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CITY OF CAMPBELL
DEPI'. OF PUBLIC WORKS
70 North Pirst St.
Campbell, CA g5008
(408) 866-2150
C?/_ / ys-
DCROACRIO!:N'I' PKRIIY'l'
(tor working in the
public right-at-way)
Issued 1/dt//9/
Permit expires in 12 IIOS.
l'Gu:ai t No.
t-Ret. tile
Application Date
Application expires in 6 IIOS.
APPLICATION - Application ia hereby _de for a P\l!)lic Worb Pel2it in acaordance with Callpbell
Municipal Code, Section 11.04. (Application ~ires in 6 IIOntba if pel2it not pulled)
A. Work .ddress or tr.ct. <3 S&l..JdA?e \ ~ <=b t--
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till
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till
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B.
utility trench location
\ ~C)~
C.
D(',-\)e.lA'Yod ~\"D~
\ 'I
Att.ch five (5) copies of . dr.wing abowing the location, extent and dJ..enaions ot the work
The drawing shall show the relation of the proposed work to existing surtace and underground
improv_ents. When .pproved by the City Engineer, said dr.wing beco.es a p.rt of thia permit.
Nature of work:
D.
The General Conditions for all peraits .re listed on the reverse side. Speci.l Provisions for
this permit are listed below. P.ilure to abide by the.e conditions and provision. _y result
in job shut-down .nd/or forfeiture of Paithful PerforlUUlce Bonds and caab deposits. (See
Gener.l Conditions 1 and 2).
B. An application fee .ust .caoapany thia application.
Name of Applicant ~ b\o ~u ~~ 0\
Addre.s <6S'<q ~~\~~
Is this work being done by the property owner at their own residence? ~es ___no
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This i. non-refundable.
Telephone:::'''' '1s - b'5 Db
Complete .nd .ttach Workers' Compen..tion .nd Contractor Inforaation foras.
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of
Campbell, its officers, .gent. .nd employee. free, ..fe and harmle.. froa any claim or deaand for
d.mages reSUlting from the work covered by this permit.
The Applicant/Permittee hereby acknowledges that
back ot this ermit, .nd that they i torm
they h.ve re.d .nd underst.nd both the front .nd
ir ontractor(s) ot the intormation.
~
Date
ACCEPI'ED
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PIANS AND ALL APPLICABLE CAllPBBLL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PIANS AND MUST MBft WITH THE P.W. INSPECTOR ON
THE SITE AT LBAST TWO DAYS BEFORE STARTING WORK.
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LBAST 24 HOURS BEFORE RESTARTING ANY WORK.
-
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SPECIAL PROVISIONS
_1.
Street .h.ll not be opan cut for underground in.t.ll.tion.. Miniaua cuts ..y be allowed
for connection. or explor.tion hole.. Such cuts must be BD8cificallv aanroved bv the
InllDeetar.
P.vement may be cut for underground in.t.ll.tions and auet be restored in .ccord.nce with
the Utility Trench Restor.tion St.nd.rd Drawing.
Work to be staked by . licensed Land Surveyor or Civil Engineer and two (2) capie. of the
cut sheet. sent to the P\l!)lic Work Dept.rtment before st.rting work.
The hours of work .re liaited to outaide the hours of 7-g .... and 3-6 p... for any work
.ffecting . tr.ffic lane.
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_3.
_4.
_5.
STANDARD
AMOUNT {/ c;
. /~d'-
DCETPI' NO.
PBRIII'1' APPLICATIOH ra
$100.00
PLAH CIIBClt DBPOSIT
BOND FOR PAI'l'IIPUL PERFORMANCE
CASH DEPOSIT
PIAN CllBCK , INSPBC'l'IOH ra
$100,000 - $500,000
APPROVED FOR ISSUANCE
iutU--L0..6:' c/
$500.00
(lOOt OP BRG. EST.)
.
.
.
