97-143
CITY OF CAMPBELL ~.--
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
.....!
r..
ENCROACHMENT PERMIT
(for working within the
public right-of-way)
Permit No. 97-/ It S
X-Ref. file
Issued , 1
Permit expires in 12 mon
Application Date l(- / - 9'7
Application expires in 6 months
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. Application Fee is non-refundable.) R"'l.Ii'" 0 8f.t....~ fer .. Pr'fr;"{l t>vstU't2.Y"
A. Worle address or tract # /3 DO Dell ~ve..' Ct\1\A t b.J.1 0"1 sJ 3$/ - 6(. -<-<.
Utility trench location
B. Nature of work jJPIJ l:>\.prrM\~"~ (.~~)
c~.lt t G:.~-< i qrtL..'IoJ~ (../-.:... jAi t..~>k C;tr 5h.r~
C. Aaach four (4) copies of an engineered plans showing the location and extent of the work, and four (4) copies of the preliminary Engineer's Estimate of work. The
plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer. said plan becomes a pan of
this permit.
D. 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 Sureties and cash deposits. (See General Permit Conditions I and 2.)
E. THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AT THE SITE AND MUST NOTIFY THE PUBLIC WORKS DEPARTMENT AT
LEAST TWO DAYS BEFORE STARTING WORK. NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
N_ "Appl",", lac-',fT <. .:>.:...\; ~' I'J.s f ~Jf J :t:N L . Td""'" t~/~ ~O - 'N 'f Y
Address ~O(,.(",. WA-r-. -S;,..-;;.J..W;intC/) li-e-fVl.C>tII-i 24 HOUR EMERGENCY TELEPHONENO.J)~ IQ) fc.'S- "'fg!!
V I r ~
Is this work being done by the property owner at their own residence?
Yes
/' No
The ApplicanllPermittee 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/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the
information.
/JIidorJ /I~,~--4t_~IfW
4-/- ? 7
Date
Accepted
SPECIAL PROVISIONS
_1.
Street shall not be open cut for underground installations. Minimum cuts~beallowedfor connections or exploration holes. Such cuts may be soecitieally
approved by the Inspector prior to cuttinl!. . .. .. .... ... .. . .... ..... ... ......... .. ... ... . ... .... ... .. . ... . . ..... . ... ..
Pavement may be cut for underground installations and must be restored in accordance with theytilityTrench RestorationSla/Idardpetails. Method . A'Backtm~
unless otherwise approved by Inspector. . .
Worle to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public WorlcsDepanment before starting work.
Per Section 4215 of the Government Code this pcrmit is not valid for excavations until Underground Service Alert (USA) bas been notified and the inquiry
identifICation number has been enrered hereon. USAPhone 1-800.2~H600. ..< SA TICKET NO.
UjE 'I c: ..... ..oJ .O/WCG AI. 1'-
_2.
_3.
_4.
_So
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
!Y.ffi
. · AMOUNT
PERMIT APPLICATION FEE AAg..i-CT,t....
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS /tJ,,2,1.. B/.(tt/t. ~>7.
~~~~~~~~~E~_
$ ~J.')' -"
s .---
$~
~:~~
RECEIPT NO.
NJ O~?
10/02..1
101 CJ 1. 7-
Ihl 0 23
!f-/-,97
Date
City of Campbell - Refundable Deposit Check Request
Interim Check Required:
To: Finance Director
Return Check to:
Please Issue Check
Payable to:
Department:
Pacific Sealing & Asphalt, Inc.
Address - Line I:
Line 2:
2066 Warm Springs Court
City:
Fremont
State: CA
Zip: 94539
Description:
Refundable Deposit
Finance Use Only
Amount Payable:
$1,250.00
(Exact Amount)
Interest Earned
Account Number:
101.2203
101.540.7448
Purpose:
Refund faithful performance surety
Voucher #:
Permit #: 97-143
Date: 4/1/97
Title: PW Inspector Date: 09/22/98
Title: City Engineer Date: 09/22/98
Title: Account Clerk II Date:
Title: Date:
Requested by:
Michelle Quinney
Approved by:
Verified by:
Approved by:
Special Instructions For Handling Check
Mail As Is:
x
Mail in Attached Envelope:
Other:
fin: S;/exceVchkreq - Revised 1/98
Requested by: ,~_ .--' -,
Robert Phillips
Approved by: ~
Michelle Quinney
FINANCE ONLY:
Verified by:
To: Accounts Receivable
Please Issue Check
Payable to:
Address - Line I:
Line 2:
City:
Description:
Amount Payable:
Account Number:
ate and Receipt No:
Permit No:
Purpose:
Approved by:
Mail As Is:
Return To:
(NAME)
Other:
rev: 3/25/95
CitJ Jf Campbell- Chel.A Re.q.uest
Pacific Sealing & Asphalt, Inc.
