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ENC2010-00111,.-~- CITY OF CAMPBELL ENCROACHMENT PERMIT e DEPT. OF PUBLIC WORKS (for working within the public X-Ref. File 70 North Flrst Street .right-of ay) Application Date Campbell, CA 95008 /I Applicat' n iratlonDae l Ph. (4018) 866-2150 Issued ~/~ APN Fx. (408) 376-0958 D Permit Expiration Date APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six (6) months if the permit is not issued. Application Fee isnon-refundable.) tFt~rm P rmit Nom w B. Nature of Work: ~ _. '~~ ~'~ ^„ V ~iYl~rv'~ S~~ ~ -ef C. Attach four (4) copies of an engineered plan showing the Iota ion and extent of the work, and four (4) co es of th 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 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 shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 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. Name of Applicant: V ~ N ~ L ~ Telephone: ~,{, p 8 ~, 7j' ~ 8 - 37 ~ 7 A. Work Address or Tract No.: ~ ,3 7~ E. 1 V GZ/1~/ l t~ n qVQ. Utility Trench Location: Is this work being done by the property owners at their own residence? r YES (~ NO The Appiicant/Permittee 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. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all damages arising out of the condition of any private improvements in the public right-of-way. ~ ~ Address: 20 L~ 2 TALL)/ R~l~D. S~-N ~'DS E ~ C.>~ ~ 5 ~ 22 E-Mail Address: ~ ____. 24-HOUR EMERGENCY PHONE NUMBER: 3 ~{ 8 ' 372.7 ~,-.~tnIDEN~T~-L~A~R~~y~-tm .co~+ ttog - Accepted: !('nntr~rtnrl (sign) s Name1 Date Date O S~IAL PROVISION 1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts ma specifically approved by the Inspector prior to cutting. 2. Pavement maybe cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A",unless otherwise approved by the Engineer. 3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public Works Department before starting work. 4. 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 has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO. 5. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be recorded. 6. Public Notification Requirements: 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES 5M0350! O U PERMIT APPLICATION FEE PLAN CHECK DEPOSIT 5 SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS °"~D 5 00 . CONSTRUCTION CASH DEPOSIT, En I?~ 3 PLAN CHECK&INSPECTIONFEE ~\ €r~i~ $- APPROVEDFORISSUANCE " " ' ~ For City Ergineer Permit Expires 12 Months After Date of Issuance O .._- CITY OF CAMPBELL ENCROACHMENT PERMIT X-Ref. File DEPT. OF PUBLIC WORKS (for working within the public 70 North First Street .right-of ay) / ~ Appllcation Date /' CempMI1,CA95008 Applicat' n iration Da e Ph. 0108) 866-2150 Issued ~ ~ APN / Fx. (4t18~ 376-0958 Permit Expiration Date iJ / APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six (6) months if the permit is not issued. Application Fee isnon-refundable.) _ ~ ~ ~~ i " - ~tUC 0 Permit N• A, Work Address or Tract No.: 13 7~ _E. l~a~~ ~ ~'on /we. _ Utility Trench Location: B. Nature of Work: ((.~~1~ ~,.fyl V• ~V~~ ~ IKJLJ v l I~I~UG( `~~ u.E~~- ~e..tv C. Attach four (4) copies of an engineered the rela~ on of thelproposed work to ex st ng surface and underground improvements. When approved Estimate of work. The plans shall sho by the City Engineer, said plan 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 shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 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. L~ .Telephone: ~ p 8 ~ 3~ g- 37 27 Name of Applicant: v ~N~ __ _ __ __ Address: ~-„~ ~ Z T U L~--1 t~ ~ ~~ - S•~t'N ~ S ~ _~ ~._1't ~ J ~ Z.2 _. E-Mail Address: ~;t~D~n-~~,(~~y~-ILl7 •~OM 24-HOUR EMERGENCY PHONE NUMBER: ~,~' -3 ~{ g ' 3 1 Z-~ Is this work being done by the property owners at their own residence? r YES (~ NO The Applicant/Permittee 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. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all damages arising out of the condition of any private improvements in the public right-of-way. ~7 /~ / I O ~_.~iu. Accepted: (sign) s Date rint Name) Date (Contractor) //I/ SPE IAL PROVISIONS: 1. Street shall not be open cut for underground installations. Minimum cuts ~ be allowed for connections or exploration holes. Such cuts m pecifically aoaroved by the inspector prior to cutting. 2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A",unless otherwise approved by the Engineer. 3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public Works Department before starting work. 4. 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 has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO. 5. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be recorded. 6. Public Notification Requirements: 7. -- AMOUNT R~)iIP N i O SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES $ O~ ~ © `~L,., PERMIT APPLICATION FEE `~.. O PLAN CHECK DEPOSIT 5~ ~ ~ SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS BCD ~ ~ZOp ^~ CONSTRUCTION CASH DEPOSIT,. €~~I $- PLAN CHECK & INSPECTION FEE r APPROVED FOR ISSUANCE or City E glneer Date Permit Expires 12 Months After Date of Issuance -. t I ~ I I I i ~~ II -~ 're4 ~ III ~;~.'.JI+ s`~''i ~ ~cjl~.~'r~i sali3ll'J':.~"',r:.w ~: i t'•"'t c ,~7 rjfNt,,l ~ ~~siU~;~ ~,1L s ! CCUl~d ~~-r. :,ili1~... (Jri; ~Ji'Si !dS"~: ~~a?s~: e. I, s.i4aCt.~r''< tit? '~14~~tlPdT tNfifi ~~ ..#~B~i:.?: ~-~~ a}.;1; .- r3`_'E%;.t.ti! y v:.' II G, ;.?~31 7~'0 ~Ht~ ...l:, C.!.: ~'~, IiCC V:;ii .... i I ~•ul1 ,i i t`d¢, ! \~~ I ~~~' ~'-- ~ GENERAL PERMIT CONDITIONS 1. A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency call-out, overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. 3. Refund or the cash deposit balance and refund or cancellation of the Faithful Performance Surety 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, bus stops, fire hydrants, and water valves. 6. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures, detours, and street closures. This plan must be reviewed and approved prior to any lane closures. 7. A Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated 1990, available at Caltrans. Traffic control equipment shall include Type II flashing arrow signs if required. 8. Replace as directed by the City Engineer any damaged or removed improvements in accordance with City Standards and Specifications at the sole expense of the Permittee. 9. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements. 10. 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. 11. Adequate signing and barricading is required on thejob site. Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost (including all labor and materials) against the cash deposit. 12. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 13. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m. 14. No storage of materials or equipment will be allowed near the edge of pavement, the traveled way, or within the shoulderiine which would create a hazardous condition to the public. 15. 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 bylaw. 16. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 17. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 18. Call back (call out) due to emeregencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence. 19. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. 20. If the public interest requires a modification of, or a departure from the plans and specifications, the Ciry shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made for City-owned or maintained facilities. 21. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and phone number. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions. Applicant Contractor (Print Name) n7~23~1~ Date: i~ / ~~ Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev. 3/08 PUBLIC WORKS DEPARTMENT LAND utvtLVrmen i ~ ~ rwrrw r«~.c~r i Effective July 1, 2010 e A I ~ ~ O l '~+ O~ ~ j TO: Clty Clerk . ~ PUBLIC WORKS FILE N PROPERTY ADDRESS ~ r ' . Please collect & recei t for the followin monies: ~ t1NT 0 .. { ; . ,,_ ncroac men ermi ica ion ee Non-Utili Encroachment Permit 350.00 Minor Encroachment Permit <s~o 000 200.00 Initial R-1 Permit N/C R-1 Permits within Two Year Period $200.00 * 2203 lan Check De osit of E is Estimate - $500.00 min " r an - ermits node osit re uiied 4722 Gradin & Draina a Plan Review Famil Lot l Si 00 $250 n e f < 10 000 Sit . 00 750 . s. e < Acre Z 10 000 s f Sit . $1 000 00 . . e Z 1 A Sit . 00 $1 500 cre e . Plan Check & Ins ection Fee Non-Utili * En r. Est. u to $250 000 14% of En ineer's Estimate 4722 En r. Est. 2 250 000 Actual cost +20% Admin Overhead Min 35 000 De osit * 2203 Emer enc Cash De osit 4% of En r. Est." 500 min/$10 000 Max * 2203 Faithful Performance Securi FPS 100% of ENGR. EST.' * 2203 nd Materials Securi L b 100% of ENGR. EST.' 4721 or a a Drainage Area Fee Per Acre St R-1 $2 120.00 orm (MultrRes $2 385.00) All Other 2 650.00 47 2 Parcel Ma 4 Lots or Less 3 600.00 + 80/lot 47 ina Tact a 5 or More Lots 400.00 + 108Aot * 2203 Monumentation Securi 100% of ENGR. EST. 4920 Parkland Dedication Fee 75%/25% Due U on Cert. of Occu anc 4722 t Line Ad'ustment L $1 400.00 4722 o Vacation of Public Streets & Easements $2 250.00 ' 4722 Certificate of Com liance $1 700.00 4722 rtificate of Correction C $500.00 4722 e A eal Filin Fee 200.00 4722 ta Fee er si nature N $10.00 4722 o Assessment egrec]ation or Reapportionment First Split $800.00 Each Additional Lot 250.00 511.7424 Postage ___ : 4728 Traffic Flow Ma Dail Traffic Volumes 34.00 472 i nal imin In ormation 72.00/Hr 4 71 Truc ermits 16.00/ er tri 472 No arkng iyns 1/each or 25/100 ~ Other Please eci 'Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. OL ""'Actual Cost Plus 20% Overhead (Non-Interest bearing deposit) TOTAL $ • NAME OF APPLICANT NAME OF PAYOR PHONE '' ADDRESS ZIP V .. ~ FOR fZ~DEI~DE81(. ~' CITY CLERK ~:~ s~ , ~'~ ONLY ~~ D r ~~Recisf ~ eposits,taead~ye low:capy:,to`~ ~Ian~.Check e: ' :', ~ , s "Date) -Ir~ltfals -- i --~ _,} m ~. ~~ ..r~~T O TGAGCIr GCf`CIDT " PUBLIC WUKIS, utrHrc I InCIV I Lhlvu ucv ~~~+~ ~.~~....~....^...- • ----.. . Effective July 1, 2010 ~J~ (/'~ ~ (~ I ~j 1 TO: City Clerk PUBLIC WORKS FILE N0. ~ Vl~[~ PROPERTY ADDRESS 1" Please collect & receF t for the followin monies: _ AMOUNT A~:CT. 1TEM .LAND :DEVELOPMENT ncroac merit ermit ication ee Non-Utili Encroachment Permit $350.00 Minor Encroachment Permit <$~o.ooo $200.00 ~. Initial R-1 Permit N/C ' Subse uent R-1 Permits within Two Year Period $200.00 ~ i 2203 Plan Check De osit 2% of En ineer's Estimate , $500.00 min Utility and R 1 Permits no deposit required _ I 4722 Gradin &Draina a Plan Review I Sin le Famil Lot $250.00 f 00 $750 . Site < 10 000 s. . A 00 000 $1 cre Site z 10,000 s.f. < . , 00 $1 500 Site ? 1 Acre . Plan Check & Ins ection Fee Non-Utilit i ' ' Ci' ~ "220 En r. Est. u to $250 000 s Estimate 14% of En ineer ~ r 8722 En r. Est. ?$250.000 Actual cost +20% Admin Overhead Min $35.000 De osit 2203 Emer enc Cash De osit 4% of Enqr F,st' ($500 min/$10 000 Max) ` ~ _ 2203 Faithful Pertormance Securit FPS i 100% of ENGR. EST. ' • r and Materials Securi ~ b L 100% of ENGR. EST. - 2203, o a Per Acre f A 00 R-1 $2 120 i 4721 ee rea Storm Draina a . (Multi-Res $2 385.00) All Other $2850.00 4722 1 Parcel Ma 4 Lots or Less $3.600.00 + $80/lot 4722 Final Tract Ma 5 or More. Lots $4,400.00 + $108/lot 2203 Monumentation Securit 100% of ENGR. EST. 75%/25% Due Upon Ce F ti di of Occu anc rt 4920 on ee ca Parkland De . 4722 Lot Line Ad'ustment $1.400.00 & Easements St t bli f P 00 250 $2 4722 ree s c u Vacation o . . fi f C $1 700 00 4722 ance om Certificate o . ti f C 00 $500 4722 on orrec Certificate o . 4722 A eal Filin Fee $200.00 4722 1 Nota Fee er si nature $10.00 4722 Assessment Segregation or Reapportionment 1 First Split $800.00 Each Additional Lot $250:00 511.7424 Postage __ _ TRAFFIC 4728 TraffEC Flow Ma Daii Traffic Volumes _, $34.00 4728 Si nal Timin Information $72:00/Hr 4271 Truck Permits $16.00/ er to 4728 No Parking Signs $1leach or $251100 MISCECEAt~EOt]S ~ 1 Other (Please S eci }~-;rl "Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. 71'1 V~/ ""'Actual Cost Plus 20% Overhead (Non-interest bearing deposit) . ~J l/ TOTAL ~ NAME OF APPLICANT NAME OF PAYOR PHONE ZIP Z' ADDRESS FOR ~REL^EIVED~ Y CITY CLERK ONLY ~~ Date ~' ~ Recei t-#- ~~ '"For Pian.Check~and.Cash Depos[ts,send~yeliow.cppy~to Finance. ..~ x.In~~•tailCiftitiais ~ i-tjvn+ w 00 0 -e ~O R r-- e G1 G~ G7 ~ G~ G~ .; .:. O~ O~ N N J J k J J lA lA ~ O ~ O ~ ~ N ~ N ~ N N N N 0 0 0 0 0 0' ,F .-. ~.. .-~ ..r ..-• •-• p i f~t~=~t x ° ~ ' ~ ~ .~ N lA N N lJ~ W ~`. O ~C O O ~O Ni `` O oo O O oo O ~ 0 0 0 0 O .: r-. ~ i ~ ~ N .-. J N t!~ ~ Qy~ N ~ O o O O .O O O ~ ~ ~ O O p A 0 0 0 ~ `~ ~~ INSURANCE REQUIREMENTS CHECKLIST Permit # ~ NC2©ip -C~11 I 13`1 y ~ , Harm I+cjn. IAV~, . 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 Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: J~ $1,000,000 per occurrence, and jst $1,000,000 general aggregate limit applying separately to the project, or ~ $2,000,000 general aggregate limit. ~` Policy expiration date y ~~ ~I ~. " Automotive Liability: "Any Auto" checked on certificate p( $1,000,000 per accident for bodily injury and roperty damage +,~( Policy expiration date ~~'C ~~13~2 ~ ~ly~/ Workers' Compensation and Employer's Liability G ~~ ~ ~ Waiver of Subrogation clause Q-~ ~ $1,000,000 per accident for bodily injury or disease ~ Policy expiration date ,,~ ~~/ 2 Course of Con. Completed ink cial Provisions) the project date RecLuired Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement ~ 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. ~,q~ ~ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail '' ~ ~~~~ such notice shall impose no obligation or liability of any kind upon the company, its 95 ~~~~ agents or representatives". M~ N~tl ins ('o, -JAIC'~3~19~14 ~~ ~ Workers Compensation Insurance Sheet Submitted ~ C~ iD~__f~~.__ 1~( For General Contractor At ` X I ~s I i ,~ For Developer or Owner Peer'IesS I ng . Co . N A~ IC ~2yt 9 8' Acceptability of Insurer(s) ¢(' Insurer(s) has current A.M. Best business in the State of California. ~( Campbell Business Licens~# ~,2 Insurance Certificate Revtewed ~ Copy of Insurance Certificate ~ /gin/~ 1~ 411 in tickler file one month prior to expiration. A : xv cA 1D ~i~y-y Rating of A:VII and is authorized to transact J:\FORMS\Templates\]nsurance Requirements\Insurance Requirements Cklist.doc (Rev 05.10) CERTIFICATE OF LIABILITY INSURANCE OP ID sL ~~ CERTIFICATE DOE8 NOT AFFIRMATIVELY OR NEGATNELY AMEND. EXTEND OR ALTER THE COYERAtNE AFFORDED BY THE POLICES BELOW, THIS CERTIFICATE OF NWStRiANCE DOE8 NOT CONBTITt1TE A CONTRACT BETWEEN THE ISStH(tKi NY$URER(S), AUTHORIZED REPRESENTATiifE ORPRODUCER. AND THE CERT'IFICAT'E HOLDER. the tem>: slid condltlons of tM policy, certain poNeies my- regWre en ~ A statarlent on tlds wrtllicate does not coniir ripMs to the caelfBcale holder in`liw or such endorsement(s). PRODUCER NAME: Boaauto i `Associates Insurance 1'10 ' NO One A1madlen Blvd Suite 810 San Joae CA 95113 cusTCMERIDS COB$C-1 Phone:800-989-8712 Bax:408-288-7130 ggNt;~ERAaIE NAlcs INSURED JiJURERA: Idt. Havel Insurance Co. 37974 2470 SonsNi~ahc~t~i B~lnid Ste D mss: °°1°'m >I,Qi• xa"="°' c°'~. 