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ENC2005-00151
f ;! CIPY OF CAMPBELL ENCROACHMENT PERMIT Permit Nom/UL ~©C1,~- C>D~S"~ DEPT. OF PUBLIC WORKS (for working within the public X-Ref. File 70 Nortft First St. ri~ltt-of--way) Campbell, CA 95008 // Application Date ~- ~ - d~S (408) 866-2150 Issued ~I ~~~~d to Application Expiration Date Fax (408)376-0958 Permit Expiration Date ~~ ~ 7 APN ~ ~' ~ 2 U ' (.J U ~-~' APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in 12 months if the permit is not issued. Application Fee is non-refundable.) /~ A. Work address or tract # ~D 2 ~ ~ G 1 ~ ~ ~A A J ~ Utility trench location ~7 B. Nature of work _r~ ~Gl K E tG.'E'2. Citl~.g tL--}- ,~ ~L~+E"i" 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. Al] 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 Surefies and cash deposits. (See General Permit Conditions I and 2.) E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Depamnent at least two days before starting work. Notice must be given to Public Wo~r1ks,,at least 24 hours before restarting any work. Name of Applicant ~~hk ~fiV `l.(,~ YtiV~i~ Telephon~~4(~~ SZ ~! ~ y ~ ~~ l ' n n print name) Address "l N /~JOGD`~ ~ /kL.L,E~j C/3~7Z~ 24-HOUR EMERGENCY TELEPHONE N0.~~3I~ ~Sr1 ' y1}/'~ E-Mail Address L S G1~ L( ~j y ~j ~ j cl ~ ~jL x.1,1 Is this work being done by the property owners at their own residence? Yes _.~No The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers, agents and employees free, safe and harmless from any claim or demand for damages resulting from the work covered by this permit. The ApplicanUPermittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all damages ~~t~the condition of any private improvements in the public right-of-way. (Applicant Permittee) (sign) 2 ~ vS Date Contractor (Print Namc) Date SPECIAL PROVISIONS 1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts11z~ be specifically approved by the Inspector prior to cutting. 2. Pavement may be cut for underground installations and must be restored in accordance with [he Utility Restoration Standard Details Method "A" Backfill, 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 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. IJSA 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. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES PERMIT APPLICATION FEE PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCEILABOR & MATERIALS CONSTRUCTION CASH DEPOSIT PLAN CHECK & INSPECTION FEE ~ ,^~ APPROVED FOR AMOUNT RECEIPT NO. $ `~ LA: -' _ (~ City? r> ~~'-~ ~~~T ' y2~ iL~ $ ,~ ~~a~ _ l~ /_ ~ For City Engineer Date Permit Expires 12 Months After Date of Issuance J:\forms\pwperm Revised 1.20.04 i 1 ~v ao 0 b w x ' ~ n a ~ p d ~ y~ b V ~ _ ~ b y~ ~ ~~ ~ xb N N N N N N N N N N N `i7 O O O O O O O O O O O ~ O O O O O O O O O O O m J J J O~ O~ to cn c~ vi t~ Cn ~ O O O O O O O O O O ~ O v, c~, A ? ~ ~ ~ ~ ~ ~ ~ N O O N N O O O O O O O~ ~D ~D O O O~ O\ O~ O~ O~ O~ rn rn w w a rn o, ~ rn ~ W ~--' N N ~-+ ~ i--~ ~ ~ O\ O~ oo J ~ A w N N N ~. A O v, A ~n .A ~n to A .~ N O~ oo ? J Oo +i cn ~O ~.-• ~O O Vi c.n W Oo .P ~D O\ N ~D to 00 ~--~ 01 N ~--~ N O cn .-~ oo W O O O O O O O O O O O 7~~'-dxc~r ~v ~p ~r `ti ~'Z n b~ t~ o ~ G ~ ~ ~ ~ ~ G ~ ,`"*' G ~ ~ ~ O ' ti '~ '' R. a fD V ~' N w 5 ~ y ~ b ~ ~ b A ~ ~ + ~. , . ~y ~. C7 C7 ~ ~ ~ ~ ~ ~ d ~ c ~ ~ `° n ~ n ~; o ~. o ~ ~. ~ ~ ~ b ' ~ Y ~ ~ :~ 7y : o ~ r p d . o ~ ~ o ,~ cu w r. ~ `~ o ~, o o ~ ~ r* o' A ~ N ~ ~ ~--~ N W N O ~n oo N O ~o ? O~ oo cn N O 0 0 ~O O N r--. Cn ~ h O O O O~ O O w O O~ O~ O ,o o ~ 0 0 O C O O O O O C O f9 O O O 0 0 O O O O O O ~ b a [si ~ N W N N O ~D A ~ oo is N O0 O ~ O w O O\ O~ O oo '7 0 0 C O O C O C p' 0 0 o O O O o 0 O n: 0 N N O\ O~ O\ O~ O~ O~ O O N N N N N N A O O O O O ~ O O O O O t~ cn t~, v~ vi ~n - ~ ~ - C7 C~ W W W W W W ('~ ~ ~ ~ ~ ~ ~ u Y O~ ~ O~ O~ O~ O~ c e ~ p o0 00 00 00 00 00 00 00 `~ N N O O O O O O A N N W W W W W W ~ r z c~ d .. ~ ` o 0 o voo ~ o v o << , a a 69 .-. W N ' ' ~ c ''' o o rn o 0 0 o O o 0 0 ~ O~ O O O O O O O O O O O v, ~ O O O 0 0 O O O O O O c ..i n m r. A~ b .. ~ /z~ l 1 N "'• O ~ O C ~ ~ O ~' O ~ F~ ~ ~-. ,.., O ~-' N ~_ N O y O r~ ~1 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) Total Payable: Purpose: Ben Schulman 4 Ronnoco Road Carmel Valley Refund Deposit 101.2203 101.540.7448 State: CA Zip: 93924 Amount: $1,316.00 Amount: Amount: Interest Earned (Fioaoce Dept only) $1,316.00 (Exact Amount) Plan Check Deposit ($500.00) and Construction Cash Deposit ($816.00) on 620 Hacienda Avenue. Voucher #• Receipt #: 180053 Requested by: Sye W hid; ~~~ Approved by: Michelle Quinney Finance Dept Only: Verified by: Approved by: Permit #: ENC2005-00151 Date: 09/06/05 Title: Public Works Inspector Date: 5/8/2007 Title: City Engineer Date: 5/8/2007 Title: Accounting Clerk II Date: Title: Accountant Date: Special Instructions For Handling Check Mail As Is: Mail in Attached Envelope: Interim Check: Needed By: Return To: Joanne D'Ambrosia Public Works/City Hall (Name) (Department) Other: fln: Forms/excel/chkreq - Revised OS/00 PUBLIC .xKS DEPARTMENT RECEIPT F-Ifective J Wy 4, 2004 Ci Cl k t A' ~ /'y~ (~ (~ ~ ~ ty er PUBLIC WORKS FILE N0. G / ~ • W V ~ ~ J +~ ~ O a ~,~ PROPERTY ADDRESS U( l.l~-/ Q, Rease collect & receipt for the following monlec: 1'. 1TEh1 AMOLiNT ROACHMEMI' PERMIT 4722 Application Fee Non-Utility Encroachment Permit (5275.00) G ~/ 'y MlAOr Encroachment Permit < 55,000 (56L00) R-1 First I'ermlt lNo Fee) SuAseauent lSl35.M1 Residenthll Street/Olher Areas (5291.00) 2203 flAn Check De t 2% of Enalmer's Estimate (5500 min) 2203 FaithfW l'erforrtulnce Securit (FPS) (100%of ENGR.FSI'.) 2203 Labor and MaterlaLs Security (l00% of ENGR. EST.) •( 2203 Monumcntation Security (100%af ENCR.ESf.) 2203 Cach Deposit (d% of Engr. Na0(5500 mtN510,000 max) 4722 flan Check $ Itnpec[ion Fcc (NomUtllity) Engr.Est.<5250,000 (13%of ENGREST.) 