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ENC2005-00165CITE. OF CAMPBELL ENCROACHMENT PERMIT Permit No ~~- ~ ~ ~~` IG 5 DEPT. OF PUBLIC WORKS (for working within the public X-Ref. File 70 North First St. right-of--way) 10~~ GS Campbell, CA 95008 / ~- Application Date (408) 866-2150 Issued ~ D ~ ~ Application Expiration Date ~ ~ (:- Fax (408) 376-0958 // '' /' Permit Expiration Date 1~ ~ ~ ~ APN T~ ~ ' 2LI'' b ~3 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 issue<d. Ap/plilcation Flee is non-refunndable.) A. Work address or tract # ~ ~ `, ~'S 1/t~ f`~~ ~ V ~~ Utility trench location ~/~ B. Nature of work ~'r'",~ -~ ,'' `~ .~ 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 undergound improvements. When approved by the City Engineer, said plan becomes a part of this permit. D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions I and 2J E. The Contractor must have [his 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. /~ yam, r~ ~y Name of Applicant ~~~ ~'~ ~~~ Telephone \ ~~CZJ~'• '~, d~~'"Y~ ~~ Address ~ ~ ~lU (~Z ~ ~nt n m~~ ~ HOUR EMERGENCY TELEPHONE NO. .~r'~/~` ~. q5 ~Z E-Mail Address [s this work being done by the property owners at their own residence? ~~Yes No The ApplicanUPermittee 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 ApplicanUPerntittee hereby acknowledges t y have read and understand both the front and back of this petmit, and they will inform their contractor(s) of the info lion. Applicant is dvi that n issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all damages~ng out of the c ndit f an)~rivate improvements in the public right-of-way. (Applicant Permittee) (sign) 4 •- J Date Contractor (Print Name) Date SPECIAL PROVISIONS _1. Street shall not be open cut for underground installations. Minimum cuts >~ be allowed for connections or exploration holes. Such cuts be specificall~aporoved bby the Inspector prior to cutting. _2. Pavement may be cut for underground installations and must be restored in accordance with the 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. 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. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO PERMIT APPLICATION FEE $~_ `~:, `'j5~ PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCFJLABOR & MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK & INSPECTION FEE ~` $~ ti .~C~' ~ APPROVED FOR ISSUANCE !~.~ ~ C~7/4 ci For City Engineer Dat-e-~ Permit Expires 12 Months After Date of Issuance J:\forms\pwpertn Revised 12.27.04 _ ~J vY~" '~` ~t ~,V i ,~ f ~~~f~ . SAFETY :xhibit B P/t. /U ~ - -- EOP o ' i APpRaVE~ f=C~f~ CpNSTRUCTION. Yl~-. ~ Public V~o~~~.~ ~ ;~~~~it f~fo.