96-263
CITY OF CAMPBELL
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)
. Permit No. q 14 - d< ~3
X-Ref. File
Application Date It) - 7--Z - ?~
ISSUED 1'-.-", ()/
\~ :;;1\.,_ :7'-.. .' \J
'71"//-'-
,/
APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section
11.04. (Application expires in 6 months if the permit is not issued.)
A.
B.
C.
Work Address =~ ~~f~~t ~()1'1 f~;~~
Nature of Work \0 "R ' It-. - ,V'n 11 IV - "SO\) )
Anach three (3) copies of a drawing showmg 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.
D.
NAME OF APPLICANT L ~Nb7~ <r..hW'\V"lj'fYlSc"n..T--
(Print Name)
ADDRESS oS??? S6lf\h(l )(7~s;\ WA~) ~_T,
TELEPHONE Lj()~' 2g1---3l/'Up
9~ /2. 3
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.
ACCEPTED
Date
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE
CAMPBELL STANDARD DETJ\ILS 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
.
.
SECURITY FOR FAITHFUL PE
AMOUNT
$
RECEIPT NO.
APPROVED FOR ISSUANCE
( SEE OTHER SIDE)
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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
l_A.L T~ !I:!E.CQ\(g-'!Aqgp,Fj=()RQ!=[) i:J'( ,.!:IE;f)()_L1c:l.E!:)uB~L9Y'(. .;
COMPANIES AFFORDING COVERAGE
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THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BE:N ISSUED TO THE INSURED NAMED ABOVE FOR THE .;:L1:~p:~~0:7,
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.
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ACORQMII'_IGIRII.t
PRODUCER
Professional Insurance Associates, Inc.
Dennis A. McClenahan Insurance Agency
P. O. Box 1266
San Carlos
Agent #14368
CA
94070
COMPANY
A CALFARMINSURANCE
INSURED
COMPANY
B
CALCOMP INSURANCE
MARK ESPINOZA DBA:
LANDSCAPE ENVIRONMENT
2539 SOUTH BASCOM AVENUE
CAMPBELL
COMPANY
C
CA
95008
co
LTR
POLICY EFFECTIVE POLIC EXPIRATION
DATE (MM/DDIYY) DATE (MM/DDIYY)
TYPE OF INSURANCE
POLICY NUMBER
LIMITS
A
GENERAL LIABILITY
X COMPREHENSIVE FORM
PREMISES/OPERATIONS
UNDERGROUND
EXPLOSION & COLLAPSE HAZARD
PRODUCTS/COMPLETED OPER
BROAD FORM CGL
SMP 40155610105 10/25/96
10/25/97
BODILY INJURY OCC $
BODILY INJURY AGG $
PROPERTY DAMAGE OCC $
PROPERTY DAMAGE AGG $
BI & PO COMBINED OCC $
BI & PO COMBINED AGG $
PERSONAL INJURY AGG $
CONTRACTUAL
INDEPENDENT CONTRACTORS
BROAD FORM PROPERTY DAMAGE
PERSONAL INJURY
A
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS (Private Pass)
ALL OWNED AUTOS
(Other than Private Passenger)
X HIRED AUTOS
X NON-OWNED AUTOS
GARAGE LIABILITY
BODILY INJURY &
PROPERTY DAMAGE $
COMBINED
EACH OCCURRENCE $
AGGREGATE $
$
-OTH~'
ER
SMP 4015561 0105 10/25/96
1 0/25/97
BODILY INJURY
(Per person)
BODILY INJURY
(Per accident)
PROPERTY DAMAGE
f-'-'''--_
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EXCESS LIABILITY
,
i UMBRELLA FORM
l....-u- OTHER TH~~ UMBRELLA FOR~_.
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
we s,-A,-O~
TORY LIMITS
EL EACH ACCIDENT
THE PROPRIETOR/
, PARTNERS/EXECUTIVE
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i OTHER
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$
$
EL DISEASE. EA EMPLOYEE $
INCL
EXCL
EL DISEASE.. POLICY LIMIT
G974122187
4/1/97
4/1/98
!DESCRIPTION OF OPERATIONSlLOCATIONSNEHICLESlSPECIAL ITEMS
: JOHN D. MORGAN PONY FIELD
~I 540W.RINC~N,C~MPBELL,CA95008.... ,,' "
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Ce"TlFIQA1j'J;HQJ,;~a'i/, ."::".:::'..'.:.:',.,..'..':,..'"
