96-276
CITY OF CAMPBELL OWNER OCCUPIED R-l
PUBLIC WORKS DEPT. ' NO FEE ENCROACHMENT PERMIT
70 N. First St. (for working within the
Campbell, CA 95008 public right-of-way)
(408)866-2150 ($5,000 maximum value of work) f')
FAX (408)376-0958 I ~j.../
ISSUED IZ/,3)1VJ iJ
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.)
Permit No. a;to,.. -27 <,P
X-Ref. File 3' '
Application Date IU /7 ~
A.
B.
c.
Work Address l
Nature of Work <. \ ,J) ~e \:
Anach three (3) copies of a1drawing showing the 10 tion, extent and dimensions of the work. e drawing sha;1 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.
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The Applicant hereby confirms that this work is being done by the property owner/applicant at their own residence.
NAME OF APPLICANT
i
j' IAAS2 L 1\ to <?
ADDRESS
L{<)?
J-i.
(Print Name)
J-S-m, ~<?er
TELEPHONE ,~<7, '--"7 '3 r
9S'11~
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.
The Applicant hereby acknowledges that they have rea and understand both the front and back of this permit, and that they will
inform their contractor(s) of ~ormation.
ACCEPTED I .
Date
5'1 b ~ 02.4-\.0 f'cgJ
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE
CAMPBELL STANDARD 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
STANDARD AMOlINT
(100% OF ENG. EST.) $ tl / A .
RECEIPT NO.
. ;/4,
,-
for City Engineer
res 6 Months After the Date of Issuance
/.).- ]- J(;,
Date
APPROVED FOR 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 wrinen 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. SA WCUT for all PCC or AC removals. Prior to concrete sawcuning 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.
Date
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STATE
COMPENSATION
INSURANCE
FUND
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NG
ctf<!21/ ~hd~
P.O. BOX 807, SAN FRANCISCO,CA 94101-0807
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 01-01-99
POLICY NUMBER: 229-99 UNIT 0013425
CERTIFICA TEEXPIRES: 01-01-00
CITY OF CAMPBELL
ATTN: RANDY WESTFALL
70 NORTH FIRST ST
CAMPBELL CA 95008
This is to certify that we have issued a valid Workers' Compensation insurance policy in a from approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the fund except upon 30 days' advance written notice to the employer.
We will also give you 30 days' advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policies listed herein. notwithstanding any requirement, term, or condition of any contract or other document
with respect to which this certificate of insurance 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.
~'D~
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSECOST$: $1,000,000.00 PER OCCURRENCE.
STANDARD EXCLUSION: INDIVIDUAL EMPLOYERS AND HUSBAND AND WIFE EMPLOYERS ARE NOT ELIGIBLE
FOR BENEFITS AS EMPLOYEES UNDER THIS POLICY.
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01/01/99 IS ATTACHED TO AND
FORMS A PART OF THIS POLICY.
RECEIVED
DEe 2 R 1998
PUBL.IC
~D"'N'8T~~~g~
EMPLOYER
LEGAL NAME
TIME LINE CONSTRUCTION
14589 S BASCOM AVE
LOS GATOS CA 95032
HARRIGAN, MATTHEW TIMOTHY
PRINTED: 12-18-98 P0408
THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND self 10265 (REV 2-951
9
0&
NG
STATE
COMPENSATION
INSURANCE
FUND
P.O. BOX 807, SAN FRANCISCO,CA 94101-0807
CERTIFICA TEOF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 01-01
POLICY NUMBER 229...98 UNIT 0013425
CERTIFICATE. EXPIRES: 01"'01-99
CITY OF CAMPBE
ATTN: RANDY WE L
70 NORTH FIRST ST
CAMPBELL CA 95008
l} j rYt? >
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 10 days' advance written notice to the employer.
We will also give you 10 days' advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document
with respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the
policies described herein is sub ject the terms, . exClusions and conditions of$uch.. policies.
..Y................r-:/ ~
~SIDENT
EMPLOYER'S LIABILITY LIMIT INCLUDING OEFENSE COST$: $1,000,000.00pEROCCU.RRENCE.
STANDARD EXCLU.SION: INDIVIDUAL EMPLOYERS AND HUSBAND AND WIFE EMPLOYERS ARE NOT ELIGIBLE
FOR BENEFITS AS EMPLOYEES UNDER THIS POLICY.
EMPLOYER
LEGAL NAME
TIME LINE CONSTRUCTION
3181 SO. BASCOM AVENUE
CAMPBELL CA 95008
HARRIGAN, MATTHEW TIMOTHY
-: ~ . ..~.~
THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND SCIF 10265 (REV 2-95)
12-18-97
., C::v 2 j Cp
NG
STATE
COMPENSATION
INSUAANCE
FUND
P.o. BOX 807, SAN FRANCISCO,CA 94101-0807
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 01-01-00
POLICY NUMBER: 229-00 UNIT 0013425
CERTIFICATE EXPIRES: 01-01-01
CITY OF CAMPBELL
A TTN: RANDY WESTFALL
70 NORTH FIRST ST
CAMPBELL CA 95008
RECEIVED
DEe 2 .3 1999
PUBLIC WORKS
ADMINISTRATION
This is to certify that we have issued a valid Workers' Compensation insurance policy in a from approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the fund except upon 30 days' advance written notice to the employer.
We will also give you 30 days' advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend. extend or alter the coverage afforded
by the policies listed herein. notwithstanding any requirement. term. or condition of any contract or other document
with respect to which this certificate of insurance 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.
A'D~
EMPLOYER'S LIAS I LITY LIMIT1NCLUDI~DEFENSE COSTS: $1.000.000 .00 PER .QCCURRENCE .