$
L(
t: PWPERMIT
Revised 4/91
/0~Y/91
oate
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It
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?.....A.::s.I'"::l--;,.~c.. ~~ "t"1.+\. ~ \'Z-l L&-, c:-~ \ C::> - \ ~ - ~
1!:!t~::',!'.~!,!,~.J~~~~~~i:I.IIIIIIIII.I.II:.::::.:1111':::::::::':1111,111...~il:l~~.i..li.i:::I:..:I...:I:1::I.i.illlllliii:.:.~:::::.:..::I.l..I.llli:ll.i:i.i.::::::::::::~I.:::I::i":~: ~DATE (MM/OO/~
THIS CERTlFICA TE IS ISSUED AS A MA TTER OF INFORMA TlON ONLY AND CONFERS
NO RIGHTS UPON THE CERTlFICA TE HOLDER THIS CERTlFICA TE DOES NOT AMEND.
EXTEND OR AL TER THE COVERAGE AFFORDED BY THE POLICIES BELOW
Compro Ins. Services Inc.
550 South Winchester Blvd.
P.O. Box 611090
San Jose. CA 95161-1090
408-236-3000
CODE
SUB-CODI!:
CA
95008
COM'ANIES AFFORDNG COVERAGE
COll'ANY A
LETTER
COll'ANY B
LETTER
COll'ANY C
LETTER
COll'ANY D
LETTER
COll'ANY E
LETTER Iw
A&W Cement Company
858 No Harrison Ave.
Campbel I.
:j:!"";"~~M~,,j{/;:;:():j:@t;:;:;::::::::j::::);:it:j:,:;:;:(:::::::::::::::t/\:::::::::::j:::j:j:::::::::j:::","";,;,;,{"',;,;,;,',:,.;.;;"""""",,,,,;,;,:,:,;,:.:.;.:.;"",.........:.:...~:~:,'))'))):........................;::;:;:;';}},:,:,),)));,)}::::.:.\:.k?:r::::I::::::';ih:);{{:;:::,,<t::{:'tj::t::C:::/):::i:},:,:,
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICA TED. NOTWITHST ANDING ANY REOUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCLMENT WITH RESPECT TO
WHICH THIS CERTlFICA TE MA Y BE ISSUED OR MA Y PERT AIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL
THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS.
TYPEOI'INSURANCE POLICY NUMBER
POLICY EffECTIVE POLICY EXPIIAT ALL LIMITS IN THOUSANDS
DATE (MM/DD/YV) DATE (MM/DD/YV)
GE~RAl AGGREGATE .
8/01/90 8/01/91 PROOJCTS.COll'/OPSAGGREGATE .
PERSONAl Il. ADVERTISING I~Y .
EACH OCCWRENCE .
FIRE DAMAGE (Any one fire) .
toEDICAl EXPENSE (Any one person) .
AUTOMOBILe: LIABLITY
A X ANY AUTO
AlL OW~D AUTOS
SCI-ELU.ED AUTOS
X HIRED AUTOS
X NON.OW~D AUTOS
GARAGE LIABILITY
906951502
8/01/90
8/01/91
500
500
500
500
50
5
COMtoERCIAl GE~RAL LIABILITY 206951500
CLAIMS MADE [i] OCClR
OW~R'S Il. CONTRACT~'S PROT
500
.
EXCESSLIABLITY
OTI-ER THAN UlIlRELLA F~M
B
WORKER'S COMPENSATION
AND
EMPLOYERS'L1ABLITY
WC307829080
3/31/91
3/31/92
1000 (EACH ACCIDENT)
1000 (DISEASE.POlICYLlMIl)
1000 (DISEASE.EACHElI'LOYEE)
OTHER
DESCRPTION 01' OPERATIONSlLOCATIONSIVEHICU!S'SPECIAL ITEMS
RE: ALL OPERATIONS PERFORMED BY THE NAMED INSURED.
THIS INSURANCE IS PRIMARY WITH THE CITY OF CAMPBELL AS EXCESS ONLY.
;C.~~!'!I~~r~:::H9~~~::tft::tt?::::::'fjr:::j:j:ffj:f"
............ ...................
.................................