10836 Caa~bell CA 9~~08 INSURERC: Peerlssa Insurance C 24198 INJURER D INWRER E NUMBER: ~~ SEEN ISSUED TO THE NVSURED NAMED A9WE FOR THE POLICY PERIOD MIDK.ATED. NOTYVITHSTAND1Nd ANY RECUNZ9YENT, TERM OR CONDITION OF ANY OONTRACT OR OTHER DO(XINEKT YVITH RESPECT TO WENCH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE NVSURANCE AFFORDED BY THE POLICES DESCRMlED HERENV IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDI110NS OF SUCH POLICIES. LNIINTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANKS. TYrE Of OrJURANCE NIMt FOLX:Y NUMBER ~TJ OIENERAL LIABNJTY EACN OCCURRENCE t 1 000 , 000 A X COMMERCIALOENERALLIABILRY ffiOLO173302 04/01/11 04101/12 PREMAOisES oocunsnoe f 50,000 CLNMS-MI1DE ®OCCUR MED EXP (My one pMaon) S 5 , OOO X PERSONAL b ADV INJURY S 1 OOO OOO 6ENERALAOORE(iATE f 2 OOO OOO OEN'L AOOREOATE UMR APPLIES PER: PRODUCTS • COMP/OP A00 S 2 , OOO , OOO POLICY X P ~ LOC i ,~ Ly~y COMBINED SgJOLE OMIT S 1, OOO , OOO B X ANY AUTO BA2913012 03/13/11 03/13/12 BODILRV(Perperaon) S ALL OWNED AUT03 BODILY rJJURY (Psr eocidenq S BCHEDULED AUTOS PROPERTY DAMAOE : NIRED AUTOS ~ ~e~ NON-OWNED AUTOS f S A uMBRELLALIM X OCCUR ~CL0370071 04/01/11 /01/12 EACH OCCURRENCE s 5 000,000 ~( EXCEJJ LIAR CLAeAS•MADE AfiOREf3ATE S 5 OOO , OOO DEDUCTMLE S RETEI~fTION i i ' TORY LIMBS ER LIMeMJTY Y / N AND EA~.OYeRe ~p~yE--~ EL. EACH ACCIDENT i ~ IX~U~~ U / A EL. DISEASE - EA EMPLOYE S ~~ yw, ~ DESCR1Pf10N OPERATIONS bebw EL. DISEASE - POLICY LJAR S C Property Section CBP8325157 09/17/10 09/17/11 BPP/D1t:D 21, 432/500 C t )Floater CBP8325157 09/17/10 09/17/11 DEadePT1011 OF OFERA41 L4O2CATION! 1 VENXxEJ (Ath}eh~ACORD 101, Ad~Tlond RennAo acM1duh, N ewn ap~ee l e JG 95008s'~ Ci~ City~ofrCn' 3~ C~an~ia h nqulred) oaeA t Av~~~~ its - ~ s i sddition~ ~ S ~ ca red X11 rs nt. I~su~anae s r non-aon $ ~ ~ D - tor Y ~C~~ Olll i t X y notice or eon paymen day notice of can~llatioa. 1 3 prem um. o w~~x~~u~~rr u~~ nen ~'~ ~ RAINRCI 1 ATIAN I SHOULD ANY OF THE ABOVE DESCItllN~ POUdEa BE CANCNN.L~ NtEFORE City of Campbell APR ~ P~l,ia Morks Depart>~t 4 Z O THE EXPIRATION DATE THEREOF, NOTICE WN1 BE DENJVEItED IN ACCORDANCE wml THE POLICY FROVISIONS. JOanne D ~ ~InbrOSli qqpp..~~~ !' 70 North lirst Stree,~l ~1/['~.- /-UTHOR~D REPREJENTATNE Camphell CA 95008-1423 , V ~IJI'Ed!'T~.o .-...~~.....-..............a..~ .~..~. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD OP ID: CE '4`,°RO~ CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 05/04/11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFER8 NO RKiHT3 UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERT~ICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATNE OR PRODUCER, AND THE CERTIFICATE H~DlE 1 PORTANT: N the certlllcate holder is an ADDITIONAL INS ,the polk:y(les) must be endorsed. It SUBROGATION 18 WAIVED, subject to the terms and conditions of the polk:y, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder fn qeu of such endorsement s . PRODUCER 408-626-6100 Leavitt Pacific Ins. Brokers 408-558-1 Lk~srlse 4MOD78874 P"o~ 888 CartlpbNl Technology Pkwy '~L Camabe , CA 88008 Dan iL aaww PRODUCER COBEC-1 . INSURER S AFFORDING COVERAGE NAIL • INSURED COBS Construction, IrIC. INSURER A:WiIliamfbUr National Ins. Co. 25780 2470 Winchester Blvd. Suite D INSURER B: Campbell, CA 95008 INSURER C INSURER D INSURER E CnVFQAAFA CERTIFICATC NIIYRFR• REVISIAN NUMRER_ THIS IS TO CERTfFY 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 ISSUEO 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 CWMS. iNaR TYPE DF INiURANCE POLICY EFF PO Y EXP LIMITS GENERAL LIABILnY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY PR MISES occwrence S CLAIMS-MADE ~ OCCUR MED EXP (An one rson) S PERSONAL 6 ADV INJURY S GENERAL AGGREGATE S OEN'L AGGREGATE LIMB APPLIES PER: PRODUCTS - COMPlOP AGG S POLICY PRO LOC s AUTOMDNLE LUUALITY COMBINED SINGLE LIMIT (Ee axidsM) $ ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accidsnq S SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE (Per saidenq S NON-OWNED AUTOS s s UMBRELLA LU1B OCCUR EACH OCCURRENCE S EXCEeSLU1B CWMSMADE AGGREGATE S DEDUCTIBLE s WORKERSCDMPENaATNN~I ' ~( W A O - A AND EMPLOYERi LU1aILITY ANY PROPRIETORIPARTNER/EXECUTIVE Ya C0576033 Oti/01/f 1 06/1)1/12 EL. EACH ACCIDENT S 1,000,0 OFFX;EWSIEMBER EXCLUDED? (MendeLOry In NH) N ! A E.L. DISEASE - EA EMPLOYE S ~,~~~,~~ M daoriW under E.L. SEASE -POLICY LIMB 1,000 OO H~Iroon~Ave.~Campbely~;ilE9(60~08Cob~eJobe44~lAilan ~~ule'NmonspacelsnqulrW) tal-Dr. Trap walv~r of su to City, City of mpbNl Radev t Agency, Its off'kers, officials, employeesd,volunteers EtJC2,01©'bv (I 1 reo~nerrere unr neo rteNe~l 1 eTlnlu CITYO-4 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of Campbell THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN Departrrlent Of Publk: WOrkS ACCORDANCE WITH THE POLICY PROVISIONS. 70 North First Street Campbell, CA 91;008 AUTHORD7:DREPRESENTATIVE ~~~~~~~ ®1888-2008 ACORD CORPORATION. All rents reserves. ACORD 28 (2009/08) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY we oa o3 os (Ed. 4-84) WAVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you pertorm work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be °k of the California workers' compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description CITY OF SANTA CLARA BUILDING MAINTENANCE C/O EBIS INC BLDGS B & C 1705 MARTIN AVE, SANTA CLARA, CA JOB:SEISMIC RETROFIT MNTN This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (Ttw intortnation below b required only when this endorsement is issued subsequentto preparation of the policy.) Endorsementfffective Policy No. WC 0576033 Endorsement No. 001 Insured COBS CONSTRUCTION INC Premium $ 17, 258.00 Insurance Company WILLIAMSBURG NATIONAL INS CO Countersigned by CA WC 04 03 Os (Ed. 4-84) Raorox~`rwas~.s - Page 1 of 1 Jeanine Grundman From: Carlyn Eaton [Carlyn~lpib.com] Sent: Wednesday, May 04, 2011 4:17 PM To: Jeanine Grundman Subject: Cobe Construction Attachments: Copy of Page 10.PDF Attached is the renewal certificate for Cobe. Let me know if you need anything further. Thank you for the opportunity to be of service. Carlyn Eaton, Account Manager Leavitt Pacific Insurance Brokers, Inc. Lic. #OD79674 695 Campbell Technology Parkway, Suite 250 Campbell, CA 95008 Direct PH 480-306169 FAX 408-558-1600 *** eSafe 7 scanned this email for malicious content *** *** IMPORTANT: Do not open attachments from unrecognized senders *** 5/4/2011 Policy Number: MGL0173302 Mt. Hawley Insurance Company ~` THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS (FORM C) This endorsement modfies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART (If no entry appears below, iMormation required to complete this endorsement will be shown in the Dedaretiorss as appli- cable mthisendorsement) WHO IS AN INSURti:D (Section In is amended to include as an insured the person or organization shown in the Sched- ule, but only with rasped b liability arising out of "your work" for that insured by or far you. To the extent requinad under oontrad, this policy will apply as primary insurance to additional Insureds scheduled bekniv and other insurance whk~s may be available to such additional insureds will t>te non-conMbutory. S~ctton IV„ Condition 4., of this policy is amended acxxxdingly. $CHF~ULE Name ofi Person or Organiudon: All persons or organizations where required by written contract. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. CGL 216 (04!98) Page 1 of 1 Insured /-'~ ~'` ORL7r °ATe (MMloawvq CERTIFICATE OF LIABILITY INSURANCE ~~ $L 04 O1 it TIES CERTIFICATE 18188UED Ati A MATTER OF N~FORMATION ONLY AND CONFERS NO RKiHTB UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFSiMAT1V~Y OR NECiATNELY AMEND, EXTEND OR ALTER THE COMERAtiE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF WSURANCE DOE8 NOT CONiTITUTE A CONTRACT BETWEEN THE ISSUIIAi INSURER(SI, AUTHORIZED REPRESENTATNE OR PRODUCER, AND THE CERTIFICATE HOLDER. an rr7u , the terms and corlditlons d the P°NcY, certain policies mh- nquke en endors7sner7t. A shterrrerlt on tl7is certlticabe does not ooMer ri~flts to the cerllBcs~ holder in lieu or such endorsSrrlwlt(si. ~OD11~ NAME: Bozzuto i Associates Insurance I'7o One Almaden Sled Suite 810 ADDREeB: San Jose CA 95113 cusTprg7ms~ COHiC-1 Phone:800-989-8712 lax:408-288-7130 INZ~eIAFFde]INOCOVERA°E NAIC• nED INSURERA: tdt. Hawl Insurance Co. 37974 C Construatioa, Inc. lti a r Blvd Ste D t INSURmee: ooia.. s.e>,e sa..raoo. corp. 10836 ~ 9 0 e Campbell ~8 INSURERC: Peerless Insurance C 24198 INeUREIt D erSURER E eNitll7llt F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: INDICATED. NOTNIITHSTANDed(3ANYREQLIIREMENT. TERM OR CONDITION OF ANY OONTRACT OR OTHER DOCUMENT WITH RESPECT TO WFNCFI THIS CERTIFICATE MAY ~ ISSUED OR MAY PERTAIN, THE prSURANCE AFFORDED BY THE POLX~ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LaaTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLANKS. TYPE of INSURANCE ^~sle POLIrw NuMeER Larrrs °~ ~~ EAgi OCCURRENCE s 1, 000 000 A X COMMERCIAL GENERALLIA81Lm ffi(iL0173302 04/01/11 04/01/12 PREMISES Eaooounenos s 50,000 cwMS.MADE ®occuR MED EXP (Any one psiaon> s 5 , 000 g PERSONAL a ADV INJURY s 1 000 , 000 GENERALACiGREGATE i 2 000 000 GErrL AGGREGATE uMIT APPLIES PER: PRODUCTS - COMPIOP AOG s 2 , 000 , 000 POLICY J[ J~ LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 6~ s 1 000 000 B X ANYAUTD BA2913012 03/13/11 03/13/12 t «+9 BODILY INJURY P , , ALL OWNED AUTOS ( er pneon) S SCHEDULED AUTOS BODILY r~JURY (Per aceidenq s PROPERTY DAMAGE : HIRED AUT03 (Per aeddenq NON-0WNED AUTOS s s A uMeRELL'~`LU1B X OCCUR i~.0370071 04/01/11 /01/12 EACH OCCURRENCE s 5 000 000 X EXCE3SLYIB CLAIMS-MADE AGGREGATE s 5,000 OOO DEDUCTIBLE s RETENTION s s AND lMPLOYERS' LIABILITY TORY LeMT3 ER Y / N ANY PROPRIETORIPARTNERIEXECUtIV~-( OFFICERIMEMB R EXCLUDED? ! A E.L. EACH ACCIDENT S u E (MendeEOry In NH) E.L. DISEASE - EA EMPLOYE s M yyeNs,, dnc~ibe under DE9CR>PIION OF OPERAT10N3 bebw E.L. DISEASE -POLICY LIMIT i C Property 3eation CBP8325157 09/17/10 09/17/11 BPP/D>6D 21, 432/500 C E nt !loafer CBP8325157 09/17/10 09/17/11 DEeC111PTI0N OF TIONB / LOCATIONS t VEHICLES CA~h ACORD 107, Add7eonN Remab 8dndub, a vole speee b Ire1 lt=: rmit C2 10-00 11, 1374 8. amiltoa Ave., C 11, 95008. 1 ~ ~ Frork in is ri hht-ol-way. Ci o Campbell, City o! C~~~lai~eve ap~eat , i t s 1 s i #,~ a are aame3 ~s tiona~l. ~trfi r~,~ ~ ~ ty s p e ,~CGL2~/98~. I sy ano¢ isfprsr ~Y, ANC-?-O IC7 - F~ I I ~ aonao tory: 30sdayaaoltia8 aanee a on. 10 ~ notice or non CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES sE CANCELLED BEFORE CI'1'YOlC TFe? EXPgtATION DATE TIIER~F, NOTICE WILL 8E OBLIVBItlD IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Campbell Attn: Public Morks Department 70 1Qorth lir:t Street Campbell CA 95008-1423 ACORD 25 (20011/09) The ACORD name and logo are registered marks of ACORD ~-- -- . Page 1 of 1 Jeanine Grundman From: Ana Rios Sent: Tuesday, June 07, 2011 11:40 AM To: Jeanine Grundman Subject: RE: mistake on pw receipts Well then fix the form!! :) I will transfer the funds. Ana From: Jeanine Grundman Sent: Tuesday, June 07, 2011 11:37 AM To: Ana Rios Cc: Joy Francois Subject: mistake on pw receipts Hi Ana, There is an acct. number mistake on the receipt customers bring down to finance that is causing a problem on the General Fund Refundable Deposit List. The mistake exists in the line for the Plan Check and Inspection Fee (Non Utility) Engr. Est. up to $250,000.00. It should be acct.4722 instead of 2203. We noticed this when we found a mistake in a file for encroachment permit ENC2010-00111, 1374 E. Hamilton Ave, the payer being Vinh Le. Please move the $4,200.00 Plan Check fee from acct. 2203 into 4722. It is not a refundable fee. If you have any questions please let me know. Hope you are having a good day, Jeanine 6/7/2011 Policy Number: MGL0173302 Mt Hawley Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OW~I~RS, LESSEES OR CONTRACTORS (FORM C) This endorsement modfies insurance pnnrided under the fdlawing: COMMERCIAL GENERAL LIABILITY COVERAGE PART (tf no entry appears below, information required to oomplete this endorsement wNl be sham in the Declarations as applh cable tp this endorsement. VYFIO IS AN INSURED (Section If) is amended to inclu~ as an insured the person ar organization shown in the Sched- ule, but only with respect b liab~ity arising out of "your work" fnr that insured by or for you. To the eoctent required under oontrad, this policy wNl apply ~ primary insuranoa to additional Insureds scheduled below and other insurance which may be available th such add4ional insureds will be non-cnntribubry. Sr+ction IV., Condition 4., of this policy is amended accordingly. SCHEDULE Nuns of Parson or OrguYzation: All persons or organizations where required by written contract. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. CGL 216 (04/98) Page 1 of 1 Insured tiE DATE (MM/DD/YYYY) ' OP ID SL ~R~ CERTIFIG i E OF LIABILITY INSURA . ~ . _ 03 O1 11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED ~ REPRESENTATNE OR PRODUCER, AND THE CERTIFICATE HOLDER. t e ce I cafe o r Is an , t e po Icy les must en or , su )ect to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: s Insurance t 6 A i t B ac No, Ext: 408-371-3400 (Arc, No): 408-371-340 e ssoc a ozzu o One Almaden Blvd Suite 810 ADDRESS: San Jose CA 95113 cusroMERiDx: COSEC-1 Phone:800-989-8712 Fax:408-288-7130 INSURER(S)AFFORDINGCOVERAGE NAICt INSURED INSURERA: Mt. HaWle Insurance Co. 37974 CObe COnStruCtiOn, Ina. INSURER B: Golden Yagle iasuranae Co:p. 10836 2470 S. Winchester Blvd Ste D Campbell CA 95008 INSURERC: Peerless Insurance Co an 24198 INSURER D INSURER E INSURER F f COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDDIYYYY) (MMIDD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1 , OOO , OOO A X COMMERCIAL GENERAL LIABILITY MGL0170140 04J01/~.fl ~~/Dl/11 PREMISES (Ea occurrence) 8 50 , 000 CLAIMS-MADE ~ OCCUR MED EXP (Any one person) S 5 , 0 0 0 X PERSONAL & ADV INJURY b 1 , OOO , OOO GENERAL AGGREGATE S 2 , OOO , OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 2 , O O O , O O O POLICY X JECT LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMB $ 1 000 000 $ ANY AUTO BA2913012 03/13/11 03/13/12 (Ea accident) BODILY INJURY (Perpersan) , , S ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ S A UMBRELLA LIAR ~[ OCCUR 1~DCL0369678 04/Ci/10~ 0#!41/li EACH OCCURRENCE $ LO , OOO , 000 X EXCESS LIAR CLAIMS-MADE AGGREGATE 8 lO , OOO , OOO DEDUCTIBLE $ X RETENTION S $ WO RKERS COMPENSATION IABILITY S' TORY LIMITS ER AND EMPLOYER L Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT 8 a OFFICERIMEMBER EXCLUDED? / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ H describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMB S C Property Section CBP8325157 09/17/10 09/17/11 BPP/DED 21,432/500 C E i nt Floater CBP8325157 09/17/10 09/17/11 DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Adach ACORD 101, Additlonal Rsmarks Schsduls, if moro space is roquirod) RE: COBS Job tF 4426, A.ilan Dental - Dr. Tran, 1374 E. Hamilton Aveaue, enc its e t A ll R d l it f C b th y, : opaten g e e ev y o amp e C C , CA 95008. The City, d volunteers are named as additional insured per l f oyees an ficers, eemmp~ o attached encrorsement. Insurance is rimary and non-contributor. ~~,~ ~ O /// t i o prem um. 30 day notice of cancellation. 10 tray notice for non paymen CERTIFICATE HOLDER CANCELLATION !,`" SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITYOFC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Campbell ACCORDANCE WITH THE POLICY PROVISIONS. Public Works Department Joanne D' Ambrosia AUTHORI~D REPRESENTATIVE 70 North First Street Campbell CA 95008-1423 . U ~~~QJIB ACQ~~ORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD i~ CERTIFICATE OF LIABILITY INSURANCE OP ID sL CERTIFICATE DOES NOT AFFB2MATNELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. e an mu .su o the terms and conditions of the policy, certain policies may req~re an endorsement. A statement on this certificate does rat confer rights to the certificate holder in lieu of such endorserrleM(s). PRODUCER NAME Bozzuto 6 Associates Insurance Arc No, Ext: 408-371-3400 (AIC, No} 408-371-340 One Almaden Blvd Suite 810 AoortESS: 3a,n Joae CA 95113 CUSTOMER IDr1t COBEC-1 Phone:800-989-8712 Fau:408-288-7130 INSURER{S)AFFORDINGCOVERA(iE NAlct INSURED INSURERA: ldt. Hawle InauranCe Co. 37974 Cobe COnatruCt].On, Inc. INSURER B: cioldwn iagl. Iasuraaa. corp. 10836 2470 3. Winchester Blvd Ste D Campbell CA 95008 INSURERC: Peerless Insurance C an 24198 INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:. HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIS LOW VE BEEN ISSUED TO THE INSU ED D OR THE POLIOY PERIOD INDICATED. NOTWITHSTANDNJGRNY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFlCATE MAY !~ ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE Of INSURANCE INgR yyyp POLICY NUMBER (MNYDDIYYYY) ( LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1 , OOO , OOO A X COMMERCIAL GENERAL LIABILITY ffiGL0170140 04/01/10 04/01/11 PREMISE S 50,DD0 CLAIMS-MADE ~ OCCUR MED EXP (Any erne person) S 5 , 0 0 0 X PERSONAL 8 ADV INJURY S 1 , 000 , 000 GENERAL AGGREGATE S 2 , OOO , OOO GEN'L AGGREGATE LIMB APPLIES PER: PRODUCTS - COMPlOP M36 E 2 , D D O , D D O POLICY X jE~ LOC S AUT OMOBILE LUIBILITY COM&NED SINGLE LIMB (Ea accidentn) S 1, 000 , 000 B X ANY AUTO BA2913012 03/13/11 03/13/12 BODILY INJURY (Perpsraon) S ALL OWNED AUTOS BODILY INJURY (Psr accident) S SCHEDULED AUTOS PROPERTY DAMAGE S HIRED AUTOS (Per accrdsnh NON-OWNED AUTOS s S A UMBRELLA LIAR X OCCUR >~Q.0369678 04/01/10 04/01/11 EACH OCCURRENCE s 10 , 000 , 000 X EXCESS LIAB CWMS-MADE AGGREGATE S lO , OOO , OOO DEDUCTIBLE S X RETENTION S L 1NO AN R COMPENSATION MPLOYERS' LIABILITY D TORY LMAfTS ER Y / N E ANY PROPRIETOR~ARTNERIEXECUTIVE~ ~ A E.L. EACH ACGDENT S OFFICER/MEMBER EXCLUDED? U {Mamle6ory In NH) E.L. DISEASE - EA EMPLOYE S r describe under DESCRIPTION OF OPERATIONS below E.L DISEASE -POLICY UMR S C Property Section CBP8325157 09/17/10 09/17/11 BPP/DLD 21, 432/500 C 8 i nt Floater CBP8325157 09/17/10 09/17/11 DESCRIPTON OF O !~~-: ~,v r' c~ 101 arks sc¢edule. N mon apace k requi I2E: Permit W>ji- 1, 3 . '' C~~e11, CA 9 008. All Ci ty oy C~e11 Redev~el work in pub c ri~~ttay. City o 1 meant ncy, its 3ffi<xra, to s 6 ua rs are name3 as additional insureds as respects liabilit pir CC~L216(04 98). Insurance is rimary t o r non-pay. noncontributory. 30 day notice of cancellation. 10 day notice f CFRTIFICOTF HAI rfFR CANCELLATION SHOULD.ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITYOFC THE EXPNtATK~W DATE THEREOF, NOTICE MILL BE DELNERED IN ACCORDJINCE WITH THE POLICY PROVISIONS. City of Campbell ~ Attn: Public Worker Depar 70 North First Street Campbell CA 95006-1423 tmen* /~ I'~7 (`~/_ AG ~>~ ` AUTNORI~DREPRESENTATNE -~"Y (,~ ~ -~) ~ro vl~.+~~,~,(~irwl Ivly. r-n nBn~s ressvrva>ti. ACORD 25 (2009/09) The ACORD ~ '"! ~~o are registered marks of ACORD ~S r-. Policy Number: MGL0170140 Mt. Hawley Insurance Company THIS ENDORSEMENT CHANC~~S THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ~- OWNERS, LESSEES OR CONTRACTORS (FORM C) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART -- - (If no entry appears below, information required to complete this endorsement will be shown in t e ec arations as appli=- cable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Sched- ule, but only with respect to liability arising out of "your work" for that insured by or for you. To the extent required under contract, this policy will apply as primary insurance to additional insureds scheduled below and other insurance which may be available to such additional insureds will be non-contributory. Section IV., Condition 4., of this policy is amended accordingly. SCHEDULE Name of Person or Organization: All persons or organizations where required by written contract. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. CGL 216 (04/98) Page 1 of 1 Insured -:, '~ OR~ DATE pBrlDD~mrn. CERTIFICATE OF LIABILITY INSURAI~E ~~1 it e 1 Leavitt Pacific Ins . Brokers License ~OD79674 695 Campbell Technology Pkwy ONLY AND CONFERS NO RI UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Campbell CA 95008 Phone: 408-626-6100 Tax: 408-558-1600 INSURERS AFFORDING COVERAGE NAIC INSURw INSURER A: TRillia~basq Ilatieeal ms. co. 25780 INSURER B: a IIna . tru a tio INSURER c. gg t }~e ivd. Suite D x~Gs ~ INSURER D: 95 08 Campbe IN9lNtER E: COVERACiEB THE POLK~ES OF M~URANCE LISTED BELOW HAVE BEEN ISSUED TO THE NfSURED NAMED ABOVE FOR THE POLICY PERIOD NVDICATED. NOTNRTHSTANDNG ANY RE(iIAREMENT, TERM OR (X~PIDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHK~1 THIS CERTIFICATE MAY 8E ISSUED OR MAY PERTAMI, THE INSURANCE AFFORDED BY THE POLKXES DESCRIED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLK~ES. AGGREGATE LMTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAl~AS. LTR TYPE OF SiSURANCE POLICY NUMBER DA DA uMTTs oE~ LlAelurr EACFI OCCURRENCE f CeNMAERGAL GENERAL UABLRY PREMI ~ ronos s CWMS MADE ~ OCCUR MED EXP (Any ens person) S PERSONAL 3 ADV INJURY f GENERAL AGGREGATE f GEN'L AGGREGATE UMR APPLIES PER: PRODUCTS • COMP/OP AGG f POLICY ~ LOC Aur DMOeILe LIABILITY COMBINED Sk.IOLE uMIT ANY AUTO ~, s ALL OWNED AUT05 BODILY NJURY SCHEDUU~AUTOS ~~) f HIRED AUTOS BODILY MJURY NON-OWNED AUT06 ~ f PROPERTY DAMAGE (~ ~ f aARAOE LUIBILITY AUTO ONLY • EA ACCIDENT f ANY AUTO OTHER THAN EA ACC f AUTO ONLY: AfiG f ~(CESS /UMBRELLA LUIBILITY EACH OCCURRENCE S OCCUR ~ CLAIMS MADE AGGREGATE f S DEDUCTMLE f RETENTION f S AND EMPLOYl1lS' UABLITY x TORY LIMBS ER A ~ A ~~7 1fC0576033 05/01/10 05/01/11 E.LEACHACCIDENi s 1,000,(?00 ~U In NHI L~-11 E.L. 018EASE - EA EMPLOYE f 1, OOO , OOO Kyss, describe undw SPECIAL PROVISIONS bsbw E.L. DISEASE -POLICY UMR f 1 OOO OOO OTNB! C.~`4V``~~ ~.~~ ~ ~ ~ p~. ~ " DESCRIPTION OF OPERATIDNS / LOCATgN81 VEHICLES / EXCUNUDNS ADDED BY B~ORSIBMIIT 18PECML PROVISIONS Imo: ~ s ]:4pMt strr. , +l~11, Ca 95008 Cube Job X4426 1lilan Daatal-Dr. Iran *10 day notice of oancellatioa for non payment of premium or con reporting of payroll (waiver of subrogation to City, City of Campbell Redevelopment Agency, its officers, officials, employaesivoluateers CERTIFICATE HOLDER ~ T/` ~ _ CANCELLATION aMOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLw BEFORE THE EXPIRA ~y~ 9 ~~Ty j7R0- 4 FF ATE THEREOF. THE NiSUWG MISUREIt WILL ENDEAVOR To MAIL 30 DAYS WItITTNI ~ Q , +} «,// City Of Campbell p~Je ~ `~~~ Department Of Pli~lrj ~S q NOTICE TO THE CERTIFICATE MOLDER NAMED TO TFE: LAT. BUT FAILURE TO DO SO SHALL NAPOEE NO OBLKIATKMI OR LUIB~ITY OF ANY KMID UPON THE BISURER, RS AGENTS OR REPRESENTATIVES. 70 Morth airst 3t Camriell CA l5ssi ~ rae ks Tj~N ~urrlloR® A ACORD 25 (2009/01) ~ aDQ8B8~U9 AGVRD GORPOHATION. All rlgrlTs reserves. The ACORD name and logo are registered marks of ACORD WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be % of the California workers' compensation pre- mium otherwise due on such remuneration. Schedule Person or Organization Job Description -~ THE CITY OF CAMPBELL, THE CITY OF CAMPBELL 1374 E HAMILTON AVE REDEVELOPMENT AGENCY, ITS OFFICERS, CAMPBELL, CA 95008 OFFICIALS, EMPLOYEES, AND VOLUNTEERS CORE JOB #4426 AILAN DENTAL - DR TRAN This endorsement, effective on (DATE) at 12:01 A.M. standard time, forms a part of Policy No. WC 0576033 of the issued to COBE CONSTRUCTION INC Premium (if any) $17,258.00 Endorsement No. 001 WILLIAMSBURG NATIONAL INS CO (NAME OF INSURANCE COMPANI~ Authorized Representative WC 252 (4-84) Page 1 of 1 WC 04 0306 (Ed. 4-84) _~ ..~ CITY OF CAMPBELL DEPARTMENT OF PUBLIC WORKS 70 NORTH FIRST STREET CAMPBELL, CA 95008 FACSIMILE/EMAYL TRANSMITTAL SHEET TO: FROM: Joseph Valasquez Jeanine Gnuidman EMAIL DATE: joseph@dbinsurance.com 2/16/11 FAX NUMBER: TOTAL PAGES INCLUDING COVER: (408) 288-7130 PHONE NUMBER: SENDER'S EMAIL: 1 (800) 989-8712 jeanineg@cityofcampbell.com RE: PUBLIC WORKS FAX #: Insurance Certificate Requirements (408) 376-0958 ^URGENT^FOR REVIEWOPLEASE COMMENT X PLEASE REPLY ^ PLEASE RECYCLE Notes/Comments: *** Please note permit number and work site on certificate of insurance*** Re: Insured: ,Inc. Permit/Project #ENC2010-00111 Work Site: 1374 E. Hamilton Ave., Campbell, CA 95008 We have received the certificate of insurance for the work your insured will be doing in the City of Campbell. In order to meet our minimum insurance requirements, we still must ask that the following changes or additions be made to the certificate or information provided to the City. 1. Automotive Liability policies are to show "Any Auto" checked on certificate. 2. The cancellation area of the certificate is to be edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents, or representatives". 3. In the Workers' Compensation and Employer's Liability area of the certificate the requirements are as follows: A waiver of subrogation clause is required in connection with the workers' compensation coverage as well as $1,000,000 per accident for bodily injury or disease. A copy of our insurance requirements and your insurance certificates follow for your reference. You may forward the requested items to us by fax or email. Thank you very much, Jeanine Grundman - Page 2 of 2 Y To: joseph@dbinsurance.com Subject: Insurance Requirements for Cobe Construction Hi Joseph, Please review the certificate of insurance for Cobe Construction, Inc. They have applied for Encroachment Permit ENC2010-00111 for 1374 E. Hamilton Ave. in Campbell. I have attached the the necessary Insurance Requirements for the City of Campbell Department of Public Works as well as some additional information that may be helpful to you. Please reference the permit number and project address on the updated certificate. Thank you very much, Jeanine Jeanine Grundman City of Campbell Department of Public Works *** eSafe 7 scanned this email for malicious content *** *** IMPORTANT: Do not open attachments from unrecognized senders *** 2/17/2011 Page 1 of 2 Jeanine Grundman From: Sandy Luu [sandyr~dbinsurance.comJ Sent: Thursday, February 17, 2011 11:05 AM To: Jeanine Grundman Cc: 'Katie Foster' Subject: RE: Insurance Requirements for Cobe Construction Attachments: City of Campbell.pdf Good morning Jeanine, Attached is the revised certificate of insurance for our insured - COBE Construction Inc. We have addressed the following items: 1. "Any Auto" for the automotive liability policy is checked on the certificate. 2. "#i~ttied the wording "3D ttefy fto~ae w~-elrrwmlrllot. 4i;'! t~lyt i ic>'r non-P~-'' irl ~ih of eIP~ ht lieu of dei~tinq the "endeavor to".and "but f~iluire tt3 f1 stmt f11D~9 use ao abli~M~ air y o1` ~ kind upcm the company, its agr`rtta, c>H` f~epf~eeettttatives." 3. Referenced the permit number and project address in the description of operations. Please be advised our office does not offer the workers comp policy. You will be receiving the Workers Comp certificate and waiver of subrogation from another broker, if you have not received it already. If you should have any questions or need additional revisions, please feel free to contact our office. Thank you, Sr""""`i' ,C'ua. (,~IS~ 8(~7~~~TCI- ~M•p3kA~6F -C 11 raCi~ Boauto and Associates 1 Almaden Blvd Suite 810 San Josa Ca 86113 Phone X08-847-3000 Fax 408-288-7130 Webslte: www.dbinsurence.com "Please note that the Information and correspondence set forth In this small are NOT legal advice, rather our Insurance perepectlve. We do not provide Isgal adults and recommend that you seek advise from your bgal counsel to identify and respond to any legal matters which may arise from these issues." CONFIDENTIALITY NOTICE: The information contained in this a-mail message, including any attachments, is for the sole use of the intended redpient (s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended redpient, and have received this communication in error, please contact the sender by reply a-mail and destroy all copies of the original message. Thank you. From: Jeanine Grundman [mailto:jeanineg@cityofcampbell.com] Sent: Wednesday, February 16, 2011 4:47 PM 2/17/2011 ~' ~~i~'cl~l~ DATE (MM1DDfY1 ~~ CERTIFICp-TE OF LIABILITY INSURANCE OP ID SL 02/17 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. e cart cafe o er s an , t e po Icy les must en orse , su lect to the tem15 and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). ac No Ext: 408-371-3400 jac,NO): 408-371-340 Bozzuto & Associates Insurance One Almaden Blvd 3ui to S 1 O ADDRESS: San Jose CA 95113 CUSTOMER ID #: COBEC-1 Phone:800-989-8712 Fax:408-288-7130 INSURER(S)AFFORDIN6COVERAGE NAIC# INSURED INSURERA: Mt. H8Wle Insurance Co. 37974 Cobe Construction, Inc. INSURERS: Peerless Insurance Co a,n 24198 2470 S. Winchester Blvd Ste D ~ Campbell CA 95008 INSURERC: INSURER D ' INSURER E INSURER F __ _ ___ ......