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crrr OF CAMPBELL
DEP'l'. OF PUBLIC: WORD
70 North Fizwt St.
t"--IIlpIoloaJ.1. , CA '5001
(401) 116-2150
4' ) -/30
ENCROA~ PmUIY'l'
(for work1D9 in tIl.
public rilJbt_f-v.y) X-Ref. f.u..
laud #;L/CJ I Application Date 06/91
PeaU.t expin8 in 12 _. Application u:p1ru in 6 .,..
APPLICAT%ON - Application 18 buwby _d. for a Pub1.ic Worb PenU.t in accordance witll c:a.pbell
lIWlicipal COda, Section 11.04. (Application expiraa in 6 ~ if puait not palled)
hE1lit Jlo.
A. WOrk addna. or tnc:t ,
C RIO
0,-..' ~
(-3 '1-'''') (If- ~,-,J
r:r\,I'v,,) rei j
,
Cf-\
Vtllity 1:nncb location
( .:::,-(- r~(-;:- J !:lc ,C~\. )
- .- _ t-. .J.~ -..-' . . _~ . /..
c. Attacb fiv. (5) copi.. of a dnwiD9 lIboviD9 tile location, extent and dia....icma of tIl. work
'l'h. dnwiD9 8ba1.l lIbov tile nlation of tile propoaed work to exiatiDq IlUZ'face and lIDdervroand
1apraveaenta. 1Iben approved by tba City In;inear, Aid dnviDt becoIIa. a part of thia pamit.
D. 'l'Jle General COnclitiona for all peE1lita an l18ted on tile NYU'H .ida. Special Prav18ioll8 for
~ pera1t an l18ted belovo r..u.un to abida by tb... cancl1ticma and prov18icma _y ruult
in job lIbut-down and/or forfeib1r8 of raithful Perfonaance IIonda and caab depoaita. (I..
General conditione 1 &lid 2).
B. AD .pplication f.. _t aClC:Cl8p&lly thia .pplication. '1'hia 18 aon-nfmldabla.
.... of Applicant r[)~c<':C_.tc Ir-.JJ(:.<:,.t f"l\. ,,) 15 'l'alapboftal '-1'J€,\76'-c:..;')J '1
Addna. I ( ~J }-;'::::'\2. \..1),) c IllX:. 'S:'\ .j y' ( C-_ C r\ Cj S'IL5
....
B. ..b1r8 of varkl
Llll ik..f- -' ()
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c~o ;..j (' l.?:::'~ -ico ~
18 tbia work beiDq don. by tile property owner .t tbeir own naidance7 --::tU L no
Ca1Iplata and attach Workan' co.pena.tion and contractor Infomation fone.
'l'ha Appl1cant/Pu1lit1:ee banby .lJnU by .ff1xin9 tbeir ailJMtun to thia'pemit to bold tba cUy
of
C&JIpbell, ita offican, .qent8 and -.ploy... free. ufa and bual... fJ'a any claia or d-.nd for
duaq.. naultin; fJ:CIII tba work c:avancl by thia pana1t.
'l'h. Applicant/.enli~a. banby ackDovladqe. that tbey bay. read and undentancl both the front and
back of tbia penl1t, and tbat tbay will intOnl tbair cantrac:tor(a) of tile infonlat1on.
~&U ~;ii~~~~na1t~~1~~~~~~ Date Lj /zl;:)
NOTES I ALL MOB IBAl.L COJfP'OJUI WI'1'B '1'BE AftAc::aD. AI'PROVBD PIoUI AlII) ALL APPL%CUI.Z CAllPULL
STANDARD DRAWDfGl AJID CDJIDr1'%01f8.
'1'BE COH'l'RAC1'OR MUS'!' RAft 'l'BIS PI:RIII'1' AND Al'l'J\uVED PLUfI AlII) IIU8'1' lID'!' WI'l'B 'rBI .... IJIIPZC'1'OR ON
'1'BB srrz M LZAS'1' 'ftIO DUS 8U'01tZ STAK1'DfG 1IOIUt.
