97-145
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)
ISSUED 4/[; /17 ~
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. cl?--- /i/;:)
"
X-Ref. File
Application Date 4'-- /!,
:;-}
/
A. Work Address I O~:l 61z-.>~ Oa.. . CAn P&.~
B. Nature of Work {)(2,\~Z.LU^'-::'\ f\-P~Qc/>C.v\
C. Anach three (3) copies of a drawing showing the location, extent and dimensions of the work. The drawing shall show
tlle relation of the proposed work to existing improvements. When approved by the City Engineer, said drawing becomes
a part 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
securities.
NAME OF APPLICANT
~..J 3o~~ euti:;)~~L
(Print Name)
TELEPHONE ~ I -~3:J ~
ADDRESS
3&ib PU2..-\"'\\,~~ Au'~ \ ~ ~~~ c:...p... ~S \).1
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.
The Applicant hereby acknowledges that they have read and understand both the front and back of this permit, and that they will
inform their contractor(s) of the information.
~W.~
ApplicantlPerminee (Sign)
ACCEPTED
413/~)
date I
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 .
=~= ~<1 ~UCce: /'JvJc-, ~ N~b7~=,JL~ ~OWU ~tw efjZ~ /N,O ~)r,;4b.
_1A_"~ ~_ r~ ruT" _LJ.+r g, __~JL _ /NIAA" _WJ6r-IJ __ '~')"';/
SECURITY FOR FAITHFUL PE
STANDARD
(100% OF ENG. EST.)
AMOUNT
$ 3000 --
APPROVED FOR ISSUANCE
ity Engineer
onths After the Date of Issuance
Date
J: orms\r 1 permit/rev. /
( SEE OTHER SIDE)
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ASSIGN~ENT AND RECEIPT OF INVESTMENT CERTIFICATE
TO CITY OF CAMPBELL, 70 N. FIT STREET
CAMPBELL, CALIFORNIA 95008 \~08) 866-2150
P.W. Permit No. 17 -14-5'
TR or r
Loc. IO~2- &~LJr
I am/We are the owner(s) of a
at its branch office at Jv.
certificate No. 'i ~ - -
'.:/(,y ~~ eAl""\~lb1..u.- and having a
account at C3Pr~\i.. (.:)y An~J2-\&
~( '~:> , California, investment
he names of SA~ -s::;'blL Coi::.CIJ..4i\-iEL ~':sA:{6LG- \6
present balance of $ 3 <.:x::D cO
.
t~,-z:....
I hereby grant, transfer and assign said account, said investment certificate, said
balance (including interest which accrues thereon), and all other rights in connection
therewith to the CITY OF CAMPBELL, assignee, for a good and valuable consideration,
receipt of which is hereby acknowledged, for the purpose of insuring construction
described as follows:
I have physically delivered verification of said investment certificate and duplicate of
this Assignment and Receipt to said assignee.
I understand that assignee can withdraw from said account any time on his signature alone
upon presentation of a written order to the issuer. I also understand that I may not
withdraw from said account unless I present a signed release from the assignee. The
issuer of the certificate assumes no responsibility for the conduct of the assignee and
may act on the signature of the assignee without further inquiry.
Executed on Af'~IL 7
194) at said office of the issuer.
sign 11~.rAl"fl( (L). ()POI ~~
print
Assignor
sign M L'.wf1U..... C.) ~,&....J
print
Assignor
ACKNOWLEDGEMENT BY ISSUER
Issuer affirms that there are no other holds on subject account, that subject monies are
available, and that the above described assignment has been noted on the Records of said
issuer.
Date II? /9'7
By
2 ;C:/
Authorized Signature
Title: FSO
ATTACH
NOTARY
ACKNOWLEDGEMENT
INSTRUCTIONS TO ASSIGNEE
Please sign below for signature identification and as acknowledgement of your notice of
Assignment. Return this Assignment and Receipt to the issuer at its address above.
