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ENC2009-00072~~Print Form Permit No ~ ~ ~ CITY OF CAMPBELL ENCROACHMENT PERMIT DEPT.OF PUBLIC WORKS (for working within the public X-Ref. File 70 North First Street right-of-way) Application Date Campbell, CA 95008 d Applicat on Expirati-otn Datrei~ 2 Ph. (408) 866-2150 Issued ~ Z`~'" / APN ~~~ U M1' d ~~"1 Fx. (408) 376-0958 Z - ~ (~ Permit Expiration Date APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable.) A. work Addressor Tract No.: 400 East Campbell Avenue Utility Trench Location: B. Nature of work: 10' deep exploratory boring for soil samples 4 S~V f~ ~~,~, l' 1~%i't ~'\ ~l:1'UK C. Attach four (4) copies of an engineered plan showing the location and extent of the work, and four (4) copies f 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 Ciry Engineer, said plan becomes a part of this permit. D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2.) E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work. Name of Applicant: (Cornerstone Earth Group Telephone: ((408) 245-4600 address: 1259 Oakmead Parkway, Sunnyvale, CA 94085 E-Mail Address: IknUtSOn@COrnerStoneedrth.COm 24-HOUR EMERGENCY PHONE NUMBER: f (408) 747-7501 Is this work being done by the property owners at 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 for damages resulting from the work covered by this permit. The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be res onsible for an and all dama es arisin out of the conditio f rivate improvements in the pub 'c right-of-way. p Y 9 9 / / n. , i ~~. /4 /(r n , -he-,,... ~i i r n (/" ~( 1.1 ~ ,~ l O / l b Accepted: (Print Name) SPECIAL PROVISIONS: 1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be specifica~ approved bkthe Inspector prior to cutting. 2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A",unless otherwise approved by the Engineer. 3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public Works Department before starting work. 4. Per Section 4215 of the Government Code this permit is not valid for excavations until Underground Service Alert (USA) has been notified and the inquiry identification number has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO. 5. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be recorded. 6. Public Notification Requirements: 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES PERMIT APPLICATION FEE PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS CONSTRUCTION CASH DEPOSIT PLAN CHECK & INSPECTION FEE APPROVEDFORISSUANCE (Applicant Permittee) ~ (sign) AMOUNT RECEIPT NO. 5 !/-f4. 0 0 ~~ ~~~ Date Date 5 S L (~~a For City Engineer Permit Expires 12 Months After Date of Issuance ~ti \~\\\~ -o m cro w ro w x 0 `G m 0 0 O O b a 0 0 0 0 0 y C" '~ CS7 .~ a z z c~ d 6A O 0 0 ~d u ~ ~ ~ N N ~ O O ~_ O O d N N ~ ~ ~ ~ ~--~ ? ? W W N O W N ~ ~ ~O O ~O W 0o O O O coo Ci7 N Z ~ co ~ v, o ,.i O ~ n w x [ ~. a b a n b n• ~ w '~ 0 o' N A O~ O O .~ O O ~ O O ~ ~ N 0 0 'C m °O 00 a rn rn p N N ~ A ~ ~ N N ^0 O O m ~ ~ a 0 0 v, cn ~ r. N N ~ A ~ ~ ~ O O f9 O O .o. J J ^• 7k z ~o 0 ~ `~ O. a D c A 0 0 _ O O y O O c n n m r ~ ~ f~ .. ~ z ~. ~ x N ~• O ~ O ~ ~ ~ o ~C O C N "S ~ N N ~ W N 7~ 1-~ ~ PUBLIC WOR' 7EPARTMENT LAND DEVELOPMENT 8~ TRAFFIC RECEIPT Effective July 1, 2008 /~ /, 7 TO: City Clerk PUBLIC WORKS FILE NO. •_. ~ ~~~- E~dv /~ PROPERTY ADDRESS (~O _ ~J ~ C~ /`4-j/P . Please collect & receipt for the following monies: ACCT. ITEM AMOUNT LAND DEVELOPMENT 4722 Encroachment Permit Application Fee Non-Utilit Encroachment Permit $310.00 Minor Encroachment Permit <$to,ooo $140.00 . ~ R-1 First Permit (No Fee) Subsequent <~o,ooo $135.00 * 2203 Plan Check Deposit 2% of Engineer's Estimate ($500.00 min) 4722 Grading & Drainage Plan Review Sin le Family Lot $210.00 Site < 10,000 s.f. $625.00 Site > 10,000 s.f. < Acre $835.00 Site> 1 Acre $1,250.00 Plan Check & Ins ection Fee Non-Utilit **2203 En r. Est. >$250,000 Actual Cost + 20% min. $30,000 De osit 4722 Engr. Est. <$250,000 13% of ENGR. EST. * 2203 Emergenc Construction Cash Deposit 4% of En r. Est $500 min/$10,000 max * 2203 Faithful Performance Securit FPS 100% of ENGR. EST. 2203 Labor and Materials Security 100% of ENGR. EST. 4721 Storm Drainage Area Fee Per Acre (R-1 $2,120.00) (Multi-Res $2,385.00) All Other $2,650.00 4722 Parcel Ma 4 Lots or Less $3,500.00 + $78/lot 4722 Final Tract Map 5 or More Lots $4,300.00 + $105/lot 2203 Monumentation Securit 100% of ENGR. EST. 4920 Parkland Dedication Fee 75%/25% Due Upon Cert. of Occu ancy 4722 Lot Line Ad'ustmerlt $930.00 4722 Vacation of Public Streets & Easements $2,200.00 4722 Certificate of Com liance $675.00 4722 Certificate of Correction $415.00 4722 A peal Filin Fee $105.00 4722 Notary Fee er si nature $10.00 4722 Assessment Segregation or Reapportionment First Split ($735.00) Each Additional Lot $200.00 511.7424 TRAFFIC 4728 Postage Intersection Turn Counts Two-Hour Count $80.00 4728 Intersection Turn Counts a.m. or p.m. eaks $155.00 4728 Traffic Flow Ma Daily Traffic Volumes $33.00 4728 Si nal Timin Information $64.75/Hr 4271 Truck Permits $16.001 er tri 4728 +MISGELLAN No Parking Signs ($1/each or $25/100) EDUS Other (Please Specify) 4722 Street Tree Plantin /Removal Permit $150.00 + $500 de osit 'Engineer's Estimate shall be as approved by the City Engineer. TOTAL $ ~~0.0 (7 NAME OF APPLICANT Ce ~ ?1 r S ~~~ ~ - / NAME OF PAYOR !< !V~ ~~~1 v7 PHONE ~~S - 60~ ADDRESS 2 G(/Ot-~ ~J ZIP ~~d ~S '*Actual Cost Plus 20% Overhead (Non-Interest bearing deposit) FOR :RECEIVED Y ITY CLERK ONLY Date'C ipt # [~~ *For Plan Check and Cash Deposits, send yellow copy to Finance. Datel Initials CI T'; OF CR~iPAELL kEC~.I+ AY: 3Rg 01000~1783D GRYOk: CDk~tEkSTDt~E EARTH TDI+AY'S LATE: OS/18iD9 kEGISTEk URTE: 06!18109 TI~SE: 11: i5 I+ESCRIPTIDN RMOUNT E~dGk 6 SUAI+I4' FILING F X140.00 CUST In: 40D E CRMPAELI AVE TOTRL nUE: ---------------- ~14D.00 CHECK PRII+: Cr+ECK wD: iaaia TEfi~UEREI+: CNA~iGE: ~14D.DD ~14D.D8 x.00 r ~,; PUBLIC WORE:S DEPARTMENT UTILITY ENCROACHMENT & MISCELLANEOUS RECEIPT Effective Jufy 1, 2008 TO: City Clerk ~~7-~ PUBLIC WORKS FILE N0. ~~~ VUV ~Z PROPERTY ADDRESS Please collect & recei t for the following monies: .,.:ACCT. ITEM AMOUNT ENCROAC HMENT PERMIT' 4722 Utility Encroachment Permit Application Fee Utilit Arterial/Collector Street $585.00 Residential Street/Other Areas $325.00 ~ 4722 Plan Check & Inspection Fee 000 * Utilit < $100 , Minimum Charqe Per Location ($260.00) ~ ~ ~ '~ Conduits/Pipelines up to 500 Feet ($2.351ft) Above 500 Linear Feet ($1.40/ft) ManholesNaults/Etc ($130.00/ea) Pole Set/Removal ($130.00/ea) Street Tree Plantin !Removal $150.00 '* 2203 000 * Utilit > $100 Actual Cost + 20% ** 4760 , Stora e Container Permit $130.00 4760 Pro ect Plans & S ecifications Pro ect No. 4760 Standard S ecifications & Details $11P $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 $100lCalendar Da Muni Code Sec. 11.34.010) 4722 Penalties: Failure to correct unsafe conditions $100/Calendar Da 4722 Work Without Permits (4 Times Ap licable Fee MISCELLANEOUS 511.7424 Posta e Other Please S ecif *Engineer's Estimate shall be as approved by the City Engineer. ,/~ NAME OF APPLICANT C~I V~~~ TOTAL $ Z~,C} ~~ NAME OF PAYOR ~ - C- ~ PHONE ~.aLSC%' " ~ l ~'s ADDRESS `~~ ~ INCA (~ ~ ii d ~ ,~~~ ~ ~ ZIP ~ S i ~ **Actual Cost Plus 20% Overhead (Non-Interest bearin de osit FOR (RECEIVED B CITY CLERK ', ~ ONLY !Date Recel t# ~l~ A' JUN ~ ~ ~~~~' l J'\FORMS\lemdalesVldmmolralNaWBCeip1 Form Uldlly Enaoacnmanl 8 Mist 0&09 Rav 1°/°B LIT.i DF CAMPBEtt ~~++ D1DDD~18DDi }'iEl.t~I~ D~~ • JAJ ~°A~`DR: 4DD E CAi'sf bEtt A~•E TDi~A'Y'5 IaATE: Db/2~.'DG REGI5TEF DATE: Db!'