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ENC2009-00032
~T PrinXEgm- CITY OF CAMPBELL ENCROACHMENTPERMIT Permit No t= 4~~ ~"L'°1 ~DG"~° ~ Z- bEPT. OFPUBLIC NtORKS {for working within the public X-Ref. Flle •. 70 North First Street right-of-way) Application Date _ Campbell, CA 95008 Issued ~~G/~ ~ ~ Appli[atio~n ~ir '' n Ddt Ph. (40i3) 85&2150 APN _ _ N ~ Fx. (a08) 376.0358 2 ~ rte, ~ U -,~- Permit Expiration Date T APPLICATION - Application is hereby made for a PuMrc Works Permit in acro:dance with Campbell Municipal Code, Section 11.04. {Application expires in six (6} months if the permit is not issued- Application Fee is non-refundable) A. work Addressor Tract NO.: W. Campbell Ave. at La Pradera Dr. Utility Trench Location: North side of W. Campbell Ave. 10' off face of Curb R. Nature of Work: BOre 343', trench 10', place 1 -2" HOPE duct and 1 - 303b handhole C Attach four (4) copies of an engitteered plan showing the location and extent of thework, and four (4) copies of Ehe preliminary Engineer's Estimate oFwork. 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. 0. A!I work shall conform to the Ctty of Campbell Standard Specifications and Details for Public Works Construction; Ute General Permit Conditions listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these condiYrons and provisions may result Injob shutdown and/or forfeiture of Faithful Performance Sureties aril cash deposits. {See General Permit Condisions 1 and 2J E. The Contractor must have th(s permit and approved plans at the site and must notify cite 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 ApplicanC. 5unesys L!C Telephone: (40f3) 723-257b Address. 3550 Charter Park Drive, San Jose, CA 95136 E-nnait Address: mcaldwellCasunesys.com 24-HOUR EMERGENCY PHONE NUMBER: (267 7i 8-0968 Is this work being done by the property owners a[ their own residence? ~' YES r NO The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell. its officers, agents, and employees free, safe and harmless from any claim or demand fordamages resulting from the work Covered by this permit. The Applicant/Permitted-ltE:reby-acknowledges that they have read and understand both the front and back of this permit, and they wilt inform their contraROr(s) of the iritormation. Applicant is advised that upon issuance of this permit, property owner, or property owners successors, shall be responsible for any and a~a~arlsing,put of the cjonditinn of arty private improvements in she public right-of-way. / / Accepted: ~~C~~'L`-L~f' .• ~/l/F/L(G .~ ~ ~" 1' 1~ (.•~ ~ G.3~G.3 (a,~d • ~ (Applicant Permittee) (sign) Oi/1 tzj~2 OF GyOGQ rt-")> tw5 - ~V~SY $ Date (Contractor) (Print Name) Daie SPECIAL PRQVWONS: _1. Street shall not be open cut for underground installations. Minimum cuts mpy be allowed for connections or exploradon holes. Such cuts maybe speyi;}y~,ly_p~roved h [the IospQctor oriar to cuttino. -„~2. Pavement may becut for underground Installations and must be restored in accordance with the Standard DetatlsTrench Restoration Method "A'",unless otherwise approved by the Engineer. _3- Work to bestaked by a licensed land Surveyor or Civil Engineer and two {2) copies ofthe cut sheets sent to the Public Works Department before starting work. ~4. Per Section 4215 of the Government Code