Retain one copy of this Assignment and R~t for ~~files..;;1
Date: fill 97 ~~tyt~ffi H~ :tf/
RELEASE ~ ASSIGNEE
Said assignee hereby releases and relinquishes all his right, title and interest in and
to said account, said investment certificate, said balance and all other rights in
connection therewith.
Date:
+17197
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ACORDTM
, DArE'(MWDD"~)'"":':':':':':lt
04 08 97 j~
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
PRODUCER
INSURED
BOZZUTO INSURANCE
3425 S. BASCOM AVE
CAMPBELL CA 95008
408-377-8712 408-377-5741
et.G
~ ~~
~V~ ~ s C
,~~ ...J 1"\
~.- ...n ~"t ."'f: MPANY
'" " \S\" D
LEGION INSURANCE COMPANY
SAN JOSE CONCRETE
UNIONAMERICA INSURANCE COMPANY
FLEMING AVE.
JOSE"CA 95127
251-5333
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,
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MIIIDD/YY) DATE (11I11DD/YY)
LIMITS
B
UAD1640
GENERAL AGGREGATE $1,000,000
PROOUCTS - COMP/oP AGG $1 000 000
PERSONAL & ADV INJURY $1,000,000
02/01/97 02/01/98 EACH OCCURRENCE 51,000,000
FIRE DAMAGE (Anyone Ii...) $50,000
MED EXP (Anyone person) 55 000
COMBINED SINGLE LIMIT 5
1,000,000
BODILY INJURY 5
(Per person)
02/14/97 02/14/98 BODILY INJURY $
(Per accident)
PROPERTY DAMAGE $
GENERAL LIABILITY
X COMMERCIAL GENERAL LIABILITY
~ CLAIMS MADE [!] OCCUR
A X OWNER'S & CONTRACTOR'S PROT GL 1 0104568
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
ANY AUTO
AUTO ONLY. EA ACCIDENT $
OTHER THAN AUTO ONL Y: ~~~~~~~~*~~~~i~~~l~~t~~~~~~~~~;~~~~llt~~~jr~jj
GARAGE LIABILITY
EXCESS LIABILITY
EACH ACCIDENT $
AGGREGATE $
EACH OCCURRENCE $
UMBREUA FORM
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
EMPLOYERS'LIABILITY
AGGREGATE
5
$
ER. ;~;~*;;;~;;;;*;;;;~~~g~~1~r:~~~~i;~~;:~~;~;;~;;~;;~~~j;
THE PROPRI ETORl
PARTNERSlEXECUTlVE
OFFICERS ARE:
OTHER
INCL
EXCL
$
EL DISEASE. POLICY LIMIT 5
EL DISEASE - EA EMPLOYEE $
DESCRIPTION OF OPERA TIONS/LOCA TIONSlVEHICLESlSPECIAL ITEMS
Subject to alJ other terms and provisions of the policy such insurance as provided by this
endorsement shaH be deemed primary, but only with respect to work performed by orfor the name
in connection with the above described contract.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
CITY OF CAMPBELL
ATTN: DEPT. OF PUBLIC WORKS
AS ADDITIONAL INSURED
70 NORTH FIRST STREET JDKIDleC
CAMPBELL CA 95008 AUTHORIZED RE ENTATlVE
_t..Yiil~l;ilim!~~~ii~lliiimmE~!~~~~~~~~!t1m~~~~l~~~ili~!~ili~l~~~~l~~~~~~~~~~~~~~~~~~~~~~~l~~~~~~~~~~~~~~~~~~~~~~~~~~~~l~~~lI:~l~~~~~~~~~~~l~~~i'~~~~~~~~~~~l~l~~~~~~~~~l~llI~::~i~~~~:}~;;:~:~i~~l~l;I~~It".l~I.~:~~:~~~
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL EIlUIE~Il(XOl: MAIL
.3.D- DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
POLICY NUMBER ARTOOOTBA
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
ADDITIONAL INSURED
-OWNERS, LESEES OR CONTRACTORS
(FORM B)
THIS ENDORSEMENT MODIFIES INSURANCE PROVIDER UNDER THE FOLLOWING:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
NAME OF PERSON OR ORGANIZATION:
All work in public right-of-way. City of Campbell, City of Campbell Redevelopment Agency,
its officers, employees and volunteers.