2066 Warm Springs Court
Fremont
State: CA Zip:
94539
REFUNDABLE DEPOSIT
Finance Only:
INTEREST EARNED
$4,250.00
101.2203
101.540.7448
4/1/97 #101021 & 101022
97-143
nd of 75% Of Faithful Performance Surety $3,750.00)
and 100% of Cash Deposit ($500.00)
TItle: Project Inspector
Date: 4/25/97
Date: 4 .'Zj /c;V
Title: City Engineer
Title:
Date:
TItle:
Date:
Special Instructions For Handling Check
xx
Mail in Attached Envelope:
(Department)
PUBUC WORKS DEPARTMENT RECEIPT
Effective JuJy I, 1996
TO: CilyClerIi PUBLIC WORKS FILE NO. 97 -J'f ~
PROPERTY ADDRESS l:1do {)o../I A~.
Please collect & receipt for the folJowinl monies:
ACCT. ITEM ...................... ........................ ........
4JS.l3H92I I Project Revenue (specify project) S
ENCROACHIlilL"IT PERMIT
~ ) Application Fee ..1...1 5 --
Non-Utility Encroachment Permit (S22S)
R-I Fint Permit (No Fcc), Subsequent PennitfYr (SIOII)
Utiliry Encroachment Permit
ArteriaVCollcctor Street (S32S)
RcsidcntiaJ Street/Other Area! (S22S)
220J Plan Check Deposit - 2% of ENGR. EST. (SSUU min) .
( 220J Faithful Performance Security (FPS) (I"I%ofENGREST.) . -
220J Labor and Motcrials Securitv (llJll"1o ofENGR EST.)
220J Monumenl4ltion Security (I")%ofENGREST.) .
(220J~ Cash Deposit (41'. ofENGREST.)(SSOO minl1lO.000 maxI . "Jt'l("} -
- Plan Ched. & Inspection fee (Non.Utility) ~t}O
~ ) Engr.Esl. < S250."lO (121'. of ENGR EST.)
.. 2203 Engr.Esl>$250.()()l) (Deposit 8e;. ofENGR. EST./SJO.OOO min.)" .
4722 Utility < SIlHI.OlKJ
Minimum C'hargc Per Location (SI20)
ConduitslPipe:lines up to 500 fcct (SI.60/11)
Above 500 Feet (SUO/fl.)
ManholesNaultsIErc:. (SIOS/ea)
Pole SetlRemoval (S IOS/ea)
Streee Tree Planeing/Removal (S 1051....)
.. 2203 Utility:> SIOll.()(IU Actual Cose + 2()1'/. .. .
4722 StreCC Tree PlantinlJl'Removal Pennie (SillS)
4761l Project Plans & Specifications Project No.
47(1) Standard Specifications & Details (Slll'g S12lBook)
4160 Copies of Enginccring Maps & Plans (S.Sll/sq.ll.)
4722 Penalties: Failure to restore public improvements (SI()(I/C.1lendar Day)
(Muni Code Section 11.34.0(0)
4722 Penalties: F3ilure to correct unsafe conditions ($ lOll/Calendar Day)
LAND DEVELOPMENT
4722 Lot Line Adjustment (S5(lO)
4722 Parcel Map (4 LolS or Less) (SI.06ll + S2SILoI)
4722 Final Trace Map (5 or More Lots) (SI,J81l + S2SILoI)
4722 Certificate of Compliance (S5IMI)
4722 Certificate of Correc:tion (SliM))
4722 Vacatian of Public SlrCClS & Easements (SSSIl)
4722 Assessment Segregation ar Reapportionmenc
Firse Splie (SS511)
Each Additional Lot (SI711)
4721 Slonn Drainage Area Fee Per Acre (R-I. S2.II'MI)
(Molo.Res. S2,250)
(All Other. S2.5"1)
4921l Pa.rkl;:md Dedication Fee:
496S Post.1ge
TRAFFIC
472'1 Interscction Turn Counts ITwo.Hour Coune} (S6II)
4728 Intersection Turn Counts (a.m. or p.m. peaks) (SI2S)
4728 Tranic flow Map (Daily Traffic Volumes) (S271
472'1 Campbell Traffic Model (Full Scope Assessment) (S2.2S0)
4728 Campbell Traffic Model (Reduced Scope Assessment) (S740)
4271 Truck Penn its (SJS/lrip)
472' No P:uking Signs (SI/each or S251IUU)
OTHER
s~3;l<; -
TOTAL
NAME OF APPLICANT ~Gjr;t:J C. .1,',.,.. ~ ~lflh~2;t /"e-.
NAME OF PA YOR ;OCif;CI ~,,~ ~ AC,Ahrlf IJrtc-. PHONE 5)(j - 1f4~ ... 9'9 ~
ADDRESS .laVe., IAJI1f~ ~"""\"J bJ. "/Q.,wt..,~ (';1/ ZIP 94,)JC?