this permit is not valid For excavattons until Underground Service Alert (USA} has been notified and the inquiry identification number has been entered hereon. USA Phone: t-800-227-2600. USA TICKET N0. _5- Prior to any work. the property owner shall execute an Agreement for Private Improvements in [he Public Right•of-Way, which shall (>e recorded. _~___6. PuhllcNotfficaponRequirements: 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT {, RECEIPT NO. PERMIT APPLICATION FEE $ ~ ~ ~ _ ~ c S t: PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $ CONSTRUCTION CASH OEPOSIT 5 T PLAN CHECK& INSPECTION FEE 5 ' - G L ~' APPAOVED FOR ISSUANCE -~ "--~ 3I (G~ O For City Engineer Date Permit Expires 12 Months After bate of Issuance ~~~ o i •, ~~ I M1 N V~` ``y'I--1i' ~,~~~ ~ ~ y GENERAL PERMff CONDITIONS I . A Construction Cash Deposit is required. Charges will be made against this deposit d there is an emergency call-out, overtime inspection or when Ciry ordered barricading is required. Any such costs in excess of the deposit wil I be killed to the Permittee. 2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by thetity. 3. Refund or the cash deposit balance and refund or cancel lotion of the Faithful Performance Surety will be Initiated by the wdtten acceptance of the work by the City. 4, The Permittee must request in writing a Rnal Inspection and acceptance of the work upon completion. Acceptance by the Gtywdl be made in writing to the Permittee_ 5. Maintain safe pedestrian and vehicular crossings and free access to private driveways bus stops, fire hydrants, and water valves. 6. A Construction Traffic Control Plan and a Consvuction Scheduleare required for all lane closures, detours, and street dosures. This plan must be reviewed and a pproved prior to any lane dosures. 7. A Construction Traffic Control Plan shall conform to the Caltrans Manual of Twtfic Controls for Construction and Maintenance work Zones, dated t990, available at Cattrans. Traffic mntrol equipment shall Include Type It Gashing arrow signs if required. 8. Replace as directed by the City Engineerany damaged or removed improvements in accordance with Cily Standards and SpeaficaNons at the sole expense of the Permittee 9. Sawcut for all PCC or AC removals. A!I PCC removals shall be to the nearest scorenwrk and shall be doweled to existing improvements. 70. Prior approval of inspector is required for any work done after normaE working bouts, on weekends or holidays and may require reimbursement of inspection costs at the current overYrnte rate t I. Adequate signing and barricading is required an the job sfte_ Failure to provide such signing and barricading may result in the City's providing signing and barricades and Charging the cost {including all labor and materials) against the cash deposit 12. Compaction testing of subgrade, base rack, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 'I3. The Contrac[oror Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractoror Permittee sha[I provide a phone number at whicfl they can be contacted outside the hours of 8:00 a.m. to 4:00 pm. t4. No storage of materials or equipment will be allowed near the edge of pavement, the traveled ~vay, or within the shoulderline which would create a hazardous condition l0 the pu bl Ic, t 5. 