City of Campbell
Attn: Dept. of Public Works
70 North First Street
Campbell, CA 95008
(IF NO ENIRY APPEARS ABOVE, INFORMATION REQUIRED TO COMPLElE TillS
ENDORESEMENT WILL BE SHOWN IN TIlE 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 WIlli RESPECT TO LIABILITY
ARISING OUT OF "YOUR WORK" PERFORMED FOR THAT INSURED BY OR FOR YOU.
CG 20 10 11 85
Copyright, Insurance Services Office, Inc., 1984
INSURED'S COpy
Page 1 of 1
04/08/1997 12:34
408-259-8555
MIKE DEPEW
PAGE 02
APR-08.97 rUE 01:44 PM BOZZUTO INSURANCE
FAX NO. 14083775741
P. 02/03
A.cOB12.. .
':~:"''''~:'\'~'\,n-:'''''''
~u~.1t
:Ii
50ZZUTO INSU~CE
3425 S. BASCOM AVE
CAHPBi~L CA 95008
408-377-9712 408-377-5741
""""hi
~"'1'lY
.. __LEGION INSU
CE COMPANY
SAN JOSE CONCRETE
cow,..,.,
· UNIONAMERICA INS
CZ COMPANY
_AN'"
c:
" On -mas IS TO CERTIFY ~T TH! II'<ilOlES OF INS\JIWfCf: LISTED III.OW ~VE BEEN ~D TO THllNlUAfO I\lAMEO 4lIOVf FOR "NE POlICY IIERIOO
INOICATig, IIIOlWrTl4$TANOINQ fIllY -QUIAEMENt, TfI>\M ~ CONDITION OF /4N'( CONTRACT 01'1 0THe1'l ~NT WlTM PfSP€CT TO WHICH THIS
CfRTI'lCAT[ MAV .. 1!lIIU'e OR MAY 1ItRT....... ~E 1N8lJFUt,NCf: ~I'<JIIU,.lCiO !IV r.." POLlCJ'S OEliCRIllED I-4E~1N IS CUbeT TO .au. lHf tt1'lU5.
rxa.USIONS AND eONt)~ OF SUCJo4 POlICIES. LIMITS $Io4OWN MAY WAVE BUN ~ID"" "''''ID Q"AIMS,
eo
L'"
,.,. G'I.~
.ouey.....
I'OUl:Y l"retI\Ir I'OI.ICY Dl'lIljInQIl
llA"'lII_lWYI IUlft 111_'"
UIII7t
GLl 0104568
~""AllI.~T1
,,~. OOI'oClIIllCiQ
~'AO'IINNPY
02/01/97 02/01/99 ~~_NC.
,.~ (Altp _fl.l
loIBllV ~ __I
_ NITO
~.llWNl1D AlIlOlJ
stlCllUI.CO Aurea
141lIIIO AlI'OC
~l/"VTO$
~"1iICO "lIIIUIl,.,,"
'1 000 000
_I~ y IlV.IRY
'''-_I
,
{JAD164 0
02/14/97 02/14/98
lOlltI.y 1_""
,.......1
~0MlACJ( .
M./fOON.. y . U~jOlHT
OYVC. T_ AURJ ONL V
1ACl!6Q;IDIiNT .