~G2O°s-~~~~~ Z ^ ---~ ~ ~ F¢- O z ( COMIUCIOf rtwsl have these plaflf m ~ O I on the lob site durlny construdlon. F~c T w~ T _ 2' HP STL. - 5' 1948 ---- -__ - ~ - BO'N AUDREY AVE(60') P,~~ GAS ONLY TREN CH - - - = TRENCH ROUTE WITH GAS rr~rs; ;:~.~~i. APPLICANT T0: ~,;n~,t *TRENCH & BACKFlLL ALL °' <r ~_ *MAINTAIN 5' OF SEPERATION FROM WET FACILITIES -._._...._.__.._.....__.._. s .D (I.E. WATER,SEWER,STORM) - ,~ PM#30416798 *CALL USA 1-800)227-2600 - 48 HOUR NOTICE `° ' MAP#3474-A2(7) FOREMAN NOTES: * ~~ SUFFlCIENT SAND ONSITE PRIOR TO FINAL INSPECTION * © ; CPA#3474-09 EMERG SD 2 APPLICANT T&B ALL #~ 408)725-2202 FOR INSPECTION - 48 HOUR NOTICE * " ' # _.._.Y.___. MAOP so PSIG INSTALL 85 -1 PL SVC (D8) HAV ' CAMPBELL E HOUSELINE PLUMBED TO NEW LOCATION ° ~. *GAS LOAD 905 CFH ®7 WC & INSPECTED BY MUNICIPALfiY BEFORE METER INSTALLATION ~----- ~~ F'D MLX-NONE 1948 . car sario EST: JWPb ADE: JJGJ SUPV: Lf~T3 ~: REP: JXWO PLNR: SCALE: DATE: N A 4-21-05 CONSTRUCTION SKETCH 1105 AUDREY AVE CAMPBELL PACIFIC GAS AND ELECTRIC COMPANY SD: NOTIf: 101571180 OTHER: SHT: iofl SHEETS Pfd: REV. 30416798 '~ cro 0 -n w b rn x 0 y 0 w A J O O b a sv A O O y O y r z z c bi? O O O y y ro z N N O O ~ o~ O S ~ ~ ~ ~ ~ O~ O~ O o ~ w oW ~., ~~ O o ~~~d ~. o ~ a. ~~b S ^~ O N ~ ~ "' r-. ~ .b ~ ~ n ^': I i n ~- F' O ~~ O ~ x N ~- ~ ~ ~- O r~ O O N ~ ~ o ~ O O G d rnrn;~ N N b O O ~ N N ('~ w w 7 w w ~ w w .~ ~ ~ v, v, b' w x ~ ~ ~o 0 ~' ~ d C A O O O O n n m r, ~ ~ ~ ~ .. ~ z ~ x N ~' O ~. ~ ~ (11 F~ O ~ ~ O ~ ~ to ~- ~ N ~ O PUBLIC W ~ DEPARTMENT RECEIPT El,....rve J Wy 5, 2005 TO: City Clerk PUDLIC WORKS FILE N0. /~ PROPERTY ADDRESS I ~ V ~ } V ~~ Pkasc niket & rcceiPl far tlrc foibrrinr mmir~~ A'eC-r.: r ^ITmN v~ -~ ~AMOI:INT ENCROACHMENT PERMIT d722 Applintfon Fee ,~ ,~ Non-Utllf[y Fdreroachrreot Permit (T275.00) Mime Elrctwehttlmt Perrtdt <SS,ooo IS61.00) FaithlW 1'erforlronec Security (FPS) (100%of ENCR.ESI'.) Labor W Materials Security (100% of ENGR. FSfJ Monumelltation Security (100% o! ENC.R.EST.) Cash Deposit (4%of EnRr. Esq(SSOfi mruS10,g1G maxj IMan Check 8 Impectbn Fee (Non-Utility) Enpr.E51. ~ 5250,000 f 13% of EN(:R.N'_Sf.) EnRr. Ett. >S2511.OOn (Ihposit 8% of Fi1Rr. Es[./f30.000 nrinl"' Utllltr <S1g1,0011 Mlntmvn Charge Per Location CandWtc/Pipelirles up to 500 Feet (TISO.gp (52.25IR) Above 500 Unear F'ect fS1.350U MaallokxlVaulLClEic. (SI25.OOlea1 Pole 5et/Ilemoval (T125.01Nea) Street Tree HaWioR/Remrval (51.15.00) llllllty > Sl W,000 Actual Cosl +211% "' Storvae CrmWncr Permit (T125d10) 14nfeel Plare & Srreelficatbns 17oiect No. 47611 Standard SpeelDntbrts&IkWis (Tlll'R SI.S_50/F{kl d7(dl Coplea of EnRtneerinR Maps & Hanc Aerial Pint 24" x 1A" Ii54.00) Aeral Hint 0 IR" x I I" (S22.gq Maps and Hans 2d" x 1d" (T8.25) d722 IYrulties: Fallurc b reuort puhlic improvements (T10WCalerrliar Uayl tM••1(11e •~~It-w.oln) d722 Penalties: Follurc In nrren ulxcafe