I J
.. Actual Cost Plus 21W.. Ovcmclld (Non.lnlcrest bearing deposit)
10 1\,)23
/010'2./
/0/022-
JIJ lOll
Jt ~7:J-2 (!. S/.J 5' - /d/Ol]
5 t:' ,.o(._~ d'l"'J\t Z2..
.:JJ 2.203 (!., J o.a.~EI ,,~.
r"i,O'~
;\l'l C~S OffiCE
FOR
CITY CLERK
ONLY
RECEIVED BY
'\
D.te
.For Pt.m Chct:l and Dsh,DeposiLS, send yellow cop)' tarmancc.
h:\recCnn4(exc)mp(rcv 1/2191)
Permit #
INSURANCE REQUIREMENTS CHECKLIST
q 7 ~ I Lj3
CIP Project #
The following insurance is required of all contractors working in the City of Campbell public
right-of-way. Insurance certificates must be accepted by City staff before work can begin.
These insurance requirements apply to work being performed under an Encroachment Pennit
and work being performed under contract for Capital Improvement Projects.
Limits
Commercial General Liability for bodily, personal injury and property damage:
~ $1,000,000 per occurrence, and
~ $1,000,000 general aggregate limit applying separately to the project, and
~ $2,000,000 general aggregate limit.
'I::::J Policy expiration date 4 J I ) Cj S
Automotive Liability - "any~o"
if $1,000,000 per accident 11' r ~odily injury and property damage
. if Policy expiration date Lt _ J I q 6
W,9fker's Compensation and Employer' ~ Liability C) .\ q V,h) ~....I\/
'd $1,000,000 per accidem for bodily UUnry or disease ~ \ I ,I / I ~ ^ lOll}
~ ,Policy expiration date -4) J 1'19-. u I r ~ oJ!)
Course of Constroction (if required in Special Provisions) ,KIP. ~ I V. rvbL"Y
o Completed value of the project \./, v . {1l/V' () Ofll'
o Policy expiration date Ii' \ ,.YJ JV~
Reauired Endorsement to General Liability and Automobile Liability Policies ~
Additional Insured Endorsement
> 0 The City, the City of Campbell Redevelopment Agency, its officers,
employees and volunteers are named as additional insured.
The insurance coverage afforded to the Additional Insured is primary
insurance.
~
.; {~\' I
\ :): .'/ '\
Workers' Compensation Insurance Sheet Submitted
o For General Contractor
o Subrogation Clause
o
~
Insuran<:e Certificate ReVi~ ~ ~t3.A......' _
Initi~ls
4 );;L3 )77
Date
){. Copy of Insurance Certificate placed in tickler file OIie month prior to expiration.
j: \fOrm. s\inscklst 4/96 (rev 6/96) .'./_ /I,~ '. ,p /! ~ ~ / A . _
ly\'i7 k- 1D (/Cc.epr-- We/r; W U"c/1UJ2:> ~-~~O .
ifl 0,) -, ~- / h rv I" CtflrpLc2cQ-
CJ::Y kAT/.-/(..--/ t.o U t^-JdG r .
AkORDN
eER'-U=,C.l\'--OFI..I.l\B1l1l"a'INStJR," . "e~~gI~~4 DA;: 7~;;r;~
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.
COMPANIES AFFORDING COVERAGE
i COMPANY
i A
- fl-E C E , " f5""
APR 181997: COM~ANY
PUBLIC WORK
ADMIN S
Pacific Insurance Company LTD
PRODUCER
All West Insurance Brokers
P.O. Box 1737
Campbell CA 95009-1737
Janice Berthold CLU,ChFC,CPCU
Phone No. 4 0 8 - 3 7 9 - 3 4 0 0 Fax No.
INSURED
Kemper National Insurance Corp
Pacific Sealing & Asphalt
2066 Warm Springs Ct
Fremont CA 94539
General Security Insurance
COVERAGES
COMPANY
D
State Compensation Ins. Fund
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.
I ,
i POLICY EFFECTIVE I POLICY EXPIRATION i
DATE (MM/DDIYY) DATE (MM/DDIYY)
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
LIMITS
A
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY i Z I 0 0 05392
CLAIMS MADE i_:lCJ OCCUR i
OWNER'S & CONTRACTOR'S PROT
04/01/97
GENERAL AGGREGATE
04/0 1/98 i PRODUCTS - COMP/OP AGG
PERSONAL & ADV INJURY
, EACH OCCURRENCE
i FIRE DAMAGE (Anyone fire)
MED EXP (Anyone person)
AUTOMOBILE LIABILITY
C X ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
X HIRED AUTOS
X NON-OWNED AUTOS
CA4010253
04/01/97
04/01/98
COMBINED SINGLE LIMIT
$ 2,000,000
$ 2,000,000
$ 1,000,000
$ 1, 000 , O~O
$ 50,000
$ 5,000
$1,000,000
BODILY INJURY
(Per person)
$
BODILY INJURY
(Per accident)
PROPERTY DAMAGE $
GARAGE LIABILITY
ANY AUTO
EXCESS LIABILITY
A X UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
TJ0002431
, AUTO ONLY - EA ACCIDENT $
, OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
I EACH OCCURRENCE $ 3, 000 , 000
04/01/97 i 04/01/98 iAGGREGATE $ 3,000,000
$
D
THE PROPRIETOR!