2203 Engr. Nat. >5240,001) (Deposit 8% of Enar. Ect./5311,000 min)•• 4722 Ut10ty <SI00,000 Minimum Charge Per location (5180.00) CondWts/Pipelines up to 500 Feet (52.25AY) Ahove 400 Linear Feet (51.35M) MAnhakSlYAWta/Elf. (5124.00/eA) Foie Set/Bemoval (5124.00/tN) Street Tree PtanllnR/Nemoval (SI35.00) 103 I1Wit >SI00,000 Actual Cost+20%•• 4760 StoroBe Container Permit (5125.00) 47611 1'roJect Rain & S Iticatlom Project No. 4760 Standard IOcatbm & Uetaik (f1/P); 514.50/Ilk) d760 Co : of EnglnrerlttR Maps & flans AertAl Rot 24"x36" ($54.00) Aerial Print 8 t!2" x tl" (522.00) Ma and PIAm 24"x36" (58.241 4722 Penalties: FAllurc to restore public I rovements (5100/CWerdar Day) (MuN CWe Ser.il_'N.01a) 4722 Penxltks: FWlurt to correct a sAfe conditbns (SI00/CAIe1War Da ) 4722 Work Without Permita (4 Tfines A Ikable Fee) LAND DEVELOPMENT d722 Lot Wne Adfustment (5900.00) 4722 PArcel Ma (41uts or Less) (53A00.00+S75llot) 4722 N7nAl Trutt MaD (5 or More Lots) (fd31q.00+SIgVlot) Certificate of CompllAree 5650.gq QrtlOcate of Correction (5400,00) Notary Fee (per sipiaturc) (510.00) Vacation of Public Streets & Nasements 152,ZOO.aO A.sacssmenl Segregation or Reapportionment Nlrst Split (5724.W) Each AddllionAl Lot (5200.00) Storm UrWnage Area Fee Per Acre (K-1 52,120.00) (MWtI-Res 52:11[5.00) (All Other 52,650.00) Parkland Ihdicatbn Fee (75%/2_e % Due Upon Cert. of Occupancy) Interaction Turn Counts (Two-lk Interaction Turn Counts (a.m or Tralrc Fbw Map (UWIy TnRc V Campbell TrAliic Model (FWI Scq Campbell Tnrtic Model (Neducet' SIgtIW Timing IMormAtbn Trcek Permits L- TOTAL f f NAME OF APPLICANT NAME OF PAYOR_~ ADDNFSS •*Actual Cost Rus 20% Overhead (Non-li FOR ~, CITY CLERK RECq ~RY ONLY •For Ran Ch Je and CASK Ikpoelts, send 7elbw eupy to Nlrlarce. ~~ • - ~ _ _ j:\ibrmstrxeipt form 05-06 rev.6R1/05 (_ i. l i iii t.(:iP1i='ii}j ~ .w k~ilJfl HY; .JAN!'; . ilir~llt1N«[)}~ P;yfiia: H~~ ~i.Fiii~I'ii]P! itiil~i iii .` V n l J U/71 ti Ji VtJI L.i ki-t'I:'-ri": - -- :ix.•=sv, z": itut~= ii41i ttr, %i~tti '?~t. , ' - aver-v-ate i1%r.Ji~,f iir'~iiiii 4 AII'Fl it M~klt~ll ty`}N~ ~, t::~:: rr .i~,r r ii~F'ii:i i - i ii i . ;''ti.'1 IiLi +'~ ~ilJl ~J -j~l, tin? i.L.w Vu/ i'F,ii~i'i k visfi{iilti Fif iti); F s.r:v:. v . sr_s _nri~n 'C ~iniiG " ''"' h ii ijv'ii ~ +~rr%: r,r.ar:s rrrr• r:l 1-~ i iF i't~i7i{~F i u ~'L~~ I ~ VI iUjCJ. VL' i~g vv'ii~i a i}fl ~...:iiUaiiyi `ice f: ~~L.Jy UV i ii i w_ iii ih ; -_--- ~~? ~ 1 : [JLt i~++~=f•k GdTiie .. - i s iti} r i.ri~i.n fiif° irli Trslnrr.rn. iLi4UCi:Cfi. sn rn> nn - i..,-. iiOaJJ..i.Uif vrtiii'at.~ .. ~a it GENERAL PERMIT CONDITIONS 1. A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency call-out, overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. 3. Refund 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 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. The 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 [he Permittee. 9. Sawcut for all PCC or AC removals. All PCC removals shall be to neazest 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. l 1. Adequate signing and barricading is required on the job site. Failure to provide such signing and barticading may result in the City's providing signing and barricades and charging the cost (including all labor and materials) against the cash deposit. 12. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 13. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m. 14. No storage of materials or equipment will be allowed near the edge of pavement, the traveled way, or within the shoulderline which would create a hazardous condition to [he 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 perrnit may be required, nor does it relieve [he 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 emergencies 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 [he 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. Applicant shall be responsible for ensurino that all those providing services under the applicant are aware of and understand all of the above conditions. Applicant Date Contractor (Print Name) Date J:\formslpwperm Revised 1.20.04 U r s ARCH PRA CITY of CAMPBELL Public Works Department April 18, 2008 Ben Schulman P.O. Box 223079 Carmel, CA 93922 SUBJECT: PERMIT NO. ENC2005-00151 LOCATION: 620 Hacienda Ave. ONE YEAR MAINTENANCE INSPECTION -ACCEPTANCE Dear Mr. Schulman: The City of Campbell has made the final one year maintenance inspection of subject Public Works improvements and find that no remedial work is required. Your warranty requirements and any surety, therefore, are hereby released. Please find attached your original Bond for Faithful Performance which we are returning to you. Sincerely, S ed Wahidi Y Public Works Inspector MQ ~~ cc: Permit ENC2005-00151 Public Works/Maintenance Division First National Bank of Central California -(~ Nnrtli Fnst Street Campbell. Laliturnia 95008-l4~0 I~RI 40S-H6o_215U IAA dUR.376.09~8 TI)U 4US 8b6.~7~>(~ of c~~~ U ~~[~" y `> U2CH ARC CITY of CAMPBELL Public Works Department Date: November 5, 2007 TRANSMITTAL FROM THE PUBLIC WORKS DEPARTMENT TO: Ben Schulman PO Box 223079 Carmel, CA 93922 FROM: Joanne M. D'Ambrosia, Office Specialist SUBJECT: 620 Hacienda Avenue, Campbell Encroachment Permit #ENC2005-00151 Enclosed is a check in the amount of $2,100.80, representing a refund of your monumentation security, plus accrued interest, in connection with the above property. Z:.._ ~~`` (Joanne M. D'Ambrosia Office Specialist Enclosures 7(1 North First Street Camphrll,Calilornia 9 5008-1 436 Tt'.L 408-86G.2ISU PAX 4UR.376.0955 TUI~ -I08-ti(io,27~)U CITY OF CAMPBELL VENDOR N0. 00007779 CHECK NO . 212 813 u Descri lion .Account Purchase Order 'Invoice Number nt Amo EFUND DEPOSIT 101 2203 101.540 7448 CR09142007 CR09142007 2,000.00 100.80 R INTEREST EARNED Oppp7779 BEN SCHULMAN 1 1 /1 1 ~ 1 1~ 1 1 1 1~ 1 1 CHECK DATE CHECK o~'~~~ ' CITY ~F CAMPBELL OF AMERICA 11-15 11 / 0 5 / 0 7 21z 813 ~~~• ~~ 70 NORTH FIRST STREET CAMPBELL OFFICE zoa THE PRUNEYARD 12.10 L r CAMPBELL,. CALIFORNIA 95008 CAMPBELL, cA 9sooe AMOI7NT ~ * * * * * 2 ~ 10 0 . 8 ~ * ~ ~! p o ~: .