I THE CITY OF CAMPBELL
I CITY OF CAMPBELL REDEVELOPMENT AGENCY
ITS OFFICERS AND EMPLOYEES
AND VOLUNTEERS
Certificate Holder is Named As Additional Insured
I
Primary Wording Form GEN 10900-6070 I Cal Farm Insurance Co.
$
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1,000,000 I
1,000,0001
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1,000,000 !
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CANCEl.l.ATlON
I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCEL~ED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL c..uc".vn ,0 MAIL
~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
gU I r"'lL.unl:. I v IVI""'" ;;Ju""n nv 1 1 ""!I;;, .olin"'...... IIYlrvwot: NU UtJL.Il:iA .IUN UH L.IADIL.II T
70 NORTH FIRST STREET
! CAMPBELL
IACq",Q~';N(1ttir/'"
,
I
OF ANY KIND UPUN THE (;UMt"ANY, II::; Al,iENT5 OR REPRESENTATIVES. i
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I AUTHORIZED REPRESENTATIVE ;
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i- (... .. ..',,' ," ..,., ,___-=----~~!'CO~[)CORPO_~~1'lON1988j
CA 95008
'1
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~8. MCCLENAHAN
TEL:408-298-9367
Oct 22.96
9:48 No.OOl P.02
--~~~~[~~~~10'~.:~~_ ;~ ~~~
PROWelll nus CEATIPlCATE IS IssueD AI A MAnt=R OF INFORMATION
ONLY AND CON,IRI NO n~HT8 UPON THE CERn'~TE
ProfessI01'lllllnlur.oce As6OClatel, Inc. Agont .14368 HOLPER. T, HI6 C, E,R, Tillie, ,An: DO, !S, ND,T AMEN, D. UlaND OR, ,
Dennis A. Ml;;Ct'l'llhtn InsuranCe Ag~y_ ALTER T!'1'_Q9.V~RAQE ~~'O!'~D .V THI "O"'~'''_'{l,.OW.
P. O. 8Q1l1288 94070 CQMPANlES A,r.Of'DING COVERA.
San C.tlo, CA I COUl"ANY . .
A CAL FARM INSUR~
I COf.,l':ANV
.. CAl.COMP INSURANCE
I ~ANY
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! COMPIlHY
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n1lS 15 TO CERTIFY TI;AT T!oIE I>Ol.lCIES OF INSURANCE LIITEll flEL.OW HAVI'. 8f-E:N ISIUEU 10THE 11II5\,1A&0 NAMF-D ABOVI: lor, TtiE JIOUCiV r't:IllOO
INDICATED. NOTWITt1ST "IIIDING ANV RE:CUIREMENT. flfllM Of! CONDITION at ANY CONT""'CT 011 01'1'1111I OOCUMl,NT WITH AE8PIlCT TO WHICH 11 liS
CERTIFICATE MAY BE ISaUEP OR MAY PfATAIN. TIlt IN8uAANCE AFFORDE!) av 'tl4l POL.IClES DESCAI"EP HE:REIN IS SlflVECT TO All THE TIAMe.
!:)(CU,ISIONS AND CONDITION9 OF SUCH POLICIES. LIMITS SHOWN MAV I lAVE flEE'" REOUCFO BY PAID CLAIMS,
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p 0 1012!W5 ,~F~' '
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A i I"'. OWftoItD AUTO& I' (Pill aoaIllIlIIl
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t X NQN.QWNfl'lA.UTO! I
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THE ,.~11:T0ftI [jINCL . I ' CL. Dlllt~ . roLICY lIMll ;' 1 000 000
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lllI"'''I'TION or OPEIlAT1OHt1l.OCATJOIftlV&lfICLeWNCI'L.IfttIl.
INIUIlID
MARK ESPINOZA DBA:
~NDSCAPE INVIIltONMIiNT
6688 SOU~CR&ST WAV
SAN JOSE
CA
U123
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.MOULD ANY ~p ,.. "'O\I~ Pf'O,,-" 'OLICIU .. CANCU~IO .,0111 ,.
IIlHIIIlTK* DIlTl T1IIIIIOP, THI ..,UIHO I;OUPAIII'I WlU. I In .-- ~ 11M\.
