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ENC2008-00084CITY AF CAMPBELL DEPT. OF PUBLIC WORKS 70 North First St. Campbell, CA 95008 (408)866-2150 Fax (408) 376-0958 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. AppliJ'c~ation/Fee is~n~on/-~refundable.) A. Work address or tract # ~ ~ ~ v l~ ~f~GCJC Utility trench B. Nature of work C. Attach four (4) copies of an engineered plan showing the location and extent of the work, and four (4) copies of the preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer, said plan becomes a part of this permit D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Constmctien; 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 Sondes and cash deposits. (See General Permit Conditions 1 and 2.) 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 24-HOUR EMERGENCY TELEPHONE E-Mail Address Is this work being done by the property owners at their own residence? Yes ~~No The ApplicandPermittee herby 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 ar demand for damages resulting from the work covered by this permit. The Applicant/Permittee hereby acknowledges that they have read and understand bhth the fret 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, ar property owner's successors, 'shall be responsible for any and all damages arising out of the ftSe flition of any private improvemen in th~ublic right-of-way. ~-e2y-y ..,~ (Applicant ermittee) (sign) Date Contractor (Print Name) Date _1. Street shall not be open cut for underground installations. Minimum cuts ng<X be allowed for connections ar exploration holes. Such cuts be specifically anoroved by the lns~prior to cooing. _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 Inspector. _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 wank. _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 wank, 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 WOI;KS FEE SCHEDULE FOR CURRENT FEES PERMTI' APPLICATION FEE PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCE/LABOR 8t MATERIALS CONSTRUCTION CASH DEPOSIT PLAN CHECK & INSPECTION FEE s.,_?1 APPROVED FOR ~`` ~ ~ROACHMENT PERMIT (for working within the public right-of--wlay) Issued J ~ ~' ~ ' Permit Expiration Date ~~ ~ O ~~~ (print Warne) For City Engin! Permit Expires 12 Months s Pet.~~ ~~~08~~D~Y' -Ref. File .. Application Date ~ -~~' Application Expiration Date APN 7.~~ 2.S-' ~~ Telephone AMOUNT RECEIPT NO. $ 31sa - 20$1 !8 $ 5~_ ?.ab 179 g ~t29p r ?1 f~ ~\ 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 Permittce. 2. A one-year maintenance period and~surety are required. Such period will begin on date of written acceptance by the City. 3. Refund of 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 Permittce 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 Pertnittee. 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 Schednle aze required for all lane closures, detours and street closures. This plan must be reviewed and approved prior to any lane closures. 7. The Construction Traffic Control Plan shall conform to the Calttans Manual of Traffic Controls for Construction and Maintenance Work 7.ones, dated 1990, available at Cahrans. Traffic control equipment shall include Type II flashing arrow signs if required. 8. Replace as dir+ectetl by the City Engineer any damaged or removed improvements in accordance with City Standards and Specifications at Ute sole expense of the Permittee. 9. Sawcut for all PCC or AC removals. All PCC removals shall be to nearest scoremazk and shall be doweled to existing improvements. t0. 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 the job site. Failure to provide such signing and barricading tray result in the City's providing signing and barricades and charging the cost (including all labor and materials) against the cash deposit. 12. Compaction [eating of subgrade, base rock, and asphalt concrete by Permittce is required unless otherwise stated by the City Engincer. 13. The Contractor or Permittce will have a supervisory represmtadve available for contact ~ the project at all times during construction. Contractor or Pertnittce 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 shoulderline which would create a ha7aMous condition to the public. 15. This permit s~rall not be construed as authorizagon for excavation and grading on private property adjacent to the work or any other work for which a separate permit maybe regnreci, not does it relieve the Permittee of any obligation to obtain any other permit required by law. 16. This permit does not release the Pemtittce from any liabilities contained in other agreements or contracts with dte City and any other public agency. 17. This permit is not transferable. Work must be performed by the Permittce or his designated agent or contractor as specified thereon. 18. Call back (call out) due to emergencies regarding this permit shall be at the current overtime rate with a throe (3) hour minimum charge per occurrence. 19. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be dischazged any material into the municipal storm drain system other' than storm water. Appticatrt shall adhere to the BBST 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 City 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. Permittce must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by 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 awaze of and understand all of the above conditions. ~ -2 r/-oq Date Date --~ ~~ CERTIFIC~ _ i E OF LIABILITY INSURt..1CE ~ ID sL °"~'""~°°"""' 04 12 11 THIS CERTIFICATE IS ISSUED A8 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 REPRESENTAT'NE OR PRODUCER, AND THE CERTIFICATE HOLDER. r sae m e ,w o the teens and condkions of the policy, certain poltciss may roqulro an endoroemerlt. A statement on this certittcate does not coMer rights to the csrtiflcate holder in Ileu of such endorseme s). PRODUCER ~: Associates Insurance Hozzuto E N" ~ NO7 . . One Almaden Blvd Suito 810 _ ADDRESS: Saul Joao C11 95113. cusroMER m e: ROH$R02 Phona:800-989-8712 Fax:408-288-7130 IrapAIER(a)AFFORDINGCOVERAGE wuCt INSURED INSURERA: Cent13 Sure C 36951 RQ1~~t$uQnstsvc ion INBURERB: sr.=.et rational xn.urano. ce. 10120 lLos Gatos C~1 952 INSURER c INSURER D BNWRER E NRRIRER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE SrSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOT1MThISTANDINGAHYREQUIREMENT, TERM OR (X)NDrTION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICFI THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAMI, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 69 SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CWMS. L TYPE OF INSURANCE INeR POLN:Y NUMBER LaaTB GENERAL LIABILnY EACH OCCURAENCE S 1 OOO OOO A JC COMMERCUILGENERALLU1BILnY CCP695895 oa/oi/11 oa/01/12 PREIiMSEB Eaaoeurones s 100 000 CLAIMS-MADE ®OCCUR MED EXP (Arty one person) s 5 000 g PERSONALaADVINJURY i 1 OOO 000 GENERALA(i(3RE<aATE s 2 000 000 GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS - CoMP/OP AGG S 1 000 000 R POLIC.w ~D- Loc s AUT OMOBILE LIABILRY COMBIIa:D SINGLE LIMIT E dd t t ( en a ec ) ANY AUTO BODILY INJURY (Per person) S ALL OWNED ~~ BODILY INJURY (Per axident) S SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE (Pa+~denU s NON-0WNED AUTOS s s UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMg.MADE AGGREGATE S DEDUCTIBLE s RETENTION S s AN TION D EMPLOYERS' LUUNLnY 02/01/11 02/01/12 TpRy LIMITS ER ANY PROPRIETORfP/IRTPEWEXECUTIVF~~ / A E.L. EACH ACCIDENT S 1 OOO OOO OFFICERIMEMBER EXCLUDED? L~ (MendNory In NH) E.L. DISEASE - EA EMPLOYE S 1 OOO OOO DESCRI OF~OPERATIONS bebw E.L. DISEASE -POLICY LIMIT S 1 OOO OOO DESCRIPTgl1 OF I VENN:LLS (Atheh ACORD 101, Ad~tlarel Renrrks Sd~rk N mae epees k regaled) ~, 670 areas Avg., S Jo:e, 9$125. C ri ht-of- Cz o~ 11 C~L~y of ~~~11 a AQe~ay,Qits offi~orr} tloysa~e and'voluhtNrs ale Hamad as 0 fnsu~ as respects 1 i ty par endorsement. CERTE:ICATE HOLDER ~ ( sw CANCELLATION ~~ ` f SHOULD ANY OF THE ABOVE DESCRBED POLICIES 8E CANCELLED BEFORE THE EXPStATiON DATE THEREOF. NOTICE YNLL BE DELIVERED IN The City of Campbell ~ ?QJ ACCORDANCE YVITH THE POLICY PROV1810NS. J Attn : Dept . of Public 70 North First Street Campbell CA 95008 works S AUTHORI~D REPRESENTATIVE ~/ All riahts reserved ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD Policy Number: COMMERCIAL GENERAL LIABILITY CO ZO 33 07 04 THIS ENDORSEMENT CHANt3ES THE I~OLIDY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsemenrt modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Sectlon II -Who Is M Insured is amended to include as an additional insured any person or or- ganization for whom you are pertorming operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an addi- tional insured on your policy. Such person or or- ganization is an additional insured only with re- spect to liability for "bodily injury', "property damage" or "personal and advertising injury' caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured. A person's or organization's status as an addi- tional insured under this endorsement ends when your operators for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury' arising out of the render- ing of, or the failure to render, any professional architectural, engineering or sunieying ser- vices, including: a. The preparing, approving, or failing to pre- pare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifica- tions; or b. Supervisory, inspection, architectural or engineering activities. 2. "Bodily injury' or "property damage" occurring after: a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than ser- vice, maintenance or repairs) to be per- formed by or on behalf of the ~ditional in- sured(s) at the location of the covered operations has been completed; or b. That portion of 'your work' out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcon- tractor engaged in pertorming operations for a principal as a part of the same project. CCi 20 33 07 04 ®ISO Properties, Inc., 2004 Page 1 of 1 ~ INSURANCE REQUIREMENTS CHECKLIST Permit # '`'~~C 2~ ~ ' ~7~~~ ~ CIP Project # The following insurance is required of all contractors working ~i9-~Che 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: $1,000,000 per occurrence, and ^ $1,000,000 general. aggregate limit applying separately to the project, or $2;000,000 general aggre a e li it. Policy expiration date ~ b A < ,~ ~ ~ L Automotive Liability: J ~ !