conditions ITIgNCakndar Ilay) d722 Work Without Permlu 147'Ines A icahle Fee) LAND UI+,VELOPMEN'I' d~vv I..r I l.u. AAl.om.nt fri00.1g1 4722 Parcel Ma (41.olc or l.e~) ITIAINI.W +S75/lotl 4722 Firwl Tract May IS or Mnrc I,nl~) IT4,7AO.g1+TIINNbt) 4722 Certificate ofC Hance f6511.gq 4722 Certlfinle of Correction ISNq.011) 4722 Noury Fec (per siaruturc) fT10.00) 4722 Vanthar of Wbik Slreeu & Fitsements (f2,21a1.4111 d722 Azca'svrent SeRreRalion or Reappnrtbnmenl Firx[ Sp111 IT725.Ig1 Each Addhbnal I,at IT2gl.g1) 4731 Storm llrairuae Arta Ft<I4r Aerc IR-I 52.1211.00) (MWII•Rrx T2.185.W) IAII (hher S2b511.181) dY20 19rkhnA Ihdicalion F'ec (75%RS% Uuc Upon C<n. of (kcuparrcyl S1i.7424 PosuRr TRA PFIC 4720 Imm~xclbn Tum Cmmn (Two-I lour CounU (T76.5111 d728 Interxeclirm Turn Counu la.m nr p.m. peaks) (SI50.180 472!{ TrcRre How Map (Rally TnTic Volumes) (532.00) 4728 Ca 111'rallic Model (FWI Scope Axsesscmcntl IActlul) d738 Ca II TnRe Model (Reduced Scope AaseusxrcnU fAClml) 4728 Signal TimnB lWnrrnatbn (T63/ifrl 4271 Trvek Permits (516.gNper trip) 4728 Nu ParWne Stans fTl/each or T25/11101 OT}IER ME OF APPLICANT Lry.~ /~ NAME, OF PAVOK /`J ~ ~ .-f~'t~` ~./p ~~j7 PIIONF ~J ~•'>~~"~~~~~ ~~ AIIDRFSS ~ ~ l / C~ \ t. ~1 ~ ~ ~ 1 ~'t 't..~~ %11' ~ ~~1.~ ~~ i •"Actual Cost 1'Im~ 211% Overhead iNmnlxteflR['llLarapF depusltl T(yi'A L j:\formctreceipt loan OS-OO rev.6721 NS ::M - ~ r,fl~t`:~',, I S _ 4 ..y j t .:~+`= t Y`~J • ~•' - a r a /. =. ta" ~~ti'. T, ..r. ' .. _...'4 .... ~- .. ~ rt ~Y~Y,T. .. ~,r?. ,. ~ il'. y` T,i cY ".Y r r i~'J t4 y,Cvr" tY } JNI.n ~!~ INSURANCE REQUIREMENTS CHECKLIST Permit #~ C2°~" ~~ ~~ CIP Project # 1 IOS' f~hJ~ ~~ ~l~~h ~~(x-~n.~, 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 to limit ~, Policy expiration date IZ ~ ~ ~ Automotive Liability: ^ "Any Auto" checked on certificate $1,000,000 per accident for bo ily injury and property damage Policy expiration date l ~' f3" ' ~ i Workers' Compensation and Employer's Liability ~r ^ Waiver of Subrogation clause ~ L, p ~ $1,000,000 per accident for b dily injury or disease ~ t/"_~c, ~ Policy expiration date ~ -~ ~ (Y 0) I Course of Construction (if required in Special Provisions) 1 ^ 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. Ct~1'~' ~,,t.(.; ^ Cancellation area of certificate edited to delete "endeavor to" and ``but failure to mail p (~,{-~,~ 3~3t ~~ such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". ~v5 • ~L ^ Workers' Compensation Insurance Sheet Submitted (~ r. '~'t.l hJ3i ~ ^ For General Contractor ~3 D~ L-~I-'t ~r o For Developer or Owner ~'~ ' ° ~ ~ ~S • ~} Xv ~ ~ C~ ('Q_~ ~~IZ~ ~~ (a-.Y~tt fI ~"_ ~ Acceptabilrty o nsurer(s) Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Insurance Certificate Rev lb t)~ Initials Date ~. Copy of