3tI- D"'" \l/IIITTIII NOTICa '0 THE CJRTIrICATl 1101.01I. NAIIIO TO Tilt LII'T.
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JOHN D. MORGAN PONV FIELD
S40 W. RINCON. CAMPBELL, CA 85008
.:..:-:~_:~"(:7:~:.~:;:.._.
THE CITY OF CAMPIEL\'
CITY OF CAMPBEl.L REPEVEI.DPM~NT "aRNCV
ITS OFFIC!RS .w$IMPLOVI!!8 tJ..t'\fA \J DIUJ\+ur.5
...j
D . A . ~1CCLEt'~AHAH
TEL : 40::::-21~l:::-93f,7
1]1: t 22, 9EI
15:43 Ho.004 P.02
pQI!RTIFle4l_"OPbIABIL.;tTY1t4SUAAN,CE , IlATe 10/25796
, ' . I THIS CERTIFIOATE ISISSUEO AS A MATTt:.R OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CI:ATtFICATE
\ HO, L.PE,FI, ',T"H,IS,CE",RTIF,IC"AT"E D,O""E,S,N ,OT,A,M, EN,O'"E,X"T,E,N",D" OR
~.I..IERTHe COVE.RAGE Af.FORD!;O..BV THl: POLJ.~,!ES BELOW.
I COMPANIES AFPORDING COVERAGE
.. :'.'~.':..'.."""'"''''
A c.OJ1D.
PRODUCIlR
Agent #14368
Professlonflllnsuwnce A!lsocil"lleS, lnc,
DennIs A. McClenahan InilUranQe Agency
P.O Box 1266
san Carlus
CA
94070
COMPANY
A CALFARMINSURANCE
lNSURJ;.b
MARK ESPINOZA DBA
LANDSCAPE ENVIRONMENT
2539 SOUTH BASCOM AVENUE
CAMPBELL
OOMf'ANY
B CALCOMP INSURANCE
, COMPANY
C
CA
9500B
bOV-.RAtllff''':''
THIS 16 TO cEf;lTIFY THAT THE POLICIES OF INSURANCE LISTeD BELOW HAVE BEeN ISSUED TO THE INSURED NAMED AI)OVE FOR THI: POliCY PERIOD
INDICATED, NOTWITHSTANDINg ANY flEQUIREMENT, TE~M OR CONDITION OF ANY CONTRACT Ofl OTHER DOCUMENT WITH I=le:SPECT TO WHICH THIS
CmTIFICATE MAY BE ISSUED OR MAY peRTAH~, THE INSURANCE AFFORDED BY THE POLICIES DESCRI~ED HEREIN IS SUfl.JE:Cl TO ALL lHE TERMS,
E:XCLiJSIONS AND CONOIT'''''''':; OF SUCH POl.1CIES. LIMITS SHOWN MAY HAVE elEEN REDUCED ~y PAID ClAIMS
i ' .
cO ,
LTR I
pOLICV NUMleR
; POLICY !PI'SC'tIVI ,PO~IO !!XPIRATION I
: PATI! (MMlDlllVY) . [IAT!! (MM/DDNV) I
........-.-. ' . '.,..
\.IMITS
TYP!! OF INSURANOE
SMP 401556101
10/25196
10/25/91
aODIL Y INJURY O~e:
~OlllL v INJURY AGe.
PRQr>..FiTY DAMA(ll' oce:
PROI't::.HTv DAMA\3t' A(lG
ill a. PO COMElINI!D oec
~, III t. PD COMt;\INF.O AGO
r>Ef.lBON!lL INNRY AG(lO
~
I~
$
$
$
~$
$
A
GENERAL LIABILITY
X .Mr>nEHcNGIV[ fORM
.. ,[.:, vi>F.RAh:lNS
,,, ,Q[::nOflOlJND
ExpLOSION ~ COLI.APSE HA~ARD
f'ROOUCTSle:OMPtgTfD Ot>ER
CONTRACTUAL
1>;f\Fr'fNr~\iNT CONlRAC:TOR5
BROAD FORM CGL
coRM PROPERlY DAMAG~ !