@' ~{ '•P E CIOID AFTER 90 DAYS 0! I °Rr,IteR~ a ~~ PAY THE SUM OF TWO THOUSAND, ONE j HUNDRED DOLLARS & 80 CENTS m~ F' Ei To Txs BEN SCHULMAN ~ ~ ~ v; ORDER P O BOX 223079 """"~ °F CARMEL CA 93922 _,_ ,I .. _~ n' 2 L 28 i 311' ~: L 2 L000 3 58:000 6 2 2080 2 4 911' i ~ -- ~-- *See Reverse Side For Easy C3pening instrucfiions* CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 BEN SCHULMAN P O BOX 223079 CARMEL CA 93922 Page 1 of 1 Joanne D' Ambrosia From: William Lai Sent: Friday, October 26, 2007 10:39 AM To: Joanne D' Ambrosia Subject: RE: 620 Hacienda Ave. Monumentation security Correct, it's Carmel Thanks, Will From: Joanne D' Ambrosia Sent: Friday, October 26, 2007 9:45 AM To: William Lai Subject: RE: 620 Hacienda Ave. Monumentation security Will -Thanks for mentioning Mr. Schulman cause his file with the signed ck request got lost in the shuffle on my desk. I will for sure put it through today. The address I have for him is 4 Ronnoco Road, Carmel Valley, CA 93924 so I will change it to PO Box 223079, Carmel CA 93922. It's Carmel, right, not Carmel Valley? Joanne From: William Lai Sent: Friday, October 26, 2007 8:34 AM To: Joanne D' Ambrosia Subject: 620 Hacienda Ave. Monumentation security Hey Joanne, Can you check the address that we're going to send the refund for the monumentation security for 620 Hacienda? I just got a call from Ben Schulmann saying he has a new address and I'm not sure if that's the one we have. His new address is: PO box 223079 Carmel, CA 93922 Thanks, Will 11/5/2007 Page 1 of 1 Joanne D' Ambrosia From: William Lai Sent: Friday, September 14, 2007 11:14 AM To: Joanne D' Ambrosia Subject: RE: Monumentation Security for 620 Hacienda Ave. Of course, how many copies do you need? From: Joanne D' Ambrosia Sent: Friday, September 14, 2007 11:11 AM To: William Lai Subject: RE: Monumentation Security for 620 Hacienda Ave. Will do a check request. Could you copy me on the letter that your received from the engineer so I can make sure we have it in all our files? Thanks. Joanne From: William Lai Sent: Friday, September 14, 2007 10:39 AM To: Joanne D' Ambrosia Cc: Edward Arango Subject: Monumentation Security for 620 Hacienda Ave. Hey Joanne, We just got a fax of the letter from the engineer saying the monuments were set. I already found that the monuments were set last week, so could you start the process to get the monumentation security for 620 Hacienda Ave. released? Thanks, Will 11/5/2007 ^~ -~ ENGINEERS+ SClRVEY{fRS+ PLANNERS October 18, 2007 BKF No. 20046x64-10 City of Campbell Public Works Dept. 70 North First Street Campbell, CA 95008 Attn: William Lai Subject: Setting of Monuments Tract No. 9742 "Hacienda de la Padilla" 620 W. Hacienda Ave., Campbell, CA 95008 Surveyor's Certificate ~. ,~,,~ rte. ~~ ~~ ~ >> ,far` ~f. a. ~,~t~ fi ~.,:- T, `'.~ )(x(71; :=~LE~LSi~ ViJC71~'K~v~ ~~~?tt441V1ST~A~C3R! I hereby certify that all the monuments as shown on the map of Tract No. 9742, entitled "Hacienda de la Padilla", filed April 21, 2006 in Book 799 of Maps at Pages 31, 32 and 33, Records of Santa Clara County, California are now set in accordance with the Subdivision Map Act, Section 66495; that BKF Engineers have been paid for this service; and that the monuments are of the character and occupy the positions indicated in said map. For BKF Engineers, \ ~~~~ dpA{p S~~ _~~ ~_ _ Davis Thresh, P.L.S. No. 6868 ~ s~p~gH License Expires: 09-30-2008 ~~_ NO•~ Date cc: Mitch Burley - BKF 09;' 07 r' 200.' 08: ?9 40878L6F'9 SCHULM~;hJ • ``: '}% ~;;: .. i ::~..• ri'tlIM'`M11i1M1~t Fcbarusry iz, zoo~r SK'F No. 200+16U64-10 Cdr o~ Compbdl Dept, afPub~c Wow 70 N. First S-lriaat Cst~bcll, CA 95008 8~b Se~g of Propa~ Corners ~aat Na 974 "As ~ Ls Psd~" 67.0 W. H~rdessda Atr., Campbe~, ~ 9~00lR PAGE 02 Y hereby cart[f~r tit atl tba pr+o~ac'tY oansara as elwwa oar tha map of '~.Ysot No. 9742., aeoett "~iscienda DMe La Pa&iih", filed ,Ape'il 21, 2006 im Book 799 of Mmpw- st Psges 31 inctuaive, RAOOrds ~Ssa1a Cf~ Canutty, C.alift~nia ana z~ sst. Iti[N ~~ Davis T6uosb, P,~No. 686$ y I.ieanse Fz~s: 09-302008 ~ ~ Date ~: ~~ B~ley - BKF John. K,naroymn - axF Page 1 of 1 Joanne D' Ambrosia From: William Lai Sent: Friday, October 26, 2007 8:34 AM To: Joanne D' Ambrosia Subject: 620 Hacienda Ave. Monumentation security Hey Joanne, Can you check the address that we're going to send the refund for the monumentation security for 620 Hacienda? I just got a call from Ben Schulmann saying he has a new address and I'm not sure if that's the one we have. His new address is: PO box 223079 Carmel, CA 93922 Thanks, Will 10/26/2007 ..~ ~. May 21, 2007 TRANSMITTAL FROM THE PUBLIC WORKS DEPARTMENT TO: Ben Schulman 4 Ronnoco Road Carmel Valley, CA 93924 FROM: Joanne M. D'Ambrosia, Office Specialist SUBJECT: Encroachment Permit # 2005-00151 Dear Mr. Schulman: Enclosed is a refundable check in the amount of $1,391.34, plus an accrued interest, in connection with the above property. 'sincerely, j_~, ~' ~ - ,. Joanne M. D'Ambrosia Office Specialist Enclosure ~F•C v ~Mn~~ ~~ ARCH A0.0 CITY of CAMPBELL May 8, 2007 Public Works L)epartment Ben Schulman 4 Ronnoco Road Carmel Valley, CA 97924 SUBJECT: PERMIT NO. ENC2005-00151 LOCATION: 620 Hacienda Avenue FINAL INSPECTION AND ACCEPTANCE Dear Mr. Schulman: 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. Refunds of your Plan Check Deposit of $500 and Construction Cash Deposit of $816.00, plus any interest due, are now being processed and will be sent to you under separate cover. The Faithful Performance Bond will be kept in force for the duration of the one year maintenance period unless you want to replace it with a maintenance bond. If you have any questions, please call me at (408) 866-2165. Sincerely, 5yed Wahidi Public Works Inspector ~- MQ cc: Suspense - 11 months Permit #ENC2005-00151 Inspector File First National Bank of Central Calif., 26380 Carmel Rancho Ln., Carmel, CA 93923 h:\word\permits\2005_151fin (jd) ~0 North Firct Street Campbell, California 95008-1 4 36 TLL 408-866.2150 fAX 408.37(.0958 TI)I) 408.866.2790 Forest Floor Joanne D' Ambrosia From: Alberto Oxonian Sent: Thursday, May 03, 2007 10:09 AM To: Syed Wahidi; Joanne D' Ambrosia Subject: Tract 9742 - 620 W. Hacienda Avenue Page 1 of 1 Please re%ase a/l the deposits that we col%ted for this pro ject as it has been finale~l a couple ofmonths ago. Right Syedll O9~1 l7xa~ait Senior Civil Engineer Department of Pub/ic Works Te% (408) 866-2162 /~ux. (41I8) 37G-U958 ~~~ 9 , ~~~- .~- v~~ ~ ~ ~~ ~ L-~ ~~ ,d1 ~~' ,~~ N ~~. ~~ ~~ ~`'";- 5/3/2007 ~~ OF C~n~r u r 4 ARCH ARC CITY of CAMPBELL Public Works Department TRANSMITTAL Apri15, 2006 From The Desk Of.