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91-138 .. . , .. ! K ~fi J - S t ........ !I - .... ....- t=f!. Nftif ~ = .. J; - ~ iHI ~ .. ~ r3ft" . i ~ t "-g, f - - .. . ~"'1 r!_ Jr; II! - i · I..: -D. r=.. .. 1 51 I I CITY OF CAMPBELL ern. OF PtJBLIC 1fOJUtS 70 Horth rirwt St. C&apball, CA '1001 (4'1) IIG-2150 9/-/~ ;( ~ ~"-" ~ !NCROACH';EHT PERMl ~ (for wo: '1"'7 ~n fo.'..1. public: ~.t:_f _.,) bned ./- 7 -' '7 =--- l'u.U apu. iD 12 _. "ralt 110. ,,-~. file ., tj '(7 . ,.Hcetion Da~e 4S s? / ~ - . Applic:aUcm exp1r.. 1ft , .... APPLICATION - AppUceUon 18 bHeby .de tor a Public Wora Pel'll1t ill eceordance vltb ~l 1IWl1c1pa1 Cod., hc:t1on 11.0C. (Applic:aUon expu. iD , aonUla 1f pel'll1t DOt pulled) &. Won addna. or Uac:t I 50 ~{4 {~ ~Lu."fkl fJ.{l. LA 9'J1Ju f .. ::." ..'::. '--:V\~~:.:=t:~~/ I: 'l~ i.~;~' ~ L~:t. '-'''" . c. Attacb fh. (I) copl.. of a dnvlft9 lIbovil'l9 tb. locaUon, atUt and dbenalona of tbe work '!'be dnvlft9 IIba1l .ov tbe nhUon of tb. propo.ed work 1:0 uJ..t1n9 .urfac. and and.rvround J,apnw-.nt.a. Wbu eppnwed by tbe Cl1:y &n9lnev, .aid dnviD9 Mc'aU a paR of tb1a pera1t. D. '!'b. General COftditiona for all pel'll1a an li.ted on tb. NYerH dd.. lpeelal l'I'DY18iona for tbb penUt an lined belovo railure 1:0 abide by tb... c:ondlUona and pnwJ.dona .y ruult ill ,. .hut-dovn and/or fnfeJ.ban of raitbful PerfoJ:'llUlC& 80nda and cub depoaJ.t.a. ('" General COnd1UOIIII 1 ADd 2). E. An applic:aUoa f_ IIUat aoeo.panr 1:Iab appUc:aUon. ft1a 18 DOn-ntandabla. . .... of Appl1C1aftt :rAy 5"'t..~...\ iA~\ ~ t-\t ~ S~...\(A. t ~ 'felepboM. (~'3g) J?/f- l, 7 oJ Addru. ..,~(,<) \-\o..,^",\~ ~ ~\t- 1..\8 S~ a.~, C(\ 7'SI.Jo ~ t.bi. work bei.n9 dona by tb. ~ CNMr at tb.1r own ne~' ...r::::;.. _no co.pl.b and attadl WorJcan' CallpeDaat10n and contractor lnforaaUon foraa. I I I I I t-3 o tJ:l ~ n o 3: 'tl t-4 ttj t-3 ttj o tJ:l t< ~ 'tl 'tl t-4 H n ;J:>I :z: t-3 I I I I I I '!'be AppUcant/PuIIltu. benby aqnu by .ttlxi.n9 tb.1r 81ipaban 1:0 tbla'pel'll1t 1:0 bold tb. City of OUIpbal1, Ita oftlcan, a uta and 0)'_. frH, .af. and baral... fr:aa any d.b or daand for daIIa,.. naul tin9 frea wor COY by tbla peI'II1~. fte Appllcent/Peral l.d,.. that tbey bav. nad and undarwtand both ~ front and back of ~J.. pe vill iDfora tbe1r oontractorca) of tb. 1.nforaation. ~ jv1 1--7~U pdnt/.1ip & Daa ALL IfO llIAlJ. cotm)ltII WI'l'II 'l'BZ AftACBEJ), Al'PItDVED PI.AJII &lID ALL APPLICULZ CAIIP8I:U. U MD c:amrnCIIIS. 'l'BZ c:oJft"RA 1101'1' aft ftU nRIIn' AKD APPJwyll) PI.AJII AlII) aI't IIEft Wl'l'Il DIE P... ~ I V c f) 'fD 1l'l'Z U LEU'f 'ftIO MU DI"OD ftAIrfDO wau. I IIO'1'ICZ IIDn D GIVIIf 'I'D IVBLIC WOJtD U IAI'1' 24 IIODU 8UOIlZ IIZI'D.R'l'IIIG Aft 1IOU. A P R () 9 199) I I Public W orL-/Eng,'n^er,' ~ l!IPEeIAL PROVISIORJI .... .. ~ _1. .t.net .ball not be open aat for andarvround iI'lat.a.11aUona. Il1Jtlaua cuta .y be allowed ~ for conn.cUona or explonUon bOl... .ucb cute lIII.t be eDllcifieallv armraved tw ~. - In.I).~or. n _2. rav_ant.y be aat for and.~ 1natallatloM and .urt be ne1:Ored ia aCCOl'danoa vith .:> tbe Dtllity 'l'rancb Rutontlon Standard Dnvlft9. 1: _3. Work 1:0 be ata.Jced by a lican.ad lAnd .uneyor or ChU Zn9lnaer and t:vo (2) copl. of tb. ~ cut .eea HIlt 1:0 tbe PubUc Work Daptarbent befon atarti.n9 work. ttj _c. '!'be houn of verk an l1ll1~ 1:0 out.a1de ~ bcnan of '7-' .... aDd ,-I .... for allY work 8 attect.1.nlJ a t:nff1c laDe. !:1:! -'. '=' ttl :< n H <-3 :< '.-1 , l!I'!'1JIDAJU) n~Pr 1m... AJmlJII'I' " /'C. !' t ~q t:' IJ (1 3 tf:.6tJ'. ('J (J .;( 7.j- :? :.L- -:2 75' ";? ~ "7 c>3 C7-- ~>F t..> '- i- I \. I'DKIT Al'PLICl.TICIII FZI nAIf CDCIt DIJIOII'l' ~ Sloo.oo "00.00 (SlO.oO) . BOND FOR rArl'BnJ1. I'Dl'ORIWrCZ (loot or DIC. a'l'.) CASH OD'OSI'l' (1200.00) (n or 1OIfD, "00 lID) I'LAK CB:ECJt , DfSPECTIOR nz (10 - Sloo,ooo lot, 1100,000 - '100,000 ,t, 'IO~OO ~ ~~.~'7t' '100 KIM) UPROVZD FOR USOAJICZ ~ K0"---7 for City &n91ftHt 36tJ. t!l() -7 ';~_' 2 ~'-7 L-L) '>,---} . _ -"'/ C;> '7 I t' -. / <-- Dab p / / /. h ~i it"!-, /)L::.-r.e'"z..... c./ ~) ~ 7 - ~ (lIE ODD m:E) *- 69-.~- ~/ OG:..'-t/CJ ~.// .-- I/..c{('''/{ -~:~> " ~- ~----- ..,..",..~ 1IINWrI' (for worJt1DCJ vi~1D tba public d9bt-of_ay) trII1~ No.9; <=>c"; (4/1-(81./ D 1/1&1.,/1) X....f. file c::rn or CIJIIIBBLL DIP!'. or PDBLtc wous 70 North rtr.t: st. c:upbe11. C& t50" (408) 866-2150 . I.ned Applicat:1on Data Pu1Iit expira8 in 12 _. . Appl1c:at1on exp1ru 1D 6 110.. APPLICA'1'%ON - Application 1& banby _de for . PubJ.ic Wora PU'llit 1D accordanca with l!.a~hall lIWlicipaJ. Coda, Sact:ion 11.04. (Application expire. in , IIOIltba if perait not palled) A. Work addrua or tract . ~ -C c: 6. /, /('] A...,. ?-~{~"1 P . ,- utility tnncA locaUcm - 8. Nature of work: /~ -~k //-( ./-(/; J;" /;...;' 2- .~"'Vei:_{j(~/ 1 /.t.~;P/~':' ~<-o:~; ~- / C. A~tach flve (5) caple. of a dravinCJ &bowinCJ th. locaUon, extent and dblenaiona of the work The dravinCJ &ball &bow the nl.Uon of the propo.eci work 1:0 axi.tinCJ ~ace and und&rqrouDd 1aproveunta. When approved by tha City Engin.er, .aid dravinCJ bef::oau . part: of thi. parait. D. The General. CondiUone for all permit. are 11.ted on tba revene .ide. Spacial Pravia10na for tb1a penai.t an 11.ted below. F.ilure to abide by ~_e condit:1ona and pnwiaiona ..y ruult in job &but-down and/or fOrfeitur. of Paithful Performance SureU_ and c:allb dapoa1ta. (See General Condi t:J.one 1 and 2). I. An .pplication f_ IIWIt aCClOJlpeny tbi. appl1cetJ.on. 'ftl1a f_ 18 non-ntundable. N..e of Ap~:icant 0c'-; '~)lL e ,-r7 / ::ILr11 I :t //J/i>I':Ac.. fa.,' I Tel.pbo~~:, ~~"7~) __ ~7L'~/ Addr...~'16Q .#o-n//h A a~ c5k.2/ f; :Sa,,, ](:' S r 9j/') C. I. th1a work beinCJ done by the property owner at their own ra8idenca? u.. -Ro CoIIplete and attach Work.ra' CGIIpanaation and Contractor Information foraa. The Applican~Permit~ee bere!ly .CJlree. by affixing their dqnature to th1a permit to bold the City of Campbell, it. officen, agents and amployee. tree, sate and barmle.. trom any claim or demand for damag.. ra8ul tinCJ from tbe work covered by this perai t. The Applicent/Permittee bereby acknowledge. that they have nad end und.ratand both the front and back of ~1a permit, and that they will inform their contnctor(.) of ~e information. ACaP'l'ED Applicant (Permittee) print/.iqn Date NOTES: ALL WORK SRAL". CONFORH WITH THE A'l'TACHED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL STANDARD DRAWINGS AND CONDITIONS. THE CCIN'l'RACTOR HUft HAVE THIS PERMIT AND APPROVED PLANS ON-SITE AND MUST MDT WITH '1'BE P.W. INSPEctoR ON '1'BE SITE AT LEAST TWO DAYS BEFORE STARTING WORK. APPLICANT HUST CON'l'ACT '1'BE INSPECTOR '1'0 ARRANGE FIELD HEE'lING. NOTICE HUft JIB GIVEN '1'0 PtJBLIc WOlUtS AT LEAST 24 HOURS BEPORE RESTARTING AllY WORK. SP~CIAL PROVTSIOHS _1. Street shall not be open cut tor underground in.tall.tion.. Minimum cuta may be allowed for connection. or exploration bole.. sucb cut. must be .