96-233
CITY OF CAMPBELL
DEPT. OF PUBUC WORKS
70 North First ~ tC ,. E ~ V ~
Campbell. CA SilK)!" ~., ",
(408) 866-2150
Fax (408) 376-0958 S E P 1 6 1996
ENCROACHMENT PERMIT
(for working within the
" public right-of-way)
Issued q.- /t. - ~t
Permit expires in 12 moJUJU~
Permit No. q 6 -A .;33
, X-Ref. file
Application Date e:, J {h It:( 6
Application expires jj 6 m'onths
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APPUCATlON. Applicatio~~_~IW'1Nluc worts Permit ill ICCOrIIaal:c Qh CIqlbdI MlIIIicipII Code. Sa:doD 11.04. (ApplqQoa C1pDa i116111ldb1
if lbe permit isllllt issued, Application Fcc is -.refuDdIb1e.)
A. Wortlddreu orlrKlI "<.tIC! f!:IE;tfb !Afft.EraJ PL.
Utilily IreDl:h Ioc:ation Sl#ne
/ "
B. tulureofwork 1NS:rlt-U. ~ SoMI. .JGw~ M~.;C.(~ rL4?"BG+t..s
C. Aach four (4) copies of an qiDeered plans abowiIIIlbe IcaIioo 8IId Clltem (1/ lbe wort, 8IId four (4) copica of lbe preIiaIMy ~'I IiIdaIc of wort. Tbc
plans IbIIJ Ihow the reIIIion of lbe propolcd wort co cIistiD& IUrfKc and lIIIdeqrauDd iqmIWIIIIaIII. WbalIppnMld by lbe O:y EapIeer,IIid pIIa becomeIa part of
dais permit.
D. All work IbIIJ conform 10 die City of CaqlbeU SWIdIrd Speclfic:alioas and DeWII for Public worts Caaanac:Uoa; lbe GeaenI Permit C.ftIIIll!itw. listed CJIIlbe revene
side; and lbe Special Provisions for Ibis permit. listed below. FIiIure co abide by dae COIIdiIioIII and proriIIioIII may I'IIlIIt ill job 1IIut-dowD -.vOl farfciIure of FaiIhfu1
Pafor1lllllCC Sureties and CISh deposits. (See GeoenI Permit Coaditiollll and 2.) 511~ (JJfJt:I...,JA) (.,S 3 7J. ).77'3
E. THE CONTRACTOR MUST HAVE THIS 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.
Name of Appli<:ant WEST VALLEY SANITATION DISTRICT Of SANTA CLARA COUNT'l T~ 378 -J.-tf/) 7
(prim ~ 2
Addressd7t).E. . S"'VN'N'r'H~ ~ Qt::TZH;-~ 24 HOUR EMERGENCY TELEPHONE NO. "ff'- 2...f'l) 7
b dais worlt beiDa done by the property owner at lbeir own l'CIidence?
Yes X- No
Tbc ApplicanllPmniaee hereby III'CCS by affq lbeir lipIIure 10 Ibis permit 10 bold lbe Cily of CuIpbdl. its oftiI:cn, .... and employees free, life and bIrmIcu from
any claim or demand for cIama&es I'CIlIlq from lbe work c:ovcnd by Ibis permit.
Tbc ApplicanllPenniaee hereby KtDowledles dIIllbey have reId and IIIIlIemand bolb lbe from and bact of dais permit, and Ibey wID inform lbeir c:omnc:IOr(s) of lbe
information.
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'UllLIC WORKS DEPARTMENT RECEIPT
Effective July I, 1996
TO: City Clerk PUBUC WORKS Fn.E NO, 9b~~33
PROPERTY ADDRESS pll ~/; If ~.
Pi.... collect &: receipt for die followina monies:
ACCT: I ItEM........................................... ......... . ,.,' >>>>>AMOlJNT'
435.535.4921 Proiect Revenue S
ENCROACHMENT PERMIT
4722 Applicalion Fee
Non-Utility Encroachment Permit ($125)
R-I Fint PermitlNo Feet Su"-uent PermitlYr (SIOOI
Utilitv Enc:roaclunent Permit
ArteriallCollector Street S32S
Residential StreetIOdter Areas S22S\ ~:L">-'
2203 Pi.... Check Deoosit - 2% ofENGR. EST. SSOO minI .
2203 Faithful Perfonnonce Security (FPS) 100% ofENGR,EST.l .
2203 l..Ibor ....d Materials Securitv lOO%ofENGR. EST.1
2203 Monumentation Security 100'.4 ofENGR.EST.1 .
2203 Cash Deoosit 4% ofENGR.EST,VS$OO minlSlO 000 IMXI .
2203 Labor ....d Material Securitv 100'.4 ofENGR. EST.1 .
Pi.... Check &: /nJpection Fee (Non-Utility)
4722 Engr,Est. < $150.000 (12% ofENGR, EST.)
.. 2203 Enar.Est.>S25O 000 m..n.>.i. r.4 ofENGR. EST.1$30 000 min. .. .