-..-.... rn. RFVICI[]N NIIMRFR' IS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD TH TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS NOTWITHSTANDING ANY REQUIREMENT ICATED , . IND 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. LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDDII'YYY) (MMIDDNYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1, O D O, O OO A X COMMERCIAL GENERALLIABILITV MGL0170140 04/01/10 04/01/11 PREMISES (Ea occurrence) $ 50,000 CLAIMS•MADE ~ OCCUR MED EXP (Any one person) S 5 , 0 t) 0 ~ PERSONAL 8 ADV INJURY S 1 , OOO , OOO X GENERAL AGGREGATE S 2 , OOO , OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS • COMP/OP AGG $ 2 , OOO , OOO POLICY X PRO LOC JECT S AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) S 1 000 000 r r $ }[ ANY AUTO BA2913012 03/13/10 03/13/11 BODILY INJURY (Per person) $ ALL OWNED AUT03 BODILY INJURY (Per accident) $ SCHEDULED ALIT'OS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS A UMBRELLA LIAR ~[ pCCUR L~CL0369678 04/01/10 04/01/11 EACH OCCURRENCE $ 10,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE S lO , OOO , OOO DEDUCTIBLE $ X RETENTION $ $ WO RKERS COMPENSATION TORY LIMITS ER AND EMPLOYERS' 1IA81LITY Y 1 N ANY PROPRIETOR/PARTNER/EXECUTIVF~ E.L. EACH ACGDENT $ OFFICERIMEMBER EXCLUDED? u (Mantlatory In NH) / A E.L. DISEASE - EA EMPLOYE S If yyssss describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMB $ B Property Section CBP8325157 09/17/10 09/17/11 BPP/DED 21,432/500 B E nt Floater CBP8325157 09/17/10 09/17/11 DESCRIPTION DF OPER TIONS !LOCATIONS /VEHICLES lAttach ACORD 101, Atltlitlonal Remarks Sehetlule, if moro apace Is requfrod 1374 E. Halmilton Ava.t Campbell, CA 9 008. All rmit EZIC2010-00111 P RE b , e : ic right-of-way. City of Campbell, City o C~be11 Redevelop work in pu l dditi 3 ona sa a went Agency, its officers, employees & volunteers are name Insurance is rimary & CGL216(04 98) lit . y per insureds as respects liabi noncontributory. 30 day notice of cancellation. 10 day notice for non-pay. vr..nr,r,vr.r~ r SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN . ~~~ ACCORDANCE WITH THE POLICY PROVISIONS. City of Campbell Attn: Public Works Depar 70 North First Street ~ 7 2~f1 AUTHOR¢EDREPRESENTATIVE Campbell CA 95008-1423 PUBLIC WORKS ' n n nn CATInAI ell .inh4a .enervnrl r.r,,..-.R.._-_ _.. V ~~ .~.~_ ..-vcivw- - - .. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD ~--~ policy Number: MGL0170140 Mt. Hawley Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS (FORM C) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL• LIABILITY COVERAGE PART (If no entry appears below, information required to complete this endorsement will be shown in the Declarations as appli- cable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Sched- ule, but only with respect to liability arising out of "your work" for that insured by or for you. To the extent required under contract, this policy will apply as primary insurance to additional insureds scheduled below and other insurance which may be available to such additional insureds will be non-contributory. Section IV., Condition 4., of this policy is amended accordingly. SCHEDULE Name of Person or-Organization: All persons or organizations where required by written contract. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. CGL 216 (04/98) Page 1 of 1 Insured Policy Number: MGL0170140 Mt. Hawley Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS (FORM Cj This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART (If no entry appears below, information required to complete this indorsement will be shown in the Declarations as appli- cable to this endorsement.) WHO IS AN INSURED (Section 11) is amended to include as an insured the person or organization shown in the Sched- ule, but only with respect to liability arising out of "your work" for that insured by or for you. To the extent required under contract, this policy will apply as primary insurance to additional insureds scheduled below and other insurance which may be available to such additional insureds will be non-contributory. Section IV., Condition 4., of this policy is amended accordingly. SCHEDULE Name of Person or Organization: All persons or organizations where required by written contract. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY. REMAIN UNCHANGED. CGL 216 (04/98) Page 1 of 1 Insured -- Page 1 of 3 Jeanine Grundman From: Sandy Luu [sandy~dbinsurance.com) Sent: Thursday, February 17, 2011 12:06 PM To: Jeanine Grundman Cc: 'Katie Foster' Subject: RE: Insurance Requirements for Cobe Construction Hi Jeanine, You're very welcome! Just so you know, the reason why we put the cancellation wording in the description of operations instead of having the cancellation section lined is because the new version of the ACORD 25 does not have the "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents, or representatives." wording. The new ACORD 25 (2009/09) read as: iiO~lJLp AMY ort 7>•k AiCly! ODD 1-Gt.1C1tf •E Gw~t.60 t ~' ~## ~bAX,fDlil GATE Tti~OAK; NG'nC~ 1WILL. 0E 0lLlYERID IN 1~ 4Yti'N ~ P+aLiC1f TONS. We haven't had any issues with the new form as long as the cancellation wording is shown in the description of operations. If your manager should have any questions or concerns, please feel free to contact me. I'll tell Kirk you said hello! We love having him here in the office! Thank you, fj ~%'i c~.tF~tE lt~r ictg Boauto and Associates 1 Almaden Blvd Suite 810 San Jose Ca 86113 Phone 408-947-3000 Fax 408-288-7130 Websfte: vvww dbinsurence.com 2/17/2011 O~ Cq,yA ,~~ den ~ r U r 0 0 ~ > y ~ ~. ~. ~R~HAg0 Transmittal Joy Francois Executive Assistant City of Campbell Department of Public Works 70 Nortb First Street Campbell, CA 95008 Pbone: (408) 866-2150 Fax: (408) 376-0958 To: Mr. Vinh Le - October 2, 2012 Address: 2042 Tully Rd. San Jose CA 95122 Re: 1374 E. Hamilton Ave, Campbell CA 95008 ^ Urgent ^ For Review ^ Please Comment ^ Please Reply x For Information & Use Enclosed please find a copy of the recorded Notice of Release of Street Improvement Agreement, Document #21797485 for the property located at 1374 E. Hamilton Ave., Campbell CA. Joy Francois Cc: ENC 20010-00111 ~~i~i~iiV~i~ DOCUMENT: 21797485 OCT ~ 12012 Recording Requested By: ) City of Campbel~i ~ Y CLE~~K'S OFFICE And When Recorded Return To: ) City Clerk ) City of Campbell ) 70 N. First Street ) Campbell, CA 95008 ) Fees.... Taxes... Copies.. ,.. ~.., ,-, , ,n^ AMT PA I D REGINA ALCOMENDRAS SANTA CLARA COUNTY RECORDER Recorded at the request of City Pages 13.00 13.00 RDE---- 8/16/2012 10 54 AM APN: 288-13-056 & 288-13-057 (Space Above This Line For Recorder's Use Only) ADDRESS: 1374 E. Hamilton Ave., Campbell CA NOTICE OF RELEASE BY CITY OF CAMPBELL NOTICE IS HEREBY GIVEN concerning the real property located in the City of Campbell, Santa Clara County, California, and described specifically as follows: 1374 E. Hamilton Avenue, Campbell California, 95008. That, whereas, T&L Family Investments LLC, a California Limited Liability Company entered into a Street Improvement Agreement with the City of Campbell, recorded January 19, 2011, Document 21053747, in the Office of the County Recorder, County of Santa Clara, State of California. That, whereas, said conditions of said Agreement have been met to the satisfaction of the City. That, Now Therefore, T&L Family Investments LLC, a California Limited Liability Company, is hereby released from all requirements contained in the agreement recorded January 19, 2011, Document 21053747, in said County Recorder's Office. IN WITNESS WHEREOF, said City has caused its name to be affixed by its City Engineer and City Clerk, who are duly authorized by Ordinance 2059 adopted September 20, 2005. ATT e Bybee, City Clerk (Attach Notary Acknowledgment) H:\LANDDEV\Notice of Release 1374 E Hamilton Ave.doc (Rev. 01/12) CITY OF CAMPBELL Michelle Quinney L~~ City Engineer, City of Campbell Dated: 7'~ 9 '~Z ,TME r01KQ01NO INSTRUMEKr Id A TINJE AND CORRECT COPY OF THE OI~ML ON rM.E IN THIB OFFICE. ATT~T: ANNE BYBEE, CITY ClBM( ~ ~k ~~ p~~p 16~! ~t2 CALIFORNIA ALL-PURPOSE CERTIFICATE OF ACKNOWLEDGMENT State of California County of ,` A yti'~, ~ ~c. f ~_ On before me, personally appeared ~ ;(^ t,,. p ~ ~ C who proved to me on the basis of satisfactory evidence to b~ the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. _ ~~ J T~1 MA OM Comn~hsuon #- tlfOllZ S my han and official seal. Ilohry PwNc - c.. Nw CNn Gw~yt (Notary Seal) Signature o Notary blic , -- ADDITIONAL OPTIONAL INFORMATION DESCRIPTION OF THE ATTACHED DOCUMENT ~~e. Zl~c ZP \2a.S.~_ (Title or description of attached document) Gam- ~'~ ~sa~~C- ~~~-}- (Title or description of attached doct~tent continued) Number of Pages Document Date (Additional information) CAPACITY CLAIMED BY THE SIGNER ^ Individual (s) ^ Corporate Officer (Title) ^ Partner(s) ^ Attorney-in-Fact O Trustee(s) ^ Other INSTRUCTIONS FOR COMPLETING THIS FORM Any acknowledgment completed in Caltfornta must contain ve-btage exactly as appears above in the notary section or a separate acknowledgment form must be properly completed and attached to that document. The only exception is if a doctanent is to be recorded outside ojCalifornta. In such instances, any alternative acknowledgment verbtage as may be printed on such a document so long as the verbiage does not require the notary to do something that is illegal for a notary in California (i.e. certifying the authorized capacity of the signer). Please check the document carefully for proper notarial wording and attach this form if required. • State. and County information must be the State and County where the document signer(s) personally appeared before the notary public for acknowledgment. • Date of notarization must be the date that the signer(s) personally appeared which must also be the same date the ackmowledgment is completed. • The notary public must print his or her name as it appears within his or her commission followed by a comma and then your title (notary public). • Print the name(s) of document signer(s) who personally appear at the time of notarvation. • Indicate the correct singular or plural forms by crossing off incorrect fomts (i.e. be/she/~hry, is /ere) or circling the correct forms. Failttre to correctly indicate this information may lead to rejection of document recording. • The notary seal impression must be clear and photographically reproducible. Impression must not cover text or lines. If seal impassion smudges, ro-seal if a sufficient area permits, otherwise complete a diffetnt acknowledgment form. • Signature of the notary public must thatch the signature on file with the office of the county clerk. Additional information is not required but could help to ensure this acknowledgment is not misused or attached to a different document. S Indicate title or type of attached. document, number of pages and date. •8 Indicate the capacity claimed by the signer. If the claimed capacity is a corporate officer, indicate the title (i.e. CEO, CFO, Secretary). • Securely attach this document to the signed document 2008 Version CAPA v12.10.07 800-873-9865 www.NotaryClasses.com r-~ Joy F~" ~is O~ • C q M Execu. M-ssistant +~ City, of Campbell `~ ~~ Department of Public Works U r. 70 North First Street 0 o Campbell, CA 95008 y ,' Phone: (408)866-2150 ~' c` Fax: (408) 376-0958 9R CHA0.~ Transmittal To: Vinh Le .Date: 3/24/11 Address: 2042 Tully Rd., San Jose, CA 95122 Re: 1374 E. Hamilton Ave. Campbell CA ^ Urgent ^ For Review ^' Please Comment ^ Please Reply x For Information & Use Enclosed please find a copy of the recorded Street Improvement Agreement, Document # 21053747 for the above referenced location. toy Francois Cc: File::, Rg~1V~Ri MN~ 1 s 2011 DOCUMENT: 21053747 Pages 11 CITY CL.ERK'S OFFICE Fees .... ~ No Fees Recording Requested by: ) Taxes .. . Copies.. City of Campbell ) ~ ~ L~ ~ ~~ ~ AMT PA I D ) REGINA ALCOMENDRAS RDE # 014 When recorded mail to: ) SANTA CLARA COUNTY RECORDER 1 / 19/201 1 ) Recorded at the request of 243 PM City Clerk ) City City of Campbell ) 70 North First Street ) Campbell, CA 95008 ) APN: 288-13-056 & 288-13-057 (Space above this line for Recorder's use ont. ~ ADDRESS: 1374 E Hamilton Avenue, Campbell, CA 95008 M~jp pp ~ ~pq p ON PILE IN THIS OFRCE STREET IMPROVEMENT AGREEMENT "T~~ ere~.aTMCxl~c - PBELL, cn RECITALS ~ ~~ l ! THIS AGREEMENT, identified by File No(s). PLN2009-00122, is entered into this ~~ day of ~ ~c ~ ~.