~, ^ "Any Auto" checked on certificate o $1,000,000 per accident for bodily injury and property damage ^ P.olicy expiration date Workers' Compensation and Employer's Liabili C~^ ~-.~ ~ \~ Waiver of Subrogation clause ''1~ ~ S oe~ c~-1 ~ $1,000,000 per accident for b dily injury or disease I ~Q Policy expiration date ~ ~-2d 1 1 . Course of Construction (if required in Special Provisions) ^ Completed value of the project ^ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies ~ tional 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. )Zi 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 agents or representatives". ^ Workers' Compensation Insurance Sheet Submitted ^ For General Contractor ^ For Developer or Owner ~"~ ~'t~ ~ (~-~ A ce tabilit of Insurer s lam" ~U J ~(~,''~_ 1/~`' Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Insurance Certificate Reviewed Initials Date i ^ Copy of Insurance Certificate placed in tickler file one month prior to expiration. .I:\FORMS\Templates\Insurance RequirementsUnsurance Requirements Cklist.doc (Rev. 03/08) From:Sandy Luu, CISR FaxID: __ Page 1 of 6 - ~ Date:11/10f2010 03:17 PM Page:1 of 6 E E3 ~-~~~ ~~° ~, sozzuTO`~''~ 1 N S U R A N C E S E R V I C E S One Almaden Blvd., Suite 810 San Jose, CA 95113 Phone: 408-947-3000 Faz: 408-288-7130 Fax From: Sandy Luu, CISR To: City of Campbell Pages: 6 Fax: (408) 376-0958 Date: 11/10/2010 03:17:14 PM Phone: ( ) - Subject: City of Campbell -REVISED Certificate Message: Joy Francois, Please see the attached revised certificate of insurance for our insured -Roberts Construction. If you should have any questions or need revisions, please feel free to contact our office. Thank you, Sandy Luu, CISR CC: Roberts Construction CC: City of Campbell/Fax: 408-376-0958 From:Sandy Luu, CISR FaxID: - Page 2 of 6 pate:ll/10/2010 03:17 PM Page:2 of 6 ~~ CERTIFICATE OF LIABILITY INSURANCE OPID $L DATE(MMIDDIYWY) 11/10/10 TH13 CERTIFICATE IS ISSUED AS A MATTER OF IN ORMATION ONLY AND CONFERS NO RIGHTS UPON THE C RTIFICATE 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 ce ate s an po yes must a en se . , s to the terms and condlHons of the polk:y, certakl poNcks may regrlire an endorsement. A statement on this certMcate does not confer rlgMs to the certNicate holder in Neu of such endorsement(s). PRODUCER NAME: BOZ ZiltO 6e ASSOCiateS IASIIISIICC (AlC, No, Ext): (AIC, No): One Almaden Bivd Suite 810 ADDRESS: $an Jose CA 95113 CUSTOMER ID #. ROBER02 Phone:800-989-8712 Fax:408-288-7130 MlSURER(S)AFFORDMIGCOVERAGE NAIC# INSURED ~ INSURERA: Century Surety RObeItS COIIStrLlCtiOA INSURER B : State C ensation Fund 16ti36 Farleyp Road Los Gatos CA 95032 INSURER C INSURER D INSURER E INSURER F CAVFRAf:FR CFRTIFICATF MIIMRFR• 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. NOTWITHSTANDINGAHY REQUIREMENT, TERM OR CONDITION OF ANY CONTR4CT 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 RJSR POLICY NUMBER (MMIDDMI'Y) (MMIDD/WYY) LIMITS GENERAL LWBILRY EACH OCCURRENCE $ $1 ~ DOD ~ OOO A X COMMERCIAL GENERAL LIABILITY CCP644070 04/01/10 04/01/11 PREMISES (Ea occurrence) $ $100 , 000 CLAIMSMADE ~ OCCUR MED EXP (Any one person) $ $5 ~ DOO X PERSONAL 8 ADV INJURY $ $1 ~ OOO ~ OOO GENERAL AGGREGATE $ $2 ~ ODD ~ OOO GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS - COMPIOP AGG $ R, 2 ~ O D O ~ OOO }{ POLICY JPERC LOC $ AUT OMOBILE LWBILrrY COMBINED SINGLE LIMIT $ (Ee accident) ANY AUTO ~ BODILY INJURY (Per person) $ , ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS IPer accident) NON-OWNED AUTOS $ UMBRELLA LU1B OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMSMADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ 8 AN D EMPLOYERS' LIABILRY - - 02/01/10 02JO1/11 X TORYLIMITS ER CUTIVE REXCLU IA E.L. EACHACCIDENi SIOOODOO ^ OFFICERlMEMBE DED9 (Mandatory In NH) X E.L. DISEASE-EA EMPLOYEE $ 1000000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE-POLICY LIMIT $ SOOOOOO Wr ed ) OCATIONS 1 VEHICLES (Attach ACORD 101, AddiMlonal Rsmerks SchsdWs, K mm ore space le rsg DESCRIPTION OF OPERAT IONS 1 L ii yp ppi a m p p eena ~ p b #~n g ~t med as and olufiteers a~ R develo employe e s ntAgencyl fts offiZers additional iasureds as respects liability per CGL18160106 and CG20370704. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THECITY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE Wmi THE POLICY PROVISIONS. The City of Campbell AttII: Dept. Of 1?ubliC WcrkS AUTIIORIZEDREPRESENTATNE 70 North First Street Campbell CA 95008 ®7988-2009 AGORD GORPORATIOR. Aq ngnrs reSefVeO. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD From:Sandy Luu, CISR FaxID: - _ Page 3 of 6 - Date:11/102010 03:17 PM Page:3 of 6 p ~ . t ~r ~~ s ~ , ~-~~,~' 30 days written notice will be provided to Certificate Holder should any of the above policies be cancelled prior to the expiration date. .o s. • . From:Sandy Luu, CISR FaxID: -. Page 4 of 6 Date:11/10/2010 03:17 PM Page:4 of 6 CERTHOLdER COPY ISSUE DATE: 11-OB-2010 CITY OF CAMPBELL 70 N 1ST ST CAMPBELL CA 85008-1458 P.O. BOX 420807, SAN FRANCiSCO,CA 94142-0807 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE GROUP: 000713 POLICY NUMBER: 0018831-2009 CERTIFICATE ICt 8 CERTIFRCATE EXPIRES: 02-01-2011 02-01-2010/02-01-2011 THIS CERTIFICATE SUPERSEDES AND CORRECTS CERTIFICATE N 5 DATED 11-08-2010 NG JOB:ENC N2008-00084 1870 GRACE AVENUE SAN JOSE CA 85125 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. We will also give you 10 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. Vi~WF~ thorized Representative Interim President and CEO UNLESS INDICATED OTHERWISE BY ENDORSEMENT, WVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPEN5ATION LAM. ILITY LTMIT INCLUDING DEFENSE C05T5: 51,000,000 PER OCCURRENCE. ENDORSEMENT ;82570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2010-11-08 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF CAMPBELL EMPLOYER ROBERTS, DAVID A 18838 PARLEY RO LOS GATOS CA 95032 NG [B13,NG] NG SREV.1~207D) PRINTED 11-08-2010 From:Sandy Luu, CISR FaxID: - Page 5 of 6 Date:11/10/2010 03:17 PM Page:S of 6 CGL 1816 0106 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS-- SCHEDULED PERSON OR ORGANIZATION -PRIMARY AND NON-CONTRIBUTORY COVERAGE This endorsement modifies insurance provided under the following: CONTRACTORS LIMITED CLAIMS MADE GENERAL LIABILITY COVERAGE FORM CONTRACTORS LIMITED CLAIMS MADE AND REPORTED GENERAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anization s : Locations Of Covered O erations City of Campbell 70 N. First Street 1670 Grace Avenue Campbell, CA 96008 San Jose, CA 96125 A. Section II -Who Is An Insured is amended to 2. That portion of "your work" out of which the include as an additional insured the person(s) or injury or damage arises has been put to its organization(s) shown in the Schedule, but only intended use by any person or organization with. respect to liability for "bodily injury", "property other than another contractor or subcontractor damage" or "personal and advertising injury' engaged in performing operations for a caused, in whole or in part, by: principal as a part of the same project. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insureds) at the location(s) designated above. 6. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insureds) at the location of the covered operations has been completed; or C. I ~ that the insurance provided for the benefit of th above additional insureds) shall be primary an non-contributory, but only with respect iability for "bodily injury", "property e" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insureds) at the locations} designated above. CGL 1816 0106 Includes copyrighted material of Insurance Services Office, Inc. with its Page 1 of 1 O permission. ©ISO Properties, Inc., 2004 From:Sandy Luu, CISR FaxID: - Page 6 of 6 Date:11/10/2010 03:17 PM Page:6 of 6 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anization s : Location And Description Of Completed Opera- tions City of Campbell 1670 Grace Avenue 70 N. First Street San Jose, CA 86125 Campbell, CA 96008 Section II -Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement pertormed for that additional insured and included in the "products- completed operations hazard". CG 20 37 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 From:Sandy Luu, CISR FaxID: _ _ Page 1 of 5 Date:11/S/2010 11:25 AM Page:1 of 5 RECEIVED Nnv - e zoto PUBI.tC WORKS A~IIIN181'FlATION ~3 CJ ~ ~ LT T Q N S U R A N C E S E R V I C E S One Almaden Blvd., Suite 810 San Jose, CA 95113 Phone: 408-947-3000 Faz: 408-288-7130 ax From: Sandy Luu, CISR To: Joy Francois Pages: 5 Fax: (408) 376-0958 Date: 11 /81201011:25:46 AM Phone: ( ) - Subject: City of Campbell -Certificate Message: Joy Francois, ~' Please seethe attached certificate of insurance for our insur - Roberts Construction. If you should have any questions or need please feel free to contact our office. Thank you, Sandy Luu, CISR CC: Roberts Construction CC: City of Campbell/Fad; ~ ~~ ~ ~2-0~~~`1, 5~~~-e - 0~ From:Sandy Luu, CISR FaxID: ---- Page 2 of 5 Date:11/8/2010 11:25 AM Page:2 015 OAl! • 11 05 10 ~~ THB C@ITiN~iCATE IN IUD A6 A MATT®1 OF INFORYA710N BLISS & GLENNON INC ONLY MD CONFBiB NO R'IOFfl'a UPON TFE CERII~ICATE , . ~ ~ ~ ~ C/0 BOZZUTO & ASSOCIATES INC F.D 81~ POLIq ~BE~A f. ~ ER TFIE CaYFAAOE A~OF~D 1 ALMADEN BLVD #810 CaMPANEBAFFORClM000~YE~iAQE SAN JOSE CA 95113 po~+pNy A CENTURY SURETY COMPANY AAw~o DAVID A. ROBERTS oor~wr B ROBERTS CONSTRUCTION 16636 FARLEY ROAD mom, C LOS GATOS CA 95432 , ~~ D THId E TO CERTl1f THAT THE FOUClS OF Nr0URI1NCE L181m BELOW HAVE BI:DI gSIJ~ Tn THE INOIBlD NAMm AOCVE FOR THE POLJCY PERIOD INDICJITED, N071MTFIBTANDINB ANY REQUAREI~IT, TERM CW OCNDITION aF ANY CONTRACT OR OTHER DOCt1YB~(T WRH RESPECT To WHICH TH18 CERTIFICATE YAY BE AlSUEI? OR MAY PERTAgA THE 818UAANCE AfPORD~ BY THE POLE DESCRB® HEREBI M SUBJECT TO ALL THE TERMS, E>DLUSpNS AND COI~DITp1E OF SUCH POLICES. L/At'8 9FiOyVN MAY HAVE ~N I~IJCED BY PAD CLAIMS. L~p T1PiO~RINI1MRCi PD{ACYNYYMR ~7lIAA~RIMMI AMYl~I~fM1~ YrTi A AISER~L u~eluAr ~16iI1LAmAECIATE 1 2 0 0 0 O D X c~~aa,ll aEnewa u~mr - o>~,oP woo / 1, 0 0 0 , 0 0 cuurrsl~oE QoccuA CCP644070 04/01/10 04/01/11 ~La~IrMUUar 1 1 000 00 owae+s s ooNrnACmAS a~or ~ a~a.