~eciticallv BDDroved bv the InB~e~or ~rior ~o eu~~ifta. P.v_ut may be cut tor und.rqround install.tiona and III1Iat be ra8tored in accordanc. with the Utility Trancb Ra.toration Standard DravinCJ. Work to be .taked by a l1can.ed Land Surveyor or Civil EnCJineu and two (2) copi_ of the cut &beet. .ant to the Public Work Department before ~tartinCJ work. The boU%1l of work are limited to outaide th. boura of 7-9 .... and 3-6 p... for any work .tfectinCJ a traffic lane. _2. _3. _4. _!S. STANOARD AMOtnM'. RE~rPT NO. PDIII'1' APPL%CM'ION PEE $105.00 $ ~~e~ ct-"7TC-.t-lt..f 1/ PLUI CBECI: DBPOSrr $500.00, $~ c~--r-~ 1...... d SURETY FOR rAl'TBFUL PERr'ORlWfa: (loot or EJIG. BS'l'.)~ $ _3 C .!i.;(f?J 4tJ(j 2. j ClSII DEPOSrr (n or SDRE'l'r, $100 KDf) '_ L $ ~ c~{lL..f(.,l PLAlf CBECI: . IHSPECT%OH FEE' . ($0-$100,000 lot, }f- $ -3 ".r c'G do(~/Z-;-_- $100,000 - $500,00979., $500,000 and ~e 7t, $100 KIH) ~ -7 . APPROVED FOR ISSUANCE L,L""'>-7L Z ,:;/<- '--,- .:.J -' '7 L) __LJ -::: { for City Engineerl Date I, f: PM PERMIT Revised 10/91 ~ ---rAt? ~-e- Gv.<2 'q (SEE OTHER SIDE)' -; / - / ,.(' L, ./ L.'/_-,c~J.,.\. 11)~'''-7/.'' L:,N/6<,',rTs... c--<.c c.. L..( L c~.., ~ v l_ r ~ ,- _ I I I I I I 1-3 o t:= ~ n o :I: ~ t:"'" ~ 1-3 ~ o t:= 10( ~ ~ ~ t:"'" H g :z 1-3 I I I I I I - I I I I I I I I I I 1-3 o t:= ~ n o 3 ~ t:"'" ~ 1-3 ~ o t:= 10( n H 1-3 to< I I I I I I I I 1/ .,# ..~ -~, .. ..... CITY OF CAKPBELL DEPARTMENT OF PUBLIC VORKS PUBLIC STREET IHPROVEKENT PLAN NOTES ( General: 1. All costs of providing the plans and constructing the improvements as shown hereon or as revised by the City Engineer shall be the responsibility of the Developer and/or the Contractor. 2. All off-site work shall conform with the current edition of the City of Campbell "General Conditions, Standard Construction Provisions and Standard Construction Details for Public Works Construction" as revised. Contractor(s) shall have a copy of said publication on the job site prior to commencing and during the performance of any off-site work. 3. Public Works Permit(s) shall be obtained from the City of Campbell Department of Public Works before starting ~ off-site work. Allow three working days for processing the application. Fees and deposits will be required. All terms and conditions on said Permit are, by reference hereto, requirements of this job. Contractor(s) shall have a copy of such permit(s) on the job site while working. A separate permit will be required for each utility. 4. Notify USA (Underground Service Alert) 800-642-2444 at least two working days prior to commencing any excavations. Record the inquiry identification number (ticket number) on the Public Works Permit. Provide this number to the City Engineer when requested. 5. It is the developer's and/or contractor's responsibility to notify the City Engineer upon finding conditions in the field which are at variance with the plans and/or which may require altering of the plans. Delays in making such notifications may cause substantial delays in the completion and acceptance of the work. 6. All existing wells shall be sealed. All existing septic tanks shall be cleaned and filled. This work shall be done in accordance with the specifications and details of the Department of Health of the County of Santa Clara and the Santa Clara Valley Water District. 7. Final inspection and acceptance must be requested in writing. See General Condition 5 on the Permit. 8~ Reproducible as-built plans must be provided to the City Engineer before acceptance will be made. 9. Building occupancy will not be allowed until acceptance of the work by the City Engineer~ 36 <::'4TAt...~.,q LA-A./c ~;z7- 9/88 /:J~~d//r 9/-/38 /I ." : ....-.. . " ~ t. VICINITY' MAP , ..",-"' VED F CONSTRUG,rfoN. ./ ~. ; y of, Ca~p,pe'l( " /-, / / ~ E ork-s PermiJ'No.~1 - ~ ' . /' L\ . I CorM "dor must have the'!llons on Ih" i"b o!ile during con lion. . . ~ - , ~ , ~\ ~. tq. 1.4 '1 h" ~: I p :pp! I 1 'I ~ .,.p, ~.9 .. \ APPR Public .... ,. . , , /' /' ~.. I' . -<.~/~. // . "J ,,,;.-' /' ./ ~" ~ // . j ,. , U' .,' )}--- --=?:. . A ' \ . . .4"--,. I " ~eJl.. LING S:}' DEEP ~6 / " . ~ I I . , " , ' , ~. .' +\ '. '. . - ' Q. ' . ; . 4 , .. -ftl . . . './ /.' ",.JAT~ me~ .-, () . '"' ;"'pI.~h"~'" oJ, t;,rtivi.~~~~ - . :6t) , 1'--, -, ,.r . i Hh14~Y -...... .,-",0( ~. '. .1' r . .; "~I Aggregate Evaluation and Suggested Concrete Mix Designs f?r ~tar C.oncrete AGGREGATE DATA Sample Identification Kaiser Radum 1 x 318" rock Hillsdale sand Gradation-Cumulative Percent Passing . 1 Inch 1./4 .. " 2 a/a " Mesh 8 " 16 " 30 " 50 " 100 " 200 " 100 92 58 32 Fineness Modulus 6.76 2.70 1.20 . . 99 87 68 43 15 2 1 2.86 2.62' 2.00 'Specific Gravity Moisture Absorption, % Suggested Concrete Mix Designs Cement Factor, scy Slump, in. ~ Type of Placement Design Quantities-l cu. yd. SSD weights Permanente Type I-II Cement, Ibs. Water, lbs. Kais er Radum 313" rock t 1 bs . Hillsdale Sand, Ibs. 6.0 4 max . conventional 564 295 1922 1289 'hese data have been dRveloped on the bases of tests of materials submitted to this laboratory which are assumed o be representative of the materials to be used. The data are intended and offered as an aid BI1d a guide only. User ;hould establish final concrete mix proportions through actual trials and adjustments in the field. AN ADJUSTMENT )F SUGGESTED PROPORTIONS IS USUALLY NECESSAHf AND RECOMMENDED. All tests have been made in compliance vith current ASTM or applicable methods of testing. LL WARRANTIES. EXPRESS. IMPLIED OR STATUTORY. ORAL OR WRITTEN ARE EXCLUDED EXCEPT AS.SET FORTH It,' 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: May"20, 1993 Mr. Jay Shimirani & Mr. Mike Shakeri 4960 Hamilton Avenue, Suite 218 San Jose, CA 95130 SUBJECT: ONE YEAR MAINTENANCE INSPECTION, ACCEPTANCE PERMIT NO. 91-138 LOCATION: 50 CATALPA LANE MAINTENANCE SURETY: WORLD SAVINGS & LOAN #04-03699618-9 Dear Mr. Shimirani and Mr. Shakeri: We have made the final one (1) year maintenance inspection of subject Public Works improvements and find that no maintenance is required. Your maintenance requirements and any surety, therefore, are hereby released. Please come into City Hall to pick up your surety. Sincerely, -?y, ~~-- Hank Imokawa Public Works Inspector II. .15 ~F:djr cc: World Savings & Loan, Stevens Creek Branch,2928 Stevens Creek Blvd., San Jose ,_:.w,- h:91-138 CITY OF CAMPBEll PUBLIC WORKS ENCROACHMENT PERMIT/PROJECT INSPECTION REPORT DATE: 5 -/1 - S) '3 PERMIT/PROJECT NO.: ') i-I 3 & TRACT NO. ADDRESS: 50 CA t/ll-PA 0,4Nt:;~ TYPE OF WORK: STREET: STORM: SANITARY: SIGNALS LIGHTING: SIGNING: STRIPING: IRRIGATION: P.C.C.: ~ PARKWAY: PLANTING: OTHER: PRELIMINARY INSPECTION WITH DEFICIENCY LIST: (Date) FINAL INSPECTION AND ACCEPTANCE: (Date) SIGNED PLANS? COUNCIL ACTION? C E ACTION? FILE NOC? YES_ YES_ YES_ YES NO NO NO NO CHARGES AGAINST DEPOSIT? YES_ NO OVERTIME: HRS. @ $ PER HOUR - $ EQUIPMENT RENTAL: TYPE;. AMOUNT: $ DATE: REASON: TOTAL CHARGES:$ ONE YEAR MAINTENANCE WITH DEFICIENCY LIST ~ ONE YEAR MAINTENANCE ACCEPTANCE -;{, ~a:~~- INSPECTOR S-/1-9~ DATE f:pw insp 9/91 CITY OF CAMPBELL BANK OF AMERICA CAMPBEll OFFICE 125 E. CAMPBELL AVE. CAMPBEll, CA. 95008 11-35 1210 No. ~ ,,,"\ r' ;- r- ~..J lJ ij ,J ~:; 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 DATE 06/02/1992 CHECK NO. 30853 AMOUNT $537.26 FIVE HUNDRED THIRTY SEVEN AND 26/100 DOLLARS SIGNATURE PAY TO THE ORDER OF .JAVAD SHIMIR1\NI 4960 HAMILTON AVE. STE 218 SAN JOSE CA 95130 ~._--.