Insurance Certificate placed in tickler file for month of expiration. j:\forms\inscklst (rev 11/99) ACORDM CERTIFICATE OF LIABILITY INSURA~'"E iii3oii 6) PRODUCER (g31)462-6900 FAX (8st)462-3884 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Moore & Mi 11 er Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR License No. OA94420 ~ ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. O. Box 757 "~~~,~vE~ Capi tol a, CA 95010 INSURERS AFFORDING COVERAGE NAIL # INSURED Mello Pipelines , Inc . INSURER A: Geml nl Insurance Co. DEC a zoa~; DBA: )eff Mello INSURER a: California Capital Ins. Co. 260 McGI i ncey Lane L~,y INSURER C: Campbell , CA 95008 ~~~ n~ ~A~r v~~~ INSURER D: 6U~L.DING DIVI3fU~ INSURER E: V V V C RAl7 C.7 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 , THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH MAY PERTAIN , POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' TYpE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY VCGP013594 12/01/2006 12/01/2007 EACH OCCURRENCE $ 1, 000, 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50 ~ 000 CLAIMS MADE ~ OCCUR MED EXP (Any one person) $ 1 ~ QQ A X PERSONAL 8 ADV INJURY $ 1 , QQQ , 000 GENERAL AGGREGATE $ 2 ~ QQQ ~ 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 2 , OOQ , 000 X POLICY PRO LOC JECT AUT OMOBILE LIABILITY 3BAP11153648 12~01~2006 12~U1~2UU7 COMBINED SINGLE.LIMIT (Ea accident) $ ANY AUTO 1 ~ 000 r 00 ALL OWNED AUTOS BODILY INJURY erson) (Per $ X SCHEDULED AUTOS p B X HIRED AUTOS BODILY INJURY (Per accident) $ X NON-OWNED AUTOS PROPERTY DAMAGE nt) id P $ er acc e ( LIABILITY G AUTO ONLY - EA ACCIDENT $ GA RA E T OTHER THAN EA ACC $ ANY AU O AUTO ONLY: AGG $ LIABILITY EACH OCCURRENCE $ EXCESS/UMBRELLA ~ CLAIMSMADE AGGREGATE $ OCCUR DEDUCTIBLE RETENTION $ WC STATU- OTH- WORKERS COMPENSATION AND EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE MBER EXCLUDED? E.L. UISEASE - EA EMPLOYEE $ OFFICER/ME If yes, describe under E.L. DISEASE -POLICY LIMIT $ SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS he City of Campbell, City of Campbell Redevelopment Agency, its officers, employees and olunteers are named as additional insured. C--~1C '~. ~ ~~ S -~ c~ 0 1 City of Campbell 70 North First Street Campbell, CA 95008 ACORD 25 (2001108) FAX ~ (408) 376-0958 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENT O EPRESENTATNES. AUTHORIZED REPRESENTATI Linda Patenaude ©ACORD CORPORATION 1988 CERTHOLDER COPY STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 COMPENSATION INSURANCE FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 08-01-2006 GROUP: 000046 POLICY NUMBER: 0014554-2006 r~rnr,r ~~_ n ~r~. 