91-147
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CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First st.
ca.pball, CA 95008
(408) 866-2150
9/- /(,l7
ElfCROACIIJIEIft' PKRIIrJ.'
(tor workinq in the
public riqbt-of-w.y)
Issued
Permit expir.. in, 12 _.
Perait No.
X-Ref. file
Application Date 5"'/1/9/
Application expires in 6 IIOS.
APPLICATION - Applic.tion is huwby _de for. Public warD Pemit in .ccordance with CUlpbell
Municip.l COde, Section 11.04. (Application expi~in 6 IIOnAper:ait not pulled)
A. Work .ddre.. or tr.ct . ~i f "rdL/7/i ~r/(,fL rEND(='
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D. The Gener.l Conditions for .11 pemits .re listed on the reveree side. Special Provisions for &;
this permit .re listed below. Failure to abide by these conditions and provisions aay result ~
in job shut-down and/or forfeiture of Faithful Perfonance Bond8 and caab deposita. (See tz:l
Gener.l Conditions 1 and 2). 0
Eo AD ...11..01... ... .... "=-- It,.... ...11........ ..... 1& --............. _ ,. ~
Name of Applicant ~CJ<. ~ /,4" .1//..5 -.3 9o?-f/,s;..f~ >
Address 9C'j '-- ~J (l,/.{ 72r ../ 'I ::g
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utility trench location
B.
Nature of work:
7/:J4J'H k' If/ e "': 17 J' t/ R c..
C.
Att.ch five (5) copies of a dr.will9 showinq the location, extent and diaensions of the work
The drawinq shall show the relation of the proposed work to existinq surf.ce and underqround
iIIprov..ents. When .pproved by the City Enqineer, s.id drawinq bacoaes . part of this permit.
Is this work beinq done by the property owner .t their own residence? ---yes
_no
Complete .nd attach Workers' COmpensation and contr.ctor Inforaation foraa.
The Applicant/Permittee hereby aqrees by affixinq eir siqnature to this pemit to hold the City of
Campbell, its officers, agent. and employees , s fe and harmless fro. .ny claill or d..and for
da..ge. re.ulting from the work covered perm
have read and underst.nd both the front and
contractor(s) of the inforaation.
/ (?4v /, /rJf /
Date '
NOTES: ALL WORK SHALL CONFORM WITH THE A'1"1'ACHBD, APPROVED PLlNS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLlNS AND MUST MBBT WITH THE P.W. INSPECTOR ON
THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK.
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
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SPECIAL PROVISIONS
_1.
Street sb.ll not be open cut for underground installations. X1nt.u. cuts asy be allowed
for connection. or explor.tion boles. Such cuts must be BDecif!callv auaroved bv the
Yn8Dect:or.
p.v..ent ..y be cut for underground installations and IIUIIt be natored in accordance with
the Utility Trench Restoration Standard Dr.wing.
Work to be .taked by a licensed Land Surveyor or civil Engin_r and two (2) copies of the
cut sbeets .ent to the Public Work Dept.rtment bafore .tartill9 work.
The hour. of work are liaited to outside the hours of 7-9 .... and 3-6 p... for any work
affecting a tr.ffic lane.
_2.
_3.
_4.
_5.
S'l'UlDARD
AMOtJHT
,0
. It-'e "-
RECEIPT NO.
281-c:(
PERKI'1' APPLICATION FBB
$100.00
PIAN CIlIa DEPOSIT
BOND FOR FAI'l'BPOL PERFORMANCE
CASH DEPOSIT
PIAN CIlIa , INSPECTION FBB
$100,000 - $500,000 9', $500,000
APPROVED FOR ISSUANCE
$500.00
(loot OF DG. BST.)
(oIt OF BOIfD, $500 IIIN)
($0-$100,000 lot,
and above 7t, $100 IIIN)
.
.
$
.
t: PWPERHIT
Revised 4/91
for City Engineer
Date
Public Works
July 23, 1991
Mr. Jack Jair
901 Stockton Street
San Francisco, CA 94108
SUBJECT: ENCROACHMENT PERMIT APPLICATION FOR TRASH ENCLOSURE AT
33 SOUTH CENTRAL AVENUE, CAMPBELL, CA.
Dear Mr. Jair:
We have reviewed your plans submitted for issuance of an
encroachment permi t to construct a trash enclosure on Ci ty
property for use by your property at 33 South Central Avenue.