'this permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a separate permh maybe required, oar does It relieve the Permltteeof any obligation [o obtain any other permit required bylaw, 16. This permit does not release the Permigee from any liabilities contained in other agreements orcontracts with the Ci[y and any outer public agency, 3 ]. 'f his permit is not transferable. Work must be performed by the Permittee or his designated ascot orcontractor as specified thereon. 18. Call back (call out) due to emeregencies regarding this permit shall beat the current overtime rate with a three l3) hour minimum charge per occurrence. l9_ Pursuant to Chapter 14.02 of Che Campbell Municipal Code, applicant shall not cause to 6e discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. 20. If the publk interest requires a modification of, or a departure from the plans and specifications, the City shall have the authority to require or approve any modifcation or departure and to speedy the rttanner in which the same is to be made for City-owned or maintained fadlitles. 21. Permitttee must provrcle advance notificationto alt parties chat may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and phone number. Applicant shall be responsible for ensuring Ehat all those providing services under the applicant are aware and understand all of the above conditions_ o s/o 3/may Ddle: Contractor (Print Name) pate: 1:\FORMS\Templates\Encroachment Penrits\Encroachmenc Permit STATIC form2.pdf Rev. 3lOB PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT & MISCELLANEOUS RECEIPT Effective July 1, 2008 TO: City Clerk PUBLIC WORKS FILE NO. ~ 2.~G~1 ~ ~"~~ ~ L PROPERTY ADDRESS GLL ~~ Please collect & recei t for the followin monies: -ACCT. ITEM AMOUNT ENCROACHMENT"PERMIT 4722 Utility Encroachment Permit Application Fee Utilit Arterial/Collector Street $585.00 _ ~ L} Residential Street/Other Areas $325.00 4722 Plan Check & Inspection Fee Utilit < $100,000 * Minimum Charge Per Location ($260.00) Z- G Conduits/Pipelines up to 500 Feet ($2.35/ft) Above 500 Linear Feet ($1.40/ft) ManholesNa ults/Etc. ($130.00/ea ) Pole Set/Removal ($130.00/ea) Street Tree Plantin /Removal $150.00 ** 2203 Utili > $100,000 * Actual Cost + 20% ** 4760 Stora a Container Permit $130.00 4760 Pro~ect Plans & S ecifications Pro'ect No. 4760 Standard S ecifications & Details $1/P $15.50/Bk 4760 Co ies of En ineerin Ma s & Plans Aerial Plot 24" x 36" $55.00 Aerial Print 8 1/2" x 11" $25.00 Aerial Search Fee $25.00 Ma sand Plans 24" x 36" $12.50 4722 Penalties: Failure to restore ublic im rovements $100/Calendar Da Muni Code Sec. 11.34.010) 4722 Penalties: Failure to correct unsafe conditions $100/Calendar Da 4722 Work Without Permits 4 Times A licabie Fee) MISCELLANEOUS 511.7424 Posta e Other Please S ecif *Engineer's Estimate shall be as approved by the City Engineer. NAME OF APPLICANT~;(~ni'~~S ~y ~~'~~~ 'TOTAL ~M~~'~ L ~~~~"'~'"~ l U' $ NAME OF PAYOR~JL~AaS~~ PHONE ~~~' `-L ll~ ~~T~ ~C ADDRESS S `~C_i C~~~~C:~-/~ ~ ~~~'1- ~ ~~ c'" `7 ~ ~ (G' ZIP "*Actual Cost Plus 20% Overhead Non-Interest bearing de osit FOR RECEIVED B CITY CLERK ONLY .Date cei "t# AR ~ 6 ~u~ I~~FORMS~TemplateetAtlmirMavatrveWeceipl Form Uldily Emoechmenl B Mlsc OB-OB Rev i°ro8 a o 0 0 ~ o o ~ . W o ~ ~ w ~ U ~ Z ~ a (Wj ~ ~ z oho U m g w U m O W ~ p H H ° H o U z o ° 0 0 H , U Z ° U °- ~ P+ o W ~ U o ° W U o O w ~ p H o ~., o H ~ o Ei o 0 o U z ' r+ ~ ° ~ ~ ~ o d, U ~ ~ ~ ~ 2 co w a ~ L1J ~ ~ ~ w V ~ o U ~ p~ ~ ~ Z z w o o ~ - N ~ O z W ~ W J J ~ =`i 'Q V p a Ya• ~ ~a Z w p ~ o ~, O ~ ~ G d ~ ~ ~ ~ O ~a ~ rn W, ~ O U I ~~ ._. - - ~~t if .. Ir '~~,. •.r u.. ll,~ ...3'.. GY, ~~~.. - i.:. L:. ~ i 1 a i I.r. ''~.f~ L ~' y7, '.. .., : ~ .., 11J Lam. 1., ~ D'~- .....