PARTNERS/EXECUTIVE
OFFICERS ARE'
OTHER
INCL i 71345096
EXCL,
04/01/97
04/01/98
'WC STATU- OTH-
TORY LIMITS ER
EL EACH ACCIDENT
EL DISEASE - POLICY LIMIT
EL DISEASE. EA EMPLOYEE
$~OJl~ 000
$ 1,000,000
$ 1,000,000
B
A
04/01/97
04/01/97
04/01/98
04/01/98
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
Certificate Holder is listed as additional insured per CG2010 attached.
Thisinsurance is primary per endorsement attached.
CERTIFICATE HOLDER
CITYCAO
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 REPRESENTA TIVES.
AUTHORIZED REPRESENTATIVE
City of Campbell
Dept of Public Works
70 North First Street
Campbell CA 95008
ACORD 25-S (1/95)
Janice Berthold CLU,ChFC,CPCU
@ACORDCORPORATION 1988
pOl.!CYNUMBER: Zl 000
'2 Pacific Sealing & Aspha~C~~
:R~!AL (.~'=,. .':", LIABILITY
---
THIS ENDORSEMENT CHANGES THE POUCY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - O'VNERS LESSEES OR
,
CONTRACTORS (FOffi\iI B)
Tnis endorsement modifies insurance provided under the following:
COM:MERCIAL GENERAL LIABILITY COVERA.GE PART
SCHEDULE
Name of Person or Organiz3tioa:
City of Campbell
(If DO e::try app~ above, information required to complete this c:ldorsement will be shown in the
Declarations as ~-plicable to this endorsement)
WHO IS AN ]},"SURED (Section II) is amended to include as arl. insured the person or organization
sho\1ffi i:1 the Sc;:~cle, but only with respect to liability ar.sing out of your ongoing operations performed
for that rnsured.
CG 20 10 1093
Copyright, Insurance Servic~ omc:, rnc., 1992
ACORD,. GER....IF1GA....-\C)F ..I..IABII..IN1NSl.JR. 'JG t IDBM DATE (MMIDDIYY)
....... ...> . ..ACIF14 04/08/97
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
All West Insurance Brokers HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. Box 1737 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Campbell CA 95009-1737 It?.\,,tO COMPANIES AFFORDING COVERAGE
.---
Janice Berthold CLU,ChFC,CPCU COMPANY
i A Pacific Insurance Company LTD
Phone No. 408-379-.3400 Fax No. I ----
INSURED ') t ~ W\" COMPANY
.~ ~~~ . B Kemper National Insurance Corp
\\V~ _...:> COMPANY
Pacific Sealing & Asphalt . yi""" \O~ C General Security Insurance
2066 Warm Springs Ct .\ \..... ~9-p..\ ! COMPANY
. .~\S
Fremont CA 94539 ...~\ D State Compensation Ins. Fund
),v .
COVERAGES
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.
---.-.---.
I I POLICY EFFECTIVE POLICY EXPIRATION
CO TYPE OF INSURANCE POLICY NUMBER LIMITS
LTR , DATE (MM/DDIYY) DATE (MM/DDIYY)
GENERAL LIABILITY , GENERAL AGGREGATE $ 2,000,000
I I
A X COMMERCIAL GENERAL LIABILITY ZIOO05392 04/01/97 04/01/98 PRODUCTS - COMP/OP AGG $ 2,000,000
CLAIMS MADE X OCCUR I ! PERSONAL & ADV INJURY $ 1,000,000
OWNER'S & CONTRACTOR'S PROT . , , EACH OCCURRENCE $ 1,000,000
I ,
, FIRE DAMAGE (Anyone fire) $ 50,000
----
I , MED EXP (Anyone person) $ 5,000
AUTOMOBILE LIABILITY
! 04/01/97 , 04/01/98 COMBINED SINGLE LIMIT $
C X ANY AUTO CA4010253 I ,
--._-
ALL OWNED AUTOS I BODILY INJURY
$
SCHEDULED AUTOS (Per person)
--.
X HIRED AUTOS ! BODILY INJURY
$ 1,000,
X NON-OWNED AUTOS (Per accident)
I -----~
I I PROPERTY DAMAGE $
I , -
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
-~---_.~.-
ANY AUTO OTHER THAN AUTO ONLY
~----._---
-- I EACH ACCIDENT $
---.---- --.
