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ENC2005-00180CITY OF CAMPBELL DEPT. OF PUBLIC WORKS 70 North First St. Campbell, CA 95008 (408)866-2150 Fax (408) 376-0958 R-1 NO FEE ENCROACHMENT PERMIT (Non-engineered work within the public right-of--way) ($5,000 maxim/um value of work ~~ ~~ ISSUED ~ 2 / 1 I)5 ' Permit Expiration Date ~ ~ I Permit No__ ~ C ~ ~~ "- UU ~ W X-Ref. File Application Date I Application Expiration Date ~ 2~ ~Q W APN ~~ ~ ~ ~ ' ~3 3 APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in 6 months if the permit is not issued.) A. Work (' J i ~ B. Nature of Work ~ i X ~Gt Wl~- \ ~" ~ ~\ ~ ~l~ ~/(~~M ~~ C. Attach three (3) copies of a drawing showing the location, extent and dimensions of the work. The drawing shall show the relation of the proposed work to existing improvements. When approved by the City Engineer, said drawing 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 securities. NAME OF APPLICANT !J O~/l V~ 1 L' ~ u.~ ~~ ~ TELEPHONE~~~ ~ ~ ~7~~~ ~ ~ ~ ADDRESS 1 V ~ ( i-- u ~ ~ ~ W (l '.'name) ( ~ ~`V1 b ~f' ~ ~ l ~ G! S I l E-MAIL ADDRESS V1(J:rO~' ~ The Applicant hereby confirms that this work is being done by the property owner/applicant at their own residence. The Applicant hereby agrees by affixing their signature to this permit to hold the City of Campbell, City of Campbell Redevelopment Agency, 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 hereby ac dges that they have read and understand both the front and back of this permit, and that they will inform their contractor(s) of the infmrmati ACCEPTED ~ ~ ~' L~ ~ IO ~' (Appli ant/Permittee) (Sign) Date NOTES: All work shall conform with the attached approved plans and all applicable Campbell Standard Details and Conditions and applicable insurance requirements. The Contractor must have this permit and approved plans and must arrange to meet with the Public Works Inspector at the site at least two days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work. 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 (Ticket No.) has been entered hereon. USA PHONE: 1-800-227-2600. TICKET NO.: Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all damages arising out of the design, installation or condition of private improvements in the public right-of-way. SPECIAL PROVISIONS 1. Prior to a~ work, the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be recorded. -2. LtMt t S ~F PA~~M~y~" fLt'-P/~~R Td 6~ t7ET~RhUN~() (~jY Ll'tY INs,Ql~tufL IN TFtt Frfr-t,t~. 3 STANDARD AMOUNT RECEIPT NO. SECURITY FOR FAITHFUL PERFORMANCE (t 00°k OF ENG. EST.) $ APPROVED FOR ISSUANCE -~ I Z~1 ~~ for City Engineer Date Permit Ex fires 6 Months After Date of Issuance. J:\forrns\rlpermit Revised 1.20.04,., 1 ~~~ ~~t~ t:~ ~ GENERAL PERMIT CONDITIONS 1. Payment of a security to insure faithful performance and completion of the work is required. This security is refundable upon completion of the work and written acceptance by the City. 2. A one-year maintenance period for all work is required. Such period will begin on date of acceptance by the City. It is the applicant's responsibility to remove and replace unacceptable improvements within the one-year maintenance period. 3. 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, fire hydrants and water valves. 6. 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. 7. Sawcut for all PCC or AC removals. All PCC removals shall be to nearest scoremark and shall be doweled [o existing improvements. 8. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading as specified by the City Engineer may result in the City's providing such signing and barricades and chazging the cost to the permittee. 9. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. 10. This permit shall be kept at the site of work and must be shown to any authorized representative of the City of Campbell or any law enforcement officer upon demand. , 11. No storage of materials or equipment will be allowed near the edge of pavement, within the traveled way, or within the shoulderline, which would create a hazardous condition to the public. 