96-259
CITY OF CM1PBBLL
PUBLIC WORKS DEPT.
70 N. First St.
Campbell, CA 95008
(408)866-2150
FAX (408)376-0958
OWNER OCCUPIED R-l
NO FEE ENCROACHMENT PERMIT
(for working within the
public right-of-way)
($5,000 maximum value of work)
ISSUED Icj/7 jC)t.f
Permit No. 9 f; -- ~t:>-q
X-Ref. File -
Application Date '10 - 2'5Cf
D.
APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section
11.04. (Application expires in 6 ~nths if the permit ~ not issu:d.) '. _/ <_/
1'-7t.f Ucab?i ~/k"? (p;tl(Jk~,;.'(,
Work Address /'-'~'
Nature of Work I ;jJ~"1Attrllla() ~ GdI~ ~7Jl/C' /~;// /tI / 7CL
Attach three (3) copies of a drawing showing the location, extent and dimenSions of the work. The drawing shall show
the relation of the proposed work to existing improvements. When approved by the City Engineer, said drawing becomes
a part of this permit.
All work shall conform to the City of Campbell 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
securities.
A.
B.
C.
NAME OF APPLICANT
6k~ 6~lrZ/lJ
TELEPHONE ~ 50 c; ;/2
{CJ 6l?t:'~' W 952: _SC)
ADDRESS
(print Name)
'??'//C 1~d'~SC'/(/ ;fbAJ/
The Applicant hereby confirms that this work is being done by the property owner/applicant at their own residence.
The Applicant hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers, agents and
employees free, safe and harmless from any claim or demand for damages resulting from the work covered by this permit.
-.,
eyhave read and understand both the front and back of this permit, and that they will
The Applicant hereby ac
inform their contractor
ACCEPTED
/c~ _-/5-7 -7h
Date
,
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE
CAMPBELL ST ANDARD DETAILS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AND MUST ARRANGE TO MEET WITH
THE PUBLIC WORKS INSPECTOR AT THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK.
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
PER SECTION 4215 OF THE GOVERNMENT CODE THIS PERMIT IS NOT VALID FOR EXCAVATIONS UNTIL
UNDERGROUND SERVICE ALERT (USA) HAS BEEN NOTIFIED AND THE INQUIRY IDENTIFICATION NUMBER
(TICKET NO.) HAS BEEN ENTERED HEREON. USA PHONE: 1-800-227-2600. TICKET NO.
SPECIAL PROVISIONS
.;J. :1'ACt' ~A"JI)I CF.J\Jf5Nr ~A.C..k..JI'/'A.,. I$' t15-t2/.J-'/Cd) fb/2 ""f'1tDIefJ iN 7710 jJ~b)c 12-/6/fr -<..JJ:::-
wAY.
SECURITY FOR FAITHFUL PE
STANDARD
(100% OF ENG. EST.)
AMOUNT
$ 'Soc). () ()
RECEIPT NO.
Q7003
/0, 17 At
Date
APPROVED FOR ISSUANCE
for City Engineer
res 6 Months After the Date of Issuance
(SEE OTHER SIDE)
GENERAL PERMIT CONDITIONS
1. A SECURITY to insure FAITHFUL PERFORMANCE and completion of the work is required. This SECURITY
is refundable upon completion of the work and written acceptance by the City.
2. A ONE-YEAR MAINTENANCE PERIOD for all work is required. Such period will begin on the date of written
acceptance by the City. It is the applicant's responsibility to remove and replace unacceptable improvements within the
one-year maintenance period.
3. REFUND or cancellation of the Faithful Performance security will be initiated by the written acceptance of the work by
the City.
4. The Permittee MUST REQUEST IN WRITING a final inspection and acceptance of the work upon completion.
Acceptance by the City will be made in writing to the Permittee.
5. MAINTAIN safe pedestrian and vehicular crossings and free access to private driveways, fire hydrants and water valves.
6. REPLACE IN KIND any damaged or removed existing improvements, including planting.
7. SAWCUT for all PCC or AC removals. Prior to concrete sawcutting or washing, the Contractor shall place filter fabric
material in the flow line of the gutter to retain all construction debris. All construction debris shall be wet vacuumed,
broom swept, picked up and disposed of by the Contractor. Concrete sawcut debris shall not be swept or water hosed
into the gutter and into the storm drain system.
8. Adequate signing and lighted BARRICADING is required on the job site. Failure to provide such signing and
barricading as specified by the City Engineer may result in the City's renting such signing and barricades and charging
the cost to the permittee.
9. The Contractor or Permittee will have a SUPERVISORY REPRESENTATIVE available for contact on the project at
all times during construction.
10. This permit shall be kept at the site of work and must be shown to any authorized representative of the City of Campbell
or any law enforcement officer upon demand.
11. No STORAGE of materials or equipment will be allowed near the edge of pavement, within the traveled way, or within
the shoulderline which would create a hazardous condition to the public.
12. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work
or any other work for which a separate permit may be required, nor does it relieve the Permittee of any obligation to
obtain any other permit required by law.
13. All necessary ROAD REPAIRS resulting from the permit work shall be made in accordance with City Standards and
Specifications at the sole expense of the Permittee.
14. This permit does NOT RELEASE the Permittee from any liabilities contained in other agreements or contracts with the
City and any other public agency.
15. This permit is NOT TRANSFERRABLE. Work must be performed by the Permittee or his designated agent or
contractor as specified thereon.
16. Prior approval of inspector is required for any work done after normal working hours, on weekends or holidays and may
require reimbursement of inspection costs at the current overtime rate.
17. Call back (call out) due to emergencies regarding this permit, shall be at the current overtime rate with a three (3) hour
minimum charge per occurrence.
e 'or ensuring that all those providing services under the applicant are aware of and understand all
/0- ;(/- 96
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.o~CH'\~O
CITY OF CAMPBELL
Public Works Department
August 11, 1998
George Green
20110 Thompson Road
Los Gatos, CA 95030
SUBJECT: PERMIT NO. 96-259 (R-l)
LOCATION: 974 Crockett Avenue
ONE YEAR MAINTENANCE INSPECTION - ACCEPTANCE
Dear Mr. Green:
The City of Campbell has made the final one year maintenance inspection of subject Public
Works improvements and find that no remedial work is required.
Your warranty requirements and any surety, therefore, are hereby released.
Sincea~
Alan Horn
Public Works Inspector
MQ vd
cc: Permit 96-259
Public Works/Maintenance Division
H: \ WORD\PERMITS\96259 ACC(JD)
70 North First Street. Campbell, California 95008.1423 . TEL 408.866.2150 . FAX 408.376.0958 . TOO 408.866.2790
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CITY OF CAMPBELL
Public Works Department
March 6, 1997
George Green
20110 Thompson Road
Los Gatos, CA 95030
RE: PERMIT NO. 96-259 (R-1)
LOCATION: 974 Crockett Avenue
FINAL INSPECTION AND ACCEPTANCE
Dear Mr. Green:
The City of Campbell has made a final inspection of subject Public Works improvements and finds the
work to be acceptable and in conformance with City standards. Accordingly, the City Engineer accepts
the improvements.
The one year maintenance period stated in the permit begins as of the date of this acceptance letter.
The permittee is responsible for repair and/or replacement of any defective work or failures that occur
within one year. The City will inspect the improvements within one year and notify you, in writing,
whether or not any repairs are required.
Your Faithful Performance Surety (FPS) cash deposit of $500.00, plus any interest due, is now being
processed and will be sent to you under separate cover.
If you have any questions, please call at (408) 866-2165.
l4#J/
C::ykvestfai{
Public W orId Inspector
MQylQ
sl w arP-ev ),4$ ~ r1~ '1 f Wlwf I-<-
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Suspense - 11 months ~.~. /)
Permit #96-259 fW
H:\ WORD\PERMITS\96259FIN(JD)
cc:
70 North First Street. Campbell, California 95008.1423 . TEl408.866.2150 . FAX 408.379.2572 . TDD 408.866.2790
NEW PW FAX #
108-376-0958
Approved by: 11d n
M.t?nelle
FINANCE ONLY:
Verified by:
To: Accounts Receivable
Please Issue Check
Payable to:
Address - Line 1:
Line 2:
City:
Description:
Amount Payable:
Account Number:
ate and Receipt No:
Permit No:
Purpose:
Requested by:
Approved by:
Mail As Is:
Return To:
Other:
rev: 3/25/95
Cit) of Campbell - Checl\. Request
George Green
20110 Thompson Road
Los Gatos
State: CA Zip: 9 5 0 3 0
REFUNDABLE DEPOSIT
$500.00
Finance Only:
INTEREST EARNED
101.2203
10/13/96 #97003
101.540.7448
96-259
Refund Faithful Performance Surety Cash Deposit
Date: 3/6/97 I
Date: 3/6/97 I
Date:1
Title: Date: I
Special Instructions For Handling Chec~
xx Mail in Attached Envelope:
Randy Westfall
Title: P. W. Inspector
Title: Ci tv Enqineer
Quinney
Title:
(NAME)
(Department)
JULie WORKll Uf;fAKTMf;NT IU;Q;1fT
Effective July 1. 1996 90 -;;2.51
TO: City Clerk PUBLIC WORKS FILE NO.
PROPERTY ADDRESS 974- C/o. rJt.l.# Ail'-<. .
Please collect & :: .....
lAter: ...;..;.. ..................................................... .....