• Marlene Pomeroy D. M. Briscoe, Vice President Executive Assistant First National Bank of Central California (408) 866-2776 26380 Carmel Rancho Lane a-mail: marlenep@ci.campbell.ca.us Carmel, CA 93923 Enclosed for your records is a copy of the acknowledged Assignment and Receipt of Investment Certificate for Bennie Schulman, Account 100686708, assigned to the City of Campbell. ~~~~z~ ~y-i~n,trf,~~ ,,/ Marlene Pomeroy '~ Executive Assistant ~'' Enclosure 70 Nortl'i First Street Camphell, California 95008-436 T[L 408 866.2150 FAX 408.;76.0958 TI>u 405.860.2790 Refundable Deposit Check Request To: Finance Director Check Payable To: Ben Schulman Address -Line 1: ~~~ PO Box 2 2 3 0 7 9 Line 2: City: Carmel _ State: CA Zip: 9392 Description: Refund Deposit Account Number: 101.2203 Amount: $2,000.00 ~i Account Number: Amount: Account Number: 101.540.7448 Amount: (Finance Dept only) Interest Earned (Finance Deptanly) Total Payable: $2,000.00 (Exact Amount) Purpose: Refund Monumentation Security on 620 Hacienda Avenue. Voucher #: Receipt #: 186271 Requested by: --~ g° ' A Approved by: ~` ichelle Quinney Finance Dept Oniy: Verified by: Approved by: Special Instructions For Handling Check Mail As Is: Mail in Attached Envelope: Interim Check: Permit #: ENC2005-00151 Date: 04/20/06 Title: Associate Engineer Date: 9/14/2007 Title: City Engineer Date: 9/14/2007 Title: Accounting Clerk II Date: Title: Accountant Date: Needed By: I Return To: Joanne D'Ambrosia Public Works/City Hall (Department) (Name) Other: f/n: Forms/excel/chkreq - Revised OS/00 PUBLIC _.KS DEPARTMENT RECEIPT Ertective Jdy S, 2005 _ // // ~ / ' 0~ ~~ / City Ckrk PUBLIC WORKS FILE NO. /V ` - ~• ~+ U / PROPERTY ADDRESS j ~ ~ _ ~tlyCd~~` flease colket & receipt for the fdlovdrtp modes: T. ITEM AMOUNT ROACHMENT PERMIT 4722 Appllcatbn Fee Nat-Utility Encroachment Permit (5275.00) Minor Encroachment PerMl < 55,000 (561.00) R-1 Fitst Permit (No Fee) Subsequent (5135.00) Unlit Encroachment Permit ArterlnVColleMOr Street (5530.00) Residential Strcet/Other A real (5291.00) 220J flan Check Deooslt 2% of Endneer's Estimate (5500 min) 2203 Cash De It (4 % of Enpr. E+0(5500 mtN510,000 max) 0722 flan Check & Inspection Frr (Non-Uli0ly) Ert6r.Est.<5250,000 (l3%of ENGR.FST.) 03 En6r. Est. >5250,000 (De It S% of &tpr. EstJS30,000 min)•• 4nz uuuty<stoo,ooo M{dmum Charlie Per Location CanddtslPipelines up to 500 Feel (5160.00) (52.25M) Above 500 Linear Feet (S1.35/R) Manhdes/Vadts/Etc. (5125.OWea) Pole Set/Removd (5125.OO/ea) Street Tree flm[iny/Nemoval (SI35.00) 3 Utllity>f100,000 Actual Cost+20%•• 4760 Sto Canulner Permit (5125.00) 4760 Project flans & S illcatbtxs Project No. 4760 Sundard clficatbns & DetalLs (51/Pp SIS.SR(Rk) 4760 C . of Ett6ittrcrinF Ma & flatn Aerial Plot 2d"x36" (554.00) Aerial Pr1M 6 1/2" z Il" (522.00) Ma and Pbm 24" x J6" (56.25) 4722 Pertaltks: Failure to restore ubllc i rovemenLS (5100/Cderdar Uay) (M•Y Cde xav.11.4.e1a) 4722 Penaltks: Falure to correct unsafe candllbns (5100/CAlerdar Da ) 4722 Wark Wlthod PermlLS 14 Times Aodicable Fee) Certi0cate of Compliance 5650.00) ~ ~ (~ (/ CertilkatedCortectbn (5400.00) Noury Fee (per siputure) (510.00) Vacalbn of Pubik Slrcefs & F~sements (52,21q.01t) Aascsurtent SeRrcpttbn or Reapportbnntenl First Spilt (5725.00) Each Additbrtal Lot (5200.00) Storm DrairuRe Area Fa Per Acre (R-152,120.00) fMdti-Nes 52,155.00) (All Other f2,650.00) Parkland Ucdkatbn Fee 175%/25% Due Upon Cert. of Occuoartcvl Trartic Flow Map (Daily Trallic Campbell Traffic Model (Fdl & Cannbell TralBc Model (Redue TOTAL S OF APPLICANT OF PAYOR Cost Pia FOR CITY CLERK RtA'L1C l ONLY - - Date l(rre(ptr . _. •For Plan Cbedc and Cam Depadtc, ee'od yelbwopy b Flwuce. .. Date/ rtltlalc \~~~~~ ~ ~~ bz1Z j:\fmms4aeipt Ibrm 05-06 rev.6Q 1/05 INSURANCE REQUIREMENTS CHECKLIST Permit # ~~~ 2~0 ~o - ~~ ~ 1 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 aggregate limit. ^ Policy expiration date/~ - /-~ 7 Automotive Liability: ^ "Any Auto" checked on certificate $1,000,000 per accident for bodily injury and property damage ^ Policy expiration date (~ - ~'0 ~ Workers' Compensation and Employer's Liability Waiver of Subrogation clause `-7 t`~EC. - Ct-~" ~` f ~1,~ ~" >} ~rt .,~ 1 S $1,000,000 er accident for bodil in ur or disease ~n ~'~'` `~ ~ IZ~~I ~,~~~~~ Policy expiration date p- !' o . ~ 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 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' Compensation Insurance Sheet Submitted ) ~ ~ r- ^ For General Contractor ~~rn ,,~-, i ~ r~S , (~' Xv OY1 LC S LI ~.. ~~~~ ~~~~ ^ For Developer or Owner ~-- ~ ~~ ~ a~ S. ~ X~ ~C~--. ~n ~ ~ ~ ~~- ~~~ <~~'~ l 1'30/ 7 ' ~~ ~ rr~t ~ ~, ~ 1-, sr~ ~- ~L C Rating of A:VII and is authorized to transact Acceptability of Insurer(s) ~' ~ Insurer(s) has current A.M. Best ~t r1"~ L - business in the State of California. ~~ ~" ~~is~ra~nce Certificate Reviewed ~`'{ i'ce`' Initials Date l~ Copy of Insurance Certificate placed in tickler file for month of expiration. j:Aforms\inscklst (rev 11/99) ~,9'a'~ O'F CAMPIBE~.~. r~i~,R~NT ~:~. .. ~ .. ~, '3RGANIZATION ~ ,-ACCOUNT r PURCH. ORDER j iNVCiCE i+iUMBER AMOUNT 5E5CRIPTION ! v ." ~,. ..ti .. r st.Ir~ir"z;.' ~ `? ~tE}`d SL,~-IULI`9i-iP'J REMITTANCE ADVICE-PLEASE DETACH BEFORE BANKING OF CgMA VOID AFTER 90 DAYS 11-35 BANK OF AMERICA WARRANT N0. ~~ ~ CITY OF CAMPBELL 1210 2 OnTHEPRUNE ARD 2 0 9 8 4 9 u r e- a 70 NORTH FIRST STREET CAMPBELL, GA. 950D8 t . CAMPBELL, CALIFORNIA 95008 DATE ~75/~~/i~? ^Ei~'1=tq.~' '- , ~. 0.~, N ~ l0 AMOUNT ~~~k~~#~.,~~1e-~~I~~'~~ PAY I~I~IE Ti-IUUSi~t~IL} , THREE HUI~IUREI} 1ki I I~IETY Ut~:1E '?t=1L.IvAF;S :?•. .-4 l:El~ll-'~i TO SIGNATURE q. ~:I~i'dI~IC~CC7 f°iD ~ ~ ~~~....~.q~~ (~WRInF_'L t~r~LLE~` CA 9Y~S~'4 ~ ,E"~ ,,~~..: °~ ~; ~ ~ :;P,,.. '~+':~'„wow .ice" ~ ~.~" `~~+~.'tl', _.... __... 7. II' 20984911' ~: L 2 L000 3 58~: 06 2 20~~~80 24911' ~ Date: 12/6/2006 Time: 1:09 PM To: 1-408-376-0958 @ 9,1-408-376-0958 James G Parker Paqe: 001 Sent Via FACSys Fax Messaging Gateway Fax To: 1-408-376-0958 Fax Number.' 1-408-376-0958 From: Deanna Regeon Subject: Revised Certificate of Insurance Date: December 06, 2006 Time: 1:09:41 PM Note: Pages: 4 Please do not hesitate to call Pat Peeren with any questions!! Thank you! De'Anna Regeon for Pat Peeren Commercial Lines Assistant James G Parker Insurance Associates License# 0554959 P O Box 3947 Fresno, CA 93650 559-241-7753 -Direct 559-241-7853-Fax ppeeren @jgparker. com R~~EIVED i:- ~ C t~ 6 2006 ~-~~ua woRKs ~DMINIBTRATION This e-mail and/or fax and any attachments are confidential and also may be privileged. If you are not the named recipient, or have otherwise received this communication in error, please delete it from your inbox, notify the sender immediately, and do not disclose its contents to any other person, use them for any purpose, or store or copy them in any medium. Thank you for your cooperation. i ~ l C :a,~-,i -~ ~-~ r ~ , ~~~_ ~~~ ,~ -~ ,~ ti,¢:; ,~~. {~ ~ .. - ~~, ~ ,i ~ ~ ~ ,-t, ~~~~, f~ ; ~~ ~Ulvr ~~~~.,~~~. f "' .,~' ~:, . II ~/~ ~' , ~'~ ~~-~ ~ ter' d ~x , ? :~!