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ENC2006-00030
CIT t tJF CHMPBELL DEPT. OF PUBLIC WORKS 70 North First St. Campbell, CA 95008 (408)866-2150 Fax (408) 376-0958 ROACHMENT PERMIT ,_~r working within the public right-of-way) Issued ~~/~/~~ Permit Expiration Date 3/~~/~1, Per Vo ~~Gz, G~1E- c~=.2(;% X-. file Application Date =~ `/~~ C~ Application/Expiration Date ~ APN ~` ~' ~ 5 ' 05 APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six (6) months if the permit is not issued. Application Fee is non-r~efjundable.) A. Work address or tract # t ~ tft ~ ~ ~- Utility trench location B. Nature of work ~~ iM'O~ £ l- 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. 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 Speciai Provisions for this petnut, listed below. Failure to abide by these conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2.) E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at (east two days before starting work. Notice must be given to Pub/li~c Works at least 24 hours before rest~aTrti-ng any work. ~)¢ Name of Applicant ` R'1TG ~1~~ ID~~M~ `~~C ~ I d~'+ ~j~ ~ r Telephone ~ " "" ~~ ~ _ ~ ~ ~~ u G~ ,n~ I (print ame) 7 Address ~ I ~ / ~ , •' ~ ~L I N L ~ AEI E ' ~rR-yti1_ ~~I ~ 24-HOUR EMERGENCY TELEPHONE NO.~G~ 7 ~ s _ ~~ E-Mail Address ~ ""_~ `= ~ ~Z('~"' `~'T t ~ n ~ Ll~~ S~~~C ~ T ttti~ r ~ C~ /~~ 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 Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all damages arising out of the condition of any private improvements in the publi ri ht-of-way. (Applicant i~r~tittee) (sign) Da ~^ Nl ~~ ntractor (Print Namg)~ ~ ~ `j ~~ ~ ~~' to _1 Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts >~ be specifically approved bathe Inspector prior to cutting. _2. Pavement may be cut for underground installations and must be restored in accordance with [he Standard Details Trench Restoration Method "A", 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 Fublic Right-of-Way, which shall be recorded. _6. Public Notification Requirements: 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT N0. PERMIT APPLICATION FEE $ LI ~ ~ ~~ PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $ CONSTRUCTION CASH DEPOSIT $ 7~- PLAN CHECK & INSPECTION FEE ~ /,A / LL APPROVED FOR ISSUANCE For City Engineer Date `~ Permit Expires 12 Months After Date of Issuance ~ ~~~~ \x t ~`~ ~~~` f'"'~ ~ -Y CfltChf leld Co~st~uctioo,inc. License # 773386 Nesidential Design Commercial Ricky Critchfield President Cell: 408.315.6706 ricky@critchfield-construction.com 845 S. McGlincy Lane Campbell, CA 95008 Phone: 408.371.3777 Fax: 408.371.4777 www.critchfield-construction.com PUBLIC. .CKS DEPARTMENT RECEIPT ERective JWy 5, 2005 City Clerk Rease collect & receipt for the folbwing monies: ACCT. 1TF,M ENCROACHMENT PERMI'P PUBLIC WORKS FILE N0. PROPERTY ADDRESS ~` ~ . ~TN~ RD S T "AMO[1NT...