! AGGREGATE $
EXCESS LIABILITY 1 EACH OCCURRENCE $ 3,000,000 I
A X UMBRELLA FORM TJOO02431 I 04/01/97 04/01/98 AGGREGATE $ 3,000,000
----
OTHER THAN UMBRELLA FORM ! $
, WC STATU- 'OTH.
WORKERS COMPENSATION AND TORY LIMITS ER
EMPLOYERS' LIABILITY I
EL EACH ACCIDENT $ 1,000,000
D THE PROPRIETOR/ INCL 71345096 I 04/01/97 04/01/98 EL DISEASE - POLICY LIMIT $ 1,000,000
PARTNERS/EXECUTIVE - I
OFFICERS ARE: I EXCL , EL DISEASE - EA EMPLOYEE $ 1,000,000
OTHER I T
! !
B ! 04/01/97 04/01/98
A I 04/01/97 04/01/98
,
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
Certificate Holder is listed as additional insured per CG2010 attached.
Thisinsurance is primary per endorsement attached.
CERTIFICATEHOtDER .,' IATIOt./
CITYCAO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
City of Campbell ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Dept of Public Works BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
70 North First Street
Campbell CA 95008 OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Janice Berthold CLU,ChFC CPCU
ACORD 25-S (1195) @ACORDCORPORATION 1988
FOLICYNUMBER: 21 0005.):12 Pacific Sealing & Asphal('~M._~..:.RC:!Ar.~8"~""':~IABILITY
TffiS ENDORSElMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - O'VNERS LESSEES OR
,
CONTRACTORS (FOR1\'I B)
This endorsement modifies insurance provided under the folIowing:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
City of Campbell
ATTN: Dept of Public Works
70 North First Street
Campbell, Ca 95008
(If no entry appears above, information required to complete this endorsement will be shown in the
Dedarations as applicable to this endorsement.)
WHO IS AN msURED (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 ongoing operations performed
for that insured.
CG20 10 1093
Copyright, lnsw'ance Services Otlice, Inc., 1992
/'
/~
POUCY NUMEER:
:-'7--"::";
cf
INS'URA..'iCE COMP~'l't
rsstIED TO:
THIS ENDOR$L'\1EI'i'I' CllA.."\GES nIE l'OLICY. PLEASE RE.....D IT CAREFUlLY.
~O~~i#
ADDIrIONAL IN5UUD-OWl'l'XRS. ussllS OR CO:\JRAcr(l~ (FORM B)
This endotse1Tlem modifies insurance providtd ~ the folll1"'ina:
COMM:fltCIAL ~UABn.m" COVERAGE PART
In oonsicle:ration of an Idd.ititllltl ptemium or S
". it is hereby ~ tlJat;
WHO IS ~ DlSlJ'"RED (SeaioA II) is Imecded to indw!e i5 art insurod U\c :)C."'$OIl or organization shO'AlI. in th:
Sclu:du1e. but 0111)' with r::spea to tiability ariSit.g out of "ya'Jt WQtk" tar ~ iNut:d by or for you..
h is further agr.ed that
The foUowml pangraJ.'h i$ aMccllo SCO:llJ94, Specbl Broad. Form Comme:n:W Celu~r.1lllibi1ity ::tado~ement.
1.. Addidonal Insureds. By CoaU'act. A:ntmot12C or Permit:
c. CO\'aage prtMcX4 by this poll'1' lO t..'!t: Mdiucnal InsurM(s) li~ed. t::e1ew sh&ll l)e pci:nat}' inslolranc;e
b'oIJ. C)~y il$ rc:spects the projl:Ct listed below and any othcr in:ur"al"ll;1;. n:aitlwir.t:d by the Addilicnal
blnre:1(s) shall be c;a;~ ud :.on~cntr.~U1ory.
SCHEDULE
Name orPersol1 Ot Org;LDiutioll:
Project:
'I1d.I i.nsunnce d~ ~ ap,ly to '"bcdiI'y ~a.rt". "pJ~ Wnige-. 'lemma! UUUIy" ~. "advertising l.I1jury"" uifu, cn.rt of lbt
r=4erilOg 01' .rai1urc tg tende: a.~ p1of'cs:sioual snvit;es by ClI' for you, mcludlua:
L The preparing. a}1Ptc"#i.:tj. or !ailing ~ prepare or :.pprnve maps. dr3.v.i~. op'nicns, fCjlCrts, :turvey5, d'.an;c o.rdUS,
designs or spcCficatiC1'ls: aM
2, Supe~. inspe::tion or c&~ee1'inc SErvices.
COYCo"a;= prQ'lidcd \UI.licr this endor&emc.t is specifiea1ly limi:d to projcclS 10Ci:.ted in th~ sta~ cr Califomi~.
~:
1lUI cndorzelnwt does ~t clul1~e the puUc., ~(lt as shown.
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CITY OF CAMPBELL
Public Works Department
September 22, 1998
Pacific Sealing & Asphalt, Inc.