~E~ 1 1 4 4 0 0 0 FFE OMAACtE {~y awA 1 ZOO D D M®E7~ oro wwa+] 1 5 0 0 ~InoAAO~aa wwun ~~~ COA6N®AANOLELMT 1 AFL ~~~~ BDdLY INAJRY 1 BCNEOULE011UIOB ~w~l ~~~~ EDOILY Il~IUR1f 1 r~aw.owt~AUme ~~~ PROPE3TIY LYiIIAQE 1 iM~OEWeLflY /IUIOd~l.Y-EAAOf7D9i1T / ~nrc~uio on+eA nyw~uro otilr. ~w~~' 1 AOCAt1EGME 1 aeoa~~ woam r~l ~ ~ao>: ~ UMBFIB.LA P~1 ALA~OATE 1 oTIA~I THMI u1rIBREILA FOIIfA 1 MORIA~CO~~AIIDMAAIO em+TUroRrLMrti'e A~u~rAAwuNa~~ r~rlr _ 1 THEPFbPRETOgI wwTHaaeufxEauTnA= iNCI. RIME-PCIJOYUMr 1 asu~ ~ o~-EACHEMRO'Pff 1 o>RSn oaa~neR or orsla~a~wwenwoR~nle+~cle~n~eul~ rr~ CERTIFICATE HOLDER IS NAMED ADDL INSURED PER FORMS CGL1816 & CG2037. PRIMARY AND PROD. COMP INCL- LOC: 1670 GRACE AVE 10 DAY NOTICE OF CANCEL FOR NON PAYMENT 4F PREMIUM Mlouo Awr of wAE AAA oNa~^AO t ~ caAeei~ AAA~OIAA 11! CITY OF CAMPBELL i0NR~110M Allllli TxwoF, T~ wswo oorNRr way w~ISeR~o ~ 7 0 N . FIRST STREET ~ a-rs wirrn~r woneE to nie ClRAA~lAAE xotne~ AuIA~ To rxE tA!Fi, CAMPBELL, CA 95008 ~ 11YE ALICIA 1 /~ G1 From:Sandy Luu, CISR FaxID: Page 3 of 5 ~ Date:11/8/2010 11:25 AM Page:3 of 5 CERTHOLDER COPY ISSUE DATE: tf-08-2010 CITY OF CAMPBELL 70 N 1ST ST CAMPBELL CA 85008-1458 P.O. BOX 420807, SAN FRANC]SCO,CA 94142-0807 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE GROUP: 000713 POLICY NUMBER: 00188 31-2008 CERTIFICATE ID: 8 CERTIFICATE EXPIRES: 02-01-2011 02-01-2010/02-01-2011 THIS CERTIFICATE SUPERSEDES AND CORRECTS CERTIFICATE # S DATED 11-08-2010 NG JOB:ENC #2008-00084 1870 GRACE AVENUE SAN JOSE CA 85125 This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon 10 days advance written notice to the employer. We will also give you 10 days advance notice should this policy he cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document wrth respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions. and conditions, of such policy. V ~~J~' thorized Representative interim President and CEO UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPENSATION LAW. EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 51,000,000 PER OCCURRENCE. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBR06ATION EFFECTIVE 2010-11-08 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF CAMPBELL EMPLOYER ROBERTS, DAVID A 1Q836 PARLEY RD LOS GATOS CA 95032 NG [613,NG] NG (REV.1.201D) PRINTED 11-OS-2010 From:Sandy Luu, CISR FaxID: - Page 4 of 5 Date:11/8/2010 11:25 AM Page:4 oT 5 CGL 1818 0106 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -SCHEDULED PERSON OR ORGANIZATION -PRIMARY AND NON-CONTRIBUTORY COVERAGE This endorsement modifies insurance provided under the following: CONTRACTORS LIMITED CLAIMS MADE GENERAL LIABILITY COVERAGE FORM CONTRACTORS LIMITED CLAIMS MADE AND REPORTED GENERAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name OF Additional Insured Persons? Or Or anization s : Locations Of Covered O erations City of Campbell 70 N. First Street 1870 Grace Avenue Campbell, CA 96008 San Jose, CA 96126 A. Section II -Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insureds) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insureds) at the location of the covered operations has been ,completed; or 2. That portion of "your work' out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. It is agreed that the insurance provided for the benefit of the above additional insureds) shall be primary and non-contributory, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insureds) at the location(s) designated above. CCiL 1816 0106 Includes copyrighted materiel of Insurance Services OKce, tnc. with its Page 1 Of 1 D permission. ©ISO Properties, Inc., 2004 From:Sandy Luu, CISR FaxID: ~ Page 5 of 5 Date:11/82010 11:25 AM Page:S of 5 COMMERCIAL GENERAL LIABILITY CG 20 37 O7 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s~ Or Or anization s : Location And Description Of Completed Opera- tions City of Campbell 1670 Grace Avenue 70 N. First Street San Jose, CA 96125 Campbell, CA 96008 Section II -Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by 'your work" at the location designated and described in the schedule of this endorsement pertormed for that additional insured and included in the "products- completed operations hazard". CG 20 37 O7 04 ©ISO Properties, Inc., 2004 Page 1 of 1 I~icrv 10 10 11:54a Roberts Cons}~~l}ion i"3564466 p.1 /G-G,,,~ r ~~ `~~~ ~ ~`~ " ~~3Z ZLTT~J I N S U R A IV C E S E R V I C E S One Almaden Blvd., Suite 81U San Jose, CA 95113 Phone: 408-947000 Fu: 408-288-7]30 %; From: Sandy Luu, CISR To: Pages: 5 Fax• 408 356-4466 S C' of Campbell -Certificate Message: Joy Francois, Bate: 1118J20i 0 i 1:25:43 AM P e: 408) 21 D-4363 Please see the attached cert~cate of Roberts Construction. If you should have any questions or Thank you, Sandy Luu, CISR CC: Roberts Construction CC: City oaf CampbelltFax: -3T6- for our insured - revisions, please fee! free to contact our office. Nov 10 10 11:54a Roberts Constr,~ inn 43564466 p.2 11 05 10 ..oar TMs Is ~a • oP i 'now ~~~ BLISS & GLENNON, INC. ONLY ~D CONS ~ R~OHT~ ~~ TFE ~ M NY TM Cj0 BOZZUTO & ASSOCIATES INC A f~Y~ ADD POLN~ ILL 1 ALMADEN BLVD #S10 CdMPwliliA~Rd1~lOCdYIM~OE SPN JOSE CA 95113 ootpAUr A CENTURY SURETY COMPANY wMweo y DAVID A. ROBERTS 0 ROBERTS CONSTRUCTIO[~ oowPeur 16636 FA~LEY ROAD C LOS GAZjOS, CA 95032 mater D 1!M Ni 70 'AUq' If!'OLIOH OT Iw~NN:LNIltO N!'L41M HMIE ~^1 IML®TO iNl M~AtgllD NM~IINOIIEf ~OR1FL POLIf.Y rlIMOD NNIIC11iD, NCIW'1f1NTwNONQAFKR~IM~1T, 7flNI al OONpf~l Ot ANY OONTIMCI' OR OTFIlA OO~N1'1M1l1 INTO MRMCH THIb ClRil!'~IITE pAY E IMtJ~ OR tt#Y PERUML THE MlxNMNCE AfFONO®0Y Tif POLtt:ES IAN IS lrilNJ~'T TD AlL THE 1Elilb, OAFO COIIDITiONO OP OIlCN POLIO. LMT! MOWN NMY HAVE e~N I®uCm !1f PAD CtA1Ils. TM Tp0lIIeI~Mii lOtIRTNf~eeR ~~ ~~ Il~if A uwsunr eer~L~mw~ i 2 0 0 0 0 0 0 X wweeuLOeNer~u,rLmr Pamucre-ootir~aoo i 1 000 000 ou-rrmtuoeQocxxiR CCPb44070 04/01/10 04/01/11 ~aw~La~orwunr ~ 1 000 000 owteeeswcoarneces~ w+Qr ~~ i t 0 0 0 0 0 0 r~cAtaoe ~. 100 000 ~~ a. ~ 5 0 0 ~et~oMOaaE wwutr aolwear®sart~.ewT i arrwtn ~t~.owneo~ume ~ ur ttt i ~ ~ so~um canoe v. a +- rtnmAU~ ~ ~y i~ i np+~owaeoAUwos ,0C ~noPt~rnr t~teNie ~ ~OeLtaeiltY At1100M,Y.EAAODDa1T i IWMAIt1L7 O~MEfITMANJM/TOpal! BAGFt/Itidflt'Mr 1 Aeeett3AT: OCOa UWflY a1t}100DLRiBiCE 1 IaY~BUI FDirA ASi~iATE 1 OIIDtENN wetau-FOIat 1 erolleeesoot~e^utoNAea erATJiOIiruNrle ~tueaalr itci~oaaarr ~ 1F18AIOIitE70p1 awl GtN'JIeE-P~.Yt1Ntr 0 o~ ~oo~ oea£N~-e~E 1 oaew inaerttoa oro~tantetttruooenottiMeaetnrt~aaK new CERTIFICATE HOLDER I6 NAMED ADDL INSURED PER FORMS CGL1816 & CG2037. PRIMARY AND PROD. COMP INCL- LOC: 1670 GRACE AVE LO DAY NOTICE Og CANCEL FOR NON PAYMENT OF PREMIUM wouu A1M eR 7s Aldr! eMClete• Pote:elt is GMGE10 tee~oee 71E CITY OF CAMPBELL ^t~nott ewe wttweoR ntt tenara ooeMtar ~ +s ~ 7 D N . FIRST STREET ESL onve rem eonee To nig eent~ne noutA ~ to rxE ten, CAMPBELL CA 95006 , ~~ ALICIA 1 P ..~..,, Nou 10 10 11:544 Roberts Const~'-`+on 4"`3564466 p.3 CERTHOLOER COPY P.O. 80X 420807, SAN FRANCISCO,CA 94 i 42-0807 CERT~ICATE OF WORKERS' CWNPfNSAT10N WSURANCE ISSUE DATE: 11-Oi-2010 (,pp~8,; 000713 POLICY NUAABEftt 0018831-2008 CERTIFICATE ID: !! CERTIFICATE EXPIRE& 02-01-2011 02-Oi-2010/02-01-2011 THIS CERTIfICATE SUPERSEDES ANO CORRECTS CERTIFICATE A' S DATED 11-08-2010 CITY OF CAI+pBELL NO JOB:EIIC ,42 008-00084 1970 GRACE AVENUE ?0 N 1ST ST SAN JOSE CAMPBELL CA 8500>I-1458 CA sS125 This is to Certify that we have issued a valid Workers' Compensatlon insurance policy in a form approved by the California Insurance Canmissioner to the employer named .below for the policy period indicated. This policy !s not subject to cancellation by the Fund except upon 10 days advance written notice b the e+t+pt0yer. We will also give you 10 days advance notice should this policy be eaneeikd prior to its normal expiration. Thls certificate of insurance is not an insurance policy and does not amend extend or alter the covsrag~ afforded by the policy listed herein. Notwithstanding any roquiremont, term or condition of any contract or other document with rarspect to which tfiis certificate of insurance may be issued Or t0 which it may perfain, the Ir~unnee afforded by the Polley deaeribed herein is subject to a+I the terms, exciusiorrt. and conditions, of such policy. i~M~G~t7t~t. ~orized Representative Interim President and CE0 UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVE RAGE. UNDER THIS POLICY EXCLUDES THE FOLLONiN6: TFgSE NAMED IN TM~E POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE E111PI.OYER; ENPLOYEES COVERED ON A CONPREHENSIYE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA IiORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' CONDENSATION LAYI. ~~. EMPLOYER'S LIABILITY LIMIT INCLUDING OFFENSE COSTS: 51,000,000 PER OCCURRENCE. ENDORSEMEf~IT A'2570 ENTITLED WAIVER DF SUBROGATION EFFECTIVE 2010-11-08 IS ATTACHED Tf) AND FORNS A PART OF THIS POLICY. THIRD PARTY NAME: ~„~ CITY OF CAMPBELL EMPLOYEE R08ERT5, DAVID A 18836 FARLkY RD LOS tiAT05 CA 95032 NG [813, NGj NG liRev.t•sotol PRINTED 11-08-2010 Nov 10 10 11:544 Roberts Construeion 4°'`3564466 p.4 col.lste aho6 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -SCHEDULED PERSON OR ORGANIZATION _ PRIMARY AND NON-CONTRIBUTORY COVERAGE This endorsement modifies insurance provided under the following: CONTRACTORS LIIuIITED CLAIMS MADE GENERAL LIABILITY COVERAGE FORM CONTRACTORS LIMITED CLAIMS MADE AND REPORTED GENERAL LIABILITY COVERAGE FORM COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Personlsl Or isatb s : Locations Of Covered O ons City ott CampbaN TO N. First Stncet 1670 Grace Avenue Campbell, CA 96008 San Jose, C'A 96126 A, Section ]I - Whn Is M Insured is arrlended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury', "property damage" or "personal and advertising injury" caused, in whole or in park try: 1, Your acts or omissions; or 2. The acts or omissions of those acting on your behalF, in the performance of your ongoing operations lot the additional insureds) at the location(s) designated above. 