All items shown in red on the plan must be corrected or added as
indicated and the plans resubmitted. We are also returning to \l"'.j
you the application form which requires your signature and date} A,j.}:..".',je.{
on the back page.
The following items must be completed prior to releasing your
application to the building di vision:
Read~ sign and return the application for the Encroachment . ' "....,.(
permlt. (~(('f ffl ,~,tU /.\tt,.J j,1.(,.f./t. ..1~t\'lA.) titr+ fJd.Jfh> ,
. <",I "',---- t? j4''' It +/I"t\\ ,
Correct plans as indicated in red, and return. for....r<Ur t itl~' P '.,! l'j
o lit. <;,;;-,,'S . .s...~ r;~: ~L: '1
approval. rA'(I'~l.tcI ale.va'I'U.1J' 6fA 1IItV7 pldl'lS /tuk Sc.,>T'htJ(II"'T
~ d~.Id i) ,r;. r .f1.l't?di ),,,,; d /' t1 IJ'}("Jc N' V 1:"1i,)~ .
Since the Building Divi;{ion will be conducting most of the
inspection, I will waive the plan check and inspection fee
of $690.
Post a cash deposi t of $500.00. (Please see general
condi tion # 1.) ).h-l dtH"-.
Post a bond for faithful performance in the amount of
$6,900. This can be in the form of a certificate of deposi t
made out to the Ci ty of Campbell. (Please see general
condi tion #2. ) ~ 1.J J(\
,vI!' I a, ~ '-t,.
25% of the fai thful performance bond will be retained for
the one--year maintenance bond. (Please see general
condi tion # 3. )
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t!t-- Provide evidence of adequate insurance coverage from your
Contractor, with the Ci ty listed as an addi tional insured.
See attached insurance requirement for wording of addi tional
insured endorsement.
Once the requirements listed above have been satisfied, the
Engineering Division will release clearance for the building
permit. The Building Division may have additional requirements
that need to be satisfied prior to issuance of the building
permi t and you need to check wi th them regarding any addi tional
requirements.
Under the terms of the stipulation you have 15 days to return
revised plans. Please let me know if you have any questions.
Sincerely,
Michelle Quinney
Senior Ci v i 1 Engineer
Attachments:
Red I ined plan
Original encroachment permi t application
Public Works Engineering Requirements
Completed Engineer's Construction Estimate
cc: Bill Seligmann, City Attorney
Frank Cauthorn, Building Official
Liz Gibbons, Redevelopment Project Manager
Tim Haley, Planning
MQ:TE04
CITY OF CAMPBELL
Permit No.
Applicant
INFORMATION SHEET FOR ENCROACHMENT PERMITS
A separate form must be completed for the applicant and each contractor
that will work under this permit.
WORKERS' COMPENSATION INSURANCE INFORMATION
Name of Contractor/Applicant
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; OR
A Certificate of Workers' Compensation Insurance
Insurance Co.
Policy No. Expiration date
. OR
,-
. . .. ... ... . ...... .... ... .. . .. .. ... . .. .. ... . ........... ... . .. ... .. .... .. .. . .
This Certificate of Exemption from the Workers' Compensation
laws printed below (certificate must be signed).
CERTIFICATE OF EXEMPTION
a, / i:) performance of the work for this permit, I
shall n t em o~na~~person in any manner so as to become subject
to the Worke 'ComPensation Laws of California. .
/ /)t / /97/
Date///ry }
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
Address
Telephone
State Contractor License No.
City Business License No.
Expiration Date
Will do the following types of work:
underground
P.C. concrete _____A.C. paving _____electrical
other (specify)
f:PERMINFO
REV. 8/88
CITY OF CAMPBELL
A licant'. Name:
APPLICATION FOR BUILDING PERMIT
'JIek ~~
S72'e~To~
DATE:/?t:1Y I) )99/
Construction Lender'. Name:
cJ a/ ;t.~ ,<(
Tele hone: /j/S-3Y2-l'S17
STA"'E~ -r -1/\/ '~/1IJI-re.oCL/r-:
9-7'/,
A licant'. Addres.:
3.3 JJ rf O-N"TA2,4.L A.::-A/.:Yc
.uildina Addre..: I tJJ d r-
Ower: J C~ ~ / ~ . Telephone: -9'/5 - .3 9 ..2'7_ ~5 J 1/
Contractor'. Name:
~ a/A/ e -e...
Stat. Licen.e 50:
Addres. :
Architect or EDainear:
State Liceu.a 50:
Addrass:
----....--.............------.................-....--......--.............................