NO'l'ICZ HOST a C:IVZN 'I'D PDBLIC WORD M LZAI'1' 24 BoaRS ID'O.RB DI'l'AIlTDIG AllY 1IOlUt.
" .
SP!:~AL PROVYSIOH!I
_1.
st:net 8ba1.l not be open c:n:rt for ~ 1nata1.l.tiona. lUnilam cuta _y be allOWed
for conn.ct.1cma or exploration bol... 8Ucb ca1:8 Imft bit u.eificallv aaaravad bY ~e
II'I.".~ar .
..v-.nt _y be cat for andU'liJftNncS iDatall.Uona &lid -.at be natond in accordance with
tbe utllity 'l'nncb Rutontion StaDdard DnvinCJ.
Work to be atakad by . licen.ad LaDd sun.yor or CivU ZftcJineer and two (2) copi.. of tbe
ClIt lIb..ta HIlt to tile Public Work Daptart:aent befon lItartinIJ van.
'l'be boura of work an l1a1ted to autaida tile bDu.n of 7-. .... &lid 3-t p... for any vark
affectin9 . traffic lane.
_2.
_3.
_4.
_5.
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$ itVA I vCD
$
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PZRKI'1' APPLICA.'1'IOH FD
Pu.II CBEc:Jt DZJIOS1'1'
IOND POR P'AI'1'BP't1I. PDI'OlUWrCE
CASB DDOS1'1'
Pu.II c:s:Ec:Jt , IHSPEC'l'IOIf FD
$100,000 - $500,000 It, '50
APPROVZD FOR ISSUANCE
$100.00
$500.00
(loot or ERG. 1ST.)
(SZOO.OO) (n OF BCIID, $500 1IDf)
($0 - $100,000 lot,
and above 7t, $100 1IDf)
. ,
($50.00)
</-Z-91
Date
(SEZ OJHER SItE)
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At~t.III." CERTIFICA 1-==. OF INSURANCE
ISSUE DATE (MM/DD/YY)
4/2/91
PRODUCER
INDEPENDENT INSURANCE SERVICE
p.O, BOX S
Los Gatos, CA 9S011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,
EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
COMPANIES AFFORDING COVERAGE
COMPANY A
LETTER
AMERICAN STATES
CODE
SUB-CODE
INSURED
GREG ONTIVEROS DBA: CONCRETE
I'TVESTMENTS
170 Her10n,g; Ave.
Sa~ Jose, CA 95121
~~i!:-~~NY B
~~~~~NY C
~~~~~NY D
~~T~~~NY E
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 TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION ALL LIMITS IN THOUSANDS
TR DATE (MM/DD/VY)' DATE (MM/DD/VY)
A GENERAL LIABILITY GENERAL AGGREGATE $ 600
X COMMERCIAL GENERAL LIABILITY 01-CC-191544-2 5/2/90 5/2/91 PRODUCTS-COM PlOPS AGGREGATE $ 600
CLAIMS MADE X OCCUR. PERSONAL & ADVERTISING INJURY $ 100
OWNER'S & CONTRACTOR'S PROTo EACH OCCURRENCE $ 100
FIRE DAMAGE (Anyone fire) $ 50'
MEDICAL EXPENSE (Anyone person) $1,000
A AUTOMOBILE LIABILITY COMBINED
SINGLE $ '300
ANY AUTO LIMIT
X ALL OWNED AUTOS 01-CC-'391544-2 5/2/90 5/2/91 BODiLY
X INJURY $
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY
INJURY $
NON,OWNED AUTOS (Per accident)
GARAGE LIABILITY PROPERTY
DAMAGE $
EXCESS LIABILITY EACH AGGREGATE
OCCURRENCE
$ $
OTHER THAN UMBRELLA FORM
A WC-218752-2 5/2/90 5/2/91 STATUTORY
WORKER'S COMPENSATION
$ 100 (EACH ACCIDENT)
AND 500
$ (DISEASE-POLICY LIMIT)
EMPLOYERS' LIABILITY 100
$ (DISEASE-EACH EMPLOYEE
OTHER
DESCRIPTION OF OPERA TIONS/LOCA TIONSIVEHICLES/RESTRICTlONS/SPECIAL ITEMS
RE: CONCRETE PARK STRIP
CERTIFICATE HOLDER CANCELLATION
"The City of Campbell and its respective
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
officers, a~ents and employees are named aSEXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
additional insureds from and against any
claims, 1055 liability, cost or expense MAIL 3..0..- DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
arisin~ out of or in any way connected with LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
the construction of the project. This cover~ABILlTY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
age shall be primary and any coverage
by additional insured shall be exce~s
insurance only,"
ACORD 25-8 (3/88) @ACORD CORPORATION 1988
3No.