__. _.'_._n !:~' ~~~''''. -.-- .-~~=:~~~~ j...."":....:///:..:.,////I' ,- \'\\'\\'\\' i////~/-:'--:''''''''/J-~:::/ /. ,;'(11\\\.\ ..\' II !, . !! // J' / '/' . , , \ " :,,: "/,'J~::;.:~;::_~,//~.2...c--' I , '\\-.:.::,-_._"::_~_.2_~~, _ /./ ~ , 11.0 :1 0 B 5 :1 II. I: * 2 * 0 0 0 :1 5 B I: 0 g * g :1"1 B 0 20 0 II. VENDOR .007 JAVAD SHIMTRANT DETAIL PURCHASE OROER # 06/02/1992 Check ;1 30853 INVOICE # DESCRIPTION AMOUNT 001.00.905.0000.4662 001.05.540.0000.4448 REFUNDABLE DEPOSIT INTEREST EARNED 5 (i 0 . ' ] ? . TOTAL 53?? CITY OF CAMPBELL BANK OF AMERICA CAMPBELL OFRCE 125 E. CAMPBELL AVE. CAMPBELL. CA. 95008 11-35 1210 No. ~ iJ"' Q r.:; f) ....,' {., \.oi ~.;.. 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 DATE 06/02/1992 CHECK NO, 30852 AMOUNT $3,683.50 THREE THOUSAND SIX HUNDRED EIGHTY THREE AND 50/100 DOLLARS SIGNATURE PAY TO THE ORDER OF MIKE SHAKERI 4960 HAMILTON AVE SUITE 218 SAN JOSE CA 95130 rr-~-c;~:-- ;'/~'~~'~~~-~--~.'.,,-} .'////,/,j '--/J '// !)., '" ~,I!' !.,/,]:,;~-,:;.~;~/__~';' (,'._ "C.~_-'-'--~_'--'_, ' , 11-0 ~08 5 211- .:. 2 .000 ~ 58.: 09. 9 ~"'80 20011- VENDOR .006 DETAIL MIKE SIiAKERI I PURCHASE ORDER # I 06/02/1992 Check Jt 30052 INVOICE # DESCRIPTION AMOUNT 001.00.905,0000.4662 OOl.05.540.0000.444D REFUNDABLE DEPOSIT INTEREST EARNED :} ,6 SO, 33 . TOTAL 3 ,6 e 3 , CITY OF CAMPBELL PUBLIC WORKS ENCROACHMENT PERMIT/PROJECT INSPECTION REPORT DATE: 5-20-92 PERMIT/PROJECT NO.: 91-138 TRACT NO. ADDRESS: 50 Cata19a TYPE OF WORK: STREET: STORM: SANITARY: SIGNALS LIGHTING: SIGNING: STRIPING: IRRIGATION: PLANTING: P.C.C.:~PARKWAY: OTHER: PRELIMINARY INSPECTION WITH DEFICIENCY LIST: (Date) x FINAL INSPECTION AND ACCEPTANCE: 5-20-92 (Date) SIGNED PLANS? COUNCIL ACTION? C E ACTION? FILE NOC? YES_ YES_ YES_ YES_ NO~ NO--1L- NO---X- NO--X- CHARGES AGAINST DEPOSIT? YES_ NO--x- OVERTIME: HRS. @ $ PER HOUR = $ EQUIPMENT RENTAL: TYPE: AMOUNT: $ DATE: REASON: TOTAL CHARGES:$ ONE YEAR MAINTENANCE WITH DEFICIENCY LIST ONE YEAR MAINTENANCE ACCEPTANCE Hank Imokawa INSPECTOR 5-20-92 DATE f:pw insp 9/91 ( 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 May 20, 1992 Mr. Jay Shimirani & Mike Shakeri 4960 Hamilton Avenue suite 218 San Jose, CA 95130 SUBJECT: FINAL INSPECTION AND ACCEPTANCE PERMIT NO.: 91-138 LOCATION: 50 CATALPA Dear Mr. Shimirani and Mr. Shakeri: 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 Engineer. 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 (certificate of deposit) in the amount of $1812.50 and hereby enclose your cash deposits of $3,650.00 and $500.00. Please feel free to call me if you have any questions. :J::-~ Sal Duckworth-Lanzo Senior civil Engineer SDL/bg (dr, wp) cc: Don King Suspense - 1 year f:91-138 ...... ~~IU~WgU' lUB ll~!'~' A' I~UC~fU~~' e~RT!'Je1TE TO CITY 0' CAMP'E~~, 1Q I.IT STREET CAMPBEL~, CAL~FCR.IA ~ooa (401' 866-2150 1>.\,1. p,. It 110....9..1-' ~R ,a or . Locuion c;n ("'~1-:"lIlpa. T.a.np ;,/ ~ I. _w. .n ... .....C",., . "Xi.., ..c..... .. !J;", (eI ~,~, I <- ~ ", ... branch oHtce'at S'I:' ~S CI\u"'-'. California, Inveu..nt Can; icaee "o-ov-~o/b)6-l.....in th. n.... of, CITY OF CAMPBELL and "avtng a p,....na: balanca of S 1 A L j...-..;!!- . r he,.aby g,..nt, tran,f.,. and ...i,n ..id account, .aid Inv..tNent Certificate, .aid belanca Cfnc~udln9 inte,.est ~ntc:n .cerue. tnereon), and alL otner rfGht. In connection fhere~ltn to the CITT a' CAMPIIL~, ...igna., for a GOod and valuable conaid.r.tion, receipt of ~hten I. hereby acknoMLadqed, for the purpo.. of {nsuring con.tructlon dascribed .. tollo~.: have ohv~fc:.llv del;ve~~d , dUDlfcate ot this A.siGnment Bnd .ee~;Dt to said a.a;qnee. und.,..t.nd that ...fgn.a can ~ithdraw frOM ..id Iccount any ti.a an hi. .ignacura alone upon p,.e.entacion of a demand letter to tha f..uer. I .Lso understand that r ..y not ~itndr.. tr~ said account unt..a I pre..nt si~n.tur. of .'s;Q"~e soorovfna said withd~ewIl. Th. f..uer of the eertificata ...u... no responafbillty for the conduct of the aasianee and may act an the signature of ChI ...iene. without fu,.tha,. Inquiry. Executed o~ dO I 19 C; ~t ..Id .fflc. .. th. I'~;;". . (Jk~ Asaigno,. .--- \ Auignor ACKHO~L!DCMfMT IT ISSUER D.u ~~/~,L- , / AI,i'(hO~ S I ill a tun fA Tifl. ,*?s~k~7.d1-..1t (/~~ INSTRUCTION TO ASSIGNEE .oni.. ar. Ivailabl., Iaauer .fflr.. thac tnara ar. no othlr hold. on .ubject account, and th.t the above d..cribed .a.ig~.nt h.. ba.n notad on tha Ie Ickno~lldgamant of your notfce of Assignment thfa A..f~~ent and 'eceipt to tha i..uer at' and Receipt f~ your~ffLes, CS ty af ~baC'{ ... 8y ) ~l ~;, Pl.... afin below for signature Identffication and .. and .. recefpt of seid Inve.tment Certificate. .eturn fts add,.... above. .etain one copy of thi. A..ilnMenc I).t. v RELEASE BY ASSICNEE Said ...i,n.. hereDY r.t..... and r.linqu;ahe. .~l hfs ,.fght, tltte and Intar.se in ,nd to .ald account, seid Inve.tmant Certificate, said balanca and all oth.r rignt, in connection ther.~lth. City of CA~bell By ~ j Dau --- f:fnv-cert (contract for..) . ,.. . ..'..,..,. ..',_ H... _.. _ _ ...''.__ .. _.. ___ .,. ._.._ _____ _~__.._.___ __'_~..__......__ __..~"___ TERM SAVINGS ACCOUNT Account Number 04-03699618-9 1. Account Summary Section Accountholder CITY OF CAMPBELL Date of Issuance OS/20/92 Term 012 MONTHS Opening Balance $ 1,812.50 Initial Maturity Date OS/20/93 Rate of Interest: 4.210 % per annum, Renewal Terms-See Section 4 365/365 Method of Calculation CONTINUOUS CONPDTJDING Early Withdrawal Penalty (also See Section 5) 6 months Interest Distribution Dates QUARTERLY Minimum Balance Requirement $ 1,000.00 . and at maturity No Additions Permitted = 1- Type of Account: o 3 Month Account o 6 Month Account tJ 1 Year Account o Other Transferable only on the records of the Association, o 2 Year Account o 3 Year Account o 4 Year Account 2. General Section This certifies that the Accountholder holds a savings account with the Opening Balance and for the term expiring on the Initial Maturity Date shown hereon in World Savings and Loan Association. a Federal Savings and Loan Association. a capital stock association. SJ TEVENS C EEK CA CITY STATE BY: BRANCH: check may not be available for immediate withdrawal, 005 Deposits 3. Inter t Section This ccount shall receive nterest at the Rate of Interest and shall be payable on the Interest Distribution Dates set fort in the ACcount Summary Section above, provided the balance in the account is not reduced below the Minimum Balance ReqUirement. If such balance IS reduced below the Minimum Balance Requirement, the Rate of Interest on the remaining balance shall thereafter be reduced to the rate then paid on regular savings accounts (also see Section 5), ." ...-.. - --- .-.--- ,.- ---- 51D\~1- c:...,.~ ~.. ~I L,c-l\ , '\\-\~~ ~IJ'--\.o\,-'t.. W"'n.