12. 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 bylaw. 13. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 14. This permit is not transferable. Work must be performed by [he Permittee or his designated agent or contractor as specified thereon. 15. 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. 16. Call Back (call out) due to emergencies regarding this permit shalt be at the current overtime rate with a three (3) hour minimum charge per occurrence. 18. 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 depazture and to specify the manner in which the same is to be made for City-owned or maintained facilities. 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. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the ~I i Date J:\forms\rl permit Revised 1.20.04 NOV 21,2005 03:39P O STATE FARM INSURANCE `APANIES stare Farm Ga~nl Imuranas Corgrany 8400 stare Farm OrNe Aohnen Park, GA 9~92g-0001 E-02- 2207-F155 F H ~~ HARPER, DENNIS D 6 BONNIE K 1D61 LUCOT WAV CAMPBELL CA 95008-6408 11,1,,,1,1,Il,,rll,„I„Ir,11t..lulllr„I„Ir,ll„r,tllltlill 9088717064 page 1 RENEWAL CERTIFI/ `E POLICY NUM9Ep 05-QY-5183-6 Homeowners Polic ~ OCT 17 2005 to C CT 1% 2006 DATE DUE PLEA8E PAY THIS AMOUNT OCT 17 2005 $1 , 3 3 3.00 Coverages and 1_Imits sectbn 1 A Dwelling $521, 500 OweNing Extensiun Up To 5?. , 75U B Personal Property 395, 6l5 C Loss of Use Actual Luss Sustained ~~ ~r~~5 Locauun: Same as Marfiny Address Loss Settlement Provisions (See Policy) Al Replacement Cost -Similar Construotion B1 Limited Replacement Cost -Coverage 8 Forms, Vptions, and Endorsements Horr~eownars ho6cy FP-)455. CA Jewelry and Furs $2,500!$5,000 OPT JF Increase Dwlg up to $105,500 OFT I D Ordinance/t-aw 10%1 $52,750 OPT Ol. Policy Endorsement FE-5320 Cov 'A' Loss Settlement FE-5363 Back-Up Sewer or Drain FE-5706 Lenders Loss Payahle 438-BFU. NS Seepage or Leakage Exclusion FE-5400 Fungus (Including Motd) Excl FE-5424 $5,000 Fungus (Inc) Mold) ).tint FE-5427 Motur Vehic;le Enuor~crSlen, FE-.;452 Deductibles -Section 1 All Losses 2 , OOU Section II L Persons) Liability $500, 000 Damage to Property of Others 500 M Medical Payments to Others 5, 000 (Each Person) Annual Premium $1, 333.00 Amount Due $1, 333 - 00 Premium Reductions Your premnnn has already been reduced by the tol-owing: Claim Record Uiscounl 95.00 Home/Auto Discount 271 .00 Continued on next page Inflation Coverage Index: 243.6 NOTICE. Information concerning changes in your policy language is included. Please call your agent it you have any questions. 1-his policy includes Buildrng Code Upgrade Coverage of $52,750. The HomelAuto discount is being increased to 15% Please review the following notice to learn more. ~~~ 2c~~s-v~~i~v ~i arr~s~ uS'st~vc~.. ayenr HILLIP RIVER III Tele~hVnP (408) 3%8-3403 Prepared AUG 22 2005 17 3368 6682 See reverse side for important Information Please keep this parr for your record. INSURANCE REQUIREMENTS CHECKLIST Permit # 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 ) Z ~ Au motive Liability: irGSs~.~~.) -:a ^ y Auto" checked on certificate t~, $l, 0,000 per accident for bodily in ury and property OL Policy piration date 4'3~23]D?~'~p Workers' Com nsa ~t Waiver of Sub g $1,000,000 per a Policy expiration tion and Employer's ation clause / t f r ily injury or disease ~ .y„ Course of Con o Completed ^ Policy e.