~~/D~ TicIE: 1D:1 i~ESCi~;IPTiD~~ AMOUNT E'tdCfi R SUAi~I~! FTtINU F C~35T iU: 4D0 E CAMPBEtt Dr-D7~ "{DTAt I~UE: :.HECK PAIR: CHECK NU: 1D`s5 TENUEkEIE: CHANUE: ~~bD.GD 32bU.DU $~bD.DD ~i~~bD . DD ~.DU Citx-p'erk's Oftice ~~ ~~ License No._ ~~ ~~~/ ~, `' 70 North First Street SIC/Classode: Campbell, CA 95008 Assessment Basis: (cos) s66-zl 17 CITY OF CAMPBELL APPLICATION FOR BUSINESS LICENSE I. All questions on thds form must be answered or designated not applicable (N/A), as approprdare. 2, There will be a $25.00 processing fee in addition to the business license fee. ;. Additional information-may be required pursuant to City of Campbell. Title 5. 4. Applicants are required to declare, under penalty of perjury, that the statements made herein are true. 5. In order to comply with requiremerits of the State Controller's Office under Revenue & Tax Code Sec T 9286.8, business licenses cannot be issued without this information. 5. Sales or use tax may apply to your business activities. You may seek written advice regarding the application of tax to your particular business by writing to the nearest State Board.of Equalization office. For general information, please call the Board of Equalization at 1-800-400.71 1 5. 6. Businesses must limit operations between the hours of 6 a.m. and 1 1 p.m. unless a Conditional Use permit is obtained through the City for extended hours of operation. Excludes home based businesses. Hours of operation for all businesses must not be in conflict with other City regulations. PLEASE TYPE OR PRINT ALL INFORMATION 1. BUSINESS NAME: C~Jt'" h 2~'S "rU r !-~ '~'C~ ~`F'~ r~ (fib / 1 /.~ 2. BUSINESS ADDRESS: ~~~ (~(,~ ~~-w121~ ~C ~- (Cc.~~ ~ yv~hLoUac,(D Ct~- 4 ~•U ~~ (Number) (Street) (Suite/Apt #) (C tv) (State) (Zip) 3. MAILING ADDRESS: ~SCLW`P Q..~S C~~ t l~ (ljdifferent from above) (Number) (Street) (Suite/Apt #) (City) (State) (Zip) 4. BUSINESS TELEPHONE NUMBER: _t-ruat 1~ S ~F-L~U_D 5. DRIVER'S LICENSE #: 6. FED EMPLOYER ID #: ~ -- 5 .(Q ,,,~ g ~ ,~~ 7. SOCIAL SECURITY #: _ _ _ -- _ _ -- _ _ _ _ 8. STATE EMPLOYER ID # ___ _ _ 9. RETAIL SALES TAX #:_ _ _ _ _ -_ _ _ _ _ _ _ _ __ 11 ""~~ ~ , (4 - S alpha plus 8 numeric) 10. OWNER'S NAME: ~~/V/V d ~ ~ z 1 G ~/~~. 11: OWNER'S PHONE NO: _(_) (] 'Check if owner's name must appear wz license. 'There are only .TS spaces itt field for owner name(s) 12. OWNER'S ADDRESS: ~ ~~ ~~ '~~~ (Number) (StreelJ (Apt #) (City) (State) (Zip) 13. TYPE Or OWNERSHIP (Check one): [ ]Sole Proprietorship( [ ]Partnership Corpo~rati(o~n [ ]Trust 14. TYPE OF BUSINESS (Be Specific): ~ QF~P ~~Vl `GCIi- \ ~ ~,/1 U tYtsvl W~Q.I.l~-1-x.11 e ~U ~Y -~ 15. Fill in as appropriate: Commercial [ ] Check one: Retail [ ] Wholesale [ Professional [ ] Avg # Employees (Include Owners): Mfg/Industrial [ vg # Employees (Include Owners): Out-of--Town Avg # Employees (Include Owners): Product(s): Vending Mac t s [ ] Amusement Devices [ ] Estimated Annual Gross Receipts: - ..Veterinarians [ ] 'Number of Veterinarians: Apartments [ ] Trailer Courts [ ] Hotels [ ] .Mobile Home Parks [ ]Retirement Inns [ ]Number of Units: Taxicabs/Limousines (]Number of Vehicles: Theaters [ ] .Number of Seats: Exempt from Fee-Nonprofit [ ] Day Care [ ]Number of Children: 16. HOURS OF OPERATION: 17. PARCEL #: Gp~,, (Community Development Dept only) ` 18.CONTRACTORSTATE LICENSE NUMBER: ~ ~V O Class: Expiration date:~~ Verified- i" . DECLARATION I DECLARE UNDER PENALTY OF PERJURY that the foregoing"is"tru"e an,,d correct and if capped as a witness I could competently tes/tify /~ to the facts contained herein. Executed this _~~ day of , 200 !, in the Town/ ity f ~j..