~i-~ ~t_ 2010, by and between T& L Family Investments LLC, a California Limited Liability Company, hereinafter referred to as "Owner ,hereunder referred to as "Owner," and the CITY OF CAMPBELL, a municipal corporation of the County of Santa Clara, State of California, hereinafter referred to as "City." On May 25, 2010 the Planning Commission granted conditional approval of a Site and Architectural Permit for an addition and exterior remodel for that certain real property described in Exhibit A attached hereto and incorporated as though fully set forth herein, and commonly known as 1374 East Hamilton Avenue, which property is hereinafter referred to as "said real property." TERMS AND CONDITIONS Now, therefore, in consideration of the above referenced approvals,' and in satisfaction thereof, the parties to this Agreement shall comply with the following terms and conditions: (1) The Owner shall provide, construct and install at his/her own proper cost and expense, street improvements as described in Section 11.24.040 of the City Code within 12 months from the date first mentioned hereinabove; provided, however, that in the computation of said 12 month period, delays due to, or caused by acts of God, viz., unusually inclement weather, major strikes, and other delays beyond the control of the Owner or his/her successors shall be excluded. (2) If the Owner fails to complete the work required by this Agreement within the said 12 month period, the City, after giving ten (10) days written notice to the Owner, or his/her successors, may construct and/or install said improvements and recover the full cost and expense from the Owner, or his/her successors. J:\DorisQH\Land Development Work\Projects -Land Development\Hamilton Ave 1374\Street Improvement Agreement.DOC (Rev 2/09) 1 STREET IMPROVEMENT PLANS (3) The Owner, shall cause to be prepazed at his/her cost and expense street improvement plans for the construction and installation of said improvements prior to such construction or installation. Said plans shall be prepared by a civil engineer registered by the State of California and submitted to the City Engineer for examination and approval. (4) All of said improvements embraced in this Agreement shall be constructed and. installed in accordance with the plans approved by the City Engineer and shall be made under the inspection and to the satisfaction of the City Engineer. Said construction and/or installation shall be in accordance with the existing ordinances and resolutions of the City of Campbell and all applicable plans, specifications, standazds, sizes, lines and grades .approved by the City Engineer, and all State and County statutes. Upon completion and acceptance of the improvements bythe City, the Owner, shall provide reproducible as- built plans to the City Engineer. PLAN CHECK AND INSPECTION FEE (5) Prior to approval of the plans by the. City Engineer pursuant to Section (3) of this Agreement, Owner, or his/her successors, .shall pay the City ,for plan checking of improvement plans, field inspection of construction of improvements and all necessary expenses incurred by City in connection with said improvements, a sum calculated in accordance with Resolution No. 10494 as adopted by the City Council on May 3, 2005, or as may subsequently be adopted by the City Council FAITHFUL PERFORMANCE SECURITY (6) The Owner, or his/her successors, shall file with City, prior to beginning construction, security acceptable to the City in amount equal to the City Engineer's estimated cost of the street improvements to ensure full and faithful performance of the construction of all the aforementioned improvement work. Said security shall guazantee that Owner, and his/her successors, will correct any defects which may appear in said improvement work within one (1) year from the date of acceptance of the work by City and pay for any damage to other work resulting from the construction thereof, as well as pay the cost of all labor and materials involved. This security shall remain in effect until one (1) year after date of final acceptance of said improvements by City. Said security amount maybe reduced by the City Engineer in his/her sole discretion after the date of final acceptance to not less than twenty-five (25) percent of its full value. (7) .Upon final release of said security by City, the obligations of Owner, and his/her successors, contained in this Agreement shall be considered null and void, except as otherwise provided by applicable law, or Sections 12 or 13 of this Agreement. FORMATION OF A SPECIAL ASSESSMENT (8) The Owner, when called upon by City to do so, shall execute a petition for the formation of any special assessment district created pursuant to any .special assessment act as provided in the Streets and Highways Code of the State of California created for the 2 purpose of constructing and/or installing any or all- of said improvements. Owner, or his/her successors, shall participate in and become a part of any special assessment district as described in Section (8) of this Agreement. (9) .The Owner's, or his/her successors' obligations contained in this Agreement that are accomplished to the satisfaction of said City Engineer by said special assessment district shall be considered to satisfy those obligations. RIGHT-OF-WAY ACQUISITION (10) Owner at his/her own cost and expense, shall acquire any easement and right-of--way within or without said real property necessary for the completion of the improvements shown upon aforesaid improvement plans. It is provided, however, that in the event eminent domain proceedings are required for the purpose of securing said. easement and right-of--way, Owner, shall deposit or cause to be deposited with City a sum covering the reasonable market value of the land proposed to be taken and to be included in said sum shall be a reasonable. allowance for severance damages, if any. It is further provided that in addition thereto such sums as may be required for legal fees and costs, engineering and other incidental costs -shall be deposited with the City. (11) The Owner, shall carry out any and all negotiations with all interested parties and .shall perform or cause to be performed at his/her own cost and expense and to the satisfaction of the City Engineer any and all work required to abandon, remove, raise, lower, relocate and otherwise modify irrigation lines within or without the boundary of said real property. INDEMNITY AND INSURANCE (12) The Owner, and his/her successors, to the fullest extent permitted by law, shall indemnify, defend and hold the City of Campbell, the City of Campbell Redevelopment Agency, and its agents, employees, attorneys, officers, officials and assignees harmless from any and all claims, actions, causes of action, liabilities, damages, losses and expenses, including, but not limited to, attorneys' fees, arising out of, or resulting from, or alleged to arise out of or result from any negligent or intentional act or omission (including misconduct) of said Owner, or his/her. successors, or any subcontractor, or anyone directly or indirectly employed by him, or anyone for whose acts any of them may be liable in the course of performance of the Agreement, except for any claims, actions, causes of action, liabilities, damages, losses and expenses proximately caused by the sole negligence or willful misconduct of the City. (13) The Owner, and his/her successors, shall also indemnify, defend and hold the City of Campbell, the City of Campbell Redevelopment Agency, and its agents, attorneys, employees, officers, officials, and assignees harmless against and from any and all claims, actions, causes of action, liabilities, demands, losses, lawsuits, judgments, damages, costs and expenses (including, but not limited to, attorneys' fees and court costs, whether incurred at trial, appellate or administrative levels) which the City of Campbell may incur or suffer, or to which the City of Campbell may be subjected resulting from, or alleged. to 3 result from the failure of Owner, or his/her heirs, assignees, successors, grantees, agents, employees, subcontractors, or anyone performing services under him, to fulfill any of the obligations imposed under this Agreement, except for any claims, actions, causes of action, liabilities, judgments, damages, costs and expenses proximately caused by the sole negligence or willful misconduct of the City. (14) The Owner and his/her successors shall also indemnify, defend and hold harmless the City, the .City of Campbell Redevelopment Agency, and its agents, officers .and employees from any claim, action, or proceeding against the City or its agents, officers or employees to attach, set aside, void or annul an approval of the City, its City Council, Planning Commission, Community Development Director, Public Works Director, Building Official, City Engineer, or other such City official concerning a subdivision, which action is brought within the time period provided for in California Government Code Section 66499.37. (15) In the event that this contract is subject to California Civil Code section 2782(b), the foregoing indemnity provisions shall not apply to any liability for the active negligence of the City or the Campbell Redevelopment Agency. The foregoing indemnity provisions are intended to fully allocate all risk of liability to third-parties.. No other rights of indemnity or contribution shall exist between the parties in law or in equity. The provisions set forth in this section shall survive the termination of this Agreement. (16) The City will promptly notify the Owner of any claim, action or proceeding to attack, set aside, void or annul any approval concerning a subdivision of said real property, and will cooperate fully in the defense. (17) Owner and his/her/its successors shall maintain insurance for injuries to persons or damage to property conforming to the following specifications: A. Minimum Scope of Insurance Coverage shall be at least as broad as: 1. Insurance Services Office (ISO) CGL form CG 00 01.11 85; and 2. ISO form G0009 11 88 Owners and Contractors Protective Liability Coverage Form -Coverage for Operations of Designated Contractor; and 3. Course of Construction Insurance covering all risks of loss; and 4. ISO CA 00 O1 06 92 including symbol 1 (Any Auto); and 5. Workers' Compensation insurance as required by the Labor Code of the State of California and Employer's Liability insurance. B. Minimum Limits of Insurance Owner shall maintain limits no less than: 4 1. General Liability: $1,000,000 combined single limit per occurrence for bodily, personal injury and property damage: If Commercial General Liability Insurance or other form with a general aggregate limit is used, either the general aggregate limit shall apply separately to this project/location or the-general aggregate limit shall be twice the required occurrence limit 2. Automobile Liability: $1,000,000 combined single limit per accident for bodily injury and property damage. 3. Workers' .Compensation and Employer's Liability: Workers' Compensation limits as required by the Labor Code of the State of California and Employer's Liability limits. of $1,000,000 per accident. C. Deductible and Self-Insured Retention Any deductibles or self-insured retention must be declared to and approved by the City. At the option of the City,. either: the insurer shall reduce or eliminate such deductibles or self-insured retention as respects the City, the City of Campbell Redevelopment Agency, its agents, officers, attorneys, employees, officials and volunteers; or the Owner shall procure a bond guaranteeing payment of losses related to investigations, claim administration, and defense expenses. D. Other Insurance Provisions The policies are to contain, or be endorsed to contain, the following provisions: 1. General Liability and Automobile Liability Coverage: a. The City, City of Campbell Redevelopment Agency, its agents, officers, attorneys, employees, officials and. volunteers are to be covered as insureds as respects: liability arising out of activities related to this Agreement performed by or on behalf of the Owner, products and completed operations of the Owner, premises owned, occupied or used by the Owner, or automobiles owned, leased, hired or borrowed by the Owner. b. The Owner's insurance coverage shall be primary insurance as respects the City, City of Campbell Redevelopment Agency, its agents, officers, attorneys, employees, officials and. volunteers. Any insurance or self-insurance maintained by the City, City of Campbell Redevelopment Agency, its agents, officers, attorneys, employees, officials and volunteers shall be excess of the Owner's insurance and shall not contribute with it. c. Any failure to comply with reporting provisions of the policies shall not affect coverage provided to the City, City of Campbell Redevelopment Agency, its agents, officers, attorneys, employees, officials, and volunteers. 5 d. The Owner's insurance shall apply separately to each insured against whom claim is made or suit is brought except with respect to the limits of the insurer's liability. e. Coverage shall not extend to any indemnity coverage for the active negligence of the City in any case where an agreement to indemnify the City would be invalid under Subdivision (b) of Section 2782 of the California Civil Code. 2. Workers' Compensation and Employer's Liability Coverage: The insurer Shall agree to waive all rights of subrogation against the City, City of Campbell Redevelopment Agency, its agents, officers, attorneys, employees, , officials, and volunteers for losses arising from work performed by the Owner for the City. 3. Course of Construction Coverage: Course of Construction policies shall contain the following provisions: (a) the ,City shall be named as loss payee; and (b) the insurer shall waive all rights of subrogation against the City. 4. All Coverages: Each insurance policy required by this clause shall be endorsed to state that coverage shall not be suspended, voided, canceled by either party, reduced in coverage or in limits except after thirty (30) days prior written notice by certified mail, return receipt requested, has been given to the City. E. Acceptability of Insurers Without limiting Owner's indemnification provided hereunder, Owner shall take out and maintain at all times during the life of this contract, up to the date of acceptance of the work by the City, the policies of insurance listed in Paragraphs 12 through 16 of this Agreement. Insurance is to be issued by an issuer with a current A.M. Best Rating of A:VII and be authorized to transact business in the State of California, unless otherwise approved by the City. F. Verification of Coverage Owner shall furnish the City with certificates of insurance evidencing coverage required by this clause. The certificates for each insurance policy are to be signed by a person authorized by-that .insurer to bind coverage on its behalf. The certificates are to be on forms provided by the City. Where by statue, the City Workers' Compensation related forms cannot be used, equivalent forms approved by the Insurance Commissioner are to be substituted. All certificates are to be received and approved by the City before work commences. G. Subcontractors Owner shall include all subcontractors as insured under its policies or shall furnish separate certificates by each subcontractor. All coverage shall be subject 6 to all of the requirements stated herein. MUTUAL BENEFIT COVENANTS BINDING ON HEIRS, ASSIGNEES, SUCCESSORS, AND GRANTEES OF OWNER (18) It is acknowledged that the provisions of this Agreement constitute covenants for the improvement of the subject real property for the mutual benefit of Owner's property, commonly known as 1374 East Hamilton Avenue, and the City's property, commonly described as Hamilton Avenue where it adjoins Owner's property. These covenants shall be considered to affect rights in the above-described real properties, and shall be binding on the heirs, assignees, successors, grantees and agents of the Owner to said real property. UNVESTED INTERESTS (19) Nothing contained herein shall be construed to transfer any unvested interests in real or personal property for purposes of the rule against perpetuities. BREACH OF CONTRACT (20) The City, upon breach any of the terms, conditions, or covenants of this Agreement by the Owners, shall be entitled to recover from the Owner, in addition to any other relief available in law or equity, all costs and compensation incurred in attempting to obtain enforcement of the Agreement, including reasonable attorneys' fees and court costs. ENTIRE AGREEMENT BINDING (21) This is -the entire Agreement between the parties, and .there are no representations, agreements, arrangements or understandings that are not fully expressed herein. This Agreement can be executed in counterparts by the parties hereto, and as so executed shall consist of one agreement, binding on all parties. PRELIMINARY PLANS (22) Owner shall provide and construct public street improvements per preliminary plans titled "STREET IMPROVEMENT PLANS - OFFSITE - 1374 East Hamilton Avenue," which are subject to approval by the City Engineer, prepared by Silicon Valley Land Surveyors, Inc. 7 IN WITNESS WHEREOF, said City has caused its name to be affixed by its City Engineer and City Clerk, who are duly authorized by Ordinance 2059 adopted September 20, 2005, and said Owner has caused his/her name to be affixed the day and year first above written. T& L Family Investments LLC, a California Limited Liability. Company ~/"""" ~ Sign e v i N-4.1 '--E M p-ti t~G,-~R Name, Title CITY OF CAMPBELL Michelle Quinney, City Eng n er (Notary Acknowledgment for above signator(ies) MUST be atta.ched.) Attest: Anne Bybee, City Clerk Escrow No.: 09-9770137gTW Locate No.: CACTI7743-7743-2977-0097701379 Title No.: 09-9770137~MC EXHIBIT "A" THE LAND REFERRED TO HEREIN BELOW IS SITUATED IN THE CITY OF Campbell, COUNTY OF SANTA CLARA, STATE OF California AND IS DESCRIBED AS FOLLOWS: Lot 23 and Lot 46, as shown upon that certain Map entitled, 'Tract No. 1115 Hamilton Square Unit No. 1", which Map was filed for Record in the Office of the Recorder of the .County of Santa Clara, State of California on April 21, 1953 in Book 42 of Maps, at Page 30. Excepting- therefrom the underground water or rights thereto as quitclaimed to San Jose Water Works, a California Corporation by Instrument .Recorded in Book of Official Records Numbered 2633, at Page 419. APN: 288-13-056 & 288-13-057 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT State of California ~ ~, ~~ ~ ~ ~ County of t~ /~ ~ j // / On ~ ~ ~~ ~'~ ~ i U before me, e d ~ "`-' (APJ (~'~ Date Insert a end Title of the icer personally appeared Y I n ~ ~e Name(s) of Signer(s) ...:.r..o.rr ANNE BYBEE Commluion. # 1794690 .