°~ ,, ,. ~,. ~1 ~` 1t_.. ,: ~, ,p ~"~ '..' .J l` ~ . Date: 12/6/2006 Time: 1:09 PM To: 1-408-376-0958 t~ 9,1-408-376-0958 James G Parker Page: 002 08- J ~~~~~ CERTIFICATE t3F LIABILITY INSURANCE uio~i o~' PRQWCER (S5g}Z22-7722 FAX (559}241-7853 THIS CERTIFICATE IS ISSU cUl AS A MATTER OF INFORMATIQN James L Parker Ins Associates ONLY ANO CONFERS NO RICsHT& UPON THE CERTIFICATE HOLDER. THIS GERT~'ICATE DOES NOT AMEND, EXTEND OR License #IOE2$839 ALTER THE COVI=RACaE AFFORDED SY THE POLICES BELOW. P O Box 3947 Fresno, CA 93650 Pat Peeren INSURERS AFFQRDING COVERAGE NAIL # INSURED INSURER A Gemini Insurance Tim Giancola Concrete INSURER 6: P.U. BOX 362 INSURER C: Hollister, CA 9SD23 INSURER D: FAX :831-636-9811 INSURER E rnvonwr_ca THE POLICIES OF INSURANCE LISTED BELQW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING TERM OR CONOlT10N OF ANY £ONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY 9E ISSUED OR ANY REQUIREMENT , MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDi'FiON5 Ot= SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY NUMBER POLICY RpsECIriE POLICY EXPIRATION ~~ GENERAL LIABILITY VCGP01333D 10/01/2006 1D/Ol/2007 EACH OCCURRENCE 5 1 ODO D X COMMERCWi t,ENERAL LIABILITY DAMAGE Tp R QNFED S 50 ~ CLAIMS MADE ~ OCCUR MED EXP {Any ona pxson) S 5 = A ~ S 5 ,000 $X/PU Qed PERSONAL 8 ADV {NJURY S 1000 O0 X per Claim GENERAL AGGREGATE 3 2 ~ X00 ~ QD GEN'L AGGREGATE LNulli APPLIES PER: PRODUCTS - COMP/OP AGG S 2 ~~ (3D POL{Cy PRD IOC JECT AUT OMOea-& LIABILITY coMSINED sINGL>; LIMY a ANY AUTO (Ea aCGdMIQ ALLOwNEDRUT'p3 BODILY INJURY $ SCHEDULED AUTOS t~ Pw~) HIRED AUTOS 8001LYIMJURY S NON-0WNED AUTOS (Par aoddeni) PROPERTY DAMAGE (Per aecideN) 3 OARAOE LU{BBILITY AUTO ONLY - EAACCIpENT S ANY AUTO OTHER THAN EA ACC S AUTO RNLY: AEG ~ ElICE39AJlABRELLA LIABILITY EACH OCCURRENCE S E OCCUR ~ CLAIMS MADE AfaGREGATE S ~ S DEDUC ~~' ~ TIBLE / f RETENTION S S NfORIf(:RS COMPENSATION ANA WC STATU- OTH- EMPLOYERS' LUUiILRY ANY PROPRIETORlPARTNER/EXECUTRIE G+WO E.L. EACHACCR)ENT i OFFICERANENIBER EXCLUDEI» Bu MINi3TRA ON £.L. DISEASE - EA EMPLOYEE 3 m ., ~~~ ~~ SPECIAL PROVISIONS hNow E.L- DISEASE -POLICY LIMIT S OTHER Ten (10) day notice IF cancelled for non pay. DESCRIPTI~t OF OPERATIONS t LOCAflONS / YEHICLE37 EXCLU8jON8 ADDED 8Y ENDORSEMENT 7 SPECIAL PROVISIONS E: lob: Pouring Concrete at 620 Hacienda Ave, Campbell ity of Campbell, City of Campbell Redevelopment Agency, its officers, employees are named as dditional isuued as respects to General Lia~itliy per form VE0182 03/04. Primary wording teas en requested and the endorsement will follow from the terrier once approved. Waiver of Subrogation pplies per form CG2404 10/93. This certificate replaces are prior issued certificates. City of Campbell Attn: Dept of Public Works 70 North First Street Campbell, CA 95008 SHOULD ANY OF THE ABOVE aESCRIBED POLICIES BE CANCELLED BEFORE THH EXPIRATION DATE THEREOF, THE ISSigNG INSURER V19LL NAIL 3O DAYS W WTTEN NOTICE 70 THE CERTiP4CATE HOLDER NAMED TO THE IFFY, )HII~IXtf<M3~Ci(XX pUTHOR{ZED REPRESENTATNE ~~, ~ ~ / Jim Harker ITI/PEP /y~/•~ ACORD25(20041tt8) FAX: {408)376-0958 ®ACORDCORPORATEONi988 Date: 12/6/2006 Time: 1:09 PM To: 1-408-376-0958 @ 9,1-408-376-0958 James G Parker Page: 004 - Polley Number: VCGPfl1333~ YE 01$2 03 64 Insured Nam: JIM GIATiGY3i.A Ct3NCItETE, INC. EfAectlve Date:1@li11/2086 Number: 3Z THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLAI~IKET ADDITIONAL INSURED ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIA$ILTl'Y COVERAGE PART PRODUCTSICOMPLETED OPERATIONS LIAI3ILY'i"Y COVERAGE PART A Section II -Who is An Insured is amended to include as an insured any person or organization for whom you are performing operations when you and such pet~san ar organization have agxeed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured but only with respect to liability caused by your ongoing operations performed far that insured. A person's or organization's status as an insured under this endorsemeat ends when your operations for that insured aze completed. This insurance does not apply to liability caused by the sole negligence of any additional insured. ~_: .., ,. $, With respect,to the u~surarii~:affors~ed`ttf=these aiili~ional tnsure~i~, the fallov,~ng a~ditiasj~l .: ~ ~, ~; exclusi~ins applies: - ~~°„"' ~ . ... ~. ,; - .. _. _ .. ~ r: finis rt~uKa~u'daaif;S tloi:=apply to: ~, . . 1. The Pre~rat~ing=approving, or failing to prepare and~appra~e, maps, shop drawings, opinions, reports, surveys, field orders, ch~artge orders or drawiags and specifications; and 2. Supervisory, inspection, architectural or engineering activi#ies. VE 4} $2 03 04 Page l of i Date: 11/30/2006 Time: 3:10 PM To: 1-408-376-0958 ~ 9,1-408-376-0958 James G Parker Sent Via FA CSys Fax Messaging Gateway Fax To: 1-408-376-0958 Fax Number: 1-408-376-0958 Date: November 30, 2006 Time: 3:10:39 PM From: Melissa Hastings Subject: Pages: 4 Paqe: 001 L r ~, ~~ /~lU - 1 ~ ~ ~ V- Note: Attached please find the **REVISED General Liability certificate"* Please do not hesitate to call if you have any questions. Thank you. Thank you, 912efissa Castings Account Representative James G Parker Insurance Associates License #: 0554959 P 0 Box 3947 Fresno, CA 93650 Phone: (559) 241-8907 Fax: (559) 241-7907 E-mail: mhnstingsC~.igparker,com From: Melissa Hastings Sent: Thursday, November 30, 2006 3:05 PMTo: '1-408-376-0958'Subject: Attached please find the certificate in favor of City of Cnrnpbell. If you have any questions or require any further information please do not hesitate to call. Thank you, ~IeCissa Castings Account Representative James G Parker Insurance Associates License #: 0554959 P O Box 3947 Fresno, CA 93650 Phone: (559) 241-8907 Fax: (559) 241-7907 Date: 11/30/2006 Time: 3:10 PM To: 1-408-376-0958 ~ 9,1-408-376-0958 James