STANDARD EXCLUSION: INDXVIPUAL EMPLOYERSANDHLlSBAND AND <WIf'E EMPLOYERS ARE NOT ELIGIBLE
FOR BENEFITS AS EMPLOYEES UNDER THIS POLICY.
ENDORSEMENT #2085 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 01/01/00 IS ATTACHED TO AND
FORMS A PART OF THIS POLICY.
EMPLOYER
LEGAL NAME
TIMELINE CONSTRUCTION
14589 S BASCOM AVE
LOS GATOS CA 95032
HARRIGAN, MATTHEW TIMOTHY
PRINTED: 12-19-99 P0408
THIS DOCUMENT HAS A BLUE PATTERNED BACKGROUND selF 10265 (REV 2 951
STATE P.o. BOX 420807, SAN FRANCISCO, CA 94142-0807
COMPENSATION
INSURANCE
FUN D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
DECEMBE~ 4, 1996
POLICY NUMBER; 2 29- 97 UN IT 00 1 3 4 2 5
CERTIFICATE EXPIRES: 1-1- 9 8
r-
CITY OF CAMPaELL
ATTN: RANDY WESTFALL
7C NORTH FIRST ST
CAMPBELL CA 95008
L
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California
Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon ten days' advance written notice to the employer.
We will also give you TEN days' advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the
policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with
respect to which this certificate ofinSlltance maybeissued>or may pertain, the insurance afforded by the pOlicies
described herein is subject to all thelerms, exclusions and conditions of such policies.
~~~~
AUTHORIZED REPRESENTATIVE
I(~
PRESIDENT
EMFLOYER'S LIAelLITY LIMIT INCL.UOING DEFENSECCSTS:tl,OOQ,QOO PER OCCLRRENCE
-4 1996
EMPLOYER
I
HARRIGAN, MATTHEW TlftlOTHY
TIMELINE CONSTRUCTION
457 N. 15TH ST.
SAN JOSE CA 95112
CERTIFICAT. OF INSURANCE
r
i
i
DATE (MM/DD/YY)
. ___________. 12./319._6__
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 POLICIES BELOW.
_.___..___~.~_..___,_~.._._~. ___._.... ___~_.__.,,_._'u ,__~___.'.._'.H. ...,.... ~____ __~ .'. _ __ 'u. __.
CONlPANIESAFFORDING COVERAGE
At~ttlll.s
PRODUCER
CLEMONS, FERRALL, & HOFMANN
INSURANCE AGENCY
1855 GATEWAY BLVD., SUITE 230
CONCORD, CA 94520
COMPANY
A
AMERICAN NATIONAL FIRE INSURANCE CO.
INSURED
COMPANY
MATTHEW & THERESA HARRIGAN B
DBA: TIMELINE CONSTRUCTION COMPANY
3181 SO. BASCOM AVE. C
CAMPBELL, CA. 95008 COMPANY
, D
_________1..___._____.__.__.____________.._____...______.__.____.___________.__~----..-...---.-. .... -.--.--....-.-.--......-..-
i COVERAGES'" 1/ 199;.;,
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 SUBJEPT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .
CO,
LTR
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MMlDD/YY) DATE (MMlDD/VY)
TYPE OF INSURANCE
POLICY NUMBER
GENERAL LIABILITY GENERAL AGGREGATE
A X COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG
CLAIMS MADE X OCCUR PAC 817 93 98
OWNER'S & CO NT PROT
9/8/96
9/8/97
PERSONAL & ADV INJURY
EACH OCCURRENCE
FIRE DAMAGE (Anyone fire)
_______ ___~_E[)~Xf>JA-"1.."neperso~L
COMBINED SINGLE LIMIT
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per person)
! HIRED AUTOS
NON-OWNED AUTOS
BODILY INJURY
(Per accident)
PROPERTY DAMAGE
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
.__.._._________.___ ___.__~<>~!:!.~~~_TE__~.._..
EACH OCCURRENCE $
AGGREGATE $
__.---t.____....________M.___.__~__........~__.____..._____..__----
,
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
_..._.--I..--------------~--_..._-,. ..-----'--.-..-,.->~..-'-._.-.-'^.^-~_.,--._---'-...:...--~--_.-_....---_.-,.,----....--
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
STATUTORY LIMITS
EACH ACCIDENT $
THE PROPRIETOR/ INCL DISEASE - POLICY LIMIT $
PARTNERS/EXECUTIVE ,
, OFFICERS ARE: EXCL . DISEASE - EACH EMPLOYEE $
,_.__._--------..--.---~---.---_-.--.-- ________.__..,__n.__ .___ ______...,_._____.____.__-,-..__.______ -___________. .--- .-..---
OTHER
~_......l_____..______.__~...._____.____..____"_.:._.._..~_,.____._<_,.__._".L.~____,___._,_______--1..-.._._~_.___..
: DESCRIPTION OF OPERATlONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
CERTIFICATE HOLDER
RANDY WESTFALL
CITY OF CAMPBELL
70 N. FIRST ST.
CAMPBELL, CA. 95008
CANCELLATION
LIMITS
$ 500,000
$ 500,000
$ 500,000
$ 500,000
$ 50,000
$- 5,000
$
$
$
$
. .~
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
ACORD 25-S (3/93)
CORD CORPORATION 1993
CITY OF CAMPBELL
FIELD ENGINEER'S DAILY REPORT
((~ I 5fJ{HtJ(l-laf) >
CONTRACTOR: IiMLi;~ C"J-k.
ITEM
DESCRIPTION
cc:
PROJECT NO. 7'b-J-l~
REPORT NO:
DATE: /J-/;.; /9&
WEATHER: ~&6 '1
INSPECTOR: K. ~G:.~1fALL
w~ ~ :J ~4-90 J /ao/:s
PAGE: /
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