¢~x County of ' ,State of (`~t.~ ~ ~LC ~~ "~ SIGNED: TITLE: t`~(1~l Ct~ ~~ ~ ~ ~ ~ FOR OFFICE USE ONLY: ~j ~~~! Amt Paid: Business Lic Fee `~ ~ Rental Dispute Fee Processing Fee $ 25.00 T~"a~ l~id~ ~~~~ Receipt ~~ ~ C6TY ~~LERK'S.OFFICE INSURANCE REQUIREMENTS CHECKLIST Permit # ~~~~~~p ~ -L? ©~~ CIP Project # The following insurance is required of all contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment 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 aggreg l~ it. ~L Policy expiration date Automotive Liability: "Any Auto" checked on certificate $1,000,000 per accident for b dil injury and property damage Policy expiration date Workers' Compensation and Employer's Liability Waiver of Subrogation clause $1,000,000 per accident for o ilv injury or disease Policy expiration date Course of Construction (if required in Special Provisions) ^ Completed value of the project ^ Policy expiration date red Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement The City, the City of Campbell Redevelopment Agency, its officers. employees and volunteers are named as additional insured. The insurance coverage afforded to the Additional Insured is primary insurance. 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 ompany, its ~~ ,~ agents or representatives". ~~~~~~~ ~~ ~ ~,x~ ~~ ^ Workers' Compensation Insurance Sheet Submitted ~~~C ~,~{~ ~~ ^ For General Contractor ~ ~~ ~rl Lw~ ((1 ^ For evel per or OA ~ner ', i -f 1 J v~ ~~ ~ ~ ~ L Acce tabihty of Insure (s) {~S~I~ ~~ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. `0 ~, Insurance Certificate Reviewed ~ ~ Initials / ~ Csate ~o~ ,d [_ ~. Copy of Insurance Certificate placed in ticlaer file for month of expiration. ~~J~ N'' ~~ ~~j~ o~s~ins last (rev 11/99) ~'~~ as ° °~ Page 1 of 1 Joanne D' Ambrosia From: Edward Arango Sent: Monday, June 22, 2009 4:10 PM To: Joanne D' Ambrosia Subject: FW: 400 E. Campbell -insurance cert for encroachment permit Attachments: Cornerstone City of Campbell Cert.pdf Hi Joanne, can you please review this insurance certificate for 400 E. Campbell Avenue. Let me know the status once you have reviewed it. Thanks, Ed From: Laura Knutson [mailto:Iknutson@cornerstoneearth.com] Sent: Monday, June 22, 2009 4:08 PM To: Edward Arango Subject: 400 E. Campbell -insurance cert for encroachment permit Ed, As discussed, attached is our insurance certificate. Hopefully it is all in order. I forwarded the City's requirements when I requested it. Call me with any questions. Thanks. Sincerely, Laura C. Knutson, P.E., G.E. Principal Engineer f.7 CO#tNERSTONE L' EARTH GROUP 1259 Oakmead Parkway Sunnyvale, California 94085 p 408 245 4600 x105 c 408 747 7501 wwvv. co rn a rsto n_eea rth.. co m *** eSafe 6 scanned this email for malicious content *** *** IMPORTANT: Do not open attachments from unrecognized senders *** 6/22/2009 GENERAL PERMIT CONDITIONS I . A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency call-out, overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. 3. Refund or the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. 5. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants, and water valves. 6. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures, detours, and street closures. This plan must be reviewed and approved prior to any lane closures. 7. A Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated 1990, available at Caltrans. Traffic control equipment shall include Type II flashing arrow signs if required. 8. Replace as directed by the City Engineer any damaged or removed improvements in accordance with City Standards and Specifications at the sole expense of the Permittee. 9. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements. 10. Prior approval of inspector is required for any work done after normal working hours, on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 11. Adequate signing and barricading is required on thejob site. Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost (including all labor and materials) against the cash deposit. 12. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the Ciry Engineer. 13. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m. 14. No storage of materials or equipment will be allowed near the edge of pavement, the traveled way, or within the shoulderline which would create a hazardous condition to the public. 15. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a separate permit may be required, nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 16. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 17. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 18. Call back (call out) due to emeregencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence. 19. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. 20. If the public interest requires a modification of, or a departure from the plans and specifications, the 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 Ciry-owned or maintained facilities. 21. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and phone number. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions. Contractor (Print Name) ~~~f ~~i- Date: o ~a ~~~~ Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev. 3/08 ruo.,+~e• ae~~s ACORD CERTIFICATE OF LIABILfTY INSURANCE Dm) ,M 06l18l09 PRODUCER THI5 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dealey, Renton & Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P. O. Box 12675 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Oakland, CA 94604-2675 510 465-3090 ~ INSURERS AFFORDING COVERAGE INSURED INSURER A: Am@CICan AUtOmObile InS. CO. Cornerstone Earth Group, Inc. d db INSURER D: XL Specialty Insurance Co. an a Cornerstone Earth Group 1259 O k d P k INSURER C: a mea ar way S l CA 94085 INSURER D; unnyva e, -4040 INSURER E: WORKS GV V EH.AGES ArIAAIAIICTR~TI(lAl THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POACY M PIRATION LIMITS /~ GENERAL LIABILITY MZG80900321 O2IOSIO9 O2IO8/1O EACH OCCURRENCE $1 OOQ QOO )( COMMERCIALGENERAL LIABILITY FIRE DAMAGE {Any one Ore) SSO OOO CLAIMS MADE ~ OCCUR MED EXP (Any one person) $5 QQQ PERSONAL&ADV INJURY $1 OOO OOO GENERAL AGGREGATE $2 QQQ QQQ GEN'L AGGREGATE LIM IT APPLIES PER: PRODUCTS -COMPlOP AGG $2 OOO OOO POLICY X PRO- LOC A AUTOMOBILE LIABILITY MZG80900321 O2lOSlO9 OZ/08/1 O X ANYAUTO COMBINED SINGLE LIMIT (Eeacddent) $1,000,000 ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) X HIRED AUTOS X NON-OWNED AUTOS BODILY INJURY (Per acddenl) $ PROPERTY DAMAGE $ (Per acddenl) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESSLUIBILITY CGU81963845 02!08109 02!08110 EACH OCCURRENCE $2 000 000 X OCCUR ~ CLAIMS MADE AGGREGATE $2 QQQ OQQ S DEDUCTIDLE $ RETENTION $ $ ~A WORKERS COMPENSATION AND ' WZP80971564 O2IO8/D9 OZlOS/1O X WC STATU- OTH- EMPLOYERS LIABILITY E.L. EACHACCIPENT $1 OOO OOO Blanket Waiver of E.L. DISEASE - EA EMPLOYEE S1 OOO OOO Subro ation E.L. DISEASE -POLICY LIMIT S1 OOO OOO g OTHER Professional DPR9615000 02!08!09 02!08!10 $2,000,000 per Claim . Liability $2,000,000 Annl Aggr. DESCRIPTION OF OPERATIONSILOCATIONSlVEHICLESfE%CLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS General Liability excludes claims arising from the performance of professional services Ref: All work performed by or on behalf of the named Insured. C1ty of Campbell, and the City of Campbell Redevelopment Agency, its officers, employees and volunteers are included as additional insured for General and (See Attached Descriptions) AV City of Campbell Department of Public Works 70 N. First Street Campbell, CA 95008 8H OULD ANYOF TH E ABOVE D ESCRIBED POLICIES B E CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WI~X~ TO MAIL3O-DAY6 WRITTEN NOTICE 70 THE CERTIFICATE HOLD ER NAM ED TO THE LEFT k r~~.