2066 Warm Springs Court
Fremont, CA 94539
SUBJECT: PERMIT NO. 97-143
LOCATION: 1300 Dell Avenue
ONE YEAR MAINTENANCE INSPECTION - ACCEPTANCE
Dear Mr. Walitsch:
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.
Your warranty deposit of $1,250, plus any interest due, will be sent directly to you from our
Finance Department.
sm21~
Alan Horn
Public Works Inspector
MQMA.-
cc: Permit 97-143
Public Works/Maintenance Division
H:\ WORD\PERMITS\97143ACC(JD)
70 North First Street. Campbell, California 95008.1423 . TEL 408.866.2150 . FAX 408.376.0958 . TOD 408.866.2790
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CITY OF CAMPBELL
Public Works Department
April 24, 1997
Pacific Sealing & Asphalt, Inc.
2066 Warm Springs Court
Fremont, CA 94539
SUBJECT: PERMIT NO. 97-143
LOOCATION: 1300 Dell Avenue
FINAL INSPECTION AND ACCEPTANCE
Dear Mr. Walitsch:
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 the 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.
The City will continue to hold $1,250.00 of your $5,000.00 Faithful Performance Surety cash
deposit, receipt #101021, as your Maintenance Surety. Additionally, your 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 me at (408) 866-2165.
Sincerely,
.......-7 ____
y// -- ~---'-
Robert Phillips
Project Inspector
MQ
lit &
cc: Suspense - 11 months
Permit #97-143
H:\ WORD\PERMITS\97143FINGd)
70 North First Street. Campbell, California 95008.1423 . TEL 408.866.2150 . FAX 408.376.0958 . TOO 408.866.2790
CITY OF CAMPBELL
FIELD ENGINEER'S DAILY REPORT
PROJECT HO.
REPORT HO:
"2
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Drc. l l
DATE :
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WEATHER:
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INSPECTOR:
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CITY OF CAMPBELL
FIELD ENGINEER' S DAILY REPORT
PROJECT NO.
REPORT NO:
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PAGE: I OF I
. .
-
March 13, 1997
Mr. Roland Buehler
2806 Bay View Drive
Alameda, California 94501
Page 1 of 2
Subject:
1300 Dell Avenue
Parking Lot Paving
Dear Roland,
The following is our updated cost for the work you requested on the parking lot.
Please note that we have included the cost for the 1320 Dell Ave., site.
SCOPE OF WORK
ITEM I - NORTH DRIVEWAY & REAR OF BUILDING
A. Approximately 6,800 square feet of 4" paving.
B. 8' x 28' of PCC approach.
C. 6" of class II baserock under approach.
D. New storm drain & line.
E. Existing sidewalk removal.
F. Curb & gutter and transition,
G, Encroachment permit.
H. 155' x 2' concrete swale.
COST:
$24,290.00
ITEM II - SOUTH DRIVEWAY
A. 15' x 8' concrete approach with 6" of new baserock,
B. New drain inlet & line,
C, 205' x 3' wide concrete swale,
D. Approximately 8,200 square feet of new pavement.
E, 12' x 30' concrete pad for garbage bin.
F. 39' of headerboards,
G. Curb & gutter with transition.
H. Re-stripe parking lot per new plan.
COST:
$31,578.00
March 13, 1997
Mr, Roland Buehler
Page 2 of 2
ITEM II/ - 1320 DELL AVENUE SIDE
A. 1/2 of the valley gutter & 820 square feet of pavement repair should be paid by
the owner of 1320 Dell Ave., since this is figured on his property. This cost is
$4,180.00 and would reduce the cost of Item 1/ ($31,278.00) by $4,180.00.
B. Place concrete approach and curb & gutter with transitions.
COST:
$2,815,00
C. Additional pavement that should be repaired at 4" thick.
(Approx. 3,800 square feet)
COST:
$7,410.00
If you have any questions, please feel free to call me.
Sincerely,
PACIFIC SEALING & ASPHALT INC.
Michael Walitsch
Vice President
Pr~;f 9/J jtf's
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CITY OF CAMPBELL
PVBUC WORKS DEPARTMENT
ENGINEER'S ESTIMATE
Address
Encroachment Permit No.
ITEM i
NO. i
'I.
DESCRIPTION
~ACE CONSTRUCTION
MOBILIZATION
i
FONSTRUCfION TRAFFIC
r:;ONTROLCONTROLIPHASING
.tONSTRUCfION STAKING
CONSTRUCfION TESTING
I
i
II, DEMOLITION/CLEARING
I. bLEARING'" GRUBBING
I
0~AWCUT P.C.C.lA.C.CUP TO 6')
~.C.C. REMOVAL
i 0FURB AND GU1TER REMOVAL
!
5. ~fEDlAN REMOVAL
I
6. DEMOLISH EXISTING INLETIPLUG RCP'S
I
; III~ ~TORM DRAINAGE
~2' R.C.P. (CLASS V)
;
2. 15" R.C.P. (CLASS 110
!
