96-183
CITY OF CAMP~r.. ,#It I! 1 V 'E ' II.<1.NCROACHMENT PERMIT
DEPT. OF PUBLJI(~ I; (for working within the
70 North First St. public right-of~)
CampbeIl, CA 95008 JUN" 51996 /- D jG ~ t
(408) 866-2150 Issued ~ V Application Date ~ q"
Fax (408) 376-0958 PUoLiC \I. vl"'i'~ Permit expi sin 12 mo Application expires in 6 os.
ADMINISTRATION
APPUCATION - Application is hereby made for a Public Works Permit in accordance with CampbeIl Municipal Code, Section 11.04.
expires in 6 months if the permit is not issued Application F~n-refundable).
A. Work address or tract # \ 3>"3 \ W Prt.....tJ l) ~ ~) eAMP8 ~u....
Utility trench location ~~ (bl0 WPrt_tJ_T PwG..
B. Nature of work I NS..,Prt..t...., 4I/SAtJ.S~'-VER-Lk,~ (APrtLox. 5F'f. 'Df>6.?)
PelL .'No. 9~---/g3
X-Ref. File
(Application
C. Attach four (4) copies of engineered plans showing the location and extent of the work, and four (4) copies of the preliminary Engineer's
Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by
the City Engineer, said plans become a part of this permit.
D. AIl work shall conform to the City of CampbeIl Standard Specifications and Details for Public Works Construction; the General Permit Conditions
listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result in
job shut-down and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2.)
E. THE CONTRACTOR MUST HAVE TIllS PERMIT AND APPROVED PLANS AT THE SITE AND MUST NOTIFY THE PUBUC WORKS
DEPARTMENT AT LEAST TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GIVEN TO PUBUC WORKS AT LEAST 24 HOURS
BEFORE RESTARTING ANY WORK.
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Name of Applicant/Permittee
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: ~ Yes No
Address
Is this work being done by the propertY owner at their own residence?
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of CampbeIl, its officers, agents and employees free,
safe and harmless from any claim or demand for damages resulting from the work covered by this permit.
The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they wilI inform their
contractor(s) of the information:
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Contractor must hove these plans
()r/ the job site during construction.
A.~..I!I.. CERTIFICA TE OF INSURANCE OP 10 DV DATE (MIIIDDIYY)
GLAGB-1 04/18/96
PRODUCER THIS CERTIFICATE IS ( ED AS A MATTER OF INFORMATION
ONLY AND CONFERS h... ItIGHTS UPON THE CERTIFICATE
Rico Pfitzer Pires (MOD) HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
220 Standiford, Suite C ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW.
Modesto CA 95350 ! COMPANIES AFFORDING COVERAGE
David H. Fry ! COMPANY
209-579-7426 A Golden Eagle Insurance Company
INSURED I COMPANY
I B
John Glage Underground COMPANY '" ....
Constr. - * ., ..", "':"~ :'-, '\,
C , , ,- .-
John Glage ,
P.O. Box 112492 COMPANY
Campbell CA 95011 I D AF,t( 2 -"'\ -;,"lflr.
COVERAGES "''-Ie
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TllE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENTWlTH 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 i TYPE OF INSURANCE I POUCY NUMBER I POUCY EFFECTlVE I POUCY EXPlRAnON i UMITS
LTRI ! DATE(MMIDDIYY) i DATE(MMlDDIYY)
GENERAL UABIUlY GENERAL AGGREGATE . $ 2000000
-
A X COMMERCIAL GENERAL LIABILITY CCP 373550-01 12/01/95 12/01/96 PRODUCTS - COMPIOP AGG $ 2000000
I CLAIMS MADE I X I OCCUR PERSONAl. & AnV INJURY $ 1000000
A ~ OWNER'S & CONTRACTOR'S PROT CCP 373550-01 12/01/95 12/01/96 EACH OCCURRENCE $ 1000000
- FIRE DAMAGE (My one f'"'l $ 50000
I MED EXP (My one person) $ 5000
AUTOMOBILE UABIUlY !
- COMBINED SINGLE LIMIT : $ 1000000
-.!.. AIofYAUTO
AlL OWNED AUTOS BOOIL Y INJURY
- $
A -.!.. SCHEDULED AUTOS CCP 373550-01 12/01/95 12/01/96 (PW~1
.....!.. HIRED AUTOS BODILY INJURY
(Pw 8Cdden11 $
.....!.. NON-OWNED AUTOS I
- I PROPERlY DAMAGE i $
GARAGE UABlUlY AUTO ONLY - EA ACCIDENT $
- I
AIofYAUTO OTHER T1iAN AUTO ONLY: I
I--
EACH ACCIDENT $
I--
AGGREGATE $
EXCESS UABIUlY EACH OCCURRENCE .$
~ UMBRELlA FORM AGGREGATE ~ $
OTHER THAN UMBRELLA FORM i$
A WORKERS COMPENSAnON AND T STATUTORY LIMITS I
EMPLOYERS' UABIUlY EACH ACCIDENT ! $ 1000000
THE PROPRIETOR! ~INCL NWC 249846-01 12/01/95 12/01/96 DISEASE - POUCY LIMIT 1$1000000
PARTNERSlEXECUTlVE
OFFICERS ARE: X EXCL SUBROGATION CLAUSB INCL. DISEASE - EACH EMPLOYEE i $ 1000 000
OTHER 12/01/961
A Bus. Pers. Prop. CCP 288261-00 12/01/95 BPP 52000
A Inland Marine CCP 288261-00 12/01/95 12/01/96\ III 95000
DESCRlPnON OF OPERA nONSlLOCA nONSlVEHICLESlSPEClAL ITEMS
Contractors License # 504668. City of C~bell, its officers! ~loyees and
volunteers are named as Additiona Insure s as respects Liab lity ~er CG 200
9. Project 33 Sunnyside Avenue/Permit #96-156. Coverage is designa ed as pri
mary .
CERTIFICATE HOLDER CANC;:ELLA TION
CAMPBEL SHOULD ANY OF THE ABOVE DESCRIBED POUClES BE CANCEllED BEFORE THE
City of Campbell EXPIRAnON DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
Building Department ~ DAYS WRITTEN NonCE TO THE CERllF1CATE HOLDER NAMED TO THE LEFT.
Dept. of Public Works :n'~~~*~~,*R-9~~~~~
70 North First Street
Campbell CA 95008 AUTHORIZED REPRESENTAnvE r'xi:JJ ~ "A~ CORPORATION ,..,
David H. Fry
ACORD 25-5 (3/93)
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