~nu ,cw ~nar11 Or "1 i~M247526 NMF 0 ACORD CORPORATION 1988 DESCRIPTIONS (Continued from Page 1) Automobile Liability. Primary insurance and severability of interests apply per policy form. A Waiver of Subrogation applies to General Liability, Automobile Liability and Workers' Gompensation. Tama z~s ~urrai~ ~ O! L iFMZ4l9Y4 POLICY NUMBER: MZG80900321 COMMERCIAL GENERAL LIABILITY CG 2010 07 04 PHIS 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 Organziation(s): Locations} Of Covered Operations City of Campbell Ref: All work performed by or on Department of Public Works behalf of the named insured. 70 N. First Street City of Campbell, and the City of Campbell, CA 95008 Campbell Redevelopment Agency, its officers, employees and volunteers are additional Information required to complete 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 persons} 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. 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- mentfurnished in connection with such work, on the project (other than service, mainte- nance or repairs} to be performed by or on behalf of the additional insureds) at the loca- tion of the covered operations has been com- pleted; 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 subcontrator engaged in performing operations #or a principal as a part of the same project. insured. CG 20 10 07 04 Copyright, ISO Proporties, Inc., 2004 Page 1 of 1 UNIFORM POLICY NUMBER: MZG80900321 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 Organziation(s): Location And Description Of Completed Operations City of Campbell Ref: All work performed by or on Department of Public Works behalf of the named insured. 70 N. First Street City of Campbell, and the City of Campbell, CA 95008 Campbell Redevelopment Agency, its officers, employees and volunteers are additional Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section li -Who Is An Insurod is amended to in- clude as an additional insured the person(s) or or- ganization(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 performed for that ad- ditional insured and included in the "products-com- pleted operations hazard". insured. CG 20 37 07 04 Copyright, ISO Properties, Inc., 2004 Page 1 of 1 UNIFORM Named Insured: Cornerstone Earth Group, Tnc. Policy Number: MZG80900321 Amendmentto Condttaon ~. Other Insurance - CG 72 53 09 OS Policy A,rnendment(s) Comrnercial General );lability The following is added as a second paragraph to Sec- tion ]V Conditions, Condition 4. Other Insurance, fol- lowing paragraph b,(2): Elowever, if you !lave added any person, organization or vendor of yours as an additional insured to this policy by way of a Multit:over ~ endorsement and have agreed in s written insured contract that this insurance is primary and non-contributory with other insurance available to that additional insured, this insurance is primary and we will not seek contribution from such additional insured's other insurance, This provision does not apply to other insurance to which -such addi- tional insured has been added as an additional insured. This Form moat be aUached to Cltaaga lndotsemeot when issued after the policy is written, One of iho Pire~xan~s Rwnd Insurance Companies as named in the policy ~a~~~ Se retary /• President CO~253 9-0S WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" needs