91-158
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CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell. CA 95008
(408) 866-2150
ENCROACHMENT PERMIT
(for workinq in the
public right-of-vay)
I..ued f; 131ft
Perai t ..pin' i 12 ao..
9/-/S-r
C'1l- \4~
perait No.
X-Ret. tile
Application Date
Application expires in 6 aos.
o
z
APPLICATION - Application i. hereby aade for a Public Works Perait In accordance vith Caapbell
Municipal Code, Section 11.04. (Application expire. In 6 ~ntha if ~rait not pulled)
A.
Work address or tract . /'800
Utility trench location ~f1I~
/"
Nature of vork: I/l/S719t..i t2..
WHIlE 0/11;5 I4t/E.
Gfi L::'"'S ;4 1/ t
L,qnf IL II t.. s t iAJ 6 R..
B.
C. Attach five (5) copies of a dravinq .hovinq the location, enent and dlaanslons of the work
The drawinq .hall shov the relation of the proposed work to exi.tlnq surface and underqround
i.prove..nts. When approved by the City Enqln..r, said dravlnq bec~. a part of thl. ~it.
D. The General Condition. for all ~rait. are li.ted on the reverse .ide. Special Provisions for
this permit are li.ted below. Feilure to abide by the.e conditions and provi.ion. ..y result
in job Shut-down and/or forfeitllre of ralthflll Parforaance Bond. and cash depo.it.. (See
General Condition. 1 and 2).
E. An apPl\n"~1.P".'t~~~U~t.~l;;/;~~ ~~!Il.P~l~9.&~~~lh, ""~";.~1~ ~n-nfunda1)le.
Ifame of APP1I~;~t . .. ~- ( '_'do<'." II '-I.. l,;, -' Ii\l '" I "', ...n." <1""""'1/ \ I,;Oi,jN_~lePhone: 67 g - ;2 7'07
f11J~ ) C/l M P8~i L
Address / 00 l.
5 ul7Jlf/ vo/1 KS
Is this work beinq done by the pro~rty owner at thair own re.idence?
2Lno
--:te.
Complete and attach Workera' Co.pansation and Contractor Intoraation foraa.
The Applicant/Permittaa haraby aqrea. by affixinq thair siqnatura to thi. ~rait to hold the City
of
Campbell. its officers, aqent. and ..ployee. tree, .ate and harale.. froa any cla1a or daaand for
damages resulting from the work cov.red by this parait.
The Applicant/Permittee hereby acknovledq.. that thay have read and Ilnder.tand both the tront and
back of thl& permlt, and that they viII infora the r contractor(.) of the inforaation.
ACCEPTED M FUL-L t 12 S- /D7.vf/
Applicant (Peralttae) Date '
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PLAJlS AlfD ALL APPLICABLE ~E~ [; a '~c """~ .'.~
STANDARD DRAWINGS AND CONDITIONS. Wi ~ ~ _ ~ v _ _
THE CONTRACTOR MUST HAVE THIS PERMIT AlfD APPROVED PLAJlS AlfD MUST MEET WITH THE P.W. INSPEC'NlR''ON; ~, ~
THE SITE AT LEAST TWO DAYS BEFORE STARTING WORl<. f{fh, "1 I_~ ;
NOTICE MUST BE GIVEN TO PUBLIC WORXS AT LEAST 24 HOURS BEFORE RESTARTIIfG ANY WORl<.p bl' W ' IE. .
U Ie orn ngmcenng
SPECIAL PROVISIONS
1.
Street shall not be opan Cllt for Ilndarqround in.tallation.. Miniaum cut. aay be allowed
for connections or exploration holes. Such Cllt. .ust be sceciticallY aDDroved by the
InsDector.
Pavement .ay be Cllt for Ilnderqrollftd in.tallation. and all.t be re.tored in accordance with
the Utility Trench R.storation Standard Drawinq.
Work to be ataked by a licen.ed Land Surveyor or Civil Enqineer and two (2) copia. of the
cut sheets sent to the ~lic Work Daptarta.nt before .tartinq work.
The hours of work are limited to ollt.ida the hOIlr. of 7-9 a.a. and 3-6 p.a. for a.ny vork
affecting a traffic lana.
-.k:.::2 .
_3.
_4.
_5.
CR-ll
STANDARD
AMOUNT
RECEIPT NO.
2 9,](, "
PERMIT APPLICATION FEE ($50.00)
$100.00
$500.00
(100' OF ENG. EST.)
(4' OF BOND, $500 KIN)
BOND, $100 MIN)
$ \~.c:o
$
PLAN CHECK DEPOSIT
BOND FOR FAITHFUL PERFORMANCE
u- ~1-1A~
$ \ 4- J (X~. (~-:) ec> "'2..00 2...'-9'1
$<S;~ ~'")< ;27'~& A-
$ leo, {).Q ...J- 9' 3. tJ '7
r
~ -';-s--41
Date
CASH DEPOSIT ($200.00)
PLAN CHECK "
APPROVED FOR ISSUANCE
f: PWPERMIT
Revlsed 7/90
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SEE PAGE 31A
CD
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ECEIVED
fll Ai :~t 1 ~ I
Public WorQ/Engin8orin~
b 3 7, <1 8
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REFUNDABLE DEPOSIT
~ REOUEST
TO: SANDY TERPKO
ACCOUNTS RECEIVABLE
Please issue check payable to:
Address:
Line 1:
Anthony .Tanovi~h
1800 White oaks Rd
Line 2:
City :
Campbp-ll
State: ...clL. Zip: Q c; () () e
Description: Refundable Denosit
Exact Amount Payable: SSOO _ 00
Account Number: 905.4662
PERMIT NO: 91-158
LOCATION: 1800 Whi te ()ak~ Rn
DATE AND NO. OF RECEIPT:
fl /4 /q 1
i7Q1hR
PURPOSE:
Refundable dp-po~ir
Requested by:
Sal nll~kwnrrh
Title: Sr ('iui 1 Etl.'JI' Date: 9-27 91
Approved by:
Rill Hp-lm~
Title: 1<'nlJr M;:m::l'J"'" Date: 9-27 91
Verified by:
Accounts Receivable
Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as is xx
Mail in attached envelope
Return to:
(Department)
(Name)
Other:
04/18/91
TO:
City Clerk
0/( -Is-,f-
PUBLIC WORKS FILE NO.