___TI ,
WH OOCUMr'Cli ,
~'I1l ,
j.--:;-; :.:.,.... y~~.~.....~-;:,~
~
IL ILfoQ/O ACelOIIf"
JI. 0l$lIAC1; . POLICY U"T ,
Il DlRAst" - .... fMIO\.OI'Cl ,
INCL
:7...~...-\"i":--!;:~~ \.~:,,': '~ ':~ ~ 7':t!J
~_ClP_~no-.e.t~_~.."elAL Ill..
Subje(;t to all other t.Cmg and provisions of the pohcy, ~\lch insurance as provided by this
endorsement shall ~ d~.med pr~mery, but only with respect to wo~k ~rfonmed by or for th.
named ln~ur~ In conneet10n with the above d8scribed ~ontract
.,-~~~ I ,,~..,. ~'.~..: .~;i;'z
~o ." V. .,.. ~" .oallC...... ~a . C"_LL.O _ 'IMI
--- 1M.... ......... __ __ COII"UY WILL 1lI0000YIM 1'0 lUlL
.3.<L_ lUlYS WlImIN NC,mU'lO Tot' ellmr~lI MOLO&".....O '" nor 1I".
1'0 IIAIl CUCII lODnt"i "'ALL IIII10M NO ClaItMTlON ClII ~ITY
- ...,...._-"....,
CITY OF C~BELL
A'I"rN t PEPT. OF PUBLIC WORl<$
AS ADDITIONAL INSURED
7Q NORTH Pt~ST STREET
CAMP&ELL, CA 95008
TTN; aANDY WESTFALL . __'
~. .'~,~"~~.~~1,~~,.}~
'",...."J~t._Jtif~J"
04/08/1997 12:34 408-259-8665
MH<E DEPEvJ
Pt:lGE 03
APR-08-97 TUE 01:45 PM BOZZUTO INSURANCE
FAX NO. 14083775741
P. 03/03
POUCY NUMBER ARTOOOTBA
COMMERCIAL. GENER"L LIADn.rrY
TIllS ENDORSEMENT CHANGES THE POLlCY, PLEASE READ IT CAREFUl~L y
ADDITIONAL INSURED
-OWNERS, LESEES OR CONTRACTORS
(FORM B)
THIS ENDORSf.MENT MODIFIES INSURANCE PROVIDER UNDER nm FOLLOWING:
COMMERCIAL GENERAl.. LlABn..ITY COVERAGE PART
SCHEDULE
NAME OF PERSON OR ORGANIZATION'
All work in puNic right-ot-way. City of Campbell, City of Campbell RedeveJopn1ent Agency_
its ottlcers, employee$ and volun~rs
City of Campbell
Ann: Dept. "fPublic Works
70 Norlh First Saur
Campbell. CA 9'008
(IF NO ENTRY APPF..ARS ABOVE, 1lIJfORMATION REQUIRED TO COMPLETE THIS
ENDORF~EMENT WIll BE SHOWN IN nlE DEClARATIONS AS APPLlCABLP. TO THIS
ENOORSEMENT,)
WHO IS AN INSVRF.J) (SSCT10N II) IS AMENDED TO INet UDE AS AN INSURED TIm PERSON
OR ORGANIZA nON SHOWN IN THE SCHEDULE. nUT ONLY Willi RESPECT TO LiABILITY
ARISlNG Ollr OF "YOUR WORK" PERFORMED fOR THAT INSURED BY OR FOR YOU,
CG20 1011 tts
Copyrigbf, In~UJ1J1C'C Scrvi~eli Orfl\:c. Jn~.. 1914
lNSI..TRI".v'S COpy
Page 1 or 1
04/08/1997 12:44
408-259-8555
MIKE DEPEW
PAGE 02
..-
".-
NIl
STATE
COM......SATION
INSU"ANC.