to be completed only when this endorsement Is issued subsequent to preparation of the policy.) This endorsement forms a park of Policy No. WZP80971564 Issued to: Cornerstone Earth Group, Inc . By: American Automobile Ins. Co. Premium (if any) TBD We have a right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us). You must maintain payroll records accurately segregating the remuneration of your employees while engaged In the work described in the Schedule. The additional premium for this endorsement shall be 2-5% of the Califarnla workers compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description City of Campbell Ref: All work performed by or on behalf Department of Public Works of the named insured. A Waiver of 70 N. First Street Subrogation applies in favor of City of Campbell, CA 95008 Campbell, and the City of Campbell Redevelopment Agency, its officers, employees and volunteers. WC 04 03 06 Countersigned by (Ed. 484) Authorized Representative CliPnfit• 1d~ ACORDrM CERTIFICATE OF LIABILITY INSURANCE Dm) 06/18/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dealey, Renton 8r Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P. O. Box 12675 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR O kl d CA ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. a an , 94604-2675 510 465-3090 I INSURERS AFFO~~O;( INSURED C t E th INSURER A: AmerlCan AUtOn'lOblle InS. CO. orners one ar Group, Inc. and db C t E rth G INSURER B: XL Specialty Insurance Co, ~~' a orners one a roup 1259 Oakm d P k INSURER C: f~l.($ ea ar way T1 , Sunn val CA 94085 4040 INSURER D: 1 1 ~~ RA y e, - INSURER E: V V V tH:AhtS THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD POLICY EXPIRATION DATE MM/DD LIMITS A GENERAL LIABILITY MZG80900321 O2/O8/O9 OT/O8I1 O EACH OCCURRENCE $1 QQQ 000 X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Any one fire) $SQ QQQ CLAIMS MADE O OCCUR MED EXP (Any one person) $5 QQQ PERSONAL 8 ADV INJURY $1 QQQ QQ~ GENERAL AGGREGATE $2 QQQ QQQ GEN'LAGGREGATELIMITAPPLIESPER: PR PRODUCTS -COMP/OPAGG $2 000 OOO POLICY X O LOC JECT A AUT OMOBILE LIABILITY MZG80900321 02/08/09 02/08/10 X ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $1,000,000 ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) X HIRED AUTOS X BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESS LIABILITY CGU81963845 02/08/09 02/0$/10 EACH OCCURRENCE $2 000 000 X OCCUR ~ CLAIMS MADE AGGREGATE $2 QQQ QQQ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSF.TION AND WZP30971564 02/08/U9 02/08/10 X WC STATU- C`TH- EMPLOYERS' LIABILITY T IMIT'• E.L. EACH ACCIDENT $1,000,000 Blanket Waiver of E.L. DISEASE -EA EMPLOYEE $1,000,000 Subro ation E.L. DISEASE -POLICY LIMIT $1,000,000 B OTHER professional DPR9615000 02/08/09 02/08/10 $2,000,000 per Claim lability $2,000,000 Annl Aggr. DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS General Liability excludes claims arising from the performance of professional services Ref: All work performed by or on behalf of the named insured. City of Campbell, and the City of Campbell Redevelopment Agency, its officers, employees and volunteers are included as additional insured for General and (See Attached Descriptions) City of Campbell Department of Public Works 70 N. First Street Campbell, CA 95008 I.CLLN l ILlN SHOULD ANYOF TH E ABOVE D ESCRIBED POLICIES BE CANCELLED BEFORE TH E EXPIRATION DATE THEREOF, THE ISSUING INSURER WIC TO MAIL3.0__DAYSWRITTEN NOTCE TO TH E C ERTIFICATE H OLD ER NAM ED TO TH E LEFT, r ~~ ^~~^~ ~~~ ~~~~~ n or ~ r>:mz4io[b NMF ©ACORD CORPORATION 1988 DESCRIPTIONS (Continued from Page 1) Automobile Liability. Primary insurance and severability of interests apply per policy form. A Waiver of Subrogation applies to General Liability, Automobile Liability and Workers' Compensation. AMS z5.3 (07/97) 2 of 2 #M247526 POLICY NUMBER: MZG80900321 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 Organziation(s): Location(s) Of Covered Operations City of Campbell Ref: All work performed by or on Department of Public Works behalf of the named insured. 