G Parker Page: 002 E-mail: mhastin sC~ ~ arker.com This fax and any attachments are confidential and also may be privileged.If you are not the named recipient, or have otherwise received this communication in error, notify the sender immediately, and do not disclose its contents to any other person, use them for any purpose, or store or copy them in any medium. Thank you for your cooperation. B: 11/30/2006 Time: 3:10 PM To: 1-408-376-0958 ~ 9,1-408-376-0958 Page: 003 ~~M CERTIFICA ~ C pF ~~Ag~~~TY DNS James G Parker PRODUCER (559) 222-7722 URANGC DATE (MM1pp1YYYY) James G Parker Ins F'~ (559) 241-7853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA ION 6 License #OE28839 Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P 0 Box 3947 ALOTER THE COVERAGE AFFORDED BOYTTHE POLIC ESEBE OW. Fresno, CA 93650 INSURED Pat Peeren INSURE Jim Giancol RS AFFORDING COVERAGE NAIC # INSUR a Concrete P D ER a Gemini Insurance • • BOx 362 INSURER g: HO11.iStel', CA 95023 INSURER C: FAX:831-636-9811 INSURER D: INSURER E: ANY REQIUIREMENT, TERMNOR CONDI ION MAY OF ANY CONTRACT OR OTHER PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED POLICIES. AGGREGATE LIMITS SHOWN MAY NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING DOCUMENT WITH RE SPECT TO WHICH THIS CERT HEREIN INSR p• HAVE BEEN REDUCED BY PAI TYPE OF INSURANCE IFICATE MAYBE ISSUED OR IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CON D CLAIMS DITIONS OF SUCH GENERAL LIABILITY POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION X COMMERCIAL GENERAL LIABILITY VCGP013330 10/01/2006 10 Ol OMITS / /2007 E CLAIMS MApE X OCCUR y° ACH OCCURRENCE $ 1, OOO, OOi DAMAGE TO RENTED ' X $5, 000 BI/PD Ded $ 50, 001 X per claim MED EXP (Any ane person) $ 5 r OO( GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL 8 ADV INJURY $ 1 r OOO OOL PRO• POLICY JECT LOC , GENERAL AGGREGATE $ 2, OOO, OOO AUTOMOBILE LIABILITY PRODUCTS-COMP/OP AGG $ 2, OOO, OQO ANY AUTO ALL OWNED AUTOS COMBINED SINGLE LIMIT (Ee a id SCHEDULED AUTOS cc ent) $ HIRED AUTOS BODILY INJURY (Per person) $ NON-OWNED AUTOS BODILY INJURY (Per accident) $ GARAGE LIABILITY ANY AUT6 EXCESSIUMBRELLA LIABILITY OCCUR ~ CLAIMS MADE DEDUCTIBLE RETENTION $ WORKER3 COIMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORlPA{=TNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? OTHER PROPERTY DAMAGE (Per accident) 9 AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EACH OCCURRENCE $ AGGREGATE $ i $ E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE -POLICY LIMIT $ Tea (10) day notice IF DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADpED BY ~~RSEMENT J SPECIAL PROVISIONS cancel led for non pay. tE: Job: pouring Concrete at 620 Hacienda Ave, Campbell :ity of Campbell, arced as City of Campbell Redevelopment A enc additional isured as res g Y. its officers, employees and volunteers are s been requested and the endorsement willGfollow fromitliy per form VE0182 03/04. primary wording pplies per form CG2404 10/93, the carrier once a pproved. waiver of Subrogation ~ERTIFIrnTr ..... ___ City of Campbell Attn: Dept of Public Works 70 North First Street Campbell, CA 95008 ACORD 25 {2001/08) FAX: (408) 376-0958 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ~ MAIL 3O-DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, ~iClW[DtBpp~[$pxCXX AUTHORIZED REPRES Jim Parker III/PEP I`1Nq ~ ~~'~-' - ' ~ 2~ V ~ ~ ` I ~) ©ACORD CORPORATION 1988 03/l3 29~Jo 9'~: 34 a933'o~95F FUBLTC 4;~',I;S P;~~E X32/92 AS5 iG~2ER'^' .4ND 1tECEI"ri <3F LW'JSSTVi}?iVT CFTtT?FIC.4 i$ F.R'. Pcrtnii ;V'o. E N C Z O O S- O O 1 S 1 TO C1'Y OF Cf>uU~~ELL, `0 N. ]=7R5~' S'P,~i"' ?'R cr D?'1' ____--- CAM1'BELI,.%:V.PCtR`iF.4 ~~5008 ;~Sj86F•3150 Lru:._62~ ac~iti~~ve:"u l arnlGvc atx; rite ow~cter(s} ~f a sr.vin s account at `r~$'~ KP1Z`IUi~~IA~ (~jAl`1K OF C.L~1,'CR'A~. ~Uf~zh~A et it< 1^raatc}t off'iee at _ R ~•.~L ~- _, Csiifotnia, investment crtf}rate Na. 100 _ it; the nn.rttes of~ M\ N SGt'~ V 4M~ ~ and hav+ng s prscttt balance of ~ ~,~~ ~~. °= I hereb}• >rcant, trans?~r and asaign said account, said investrrtent certifcatn„ said laaiatace (including iYaterest tt~hich accrues thereonj, and aF1 oti5cr dghts in connection ihcrewittt to the CITY i?i" C.4IvIPAEI.L: assignee, for > good trrd ~•aluttble consideration, receipt of which is hereby acknorvlydged, fvr the putpnse of insarin~ ronst+sction described Rc fnllryws. T av hysicai~Y d::'.i~'': vgrl. icstio!± of sand inv~stxnent ~•;eciifeat~t~~upiicate of this Ass;~nz kectt end RGG~1;1t t~,,S3~?d dS51~ tCC. J understand tEtai ass'tgttee can tz;thdraw from said account 2tny time nn ilia signature alone upon F=rt;sent.~tias: ~ ,. wt9ttrta order tc the issue2. 1 aisa 11n$ertand t??et T minty not withdraw from said account unless I preaeri a sighed release from the as.~ignee: 'Crte issta~r or the re-tirictte assumes net responsibility fo* the oondu:t pf the assigmae sttd may act on the signatut~ of the itssiQne,• without funh:r inquiry. .Execrated on ~~Z~1.~Q , 2~~_, tu; sari co of ~c isa fi55i~nOr 's'~~ ~CN,NI~. ~,HV~-tMWly '~,.z~~+OR'T.E1X3141E1YT 13~" T°~R Issuer affirms that Jtere are no ot3tcr Iwidc on subject account. that suh'ect monies are avaiisible. anc' rhat :ire :,hovel;cscribtd as,sagrmcnt },as been noted nn tke Records of sa;a iscmr. 3 30 ~oOG .~Ir 5 MI ~{~'~~~(~~ A ~ ~ `„tEtC I By 1~J~ L'\~M~ °-11a Ur.C ti_ (Au ~ rn~ SigrQ r~~i ,'-1TTrlC?i ti'CYTARY ACKhrOA'LED'vA'C>;:+iT Tstle V 1C ~ 'n IV,T .f~STRLi~T,IC3i`IS TG _ASSItiA Please sign ire}ow For cignaturo identific:ution and as acknowledgment of your notice of 4ssigntnem, Ner~arn thi. ,4ssigr,nart and lieccipf t~ the issuer nt iCC addret• alxive. Reutin enc copy csf tF.ia Assignmetr and T.teceipt i'or you. talcs, Date ~~`~`~d(O %itv,ofjC' -stpbc E ` ~ST:' O' ACseGh~ Seici Kssi~new. henby rcieasex and rctinquishes Wll his rigk;t, t;tle a.nd intearst in end to said account, said investmert c>rtificxtc. e4,ri baias: a anct all other rights in ecrrection ther::wirrr. Date City of Camp'odl P Y ~..~ :~inrrr,s;1s~ernmcnt~rcxstlt0~invastm:xtc^kfias~adnr t t/10d~5 Date: 11/30/2006 Time: 3:10 PM To: 1-408-376-0958 ~ 9,1-408-376-0958 James G Parker Page: 004 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 {2001108) CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT State of Califor~ni/a~ 1" t ~~~'~Jr-ey( ss. County of On Maw i ~.