4722 Utilitv < S I 00 000 (~.l Y<1f" -
Minimum Charae Per Loc8tion (SI20)
ConcIuitsIPipelines up 10 500 Feel (SI.601fI) >< A.l"l s
Above 500 Feel (SI.101ft.)
ManholesIV aultslEtc. (S I 05/ea) X; b-
Pole SetlRemoval (S I 05/ea)
Street Tree PlllltinaIRemoval 1$ I 051tree\
.. 2203 Utilitv > S I 00 000 Actual Cost + 20% .. .
4760 Proiect Plllls &: Soecificalions Proiect No.
4760 Standard Soecificalions &: Details (SlIP- SI2/Book
4760 Cooies of En.ineerin. Maos "- Plllls (S.50/....ft.1
4722 Penalties: Failure 10 restore Dublic imorovements (SIOO/CaIendar Davl
(Muni Code Section 11.34.010\
4722 Penalties: Failure 10 correct unsafe conditions Is I OOlCalendar D..v\
LAND DEVELOPMENT
4722 Lot Line Adiustment S500
4722 Parcel MaD (4 Lots or Lessl SI 060 + S251Lot1
4722 Final Tr1ICI Mao (5 or More Lotsl SI 380 + S251Lot1
4722 Certificate of ComDlilllce S500\
4722 Certificate of Correction S3001
4722 Vacation of Public Streets &: Easements S550
4722 Assessment Segregation or Reapportionment
Fint Split (S55O)
Each Additional Lot S170\
4721 Storm Drainlll!e Area Fee Per Acre (R-I,S2,OOO)
(Multi-Res. $1,250)
(All Other $1 SOOI
4920 ParkJ....d Dedicalion Fee
4965 Postaoe
TRAFFIC
4728 Interseclion Turn Counts (Two-Hour Countl $60\
4728 In_tion Turn Counts o.m. or D,m. ........1 SI251
4728 Traffic Flow Mao (Dailv Traffic Volumesl $17\
4728 Camobell Traffic Model (Full Scone Assessment\ $1.2501
4728 CemDbell Traffic Model (Reduced Scope Assessmerltl S74O\
4271 TRIck Permits S35ltriol
4728 No P.oon. Sions SI/-" or S25/1001
OTHER
TOTAL S / J .:2 I. at
/.tJ.ur t/4/ /" ~ ~ I
NAME OF APPLICANT .L ..L. ,-- .J
NAME OF PAYOR i..d J ~AA/~J A ~~. .
..-- '4 ~ PHONE
ADDRESS :521 #- ~, ~r - /- .If? ZIP ..J?~2JC7 f7
.. Actual Cost Plus 20".4 Overhead lNon-lnterest barina deoooitl /
FOR
OTY CLERK
ONLY
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. ,................
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RECEIVED
SEP 1 61996
CITY CLERK'S OFFiCe
'.For Plan Check lIIId Cub Deposits, Send yellow ""py 10 Financi
h:\recfrm4. wk3(mp )rev711196
~jrijtialil
q~- ~3
Certificate of Insurance
THIS CERTIFICATE IS IS5L'ED..1\S A ~IATTER OF It\ .MATION ONLY AND CONFERS NO RICHTS L1'nN YOU TI c,RTIFICATC HOLDER. THIS CERTIFICATE IS f'..OT
AN INSURANCE POLICY A\iD onES NOT AMEND, EXTEND, OR ALTER THE COVERACE AFFOImED Ill' [HE POLICIES LISTED BELOW
IThlS Is to Certify that ~i E C ~ ~ 'I E ~
~~~s~~INC. SEP 181996 .- ~=:S~~f
CAMPBELL, CA 95008 Insured.