I=UND
P,Q, BOX 807, SAN FRANCISCO,CA 94101 -0807
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: '0-01-"
POLICY NUMBER: 171-11 UNn 001~1'
CERTI~ICATE EXPIRES: 10-01.'7
DEPEW. "'CHAEL WARD AND DEPEW, FRANK J,
SAN JOSE CONCRETE
360 FLE"ING AVE.
SAN JOSE CA 95127
.JO_: .PIUH)' 0' INSUMNCE
CIItTZI'ICATI!"
ThiS Is to certify thlt we hIve Issued a valid Workers' Co~'nsation inSUrM1CII policy in a fOrm approved by the
Callfo,""i. Ins "ranee CommissIoner to the employ.r named O.low for the policy Penod Indic~ed,
Thl!l pOliey js not subject to c....c..u.Uon by t1'e Fund except upo" '0 day,' .svanc. written "otIC. to the employ.r.
We Will also give you 10 clayll' .svartee notic. .hould thiS POlicy b. c""c:ened grior to 1\11 normal expiration.
ThiS cer\",cate of Insur""ce III r'IOt "" ,nlur.nce POlley ..d do." not ame"d. .xtend or alter the coyereg. ~torded
by the POltCI.,S listed herein Notwlthltanding any requlr.ment term, Or cO/'ldltion of any contract Or other document
WIth respect to which this certificate of I".uranee may be issued or ""-y pertain, the Insurance afforded bv the
pol;cj.1: described her.,n ill subject to .It t~ terl'l'l~, exclUSions and conditiOns of SUCh poliCies.
~-~
E.LOVltt'l; LJ_ILITY LIMn INCLUDINrI De'!NS! COSTS: ",000.000.00 PEII OCQIMrNCI.
-
-
-
EMPLOYER
LlUL NMl
SAN JOSE CONCRETE
360 HE"' HG AVE
SAN JOSE CA 9512]
DEPEW, MICHAEL WARD (PARTNlIt) AND
DEPEW, FRANK ~ (-AaTNIII)
-
.
~OI-fiiiililill.
I!U..:..telilUlllll~e.:fJ.~:IUf=ISI"..;ll"'IIII:T!Ii;,..:~ .
o \'. C.44(
~' A~
", ~
... r"
U >' l""'
.. "-
os. "-
.. ,,'
.O~CHARO
CITY OF CAMPBELL
Public Works Department
September 22, 1998
Mr. Michael Depew
San Jose Concrete
360 Fleming Avenue
San Jose, CA 95127
SUBJECT: PERMIT NO. 97-145
LOCATION: 1082 Bent Drive
ONE YEAR MAINTENANCE INSPECTION - ACCEPTANCE
Dear Mr. Depew:
The City of Campbell has made the [mal one year maintenance inspection of subject Public
Works improvements and find that no remedial work is required.
Your warranty requirements are hereby released.
Since?b ~
Alan~
Public Works Inspector
MQV
cc: Permit 97-145
Public Works/Maintenance Division
H: \ WORD\PERMITS\97145ACC(JD)
70 North First Street' Campbell, California 95008,1423 ' TEL 408,866.2150 ' FAX 408,376,0958 ' TDD 408,866,2790
o~' C4.At
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CITY OF CAMPBELL
Public Works Department
R-1 PERMIT
April 17 , 1997
Mr. Michael Depew
San Jose Concrete
360 Fleming Avenue
San Jose, CA 95127
RE: PERMIT NO. 97-145 (R-1)
LOCA nON: 1082 Bent Drive
FINAL INSPECTION AND ACCEPTANCE
Dear Mr. Depew:
The City of Campbell has made a fmal inspection of subject Public Works improvements and fmds 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.
Please, find enclosed your original Certificate of Deposit in the amount of $3,000.00, and the signed
Assignment form which we have released.
If you have any questions, please call me at (408) 866-2165.
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cc: Suspense - 11 months
Permit #97-145
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H:\ WORD\PERMITS\97145FN(JD)
70 North First Street. Campbell, California 95008,1423 ' TEL 408,866,2150 ' FAX 408,376,0958 ' TOD 408,866.2790