~. ~+. JI'r1 ~~,r...."", 1\wt... \-\~l<". r:. '^^ Q Kd.VIl ~. , p\~. l:>c. ~. \.:::..:..... cl h O~v~ VI-? . ~ b""~ h~ Ar, i){ w'~ w0 Ctfr(,,):>tIo-L~ " c.OLQ. e w\.,~~ w ~{I'-. k..... ~ f~.{' A')f>.o!/ Arpth.~~ GtI-\1L ( e t...A-.--n...et..... ~. C--rJ..J1, CA. ~JN -3. NCl. o--t .. 'II., 5\l IF-. A "''I <;\....... ~ r.Q..1.WVo. CuM. ~. cd-. l'-{\;lq y)'\~~1\)7. \~ 1fr'A-' t'\ ~ ~ S \.u..tLt. ( , k~' TO: SANDY TERPKO ACCOUNTS RECEIVABLE Please issue check payable to: {-.., REFUNDABLE DEPOSIT CHECK REOUEST Mike Shakeri Line 1: 4960 Hamilton Ave. Suite 218 Address: Line 2: City : San Jose State: CA Zip: 95130 Description: Refundable Denosit Exact Amount Payable: $3,650.00 PERMIT NO: 91-138 Account Number: 905.4662 LOCATION: 50 Catalpa #40021 DATE AND NO. OF RECEIPT: 3-31-92 PURPOSE: Return of Faithful Performance (Cash) Deposit Requested by: Approved by: Verified by: Hail as is SPECIAL INSTRUCTIONS FOR HANDLING CHECK: Return to: Public Works (Department) Hail in attached envelope ~a1 Duckworth-Lanzo (Name) Other: 04/18/91 " >, : ) REFUNDABLE DEPOSIT ~ REOUEST TO: SANDY TERPKO ACCOUNTS RECEIVABLE ,. Please issue check payable to: Javad Shimirani Address: Line 1: 4960 Hamilton Ave. Suite 218 Line 2: City : San Jose State: ~ Zip: 95130 Description: Refundable De>>osit Exact Amount Payable: $500.00 Account Number: 905.4662 PERMIT NO: 91-138 LOCATION: 50 Catalpa DATE AND NO. OF RECEIPT: 4-10-91 PURPOSE: Return of Cash Deposit Approved by: Hank Imokawa 1fJ.~ Title: P.W. InspectorDate: 5-20-92 .i~ Sal Duckworth-LanzOTitle: Senior EngineelJate: 5-lo-'9<.... Requested by: Verified by: Accounts Receivable Date: SPECIAL INSTRUCTIONS FOR HANDLING CHECK: Return to: Public Works (Department) Mail in attached envelope Sal Duckwoth-Lanzo (Name) Mail as is Other: 04/18/91 E-t H ~~ Z~ HO-I l:i:: ~gg ~ 0:: OZ ~O H ClE-t ~..:x: o::U HH 0.....:1 00-1 ~O-I o::..:x: ~E-t ZH ~~ ~~ ~O-I Z H~ ~Z ZH ~Cl .....:I ~H 00 CCl ~ Uo:: ZO ..:x:~ o tf.lo:: tf.l~ HE-t E-t o::~ 0.....:1 ~ ~ ClU ~Z ~~ O..:x: O~ ~.....:I o::U E-t ~H ~~ ..:x:~ 00-1 tf.l tf.ltf.l Hl:i:: 0:: 0::0 O~ ~ U ClH ~.....:I o::CCl HO 00-1 o ~~ 0::0 ENCROACHMENT PERMIT ISSUANCE l ....'1{ LIST Ci ty of Campbell Department of Public Works ~App1icant section complete ~App1icant signature and date cj/-/3y Encroachment Permit No. ~Permit Application fee $100.00 ($50.00 for R-l Homeowner), paid. Receipt number ~ '7 0.2:;"" / Plan check deposit, $500.00 (waived for R-1 Homeowner), paid. Receipt number d- 75';1.. 3 _____Five sets of improvement plans submitted ~Bond for faithful performance, 100% of City Engineer's estimate, (waived for R-1 Homeowner), supplied or paid. ~ Amount $ ~ Ie I) (), () (~ Form C i;:-J 1. D. #c:xf_<l - 4 Ob S 4(;; \ ~ .-t' :s~5D.V(.7 ,;4':;/-1 t-fOo2-f ~Cash Deposit: 4% of FP bond, $500 min. ($200 for R-1 Homeowner), paid. Amount $ _S-O 0,0 () Receipt No. :27.5'.:) 3 ~P1an 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 fo~ ~-l Homeowner) paid. , (;>" - c "7. Amount $ 3" 0 ,() 0 Receipt No. "Z- C./;; r-) j I ?, C _:;..: l 'i DC 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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ----- - - - - - - --- - - - - - - - - - -- ~Workerls 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 ABOf'ZEMS ARE COMPLETE, ~ERMIT MAY BE ISSUED Issuer: Initial ' nd date /-7- 57 z.-. and file with permit "3 --'2,0 -. q <- J~UPON ISSUANCE, INITIATE CHECK REQUEST FOR PLAN CHECK DEPOSIT REFUND f:pmtck1st (Misc forms) 7/90 STATE COMP.NSATION INSU.-ANce FUND P.O. BOX 807, SA.N FRANCISCO, CA. 94101.QS07 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE MARCH 26, 1992 POL.ICY NUM8ER; CERTIFICATE eXPIRES: 1255611-91 8-1-92 r CITY OF CAMPBELL ATTN: BLDG DIPT 75 N. CENTRAL CAMPBELL, CA 95008 L This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California .'I'lsurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upo.n ten days' advance written notice to the emplo'ver. We will also give you TEN 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 b.y the policies listed herein. Notwithstanding any requirement, term. or condition of any contract or other docurnent with respect to which this certificate of insurance may be issued or may pertain,the insurance afforded by the policie. described herein is subject to all the tt!trnS, exclusions and conditions of such policies. /f~ PRESIDEN'r 1t1~I'VkO tll~R 2 6 '992- kJIEngin..,i"1 2ubUcWor EMPLOYER r JAIME RUBEN GUTIERREZ OAK CREEK CONSTRUCTION 7032 VIA BARRANCA SAN JOSE, CA 95139 L C:;;"'I~ In..,';~ ID~V. ,n.JU:Ol ('\1 ~ 11)&.,. MISSlnN COUNTY INSURAN TEL No. Mar 26.92 10:28 No.OOS P.02 P.O. Box 6717 San Jose CA 95150- CERTIFICATE OF INSURANCE ___'__.______...----_____....___ .._._..__'.'.._ ",03/..2.()1.~4,2.__,__, THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA liON ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE OLlelES BELOW.___.__.._.__._._.....__, _.___.__._..._. .._.__.__... ... ..... ....._., ...__ COMPANIES AFFORDING COVERAGE "SUE OATE (MII'IIDD/YYJ AU.lllt. PROllUCER Mission Counties Ins. Agcy lnc f~~~NY A American Staten Insurance Co INSURED Oak Creek Construction Jamie Gutierrez 7032 Via Barranca San Jose CA 95139 ~~T~~:Y B ~~T~~:Y C ~T~~~Y 0 COtllPANY E LEllEI'I COVEFlAGES THIS IS TO CeATIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABovl; "OR "H~ POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OA CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CE~TIFleAn MAY &~ IssueD OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES OESCFlIE!t;D HtiHtilN IS SU8JeCT TO All THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLIOIES. ~Ihms SHOWN MAY HAVe 8eeN REDUCED BY PAID CLAIMS. 00 I.TA TYP! 01' IN&U"ANCl POLICY NUMBER POLICY EFFEOTIVE ,"OLley I:!X..IIIATION DATE (MM/OD/TYI DAn (P11P11100/TYJ LIMITS GENERAL LIABILITY A X COPIIPIII!RCIAL G~NEI'4AL LIAlllLITY CLAIMS NAOE X OCCUR, OWNI<R'S II. CONTRACTOI'I'S PI'IOT. OENERALAQOREGATE S 1000(1(1(1 I'HOLJU';; I $.1:;1)',41'11)1" Aut;, , 1 0000 I) (t o l'~ CC - 900936 -1 08/08/91 08/08/92 ~tr-'SONAL & AOV. INJUI'IY S SOOC).,O EACH OCCURRENCE I 500000 FIRE DAMAGE; (Any onell.e) 5 50000 ___~_________.____.~_.._._.._.~.E~.\.~~~~s.e}A~'!~'!8 ~.~!l...$.... _ ..' ...5..QO .. AUTOMOBILe LIA81..ITV ANY AUTO ALL OWNED AUlOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS GARAGE LIA8ILI' Y COhllllNEo SINGLE S LIMIT BOOIL Y INJURY $ (Pur pe.son) BOOILV INJURY $ (Per acciden.) PROPERTY DAMAC3E $ UClSS I.lA81LITY UMBRELLA Fon", OTHeR nlAr.l UNBRELL.A FOI'IM ._.H..._...._......._......____________. EACH OCCURRENCE $ AGGREGATE I llTATUTORY LIMITS EACH ACCIDENT S DISEASE-POLICY LIMIT $ _._.__._~~~~~~.~~!:!.~~!:~c:>_!.E.~..!......,.._ __'.__ WOAKER'S COMPENSATION AND EMPLonllS' LIABILITY OTM!A .~.m:i!~f~~~:~iti'~i~;fIi:p~&i~ii~~y of~~g~~~;E AGEN~~:~~~~~~O~~E~~. .~.~~ ---xJ CERTIFICATE HOLDER CITY OF CAMPBELL ATTN: DON KING 70 NOR'fH 1ST CAMPBELL CA 95008 CANCELLATION SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEPORE THE EXPIRATION DATE THEREOF, THE ISSUING COMf:>ANY WilL ~ MAIL 3(1 DAYS WRITTEN NOTICE TO THE CERTifiCATE HOLDER NAMED TO THE LEFT.lIliK~m.