435.535.4921 I Project Revenue (specify project) S
ENCROACHMENT PERMIT
4722 Application Fee
Non-Utility Encroachment Permit (S225)
R,I First Permit (No Fee), Sub""'uent PermitIY;(SIOO\
Utility Encroachment Permit
ArteriaVCollector Street S325)
Residential Street/Other Areas S225)
2203 Plan Check Deonsit- 2% ofENGR. EST. S500 Olin) .
2203 Faithful Performance Security (FPS) 100"1t ofENGR.EST.) . ;;O() 00
2203 Labor and Materials Security lOO"It ofENGR. EST.)
2203 Monumentation Security lOO"It ofENGR.EST.\ .
2203 Cash Deoosit 4% ofENGR.EST.)(S500 minlSlO,ooo maxI .
2203 Labor and Material Security 100"/. ofENGR. EST.) .
Plan Check & Inspection Fee (Non-Utility)
4722 Engr.Est. < S250,000 (12% ofENGR. EST.)
.. 2203 En.....Est.>S250,000 - iD"",,,sit 8% of ENGR. EST.lS30,000 min.)" .
4722 Utility < Sloo,ooo (8%)-
Minimum Charge Per Location (SI20)
ConduitslPipelines up to 500 Feet (S1.6O/ft)
Above 500 Feet (SUO/ft.) ;
ManholesIV aults/Etc. (SI05/ea)
Pole SetlRemoval (S105/ea)
Street Tree Plantimu'Removal (S105/tree)
.. 2203 Utility> Sloo,ooo Actual Cost + 20'1t .. .
4760 Proiect Plans & Specifications Pro.eel No.
4760 Standard Soecifications & Details (SlIP. $12/Book)
4760 Cooies of En.ineerin. Mans & Plans IS.50/so.ft. )
4722 Penalties: Failure to restore oublic imorovements 1$loo/Calendar Dav)
(Muni Code Section 11.34.010)
4722 Penalties: Failure to correct unsafe conditions !$Ioo/Calendar Day)
LAND DEVELOPMENT
4722 Lot Line Adjustment $500)
4722 Parcel Man 14 Lots or Less) $1,060 + $25/Lotl
4722 Final Tract Man (5 or More Lots) $1.380 + $25/Lot)
4722 Certificate of Comoliance $5(0)
4722 Certificate of Correction S3oo)
4722 Vacation of Public Streets & Easements $550)
4722 Assessment Segregation or Reapportionment
First Split ($550)
Each Additional Lot IS170\
4721 Storm Drainage Area Fee Per Acre (R'I, $2,000)
(Multi-Res, $2,250)
-iAlI Other, $2,5(0)
4920 Parkland Dedication Fee
4965 Postalle
TRAFFIC
4728 Intersection Turn Counts (Two-Hour Count) 1$601
4728 Intersection Turn Counts a.m. or c.m. oeaks) (SI25)
4728 Traffic Flow Man lOailv Traffic Volumes) ($27)
4728 Camobell Traffic Model (Full Scope Assessmentl ($2,250)
4728 Camobell Traffic Model (Reduced Scone Assessment) ($740)
4271 Truck Permits 1s35/tr;;;\
4728 No Parkin~ SilUlS (SI/each or $25/1(0)
OTHER
TOTAL $ '500 . () 0
NAME OF APPLICANT Geo12Gt: GIC.t;E./IJ
~M CJ1aN 7bJ. ?SV C?-7'
NAME OF PAYOR PHONE ~-7';;>!.5
ADDRESS //0((0 11foctfPJtNj (~AO ,LoS 6-/J;cS ZIP t?5C7 ~(~
.. Actual Cost Plus 20'10 Overhead (Non-Interest bearin~ deonsitl
FOR
CITY CLERK
ONLY
RECEIVED BY C~
Date ; () I ;il <i ( Receipt #
97003
. For Plan Check and Cash Deposits, send yellowcopytc>FirlllJlCli;
h:\recfrm4. wkJ(mp )rev7/1 /96
WORKER'S COMPENSATION INSURANCE INFORMATION
The following worker's compensation insurance information is required for all Applicants and
Contractors. One of the following items for each Applicant and Contractor must be submitted
prior to working under a Public Works permit or contract.
WORKERS' COMPENSATION INFORMATION:
Name of Contractor/Applicant
&oil&; b~1ZcJ{)J
o A Certificate of Consent to Self-Insure issued by the Director of Industrial Relations; OR
o A Certificate of Workers' Compensation Insurance
Insurance Co.
Policy No.
Expiration Date
; OR
~.
A signed Certificate of Exemption from the Workers' Compensation laws as printed
below.
CERTIFICATE OF EXEMPTION
I certify that in the performance of the work for this contract, I shall not employ any
person in a mann r so as to become subject to the Workers' Compensation Laws of
California.
Signed
Date
/C' -/c1-i6
I
Title
() 1(/ IC. r;[
NOTICE TO APPLICANT/CONTRACTOR: 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 the Permit or Contract
will be cancelled or revoked.
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