of
Pages
CONCRETE INVESTMENTS
170 Herlong Avenue
San Jose, CA 95123
(408) 578-0554
Contr. Lie. ##489822
PROPOSAL AND
ACCEPT ANCE
DATE OF PLANS
JOB PHONE
We hereby submit specifications and estimates for:
CD..)c.t2-<? t€:-
u
. P,l:\/Z...\{..S+a1rLC::2fpofbd
~
Aca'5I.2&~ t6 )
etMovG:
Gcz.A c1 C,
Lv A
.
(YI/y..
B~
Gi2.A ~ I DI4. +-, J2.oa +S A....)dc..::)..,)~tc::...-;.HP)(.JLj-..:;)duMP-
to. ... YJtmd6;:rJ h -~~'1~/o.-l/Ptz.c,) ~J ..w Ig.,S......PJ.I.l~. .})) v~dGt2-~
[) f.,(.. g.ghv~ ... ..Prt tt~'4..~..~ YOu f2... .<::o~. .c:::. ~~~ m_~~J~5 Ft . .~ .$"4,- K-~'f"
S6c.dw; tb. YLI 11 A'f3~:5Ak (O...u~m~hQ'c.~) ...wAsH-tc
..E~Q:;Sd.f,.~.,.~ H... C.LC:A-.J Akl..... d6Brz...iS......J:2SLAtGd ......:tQ..m2(4,D~c:...t
;Jj( ~ 5"-&1-,,,,-\ fa 14
NonCE TO OWNER: Contractors are required
by law to be licensed and regulated by the
contractors' state license board. Any
questions concerning a contractor may be
referred to the registrar of the board whose
address Is: Contractors' State License Board,
3132 Bradshaw Rd., Sacramento, CA 95827.
'V3 :: "Or: CS.3 hereby to furnish material and labor-complete in accordance with above specifications, for the sum of:
P(2..1 kG
D0^1p f'6"~.5
l..JcLud.c;s l\LL LABD~ j"f'v1 t62-:'A LS
+ 'Oa.&...J l-.J 5 fO!Lf>~\'T,5
CALIFORNIA ONLY:
--
dollars ($
~O,O{)
).
All material Is guaranteed to be as speciflad. All work to be completed in a workmanlike manner
according to standard practices. Any alteration or deviation from above specifications involving
extra costs will be executed only upon written orders, and will become an extra charge over and
above the estimate. All ag~ts contingent upon strikes, accidents or delays beyond our
control. Owner to carry fire, tornado and other necessary insurance. Our workers are fully
covered by Workmen's Compensation Insurance.
Authorized
Signature
/ S- days.
. >.; ,.--~3 Cf 3 r; G 2 : '~r c c c ~ ~ j -The above prices, specifications and
conditions are satisfactory and are hereby accepted. You are authorized to do the
work as specified. Payment will be made as outlined above.
Signature
Date of Acceptance
Signature
PACC892.3