~Q0(X~JQlXHBD! XWI~~}QOOlI~~~~P'JX1. ~".. """"....,,{v~: /J~_.._-- MISSION COUNTY INSURRN TEL No. Mar 26,92 10:28 No.OOS P.03 Or. I THIS ENDOR~ .,ENol CHANGES THE POLICY. PLEASE READ I. ..AREFULLY. ~J. ADDITIONAL INSURED PRIMARY COVERAGE CG 76 34 01 89 COMMERCIAL GENERAL LIABILITY ThIs endorsement'modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: THE CITY OF CAMPBELL AND ITS RESPECTIV~ OFfICERS, AGENTS AND EMPLOYEES, (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, subject to the following provIsions. 1. This insurance applies only with respect to liability: a. Arising out of "your work" for that insured by or for you; or b. Arising from the general supervision or "your work" by the person or organization shown In the Schedule. 2. This insurance does not apply to "bodily Injury" or "property damage" arising out of the sole negligence or willful misconduct or, or for defects In deSign furnished by, the person or organization shown in the Schedule. With respect to the Insurance afforded the additional insured. paragraph 4 of COMMERCIAL GENERAL LIABILITY CONDITIONS (Section IV) is deleted and replaced by the following: 4. Other Insurance 8. This insurance is primary, and our obligations are not affected by any other insurance carried by SUCh additional Insured whether primary, excess. contingent, or on any other basis. b. This additional provision applies only to the person or organization shown in the Schedule. raga' of 1 . .\T'TO'IOBI tF: I\'St'R\\;("F B 1'\]:[1 GOlI'DO\~ EOOYEr;;~ T :': S 1:[:,\\ C E Slle TIHY{\hOUD DI:T','E ')(Trr: 20(; ~.:;:\\ ~-.':C)~:,~ E-: C:\ L T FC)F~:~T ,\ 9.S 1 ~~ 3 --I 22.J TF110B 2:~C: 8198 !~\\ 108 225 1838 CO"IP.\\JY POLIC'" Nt"lBFU ~~-,' T \J _\\! (' J i\ L T' T< r) E:;'\,>1:.,: T "r1:' C'()>1 Ii ~-\ \ \- C70572("0 ""*:';;,' JAMIE GCTIEUREZ, MARIE RITZMAN, OAK CREEK ~-O\STRCCTIO\; 7032 VIA B\RR'\\Ci\ SA\' JOSE f"\lIFOH\i\ ~:,513q 1;: FT"I,:('T T V F F \; P I r~ E S 12/01/91 GelD 1/9:: <jO I~'O n D FLAT U'DLF! 7G8LCLH)9f389 T,T,\nTI fT'{ 1 ,000, uoo COMPREHENSIVE DEDUCTIBLE S () [) C();.[,r::-~TON DEDl'CTrnr,F 500 ~1F])I CAT. Pi\ Y'lENTS I,OOC) 1.',\ T N S UHF~) '!OTOFi 1ST :1 0 , CJ!) 0 / (i 0 , 0 0 Ii L, OF ~A"P8ELL, BlJ[LDJKC DFPT 70 \CmTIT STREET CA'jPRELT ,C \LT FOf.'\' T\ 9500E \S ADD! T1 0\\1 r :SC[?ED S1C\F:D ~~. ~~.~ ..:) '7' ~ - () 'iOR"fC\GEE [] IE'JT r~ ()!'! [' '\ ~'-- \' FIT;: ~??) DECl ATIONS COMMERCIAL VEHICLE AMENDED DECLARATION 01 * * EFFECTIVE 12/18/91 SUPERSEDES ANY PREVIOUS DECLARATION BEARING THE SAME NUMBER FOR THIS POLICY PERIOD C 7057250 12/01/~1 NAMED INSURED AND ADDRESS RITZMAN MARIE 7032 VIA BARRANCA SAN JOSE CA 95139 POLICY 408- 225-8498 AGENT GORDON KOOYERS IN 5450 5446 THORNWOOD DR#206 SAN JOSE CA * * * * * DRIVERS * * * * * RIVER 10 DRIVER NAME ,LICENSE NUMBER BIRTH DATE 1 RITZMAN MARIE E 2 GUTIERREZ JAMIE R P0930038 N6510691 12/08/43 12/04/56 * * * * * ADDITIONAL INTERESTED PARTIES * * * * * NIT LOSS PAYEE UNIT LOSS PAYEE 01 ~~~~ ~F 3;~~6~~~~~ <<)\ 1P''V POBOX 196 31,\=:, '>-,' IRVINE CA 92713 * * * * * MISCELLANEOUS INFORMATION * * * * * NIT UNIT 001 MEDIUM WEIGHT CLASS APPLIES 01 500 COMPREHENSIVE DEDUCTIBLE APPLIES DUE TO VALUE OF 90 FORD FLTBED ISSUE DATE 12/28/91 POLICY PERIOD- 12:01 AM STANDARD TIME DP-44L 1041871 AGENCY 450 95123 POINTS DISC. o o i I A.~.tlll.. .... CERTIFICA.~ _ OF INSURANCE .... ISSUE DATE (MM/DD/YY) I PRODUCER ! I , PRANK P. O. SAN'l'A R. OLMO & SON BOX 58152 CLARA, CALIPORNIA 95052-8152 01/03/92 r"'" --'.'_. '-.--"....--.--"--,.... 'o.-... ''''''''_'''''''' __..,., ",__, ....__...,.._.. ',__._", , I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND I I CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE I I DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE I -PQJ.J.Clf.SJ~f.L.QjV.L..___,_,__~_.._.., ,., __ ....'..___._______ ..__..~ COMPANIES AFFORDING COVERAGE COMPANY A LETTER AE'l'NA CASUAL'l'Y & SURErry INSURED COMPANY B LETTER GOLDEN EAGLE INSURANCE D. A. L. CONSTRUCTION DAVID A. LANNING, DBA: 21610 JENSEN SPRINGS ROAD LOS GATOS, CALIFORNIA 95030-8549 b f~T"i~~NY E I CO~~~~~~~ CERTIFY THAT THE POLICIES OF INSURAN:E L~S::-= HAVE BE=~~~~:~~-~~~.:~. N~M'ED ABOVE FOR':=~PERIOD I INDICA TED, 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, I EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE (MM/DD/YY) DATE (MM/DDIYY) r---~~~;'~~~"-- "'---.. ....-.__._._..-..._...~".. "---'~~~~-;;;;:-;G~~~~ATE-_..-~-..-l , 000,000 I A X COMMERCIAL GENERAL L1ABllIfY AE 00213450 01/03/92 01/03/93 PRODUCTS,COMP/OP AGG. $ 1,000,000 I CLAIMS MADE X OCCUR, PERSONAL & ADV, INJURY $ 500,000 I X OWNER'S & CONTRACTOR'S PliOT, EACH OCCURRENCE $ 500,000 I FIRE DAMAGE (Anyone fire) $ 50,000 /" MED, EXPE~~~J~~Y ?~':.~j,,,.~__ .......2..t.QQ.Q I A-;;;;;;;,~;:~,~A;;;;:;;;---.- --.:E ~~~~.~.4 5 0 01/03/92 01/03/9 3 f,~~!'''" """ $ 500 . 000 ALL OWNED AUTOS COMPANY C LETTER COMPANY D LETTER SCHEDULED AUTOS BODIL Y INJURY (Per person) $ X HIRED AUTOS X I I ['_..__.._-- - -"-"'-'-..---. -- -.---...... EXCESS LIABILITY .. ...~~~:;.~~U:~RE~L~.:.9..R~,..,,__ NON,OWNED AUTOS BODIL Y INJURY (Per accident) $ GARAGE LIABILITY PROPERTY DAMAGE $ .... "".- -~-'''''"'-''''--'~- "~"'---""~"~.-.., ~--=-","--- EACH OCCURRENCE AGGREGATE $ $ B WORKER'S COMPENSATION AND EMPLOYERS. LIABILITY ,,-~- ',,,.._._-...,.,,...,...~., '--'"~,"-_._.-.--.,,.~>..,,~--,------ tl\7Cl'. 113362-00 08/01/91 STATUTORY LIMITS 07/01/92 EACH ACCIDENT $ 2,000,000 DISEASE-POLICY LIMIT $ 2,000,000 ~.",__~~,:!,SE_".:"~~c::~__E~PLO~~"".!2.t.QQ 0 1. 0 0 0_ OTHER _._--.....,~_.-..,~....-.._-~__~._.....m......~_,,,..,_ '.,,_. _"__'__'_"'___"'.~ ..,...._.~_._ ------_."".._--~-,_.- "'---""'-"~"'."''''_''''''''''''''''''''''-'''.r._~' ~....___....,_~___.~_~____~........ DESCRIPTION OF OPERA TIONS/LOCA TIONSIVEHICLES/SPECIAL ITEMS AI,L CAIJIFORNIA OPERATIONS AND LOCATIONS CERTIFICATE HOLDER "-----..,--.._~---"....-.",.. CANCELLATION ""~'-''''-.'--~._..._~-- AUTHORIZ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ~ilIIl{XPCX MAIL -22... DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. OOt~Kml2WQXXMOO{}QE:xJEE:)6)eKllO{lX'DfJl!XlXJ9~lQfKK*X!Xl1'l)oo{ ~~XJ<<ffl{~~~~llI~~, d, Ol\)(~ @ACORD CORPORA"rtoN 1990 CI'l'Y OF Cl,MPBELL BUILDING INSPECTION DEPT. 75 N. CENTRAL AVENUE CAMPBELL, CALIFORNIA 95008 :ORD 25-S (7/90) 1-:. c ( ~ .. ; ~_/ ... - I POLlCY NUMBER: COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED- STATE OR POLITICAL SUBDIVISIONS-PERMITS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE D. A. L. CONSTRUCTION State or Political Subdivision: CITY OF CAMPBELL, ITS EMPLOYEES, OFFICERS, AGENTS AND CONTRACTORS ARE HEREBY ADDED AS ADDITIONAL INSUREDS 75 N. CENTRAL AVENUE CAMPBELL, CALIFORNIA 95008 (Ifno 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 any state or political subdivision shown in the Schedule, subject to~he following provisions: 1. This insurance applies only with respect to operations performed by you or on your behalf for which the state or political subdivision has issued a permit. 