ...
ctS -'-' '" l1' ...3'-
'" "
( " f........ o ". It
.c: ~
.""...,.... ........ _ 'rJ
Q "'l.A' y, .~
.\.. .~ .~
....if- l.{..... ,,~ ')
Sf . "'
@~ '. r, ,
~ '-.,J ". -<; "
. "
. ." ~
I ;' l., ..... ~ ~
: ....) .,- ~
i Ql ? , I ..,4....-4 ~-',/ ~ ....
.a .0 \ 53 '\..) :,,: ~
C. (,
~ tIl 0 I )
~ ...., '-,
4-l ~ l-< I (....,
a ';~"'/
0 U 0 Ql ~ ~ i .....,.
@~ OM :3 ..c: !:: i S
!:: ~ ~ 1\1 \'
0 0 0 \ ~'''J ~
'M ~ OM "~) , \
~I-l~ i i j > f~1U' ()
'M ~ .0 \ ... '.. .
'0 tIl ~ \
<II ~P-. ~) ".') ..0
0 :.:J
~Ul-l ~ 1\1 I '. .
~ 0 1\1 ~ . I \ .~,. 0...
I <II'04-l ~~ >:,~) I' . I
I-l I-l , ;".~
~ I-l 1\1 tIl I
~'O.-l ~~. Y11-~J I ~'......': .
G>~ 0 ~ 'M
1\1 III 0.0.( I ~ r~
Ql ~ ~
.aCll <II ~~? ~<)j
~ Cl
- 1\1 ~ :"< ;. ..1 .'J
..c: tIl ~ · ~ ~ \!l
~ ~ 0 ,
4-l~.
OM o 'M O'~ I~ ~
) 'M ~ '~~. \\
~ 0 ~ .
l3 OM ~ ~~ ~3: · =
I-l '0 I-l 0.'0 i ~ \ . iY ~
0 ~ ~
4-l 0 tIl ~! '-II ~ ~ ~ . J i ~;, "
~U ~
G)~~ 0 0
O.-lU
III '0 ;.~~ ~~I
.-l1-l'O Ql ~'r- =
.-l Ql I-l tIl k.
1\1 ~ IIl'M
.aQl'O~ ) ~... a:
tIl c:" l=: <II
~ :: III I-l .~~'~/'I~1 ~;Z
~ ~ ...
I-l ~ CIl tIl .a 0 I ~ ~ ~j \
O.-l 1\1 tIlO ),) /
) Ql'O ',' 'SS' !. UJ a.
.0 ~ :: ..-.. 0 ~ ,II !
~ ~ ~ > i' (-' . ~u~ I \
<II 0.1\1 !:: I.
~ @ 0 ~. '
OM tIl OM I-l I-l )) I. " . t) I r .."/.
tIlU l=: ~ ~ 'C ~l! \~~! j/ kO. .....
~ I 0 0 -i
4-l 4-l 'M ::l ...
6)~ 4-l 0 tIl I-l III 0. oM. \ K .. . j : ,.
0 'M ~ l-< tIl \ \ " : !.,
~~ tIl ~Q)I, ~ W ~ ...
.-l~ 0 l=: l=: ~ 4-l ~,r; f.
.-l OM l-< 0 o 'M 4-l ~ ;1' ~ I J j.' I -
<CUP-.U U . 0 ~.~ ~ . :(Z
'"
~~ ~. ...
I.
K~ ~ I ~ r,... '.
~~ f
;Q<:s \ ; , ~) ,.
@~~~
~'(l : ~ :.:",-
\J) ~ ;:'M'
~ \, ~
:~JQ
~~ \ 'L (
@ ~ \
Q~~f ."( \S ''\
,
t I I
~
/
, .\oJ ,
. c:s ~ f i. .
# . '.~/~ '
'-_.~, ~ ,. ~ v)ic--<J \,) ,
.,+/ ~'~:.,j
, . ~.o....'
,~, ~.,'
. a... ,
'. · 4f- '
~ I O.......,;.,.j.
1"0:> -.. Do, ',.
..' .:....~i ,
, Ii' ~. li',
+. ~ .~ ~.~ . .
..[ .\' .'. 0
. ',..... c(" .
"', ~: 3i .
, 0 ~i ~.
.6 . '.., ():., .~,
~"""'~~~-. .~. ,.
~.,"'Y~~~~ 'J':::;,
-i,., ? /"71{>
---.
\.
.
~' . . :',. .
~ I
.... ". 4
-
~ ":1: u
.
. ,.' . "
,t >C
II!- ~
'"
~ c
a: ..
II
I
c:I I 0
z
I
= l
--
w
>
~.
G