8. Witn respect to the insurance afforded to these adcitional insureds, the fdlowing additional exclusions apply: This insurance does not apply to 'bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnisl'red in connection with such work, on the project (other than service, maintenance or repairs) to be pertormed by or on behalf of the additional insureds) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by arty person or organization other than another cantracbor or subcontractor engaged in pertorming operations for a principal as a part of the same project. C. It is agreed that the insurance provided for the benefit otthe above additional insureds) shall be primary and non-contributory, but only with respect tc liability for 'bodily injury", "property damage" or 'personal and advertising injury" cae,lsed, in whde or in pact, by: 1. Your ads or omissions; a 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(S) at the location(s) designated above. CGL 1816 0106 Inch~des copyfigMed mererfal ar Insurance SsnAces Orrice, Inc. with hs Page 1 OiF 1 O pertnissiart. ®I30 Prope~Ues, Inc.. ZOO1 Nov 10 10 11:54a Roberts Constr~-~tion 43564466 p.5 COMMERCIAL GENERAL LIABILITY Cf3 20 37 OT 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Nam® Of Addlfional Insured Person(s) or o anizatl s : Location And Description Of Completed Opera- lions Clty of Campbell 1670 Grace Avenue TO N. First Street San Jose, CA 96126 Campbell, CA 96009 Section II -Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with res{~ect to liability for "bodily injury/' or "property damage" caused, in whole or in part, by 'your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products- oompleted operations hazard". CG 20 37 07 04 ®ISO Properties, Inc., 2004 Paye 1 of 1 W N M A ~~ a ~ ~ b f x ro ~~ S o S o8 000 0 ~ ~ ~~ N N N N ~ ~ ~ ~-+ ~ .-. --. r+ 00 00 00 00 O O O O ~•-~ r ~. --~ U i i i W W N N V i V i V i o 0 0 ~+ J ~O W 00 In 00 N b ~ ~ i CA O ~ v N O O O O O O O O ~~~ N ro~ p b 0 0 0 ~ ~ ~ ~ o~ ~• ay ~ ~' c ~ G ~ ~ ~ ~ ~ ~ ~ ~ ' b .d ~ ~' • ~ ' `~ ~ ~ ~ f 1 ~ f9 ,~ ~ ~ ~ b '. C ~ ~ C ~ H ~ ~ ~ 0• K ~ 69 ~ A rr ~-. ~ W W O Q~ W N N tJ~ W U p O O O O O O O W O p O O O O p O O O O ry a ~, ~ ~. ~ ~ w ~ Op~ N ~ O Cn O O °° O w 0 O O O o 0 'Wo °o $ ~ °o $ g g °o o y yO a d C17 o, o~ o, a N N N N --~ r-+ -+ .-+ O O O O 00 00 00 00 N N N N N N N l~ p O O O O S O O O ~D ~C ~C ~O 00 00 00 00 O O O O U v, CIi to r+ r-~ H+ ~-+ W W W W ~O ~O ~O ~O O O O O 0 0 o O ~ ~ ~ ~ ~ ~ ~ ~ N N N N 00 00 00 ~O `v `v `v `v `v `v `v `v ~ O O O O O O O O o Sob S $ o oS ~ ~ ~ ~ z n x N y O ,,.r o p 00 O 0~0 O .p n'1 ~O N ao ~~ PUBLIC WORKS DEPARTMENT LAN DEVELOPMENT 8 TRAFFIC RECEIPT Effective July 1, 2009 TO: City Clerk PUBLIC WORKS FILE NO. ~~C O -- OOd PROPERTY ADDRESS ~ ~o~ V /e~KF Please collect & reoei t for the followin monies: P.C i VE.L;OI~ NT ncroac men ermi ica ion ee Non-Utili Encroachment Permit $320.00 Minor Encroachment Permit <gto,ooo $145.00 •- Initial R-1 Permit $50.00 .Subs uent R-1 Permits within Five Year Period $145.00 * 2203 Plan Check De osit 2% of En ineer's Estimate $500.00 min 4722 Gradin & Draina a Plan Review Sin le Famil Lot $215.00 Site < 10 000 s.f. $640.00 Site z 10 000 s.f. < Acre 860.00 Site Z 1 Acre $1 280.00 .Plan Check & Ins action Fee Non-Utili D **2203 En r. Est. >$250 000 Actual Cost + 20% min. $30 000 De sit 4722 En r. Est. <$250 000 13% of ENGR. EST. * 2203 Eme enc Construction Cash De sit 4% of En r. Est $500 min/$10 000 max * 2203 Faithful Pertomtiance Securi FPS 100% of ENGR. EST. * 2203 . Labor and Materials Securi 100% of ENGR. EST. 4721 Storm Drainage Area Fee Per Acre (R-1 $2,120.00) ~ a (Multi-Res $2,385.00) All Other $2 650.00 4722 arcs a 4 Lots or Less 600. 0 + 80/lot 4 ma ract Ma 5 or More Lots 400. + 108/lot * 2203 Monumentation Securi 100% of ENGR. EST. 4920 Parkland Dedication Fee 75%/25% Due U on Cert. of Occu anc -4722 Lot Line Ad'ustment $960.00 4722 Vacation of Public Streets & Easements $2 250.00 4722 Certificate of Com liance $695.00 4722 Certificate of Correction $425.00 4722 A sal Filin Fee $110.00 4722 Nota Fee er si nature $11.00 472 ssessment egregation or eappofionment First Split ($770.00) .Each Additional Lot $205.00 511.7424 T~AFFaC 4728 Postage Intersection Turn Counts Two-Hour Count 82.00 4728 Intersection Tum Counts a.m. or .m. eaks $160.00 4 28 ra rc low a all ra c olumes 4 8 i na imm n ormation .0 / r 4271 ruc ermits 16. / er to 4 CELLA No arkinq igns ( leach or 25/100) ther Please eci 4722 Street Tree Plantin /Removal Permit $155.00 + $500 de osit `Engineer's Estimate shall be as approved by the City Engineer. n ~-~ TOTAL $ ~ oc.7~ ~ O NAME OF APPLICANT NAME OF PAYOR ,~ZSj N / PHONE ADDRESS ZIP **Actual Cost PIus20% Overhead Non-Interest bearin de osit FOR /" /~ _. RECLI-' ED BY CITY CLERK ONLY n ~~~~ ~~ Da~ ecel t # tom' "For Plan°Check and' Cash Depostts,s~nd-yellow»copy~t~i=k~atue. ~ Datel yin Is ,:row.a~rr...w.e.a s.M, ~.,e w..~n..,.n.k oa,u fin.,. awo~ t CITY OF CRMPAELL RECUR BY: JAS pAYOR: TER5IGNi FAMILY Ol0OD21864?, TODAY'S DATE: 0T/2O/D9 REGISTER DATE: D7/2D/D9 TIKE: D8:5! DESCRIPTION ANDUNT ENGR 8 SUBDIV FILING F ~4,.?yO,OO CUST ID: ENC ~OOg-OD084 REF DEPOSIT - !O1 CUST ID: l.DOO X1,320.00 STORM DRAIN FEES- FN CUST ID: STORM DRAIN 61,643.00 REF DEPOSIT - !D1 CUST ID: NONUEMENTATION SECURITYTOOO.OO TOTAL DUE: ------sl1,253.DD CHECK PAID: 6!!,253.00 CHECK ND: 3019 TENDERED: 6!!,253.00 CHANGE; 6.00 of ~Qi ~r n~~tc n~oeQrruFNT t 1~ TRAFFIC RECEIPT ` Effective July 1, 2007 TO: City Clerk PUBLIC WORKS FILE NO. PROPERTY ADDRESS ~ ~fr~ Please collect 8 recei t for the followin monies: ..ACC << 2203 . ITEM':: ' AM©UNT RMETJT "` Plan Check De osit 2% of En ineer's Estimate $500.00 min Faithful Performance Securi FPS 100% of ENGR. EST. 2203 Labor and Materials Securi 100% of ENGR. EST. 2203 Monumentation Securi 100% of ENGR. EST. 2203 Eme en Construction Cash De osit 4% of En r. Est $500 min/$10 000 max Plan Check & Ins action Fee Non-Utili ••2203 En r. Est. >$250 000 Actual Cost + 20% min. $30 000 De osit 4722 En r. Est. <$250 000 13% of ENGR. EST. 4722 A lication Fee Non-Utili Encroachment Perrnit $300.00 Minor Encroachment Permit <S~o 000 $135.00 R-1 First Permit No Fee Subse uent <~0 000 $135.00 4722 Util' Encroachment Permits: Arterial/Collector Street $560.00 Residential Streets/Other Areas $310.00 4722 A eai Filin Fee $100.00 4722 Lot Line Ad'ustment $900.00 4722 Parcel Ma 4 Lots or Less $3 400.00 + $75/lot 0- 4722 Final Tract Ma 5 or More Lots $4 200.00 + $100/lot 4722 Certificate of Com liance $650.00 4722 Certificate of Correction $400.00 4722 Gradin & Draina a Plan Review Sin le Famil Lot $200.00 2~ Site < 10 000 s.f. $600.00 Site > 10 000 s.f. < Acre $800.00 Site > 1 Acre 1 200.00 4722 Nota Fee r si nature $10.00 4722 Vacation of Public Streets & Easements $2 200.00 4722 Assessment Segregation or Reapportionment First Split ($725.00) Each Additional Lot $200.00 4721 Storm Drainage Area Fee Per Acre (R-1 $2,120.00) (Multi-Res $2,385.00) All Other $2 650.00 4920 Parkland Dedication Fee 75%/25% Due U on Cert. of Occu anc 511.7424 TRAFFIC'. 4728 Postage Intersection Tum Counts Two-Hour Count 76.50 4728 Intersection Tum Counts a.m. or .m. eaks $150.00 4728 Traffic Flow Ma Dail Traffic Volumes $32.00 4728 Si nal Timin Information $62/Hr 4271 Truck Permits $16.00/ ertri 4728 Nth ~ ~ .; No Parking Signs ($1/each or $25/100) ._ ~ . Other Please S ec' 4722 Street Tree Plantin /Removal Permit $145.00 + $500 de osit *Engineers Estimate shall be as approved by the City Engineer. dp TOTAL $ S50 • "~~ NAME OF APPLICANT ~X 4s ) NAME OF PAYOR ~ t ~ ~ ~-~ PHONE 2.3' ~ 1 Ua ADDRESS O 1h1 ~ • ZIP 2 ""Actual Cost Plus 2096 Overhead Non-Interest Gearin de sit FOR RE ITY CLERK ONLY ,. ~'. ~ ~~~ ' a'1~',:~ ~~~ ... ~.: Dati" `: ~' I , ,~ w ~ Qx~ ~ v * 'or ~ an:.Check a w py to Finance. ~, ~~ . . ~.,. .s ;,w ....,. .3 _ . D l lnitlals .;, "l 1~ .,ro,.~.,.,.._M.........~...,...,.. o...,....,.M, •,.~ a... ~.~ \f r CITY OF CAMPBELL RECVD BY: IANH 010002081?