2. This insurance does not apply to: a. "Bodily injury," "property damage," "personal injury" or "advertising injury" arising out of operations performed for the state or municipality; or b. "Bodily injury" or "property damage" included within the "products-completed operations hazard." IT IS UNDERSTOOD AND AGREED THAT AS RESPECTS THE ABOVE PROJECT AND ADDITIONAL INSURED THIS INSURANCE IS PRIMARY AS PER SECTION IV-COMMERCIAL GENERAL LIA- BILITY CONDITION NUMBER 6 ON PAGE 9 OF FORM SD003. CG 20 12 11 85 Copyright, Insurance ~ervices Office, Inc., 1984 o -.'-. GOLDEN EAGLE l1~SURANCE COMPANY ,..,. P.O. Box 85826 - San Diego, CA 92186-5826 WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY REINSTATEMENT NOTICE Policy No: WCA-113362-00 Reinstatement Effective: 12/27/91 at 12:01 A.M. Standard Time Date Mailed: DEe 1 t. '991 Mailed From: San Diego CA 92119 It is understood and agreed that the policy for the number shown above and issued by the company named above is hereby reinstated effective on the reinstatement effective date shown hereon. By: ~e~ ......... Named Insured: LANNING, DAVID A. (AN INDIVIDUAL) D.A.L. CONSTRUCTION 21610 JENSEN SPRINGS RD. LOS GATOS CA 95030-8549 Agent: FRANR R. OLMO & SON P.O. BOX 58152 SANTA CLARA CA 95052 Certificate Holder: !II'I 002 12/fl1) Insurett '.I' Copy CUSTOMEP H ze057 C [ R T 1 r I ( ,\ T E. 0 fIN S U FAN ( [ ISSUE DATE: :09(O~19P ::====:: === =:====== ===:::===:: == ::: ==== =::== :==== :::: ::==: ::::=::: === ::::;==== =::::: ==: ::::: ::::::= ===:= :::=: =============:=====., PRODUCER HII) C[RTIFICATf IS ISSllfD AS A f' T[R OF INFORMA HON ONLY A.NO CONFERS FRANK R. OLMO ~ SON NO RIGHTS llFOti THE C[RTIFICATE H R. THIS CERTIFICATE DOES NOl AMEND, 2005 DE lA CRUZ BL, UZCO I r XT[~n OR AITF.h TI!F COVERAGe AfFUI'uED S', THE POLICIES BELOW. P. D. eox 58152 I SANTA CLARA, (AL IFORNH I ZIP CODE 95052 ---------------------------------------1 I I I I COMPANIES AFFORDING COVERAGE INSURED o. A. l. (CNSTRUC TIori DAVID A LAN~ING, DBA: 21610 JENSEN SPRINGS RC LOS GATOS, CALIFORNIA ZIP CODE 95030-8549 [[lfiP Mil L[T T ER A GO LD EN E AG L E 1 ~~ s. CO ([[MPANY LETTER B (OMF'AliY LU TER ( ((1 Mpf,NY LeTTER D COMPf.NY Lr IT [f, E -----.--------.-------------------------------.-----------------------.---------------------------------------------.-- - - ____ - - - - - __ - __ ________ __ ___ ___ __ __ ___ - - ___ __ _..... __.w __ __ ___ _ __ ____ _ __ __ _ ..._ ___ ____ ___ _w.. _ __ _.. ___ __ ___ __ _ _____ _ ___________. COVER AGE S THIS IS TO CERTIFY THAT POLlCIES Of I1;SUF.ANCE LIS1[D FElOh HAVE BEEN ISSUfD TO lHE H;;,Uf.;ED NAMED ABOVE FOR THE POLIn PERIOD INDTUTED, NOTWITHSTANOIt;G ANY REQUIREt'un, TER~1 OR CONDITION CF t'NY CONTRACT CR OTHER DOCUMENT WlTH RESPECT TO WHICH TilTS CERTIFICATE MAY BE ISSUED OR f"AY PtpTf.}N, HIE JNSUF.A/J(E AFf'OROFIl BY THE POLICIES DESCRIBED HEREIN 'IS SUBJECT TO ALL THE TlRMS, EXCLUSIONS, M,D (ONDITJO~S OF SUCH rOLICIlS, LJ,~ITS SHm:1 MAY HAVE bEEN REDUCED BY PAID ClAIHS. ::======:====:==::===:=====:=====:::===:====:=~==:===:=:=:=:=:====:=:==~========:=====:=:=::====:==:~=::====::::===:=== CD UP TYPE OF INSURANCE POLICi POLICY POLICY ~UMBER EFF. nATE EXP. DATE ALL LIMITS IN THOUSANDS :=:=:==::===:=:::==:=:========::==:==;=::==:==~==:==========:~~===:::=;=======:======::=:==:==:==:==:====:===:=========: \ GE~[RAL AGGREGATE $ I PROQUCT-COMP/OPS AGGREGATE $ I Pf:R~)Ct,AL [.ADVERT ISING INJURY $$ EACh (eCURRENCE I FIRE DAMAGE (ANY ONE FIRE) $ I MEClC I<L EXPE NSE (ANY DNE PERSON) $ ----....--..--.-- .-._--- .....-. ..-- ----- ..'"........ .-- '" -...,..-..-.......----- -.... ......- ---- -.............. ..--... -.---------------.-----.--.----.--. IAUTor05ILE LIABILITY I ( ) AI~Y AUTO ( ) ALL O~NED AUTOS ( ) SCHEDULED AUTOS ( ) HIREC AUTOS ( ) fION-r~NED t, UTOS ( ) GArAGE LIABILITY ( ) IGENEPAL LIABILITY I ( ) crH~ERCIAL GENERAL LJAGILITY I ( ) CLAIrs MADE () OCCURRE~CE ( ) OWNERS E CONTRrCTORS PROTECTIVE I I ( ) ( ) I I \ ----- ---.- --- --._--. ,.,.---.. -..... ..-....--- .-- --------.. -... ...-- - ---....---..-...... ........ _....-- .....- -.-. ........- .......----- --... ....--- ..-----.-----------.--- I EACH EXCESS lIABILITY OCCURRENCE ( ) U~eR[LU FORI\ I ( ) OTHU THAN lJ~P,RrLU fORI' I I I ___.... ___ - _-....__........... _......... ____________. __ _____.'" _...... ...__.. _..._..._..._...__... t..... ......_..... ....... ...___.___ ....._____ ___._ _...._ ...-__.__._-______.__. I I ST A TUTORY ~IWORK[RS' CCHPEtiSATI()N ~CA 1133t2-00 08/01lGJ 07/0]/92 12,000 (EACH r.cCIDENl) , AND $2,000 (DISEASE-POLICY LIMIT) IE~rLOYFFSI Llf,BIlITY Ii:Z ,oeD (DISEASE-EACH EMPLOYEE> , I _..-._-------------_.----._---_._---------_._----~.-------"-----------.----~--------_.__..._----------------------.-----. I I IOTHER I ~(Q)[F)W CSL SOulL Y INJURY (PER H':RSON) BOD::L Y INJURY (PER AECIDE~T) ~ PROP[RTY DAMAG[ 1 1. $ _...-----------------------------------.._------~-----_.------_._~-----------------------------_.--._-------------.------ oeSCp! PITON OF OPERATIOt;S/LOCAT Ie IISI VEIlI Cl lS/SPUI .~1. I T[~S HL (I\llF[J~NIA llP[Rf.T1CiNS HiD L[ICAiIONS LTwn ~61[]187 - ---- --- --- -- --- ---- --- --- -- - -- -- -- -- - --... - - - -- --.- ---- ---- -- -... - - - - - --- -- - .. - --- -- -- -- - --... --- ------ -- -- - --- --- -.---------- -------------------..------------------------..-----------.-----------------..--------------------------------------------- I Wier l U TJ[I N CONHACTOR: STATE L!UNS[ aD I SHDULD rNY (if THl i\f\[)V[ DESeRTFED POLICIES BE CANCELLED BEFORE THE EX- OEPT CCt;SU~ER AFFAIRS I PIRt TII"I DHE THEREO; , TIlE ISiUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS P, 0, BOt 26000 I wrnTT[r, NonCE TO TI!~, CERTIfICATE HOLDER t,AHEC TO THE lEFT, BUT FAILURE SHRAMEflTO, CALIFORt<IA TJ ~.tdl SUCH NOTICE SHALL I~;PCS[ NO OBLIGIiTION OR LIABILITY OF ANy KINO ZIr CODE 9SEZ6 I UPO~ THE COMPANY, ITS AGENTS OR REPRESENTATIVES. --------_._-----------"~-.----------------~--~-_.----------.---------------------._-------------~--.------_..---...-.-. I AUT H [I RIlL D R E P PE S un A TI V E I CEPTIFICATE HOLDER THIS 1I0ND SHALL BE PILED WITH TIlE REGISTI\AR OF CONTI\ACTOHS THE PREMIUM ON THIS BOND IS FULLY EARNED FROM INCErlrIOI~ STATE OF CALIFORNIA \.;ONTHACTOHS STATE LICENSE BOA/H) CONTRACTOR'S BONO SUHETY CODE BOND NO. A "'J U V L~ !lll/llll) '.1 (OOU SecliollS 7071.5-7071.11. Business and ProfesslOlIS Code LICENSE NO, (ii pt-".ilnK, IftIwe blankl i (J ') . ()[J The premIum on this bond is $,______ KNOW ALL MEN BY THESE PRESENTS: Tholl fortheterm [1^1l'1l1 y-I-{JlII' 1I1l1rlll1~i /) II l C () II S t I'l JC: t i () n whose address is (Nallle Shown On Applicallon Or Li<ense) ________~I {J I U Jl'II'WII .