:::::::ffr~~rf?t~t:::~:~:~:~:~::.:.:.::. .
\\\\\::::qANqr;'PMI1Qtf\tt(::::~.:::?:::::::::::::::::. '.::..:'.:::' ~\\::.::.?\;'.;"::/\fff\fmt,:::::",:,:"""",;",:::;:;ttf:::.:.:::. .::"":j::'::':::
..........::::::::.......................................................................... .. ....... .... ........... ...............................
:!:}: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
j:jjjjj EXPIRA TlON DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO
(:!:: MAIL ---1Q. DA YS WRIT TEN NOTICE TO THE CERTIFICA TE HOLDER NAMED TO THE
::::: LEFT. BUT FAILURE TO MAIL SUCH NOTICE SHALL MPOSE NO OBLlGA TION OR
}) LIABILITY OF ANY KIND UPON THE COMPANY. ITS AGENTS OR REPRESENT A TlVES.
City of Campbel I
70 N. First Street
Campbel I. CA 95008
AUTHORIZED REPRESENT ATIVE
Attn: Don King
~~~ ~Jiz /-&<-1
... ....:. . .... .:: ,.:',.,.....:.:.,.;.;:.:.:..:' . ,',., ..:..::::..:./ ..~:,:: :...................Ab.Q.fb.(n~~QMtiQRlIi..'..
100011000
:::~gg~~'tJ.F:lj]~~'n:::j:::::::~::(r:tt::::::::::::~(:::;;::::::::(::::::::::::
04/23/91
13:48
'0'408 246 8266
'i~~~" ;"0002/002
~~~ CITY OF CA3~~tLL ~
--'-
Compro In.. Servicel Inc.
550 SDut~ Winch..ttr Dlv..
P.O. 80x 811080
Sl~ JaIl, CA 85181.1000
401-238-3000
000.. M.ooGI!
THIS CERTIFICA TE IS ISSUED AS A MATTER O~ INF'ORMA liON ONLY ANO CONF!:RS
NO ~IOHTS UPON TI-tE CI;RTlFICA TE HOLDER, TIoIIS CI;RTlFICA TE Ooes NOT AMENC.
!)(TENO OR Al.TER THE COYE:RAGI; AFFORDED BV THE POLICIES eELOw
1\~ AfDftlllL
""'JiitdllltOl.o:.""",,,,,,,..
COMPANIES AFFORDING COVERAGE
OO":>ANY A
LIiTTER
CO'*'ANV
LETTER B
AlW Cement Company
B5B No HlrrllDn Ave.
C.mpbll I,
CO~ANV
~ETTER C
COt4PANY D
LETlER
CA
85008
TVPIOII INIUIIANoI'
JllDl.IO Y NYMII""
PO~IOUI'PRTIYI!
DATI! (uMIOOIVV)
)( COWIERCIAl, QE~~l L1ABI~ITY
;ii:::i: ClAIMS WAllE i7:1 OCCUR.
""",: L.!.J
OWtEFl'S L CONfRACTOF!'S PROT
208!l51S00
8/01/90
PO~I.Y I'XPIAA"r1O
DATE (WW/CD/VY)
ClEtERAL AQQAEClA TE .
81 Cl11 g 1 PROOucTS'COlf'/~$ AClClREClArE .
Pl;"~$ONAL "ADvE~rISINClI~Y .
EACH OCCURJlIE~ .
FIRE DA~ClE (Ariy _ lirl) .
~DICAL EXPENSe (Any ON ~r.CI1) .
AU. LIMITS IN THO"'.I
AUTOWOllILI' L14ll1~ITV
ANV AUTo
ALL OW~O AUtos
SC:fi;cu..ED AUf OS
HIRED AUrOS
NOt;.OW~O AUTOs
rlARAClE LIAl3tLITv
906951502
B/01/90
$1 NQl..E .