$ PAYOR: TERSIGNI FAMILY TODAY'S DATE: 06/18/08 REGISTER DATE: 06/18/08 TIME: 10:56 DESCRIPTION AMOUNT EHGR R SUBDIU FILING F 63D0.00 CUST ID: 1670 GRACE EHGR R 5UBDIV FILING F 63,550.00 CUST IU: 1670 GRACE PARCEL MAP EHGR x SUBDIU FILING F 6200.D0 CUST ID: 1670 GRACE GRADING TDTAL DUE: 64,050.00 CHECK PAID: 64,050.00 CHECK N0: 2530 j TENDERED: 64,050.00 ~ CHANGE: 6.00 CITY OF CAMPBELL RECVD BY: dANH 01000208179 PAYOR: TERSIGNI FAMILY TODAY'S DATE: 06/18/08 REGISTER DATE: Ob/18/fl8 TIME: 10:56 DESCRIPTION AMOUNT REF DEPOSITS -101.2203 X500.00 CUST ID: 1670 GRACE ---------------- TOTAL DUE: 650D.00 CHECK PAID: 6500.0D CHECK N0: 2530 TENDERED: 6500.OD CHANGE: 6.00 ,_~ Of • C A,k ~~ A~~ r U r 0 0 ~ > 6 ~ A ~,~ ~RCHA~~ Transmittal Joy Francois Executlve Assistant City of Campbell Department of Pnbllc Works 70 North First Street Campbell, CA 95008 Phone: (408) 866-2150 Fax: (408)376-0958 To: Mr. Joe Tersigni October 2, 2012 Address: 1830 Hamilton Ave., San Jose CA 95125 Re: 1670 Crrace Avenue, 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 #21797484 for the property located at 1670 Grace Ave., Campbell CA. Joy Francois Cc: ENC 2008-00084 R~C~lVB~9 ~ICT 012012 Recording Requested By: CITId CLERK'S OFFICE City of Campbell ) And When Recorded Return To: ) City Clerk ) City of Campbell ) 70 N. First Street ) Campbell, CA 95008 ) Pages 2 Fees.... 13.00 Taxes... Copies.. AMT PAID 13.00 REGINA ALCOMENDRAS RDE # 014 SANTA CLARA COUNTY RECORDER 8/16/2012 Recorded at the request of 1054 AM City APN: 288-25-085 (Space Above This Line For Recorder's Use Only) ADDRESS: 1670 Grace Avenue, 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: 1670 Grace Avenue, Campbell California, 95008. That, whereas, the Tersigni Family L.P., A California Limited Partnership, entered into a Street Improvement Agreement with the City of Campbell, recorded October 27, 2009, Document 20481053, 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, the Tersigni Family L.P., A California Limited Partnership, is hereby released from all requirements contained in_ the agreement recorded October 27, 2009, Document 20481053, 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. CITY OF CAMPBELL A Michelle Quinney City Engineer, City of Campbell e Bybee, City Clerk (Attach Notary Acknowledgment) Dated: ~ - /9 -/ 2 THE FORE~OINO INSTRUMENT Id A TRUE AND CORRECT COPY OF THE ORIt~INAL ON FlLE IN THIS OFFICE. ATTEST: ANNE BYBEE. CITY CUEIK F M ELL, CA H:\LANDDEV~Notice of Release 1670 Glace Ave.doc (Rev. 01/12) gY ~-~ DATED ~ ~ CALIFORNIA ALL-PURPOSE CERTIFICATE OF ACKNOWLEDGMENT State of California County of~ ~,~~c, ~.~`CC~ On \ © ~ before me, personally appeared ~~~~;~~~ name and till! of the officer) who proved to me on the basis of satisfactory evidence be the person(s) whose name(s) is/are subscribed to the within. instrument and acknowledged to me that he/s a/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. ~~, my hand and official seal. d0AN11 TIIOM~iON ~ ~ ADDITIONAL OPTIONAL INFORMATION DESCRIPTION OF THE ATTACHED DOCUMENT 2 (tYUe or aeserrpnon or arracnea aoc~enct ~e \~ l fTCbS P ~~e.• (Title or description of attached document 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 apptars 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, arty 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 jor 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 ijrequired: • State and County information must be the State and County where We 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. ime/she/timey,- is /are) or circling the corral 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, re-seal if a sufficient area permits, otherwise complete a different ackmowledgment form. • Signature of the notary public must match the signature on file with the office of the county clerk. ,O Additional information is not required but could help to ensure this acknowledgment is not misused or attached to a different document. ti 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 Cgaptiaba ~ 1lC9i~2 N~tacy ~u0N0 - C~MIKM~ t~ Clan Cwlb (Notary Seal) 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 # ~ tv ~ ~~$ - Z'nD~y Property Address (¢"IO C9 ~f0.CP~y P ~" Date Street Improvement Agreement recorded tDIZ`I ~ ~4°I C~ Date of Final Acceptance Letter ~5~~1 ~ 1\ ~- [~ Date tickler letter given to inspector ~~ \Z [~ Date of One-Year Maintenance Acceptance Letter ~- `~-\ Z ^ All deposits refunded (Date of last refund) Co~Z~1 ~ ( I `~ Inspector's Encroachment Permit file merged with Main Permit File ^ Date Permit archived in Permit Plan Processed by: Reviewed By: Ins ector Reviewed by: ~-l9.2fl~L Land Development Engineer Date Check Request Submitted to Finance for Recording Fee ~ 1 ~l {~ ^ Date Notice of Release sent for recording: ~ 131\~-- '~D C, J:\FORMS\Templates\Administrative\Checklist - Release of Street Improvement Agreement.doc (Rev. 10/11) MEMORANDUM CITY OF CAMPBELL PUBLIC 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 #237791 in the amount of $13.00 for recording: Notice of Release Street Improvement Agreement, 1670 Grace., 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 ;' CITY OF CAMPBELL vF:NDOR No. T0006218 f CHECK N0. 237751 Acevunt YurehnSe Order i Invoice (Vumher' Antpunr _ I)es.•ri~on 101.701 7427 CR071912 13.00 1670 c;ttAC„ AVis TIXA167.1ft S C C CLERK RECORDER c rA v ie P D V n V N , CITY OF CAMPBELL O~ ~C~ tears PAxco aArrx rr a CHECK DATE CHECK N0. p 4~ ~ ~ ~ 70 NORTH FIRST STREET , . . 1i=za azo raorrrcon~xr szRiz~r lzlo 07/30/12 237791 ~ ,{ CAMPBELL; CALIFORNIA 95008 SAN B'RANCISCO, CA Y4104 ~ ~ I ,` o ~~~ ~ ` ~ ~ * * * ~. ~ * * * AMOLJN'r 13 . U 0 ~ o ~~+cnne~ VOID AI~'CER GO llAYS ~~ D h`AY THE. SLIM OF THIRTEEN DOLLARS & ZERO CENTS m F To ~rx> S C C CLERK ,RECORDER oRnLR ..- /~ ~ ~' `"°`"~ , I 70 W HEDDING ST ` ' COUN'PY GOV CNTR EAST WING 1ST FLR SAN JOSE CA 95110-1705 ~_.- 11'23779i1i' ~:L2i0002 48~: 4L2L8554L511' .. *See Reverse Side For Easy Opening instructions* f- -.I 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 CA 95110-1705 Recording Requested By: ) City of Campbell ) And When Recorded Return To: ) City Clerk ) City of Campbell ) 70 N. First Street ) Campbell, CA 95008 ) APN: 288-25-085 (Space Above This Line For Recorder's Use Only) ADDRESS: 1670 Grace Avenue, 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: 1670 Grace Avenue, Campbell California, 95008. That, whereas, the Tersigni Family L.P., A California Limited Partnership, entered into a Street Improvement Agreement with the City of Campbell, recorded October 27, 2009, Document 20481053, 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, the Tersigni Family L.P., A California Limited Partnership, is hereby released from all requirements contained in the agreement recorded October 27, 2009, Document 20481053, 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) CrI'T/Y OF CAMPBELL G~~1G~ Michelle Quinney City Engineer, City of Campbell Dated: ~ - /9 -/ 2 H:\LANDDEV\Notice of Release 1670 Grace Ave.doc (Rev. 01/12) CALIFORNIA ALL-PURPOSE CERTIFICATE OF ACKNOWLEDGMENT State of California County of ~ ~,.~~, On ~\ ~ \ before me, personally appeared ~~~ e \\E name and till! of the officer) who proved to me on the basis of satisfactory evidence ~be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/s a/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. S my hand and official seal. ,WAitiiN THOMI~QN Conmtissaiort I- t ~906e2 Nobry- Public - CMIIotM~ BMtb Can t (Notary Seal) ADDITIONAL OPTIONAL INFORMATION DESCRIPTION OF THE ATTACHED DOCUMENT (Title or description of attached document) 1(A-ll C~Cc~r~ _ Ave.• (Title or description of attached document 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 Californta 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 os the verbiage does not require the notary to do something that is illegal jor 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 ifrequired. • 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 acknowledgmart is completed. • The notary public must print his or hec name as it appears within his or her commission followed by a comma and then your title (notary public). • Print the name(s) of documart signer(s) who personally appear at the time of notarization. • Indicate the correct singular or plural forms by crossing off incorrect fomms (i.e. i~e/she/tltey- is /are) or circling the correct 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, re-seal if a sufficient area permits, otherwise complete a diffaart acknowledgmart 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 differart document. 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 Of ~CA'1'll~ ti~ ~~~ U r. s '" G •CRCHAR~• CITY of CAMPBELL Public Works Department July 19, 2012 Mr. Tersigni 1830 Hamilton Ave. San Jose, CA 95125 SUBJECT: PERMIT NO. ENC 2008-00084 1670 Grace Ave. Campbell, CA 95008 ONE YEAR MAINTENNACE INSPECTION AND ACCEPTANCE Dear Mr. Tersigni: 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 $8,250.00 which we are returning to you. Sincerely, Syed Wahidi Public works Inspector Cc: Permit #ENC 2008-00084 Public Works Maintenance Division Comerica Bank, 444 N. Santa Cruz Ave., Los Gatos, CA 70 North First Street Campbell, California 95008-1423 TEL 408.866.2150 Fax 408.376.0958 Tnn 408.866.2790 ASSIGNMENT AND RECEIPT OF INVESTMENT CERTIFICATE P.W. Permit No. L•'~ ~ 2VtJ O '~ OW S~ TO CITY OF CAMPBELL, 70 N. FIRST STREET TR or ~EV CAMPBELL, CALIFORNIA 95008 (408)866-2150 Loc. 11°~ ~- COMERICA BANK I am/We are the owner(sdl~f~a ~viSTT~ CRU at its branch office at ___ ,California, investment certificate No. 385108952313 in the names ofmt~ verrtoT FAMTLY LP DBA DOMA TNV .gym F:NmS and having a present balance of $ 8 , 2 5 0 .0 0 I hereby grant, transfer and assign said accaunt, said investment certificate, said balance (including interest which accrues thereon), and all other rights in connection therewith to the CITY OF CAMPBELL, assignee, for a good and valuable consideration, receipt of which is hereby acknowledged, for the purpose of insuring construction described as follows: LIGHT AND STREET IMPROVEMENTS I ave phvsicaily delivered verification of said investment certificate and duplicate of this Assii?nnment and Receipt to said assignee. I understand that assignee can withdraw from said account any time on his signature alone upon presentation of a written order to the issuer. I also understand that I' may not withdraw from said account unless I present a signed release from the assignee. The issuer of the certificate assumes no responsibility for the conduct of the assignee and may act on the signature of the assignee without further inquiry. Executed on , 20 / l , at said office of the issu ~` ~r~ ~gnor sign .., ,..r---- ac~ /~.e /~~SIG~ (print} ACKNOWLEDGMENT BY ISSUER Issuer affirms that there are no other holds on subject account, that subject monies are available, and that the above-described assignment has been noted on the Records of said issuer. Date AUGUST 4, 2011 BY Sg ATTACH NOTARY ACKNOWLEDGMENT TitlePE d B~~~ INSTRrTr•TinATC Tn aS~iONEE Please sign below for signature identification and as aclrnowledgment of your notice of Assignment. Rettun this Assignment and Receipt to the/issuer at its address above. Retain one copy of this Assignment and Receipt for your files. Date ~ / ~/ ~ ( City of C ell - By l~urbl~~ ~.U«t~t~ RELEASE OF ASSIGNEE Said assignee hereby releases and relinquishes all his right, title and interest in and to said account, said investment certificate, said balance and all other rights in connection therewith. Date 'z~~ City of bell By J:\FORMS\Templates\I.artd Development\Stn~et hnprovements\Assignment & Rxeipt of Investment Certificate.doc (Rev. 03/08) ~a~ifolrnia ~ltl-P~rpmse 14.