~f~i' I Uf, Cd l ()~" ['A <J'JD5D ._. as Principal. and TUE CONNECTICU'I' INDEMNI'I'Y COMPANY a corporation organi~ed under' the laws of CONNECTI CU'l' and authori~ed to transact a gelleral mrety business in the State "f California, as Surety, are held and firmly bound unto th" St<\le \,[ CaHforml? in the pe!!al sum of FIVE THOUSAND _-Dollars ($ 5,000.00 ) for the payment of which well and truly to be made we bind ourselves, our heirs. administrators. successors and a"'lgm, jointly and severally, firmly' Lv these presents. WHEREAS. The provisions of Sections 7071.6 and 7071.8, BusilH'ss and Professions Code, require that the Principal file or have on file with the Registrar a bond issued by an adulltted surety in the sum 01 S-" 5 ,ono aiL ____ and this bund i.> executed and tendered in accordance therewith. NOW THEREFORE. The concliliotiS of the foregoing obligation are that if II Principal shall comply with and be subject to the proviSions of Section 7071.5, B'l.Siness and Professions Code, then this obligation shall be !lull and void; otherwise to remain in full force and effect. PHOVIDED HOWEVEH. Thi, lXJlhJ is is.sued sur.jL>d to the follOWing e"'pres.s conditions: I This bond may be cancelled Ill' the Suret\' in accordance with the provisions of SL"Ctions 996,:310 et seq, of the Code of Civil Procedure, 2. This bond shall be deemed contlnUOIJS in form and shall remain in full force and effec,t and shall run concurrentlv with the license period for which liceme il granted and each and every succeeding license period or periods for which $did Principal lIlay be licensed. after which liability hereunder shall Cease e~cept as to any IlaLilitv or in debtedness therefore incurreJ or accrued hereunder 3, The conditions of the bond are as set forli, in Sections 70715 a nel 707111. Business and Professiol15 Code and any person claiming agalflst said bond Illay or, ng an acllon in a proper court on this bond lor Ihe anJUlln! of the damage he iliaI' sllfler as the result of such acts or ornissioTlS L\' the Ptlncipal. e",cePt thJt such aclinn enlist lx. brnught within two (2) years after the ';\p,ration of the license period during which the act or omission occurred, e.cept provided further that a claim for ftlnge benefits Ilull be brought within six (6) months aill'r .h,> dale the fringe benefit delinquenCies were discovered. and any Civil action thereon shall be filed within two (2) vears after the dale the fflnge benefit contributions were due. 4 The aggregate liabilitv uf ~uf('ly 0" Claims ftll wag"s and fl'lng" benefits oll,er ['Jan on a l'(}nd req\lIred b\' Sectlun i07LS shall not e,\cl:ed the sum of Thrr:e Thumand Dollars (S:3,000.00) The aggregatc' !.alility of llie 'lurel\' hereunder on all claims whatsoever ,hall not e.\eeed the penal sum of this l~)nd in anv e\'ent. S, Dam,lges for failure to pa\ IlInge oencHts In "" "'1'lfess trllst fund established pursuant to a collective-bargaining agreement shall be limited to actual ioss sust'llncd by the trllst fund due to Prim'ipa\'s i.>lllIrt: lu pa>' lu~h tIlllgC benefits, 6 ,\nv employt'<., of Pflncip,,1 \vr", is damat:,.d \'>' I'IJncipal's failule tu pay fringe b.-nerds. who i, 1101 ft'pr""'"led by a Uniun, may brillg an action at law on IllS own t",half 10 r(,L'over such fringe bendlls . 7. This bond is e,ecutt.J by the :;urety to t'omply with the provisions of D,visi"ll 3, Chapter U. of th,..BuSllll'SS and f'roft.'5sions Code and of Chapter 2, Title 14, Part 2 ,J the Code of Civil Procedure and S<liJ i:"md shall be SUIJ)t'd to all of the terms and provisions thereof. . ' , DecE'IIlLw r 2D. ) C)C)(J R rillS bond to become effecl!>!: ________,_ 'rUE CONNEC'l'ICUT INDEMNITY COMPANY ~~" Surd} - FARMING'rON, CONNEC'l'ICU'f ^ddr~\ I certify (or decla,e) ullder pell_,It., of ,_",rjmy that ll,ave l:'l'clJtl~d the foregoing IxJtld nlldcl an ur,,,,vok,,d power of attorncy E>t"cuted In ~; ,J ,t ; I (- I <J i ; I, (' il ] L 1- (I I" I j :l .-..------{:~;[.,701lt': __ on _. DC'('I'IIII){' r 2Cl, ----tj;i(. ] t)f)D . lIllder the bws of th" State of Cllif"rrlla SI~llatllrl:-;;lMi7)~llll'~'Ul. Fa<'1 AI'I'1I0VED BY TIlE ^rrOIlNEY CENEI\AL ^ UC UST 2!J. WH.j , 3B-' IR"v.0-84) 1'/IlII..,I", TrllC'"il N..mt~ III ^llll(fll'~.llI.F..C't ~;,:lIllilld I1d ,J. II'nviJ 111I!'1' 1.'HANK H. OIoMO & SON ( 108) 72 '/--0 22 2 P. o. UOX 58152 SAN'l'A CLARA, CALIFORNIA 9S052-Bl~)2 ... 3......", TO: City Clerk PUBLIC WORKS FILE NO. 9/-/:3X Please collect & receipt for the following monies: NAME OF APPLICANT 5 h e Wl ," reU 1 ; ADDRESS ,5"Lfo )UeuJ ~)e;-Si2l. 35-3396 3372 3521 3521 3521 3373 3373 3373 3373 3373 3372 3372 3372 3372 3372 3395 3370 3380 3510 FOR CITY CLERK ONLY $ 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. ESn (4% of FPB) ($500 min.) 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 $1Ipage) "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 Drainage Area Fee Public Works Special Projects Postage 3~' () (J .J.j.:J,g 7 ,3f.J;O' 'c;. TOTAL $ / 511 Q ktr,' I ~. y, Cfb-/:J..'f PHONE ZIP V" RECEIVED BY % . DATE 5-; 111/ . - Branch: STEVENS CREEK Imperial Federal Savings Account Number Account TItle , , **CITY OF CAMPBELL** -Date Opened 04130/91 Opening Deposit S 3. 600 . 00 Minimum Balance S 500 . 00 Interest Rate 6.30% . Frequency of Compounding QUARTELRY Minimum Additions S NONE Annual Yield 6.45% Term 90 DAY' CD Maturity Date 7 /29 (91 Beginning 06/30/91 Interest Payable QUARTERLY' (See other side for additional terms) Renewal Record . Date Renewed New Rate New Term Balance at Renewal ' " New Maturity Date Employee Initials . , , - '.' , . " . l~~I~UM(U' lUB II!IIJ' 6J I~U~tfN~N' elRfr.rCATE To CITY OF C~P'ELL, 70 M. FIRIT STREET CAMPBELL, CAL~FORNIA 95008 (408) 866-2150 ~.w. PtrMlt MO.~ TIt or DiY Locltion 50 ~at:alpa T.an... I "'We ar. the owner(.) of I ..vinls account It br.neh office .t 5~ cPo:.c. , CII ffornil, the nu.. of CITY OF CAMPBELL .nd havtnll . pr..ent bel.nee of S i<OOQ c.:!. BANK OF THE WEST It ft. Inven..nt Certificate 110. 95-4063465 in [ her.by grant, trln.fer and ...iln .aid account, .aid Invelt_cnt Clrtificate, ..id b.llnce (including Intere.t which .ccrue. thereon), and all other right. In conneotion ther.wlth to the CITY o. CAMP8ELL, a..illnee, for. good .nd va~uable constderatlon, receipt of which t. hereby acknowledged, for the purpo.e of Inluring construction described .s follow.: have Dhvlfcallv delivered. dUDliclte of this Assianmlnt end Ree.iDt to said Blsignee. r understlnd thlt ...Igne. cln withdraw frOM s.id .ccount Iny tiMe on hi. signature Ilone upon pre.entltion of I demand letter to thl i.suer. I also understand thlt I ..y not withdraw fr~ ..id account unles. I pre.ent Lign.ture of a..ianee .oDrovina 'aid withdraw.l. The I..uer of the certificate a..u.es no responalblllty for the conduct of the Is.ignee Ind mlY act on the .ignlture of the I..fgnee without further {"q~iry. Executed on ~ /3 c . ,,~,t ',Id "'1.. ., th, I.,..,. ~ All i liInor fJ~ Au hnor ACKNO~LEDGMiKT I' ISSUER [s.uer affirm. that there are no other holds on .ubject accovnt, thlt subJlct Moniee are IVlilable, Ind that the lbove described a..i8~ent hi' b..n noted on the .ecord. of Slid I.auer. "t'~1/ ~/ .y~9 ~ ~~j~::;~a-L /~ J INSTRUCTION TO ASSIGNE~ '- Pl.... .10" below for .fsnatur. identtfication end a. acknowledgement of your notice of Asslgnm.nt and .1 r.ceipt of s.id lnveatmlnt Certificate. Return thl. A.slgo.ent and Receipt to the i.sulr at its addr... above. Retain one copy of thia As.ignment and Recllpt for your~ff~es. City of C'l1Ipbe~l DIU Iy RELEASE BY ASSIGNEE said aa.ignee account, .aid Dlte 5- r CJ - ~ L hereby rel..... and r.