L :DU~~~~S~~~~I~~. ~
Is, at the issue date of this certificate, insured by the Company under the poI'lC)'(ies) lisled below. The insurance afforded by the Iisled policy(ies) is subiect to all their
limns, exclusions and conditions and is not a111eied by any l8qUirement, term or Condition of any contract or other doaJment with respect to which this certificalB may be
LIBERTI ~
MUTUAL@ ,
issued
EXP.DATE
-0 CONTINUOUS
TYPE OF POLICY o EXTENDED POLICY NUMBER LIMIT OF LIABILITY
181 POI ICy TFRU
WORKERS COVERAGE AFFORDED UNDER WC EMPLOYERS UABIUTY
COMPENSATION LAW OF THE FOllOWING STATES: Bodily Injury By Accident
04/01196 $1,000,000 Each
Accident
To WC2161 030020 146 CALIFORNIA Bodily Injury By Disease
04I0V97 $1,000,000 Policy
Limit
Bodily Injury By Disease
$1,000,000 ~:~~n
GENERAL General Aggregme .. Other than ProcIuctslCompletad Operations
LIABILITY $2,000,000 PER PROJECT
~ OCCURRENCE 04I0V96 ProductsIComplelad Operations Aggregate
To -TB2161 030020 116 $2,000,000
0 CLAIMS MADE 04I0V97 Bodly Injury and Property DamaQe Uabi~ty
Per
$1,000,000 Occurrence
Personal and Adver1ising Injury Per Personf
I RETRO DATE I $1,000,000 Organization
Other $50,000 FIRE LEGAL IOther $5,000 MEDICAL
UABIUlY PAYMENTS
.
AUTOMOBILE $1,000,000 Each Accident - Single Umit
LIABILITY B.I. and P.O. Combined
~ OWNED 04/0V96 Each Person
To AS7161 030020 126 Each Accident or Occurrence
~ NON-OWNED 04/0V97
~ HIRED Each Accident or Occurrence
OTHER 04I0V96 TIn 161 030020 136 $4,000,000
UMBRELL EXCESS To
LIABILITY 04101197
ADDITIONAL COMMENTS
RE: ALL WORK IN PUBUC RIGHT-OF-WAY
.ADDmONAL INSURED: CITY OF CAMPBELL, CITY OF CAMPBELL REDEVELOPMENT AGENCY, ITS OFFICERS,
EMPLOYEES AND VOLUNTEERS
. If the certificate expiration date is continuous 01 extended term, you will be notified if coverage is terminated or reduced before the certificate expiration date.
SPECIAL NOTICE.otlO: ANY PERSON WHO. WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER. SUBMITS
AN APPLICATION OR FILES A ClAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
NOnCE OF CANCELLATION: (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS ENTERED BelOW.) BEFORE
THE STATED EXPIRATION DATE ll-lE COMPANY Will NOT CANCel OR REDUCE ll-lE INSURANCE AFFORDED
UNDER THE ABOVE POLICIES UNTIL AT LEAST :4 0 DAYS
NOTICE OF Sup::u:ANCEllATION HAS BEEN MAILED TO:
I CITY OF CAMPBELL
CERTlFr.ATE AnN: DEPT. OF PUBUC WORKS
~ 70 NORTII FIRST STREET
CAMPBELL, CA 95006 .-
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ALMA G. SABLAN
AUTHORIZED REPRESENTATIVE
SAN JOSE. CA
OfFICE
(408) 453-3580
PHONE NUMBER
09/13/96 pcm
DATE ISSUED
fhi... I..-ertltic,lte is L''\t.'cutt'd by LIBERTY \lLTL'AL CROUP .1S respects ~lIch insur.lllce as b clffllrded b\ rh~'St' C\)ll1F',lnies
BS 772L R2
TB2-161-030020-116
SANCO PIPELINES, INC.
TInS ENDORSEMENT CHANGES THE POllCY, PLEASE READ IT CAREFULLY,
POllCY NUMBER:
ADDITIONAL INSURED - OWNERS, LESSEES, OR
CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:
COMM:ERCIAL GENERAL liABILITY COVERAGE PART
SCHEDULE RE: ALL WORKINPUBUCRIGIIT-OF-WAY
Name of Person or Organization:
an OF CAMPBELL,. an OF CAMPBELL REDEVELOPMENT AGENCY, ITS OFFICERS,
EMPLOYEES AND VOLUNTEERS
(If no entry appears above, information required to complete this endorsement will be shown in the
Declarations as applicable to this endorsement,)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization
shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by
or for you.
PRIMARY INSURANCE
Such insurance as is afforded by this endorsement is primary insurance,
CG 20 10 1185