9C CERTIFICATE EXPIRES: 08-01-2007 08-01-2006/08-01-2007 CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL CA 95008 NG This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This policy is not subject to cancellation by the Fund except upon SO days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy. THORIZED REPRESENTATI PRESIDENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #1600 - TONY MELLO SR, OWNER - EXCLUDED. ENDORSEMENT #1600 - DOROTHY MELLO, TRES - EXCLUDED. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-01-2004 IS ATTACHED TO AND FORMS APART OF THIS POLICY. ~ G~C2~~s-~~~~~ EMPLOYER MELLO PIPELINES, INC DBA:MELLO PIPELINES, INC 260 E MCGLINCY LN CAMPBELL CA 85008 ~~~~~~ ,IUL ~ 1 i©l%6 pueuc vvoR~ ADMIN(STR~q-npN NG M0408 (REV.2-05) PRINTED 07-18-2006 Oct 06 05 02:06a MELLO PIPELINES 4083776108 p.2 JUN-15-2005 17=43 MC -AND MILLER '1 462 3884 P.01 ~Q$!~, CERTIFICATE, JF LfABiLlTY INSURANCE IISi1~JZOOs ~+~- (831)462-6900 FAX 83 ] 461-3x84 T1115 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Moore i Mi11 er Infurance Agency ONLY AND CONFERS NO RIGHTS UPON TNB CERT~ICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR License No, OA94420 ALTER T VERAGE ARFORDEO Y H POLiC~S BELOW. P. 0. eox 757 Capitols, CA 95010 INSURERS AFFDRDINti COVERAGE NAIL x xlwASO INello P pt tNIS, ec. IWSURFJIA Scottsdale ITlwrancc _ mA: ]!ff I+lello INSURERS: Cali ornia Capital Ins. Co. 260 McGl incey Cane lNSUREa c: y - Canlpbcli, CA 95008 'NS~R° INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INStNtEO NAMED AeOVE FOR THE POLICY PERIOD n10+CATEO NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO Wti1CH TkiS CERT+FICATE MAY 9E IS$LIED OR MAY PHRTAIN. TN€ M15URANCE AFFORDED BY THE POLICIES OESCRI@EI~ r+E'REIN IS gUeJECT TO ALL TtiE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH PpLICIES. A<;GREGATE LIMITS SHOWN MAY NAVE BEEN REDUCED BV PAID CWMS_ -- __ TYPE OP INiyRANCE POLICY NUMSRA ICY C7IV! T P1RATlON .._ LRtiT6 eENERALLUrILRY CLS1094209 12/01/2004 12/O1f2005 EACNtkct+RRENCE G 1 000,00 E To Vii'- s 50 00 X GEARMCRCtALGENERALLtASE,ITY nwoH- C~PAS ~~ a OCCUR MGD Exv (Anr ane panEnl i 1 OO A X Pr~asaNAt a ADv w~++uRY s 1000.00 aENraRAL AGGREGATE _ s 2000 GEWLAWREOATEpplppMppIYAPPLIESPER: PRODUCTG-CGMPAaPAGG .t 2,000,00 X -OLKY JECT tOC Av,GMO.ILSLtMtwTY 3BAP11I5364E 12/O1J2004 12/OIJIDDS cOMelNEOS+NGLEtRdIT s +E' •en0~"} 1000 ANT Au7o ALL OWNED AVrGS BOdLY INJURY S (oa,p~nonl 8 x 9CHEWKEDAVfOb ' 1( Hla¢D Au*os eoD,LY ~x~uRr s • tver N.YIt1onl! x NoNawnED Auros PROPERTT iMMAGE s IPM starvY) AUTO ONLY-EA ACCIDENT S WIRAGi~ ItA~K+TY .... .. ANT AUTO OTHER iWIN 6A ACC 3 AUTO ONLY: AGC S ~AG!!OCCURRENCE ~ EROESGNYRRELLA uASaItT . occuR ~ eLARO MRDE aca~t:GATE s _ s OEDUCTMLE "- RETENTIDN S gTAT OTH- WOMCEIp COYPSRaAT10N AND anLOYERruAwTV E.L. eAtNACtloeNr s aFFIC~ERIIAEAAiSR AgT~~CUTNE E.L.OISEASt-FAGART.DYEE t k