~ Wotory Ribllc - Califonwa Banta Clara County Mylponnr.6~is#Ar:~0. ~7Z Place Notary Seal Above who proved to me on the basis of satisfactory evidence to be the person(s) whose names} is/are-subscribed to the within instrument and acknowledged to me that he/s#e>~El+ey executed the same in his/faer##~eir authorized capacity(ies}, and that by his/l~erkheir signature(sj on the instrument the person(s},- or the entity upon behalf of which the persons} acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. , "~ WITNESS my taand ~+'~d official seai. Signature ,/ Signature of Notary ublic OPTIONAL Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent. removal and reattachment of this form to another document. Description of Attached. Document Title or Type of Document: Document Date: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: ^ Individual ^ Corporate Officer - ^ Partner - ^ Limited ^ Attorney in Fact Number of Pages: Name: Individual Title(s):. ^ Corporate Officer -Title(s): _ ^ General ''~ ^ Partner - ^ Limited ^ General ^ Attorney in Fact ^ Trustee ^ Guardian or Conservator ^ Other: -'"~ Signer Is Representing: ^ Trustee ^ Guardian or Conservator ^ Other: Signer Is Representing: ®2007 National Notary Asaociadon • 9350 De Soto Ave., P.O. Box 2402 • Chatsworth, CA 91313-2402 • www.NationalNotaryorg Item #5907 Reorder: Call Toll-Free 1-800.876.6827 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT State of California 1 County of ~_/"i7'c ~_~ 1cJ,~~ On before me, .-~ Z + ~ ~ ~ ~~ r +p , ate ~ tt Here Insert Name and Title of the t~cer,y~ ~ _ r personally appeared ~~ ~~ e ~ .lam ~~- ~~ Na~cP 1 ngneres) ~J VJ~ ~ L, JOAINE M. D' MINA Conwnis~ion ~ 17J5773 NeYrr PYbYc - CrNaM~ ill.. cMra CowNp .. who proved to me on the basis of satisfactory evidence to be the person whose name is/~; subscribed to the within instrument and acknowledged to me that, ~e/she/tidy executed the same in hi~/her/t~ir authorized capacity(i~, and that by his/herl~I't~ir signature.( on .the instrument the person~a'~, or the entity upon behalf of which the person ;),, acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that .the foregoing paragraph is true and correct. WITNESS my hand and official seal. ~~ ~ l Signatu~rgr~~~'~:~'" 1~ ~~~~~ ~~i-~s~ Place Notary Seal and/or Stamp Above j/ Signature of Notary Public OPTIONAL Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document. Description of Attached Document Title or Type of Document: Document pate: Number of Signer(s) Othei Capacity(ies) Signer's Name: ^ Corporate Officer -Title(s): _ ^ Individual . ^ Partner - ^ Limited ^ General ^ 'Attorney in Fact ^ Trustee ^ Guardian or Conservator ^ Other: Signer Is Repenting: ^ er - ^ L ^ Attorney IrrF.a ^ Trustee ^ Guardian or C ^ Other: Signer Is Representing: invited ^ General Top of thumb here ct onservator 1~' ~_ Named Above: Signer(s) ^ Corporate Officer -Title(s): ®2008 Natbnal Notary Association • 9350 De Soto Ave., P.O. Box 2402 • Chatsworth, CA 91313.2402 • www.NationalNotary.org Item #5907 Reorder. Call Toll-Free 1-800.876-6827 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR NOTICE OF RELEASE OF RECORDED STREET IMPROVEMENT AGREEMENT ~NC.aola- Do~~ ~ Encroachment Permit # Property Address ^ Date Street Improvement Agreement recorded 1 ~ 1 ^ Date of Final Acceptance Letter - ~e'-~` ^ Date tickler letter given to inspector L'~-~Z-.. ^ Date of One-Year Maintenance Acceptance Letter 7~ ~ -`- ~ Z ^ All deposits refunded (Date of last refund) -~e ~ Z~ ~ 11 Inspector's Encroachment Permit file merged with Main Permit File 0 Date Permit archived in Permit Plan Processed by: Reviewed By: Inspector Reviewed by: 7 -~ 9 _ ~~ Land Development Engineer t Finance for Recordin Feed I1~ I ~~ Date Check Request Submitted o 9 Date Notice of Release sent for recording: ~ ~~~\\Z ~ C'~-c~ J:\FORMS\Templates\Administrative\Chxklist -Release of Street Improvement Agroement.doc (Rev. 10/11) MEMORANDUM crrY of cv~PSE~ PuBt~c woxxs D~xnx~urrr TO: Anne Bybee, City Clerk DATE: July 31, 2012 FROM: Joy Francois, Executive Assistant Public Works Department SUBJECT: Document for Recording Please attest and send the following document and our check #237792 in the amount of $13.00 for recording: Notice of Release Street Improvement Agreement, 1374 E. Hamilton., Campbell. Public Works will need a copy of the final recorded document for our file. No conformed copy is necessary. Thank you for your assistance. Attachment 237792 - Account I'ctrchusc .Order Invi7ce Nirmher' _._ .tnwunr .._.___ ~~re~•r~ptinn> _ __ 101.'701 "/427 C12071912A 13.00 1:174 1~; HAI'llL7'ON AVE T(]0116218 J (: C. C;LCKK KbI:VKUCK ~t:.c„'Ur„ C1TX OIa CAMPBELL W, ~.4~ BARC;Q B~N>< 1,~.~. 11-2a ` ' CIIECK DATE CIiECK NO 0'7/30/12 - 237792 , ~~ . ~F- 7t7 NORTH FIRST STREET +E 42n MONTGOMERY StR P 1210 sFw )~rsaxcrs;co, cn ?aloa ~ ' O CAMPBEI L, CALIFORNIA 95008 I' ~^ * * * * ~` * * * 13.0 0 AMOLJN' * ~~ ''i .~ .~ o . t OLD A]PfER 50 PAYS °krune~ s ;~ PAY THE SUM OF THIRTEEN DOLLARS & ZERO CENTS ~ F i z'o THF, S C C CLERK RECORDER i~ ~ ~ /` t' ~ ~ ~... -~ • on1~Ex 7 0 W HEDDING ST r COUNTY GOV CNTR EAST WING 1ST FLR <, < ~°., o C~~,L~ y ~„t SAN JOSE CA 95110-1705 r j f 11.23779211' ~:~210002 48~:'4L2L8554i~511' r _ _ ~, __ . *See Reverse Side For Easy Opening Instructions* CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 S C C CLERK RECORDER 70 W HEDDING ST COUNTY GOV CNTR EAST WING 1ST FLR SAN JOSE ^_A 95L10-1705 -i Recording Requested By: ) City of Campbell ) And When Recorded Return To: ) City Clerk ) City of Campbell ) 70 N. First Street ) Campbell, CA 95008 ) APN: 288-13-056 & 288-13-057 (Space Above This Line For Recorder's Use Only) ADDRESS: 1374 E. Hamilton Ave., Campbell CA NOTICE OF RELEASE BY CITY OF CAMPBELL NOTICE IS HEREBY GIVEN concerning the real property located in the City of Campbell, Santa Clara County, California, and described specifically as follows: 1374 E. Hamilton Avenue, Campbell California, 95008. That, whereas, T&L Family Investments LLC, a California Limited Liability Company entered into a Street Improvement Agreement with the City of Campbell, recorded January 19, 2011, Document 21053747, in the Office of the County Recorder, County of Santa Clara, State of California. City. That, whereas, said conditions of said Agreement have been met to the satisfaction of the That, Now Therefore, T&L Family Investments LLC, a Califomia Limited Liability Company, is hereby released from all requirements contained in the agreement recorded January 19, 2011, Document 21053747, in said County Recorder's Office. IN WITNESS WHEREOF, said City has caused its name to be affixed by its City Engineer and City Clerk, who are duly authorized by Ordinance 2059 adopted .September 20, 2005. ATTEST: Anne Bybee, City Clerk (Attach Notary Acknowledgment) CITY OF CAMPBELL ~~~~ Michelle Quinney City Engineer, City of Campbell Dated: 7-~ 9 '/Z H:U,ANDDEV~Notice of Release 1374 E Hamilton Ave.doc (Rev. 01/12) CALIFORNIA ALL-PURPOSE CERTIFICATE OF ACKNOWLEDGMENT State of California County of ,v ,,,~p~ ~.~~ f e,~_ On,,y~\~ ~9 ~~.,~ before me, ~~ A~.l~ ~~i~M ~~ 4~, N~ (Here insert name and personally appeared who proved to me on the basis of satisfactory evidence to b~ the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. ~o~+ nio~- at WI S my han and official seal. ConNnis<s<ion ~ t{gOd~t Nohry- PwrbNc - C~Ilfotn~l~ ~Mlgl CNn CowN~- ~a Signature o Notary blic (Notary Seal) ADDITIONAL OPTIONAL INFORMATION DESCRIPTION OF THE ATTACHED DOCUMENT ~~~ t~`3e~eose - (Title or description of attached document) (Title or description of attached docr~nent continued) Number of Pages Document Date (Additional information) CAPACITY CLAIMED BY THE SIGNER ^ Individual (s) ^ Corporate Officer (Title) ^ Partner(s) ^ Attorney-in-Fact ^ Trustee(s) ^ Other INSTRUCTIONS FOR COMPLETING THIS FORM Any acknowledgment completed in California must contain verbiage exactly as appears above in the notary section or a separate acknowledgment form must be properly completed and attached to that document. The only exception is if a document is to be recorded outside of California. In such instances, any alternative acknowledgment verbiage as may be printed on such a document so long as the verbiage does not require the notary to do something that is illegal for a notary in California (i.e. certifying the authorized capacity of the signer). Please check the document carefully for proper notarial wording and attach thrs form if required. • State and County information must be the State and County where the document signer(s) personally appeared before the notary public for acknowledgment. • Date of notarization must be the date that the signer(s) personally appeared which must also be the same date the acknowledgment is completed. • The notary public must print his or her name as it appears within his or her commission followed by a comma and then your title (notary public). • Print the name(s) of document signer(s) who personally appear at the time of notarization. • Indicate the correct singular or plural forms by crossing off incorrect forms (i.e. lre/shdt~ey; is /ere) or circling the correct forms. Failure to comctly indicate this information may lead to rejection of document recording. • The notary seal impression must be clear and photographically reproducible. Impression must not cover text or lines. If seal impression smudges, ro-seal if a sufficient area permits, otherwise complete a different acknowledgment form. • Signature of the notary public must match the signature on file with the office of the county clerk. Additional information is not required but could help to ensure this acknowledgment is not misused or attached to a different document. •y Indicate title or type of attached document, number of pages and date. Indicate the capacity claimed by the signer. If the claimed capacity is a corporate officer, indicate the title (i.e. CEO, CFO, Secretary). • Securely attach this document to the signed document 2008 Version CAPA v12.10.07 800-873-9865 www.NotaryClasses.com CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR NOTICE OF RELEASE OF RECORDED STREET IMPROVEMENT AGREEMENT Encroachment Permit # ~ N ~ ~G' j ~' ~ ~©tl ~ Property Address ^ Date Street Improvement Agreement recorded ~ ~, ^ Date of Final Acceptance Letter Cc2~ ~n "\ ~ ^ Date tickler letter given to inspector ~'~'~Z-' ^ Date of One-Year Maintenance Acceptance Letter 7~ ~ t- (Z' ^ All deposits refunded (Date of last refund) ~af Z~ (i ~ ^ Inspector's Encroachment Permit file merged with Main Permit File ^ Date Permit archived in Permit Plan Processed by: Reviewed By: Inspector Reviewed by: ~ , ~ g _ ~~ Land Development Engineer Date Check Re uest Submitted to Finance for Recordin Feed I ~~ I ,~ G 9 Date Notice of Release sent for recording: ~ ~~~\\y -~ Ck~- J:\FORMS\Templates\Administrative\Checklist -Release of Street Improvement Agreement.doc (Rev. 10/11) MEMORANDUM CITY OF CAMPBELL PUBLtC WORKS DEPARTMENT TO: Anne Bybee, City Clerk DATE: July 31, 2012 FROM: Joy Francois, Executive Assistant Public Works Department SUBJECT: Document for Recording Please attest and send the following document and our check #237792 in the amount of $13.00 for recording: Notice of Release Street Improvement Agreement, 1374 E. Hamilton., Campbell. Public Works will need a copy of the final recorded document for our file. No conformed copy is necessary. Thank you for your assistance. Attachment I 1 ...~\ CITY OF CAMPBELL ~n:NDOR No. T0006218 cxECK rvro. 237752 F ~' Account --- 1'urchust~ girder ' Inroice N~tmiier__ _._ Anwun/ ___ _ ___ I)es~~r~rnt _ _ 101..701 '/4?.'7 C12071917_A 13.00 1374 l'; HAfd]L9'UN AVE T0006218 S C C CLERK RECORDER i. CIT 7~ D~T~ r ~lt'{f'~ ~PBF T T rt t~ wt r,LS eaxc~ enxK CI~TECK. DATE CI~iECK NO. J . i i i ~~ ~ r., t- 70 NORTH FIRST STREET . . . . ;?4 MONTGOMERY S fRFfE`P 11-2~t 1210 0 7/ 3 0/ 12 2 3 7 7 y 2 f ~' CA'MPBELL; CALIFORNIA 95008 53W 1:+RAIdC.I~.GCO, C/1 `4104 o AMOUNT ~ ****~; ***13. ()0* n I~.