Please collect & receipt
for the following monies:
TOTAL
NAME OF APPLICANT IJ,uTfltJPv JH.utJl/l~
ADDRESS /R-DlJ WA t ~o.4tc::S Kd . /f/.?b~:-LL)
r , " ,
FOR I ~~~\~
CITY CLERK RECEIVED BY \
ONLY DATE ~\~\~\
,
3372
3521
3521
3521
3372
3373
3373
3373
3373
3373
3372
3372
3372
3372
3372
3395
3370
3380
3510
Project Revenues (specify project)
Public Works Excavation Permit Fees:
Application Fee
Plan Check Deposit
Faithful Performance (Cash) Deposit
Other:
($100)
($500)
(100% of)
(ENGR. EST)
(4% of FPB)
($500 min.)
tV .J.l\ '1. 'of
3- Ol) ..>
di)
Of) 9(:\ b1
R-1:
($50)
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 $1/page)
"No Parking" signs ($1Iea. or $25/100)
Work Area Traffic Controi 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 FeelCertificate 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
$
PHONE
L!-/f
CITY OF CAMPBEll
PUBLIC WORKS INSPECTION REPORT
I
DATE: UJ
/ ;;51 /
/9CO
PERMIT/PROJECT NO.: c:?/ / - /58
TRACT NO.
ADDRESS:
~
(AJhJft Od~s
TYPE OF WORK: STREET:
STORM:
SANITARY: Y
,
ELEC:
P.C.C. :
PARKWAY:
OTHER:
[] PRELIMINARY INSPECTION WITH DEFICIENCY LIST
[] FINAL INSPECTION WITH DEFICIENCY LIST
)~"/FINAL INSPECTION ACCEPTANCE
SIGNED PLANS ? YES
NO
COUNCIL ACTION? YES
NO
CHARGES AGAINST DEPOSIT? YES
NO
OVERTIME:
HRS. @ $
PER HOUR = S
EQUIPMENT RENTAL: TYPE:
AMOUNT: $
DATE:
/
/
REASON:
TOTAL CHARGES:$
[]
[]
ONE YEAR MAINTENANCE WITH DEFICIENCY LIST
ONE YEAR MAINTENANCE ACCEPTANCE
f2ii!OR
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
June 25, 1991
Anthony Janovich
1800 White Oaks Rd.
Campbell, Ca 95008
SUBJECT: FINAL INSPECTION AND ACCEPl'ANCE
PERMIT NO.: 91-158
LOCATION: 1800 White Oaks Road
Dear Mr. Janovich:
We have made a final inspection of subject Public Works
construction and find the work is satisfactorily completed
in conformance with City standards.
Your cash deposit will be refunded under separate cover.
Please feel free to call me if you have any questions.
sincerely,
Alisa scimeca
Assistant Public Works Inspector
";~~~~::~~?rc:;-_:;-:~_:.r~_~~~~~'"
WEST VALLEY SANITATION DI~
SANTA CLARA COUNTY
; 100.E~ Stmnyoaks Ave.,. Campbell, CA 95008
(408) 378-2407
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A.P:r-C-
SMrLocation: Bk.
Tract Lot
Proj. rl~smt.
Add~:~1f ()Ptd-;.
Jurisdictioh {}~,,'~JA-,
~INGTVPe,;.
_ Single Farrnly
_ Condominium/Town Houses
~ Multiple Dwelling
Numb8t-ot Units
_ Commercial
I _ Industrial
Other Information: <; ~~/ilr ..\--
. ' ~ ..' t Ii .\. . i......
Change in Status:
~Aii:
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,~"';,r.'"""".".",, ,,"-,"", " "" :."""',.>1':.:<"""";' ''!'o''':e~~SEWERCO'''' ,
..ICT ' PERMIT NUMBER
:;".t...,.,.:p
Disposition;
~ Zone ~
INSTRUCTIONS:
o Street encroachment permit required from (:J\:,.....VI':e'LC.....
o Permit invalid if not connected within 12 months of issue.
o Do not connect until main sewer is accepted by District.
o Obtain a building or plumbing permit from the jurisdiction listed above; .
tFEES:.
,.;..~eage
Frontage
Service Advance
Processing
Other:
Capacity
$
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............... ~ L-/
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~4-0 '-:1::.
TOTAL
E2IY0 O~
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......- ._ I r--, '-' I
iX~If;;cr o;~ <~I:~':;.\ 0; ,,,~ COU. f"'[V
- "11.1 v.:...dl\ii 1 L
Issue Date
4
~.
.~~:t~'~ r,!-~
line _ feet from Main Sewer'
and _ feet deep. 47)".jiJe ..
Connection to Main sJw";r -
Feet upstream from M.H. /#S'<I ~/::;14
Using
BACK FLOW PROTECTION:
_ FieldCh~~~~'
_ Call District for foundation survey
Device Required; Yes L No .
Type:
-....
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DISTRICT COpy
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Public Works/Enginoering
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