3. ~8" R.C.P. (CLASS III)
4. 24" R.C.P. (CLASS 110
I
5. ~" R.C.P. (CLASS 110
!
6. rV. INSPECfION (12")
I
7. STD. DRAINAGE INLET
I
rC.C. DETAIL 9)
8. FLAT GRATE INLET
fC.C. DETAIL 6)
9. STANDARD MANHOLE
fC.S.!. DETAIL 0-11)
tlNCLUDES FRAME'" LID)
I
;fo:\~REAK AND ENTER M.H./D.l.
i~
i IV. fONCRETE IMPROVEMENTS
t. SIDEWALK
I
I
0RIVEWA Y APPROACH
27-Jun-96
QUAl'ITITlES
J
Da..
Application No.
UNIT PRICES FOR PROJECf AMOUNT
<S3OK 1 S30KtoSISOK I >SISOK
LS
LS
LS
LS
LS
LF
$4.501
SY
,
i
S3O.oo 1
I
;
LF
$6.001
SF
$4.SO:
i
EA
LF
$60.00 .
LF
565.00 '
IF
!
S70.oo I
LF
S80.oo
LF
S90.oo
LF
S1.20 t
!
S1.6OO.oo !
EA
EA.
S1.4OO.oo :
EA
S2.000.oo !
EA
S700.oo '
SF
$6.SO,
SF
S7.SO
SI,300.oo
SI,loo.oo
SI.6OO.oo
$5SO.oo
Page 1 of 4
$3.00
$23.001
$3.001
I
$2.251
I
1
$40.00
$48.001
$60.001
$68.001
$75.00 '
$0.75
$4.SO
I
$2.001
SIO.ool
I
$2.001
I
SI.251
I
$20.00 I
::1
$59.00 I
565.001
$0.60
SI.OOO.oo
S9OO.oo
SI.300.oo
S450.oo
$2.751
I
S3.75 1
S AMOUNT
ITEM I
DESCRIPTION
3. FURB AND GlJITER
1
I
4. IV ALLEY GlJITER
S. HANDICAP RAMP
6. TYPE B-1 CURB
7. TYPE AI-B3 CURB
1
I
8. FOBBLESTONE MEDIAN SURFACE
9. P.C.C. DRIVEWAY CONFORM
I
@ ,A.C. DRIVEWAY CONFORM
I
I V. PAVEMENT
I. ~SPHAL T DIGOUT AND REPLACE
I
2. PA VEMEI'<f WEDGE CUT (6')
I
3. "A VEMEI'<f GRINDING
4. rAVEMEI'<f FABRIC (PETRO-MAn
,
S. i^SPHALT CONCRETE (TYPE A)
! G AGGREGATE BASE (CLASS 2)
7. SLURRY SEAL (TYPE n)
8. SLURR Y SEAL (TYPE nn
VI.
~mc SIGNALSILIGHTS
t. pETEerOR LOOP (6' ROUND)
i
2. DETEerOR LOOP (6' x 30')
,
3. DETEerOR LOOP (6' x SO')
4. ELEerROLfER
S. 11/2" RIGID CONDUIT
I
6. 2" RIGID CONDUIT
27 -Jun-96
U AI'<fIT/ES
LF
I
SFI
I
SF!
i
SF!
I
!
I
CFI
!
LFI
I
I
SFI
!
,
I
SYI
I
Ti
i
TI
I
SFI
I
i
SF I
I
EAI
,
i
EAi
I
I
EAI
I
EAI
I
LFI
I
1
LFi
S AMOU/IIT
<S3OK
$22.001
I
UNIT PRICES FOR. ,Eer AMOU/IIT
,
SF
S12.S0!
,
,
EA
SI,200.001
LFI
S12.001
I
I
SIS.OOI
,
i
,
SI2.00!
LF
$7.001
!
~'SOI
!
SS.OOI
I
SS.OOi
i
so.801
I
I
$2.00!
I
S80.001
,
,
~,ool
so.071
I
SO. 11 1
I
I
I
S450.00 i
!
S6.50.00 i
1
I
S900.00 I
$2,600.00 I
I
S9,001
SI7.001
S30 K to SISO K
SI8.00
SIO.OO
SSOO.OO
SI2.00
$8.00
SS.SO
S3.SO
$2.S0
SO.SO
SI.~I
sso.oo/
,
$20.00
SO.06
SO.09
SJOO.OO
SS40.00 I
S7SO.00
$2,200.00
$7.00
SI3.00
Page 2 of 4
S9.SO
> SISO K
SIS.OO!