8/e 119 1 LIMIT
SOD
OTfoeR THAN UMBRELLA FMM
I~Y
(Per.cciderll
PROPER Tv
OAhlAOE;
1!1!liiil!lill!!I!!!: I_a
EllOl'III.IAlILIT'I
8
WGRlCp'1 OOIolP..NIATION
AND
..MPLOYIHI'LIAlILITV
STA TUTORY
~fj ~ii i! i~iH iHHi i ;iri! iHi iWi; ;H!i ~~i: ii~!
WC3078290BO
3/31/91
3/31/92
.
.
.
100 (EACM AC:CICENT)
1DOO (DlSEASE.PQ,ICVLIMI1)
o DO (DlSEASE.l;"ACHEMP1.0VEE)
OTHI!Il
OllOAlI'TION 01' OPI!lilATION$lLDOATIOHIIVlIHlCIUllIllIEelAL 1T11of1
RE: ALL OPERATIONS PERFORMED 8V THE NAMED INSURED.
THIS INSURANCE IS PRIMARV WITH THE CITV OF CAMPBELL AS EXCESS ONLY.
Attn: Don King
~Bn~?~;'
SHOULD ANY OF THE ABOVE CE'SCRIElED POLlCIES BE CANCELL.EO BEFORE 'THE
i:!:~11 EXPIRA ilON ClA rE THE:REOF. niE ISSUINQ COMPANY WILL ENOEAVOR TO
)llljMAIL 30 CAYS WRITTEN NOTICE TO THE CERTIFICATE HOLCER NAMED TO THE
i;;:,~ ll!'F'T:Bi:j'f"FAIL.URE TO MAIL SUCH NOTICE SHALL tviPOSE NO o ElLlOA TlON OR
!;\1l1 LIAElILlTY OJ: ANY KINO UPON THE COMPANV.ITS AGENTS OR REPRESENT ATIYES,
~~n~;
jl~~1! AUTHORlZl!D R....AI!.I!IIlUTII/!
,~;:i::: ~ hit. . 100011000
llliM!l1ll!i11!l*~~'llIllI._~_'"
City Df Clmpbell
7D N. FIrst Strut
Clmpbel r. CA 95008
l\i1.i#9.,"ff",~j.)i(:.,1,"jj~~\\~1\~\t\(i;l;in~1~i>'!;\l;~!~\1;,\\\iV1;:!l\1~~i;l~~i~;\j;l~\~;;;;\1~:X: ,.
TO:
City Clerk
PUBLIC WORKS FILE NO.
L)/_ /~7/J-
ACCl ITEM AMOUNT RECEIPT NO
Please collect & receipt
for the following monies:
35-3396
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.)
cC' 0 I
/C'L' - ::LfJ I ~
3521
Other Cash Deposit (specify)
($200)
3372 Plan Check & Inspection Fee ($0 - $100,000 10%;
$100,000 - $500,000 9%; $500,000 and above 7%; $100 min.)
3373 Project Plans & Specifications ($10)
3373 General Conditions, Standard Provisions & Details ($10 or $1/page)
3373 "No Parking" signs ($lIea. or $25/100)
3373 Work Area Traffic Control Handbook ($5)
3373 Copies of Engineering Maps & Plans ($.50/sq.ft.)
3372 Final Parcel Map Filing Fee ($450 + $20 per lot)
3372 Final Tract Map Filing Fee ($500 + $20 per lot)
3372 Lot Line Adjustment Fee/Certificate of Compliance ($400)
3372 Vacation of Public Streets and Easements ($500)
3372 Assessment Segregation or Reapportionment
First Split ($500)
Each Additional Lot ($150)
3395 Park Dedication In-lieu Fee per Unit ($4,548)
3370 storm Drainaqe Area Fee
3380 Public Works Special Projects
3510 Postage
TOTAL
$ /00
i:' (l
FOR
CITY CLERK
ONLY
f116er t BUrk h Qrdl-
l-!-cU^I"/ SOh. 5;+.
I
PHONE
NAME OF APPLICANT
ADDRESS )? 6"9
r'(LY1n"be. , I
,
ZIP
~ 7>-0-0 g
37,?-050'
RECEIVED BY (.~
DA TE If I/).'I Is /
, I