~ ~~ okGUAav GOCD Ali"PER 50 DAYS O n PAY THE SUM OF THIRTEEN DOLLARS & ZERO CENTS ~ ~~ : ~ F To TxF S C C C~,ERK RECORDER ' ~~ ~ ~ ~ \ ,~~~~ ~, ~~'` oRn~R 70 W HEDDING ST COUN'.CY GOV CNTR EAST WING 1ST FLR ~ ~ L~'. / ,, '"-" ~,~,/ SAN JOSE CA 95110 -17 0 5 C M ~ j CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 S C C CLERK RECORDER 70 W HEDDING ST COUNTY GOV CNTR EAST WING 1ST FLR SAN JOSE ~A 95L10-1705 Recording Requested By: City of Campbell And When Recorded Return To: City Clerk City of Campbell 70 N. First Street Campbell, CA 95008 APN: 288-13-056 & 288-13-057 (Space Above This Line For Recorder's Use Only) ADDRESS: 1374 E. Hamilton Ave., Campbell CA NOTICE OF RELEASE BY CITY OF CAMPBELL NOTICE IS HEREBY GIVEN concerning the real property located in the City of Campbell, Santa Clara County, California, and described specifically as follows: 1374 E. Hamilton Avenue, Campbell California, 95008. That, whereas, T&L Family Investments LLC, a California Limited Liability Company entered into a Street Improvement Agreement with the City of Campbell, recorded January 19, 2011, Document 21053747, in the Office of the County Recorder, County of Santa Clara, State of California. City. That, whereas, said conditions of said Agreement have been met to the satisfaction of the That, Now Therefore, T&L Family Investments LLC, a Califomia Limited Liability Company, is hereby released from all requirements contained in the agreement recorded January 19, 2011, Document 21053747, in said County Recorder's Office. IN WITNESS WHEREOF, said City has caused its name to be affixed by its City Engineer and City Clerk, who are duly authorized by Ordinance 2059 adopted September 20, 2005. ATTEST: Anne Bybee, City Clerk (Attach Notary Acknowledgment) CITY OF CAM~~PBELL Michelle Quinney City Engineer, City of Campbell Dated: 7-~ 9 '/Z H:~I,ANDDEV~Notice of Release 1374 E Hamilton Ave.doc (Rev. 01/12) CALIFORNIA ALL-PURPOSE CERTIFICATE OF ACKNOWLEDGMENT State of California County of ~„~n~ ~.\ct f ~___ On ~ before me, ~ ~~~ YYI c;~ (Here insert name personally appeared who proved to me on the basis of satisfactory evidence to b$ the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. JOAI~I THEM ON WI S my han and official seal. C°mmits<ion * t Nogry P~lic - CitMornfrt ~ CMn Codah- 15 Signature o Notary blic (Notary Seal) ADDITIONAL OPTIONAL INFORMATION DES~CtRIPTION OF~ (T` HE~ATTACHED DOCUMENT (Title or description of attached document) (Title or description of attached doc ent continued) Number of Pages Document Date (Additional information) CAPACITY CLAIMED BY THE SIGNER ^ Individual (s) ^ Corporate Officer (Title) ^ Partner(s) ^ Attorney-in-Fact ^ Trustee(s) ^ Other INSTRUCTIONS FOR COMPLETING THIS FORM Any acknowledgment completed in California must contain verbiage exactly as appears above in the notary section or a separate acknowledgment form must be properly completed and attached to that document. The only exception is if a document is to be recorded outside of California. In such instances, any alternative acknowledgment verbiage as may be printed on such a document so long as the verbiage does not require the notary to do something that is illegal for a notary in Calfornia (i.e. certifying the authorized capacity of the signer). Please check the document carefully for proper notarial wording and attach this form if required. • State and County information must be the State and County where the document signer(s) personally appeared before the notary public for acknowledgment. • Date of notarization must be the date that the signer(s) personally appeared which must also be the same date the acknowledgment is completed. • The notary public must print his or her name as it appears within his or her commission followed by a comma and then your title (notary public). • Print the name(s) of document signer(s) who personally appear at the time of notarization. • Indicate the correct singular or plural forms by crossing off incorrect forms (i.e. 1!e/she/4hey- is /are) or circling the cored forms. Failure to correctly indicate this information may lead to rejection of document recording. • The notary seal impression must be clear and photographically reproducible. Impression must not cover text or lines. If seal impression smudges, ro-seal if a sufficient area permits, otherwise complete a different acknowledgment form. • Signature of the notary public must match the signature on file with the office of the county clerk. Additional information is not required but could help to ensure this acknowledgment is not misused or attached to a different document. Indicate title or type of attached document, number of pages and date. •'r Indicate the capacity claimed by the signer. If the claimed capacity is a corporate officer, indicate the title (i.e. CEO, CFO, Secretary). • Securely attach this document to the signed document 2008 Version CAPA v12.10.07 800-873-9865 www.NotaryClasses.com -. --~. o~•cA,~~ ti~ ~~ ~~ v r y~ G ,~RCHARV• CITY of CAMPBELL Public Works Department July 19, 2012 Mr. Vinh Le 2042 Tully Rd. San Jose, CA 95122 SUBJECT: PERMIT NO. ENC 2010-00111 1374 E. Hamilton Ave. ONE YEAR MAINTENNACE INSPECTION AND ACCEPTANCE Dear Mr. Le: The City of Campbell has made the final one year maintenance inspection of the subject Public Works improvements and finds that no remedial work is required. Your warranty requirements and any surety, therefore, are hereby released. Please find attached your Assignment and Receipt of Investment Certificate in the amount of $30,000.00 which we are returning to you. Sincerely, Syed Wahidi Public works Inspector Cc: Permit #ENC 2010-00111 Public Works Maintenance Division Wells Fargo Bank, 2170 Tully Rd., San Jose, CA 70 North First Street Campbell, California 95008-1423 TEL 408.866.2150 Fwx 408.376.0958 TDn 408.866.2790 12/18/2010 20:48 4e8376~--° SAN 0 ~ 20~~ PUBLIC WORKS '- PAGE 02/02 PUBLIC WORKS ADMINISTRATION ~~NN tt n ASSIGNMENT AND RECEIPT OP INVF•STNIENT CERTIFICA'l:'): P. W, Permit o.C/`I~CJ ~~ _ t~ !r r TO Gl"I'Y Oit CAI~IPBET~, 70 N. k~ItST STREET TR or DL•V ~ l/>7/ ~~-r/T CAMP13ELi.• CALTPORNin 95008 (40$)SGf,-2150 Lac. T am/vVc are the owner(s) of a savings account at W Ells ~-~RG-a ~~N ~ at its branch office at x.17 0 "TLILL`/~0~-D , ShN ~S>~ ,California, investment certificate No, ~ °I' ~6 S 12 0 ~ 0 7 in the names of Li i y o~ LA MP R E IrL and having a present balance of $ 3 0~ O UO • 0 O I hereby grant, transfer and assign vaid account, said investment certificate, said balance (including interest which accrues thereon), and all other rights in connection therewith to the CITY OIL CAlvi1~I3ELL, assignee, for a good .end valuable eonsideratio ,receipt of which is h_eteby acknowledged, for rho purpose of insuring construction descr, ibcd as followv: ~ l l~ S~h-~.~ 1m.~ i~t~rrten~~ UV I have nhvsieally delivered verification of said investment certificate and duulicate of this AssignmenC and Receigt Co said assignees I understand that assignee can withdraw from said account any Cime on his signature alone upon presents.tion of a written order to the issuer. i also understand that Z may not withdraw from said account unless I present a ~igncd 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 _ - 2 22 ~, 20 I O , at said office of the issuer. Assignor (sign . v ~ N i-1 1-£ (print) ACICNOWLET~GIVIEI~TT' BY ISSUER Jssuer affirms that there arc no other holds on sttliject account, that subject monies arc avaitable, and that the above-described assignment has been noted on the Records of said isaucr. ire ~~~/ ~-~ 13y (Authorized Signature) T1'ACi~ 1VOTARX ACTCNOWI F.DGMENT 1'itic R ~ g .Ti/V E f S ~V E ~ ~ % , i~l~t-A R-`/ P Cl°3irtc : C~-u`j ~ht i`-t ai\1 TI ~I INSTRUCTIONS TO ASSI~NI~ Please sign bclaw for signature identification and as acknowledgment. of your notice of Assignment. Return this Assignment and Receipt to the issuer at its address abc-vc. Ret•un one copy of this Assignment and Receipt for your files. Jute ~~_ City-5~~~~1 sy RELEASE OT ASSIGNEE Said assignee hereby releases find relinquishes all his right, title and interest in and to said account, said investment. certificate, sntd balance and ail ether rights in connection therewith. Date~7 t7 Z city cf. pbetl t;:1DOCUMF.-I\Admin\IAC'ALS- I lTcm~\ASSiBnment Rc Rceci~G of Inv~~incnc Ccrcif~catadx fRcv, 0~/08) In addition to signing here, notaries may attach a standard form of acltnowledgement if they wish NOTARY ACKNOWLEDGEMENT Document Title: - ~`. a~~ ~ la~u,~~~~--~;~-t~ (~r~l `cif ~ Yl a v~C t ~- c~ y ~f C~ c- (~- Signature: State of California County of Santa Clara On ~, ~ --- 2 ~ ~ 21,E L V ,Before me, Quyen Man Tieu (Notary Public), personally appeared ~y N cYec ~~ roved to me on the basis of satisfactory evidence to be the person(s) whose name sure subscribed to the withinrr i~~ns~~tr~~ument and acknowledged to me that he a ey executed the same in his~:::%'.'eir authorized capacities, and that by hi er eir signatures on the instrument the person (s), or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand and official seal. ._. ~__. Signature of No Public: Quyen Man Tieu GUYEN MAN TIEU~ Commission # 1761610 Nota~t Pubilo - California Santa Clara County /-up 13.2011 UYEN AN TIED Commbslon ~ 1761610 Nofary Public - Cailtornlo Santa Clora County MYGbmn, E>~NasAtg 13, 20t l CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit # ENC2010-00111 Property Address 1374 E. Hamilton Ave., Campbell, CA 95008 Date of Final Inspection: 6/18/12 On File: ^ Bonds ~ CD ^ Cash ^ Faithful Performance: $30,000.00 ^ Labor and Material $ ^ Construction Cash Deposit to be released ^ Other overdue deposits to be released (Description): Processed by: Administrator Reviewed by: In Reviev~ed by: 0 , tip~1, (~,2 Land Development Engineer C:\Documents and Settings\joannat\Desktop\My Forms\Deposit refunds\Checklist - Clearance for Final Insp and Acceptance.doc (Rev. 10/11) ,~ __. _ i CITY OF CAMPBELL vENDOR No. 10010945 cxECx No. 232373 Account Purchase Order Invoice Number Arrwttnt Descr tion 101 2203 101.540 7448 CR060511 CR060511 598.04 .82 DEPOSIT REFUND INTEREST IWIl1Y4S ALLAN IrtAI`1 ,,.-c z 'x g n ~ __ _ - _ _ a ., _ __ .. ._. "See Reverse Side For Easy Opening instructions* CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 ALLAN TRAN 2042 TULLY RD SAN JOSE CA 95122 O~'~~b ~]~ Q~ CAMPBELL ~ WEt,t.C BAROd. BANK, t~,R. T $ CHECK DATE CHECK NO., X11-24 0 6 / 2 7 ~ 11 2 32 3 7 3 70 NORTH FIRST STREET ~~ .: ~~ B a za MorrraoMERY sTR CA4104 SSAN FRANCISCO lalo f c; r Cf~MPBELL, CALIFORNIA 95008 , AMOUNT ~ *******598.86* ~ a o ~ ~ . r'`°' c', VOID AFTER 90 DAYS ~ ~ ~KQIfA49.. PAY THE SUM'OF FIVE HUNDRED NINETY EIGHT DOLLARS & 86 CENTS TO THE ALLAN TRAM oRDEx.' 2042' TULLY RD ~~s"`~r .' ~A aF 5AN JOSE CA 95122: u'23237-3u~ ~i2LQa0>248 .. :. ~. 4i2i8554 : L511* _ __ ..~~ ~~6i0-ooi l~ _ ~ __ _. i - CITY OF CAMPBELL vENDOR No. 10010944 CHECK No. 232326 Account Purchase Order Invoice Nrtatbe~ Amount Descrtiom 101 2203 101.540 7498 CR060511 CR060511 1,200.00 .87 DEPOSIT REFUND INTEREST 1001044 VINH LE • 1 ,Q~'~~tp~ CITE' Off' CAMPBELL WES:L5 FARGO SANK, N.A. CHECK DATE 11-24 06/27/11 CFjECK NO, 232326.' ~ ~ ~ 3p NORTH FIRST STREET 4zo MoNTCOMSxx sTTZEer 4 lzlo L "r CALIFORNIA 95p08' CAMP9ELL SAN.FRANCISCO; CA9410 i ~o o ., - AMOUNT ~ *****1 , 200 . 87* ~j ~ ` ~ ~' , ~i ~ ~ i ~kCItAAV VOID AFTER 90 DAYS DI PP,Y THE SUM'OF ONE THOUSAND,: TWO ~ HUNDRED DOLLARS & 87 CENTS m~ F To Tx~ VINH LE ~,,p` .---- ~ ` ~ ~ ~ ~ oRDEx 2 0 4 2 TULLY RD /{ r 1 ,/ ' ~ ' ? A ~tr.-,~,- -'c +O v m V ~~of~~ SAN JOSE CA 95122. t ~_..~ 4 u^23232'611' ~L2000248r: wi2i85545ii' ~- _ __ *See Reverse Side For Easy Opening instrucfiions* F- ~ CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 VINH LE 2042 TULLY RD SAN JOSE CA 95122 ENC2n 1o-C7~ I11 ~ ~ 12/18/2010 20:48 408376958 ,AN O ,~ 20~~' PUBLIC WORKS -~~ PAGE 02/02 PUBLIC WORKS ~ ~S _ ~ V~~' ~,' \'~ \ ` ADMINISTFWTION ASSIGNMENT AND RECETPT OP IIVVFsSTIVIlr~VT CERTIFICATE P.W. Permit o.~~~ ~~ -~ r ~ T(7 CITY O>t~ C/~MPBEL.I,r 70 N. FIRST STREET. TR yr AL-V J''>~~_ -~_ . ,~/p/ .~ ~ CA1vIPi3EI.T., CAi.1PORNi/~ -95008 (408)BGG-2150 ~,o, i Am/Wc are the owner(s) df. a savings account aC W ELLS •(= fZG~ P tit its branch office at ~~ D "TLI I..LY RO ~D ,~ S N ; ~U S>; ,, California, investment certificate No. $ °I' b S 1 ~ o ~ 0 7 in the names of ~~ ~ y o~ LA MPR : ~- ,__, and having a present balance of $ 3 0~ 0 v o• 0 0 I hcxeby grant, transi'er and assign vaid account, said investment certificate, said balance (including interest which accrues thereon), and all other rights in connection therewith to the CTTX' Or CAMPI3F.LI,, assignee, for a good and valuable eonsidersttio ,receipt of which is hereby aclmowledged, for the purpasc of insuring construction described as follows: ~, Sl k? .~~{Yp,~- 1mQI~tJP(1r7~/~~ I have nhvsically delivered verification of said investment certificate and duplicate of this Assi~nmenC and Receipt Co said assignee, I understand that assignee can withdraw from said account any time on his signaCUre alone upon presentation of a. written order to~thc 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 cerl:ificate assumes no responvibility for the conduct of the assignee and may act on the signatutc of the assignee without further inquiry. Bxecutcd on _ l ~:f 22 ,,,_, 20 I O , at said ofFce of the issuer. (print) ~- ~~'~'"~ Assignor (sign ACKNOWLEpGMENT BY ISSUER issuer affirms that there arc no other holds on subject account, that subject monies arc availl~le, and that the abovo-de.~cribed assignment has been noted on the Records of said issuer. ate~o~o~./ i.~ 13y (Authorized Signature) '.t1'ACHNOTARX ACIZNOWi.EDG1vIENT 1'itlc )~S.TiIV EIS ~'J'E"~'2~-~ s j , ~„ htorA R-`( P UniLlc ~ C~-uy ~N 1`~-AN T[ I~ CSI INSTRUCTIONS TO ASSIGNEE Please sign below for sigr-ature identification and as acknowledgment of your notice of Assignment. Retuir this ,Assignment and Receipt to the issuer at its address abnvc. Rcttiin one copy of this Assignment and Receipt for your files, )~ate~~ City-~~j~~ll eft By C ~~~~~~ .. ~ A E 01~ ASSIGNEE Said nssignce hereby releases and relinquishes all his risht, tide and interest in snd to said account, said investment. certii~icate, said balance and all ether rights in connection therewith. Date City of Campbell RY~ (;:1D000MF.-• 11AAmin11.OCALS~ I \Tcmp\ASSiBnment Rc Recci~t o(Invr.~tment Cen:i ricatc.dx (Rev. 03/08) `\ In addition to signing erre, notaries may attach a standard form of acKnowledgement if they wish NOTARY ACKNOWLEDGEMENT Document Title: 1~ z~~ -~-l ' ~ (~lU ,l~(•yl-~;~-f- (Q''y-~, ~;~. ~/ I ~-I~ U y ~1~' C~ c- l~- Signature: State of California County of Santa Clara On __~ -- 2 ? -- ~ (~ ,Before me, Quyen Man Tieu (Notary Public), personally appeared Tiit.(Y N e,cc ~~ roved to me on the basis of satisfactory evidence to be the person(s) whose name • sure subscribed to the within instrument and acknowledged to me that he a ey executed the same in his er eir authorized capacities, and that by hi er eir signatures on the .instrument the person (s), or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand and. official seal. _.