~inqui.he. a~l hi. right, tltl. Inv.atm.nt Certificlte, ..id balance Ind all other ri C icy of By f:lnv-cert (contr.ct for..) CITY OF CAMPBEll Permit No._ Applicant '"1/ -/3'p 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 7t-'t'f oS N-W\A,\ i~~\. Name of Contractor/Applicant ""\~ ~ ~~ One of the following must be on file with the Public Works Department: A Certificate of Consent to Self-insure i..ued by the Director of Industrial aelations; 2R A Certificate of Workers' Compensation Insurance Insurance Co. Policy No. Expiration date ; 2R ........................................................................... 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' Co p~nsatio s of California. Date y (, (c, I Signed NOTICE TO CONTRACTOR/APPLICANT: If, after signing this Certificate of Exemption, you should become .ubject 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 Address Telephone State Contractor License No. City Business License No. Expiration Date .. ~ill do the following types of work: _____underground P.C. concrete A.C. paving electrical _____other . (specify) f:PERMINFO REV. 8/88 , TO: City Clerk PUBLIC WORKS FILE NO. 9/-/32 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.) $ L"J;} /60 j.. 7 '5 ;l. , ~() r(./ 2.15~:J..3 ;L 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 Reapp'ortionment 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 <:>0 $ ?-tf6' PHONE 37 7 ~t '7 tJ 7 -Y' ZIP 1'~/,;l.f- FOR CITY CLERK ONLY RECEIVED BY DATE ADDRESS NAME OF APPliCANT t<s-. TO: City Clerk PUBLIC WORKS FILE NO. c) /_ / ~--:: ,{.:, , - 35-3396 ACCT. ITEM AMOUNT RECEIPT NO. Please collect & receipt for the following monies: 3372 3521 3521 3521 Project Revenue (specify project) Public Works Encroachment Permit Fees: Application Fee Plan Check Deposit Faithful Performance (Cash) Deposit $ .-, - 'lC; ,c/ trOQ ':"'(;, ;:;~> S' (_.~.~~ }f-OOJ;- Other Cash Deposit (specify) ($105) ($500) (100% of) (ENGR. EST) (4%of FPB) ($500 min,) 1.1 3372 1./ 3373 3373 3373 3373 3372 3372 3372 3372 3372 3370 3380 3395 3510 Plan Check & Inspection Fee ($0 - $100,000 10%; $100,000 - $500,0009%; $500,000 and above 7%; $100 min.) Project Plans & Specifications General Conditions, Standard Provisions & Details ($10 or $1 /page) "No Parking" signs ($1/ea. or $25/100) Copies of Engineering Maps & Plans ($.50/sq.ft.) Final Parcel Map Filing Fee ($475 + $21/ per lot) Final Tract Map Filing Fee ($525 + $21/ per lot) Lot Line Adjustment Fee/Certificate of Compliance ($420) Vacation of Public Streets and Easements ($500) Assessment Segregation or Reapportionment First Split ($500) Each Additional Lot ($150) Storm Drainage Area Fee per Acre (R-1, $1,875; Multi-Res" $2,060; all other, $2,250) Public Works Special Projects Park Dedication In-lieu Fee Postage TOTAL S'ft "tf(( {, . / I I hivl ,4--V"-Q-- J -ft t ( ;{ ~ d.. .-- vc c $' () ('-I -- 3 ) (; - h 7 J 7 CA ZIP NAME OF APPLICANT Mike ADDRESS I.f 1 {;:; f-tt,- ~,1 , FOR CITY CLERK ONLY PHONE )C"L -J1~ , )%'l~l-- CiJ.! .? 'J RECEIVED BY DATE At~t.lllt" CERTIFICA". .: OF INSURANCE _ 03/26/92 THIS CERTIFICATE IS ISSUED AS A MAHER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE PO.\..ICIES .aJ;kQW, ISSUE DATE (MMIDDIVY) PRODUCER Mission Counties Ins. Aqcy Inc P.O. Box 6717 San Jose CA 95150- COMPANIES AFFORDING COVERAGE COMPANY A LETTER American States Insurance l.a INSURED Oak Creek Construction Ja.mie Guti..3rrez 7032 Via Barranca San Jose CA 95139 ~~T~~~NY B ~~T~~NY C i ~ e.-: &1 I V i.i .;) MAR 3 0 1992 COMPANY D LETTER Public Works/Engineering COMPANY E LETTER COVERAGES 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 POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE (MM/DD/YY) DATE (MMIDD/YY) LIMITS GENERAL LIABILITY A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE X OCCUR, OWNER'S & CONTRACTOR'S PROT, 01'-CC-900936-1 GENERAL AGGREGATE $ 1000000 PRODUCTS-COMPIOP AGG. $ 10(10 (100 08/013/91 08/08/92 PERSONAL&ADV, INJURY $ 500000 EACH OCCURRENCE $ FIRE DAMAGE (Anyone fire) $ MED. EXPENSE (Anyone person) $ 500000 50000 5j)J).f!._~ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON,OWNED AUTOS GARAGE LIABILITY COMBINED SINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE EXCESS LIABILITY UMBRELLA FORM OTHER THAN UMBRELLA FORM EACH OCCURRENCE AGGREGATE $ WORKER'S COMPENSATION AND EMPLOYERS' LIABILITY STATUTORY LIMITS EACH ACCIDENT $ DISEASE-POLICY LIMIT $ DISEASE-EACH EMPLOYEE $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/SPECIAL ITEMS THIS INSURANCE IS CONSIDERED PRIMARY INSURANCE. THE CITY OF CAMPBELL ITS RESPECTIVE OFFICERS. AGENTS AND EMPLOYEES ARE HEREBY NAMED AS ADDITIONAL INSURED. }~-,,~~=~- ~-- ~._---_.".".^... ._-",.~~~._,.~ '.'" .., CANCELLATION : CERTIFICATE HOLDER CITY OF CAMPBELL ATTN: DON KING 70 NORTH 1ST CAMPBELL CA 95008 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ~ MAIL 30DAyS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, ~ ~MEX~ '"'"0""" """''''''''{Jj[~ (' 1~~~ORATlO~)~90_' ~.9.Q.B.Q-.2..~:~,[!J~91, THIS ENDOf, ..ENoT CHANGES THE POLICY. PLEASE READ, \REFULL Y. ~3. ADDITIONAL INSURED PRIMARY COVERAGE CG 76 34 01 89 COMMERCIAL GENERAL LIABILITY This endorsement'modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: THE CITY OF CAMPBELL AND ITS RESPECTIVE OFFICERS, AGENTS AND EMPLOYEES. (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, subject to the following provisions. 1. This insurance applies only with respect to liability: a. Arising out of "your work" for that insured by or for you; or b. Arising from the general supervision of "your work" by the person or organization shown in the Schedule. 2. This insurance does not apply to "bodily injury" or "property damage" arising out of the sole negligence or willful misconduct of, or for defects in design furnished by, the person or organization shown in the Schedule. With respect to the insurance afforded the additional insured, paragraph 4 of COMMERCIAL GENERAL LIABILITY CONDITIONS (Section IV) is deleted and replaced by the following: 4. Other Insurance a. This insurance is primary, and our obligations are not affected by any other insurance carried by such additional insured whether primary, excess, contingent, or on any other basis. b. This additional provision applies only to the person or organization shown in the Schedule. Page 1 of 1 C,UN,17,PRINT001-0185-0009-L /~c. (o'.' C CITY OF CAKPUlJ., CITY ENCINEER 0 S CONST1lUCTION COST ESTDVoTE Addre.. 5J C ,...1'7 ;,\ [' / ' r t:'. -' 1'" C Surf.~. Con.~~~tion C1aarln& . Crubbln& .J-'i Sa.cut Concrete Concrate la.oval 38)- Curb . Cuttar la.oval ~/o Inlot Dra1n .1th Plpe CUrb . Cutter Slda.alk u.p Sua latllUte -/'c/ LF @ $ 4.00 , ' ~....',~. SF @ 3.00 LT@ 5.00 EA@ 600.00 LF@ 14.00 SF @ 4.00 SF f 5.50 lA, 400.00 LT@ '.50 LT' 50.00 SF)K($0.10)Kt-..-.) 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