~ before me,~~tt~ ~~ 1~~~n~tey , Date mm Name and Title of Officer (e.g., "Jane Doe, Notary Public") personally appeared rl. ~ r7000~ , Name/(s) of Signer(s) P personally known to me ^ proved to me on the basis of satisfactory evidence ~~~ DJINELLE DAMES ConM~1 ~ 151 T90© P~iO~C - CaMOrWq G ~ ~ ~ to be the person~'j whose namef~) is/~ subscribed to the withir) instrument and acknowledged to me that f~/she/t17Ey executed the same in tit's/her/tt~ir authorized capacity(i~, and that by t~t~5/her/tt~r signature(b'j on the instrument the person~'j, or the entity upon behalf of which the person(e') acted, executed the instrument. WITNESS my hand and official seal. Signature of Nota OPTIONAL Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document. Description of Attached Document Title or Type of Document: Document Date: Signer(s) Other Than Named Above: ?~~, Capacity(ies) Claimed by Signer Number of Pages: Signer's Name: ^ Individual Top or tn~me r,ere ^ Corporate Officer -Title(s): ^ Partner - ^ Limited ^ General ^ Attorney-in-Fact [_~ Trustee ^ Guardian or Conservator Other: _ Signer Is Representing: U 1999 National Notary Association • 9350 De Soto Ave., P.O. Box 2402 • Chatsworth, CA 91313-2402 • www.nationalnotary.org Prod. No. 5907 Reorder. Call Toll-Free 1-800-876-6827 ~'? a-1 ~ S~iV 17 Yi The Network of Comm ~~J Banks~~~ CERTIFICATE OF DEPOSIT Bennie Schulman Pledged to City of Campbell 4 Ronnoco Rd Carmel Valley CA 93924 Account 100686708 Deposit Amount The Annual Percentage Rate The Annual Percentage Yield Interest Will Be Paid Monthly All Items Credited Subject To Final Payment Penalty for Early Withdrawal $ 20,430.00 3.75 3.75 Check to the owner 46-0008 (3/02) Members of the Network of Preferred Open Date 03/30/2006 Maturity Date 03/30/2007 Term 12 Month ' Automatically Renewable BanksSM are brands of Pacific Capital Bank, N.A., which is a member FDIC 46-0008 (4/03) Date: 11/30/2006 Time: 3:06 PM To: 1-408-376-0958 (~ 9,1-408-376-0958 James G Parker Page: 001 Sent Via FA CSyS Fax Messaging Gateway Fax To: 1-408-376-0958 Fax Number: 1-408-376-0958 Date: November 30, 2006 Time: 3:05:59 PM From: Melissa Hastings Subject: Pages: 9 Note: Attached please find the certificate in favor of City of Campbell. If you have any questions or require any further information please do not hesitate to call. Thank you, ~Ytelusa Castings Account Representative James G Parker Insurance Associates License #: 0554959 P O Box 3947 Fresno, CA 93650 Phone: (559) 241-8907 Fax: (559) 241-7907 E-mail: mhastinas@.iaparker.com This fax and any attachments are confidential and also may be privileged.If you are not the named recipient, or have otherwise received this communication in error, notify the sender irnrnedintely, and do not disclose its contents to any other person, use them for nny purpose, or store or copy them in any medium. Thank you for your cooperation. Date: 11/30/2006 Time: 3:06 PM To: 1-408-376-0958 ~ 9,1-408-376-0958 James G Parker Page: 006 ACORD ~ c OF LIABILITY INSURAN( CERTIFICA 1 M . ~ 11/30/2006 PRODUCER (559)222-7722 FAX (559)222-1724 THIS CERTIFICATE IS ISSUEDASAMATTEROFINFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE James G Parker Ins Associates HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR License #OE28839 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P 0 Box 3947 Fresno, CA 93650 INSURERS AFFORDING COVERAGE NAIC # INSURED Jim Giancola Concrete Inc INSURER A: P@Br1esS insurance Company P.O. BOX 362 INSURER B: Hollister, CA 95023 INSURER C: INSURER D: INSURER E: V THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR ANY REQUIREMENT , 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. INSR DD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE 70 RENTED $ CLAIMS MADE ^ OCCUR MED EXP (Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS • COMPIOP AGG $ POLICY PRO LOC JECT AUT OMOBILE LIABI LITY C$P$478254 10/41/2446 14/41/2447 COMBINED SINGLE LIMIT $ ANY AUTO (Ea accdent) 1, 444, 00 ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) A X HIRED AUTOS 80DILY INJURY $ X NONAWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accidenQ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ~ CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WC STATU- OTH- WORKER3COMPENSATION AND EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ OTHER Ten (10) day notice of Cancellation IF Cancelled for non payment of premium. DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS E: Job: Pouring Concrete at 624 Hacienda Ave, Campbell r~oTlrlr~eTr uAl n~o CISNRFI I ATIAtJ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAY3 WRITTEN NOTICETO THE CERTIFICATE HOLDER NAMEDTO THE LEFT, 34 City of Campbell _ Attn: Dept Of PnbliC WOrk9 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 70 North First Street OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Campbell, CA 95448 AUTHORIZED REPRESENTATIVE ~ ~ / ~/,• ~~, Jim Parker III/MRH , ACORD 25 (2001108) FAX: (408) 376-0958 ©ACORD CORPORATION 1988 Date: 11/30/2006 Time: 3:06 PM To: 1-408-376-0958 ® 9,1-408-376-0958 James G Parker Paqe: 007 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 {20011Q8) Date: 11/30/2006 Time: 3:06 PM To: 1-408-376-0958 ~ 9,1-408-376-0958 James G Parker Page: 004 ACORDM CERTIFICA . ~ OF LIABILITY INSURAN(._ DATE (MMIDD/YYYY1 11/30/2006 PROIwcER (559)222-7722 FAX (559)241-7853 James G Parker Ias Associates License #OE28839 THIS CERTIFICATE IS ISSUEDASAMATTEROFINFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P 0 Box 3947 Fresno, CA 93650 Pat Peeren INSURERS AFFORDING COVERAGE NAIL # INSURED wsuRER A: EMPLOYERS COMPENSATION INS CO Jim Giancola Concrete Inc INSURER B: P.O. B07L 362 INSURER C: Hollister, CA 95023 INSURER D: FAX: 831- 63 6 - 9811 INSURER E: rn~i~ows^cc THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY RE4UIREMENT, 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. INSR D' 7ypE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILRY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE ^ OCCUR MED EXP (Any one person) $ PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ POLICY PRO LOC JECT AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NONAWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR O CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND EIG10052380 10/01/2406 10/01/2007 X WC STATU- oTH- EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE E.L. EACH ACCIDENT $ 1, 400, U04 A OFFICERIMEMBER EXCLUDED? E. L. DISEASE-EA EMPLOYE $ 1, OOO, aao If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ 1, 000 , 00 OTHER Ten (14) day notice IF cancelled for non pay. DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLE31 EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS E: Job: Pouring Concrete at 620 Hacienda Ave, Campbell avier of Subrogation requested form to follow from Carrier. ~~ ~, ZUU ~ ~1.