~[~r~a~w~ecig~erlR~ State of California County of SA1~ P CU~h'~ s.s. Ft~NVo~ c,,na cll. , Nos-tu.~t f~~~~ _ , On Av ~ - ~t~, ~~\ before me, personally appeared L-~~"'~ ~'~""'^ who proved to me on the basis of satisfactory evidence to be the o ~ whose ~~''~~gg~ ' instrument and acknowledged to met at h i}byR~x'ecuted i ~ subscribed to the within ~e same in hl e /th~i~r authorized cap I ~, and that by h ~/the, it s' n u ~ on the n the e o or the entity upon behalf of which the~~~~' J`s~acted, executed the Instrume t ~ ~~C~. instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNE my hand a fficial seal. ~mwimunnununn-nmuFERNANDQ ~ CROCE °m~ COMM. # 1874285 5 N07A~R~q~~A CO FORMA y f"tY Comm. Ex . NTY ~nminnmmtmuumimm~nmiumiumtmnnnn~ imn iu2013" ~.__• < OPTIONAL INFORMATION Description of Attached Document The preceding Cert~cate of Acknowledgment is attached to a document titled/for the purpose of ASCIt~N'^`~"r ~ ~CSL~r ~ ctW1~'«+~A;c~F CS~S\`(^lVR'10~ , /~ t~~ containing t pages, and dated ~ / The er(s) capacity or authority is/are as: Individual(s) Ci Attorney-in-fact !C Corporate Officer(s) '- Guardian/Conservator ~. Partner -Limited/General ~; Trustee(s) _-! Other: _ - --z------= Method of Signer Identification Prove me on the basis of satisfactory evidence: ~ form(s) of identification ^ credible witness(es) Notarial event is detailed in notary journal on: Page # ~S Entry # ~ Notary contact: ~O~- -~~~ y'~1'S Other L_i Additional Signer ~, I Signer(s) Thumbprints(s) representing: ,.~ " Time Deb' ~t Receipt Non-Negot~a~le/Non-Transferable Date 08/04/2011 There has been deposited with Comerica Bank The sum of Eiaht Thousand Two Hundred and Fifty and 00/100 dollars. Not valid unless signed by an authorized bank representative. Authorized _`__`____ ~ _ Bank Issuing Customer ~ ~ ~., , c,,.,~+~ ~~a ~,~ ~ ~ ~ ~ bs7nJ~c~pffice 93865 Issued Ter igni Family Lp GP DBA To D a Investments ayable to City Of Campbel 1830 Hamilton Ave San Jose CA 95125 Customer Copy I Account Number: 385108952313 Account Type: Fixed Rate CD Term: 301 Days Interest Rate: 0.15% % Issue Date: 08/04/2011 Amount: $8,250.00 Maturity Date: 05/31/2012 Source Code: 07 Assignment of Time Deposit Agreement I am/We are the owner(s) of the following. ERS~GNIit FAMILY I P eDBA ~OMA INVESTMENTS Account Name p~YA$LE T9 THE CITv nF C`AMPRF.T,I, Time Deposit Account Number 3 8 510 8 9 5 2 313 Present Balance of Account $ 8.2 5 0.0 0 Assignee Name CITY OF CAMPBELL I hereby grant, transfer and assign this account and all rights in connection therewith to the Assignee for a good and valuable consideration, receipt of which is hereby acknowledged, for the purpose described as follows: STREET LIGHT AND STREET IMPROVEMENTS I understand that the Assignee can withdraw from this account any time on the Assignee's signature alone. I also understand that I may not withdraw from this account unless I present Assignee's signed release of Assignment. The Bank assumes no responsibility for~l~~ct of tl~ Assi~i~nd may act on the signature of the Assignee without further inquiry. Executed on at said office of Bank. Account Holder: ~ ~D ~ ~~° ~~ ~ ~~Sl~ i~/ ~ Print Name Signature Date ~'' Y- Zo~~ BANK ACKNOWLEDGEMENT Bank affirms that there are no other holds on this account, that monies are available, and that the above described assignment has been noted on the Records of said Bank. AUGUST 4 2 011 / ,~~ ~ ~ ~/) Date ~ ~~ ~~ C.: = ~ i <.,~~'~-O Aut rued Bank Representative Signature INSTRUCTIONS TO ASSIGNEE Please sign below for signature identifications and as acknowledgement of your notice of Assignment. Return this Assignment to the Sank. In acting on the signature of the Assignee, the Bank assumes no responsibility for the conduct of the Account Holder. Retain one copy of this assignment for your files. ~ ,-_1 Assignee: ~t''Q~r ~G~ -~-~e~ .tr,~ ~t ~_.~l~l.A~ Print Name 'c (~~~ h-~1~ Date g ~ ~ ~. RELEASE BY ASSIGNEE Said Assignee hereby releases and relinquishes all rights, title and interest in the accoun scribed above. Date ~~ 17 ~f Z By Assignee's Si ure CAOPS518 (5107) CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit # ENC2008-00084 Toe Tersigni Properly Address 1670 Grace Ave. Date of Final Inspection: 6/18/12 On File: ^ Bonds ~CD ^ Cash 'l`(~, t~kr~ Ac,C. ~ l~ F nce: $~ ~~ ^ Labor and Material $ ^ Construction Cash Deposit to be released: 0 Other overdue deposits to be released (Description): Processed by: °~, Z Administrator Reviewed by: Ins Reviewed by: Land -'L _~-?~ pment Engineer J:VoAnnaT'\Templates\Checklist -Clearance for Final Insp and Acceptance.doc (Rev. 10/11) __~R ''' J .e Grundman OF ' C A,~A . Ot~n~ Aasistxnt `.~ y~ City of Campbell Department of Public Works U r 70 North First Street o ° Campbell, CA 95008 s ~ Phone: (408) 86(x2150 `~' o e v • °~ Fsx: (408) 376-0958 CHAS E-Mail: jeanineg@cityofcampbell.com Transmittal To: Assistant Manager Date: 8/8/2011 Company: Comerica Bank Address: 444 North Santa Cruz Ave. Los Gatos, CA 95030 Re: Assignment and Receipt of Investment Certificate ^ Urgent ^. For Review ^ Please Comment ^ Please Reply X ^ For Information & Use Enclosed please find a copy of the replacement Assignment and Receipt of Investment Certificate for $8,250.00 for Encroachment Permit ENC2008-00084, 1670 Grace Ave. in the names of the Tersigni Family LP DBA Doma Investments. Thank you, O~ ~ ~~~i<A --~ .~. 'r U ~ >. ;y ~kCH ARn ~~~Y c7P ~~AAPB~~..~. Puoiic Works Department May 31, 2011 Joe Tersigni 1830 Hamilton Ave. ~ San Jose, CA 95125 SUBJECT: PERMIT NO: ENC2008-00084 LOCATION : 1670 Grace Ave. FINAL INSPECTION AND ACCEPTANCE Dear Mr. Tersigni, The City of Campbell has mad abler and nnc onformance Je Cby standard mprovements and finds the work to be accep Accordingly, the City Engineer accepts the improvements. The one year maintenance period stated in the permit begins as of the date of this acceptance letter. The permittee is responsible for the repair and/or replacement of any defective work or failures that occur within one year. The City will inspect the improvements within one year and notify you, in writing, whether or not any repairs are required. Your Plan Check Deposit of $500.00 and Construction Cash Deposit of $1,320.00, plus any interest due, are now being processed and will be sent to you under separate cover. We will continue to hold the Assignment an oRonepear unless youtwou dllike t oreplace Improvements in the amount of $33,000.00 f y it with a Maintenance bond. 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 # ENC2008-00084 Inspector File J:VeanineG~ENC2008-00084, Final Inspection,doc 70 h3orth Firsi Street: ~ ~:.ampbell, California 9500&- ~ 42~ TFL 408.86Ei.2t 50 Fnx 408.376.0958 Tnn 408.8fi6.2?90 - L~ I i --` CITY OF CAMPBELL vENDOR No. 10010946 CHECK No. 232372 Account Purchase Qrder Invoice Number Amount Uescri tiara 101 2203 101.540 7448 CR053111 CR053111 1,820.00 6.29 DEPOSIT REFUND INTEREST l W 10946 1 Ub 1 CKJItiIV 1 c~~"''~~rA C~TI' dP CAMPBELL WELLS aARGO enRx, N. A. CHECK DATE CHECK NO. 11-z4 06/27/11 232372 I r` ~ i20 'MONTGOMERY STREET 1210 tn~, 70 NORTH FIRST STREET snN aanNCxsco, ca 94104 ~ L' r GAMPBEI:L, CALIFORNIA 95008 ~o ,o AMOUNT ~ *****l, 826.29* ~ •,, ,~ ~ i ~ G -VOID AFTER 90 DAYS ~ ~kCHARV DIf ~i PAY THE SUM OF ONE THOUSAND, EIGHT HUNDRED TWENTY SIX DOLLARS & m 29 CENTS To THE JOE TERSIGNI ^ ~} E ORDER 18 3 0 HAMILTON AVE ~~ a `'` ~ - ~? A ~;- ~~'oF ~~~ SAN JOSE CA 9512 5 Y fI ~i ~I' 2 3 2 3 712 u' ~: L 2 L000 248; 4 L 2 L8 5 54 iS~~' JOE TERSIGNI 1830 HAMILTON AVE SAN JOSE CA 95125 c ,9 itt Np G ~; c2~~o~>--cam ~ y ' Je: ' ~rundman p~ ~ CAtijA Offi~ tistant '~ d+ City o...ampbell .~. r Department of Public Works U r 70 North First Street 0 o Campbell, CA 95008 9~ ~; Phone: (408) 866-2150 ~R ~ H A g0 ~ FBX: (408) 376-0958 E-Mail: jeanineg@cityofcampbell.com Transmittal To: Assistant Manager Date: 8/5/2011 Company: Comerica Bank Address: 444 North Santa Cruz Ave. Los Gatos, CA 95030 Re: Assignment and Receipt of Investment Certificate ^ Urgent ^ For Review ^ Please Comment ^ Please Reply X ^ For Information & Use Enclosed please find a copy of the release of the Assignment and Receipt of Investment Certificate for Encroachment Permit ENC2008-00084 for 1670 Grace Ave. in the names of the Tersigni Family LP DBA Doma Investments. Thank you, Jeanine Grundman J:UeanineG\Transmittal Form Jeanine, CD.DOC Time Depo~eceipt ~~ Non-Negotiab-~;~Non-Transferable Date 10/06/2009 There has been deposited with Comerica Bank The sum of Thirty Three Thousand and 00/100 xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx dollars. ^ Not valid unless signed by an authorized bank representative. ~--•.~ Authorized n n .n ~ ~__..:..,. Customer Issued Tersigni Family Lp LP To 1830 Hamilton Ave San Jose CA 95125 Account Number: 385108951968 Account Type: Fixed Rate CD Term; 12 Months Interest Rate: 0.60 Issue Date: 10/06/2009 Amount: $33,000.00 Maturity .Date: 10/06/2010 e,.. ~...e r.,.~o• 07 Customer Copy ASSIGNMENT AND RECEIPT OF INVESTMENT CERTIFICATE P.W. PermitNo.