~ ~ ,_. ~..... Sk Mu Fp f~:t I...._ f_... 1 i M-n f-.- ~u:L la (.l i~A=1 ice] .~., t t.~ ~ ~._ Ctii Fri p._ i~.a ~ .~. U,1 C.i 1...-! ':_~ ~~ w 'I.y MI i tl F C..:t 1.11 L.1'. .. ~3 ~' ~~ 1..... il. .n 1...:.. .. 0 0 a~ 0 0 o ~ 0 0 in o ~ w ~ ~ 0 r K O z H ~ w J ~ I- _ U Q w 0 ~ w ~Q ~a W ¢7 Z O LIl O M U ~ 1 ® ,4~ ° CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYVY) 7 21 11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER John L L P Wortham & Son CONTACT NAME: . . , . P. O. BOX 1388 ~ 713-526-3366 AIC No : 713-521-1951 PH ~~ , Houston, TX 77251-1388 E MAIL ADDRESS: ~ ~ G ~~~ INSURERS AFFORDING COVERAGE NAIC # ~ ~~ ~/ INSURER A : Old Re ublic Insurance Com an 24147 INSURED Golden State Utility Co. , G INSURER B : ACe PrD ert & Casualt Insurance Co. 20699 4425 Farm Supply Rd. ~r~''` -~ ~ INSURER c : Zurich American Insurance Com an 16535 Ceres CA 95307 ~+~ INSURER D INSURER E INSURER F f~CQTILI/+ATC \111\ADCD• ~r1700/1r1r1 REVISION NUMBER: I+VVCRAbCJ ~IGn11rIVHrL ~.a.m.+~~.. ivicwo -.----- - THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED . THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN , EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MMIDDIYYW MMIDDM'W LIMITS GENERAL LIABILITY MWZY59308 8/1/2011 8/1/2012 EACH OCCURRENCE $ 5,000,000 A DAMAGE TO RENTED 000 000 5 AL GENERAL LIABILITY PREMISES Ea occurrence , , $ COMMERCI E ~ OCCUR MED EXP (Any one person) $excluded CLAIMS-MAD PERSONAL 8 ADV INJURY $ 5,000,000 GENERAL AGGREGATE $ 5,000,000 PPLIES PER ' PRODUCTS -COMP/OP AGG $ 5,000,000 : L AGGREGATE LIMIT A GEN A POLICY ~ PRO LOC AUTOMOBILE LIABILITY MWTB21321 8/1/2011 8/1/2012 EOa eocideDtSINGLE LIMIT $ $ 5 000 000 BODILY INJURY (Per person) $ ANY AUTO NED ULED BODILY INJURY (Per accident) $ AUTOS ~ AUTOS NON-OWNED PROPERTY DAMAGE Per accident $ HIRED AUTOS AUTOS / UMBRELLA LIAB OCCUR XOOG25908971 8/1 /2011 8/1 /2012 EACH OCCURRENCE $ 5 OQQ 000 B EXCESS LIAB ~ CLAIMS-MADE AGGREGATE $ 5 000 000 DED ~ RETENTION$ er olic CM Retro Date 8/1/2002 $ p p y A WORKERS COMPENSATION MWC11713400 $/1/2011 $/1/2012 WcsTATU- OE7~1- TORY LIMITS AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. E4CH ACCIDENT $ 1 000 000 OFFICER/MEMBER EXCLUDED? ~ in NH) t M d N / p` E.L. DISEASE - EA EMPLOYEE $ a ( an ory If yes, describe under E.L. DISEASE -POLICY LIMIT $ 1 000 000 DESCRIPTION OF OPERATIONS below C Property MCP3548287-05 8/1/2011 8/1/2012 See Attached Addendum for Limits C Property MBR5423663-00 8/1/2011 8/1/2012 See Attached Addendum for Limits DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Division #03 Re: All Work In Public Right-of-way see attached addendum -zc; ~ - coca ~s ~. CERTIFICATE HOLDER CAN ELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of Campbell ACCORDANCE WITH THE POLICY PROVISIONS. Department Of Public Works 7O N. FIfSt St. AUTHORIZED REPRESENTATIVE Campbell CA 95008 John L. Wortham 8 Son, L.P. ~/11'fnAQAT1A\I All ~•..M4~ ~ecnnina V IJOO'LV IU MV Vnv vv nr vr~r+~ ~v~.. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD CERT NO.: 10722090 CLIENT CODE: lOQUANTSER (HOU) Sandy Moore 7/21/2011 5:28:46 AM Page 1 of 6 CERT NO.: 10722090 CLIENT CODE: lOQUANTSER (HOU) Sandy Moore 7/21/2011 5:28:40 AM Page 2 of 6 ecertsonlinaT" GtK I IrIGA I t AUUtNUUM CERTIFICATE ATTACHMENT I DATE ISSUED 7/21 /201 NAMED INSURED: Golden State Utility Co. 4425 Farm Supply Rd. Ceres CA 95307 Installation Limits: Policy # MBR5423663-00 $25,000,000 - Per Project $ 5,000,000 - At Any Temporary Storage Location $ 5,000,000 - Any One Occurrence As Respect Horizontal Drilling Projects $ 2,000,000 - In Transit Any One Conveyance $ 1,500,000 - Debris Removal $ 1,000,000 - As Respect Expediting And Extra Expense Policy Aggregates: Flood - $10,000,000 Any One Occurrence/annual Aggregate Earthquake - $10,000,000 Any One Occurrence/annual Aggregate Coastal Named Windstorm - $15,000,000 Per Occurrence/annual Aggregate Contractor's Equipment - Policy #MCP3548287-OS $25,000,000 - Any One Occurrence $ 2,500,000 - Any One Item Borrowed, Leased Or Rented Items (SHORT TERM) $ 1,000,000 - Any One Occurrence As Respect Riggers Liability Real Property, Business Personal Property, EDP Hardware & Media, Extra Expense/Rental Expenses $25,000,000 - Any One Occurrence $ 500,000 - Extra Expense and Rental Expenses $ 500,000 - Unnamed Locations $ 500,000 - Personal Property in Transit Policy Aggregates: Flood - $10,000,000 Any One Occurrence/annual Aggregate Earthquake - $10,000,000 Any One Occurrence/annual Aggregate Coastal Named Windstorm - $15,000,000 Per Occurrence/annual Aggregate Valuation: Installation - The Cost To Repair Or Replace The Property Lost Or Damaged At The Time And Place Of Loss With Material Of Like Kind And Quality. Contractors Equipment- Owned Equipment - The Lesser Of The Cost To Repair Or Replace With Like Use, Kind And Quality Valued As Of The Time Of The Loss Or Damage Or The Stated Value For Any One Item Insured As Shown On The Schedule On File With The Company. Borrowed/leased/rented Equipment - The Cost To Repair Or Replace With Like Use, Kind, And Quality Valued As Of The Time And Place Of Loss Or Damage Or The Named Insureds Liability As Set Forth In The Lease Or Rental Agreement. Real Property, Business Personal Property, EDP Hardware And Media - Replacement Cost Extra Expense and Rental Expenses - Actual Loss Sustained Certificate Holder Is Included As Loss Payee As Their Interest May Appear. ecertsoniineT"' CERTIFICATE ATTACHMENT CERT NO.: 10722090 CLIENT CODE: lOQUANTS ER (HOU) Sandy Moore 7/21/2011 5:28:98 AM Page 3 of 6 \ICR I IrIVhI G M 1 1I1v~~m V~• ~ ecertsonlineTM CERT NO.: 10722090 CLIENT CODE: lOQUANTSER (HOU) Sandy Moore 7/21/2011 5:28:48 AM Page 4 of 6 CERTIFICATE ADDENDUM NAMED INSURED: Golden State Utility Co. 4425 Farm Supply Rd. Ceres CA 95307 CERTIFICATE HOLDER: City Of Campbell Department Of Public Works 70 N. First St. Campbell CA 95008 DATE ISSUED 7/21 /2011 General Liability Policy Includes The City Of Campbell, The City Of Campbell Redevelopment Agency, Its Officers, Employees And Volunteers As An Additional Insured When Required By Written Contract But Only As Respects Liability Arising Out Of