96-188
CITY OF CAMPBELL ENCROACHMENT PEIU.HT
DE:7T. OF PUBLIC WORKS (for working within the
70 North First St. public right-of-way)
Campbell, CA 95008 Issued /, It?,. ~/ I / a F
(408) 866-2150 ~ 10 Lc. ~ rI Application Date t;? - I - I ~
Fax (408) 376-0958 Permit expires in 12 mo~, Application expires in 6 mos.
APPUCATION . Applic:ation is berc:by IIIIIdc for. Public worts Pamit ill KiCillI'daDce wkh CaqlbeII MuDicipaI Code. Sa:Iioo 11.04. (Applicllioa apinl ill 61Dl111d1s
If Ibe permiI is DOt issued. AppIic8lion Fee is _refundable.)
Permit No. Cfb - / ~ r
X-Ref. file-rrad' f'7t,l, PUtt4 iT 9>~/ 'i
.
Utility llaICb location
A. wort address or tract ,
B. NIIIUre of wort
C. AlIKh four (4) copies of m qineered plaas Ibowiq Ibe !oc:IIioo ad exraa of lbe wort. ad four (4) copicl of lbe pnIi111my EaciDeer's IiItimIIe of wort. The
pIaDs IballIbow Ibe rdation of lbe propllICld wort to eIiIliq III1'face adlUlllc:rpcund ~_. WbcaIlppfOWd by lbe City ~. IIid plan ....... . .. of
IbiI permit.
D. All wort shall conform to die City of Campbe1I Standard Spec:itic:aIioas ad DeIaiIs for P\lblic Worts COIlSII1ICtion; lbe GcaeraI PermIt o-tilioas lilted OIIlbe revcne
side; IIId die Special Provisions for this permit. listed below. Failure to abide by lbese CODdiUoaI ad provisions may rauIl in job sbut-dowll aJar forfeiIure of Faithful
Pcrfonnanc:c Sureties IIId cash deposita. (See GeoeraI PermIt Coaditions 1 ad Z.)
E. THE CONTRACTOR MUST HA VB THIS PERMIT AND APPROVED PLANS AT THE SITE AND MUST N011FY THE PUBUC WORKS DEPARTMENT AT m
LEAST TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GIVEN TO PUBUC WORKS AT LEAST:z.4 HOURS BEFORE RESTARTlNG ANY W ". ~ ",.."cc,
. S /'I. -::---. L/l>~.....J ~r /." I'C'x
Name of Applicant A.o"i7\.. '---l..A.-eA D~P1 {)F~~ T~ 3."1 - /Ij,d-.
(print name) ro,j4.Ct f'4t.X 37 f-7'7b3 2411>UR
Address /11 B 1Jfr- J)U,I4tEIJA TELEPHO~~ 3Y$ -17' Z
X'~ ~ /
b this work beiDa done by the property owner at their own raidence?
The ApplicantlPmniaee hereby agrees by affWna tbeir sipature 10 thiJ permit to bold lbe City of Campbell. iIs otr.... aaaa IIId ..,Ioyecs free. life ad barmIess from
any claim or demand for dama&es raulq from lbe wort covered by this permiI.
The ApplicantlPerminee hereby acknow~ that they have rad ad understand boIh lbe froIIllIId bIdt of IbiI permit. ad tbey will inform lbeIr COIIlI'II:lOI1s) of the
information. ' ~
, \
I - -1/-76
Acccptcd
. ) (sian)
Dale
;9:<(,cf h1!,. : Wry G",lli cK-flJ'I '1.)S" - ~()JI
AI? d/~ ' C~~()I cA 9>"19-
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PUBLIC WORKS DEPARTMENT RECEIPT
Effective July 1, 1995
City Clerk
PUBLIC WORKS FILE NO.
.) &, - /1 '/
PROPERTY ADDRESS
Please collect & receipt for the following monies:
AC<:r, rnM
435.535.4921' Pro 'ect Revenue (s
ENCROACHMENT PERMIT
472 Application Fee
I Non-Utility Encroachment Permit
AMOUNT
($225)
$
I
i
I R-1 First Permit (No Feel, Subseouent Permit/Yr ($1001
Utili~ Encroachment Permit
Arterial/Collector Street ($325)
Residential Street/Other Areas ($225)
220 Plan Check Denosit ($500)
220 Faithful Performance Surety (FPS) (100% of ENGR.EST.)
220 Monumentation Surety (100% of ENGR.EST.)
2203 Cash Deoosit (4% of FPS)($500 min.1
2203 Labor and Material Surety (100% of ENGR. EST.)
472J Plan Check & Inspection Fee (Non-Utility)
! Engr.Est. < $250.000 (12% of ENGR. EST.)
(De osit 15% of ENGR. EST.)"
I
i
I
! .:::-s ::}q OC
I
I i
~ I
I
. I
~
!
220
476
476
476
472
1$1.60/ft.) (MIN. $105)
($1.10/ft.)
($105/ea)
($105/ea)
($120)
($105/tree)
os it 15,,& of ENGR. EST.)"
Pro'ect No.
i $lIP $12/Book)
($.50/s .ft.)