~1`1~~~ ~^~'~~~'~~ TO CITY OF CAMPBELL, 70 N. FIRST STREET TR or DEV CAMPBELL, CALIFORNIA 95008 (408)866-2150 Loc. ~~~ ~~ I am/We are the owner(s) of a savings account at GOD~IERI('A RANK at its branch office at Los Gatos , Califomta, investment certificate No. 385108951968 in the names of TERSIGPTI FAMILY LP DBA DOMA INVESTMENTS and having a present balance of $3 3 , 0 0 0 .0 0 I hereby grant, transfer and assign said account, said investment certificate, said balance (including interest which accrues thereon), and all other rights in connection therewith to the CITY OF CAMPBELL, assignee, for a good and valuable consideration, receipt of which is hereby acknowled ed, for the purpose of insuring construction described as follows: P ~~ I have physically delivered verification of said investment certificate and duplicate of this Assignment and Receipt to said assignee. I understand that assignee can withdraw from said account any time on his signature alone upon presentation of a written order to the issuer. I also understand that I may not withdraw from said account unless I present a signed release from the assignee. 'The issuer of the certificate assumes no responsibility for the conduct of the assignee and may act on the signature of the assignee without further inquiry. Executed on ~'~ ~ _ ~ , ZO off, at said office of the issued-- ' Assignor (sign ~! e , /~~ S i (pmt) ACKNOWLEDGMENT BX ISSUER Issuer affirms that there are no other holds on subject account, that subject monies are available, and that the above-described assignment has been noted on the Records of said issuer. _ Date 1© ~ ~ By ~~ - orized SignatureQ~ ATTACH NOTARY ACKNOWLEDGMENT Title INSTRUCTIONS TO ASSIGNEE Please sign below for signature identification and as aclaiowledgment of your notice of Assignment. Return this Assignment and Receipt to the issuer at its address above. Retain one copy of this Assignment and Receipt for your files. . '1 Date 1 By ... ,~~~; , A /` RELEASE OF ASSIGNEE Said assignee hereby releases and relinquishes all his right, title and interest in and to said account, said investment certificate, said balance and all other rights in connection therewith. 8 f 3 /~ l City of Camp Date By ~-- 'r" ~~.c..'~t.~ Luc it~~"j J:\FORMS\Templates\Land Development\Street Improvements\Assignment & Receipt of Investment Certificate.doc (Rev. 03/08) ~ CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT State of California ~~~ ~~ ~ County of p~ ~1 ~ 2b ~ \ before me, 'i `" , Or ~ ~ (~ ' On f Here Inse N me an TiBe of the ioer Dat ` .. t 1 ~ _s.- _ .. personally appeared ~~~ W Ce~NNf~ ~ 1~0~1lr !~ ICIIra C~ Cam. ~ who proved to me on the basis of satisfactory evidence to be 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. WITNESS my .official s ~L Signature Place Notary Seal Above 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 Date: _L Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: ^ Individual ^ Corporate Officer -Title(s): - ^ Partner - ^ Limited ^ General ^ Attorney in Fact ^ .Trustee ^ Guardian or Conservator ^ Other: Signer Is Representing: Top of thumb here Number of Pages: `~~~ Signer's Name: ^ Individual ^ Corporate Officer -Title(s): ^ Partner - ^ Limited ^ General ^ Attorney in Fact ^ Trustee ^ Guardian or Conservator ^ Other: Signer Is Representing: Top of thumb here ®2007 Nelional Notary Association •93,0 D8 Solo Ave., P.O. Box 2402 • Chatsworth, CA 91313-2402 • www.NationalNotaryorg Item #5907 Reorder: Call Toll-Free 1-800.876.0827 Jeanine Grundman From: Jeanine Grundman Sent: Tuesday, August 02, 2011 2:29 PM To: 'jtlmt~aol.com' Cc: Joy Francois Subject: FW: Subject: Attached image data. Attachments: 163949. pdf 163949.pdf (43 KB) Hi Joe, Attached is the form for the Assignment and Receipt of Investment Certificate. Please complete, obtain proper signatures and have your paperwork notarized. Please call our office at 866-2150 to arrange for a time to release the original CD and submit the new one. If you have any questions, don't hesitate to give us a call. Thank you very much, Jeanine Jeanine Grundman City of Campbell Public Works Department 70 North First Street Campbell, CA 95008 408-866-2150 --Original Message----- From: PWCopier@ci.campbell.ca.us [mailto:PWCopier@ci.campbell.ca.us] Sent: Tuesday, August 02, 2011 7:18 AM To: Jeanine Grundman Subject: Subject: Attached image data. This is image data from the scanner. . -- of • cAM~ _~ ~~ u r` A yf ~; ARCH An~• CI'I'Y of CAM~'BEI.~, Public Works Department May 31, 2011 Joe Tersigni 1830 Hamilton Ave. San Jose, CA 95125 SUBJECT: PERMIT NO: '~`~=°"~ LOCATION: 1670 Grace Ave. FINAL INSPECTION AND ACCEPTANCE Dear Mr. Tersigni, The City of Campbell has made a final inspection of subject Public Works improvements and finds the work to be acceptable and in conformance with City standards. Accordingly, the City Engineer accepts the improvements. The one year maintenance period stated in the permit begins as of the date of this acceptance letter. The permittee is responsible for the repair and/or replacement of any defective work or failures that occur within one year. The City will inspect the improvements within one year and notify you, in writing, whether or not any repairs are required. Your Plan Check Deposit of $500.00 and Construction Cash Deposit of $1,320.00, plus any interest due, are now being processed and will be sent to you under separate cover. We will continue to hold the Assignment and Receipt of Investment Certificate for Street Improvements in the amount of $33,000.00 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. Sincerely, ~- ~! Syed Wahidi Senior Public Works Inspector ~.~., ~.~~ ~ c~ ~~ ~ ~~ ~~ O~ ~~ ~~~ C fi MQ cc: Suspense - 11 months Permit # ENC2008-00084 Inspector File ~~ ~~J, ~jvV ~e~ues~ , CD 1~-QQ-a-~~. 8/a./~ i J:VeanineG~ENC2008-00084, Final Inspection.doc 70 North First Street ~ Campbell, California 95008-! 423 'I'Et. 408.866.2 t 50 Fnx 408.376.0958 TDU 408.866.2790 .~r !-. O ~ ~ ~ N N .-. y~ 0 r O 0 C~ N .y z V1 W y ~+ U p p O O O O O O O O O O O C O O O O O O O C 00 O N 00 V1 M rl '~"~ H 0 0 0 0 0 0 0 0 0 0 ~ O O C O O M O S ~ V01 M try N N M~ 0 V~1 M 00 00 00 00 0~ o+ o~ o~ •~ -~ ~~ °o g o g °o S o 0 0 0 N N N N N N N N N N 00 00 00 00 .-~ ~ ~--~ •-~ ~ ~ ~ .-~ ~+ .-~ N N N N N N ti ti N N N N ~--~ ~ r r ~ r M~~~~ M ~ M M M O O O O O O~ N N N N et ~ ~' ~t N N I~ l~ [~ [~ N l~ N N N O O O O O O O O O O O ~ '~ N O ... O ~ a a ~ . ~. ~ cs! a, 'S ~ ~ A ~ ~ y v U A ~ ~ ~ ~" ~ ~ ~ ~ ~ ^d q ~ ~ ~ U a W a C~7 Z U r%~ ~ a U 7 Q .~ O F o °oOO O g o o°~° °o N N N N N N N N O N O O O M M O 0 0~ 0 V7 O ~/1 O v1 O ~pA V1 V1 O pp N O N O N O O O N N~ N 0 N~ N N N~ In ~ ~ ti l/y .r V1 ~ V .-i a, ~ O a¢~ V a U A~ a U ~i w Op e0 a v CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit # ~.NC',?mom - C~8 y Property Address X1070 Grace Ave Date of Final Inspection: ~ " 3 ~ " ~ ~ On File: ^ Bonds l~ CD ^ Cash ^ Faithful Performance $ N /A ^ Labor and Material $ N A ~ Plan Check DePosik ~# .~~ °° '® Construction Cash Deposit to be released: $~.~.~- - Other overdue deposits to be released (Description): I'~or1i.,~.~m ~' sP~~r~~~u~ ~ ~{ ~n~• o0 l 1 ~~J. U~o ,~% - Processed by: Reviewed by: Reviewed by: Administrator ~,.~~,.. Ce ~ ~'ca 4e (S+ree+- 1 vr-~-v~/erne,~5 Ins or Land Reviewed by: Engineer City En eer J:\FORMS\Templates\Administrative\Checklist -Clearance for Final Insp and Acceptance.doc (Rev. 03 10) O~ C A,yf ~~ A~e~ ~• U r 0 0 a ~ 6 ~ A G~ ~RcHAgO Transmittal Jea "` ~° Grundman Of. assistant City of Campbell Department of Public Works 70 North Firat Street Campbell, CA 95008 Phone: (408) 866-2150 Fax: (408)376-0958 E-Mail: jeanineg@cityofcampbell.com To: Joe Tersigni Date: 6/2~~i ~ Company: Address: 1830 Hamilton Ave. San Jose, CA 95125 Re: Check for funds release of permit # ENC2008-00084 ^ Urgent ^ For Review ^ Please Comment ^ Please Reply x ^ For Information & Use I have attached your check totaling $1,826.29 of funds released for the project at 1670 Grace Ave., Campbell, CA 95008. This check represents your Plan Check Deposit of $500.00 and Construction Cash deposit of $1,320.00, plus any interest due. Thank you, Jeanine Giundman J:UeanineG~ENC2008-00084, Transmittal Grace Ave. 1670.DOC 232372 - CITY OF CAMPBELL vENDOR No. 10010946 CHECK N0. u Descai tian Account Purchase Order /gvpiee Number' nt Amo EPOSIT REFUND 2203 101 101.540 7448 CR053111 CR053111 1,820.00 6.29 . D INTEREST fOplpggb JOE TERSIGNI CHECK DATE CHECK N'0. op''~`~,~ CITY OF CAMPBELL w~i,zs caJceo aaanr: M.x. 11-za 06:/27/11.. 232372 420 MONTGOMERY STREET 1210 ,c'y ~~ 70 NORTM FIRST STREET. sax aRnNCisca, cA salon c: ~' CAMPBELL, CALIFORNIA 95008 AMOUNT ~ * * * * * l , 8.2 6 . 2 9 * ~ o c ~ ~~~- G~ VOID. AFTER 90 DAYS OT ~kCHAItV,. ~ PAY THE SUM OF ONE THOUSAND, EIGHT HUNDRED TWENTY SIX DOLLARS & F VIII 29 CENTS TO TxE JOE.. TERSIGNI ~ oxnER 18 3 0: HAMILTON AUE ~ ~~. ; ~ A ~-~. of SAN. JOSE CA 95125 \`~ ~' CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 JOE TERSIGNI 1830 HA~!IILTON AVE SAN JOSE CA 95125 .» N ~ .fir \p ~ N 00 ~' O 0 3° ~o N N ~o z v~ W as ~+ V ~- 0 o°o,°o,S°o,°o,°oo° 0 0 0 0 0 0 0 0 °~ 0-- r ~ O` ~~ p 0 0 0 0 0 0 0 0 8 0~ O~ N M 0 If'1 M h N N M~ 0 d M d~ ~--~ ~" ~t 7 0 O F 00 00 00 00 O~ O~ O~ O~ 0 0 0 0 0 0 0 0 N N N N N N N N ~ ~ ~ ~ ~ ~ ~ ~ 00 00 00 00 r+ ~ •-~ •-• .-. .--~ .-+ .--~ N N N N ~ ~ ~ ~ ~ ~ r ~ N N N N ~" M ~ ~ R ~ M ~ M 0 0 0 0 0 0 V1 O N !h ~ Q ~ N ~ N N l~ l~ [~ l~ N t~ N .-i r+ .--~ .-. .r .--i ~ .-r O O O O O O O O .-~ .-~ ~-. .--i ..~ .-. N ... ~, ~ ~ ° o ~ a a ~, .~ = ,~ a> ~ Q ~ A ~wq ~ awn U U ~ Q G p ci, W a C7 Z U ~ ~ 00 00 00 00 0~ oo O O °o °o g °o o °0 0 0 N N N N N N N N ~ ~ ~ ~ ~ ~ ~ ~ 0 0 0 0 0 0 0 0 M M M M M M M M ~ ~ b ~ ~ ~ ~ ~ ~o~o~o~~ 0 0 0 0 0 0 0 0 O N O N O N O O N~ N O N ~ N N ~ ~ ~ ~ ~ ~ ~ r .r Aaa.a~~~¢ av.,¢wC7aUA~ ~' .~ r, Viz' ~~ ~.