Named Insured's Work For Additional Insured. Auto Liability Policy Includes The City Of Campbell, The City Of Campbell Redevelopment Agency, Its Officers, Employees And Volunteers As An Additional Insured When Required By Written Contract. Insurance Is Primary As Regard To Additional Insured Coverage Extended To Certificate Holder. Workers' Compensation policies include waiver of subrogation in favor of The City Of Campbell The City Of Campbell Redevelopment Agency, Its Officers, Officials, Employees And Volunteers when required by written contract but in no event shall such coverage exceed the limits, terms or conditions of the policy. Property policy includes waiver of subrogation in favor of The City Of Campbell The City Of Campbell Redevelopment Agency, Its Officers, Officials, Employees And Volunteers if required in writing and prior to a loss. CERTIFICATE ADDENDUM ecertsonline T" CERT NO.: 10722090 CLIENT CODE: lOQUANTSER (HOU) Sandy Moore 7/21/2011 5:28:48 AM Page 5 of 6 THIS FORM DOES NOT APPLY IN: CO, MT, NM, OR COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anization s : Locations Of Covered O erations City of Campbell, City of Campbell Redevelopment -Agency, its officers, employees and volunteers Re: All work in public right-of-way Attn: Dept. of Public Works 70 North First Street Campbell, CA 95008 InSUred's Name: Golden state utility Co. Si nature Line: Information re uired to com lete this Schedule, if not shown above, will be shown in the Declarations. 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) desig- nated above. CG 2010 07 04 Quanta Services, Inc. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be pel-formed 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 in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. ©ISO Properties, Inc., 2004 Page 1 of 1 MWZY 59308 Policy Period: 08-01-11 to 08-01-12 CERT NO.: 10722090 CLIENT CODE: lOQUANTSER (HOU) Sandy Moore 7/21/2011 5:28:48 AM Page 6 of 6 John L. Wortham & Son, L.P. P. O. Box 1388 Houston, TX 77251-1388 MAIL DOCUMENT Certificate of Insurance Delivery by ecertsonline TTM Sender: (HOU) Sandy Moore City Of Campbell Phone: Department Of Public Works 70 N. First St. Campbell CA 95008 Subject: Date: No, of Pages URL: 713-526-3366 ACORD 25 (05/10) Certificate of Liability: Quanta Services, Inc. 7/21 /2011 7 THIS MESSAGE IS INTENDED FOR THE USE OF THE INDIVIDUAL OR ENTITY TO WHICH IT IS ADDRESSED AND MAY CONTAIN INFORMATION THAT IS PRIVILEGED, CONFIDENTIAL AND EXEMPT FROM DISCLOSURE UNDER APPLICABLE LAW. IF THE READER OF THE MESSAGE IS NOT THE INTENDED RECIPIENT, OR THE EMPLOYEE OR AGENT RESPONSIBLE FOR DELIVERING THE MESSAGE TO THE INTENDED RECIPIENT, YOU ARE HEREBYNOTIFIED THAT ANY DISSEMINATION, DISTRIBUTION OR COPYING OF THIS COMMUNICATION IS STRICTLY PROHIBITED. iF YOU HAVE RECEIVED THIS COMMUNICATION IN ERROR, PLEASE NOTIFY US IMMEDIATELY BY TELEPHONE, AND RETURN THE ORIGINAL MESSAGE TO US AT THE ABOVE ADDRESS VIA REGULAR POSTAL SERVICE. © 2002 Certificate of Insurance Delivered by ecertsonliineT"' Insurance Visions, Inc. All rights reserved. INSU~.ANCE REQUIREMEl\rTS CHECKLIST Permit ~ O(~ -b0 2,, ~.._ CIP Project # --~,~~.s~~.. c~~ The following insurance is required of all contractors wo king in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: 