~1i fn (if r uired in Special Provisions) of the pro' ct date ~~-ye~ 1 ~-~1~'~ ~' iii/ ,<Q ~..' ~ ~ ~~ ~~-'~ ~- ' ~ti~ r~ ~~ ~~ ~v1 vl r~~ Re uired ndorsements to General Liabilit and Automobile Liability Policies A itional Insured Endorsement The City, the City of Campbell Redeye ment Agency, its officers, employees and ~ S~,`~. volunteers are named as additional insured. ~ ~ ^ The insurance coverage afforded to the Additio Insured is primary insurance. bSi Cancellation area of certificate edited to delete ``e eavor to'' and '`but failure to mail such notice shall impose no obligation or liability o ny kind upon the company, its agents or representatives''. ~Qs~; ^ Workers' Compensation Insurance Sheet Submitted , n~,r ~C~ - ^ For General Contractor I(tfi~'s~~ (~ ~ ~ i~s~l4~-1 ~ ' ~ ~5 ^ For Developer or Owner Ah~-r'~v~ (~svra~-,c~ ~+'. X11/oK-~~ <'~ - 2 ~~ tom, --~j ~ G. ~-`' yr- r~ I ~, s ~lrt `.` (~' • vl' ~ C>~ ~' ~ (rt X ~ Acceptability of Insurer(s) V ~ ^ Insurer(s) has current A. VI. Best Rating of A:VII and is authorized to transact j US L~ ~ business in the State of California. a'~~l 1/i ~ [~ ranee Certificate Reviewed dJ~~~. I Initials Date ~~ ~ l~ ~i~v~]- I ~ ..~ ^ Copy of Insurance Certificate placed in tickler file for month of expiration. ~)C i IZn j:\forms\inscklst (rev 11/99) ACORD,M CERTIFICATE OF LIABILITY INSURANCE 01/24/2006 PRODUCER (949)472-6560 FAX (949) 588-8348 California Southwestern Insurance Agency License Number 0443354 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 21 Orchard Lake Forest, CA 92630 INSURERS AFFORDING COVERAGE NAIC # INSURED K & M Asphalt Maintenance Specialists, Inc. INSURER A: l4dmlral Insurance Company 5724 Hal l eck Dr INSURER B: San Jose, CA 95123 _ 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 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. INSR DD' TYpE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY CA00000839801 01/24/2006 01/24/2007 EACH OCCURRENCE $ 1 ~ QQQ ~ QQQ X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50 ~ 00 CLAIMS MADE a OCCUR MED EXP (Any one person) $ iPEXCI uded A PERSONAL & ADV INJURY $ 1 ~ QQQ ~ QQQ GENERAL AGGREGATE $ 2 ~ QQQ ~ QQ GEN'L AGGREGATE LIMIT APPLIES PER: ~M~ , ~ + r PRODUCTS -COMP/OP AGG $ 2 ~ QQQ ~ QQ X POLICY JECT LOC r - ~ r . . ~ V L~ AUT OMOBILE LIABILITY _ COMBINED SINGLE LIMIT $ ANY AUTO ~ EB ~. 5 OQ6 (Ea accident) ALL OWNED AUTOS "7U~UC ` BODILY INJURY $ SCHEDULED AUTOS + .r W AQMINI ^S . (Per person) HIRED AUTOS n f v~tl 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 $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ~ CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU- OTH- I $ EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ OTHER DESCRIPTION OF 0 ERATI NS I LOC TI NS I VEHI ES / EX LUSI NS ADDED BY ENDORSEMENj / S ECIA P QVISIONS he City, Tie City o~ C~ampbe~~ Rec~eve~opment Agency, its o~f~icers, employees & directors are named s additional insured per attached endorsement CG2010 07/04 with respects to general liability only °Except: 10 day notice of cancellation for non payment of premium. rAUr~l I eTInIJ ~~R r ~rwn ~ ~ nv~a+a.~~ - ---- - - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL i~n161~XIX~(fl6 MAIL c, ty of Campbell '` 3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT Dept of Public Works i D'A b i(IX~XK~(~116XA(K1E1(El~lfX~i(](xlk~[is~rl6Yd(al(~EX~Wfdli'14X~XlQ~fXX: m ros a Attn: Joanne 70 North First Street X~AQJFXdD6X~f~(~ XXXXXXXX: Campbell , CA 95008 AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) FAX ~ (408) 376-0958 ~ ~ © ORD CORPORATION 1988 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 2010 O7 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 O anization s : Locations Of Covered O erations Information re wired to com lete this Schedule, if not shown above will be shown in the Declarations. A. Section II -Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insureds) at the location(s) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after. 1. All work, including materials, parts or equip- ment furnished in connection wfth such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insureds) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor engaged in performing operations fora princi- pal as a part of the same project. CG 2010 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 D