_,'~ H_sor;A~tN.J\II1Y...__.__.,
AUTOMOBILe LIAatLITY
SMP 401 5561 01
10/25/96
10/26/97 i BODll V INJURI'
(P9' ~8r.on)
^KY AUTO
A I ALl. OWNED AliTO:' IPrlvMe p~.~)
I 'ALL OWN I'D AUTO&
I (O\h~r than Prlv~tl!ll'8.oS9nQ~r)
I Xl HIR~D AU106
I X NON,OWN!;.D AUTOS
GARAGE LIABiI,lTY
aODILY INJURY
(Po' ..cclaenl)
i pf\OPEIlTY DAMAGlO
: BODII.Y INJURY to
PROPERTY flAMIIoQE
,~OM8INEfl
, EACH OCCURRiONCI' i I;
AGGREGATE $
I, EXC:l!.88 LIABILITY
UMBRELLA FORM
".:_QI!:,_E~ T,HA~ VM~R.~,\,~fQf'\_~,
I WORKER8 COMPI!:NlIATION AND
, ll.MPLOVI!RB' LIABILITY
I TtlE I'ROPFiliOTOPJ
B ! I'ARTNF.RS/EXECUTIViO
_..I PF~JQ~~.s.!lR~;______
:OTlil'R
,.~
OTH- I
ER '
S
$
.
4/1/96
4/1/91
we STATU. '
TORY LIMITS
i EL !;:ACH ACCIDENT
I<L DISeASE. POLICY LlMI'
El DISEA~~ . !OA I'MPLOYEt:
INCL
!'X9LL___~_96 4122187
_. "." 1
DI!SCRII>TION Of Ol>EAATION8ILOCATION9NI'HICIJ!8ISI>ICIAL lTiM$
JOHN D. MORGAN PONY FIELD
640 W. RINCON. CAMPBELL, CA 95008
CtIlIIlC.W Holder 1& Named A6 AcI~IUonalln."r.d
I
Prlm~r~ Wording FarM G!!N 10DOO-l1010 leal fllTm Insuretlce Co.
1,000,000
1.000.000
1,000,000
,
$
1,000.000
01
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1,000,000
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iO.~TiPICATEf10Lb'A .
THE CIT ')F CAMPBELL
CITY (~'. '\OBF.LL REDEVb
ITS () ",ND EMPLOY 1 ,
AND \/1 ;:.ERS
;:,r\JT AGEW
IiXPIRATION DATE THIiREOF, TH! ISIUING OOMPANV WILL ~Ii ....'tlil ." MAl\.
ao DAYI WAtHEN NOTIC:I! TO THi CIRTlFIOATE HOLD!'" NAM!O TO TH~ LEFT,
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70 NORTh FIRST STREET
CAMPBELL
CA 95008
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D.A.MCCLENAHAN
TEL:4"-29S-9367
Oct 22.96
15:08 No.003 P.02
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PrO'.IIOllellll5Urlnco AllOdates. Inc. Agl'llt .14368
J')flnOlli A. McClenahSIl Insurance ~.ncy
P. O. eo. 12"
Sin ClMI CA 04010
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.............- 't!...I<~<."<"''l.;~;{'',;;o''4' 1 0122/96
THI C!RTII'ICAT! IS l.surD AS A MATTER OF INFORMATION
ONLY AND CONFER. NO IIIIQt1TS UPON THE CIIRT1PltAlI:
HOlDIR. THIS CI!RTIFICATE DO&I NOT AME'fD, EJ(TENb OR
AL T III THE COYlAAQI! 4"'ORDI!D B' THE POL CIES DELOW.
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LANDSCAPE ENVIRONMENT
5NI80~Esr WAY
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C.~Mf'I\NY
B CALCOMP IN$URANCE
CA
911123
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INDlCA1EO, NOTWlTH(lTANOI"IG ANY AECVIRI:MENT. T~nM O~ CONDITION OF ANY (,'()Nl HACT ore OTHER DOCUMENT WITH REGPCCl 10 WHICH THrill
CIATlFlCATE MAV DC! 188UEO OR MAY PEATAIN. THE INSlJRANCF AFFORCED BY ~E POLICIES Ol:lJCI\IEtE:D HEnEIN IS SUBJECT TO ALL THE If.HMr.l.
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JOHN D. MORGAN PONy FIELD
~40 W. RINCON. CAMPBELL, CA ~08
TH! CITY OF CAMPBELL
CITY OF CAMPBEll. REDEVELOPNIENT AGENCY
ITS OfFICERS AND EMPlOYEES
AND VOLUNTEERS
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