S8.2.S I
,
I
S7lXl.00 I
I
I
S7.SOI
I
SIO.OO
SS.OO
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$3.00
$2.SO
SI.SOI
1
~~I
St.SOI
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S:.:I
I
SO.071
I
I
S2S0.00/
S440.00 '
S640.00
Sf ,800.00
I
SS'OOi
SIO.OO
UNIT PRICES FOR Pk~,eCT AMOUr-rr
DESCRIPTION UAJlITITIES < SJOK . SJOKTO SISOK > SISO K S AMOUJIIT
LFI SO.701 SO.55 SO'45/
i
I I
S. ~ULL BOX (NO.3 1/2) EAI S300.oo ' ~~'ool SIBS.oo[
1 I
! i
9. PULL BOX (NO.5) EAI S4OO.oo : S350.ool S3OO.oo
i I I
VII. ~ING AND SIGNS I
I. . EMOVE PVMT. MARKINGS (PAlm) SFj $2.50: SI.SO Sl.oo
I I
I
Z. R.EMOVE PVMT. MARKINGS (THERMO) SF! 53.00 ~.OO SI.~
I I
I I
3. REMOVE PVMT STRIPING LFI SI.~ SO.lkIl SO.~
I ~
I
4. fI'RIPING DETAIL 9 LFi SI.35 SO.BS' SO.35
1 i
i LFI
5. FRIPING DETAIL 29 $2.25 SI.6S S1.20
6. rRIPING DETAIL 32 LFI ~.~, SI.751 SI.25
I
1
7. fRIPING DETAIL 37 (THERMO) LFi SI.BS SI.SO Sl.oo
I I
i I
S. ~RIPING DETAIL 38 (THERMO) LFi ~.50, SI.BS SI.15
9. LRIPING DETAIL 39 LFI SI.SO SO.BS SOA5
I
I i
I
10. ISTRIPING DET AIL ~ LFI $2.20i SI.70 Sl.oo
I
I LFI
11. 1.IMIT LINE SI.35 SI.05 so.~1
I I SI.05I I
12. ~'=WAU LFI S1.J5 SO.~
I I
13. AVEMEr-rr MARKINGS (PAIJIIT) SFI S2.50 SI.~I SI.60
I I
I
14. rAVEMEr-rr MARKINGS (THERMO) SFI 55.50' 53.lkIl ~.60
EJ
15. rAVEMEr-rr MARKER (NON.REFL.) $4.50 53.00 ~.20
I I
16. ~A VEMEr-rr MARKER (REFLECTIVE) EAi $6.00: $4.15 53.15
i I
I
i I
17. rPE K MARKER EA S95.OO $80.00 $70.00
18. hPE N MARKER EA S95.oo i $80.00 $70.00
I EAI
t9. ~ALVAGE ROAD SIGN $85.00 : $75.00 565.00
I
20. rELOCATE ROAD SIGN EA Sloo.oo I $85.00 S75 .00
i 'S110.oo
21. rNST. RD. SIGN ON EXIST. POLE EA $200.00 I S145.oo
I
I
22. rOAD SIGN WITH POST EA S300.oo I S240.oo SI95.oo
27-Jun-96
Page 3 of 4
ITEM I UNIT PRICES FOR PRuJECT AMOUNT
,
NO. DESCRIPTION <S3OK 30 K TO SISO K SI50K S AMOUNT
VIII. ~SCAPING
t. IRRIGATION, PLANTING WORK LS;
, I
!
2. ~RUNE TREE ROOTS EAi SI25.oo I Sloo.oo sas.oo
i
I
3. TREE REMOVAL EAI S6S0.00 SSOO.OO S4OO.oo
i I
I
,
i
4. ROOT BARRIER (12") LF' $20.00 I SIO.oo $6.00
I
5. ROOT BARRIER (IS") LF $25.00 I S15.OO SIO.oo
I I
i
6. ~REETTREE (24' BOX) EA, $4SO.OO I $325.00 S2S0.00 I
i I
7. ~REET TREE (36' BOX) EA S1OO.oo I $5SO.oo S4OO.oo
,
8. ~OP SOIL BACKFILL CYI
i
,
i
IX. ~ISCELLANEOUS
t. PEDESTRIAN BARRIER LF S75.OO $60.00 $50.00
,
I
2. CHAIN LINK FENCE (6') LF' SI5.oo/ SI1.SO S9.25
I
I
I
I ,
3. rAISE MISe. BOX TO GRADE EAI S3OO.oo I S2OO.oo S175.oo
I
4. RAISE MANHOLE TO GRADE HI S4OO.oo I S275.oo S2OO.oo
!
i
5. ~NSTALL MONUMENT BOX E.... $4SO.OO S3S0.00 S3OO.oo
S19.00I
i
6. ~EDlAN BACKFILL CY S17.OO SI5.SO
SUBTOTAL
PREPARED BY:
IO~ SECURITY ENFORCEMENT FEE
REVIEWED BY:
TOTAL ESTIMATE FOR FAITHFUL
APPROVED BY: PERFORMANCE SECURITY
"See Section 66499.4 of the Map Act.
H:\CECOSTEST. WK3(MP)REV6/3/96
27 -Jun-96
Page 4 of 4
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