70 N. First Street City of Campbell, and the City of Campbell, CA 95008 Campbell Redevelopment Agency, its officers, employees and volunteers are additional Information required to complete 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. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: insured. 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, mainte- nance or repairs) to be performed by or on behalf of the additional insureds) at the loca- tion of the covered operations has been com- pleted; 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 subcontrator engaged in performing operations for a principal as a part of the same project. CG 20 10 07 04 Copyright, ISO Properties, Inc., 2004 Page 1 of 1 UNIFORM POLICY NUMBER: MZG80900321 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 Organziation(s): Location And Description Of Completed Operations City of Campbell Ref: All work performed by or on Department of Public Works behalf of the named insured. 70 N. First Street City of Campbell, and the City of Campbell, CA 95008 Campbell Redevelopment Agency, its officers, employees and volunteers are additional Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II -Who Is An Insured is amended to in- clude as an additional insured the person(s) or or- ganization(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 performed for that ad- ditional insured and included in the "products-com- pleted operations hazard". insured. CG 20 37 07 04 Copyright, ISO Properties, Inc., 2004 Page 1 of 1 UNIFORM Named Insured: Cornerstone Earth Group, Inc. Policy Number: MZG8090032I Amendmentto Condition 4. Other Insurance - CG 72 53 09 OS Policy Amendment(s) Commercial General Liability The following is added as a second paragraph to Sec- tion IV Conditions, Condition 4. Other Insurance, fol- lowing paragraph b.(2): However, if you have added any person, organization or vendor of yours as an additional insured to this policy by way of a MultiCover ®endorsement and have agreed in a written insured contract that this insurance is primary and non-contributory with other insurance available to that additional insured, this insurance is primary and we will not seek contribution from such additional insured's other insurance. This provision does not apply to other insurance to which such addi- tional insured has been added as an additional insured. 77ris Form must be attached to Change Endorsement when issued after the policy is written. One of the Fireman's Fund InsuraRCe Companies as Warned in the policy Se retary /~ President CG7253 9-05 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following "attaching clause" needs to be completed only when this endorsement is issued subsequent to preparation of the policy.) This endorsement forms a part of Policy No. WZP80971564 Issued to: Cornerstone Earth Group, Inc . By: American Automobile Ins. Co. Premium (if any) TBD We have a right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us). You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2-5% of the California workers compensation premium otherwise due on such remuneration. Schedule Person or Organization Job Description City of Campbell Ref: All work performed by or on behalf Department of Public Works of the named insured. A Waiver of 70 N. 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