APN: if:< - 0 7 -03/ Pl&J1llUI Dapt _ .0_
Group: l( Type: /1 I
EIleray Calc.. NO
rire Sprinltlered: ;() 0
No. of Bldgs:
..sid.ntial Unit.:
Commercial Units:
D.scription of Work: ~~~~
Square Feetea) 0f.l-Uk170/J
Square FutCb)
Other:
p-;tJ'cco.su,/LC' ~,
PO/f-IA :j
:5 000. --
/
Building Permit Fee:$
Valuation (a)
Valuation (b)
Total Valuation: 3/ 000, -
,
Date: 'or:; / Iff ( Receipt I: ~-:J.r '-/(; 6
/ I '---
Total Build1na Permit rea: $ 1t) _ go
Balance Due : . cS{,:7.,.;2 0
Enl_ Calc.: ;(./() Lolled: "J/(J
--P ~ " (~D
cYO(-;~~ rJK- ~- -d. / <~ -
~r ~-r-CLC120V~f ~v1-U.u( {
7
Advance F.e Paid:
.
/ 3~ ~O
~7.J.o
Construction Tax:
$
No. S.ts of Signed Plans:
'Y
~
Condition or ..marks:
COMPLETE OTRE. SIDE
~..~
55. S',_ CEb'~c... A-ee- DATE: G///C/(
/ /
Applicant ~.t contact department. and provide additional tnformacion
aarked 'X' belove Approval. vill be ,ranced b7 .ach city departaaDt
throulh iDt.roff1cs ..11 OD aeparate for.a.
PROJECT ADDRESS:
aequired Approved
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WEST VALLEY SANITATION DISTIlICT:
100 E. Sunnlolta AVI, Cllllpbell, CA '5001. "1171-2.07
Suppl, one (1) .It of plana for tndultrlll Ind conmerclal devllop.enta.
Ilturn ,.11011 coPl of .....r ,.,.,t to luf1eUnl Deplrc..nt.
PLANNING DEPARTMENT:
10 N. Ffrat St., c:...pbet1, CA "DOl. '01/1"-21.0
Suppl, plot plln, 111vltlon Ind floor ,Ian.
rIlE MARSHAL'S OFFICE:
123 LMion AVI. Clllpbe11, CA '5001. .oa/lll-2111
Suppl, one (1) ..t of co.pllte bufld'nl ,Iana.
PUBLIC VOUS DEPAl'1'HENT:
70 H. ff rat St. Cal!!Pb.l1, CA '5001. .01/111-2150
SUPpl, flvl ..ta of off-aite l.prov...nt pl.ftl Ind I.clvatlon ,.~It Ippllcltlon.
NOTICE: Purluant to Chlptlr 11.12 of the Clllpbell Munlcfpll Code, anI dirt or
d.bria I.n.rlted It . conltructlon "te thet II .1'owed to r...in on . public
right of WI)' for Mrl than t...}VI (12) houri u)' be removld b)' the city AT THE
EXPENSE OF THE APPLICANT fOR THIS IUILDINC PERMIT. fAILURE TO PAY THE ElPEHSE
.'ll RESULT IN SUSPENSION Of NtTHER IUILDINC INSPECTIONS.
ENVIRONMENTAL HEALTH SERVICES: Stlvl Irooka, .oa/2"-I05O. _
2220 Hoorplrt AVI, San Joal, CA .5121
SuPpl, t.o (2) ..tl of compllte ~Ildlnl ,'lna.
VATER POLLUTION CONTROL: CUfforel I. YO&lftI, '01/"'5-5100.
700 LoI EltarOI Id, Sin .1011, CA 611_
CAMPBELL UNION SCHOOL DISTIlICT: Ja"'ln CUlld" .oaIJ7.-s.D5
155 N. Third St, CI/Ilpbe11, CA 6001
CAMBRIAN SCHOOL DlSTllICT: C.I. Towner, .oe/377-2103
'115 Jlctlol Dr, Sin .1011, CA 1512'.
TO:
City Clerk
PUBLIC WORKS FILE NO,
?/- /~ 7
ACCT 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.)
$
(.^.u :1 ~ -"
/~{' ,- - LH)
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 ($4,548)
3370 storm Drainage Area Fee
3380 Public Works Special Projects
3510 Postage
TOTAL
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$ / ",;{.. ---
I
NAME OF APPLICANT
ADDRESS
FOR
CITY CLERK
ONLY
PHONE
DATE
RECEIVED BY
(--
ZIP