~ ~ ~ _~ w 0 a ~~ of ' CAMn~ ~~~ V ~' a a ti ~ •~RCH A~~• CITY ol~ CAMPBELL Public Works Department May 31, 2011 Joe Tersigni 1830 Hamilton Ave. San Jose, CA 95125 SUBJECT: PERMIT NO: ENC2008-00084 LOCATION: 1670 Grace Ave. FINAL INSPECTION AND ACCEPTANCE Dear Mr. Tersigni, The City of Campbell has made a final inspection of subject Public Works improvements and finds the work to be acceptable and in conformance with City standards. Accordingly, the City Engineer accepts the improvements. The one year maintenance period stated in the permit begins as of the date of this acceptance letter. The permittee is responsible for the repair and/or replacement of any defective work or failures that occur within one year. The City will inspect the improvements within one year and notify you, in writing, whether or not any repairs are required. Your Plan Check Deposit of $500.00 and Construction Cash Deposit of $1,320.00, plus any interest due, are now being processed and will be sent to you under separate cover. We will continue to hold the Assignment and Receipt of Investment Certificate for Street Improvements in the amount of $33,000.00 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. Sincerely, Syed Wahidi Senior Public Works Inspector MQ~ cc: Suspense - 11 months 'Permit # ENC20a8-00084 Inspector File J:UeanineG~ENC2008-00084, Final Inspection.doc 70 North First Street Campbell, California 95008-1423 ret. 408.866.2150 FAx 408.376.0958 To~> 408.866.2790 Refundable Deposit Check ReQuest To: Finance Director Check Payable To: Address -Line 1: Line 2: City: Description: Account Number: Account Number: Account Number: (Finance Dept only) Totat Payable: Purpose: Joe Tersigni 1830 Hamilton Ave. San Jose State: CA Zip: 95125 Refund Deposit for ENC2008-00084 101.2203 Amount: $1,320.00 101.2203 Amount: $500.00 101.540.7448 Amount: Interest Earned (Finance Dept only) $1,820.00 (Exact Amount) Refund Construction Cash Deposit ($1320.00) and Plan Check Deposit ($500 00)• ENC2008-00084 for 1670 Grace Ave. Voucher #: Permit #: ENC2008-00084 Receipt #: 218642 8 179 Date: 7120/2009 & 6/18/08 Requested by: Syed Wahidi Title: PW Inspector Date: _ Approved by: Michelle Quinney ~ Title: City Engineer Date: _ Finance Dept Only: Date: Verified by: Title: - Approved by: Title: Date: 5/3112011 5131 /2011 ial Instructions- For Handlin4 Check Mail As Is: Return To: Other: Mail in Attached Envelope: Interim Check: Needed fay: Jeanine Grundman (Name) Refundable Deposit Check PW (Department) f/n: Formslexcxl/chkreq - Revised 05/00 Joy Francois C q Executl~~sistant ~~ MA ~~ City of ,~pbell ,L~ ~~ Department of Public Works U ~.. 70 North First Street 0 o Campbell, CA 95008 '' '' Phone: (408) 866-2776 6 ~ ~' c` Fax: (408) 376-0958 CRCH ARC Transmittal To: Lucille M. Tersigni, Tersigni Family LP Date: 1/5/10 Address: 1830 Hamilton Ave., San Jose, CA 95125 Re: 1670 Grace Ave., Street Improvement Agreement D Urgent Q For Review ^ Please Comment ^ Please Reply x For Information & Use Enclosed please find a copy of the recorded Street Improvement Agreement, Document #20481053, recorded 10/27/09. Joy Francois ;~~ aoo~-~u~~y ~--- r-, Pages 10 DOCUMENT: 20401053 .Fees.... No Fees Recording Requested by: ) Taxes .. . ) Copies.. ~- City of Campbell ) ~~~~ `~.~-~ AMT PAID ) RDE # 005 When recorded mailto: ) REGINA ALCOMENDRAS 10/27/2009 SANTA CLARA COUNTY RECORDER 2:09 PM City Clerk ) Recorded at the request of City of Campbell ) C i t y 70 North First Street ) Campbell, CA 95008 ) (Space above this ]ine for Recorder's use only.) APN: 288-25-085 ADDRESS: 1670 Grace Avenue, Campbell, CA 95008 STREET IMPROVEMENT AGREEMENT RECITALS , THIS AGREEMENT, identified by File No(s). PLN 2007-00102 is entee~d info 1~1~_ d A ~ , 2009, by and between T gn Y of C,JC~' % ~~ .Ch ~' ~ California Limited Partnership, 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 a s "City." On September 18, 2007 the City Council granted conditioon~all nphat certain Parcel Map filed for for that certain real property described as Parcel A, as sh ~ 5' record in the Office of the County Recorandedr oommonly lknownuas~16701Grace~ Avenanue~which 1990, in Book 609 of Maps, Page 4~, 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. THE INgrnt~~EHr ~ A ~ ANO conr•ECr ooPY of THE OIrOS1AL ON RI.E IN THIS OFRCE AT11E8T: ANNE BYBEE, CITY CL9M( CA 1 dY DATEC ~~--`~~ -- ~'~ ' - - STREET IMPROVEMENT PLANS (3) The Owner, shall cause to be prepared 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, standards, sizes, lines and grades approved by the City Engineer, and all State and County statutes. Upon completion and acceptance of the improvements by the 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 Counci] 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 guarantee 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 may be 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 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 oi• willful misconduct of the Cite. (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 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 Ol 11 85; and ^. ISO form G0009 11 88 Owners and Contractors Protective Liability Coverage Form -Coverage for Operations of Designated Contractor; and ;. Course of Construction Insurance covering all risks of Ions; and 4. ISO CA 00 Ol 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: 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: 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 ow~led, 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. 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. E. F G 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. ;. 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 Cite. 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. 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. 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. Subcontractors Owner shall include all subcontractors as insure furnish separate certificates by each subcontractor. to all of the requirements stated herein. d under its policies or shall All coverage shall be subject h 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 1670 Grace Avenue, and the City's property, commonly described as Grace Avenue and 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 - 1670 Grace Avenue," which are subject to approval by the City Engineer, prepared by Nelsen Engineering. 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. Tersigni Family L.P., A California Limited Partnership Lucille M. Tersigni, Trustee ``,~ CITY OF CAMPBELL Michelle Quinney, City Engi er (Notary Acknowledgment for above signator(ies) MUST be attached.) Attest: `, -.,~, ~ -, 4 ~~ -` ,_,,,,L , Anne Bybee, City Clerk ,~ CALIFORNIA ALL-PURPOSE ACKNOWLEDOMEN'i• State of California County of~G~n~ ~~~~ Da personally appeared L K. ROACH -~ COMM. #1$37256 -' t"-7 m NOTARY P!lBLIC - CALIFORNW~`. ~" SANTA CLARA COUNTY d My Comm. EzPires March 16, 2013 vv who proved to on the basis of sati ctory evidence to be the personwhose namef~`S is/ re subscribed to the within m trument and acknowledged to me that f~/she/~y executed the same in t~iS~/her/thetf authorized capacity(i~, and that by h~/her/thei~signatur~(s) on the instrument the person(s`~ 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. Place Notary Seal Above WITNESS my hand and offici_ I seal. . Signature Signature of Notary Public OPTIONAL Though the information below is not required bylaw, 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: Number of Pages: Capacity(ies) Claimed by Signer(s) Signer's Name: ~!~a%~-~-~ ~ Signer's Name: ^ Individual ^ Individual ^ Corporate Officer -Title(s): ^ Corporate Officer -Title(s): ^ Partner - ^ Limited ^ General _ _ ^ Partner - ^ Limited ^ General ^ Attorney in Fact • - ^ Attorney in Fact Top of thumb here Top of thumb here ^ Trustee Trustee ^ Guardian or Conservator ^ Guardian or Conservator ^ Other: ^ Other: I Si r Is Represent' Signer Is Representing: ©2007 National Notary Assoaation • 9350 De Soto Ave.. P.O. Box 2402 • Chatsworth. CA 91313-2402 • www.NationalNotary.orc Item #590' Reorder. Call Toll-Free 1-800-876-682- CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT State of Califo~~rn~~ia,,~~ ^~ ~ County of __`~lllG' ~-(~Rc_~ , / e ' ~J , On ~ 0! ~ beforeme, ~1 '""Y ~ 1 ~ ~ ~~ ~ ate /~ ,~~ Here Insert Name and Title of the Officer personally appeared '" 1 ~ ~-V ~J~ -~. ~~(~~ i''1 e/)n me(s) of Si ner(s) JOANNE M. D'AMBROSIA Commission #r 1735773 Notary Public - Calffornia Santa Clara County Cantu. AAar 31,2011 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/y executed the same in~'s/her/tp~ir authorized capacity(~^s), and that by t?!S/her/tt}t~r signatures on the instrument the person~'j, or the entity upon behalf of which the persoh~, 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 sea Signatu Place Notary Seal Above 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 Document Date: Signer(s) Other Than Named Capacity(ies) Claimed by Signer(s) Signer's Name: Si ^ Individual ^ ^ Corporate Officer-Title(s): Partner - ^ Limited ^ Ger ^ Attorney in Fact ^ Trustee ^ Guardian ^ Other: Signer Is Representing: Top of thumb here Number of ^ Corporate Offic Title(s): _ ^ Partner - ^ Limited eneral ^ Attorney in Fact ^ Trustee ^ Guardian or Conservator ^ Other: Signer Is Representing e - , Top of thumb here ' ®2007 National Notary Association • 9350 De Soto Ave., P.O. Box 2402 • Chatsworth, CA 91313.2402 • www.NationalNOtarv.org Item ri5907 Reorder: Call Toll-Free 1-B00-876-6827 OF • CA,t1~ ~~ ,_ ~~~ ;~ r ~. YF. `~ •GkCHr~Rn• CITY of CAMPBELL Public Works Department November 5, 2009 Assistant Manager Comerica Bank 444 North Santa Cruz Avenue Los Gatos, CA 95030 Re: City of Campbell Encroachment Permit ENC2008-00084 Tersigni Family LP DBA Doma Investments Investment Certificate No. 385108951968 Dear Comerica Bank: Enclosed for your records please find a copy of the acknowledged Assignment and Receipt of Investment Certificate on behalf of Tersigni Family LP DBA Doma Investments for their project in the City of Campbell at 1670 Grace .Avenue. When the project is accepted by the City, we will notify the Bank of the release of this assignment. 1 ~~~~~ Joanne M. D'Ambrosia Office Specialist Enclosure 'r~~., ~, ~ ir,t _ _~. :;;:~mn~,eli, L:µlifornia 95005-142 • 'rat 408.866.21 50 • Fnx 408.376.0958 Tnn 40£i.866.279G 0 0 N C ~--i i-~ V H ~-+ C~ "~ 00 0 0 N O M O z c c ~i i~ ti r (.J U y .S C.S f- „_ ~ 'A ~~ i ~.~ ~`~ ® t.~ y~ x 1 r 1 ,~, r . t~. ~.. ~, c .~ c~i 0 ~~ 0 I a~ ~~ . l ~. ~ '~ ' i / zr 0 ~i a~ Q c ~~ [-