rr, eo~eli0~ wOr i.l. DISEASE . POLICY 4MhT S SPECIAL PRGVIS+ONSselor OTHER DESCRIPTION OF OI~RATONS I WCAT+DU7 / VENICI.lS I EIICLtMlOhS ADDED sY ENDORSEMEIff +SPlCNL PROVISIONS e City of Calllpbe)7. City of Campbell RedevelapTEent Agency, its officers, employees and 7Llnet:ers are trawled as additional insuetid. ~L~~S-do~b5 SIIOYLD AhY Oi THE AtNWE pESCR+S[D POLICRf !TE GANCd-LEJ7l~ORE THE EXPMNTiDN DATC TMERlOP, THE RWIING INWRER WILL f NDEAVGR TD MAIL O~ OATS WRITTEN NOTCE TD 7Hi CiRTtFICATE MOLDER NAMED t01Rt L!1'Y. wUi FNLUAE TO NAIL wUCN NOTICE SHALL I1IPOSE 11D C1SLlDAtR7N DR LMSILITY City OF CaMQbEa7 ~ Os ANY aNO UPON THE IatuRER-If5 AGENTw oR RRPRESENTAnYES. 7O NOrtil Fir'tst Street ADfHdD?EORE-RESENT Tn+E tanpbel t , FJ- 98008 ACORD Y6 (Z04t/Cf) FAX ~ (408) 97CI-09SE ~ACORD CORPORATION t916E y~8 3?Z-~~'.S Oct 06 D5 02:06a MELLO PIPELINES 4083776108 POLICYHOLdER COPY STATE P.o. Box ~Q~, SAN FRAIVCISCO,CA s4 ~ 4aa08C7 COMPENSATION INSURANCE- ~U N D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 08-01-2005 GROUP: 000046 POLICY NUMB€R 0094556-2005 CERTIFICATE ID: 25 CERTIFICATE EXPIRES: 08-01-2006 08-Of=2005/08-09-2006 LiTY OF CAMPBELL N6 JOB: 70 NORTH FIRST STREET CAMPBELL CA 95008 This is to certify that we have issued a valid Workers Compensation insurance policy ir. a form approved by the California Insurance Commissioner to the employer named below for the policy period indicated. This palicy is not subject to cancellation by the Fund except upon gpdays' advance written notice to the employer. We will also give you 30 days` advance notice should this policy be cancelled prior to its normal expiration. This eertificate of insurance is not an insurance policy and does not amend.. extend .or alter the coverage afforded by the policies listed herein. Notwithstanding any requirement, term, ar condition. of -any contract or other document with respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policies described. herein is subject to all tht; terms,: exclusions and conditions of such policies. ~,t_ ~ . ~ AUTHORIZED REPRESENTATIVE PRESIDENT EMPLOYER'S LIASILITY LIMIT INCLUDING DEFENSE COSTS: 51,000;-000.00 PER OCCURRENCE. ENDORSEMENT'f/2065 ENTITLED CERTIFICATE HOLDERS` NOTICE EFFECTIVE 08-01-2005 IS ATTACHED TO AND FORMS-APART DF THIS PQLICV. ~ cz~~ s- oe ~ cos EMPLOYER MELLO PIPELINES, iNC 260 E MCGLINCY LN CAMPBELL CA 9SQ0$' REV.3-03y LEGAL NAME MELLQ,PIPELINES, INC p.3 NG PRINTED: 07/98/2005 P0410 Oct 06 OS 02:06a MELLO PIPELINES 4083776108 p.l FROM :JEFF MELLO Questions ?Call (408) 377-6103 Fax (408) 377-6153 PAGES: ~ (including this one) DATE: ~~ - ~ `~ Please cat! immediately: Please review and respond: ~ For your information: MESSAGE: / ~-~~r2~5 ~ ~5. FAX TRANSI+~ISSIQN 260 McGlincey Lane Campbell, Ca 95008