~ I ~ I nror, rrn wrr u~r n nw unrr r wrrnu SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, S fl City of Campbell _ Attn : Dept Of PUbl1C WOrk9 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY 70 North First Street OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. Campbell, CA 95008 AUTHORIZED REPRESENTATIVE ~ ~ ~~~ ~~, Jim Parker III/PEP ACORD 25 {2001!08) FAX: (408) 376-0958 ©ACORD CORPORATION 1988 Date: 11/30/2006 Time: 3:06 PM To: 1-408-376-0958 Q 9,1-408-376-0958 James G Parker Paqe: 005 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001!08) Date: 11/30/2006 Time: 3:06 PM To: 1-408-376-0958 (~ 9,1-408-376-0958 James G Parker Page: 002 Policy Number: VCGP013330 VE 0182 03 04 Insnred Name: JIM GIANCOLA CONCRETE, INC. Number: 32 Effective Date: 10/01/2006 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. Section II -Who is An Insured is amended to include as an insured any person or organization for whom you are performing 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 additional insured on your policy. Such person or organization is an additional insured but only with respect to liability caused by your ongoing operations performed for that insured. A person's or organization's status as an insured under this endorsement ends when your operations for that insured are completed. This insuxance does not apply to liability caused by the sole negligence of any additional insured. ,,,: $ ~ `With respect to the nsurarice,,afforded~to these additional Insured., the following additional .: ;. ,: • - ;,:. , exclusions applies: ,._ .. This.-insuxance does.not apply to: 1. The preparing,-approving, or failing to prepare andapprove, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and 2. Supervisory, inspection, architectural or engineering activities. VE 0182 03 04 Page 1 of 1 Date: 11/30/2006 Time: 3:06 PM To: 1-408-376-0958 ~ 9,1-408-376-0958 James G Parker Paqe: 003 Policy Number: VCGP013330 CG 24 0410 93 Insured Name: JIM GIANCOLA CONCRETE, INC. Number: 33 Effective Date:10/01/2006 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under tlae following: COMMBRCIAL GENERAL LIABILITY COVERAGE PART SCIIEDULE Name of Person or Organizatim~: AS REQUIRED BY WRITTEN CONTRACT (If no entry appears above, information required to complete this endorsement will be shown in the Dcclaratioris as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV - COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition ofthe following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or;organizO,Iion and included in the "products-completed operations hazard". This waiver applies only to the person or or~ariization shown in-the Schedule above. CG 24 OA 10 93 Copyright, Insurance Services Office, Inc., 1942 Page ] of 1 ^ CITY OF CAMPBELL, GA RECVD BY: ANNEB 01000192186 PAYOR: 022b99 3I~4 GIA~tCOLA TOIjAY' S DATE: 11/30/06 REGISTER i~ATE: 11/30/06 TIME: 15:40:32 I1E5CRIPTION AMOUNT BU5 LIC NEW/5H0RT TERM 835.00 NEW BU5 LIC APP FEE 825.00 ---------------- TOTAL BUE: 8b0.00 ;ENIIERED: 8bO.00 ~ CHANGE: 8.00 '~: ;; 0:3123.- 200o F~9: 8= 49337n99;i6' FUBI..C O;r~,?1;S P~,E X32/92 AS51G*]1,2E.A`T .4N171tF~Ei" i CF hTP'JBS'T'!~i°1V7 CF?ti~IC.4i'8 F. W. Petmii Na E N C 2 0 0 5- 0 0151 i'0 C7`Y OF Cr1D~3RgS.l,., .G N.1~TRST S1~t C-F."' '?'R cr D.~1' ---`--- CAMPBEl,i.. C:V.~C3R114 43GGi3 (GOSj866.2150 Lc,v. 62 a0-~ c i~">~~v~e--- l atnlgvc a;x; rite owrer(s} of ~ st.vin s accouztt nt. FIRST' 1`1A'C'11~1~\IPII (~jP.1~1k OF CSCO~TRIAL ~l.~f~Lt~1A at its heanc'r: office at R~_~L Caiifnrttia, investment rniiirate No. 1 ~~~__ ~; the names of ~~~.~ M\,1~,~ SGIC~I~~„M~ and hrvin~ d prascnt balance cf S_2O . ~ ~~. °= I hereb}• grant, transfer ane? assign said aeeaun4 said investment cetuftcate, said tulance (including interest which acertes thert;,onj, and all afnct nights is connection therewith to the CITY {?p C ,4MPBEL.I., sssignee, for s good and t•aluable considerEiion, receipt of which is herby ac"icnotvlydged, fo7 the gutpase of insuring constrsetion descrilted as follows. l ave hysicaily d::?rye? verif~~adon~f saad inv~stnrnt retiifleat° and duolicatc of th*s Assi,~rtr-~gn and kCCdlnt ti;Qs?id ;sssic >ee. T understand that assignec.<1rt u:thuraw from said aaout;t any tithe nn his signature alone upon ~~rest;ntaltiot; a; a wtitt:tt order tilt tttt issutx. I aisa Irtder:,tnnd tfet T may not withdraw from said amount unless 1 preseri a sighed taleasc fre:n the asai.gnee: The issuer at the certir3cate assutnes no respotsibiiity fot~ the cnaduct of the assiQ_nve and may act ;,n trite signatut~ hf the tssigne^, witH:,ut funh_r inquiry. • Bxec+sted on MAt~,~1 ~Q , 2~~_, st 5ai ce, of Ike iss „Assi?rt~u• (prir t) __" ~~~'+9R'Lf?DOb1ENT H1' TSSUr'R Issuer affirms :hat dtere are no otiter h,iQs nn subject account, that suh;ect monies are avaiitible..tnd thu tine :,t cvc-<lescribEd assignrtunt has been noted on tFx Records of Bald issuer. ~p~y ~ n ';,~str. 3 ~ ~ ~ ~~~ By Y) 1\~ Y1~1 n~ 0 Q a fAuthori~ Signatut•e iTTrIC?7 NOTARY ACKNpW1,EAGA!~:~'i Title ~f 1~' ~ ~Q ~ S ~ {>f• tV,'~' .4n~•CTi21i T,IC 3Sy`S Tt~ fiA SIC~~~E l']casc tigtr ue)ow fi7r tignaturo idetsiifcatl~n asd s, acknowledgment o£ your notice oi' assignment, ZL.!urn this .4.sigrtnent and l2eccipr to/the issuer at iCC addrssa above. Reuiin enc cepy os thia Assignment and Receipt for y~,ut f81cs. T?atc ~~`~! d~ City,of~C: ~stpblj~ $ErSE dF AS3iv!y~EE Said assig~,c hereby releases and retinquishes:ll his rigFa, t.tle and interest in and m s.^.id account, said investmert certificate. =.y,ri ha!an:x nnc! all athc* rights in ccnrection therewirh. Bate City of Campbell gY ~, :tiinrrr,s~,b¢r~tnmcntt;rtaitftb~inv~stm~:ic^tifiaaradcc I1/IQ+JS