($100/Calendar Da
($500)
($1,060 + $25/Lotl
($1,380 + $25/Lotl
($400)
($300)
($550)
492
496
TRAFFIC
472
472
472
472
472
427
472
($550)
($170)
(R-1, $2,000)
(M.-u1ti~Res, $2.250)
(All Other, $2,500)
on Cert. of Occupancy)
472
($60)
($1251
OTHER
TOTAL $
NAMEOFAPPUCANT ku ~ 'k~~
NAMEOFPAYOR~~ V~ L.I. PHONE:3/S-/~1
ADDRESS lct"<6~~.!i..:f ZIP qS/2~
fOIl
CrrYCLERX.
ONLY
Date/Initials
RECEIVED
JUN 1 8 \996
CiTY CLERK'S OFFICE
send yellow copy to Rnance;
h:\recfrm3. wk3(mp)rev. 1/9/96
I~!!!"!~~_~jl:~............
. 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
POUCIES BELOW.
PRODUCER
Sc....rer-Smlth..........,
2002 .. O.bom 1I0.d
P.O. .OJ( fOO.7
P"o...I.
COMPANIES AFFORDING COVERAGE
85084.72.f
~ANY A ell.
INSURED
COMPANY B
LETTER
Su.. La.... Co...tructlo.. of Callfor..'.
S...1a CI.r. Dev.lopm...t
1978 T". "am.da
Sa.. .10.. C. .512.
COMPANY C
LETTER
ria In.urance
(% Crump~rou~JRHEHCHEHlVEb
JUN 19 1996
COMPANY D
LETTER
COMPANY E
LETTER
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'
LlR :
TYPE OF INSURANCE
POLICY NUMBER
. POLICY EFFECTIVE POLICY EXPIRATION
DAlC (MMIDDfY'Y) DAlC (MMIDDfY'Y)
LNrrs
A : GENERAL LlABLITY
X COMMERCIAL GENERAL LIABILITY
. : CLAIMS MADE X OCCUR.:
..................
. OWNER'S & CONTRACTOR'S PROTo
SE1012556267
01/01/96
01/01/97
, GENERAL.A~.a.flE.a.~TI:.H.H.$ 'HHHHH~!.o.o.~.!.o.o.~..
: PRODUCTS-COMPIOP AGG.$ ....1.000,000
: PERSONAL & ADV. INJURY . $ 1 ,000,000
.................................... ..................".,.......................
, EACH OCCURRENCE $ 1 , 000 , 000
...---.................-.-.-.......
:.F.IFlf:.~~.~a.E..(~y.ClIl4l.~~~)...$ 50,000
: MED. EXPENSE (Anyone person): $ 5.000
X ,CONTRACTUAL liABiliTY
. : Al..'TOMOBLE LWlLITY
X ' ANY AUTO
. ALL OWNED AUTOS
: SCHEDULED AUTOS
X : HIRED AUTOS
X ' NON-OWNED AUTOS
, GARAGE LIABILITY
BUA1004982693
01/01/96
01/01/97 ' COMBINED SINGLE
, LIMIT
:$
1.000.000
: BODILY INJURY
, (Per person)
$
.........-..-...-..
: BODILY INJURY
: (Per accident)
'$
....--................-,....-.-.
: PROPERTY DAMAGE
$
$ 15,000.000
...............................
$15,000,000
.........--.-....... ........
. : EXCESS UABl.ITY
X UMBRELLA FORM
. OTHER THAN UMBRaLA FORM
XlB9271091
01/01/96
01/01/97
........,.............-.-...........
: EACH OCCURRENCE
: AGGREGATE
WORKER'S COMPENSATION
STAlUTORY LIMITS
AND
EMPLOYERS' LIABILITY
. . . . . . . . . . . . . . . . . . . . . . . - . . . . .
: EACH ACCIDENT : $
........................................ ............. ....
, DISEASE - POLICY LIMIT . $
...............-...............,......-.
: DISEASE - EACH EMPlOYEE ,$
..........".......
: OTHER
DESCRIPTION OF OPERATIONS\.OCATIONSlVEHICLESlSPECIAL ITEMS
The City. its officers, employees and volunteers are to be named as This coverage shall be primary and any coverage
Additional Insureds as respects: liability arising out of activities carried by additional insured shall be excess only
performed by or on behalp fo the Contractor, products and completed ops. of McCoy Avenue, Tract #8761 landscape Mangement i~ ~
the contractor, premises owned, occupied or used by the Contractor, or agreement, SlIIIIIerfield Village loP. %~J "0 "
automobiles owned, leased. hired or borrowed by the Contractor. Special Cancellation Claus.
i:i..M"Pifl:::lmA_,iii::i::i::i:::::::::::::::::\:!:::!i!:!:!:!i!i:\i::!::i:::::i::::::::::::::::!::i!:::!:!i!i!:!i!i?!i!:::!:!::m'i'i:::m:::'::::::::::::::::::::!::i::::::!:'::!!:p@i.,_Mii_!!:::::::i:::::::::::!:!:':!:!:!::::::::::::::::::i!::i!i:::::::i:i!'::!i!i!i!iii!i!:!:!:::!:::):::::):::::::):::!:!:::::!:!:::!:!:!::::::::::::::::::::::tt::::::::::::::::::::::::::':::::::::::::::::::::::::::::::::::::::::':::::::::::::::::::::'::::)i)'}:
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCElleD BEFORE THE
... EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
....
MAil ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAilURE TO MAil SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
.... LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
Cn, of Campb."
Public Wo,'" Dept.
70 II. fat St.
Campb.II
032...
CA
.5008
{{AliTHOR~
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