000,000 per occurrence, and 1.000,000 general aggregate limit applying separately to the project, or ,000,000 general aggregate limit. ~; Policy expiration date ~~~~~ Automotive Liability: "Anv Auto" checked on certificate ,,000,000 per accident for bodily injury and property damage ~ Policy expiration date Workers' Compensation and Employer's Liability Waiver of Subrogation clause $1,000,000 per accident fo~,b /dil ~ ~ rv or disease Policy expiration date `f~ 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 Additional Insured Endorsement f~ 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. 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' Com ~ ensation Insurance Sheet Submitted ~ - ~- ^ For General Contractor / ~~ ~ ~nl q ^ For Developer or Owner ~~ ~~r ~~ v~~-~- ~ ~ ~ ~; ;; 1~~1~~"~ ~ ca `~ , _ .. __ U °j Acce bility of Insurers ~ ~..~ ~- ~,J~~ ~~ ,Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact ~~ "~ business in the r L ~ ~~ Insurance Certificate Reviewed ~~/ ~~~' ~'~J~ `~ Copy of Insurance Certificate placed in tickler file for month of expiration. `~ ~/~© j:\forms\inscklst (rev 1 1 /99) ~~ Page 1 of 1 Joanne D' Ambrosia From: Syed Wahidi Sent: Tuesday, March 10, 2009 7:45 AM To: Joanne D' Ambrosia Subject: RE: Golden State Utility I believe so. He left message that he will be e-mailing insurance. Please let me know how it looks. Syed From: Joanne D' Ambrosia Sent: Monday, March 09, 2009 5:02 PM To: Syed Wahidi Subject: Golden State Utility I received insurance on email today from insurance agent for Golden State Utility today. Is that the company doing work for Sunesys on ENC2009-00032 on Campbell Avene? Joanne 3/10/2009 Page 1 of 1 Joanne D' Ambrosia From: Syed Wahidi Sent: Tuesday, March 10, 2009 7:53 AM To: Joanne D' Ambrosia Subject: FW: Attachments: Scan2300.pdf FYI From: Valverde, Saul [mailto:SValverde@sunesys.com] Sent: Monday, March 09, 2009 2:17 PM To: Syed Wahidi Cc: Carlucci, Daniel Subject: Syed, Attached are the insurance documents that you asked from our contractor. Please review and let me know if this is suffice to get our permit. we are suffering everyday thousands of dollars in liquidated damages while not having possession of this permit. We would greatly appreciate your help in obtaining this permit as soon as possible. Thank you Saul Valverde Northern California Project Controller Sunesys L.L.C. (408) 723-2567 Fxt.19 -Office (408) 466-8916 -Mobile svalverde@sunesys.com *** eSafe 6 scanned this email for malicious content *** *** IMPORTANT: Do not open attachments from unrecognized senders *** 3/10/2009 ° ~.,_, ~ O VJ ~ ~ ~Sul^ H-i ~ N i `~ ° J P a U ~ °~~g~~ ~ r a c `~ J w ~ h_- ~ s~~o~~ v Q` ~ d' ~QR d N Q O ~~ O <L $5~~~~5 U N O O W O lL V C1 ~/ [O m O a ~ c LL J ~ N ~ C17 ~ ~ ~ 3~ ~ r-r CI'7 \/ ~ ~ O O ~~ W w Z Z W ~ m ~ z ~~~~ ~~~ ~ ~ N.`v QOD ~_ ~ W ~ ~ r ~~" i5 ~ O Ip~ o ",lo=w~rrUZw a ~ z ~ n i:.] ~C~'~~7't ~ Z ~ Vd 3 cGZZawwww~ o c:a ~ ¢ ~ a ~'~ ~ ~ ~ S~~Tmu_o~Q ~ d w o o a cvn z 0 ~ ^ N_ r 1/1 ~i ~ N o ~ ~ d -- ~ O ~ F- ~ p I I W H H O M OU ~ Z ~ Z a o 1D `° ~ z to ac ~- r~ z ~ z ~ W o ~~ M ~ O U~ 01 ~ Z° U _H O O 4 Z ~ Z O H W U Z x ~ p W ~ O O ~ VI cnacoeo > o~QO J ~ 3 Uw ~ ~ U 0 w ~~o,...U~pO ~~ °^c.~~ jo w~ wVt- O a w Z > Up=N~`-.' 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