__._ ~- } - --_... Signature of No Public: Quyen Man Tieu ~C1UYEN MAN TIED ! Commlaalon # 1761610 Notary Public • Colifornla Banta Ctora County MyC~rm,B~i~rtN,rp) 8,207 1 DOYEN MAN TIED Commlulon #r 1761610 Nofary Public - Calltornia Sanfa Ctara County MyComm, E~ia~sAuA 13,2011 June 6, 2011 Allan Tran 2042 Tully Road San Jose, CA 92122 of . oAM~~ ~~~ ~ V r ,, > ti ~ f (; •~RCH A0.• CITY of CAMPBELL Public Works Department SUBJECT: PERMIT NO: ENC2010-00111 LOCATION: 1374 E. Hamilton Ave. FINAL INSPECTION AND ACCEPTANCE Dear Mr. Tran, ~,,, 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 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. Your Plan Check Deposit, 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, -- Syed Wahidi Senior Public Works Inspector MQ'~i,~. cc: Suspense -11 months Permit # ENC2010-00111 Inspector File J:~.TeanineG~ENC2010-00111,2nd Ref. Final Inspection.doc 70 North First Street Campbell, California 9 5008-1 42 3 're[ 408.866.2150 Fnx 408.376.0958 ton 408.866.2790 ~- 1 -•. CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit # Cf~IC~2~t- n- p D ~ 1 I Property Address 1~1'~ ~ , ~'{~wli l-~YU ~c~JP, Date of Final Inspection: On File: ^ Bonds ^ CD ~" Cash ^ Faithful Performance $ ^ Labor and Material $ ^ Construction Cash Deposit to be released : $ Other overdue deposits to be released (Description): P1al~ Cl~~k D.~cx-~~it~ ~R8 D~ ,(Processed by: C~ Reviewed by: Administrator Ins Reviewed by: Land Development Engineer Reviewed by: Engirl+ger J:\FORIv1S\Templates\Administrative\Checklist -Clearance for Final insp and Acceptance.doc (Rev. 03 10) Jea~ _ ` Grundman p~ ~ C'4.tt Oft. ,~¢sistant ~~i A~~ City of Campbell ~, r Department of Public Works U r 70 North First Street 0 o Campbell, CA 95008 Phone: (408)866-2150 yA o e v • °~ Fax: (408) 376-0958 CH A¢ E-Mail: jeanineg@cityofcampbell.com Transmittal To: Allan Trap Date: 06/27/11 Company: Address: 2042 Tully Rd. San Jose, CA 95122 Re: Check for funds release of permit #ENC2010-00111 ^ Urgent ^ For Review ^ Please Comment ^ Please Reply x ^ For Information & Use I have attached your check totaling $598.86 of funds released for the project at 1374 E. Hamilton Ave., Campbell, CA 95008. This check represents your Plan Check Deposit of $598.04, plus any interest due. Thank you, Jeanine Gnmdman J:UeanineG~ENC2010-00111, Transmittal Hamilton Ave., 1374 E..DOC ~- CITY OF CAMPBELL vENDOR No. 10010945 cHECx No. 232373 ., Account urchase Qi~ler Invoice Number Amount Descr ton 101 2203 101.540 7448 CR060511 CR060511 598.04 .82 DEPOSIT REFUND INTEREST 10010945 ALLAN 1 KAIV 47~'C'utp' C'X Q~ CAMPBELL WEL5 eAROO sANR, m:A, ~ CHECK DAVE CHECK" NO .: x,31-2a 06/27/11 232373 ~~ - ~ 4ZG MONTGOMERY 5TRE~ET 1210 to 70 NORTH FIRST STREET sAN FRANCiseo, cA 4aloa ,. U ~' CAMPBELL, CALIFORNIA 95008 c o AMOUNT ~ ~*******59$.86* ~ ~ ~ ,~~ ~~cli~ao ~` VOID AFTER 90 DAYS ~ '.PAY THE SUM OF FIVE HUNDRED NINETY EIGHT'DOLLARS & 86 CENTS ~, ~.. F TO THE ALLAN TRAN _ oxD~ia 2042 TUT,LY RD 5~}`'~ ;' ~A -~, of SAN JOSE CA 95]::22 /~tc~ 1 L 1 CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 ALLAN TRAM 2042 TULLY RD SAN JOSE CA 95122 ~. of ' oAMn _~' ~~ V r ,, ~^ - c; •~~CH AR~• CITY of CAMPBELL June 6, 2011 public Works Department Allan Tran 2042 Tully Road San Jose, CA 92122 SUBJECT: PERMIT NO: ENC201 0-001 1 1 LOCATION: 1374 E. Hamilton Ave. FINAL INSPECTION AND ACCEPTANCE Dear Mr. Tran, 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 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. Your Plan Check Deposit, 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, =~~~ Syed Wahidi Senior Public Works Inspector MQ"~. cc: Suspense -11 months Permit # ENC201 0-001 1 1 Inspector File 7:UeanineG~ENC2010-00111,2nd Ref. Final Inspection.doc 70 North First Street ~ Campbell, California 9 5008-1 42 3 ~ Tee 408.866.2150 ~ FAx 408.3/b.vy~u ~ ~w vvo.a --- a Refundable deposit Check Request To: Finance Director Check Payable To: Allan Tran Address -Line 1: Line 2: 2042 Tully Rd. City: San Jose State: CA Zip: 95122 Description: Refund Deposit for ENC2010-00111 Account Number: 101.2203 Amount: $598.04 Account Number: Amount: Account Number: 101.540.7448 Amount: (Finance Dept only) Interest Earned (Finance Dept only) Total Payable: $598.04 (exact Amount) Purpose: Refund Plan Check Deposit ( $598.04) for 1374 E. Hamilton Ave. Voucher #: Permit #: ENC2010-00111 Receipt #: 227910 Date: 7/26/2010 Requested by: Syed Wahidi Title: PW Inspector Date: 6/5/2011 n~ ~A ~~ Approved by: Michelle Quinney ~'V~ Title: City Engineer Date: 6/5/2011 Finance Dept Only: Verified by: Title: Date: Approved by: Title: Date: Special Instructions For Handl in4 Check Mail As Is: Marl in Attached Envelope: Interim Check: Needed By: Return To: Jeanine Grundman PW (Name) (Department) Other: Un: Fortns/exceUehkreq - Revised 05/00 ,~ CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit # y,~w~ tie Property Address I ~~ y ~. H ~ vn i ~~o tit A v~e Date of Final Inspection: 1o~5~2D l ~ On File: ^ Bonds ~. CD ~ Cash !/~ Faithful Pertormance $~TOOD. ~U ^ Labor and Material $ ~l Construction Cash Deposit to be released: $ I,~DO ~ OU ^ Other overdue deposits to be released (Description): Processed by: Reviewed by: Reviewed by: Reviewed by: (/ Administrator ..~~--~ Inspector Land D opment Engineer City nginee J:\FORMS\Templates\Administrative\Checklist -Clearance for Final Insp and Acceptance.doc (Rev. 03 10) ,~ __ _ _ .., ! -I CITY OF CAMPBELL vENDOR No. 10010944 CHECK NO. 232326 Account P«rchase Order Invoice Num6e~ Amount I~escri tiorr 101 2203 101.540 74A8 CR060511 CR060511 1,200.00 .87 DEPOSIT REFUND INTERES'P IOOIU944 VINH L8 • ~"~'~'~' QF CAMP~ELL p~' ~C~t CHECK DATE '; CFjECK NO. wEr~r,s aARC,o er~rnc, N.A. p Q~ ~ 70 NC7RTH FIRST STREET ` t a-za 4 2D MONTGOMERY STREET 1210 0 6~ 2 7~ 11 2 3 2 3 2 6; , r, L' r GAMPBEtL, CALIFORNIA 95008 sax FRaxcrsco, cA 9a1o4 0 0. - AMOUNT ~< *****1,200.87* oI ~. : ~ ~ p~0j{Aw • VOID AFTER 90 DAYS ~~ D .FAY THE. SUM OF ONE THOUSAND,. TW'O HUNDRED. DOLLARS.& 87 CENTS ~~ -1 TO THE VINH LE 1 _ ORDER 2042:-TULLY RD r„ (~ ~~~`'~ ~ - ~?A~~`- °•~ ! - of ~ ~ SAN JOSE CA 9.5122 / _...~ ~ .L~ ~ L.../ ~ ,~~,,. (. Q. ~- ~ CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 VINH LE 2042 TULLY RD SAN JOSE CA 95122 Jean Gruudman OF Cq,kA Ofi ssistant `'~ ~~ City of Campbell U ~ Department of Public Works 70 North First Street 0 o Campbell, CA 95008 yR ~: Phone: (408) 866-2150 ° e c H ~ 40 ' Fax: (408) 376-0958 E-Mail: jeanineg@cityofcampbell.com Transmittal To: Vinh Le Company: Date: 06/27/11 Address: 2042 Tully Rd. San Jose, CA 95122 Re: Check for funds release of permit #ENC2010-00111 ^ Urgent ^ For Review ^ Please Comment ^ Please Reply x ^ For Information & Use I have attached your check totaling $1,200.87 of funds released for the project at 1374 E. Hamilton Ave., Campbell, CA 95008. This check represents your Construction Cash Deposit of $1,200.00, plus any interest due. Thank you, Jeanine Gruudman J:UeanineG\ENC2010-00111, 2nd Transmittal Hamilton Ave., 1374 E..DOC of ' cAMn~ ,'~~ F V r y f L •~RCH AR~• June 6, 2011 Vinh Le 2042 Tully Road San Jose, CA 92122 CITY of CAMPBELL Public Works Department SUBJECT: PERMIT NO: ENC2010-00111 LOCATION: 1374 E. Hamilton Ave. FINAL INSPECTION AND ACCEPTANCE Dear Mr. Le, 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 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. Your Construction Cash Deposit of $1,200.00, plus any interest due, is now being processed and will be sent to you under separate cover. The Faithful Performance Security Deposit will be kept in force for the duration of the one year maintenance period. We will continue to hold the Assignment and Receipt of Investment Certificate for Street Improvements in the amount of $30,000.00 for one year unless you would like to replace it with a Maintenance bond. If you have any questions, please call me at (408) 866-2165. Sinc ely, Syed Wahidi Senior Public Works Inspector MQ cc: Suspense ~- 11 months Permit # ENC2010-00111 Inspector File J:UeanineG~ENC2010-00111, Final Inspection.doc 70 North First Street ~ Campbell, California 9 5008-1 42 3 ~ -rs~ 408.866.2150 Fnx 408.376.0958 ~ T~~ 408.866.2790 r-- ~~ Refundable Deposit Check Request To: Finance Director Check Payable To: Vinh Le Address -Line 1: Line 2: 2042 Tully Rd. City: San Jose State: CA Zip: 95122 Description: Refund Deposit for ENC2010-00111 Account Number: 101.2203 Amount: $1,200.00 Account Number: Amount: Account Number: 101.540.7448 Amount: (Finance Dept only) Interest Earned (Finance Dept only) Total Payable: $1,200.00 (Exact Amount) Purpose: Refund Construction Cash Deposit ($1,200.00) for 1374 E. Hamilton Ave. Voucher #: Permit #: ENC2010-00111 Receipt #: 231653 Date: 12/22/2010 Requested by: Syed Wahidi Title: PW Inspector Date: .~--° Approved by: Michelle Qui __ Title: City Engineer Date: Finance Dept Only: Verified by: Title: Date: Approved by: Title: Date: ~ecial Instructions For Handlinc Mail As Is: I Return To: Other: Mail in Attached Envelope: Jeanine Grundman (Name) Interim Check: Needed By: PW (Department) 6/5/2011 6/5/2011 eck f/n: Fonns/excel/chkreq - Revised 05/00 ~~ O~ CA~A~ .. r U r 0 0 ~, y ~ ~ G~ 'pkCHA¢~. Transmittal Joy Francois Executive Assistant City of Campbell Department of Public Works 70 North First Street Campbell, CA 95008 Phone: (408) 866-2150 Fax: (408)376-0958 To: Vinh Le Date: 5/17/11 Address: .2042 Tully Rd., San Jose, CA 95122 Re: 1374 E. Hamilton Ave. Campbell CA ^ Urgent ^ For Review ^ Please Comment ^ Please Reply x For Information & Use Enclosed please find a copy of the recorded Certificate of Compliance, Document # 21141687 for the above referenced location. Joy Francois Recording Requested by and when recorded mail to: Public Works Department ) City of Campbell ) 70 N. First Street ) CAMPBELL, CA 95008 ) REGINA ALCOMENDRAS SANTA CLARA COUNTY RECORDER Recorded at the request of City Pages ~ 24.00 24.00 RDE # 009 4/11/2011 10 19 AM APN: 288-13-056 & 288-13-057 (Space above this line for Kecorder's use oruy) Address: 1374 E. Hamilton Avenue, Campbell, CA CERTIFICATE OF COMPLIANCE Lands of: T&L Family Investments LLC, a California Limited Liability Company Notice is hereby given pursuant to Section 66499.35 of the Government Code of the State of California that the real property described in "Exhibit A" attached hereto and made a part hereof, complies with the requirements of the Subdivision Map Act, and all local ordinances enacted pursuant thereto. This Certificate of Compliance is issued for Lot Line Adjustment purposes approving the adjustment of parcels as described in Exhibit A attached hereto and made a part hereof. The pazcels affected include: Assessor's Pazcel No. Address 288-13-056 1374 E. Hamilton Avenue, Campbell, CA 288-13-057 1374 E Hamilton Avenue, Campbell, CA CERTIFICATE OF COMPLIANCE NO. 2011-003 Date: ~' S - j/ Michelle Quinney City Engineer DOCUMENT: 21141687 Fees.... Taxes... Copies.. .-. .. .. n-, AMT PA 1 D Date: ~ Z~ H By: H 'chs Comm evelopment Director STATE OF CALIFORNIA ) COUNTY OF SANTA CLARA )SS On ~ I ~.~ i l ,before me, fTl1Y~ ~ ~t ~ , a Notary Public in and for said State, personally appeared Michelle Ouinney and Kirk E Heinrichs , who proved to me on the basis of satisfactory evidence to be the persons whose names are subscribed to the within instrument and acknowledged to me that they executed the same in their authorized capacities, and that by their signatures on the instrument the persons, or the entity upon behalf of which the persons acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand official seal. ANNE BYBEE CommbBlon # 1794690 Notary Public - California Signature 1 Santa Clara County Signature of Notary Public ~r++~ t~tMar~'2otZ Silicon Valley Land Surveying, Inc. Project No. 10-0180 November 1, 2010 Exhibit "A" Legal Description for Merged Parcels Lands of Duerksen Campbell, California Certain real property situated in the City of Campbell, Santa Clara County, California, being Lots 23 and 46, Tract No. 1115 as recorded Apri121, 1953 in Book 42 of Maps at Page 30 in the Official Records of Santa Clara County, California, and more particularly described as follows: Beginning at the southeasterly corner of said Lot 23; thence along the southerly boundary of said Lots 23 and 46 South 89°45'00" West 217.00 feet to the southwesterly corner of said Lot 46; thence northerly along the westerly boundary of said Lot 46 North 00°11'45" West 46.69 feet to a tangent curve to the right concave southeasterly with radius 20.00 feet, said curve being the northwesterly boundary of said Lot 46; thence along said curve with internal angle 89°51'45" and length 31.37 feet to the northerly boundary of said Lots 23 and 46; thence easterly along said northerly boundary North 89°40'00" East 177.00 feet to a tangent curve to the right concave southwesterly with radius 20.00 feet, said curve being the northeasterly boundary of said Lot 23; thence along said curve with internal angle of 90°08' 15" and length 31.46 feet to the easterly boundary of said Lot 23; thence along said easterly boundary South 00°11'45" East 46.91 feet to the Point of Beginning. Area of parcel: 14,324 square feet The basis of bearings for this description is the centerline of East Hamilton Ave between Manchester Avenue and Nottinghanz Way as shown in Book 42 of Maps at Page 30 of Santa Clara County Official Records, recorded Apri121, 1953. End Description SHT 1 of 2 4~~~ ~; ~~ Ems. ' ~-- ~ ~-.cl~. No. L7527 W 0 R=20.00' ~=90'08'15" L= 31.46' I `'-ti NOTTINGHAM WAY S00'11'45"E ~~ POB - 46.91' IDOC. N0. 19096211 I LOT 23 I APN: ---- 60~ -~ I 288-13-057 LOT 24 0 o_ Q I N (/') Z Q w m 0 Q 100 .. w 0 0 0 ao I~ z W 4' I APN: I` 288-13-058 ~ LOT LINE TO r~~,!~ r r ~~~ J, I BE REMOVED 66.80' 10' r 1-~ r ~.~ w Opl L- ~--- N------- O ~ .__., ......_.~......_..... _._. . .......... .........._.~. ~... - - - - - - - - - - - - - - - ~~~~ f I II MERGED AREA: ° LOT 45 4' R=20.00' ~=89'51'45" L=31.37' , 14,324 SF .~- I IDOC. N0. 14659083 LOT 46 _ I APN: I 288-13-056 46.69' S00'11'45"E ~- --~ z JJJ J-~ APN: ~ , 5~~ ~J0 '~~'~L~ 288-13-055 ~~ ~; ~ .- ,.v 1* _ *5 _~; f -- fi -- MANCHESTER AVE . LEGEND S00'11'45"E POB POINT OF BEGINNING 0 40 80 - CENTERLINE V ,~ ,. - - BOUNDARY LINE L - - - - - - - - - PUBLIC UTILITY EASEMENT 42-M-30 SCALE: 1 "=40' LOT LINE ADJUSTMENT FOR ALAN DENTAL CARE, EXHIBIT "B" 1374 E. HAMILTON AVE, CAMPBELL, CA 95008 ~u~; 1 "= 40' SILICON VALLEY LAND SURVEYING, INC. DATE: 11 01 10 DES1~1 BY: v ~JRV. DAIS 06/08/10 ORANM BY: AA L LAND AND ENGINEERING SURVEYS ~ ND. 10-0180 CHECK BY: 1093 NORTH FIFTH ST., SAN JOSE, CA 95112 TEL (408) 971-3800 FAX (408) 971-8501 SHEET ? ~? SHEETS S00'11'45"E