`:. Application Fec ~ ` 7a ~-) ) Non-Utility Encroachment Permit (5275.00) l•/•l` v, (/ (,! Minor Encroachment Permft < 55,000 (501.00) Residential Street/Olher Areac (5291.00) 2203 flan Check De it 2% of Engineer's Estimate (5500 min) 2203 FaithfW Performance Security (FPS) (100% of ENGR.ESTJ 2203 labor and Materials Security l100%of ENGR. ESf.I Monumentalbn Security (100% of ENGR.F3T.) Cash Deposit (4% of Ertgr. Est)fS.501) mirJS10,000 nwx) Plan Check & Impedion Fee (Non-lRility) Engr.Esl. < 5250,000 (t 1% of ENGR.EST.) Engr. Est. >S250JM10 (Depasll g% of Fagr. FFtJS30,gp Mn)"" Utility < 5100,000 MlWmum Charge Per Location CondWtslPipelincs up la 500 Feet (SIaO.oo) (52.25/It) Ahove 500 Wnear Fee[ (51.3501) ManhWes/VaWts/F.ic. (S125.00/ea) Pole Set/Removal (S125.00/ea) Street Trce flanting/Ilemoval (5135.00) uuuty > slta,iwo actual cost + zd% •• Storage Conlalner RrMt (S1iS.W) 4760 Protect Bans & Speclfiwtbns Project No. 47(A Standard S cNcalbm & Uc1aR (51/I'g SI5.50/Rk) 4760 Copies of Engineering Ma ~ & Ram Aerial Rot 24"x36" (S54.U0) Aerial Print 8 1/2" x Il" (522.00) Ma and Raro 24"x96" (118.15) 4722 Penalties: Failure to restore blici rovemenu (S100ICnkndar Day) (iuvaicai"s«.u_M.oup 0722 Penaltes: Failure to correct unsafe condilwm (5100/Calerdar Day) 4722 Work Without Permit f4 Times A Iicahle Fee) LAND UEVELOPM EN7' 0722 Lol Line AQ)ustmenl (5900.00) 4722 Parcel Ma 141aks or Lev) (R3,A00.00+E75IIW) 0722 Flnal Tract Map IS or Morc IaLS) (54,2110.00+SI00/lot) 0722 Certificate of Comolianre S(511.011) 4722 A.cvesvneM Segregation or Reapportbmnenl First Split (5725.00) Each Addltimral Lot (5200.00) 4721 Storm Uralnage Arca Fee 1'er Acre (R-1 52,120.00) (MWti-Res 52185.00) (All Other 52,650.00) 0920 Parkland Uedlcatbn F'ee (75%/15% Due Upon Cert. of OCCUpa1wY) Trattic Fbw Map (Dally Troflic Canmbell Traffic Model (FWI1t ~-o ~jv / '' t~ TOTAL /' S ~ "T~..~r ~~ NAME OFAPPLICANT~~'k lC. ~~~~~~'~" ~'J~~~~G,'{ C`, I~'1 i ~ •'~I l... NAME OF PAYOR 4 v ~ ~ r , ~ C ~~` ~ ~ ~ PIIONE ~) yr' / l ~ _ ~~~~. ADDRESS "~~ S S ~ ~ 1 c ~ ~ ~ hl c s' l '~( 7.IP 1 ~VD~ ""Actual Call Ru' 20% Overhead (N wring depuslt) FOR CITY CLERK RECEIVED R ONLY ., a _ cr, rhrv "For Plan Check wad (:asfi Deposftti. eeM ye0ow copy to Fbunce. ue j~.\forms4eceipt linen 05-06 rev.62I /OS n ~ -3 ~ ~. N N 8 8 ,v ~ ~ iii ;a ~~ m WW 0 0 N N d ~ ~~ W d ~, ~ ro 0 d 'fl: O ~ ~ ~ . n ~.. ~ b ~ W ~ ~ ~ n ~ ~ ~ ~. 'b w O '» d b '. O C .~ ~. ~ ~~ 00 ~~ 0 o c x ~< N N Z C C~ ~ C ^~ ~ ~ fD Ch zo N ~. o~ ~a o~ 0 o~ o ~ ~"' d '--a d ~ n" m W W A' ' ~ N N d O O to O~ O~ y 0 w_ d cn 0 ~ 0 c S ° _,:~ ,, o , ~ ~' °' N W ~ ~ ~ N C7, ~ N ~ ~ 7 ~ 7 ~ ~ O O ~s b~~ ~ .. ~- ~~'~ ~ ~,~~`' I URANCE REQUIREMENTS CHECKLIST rt # ~C2~~~-'~~~ CIP Project # The olio ing 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: ~5. $1,000,000 per occurrence, and $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general agar gat limit Policy expiration date~~ 2 Automotive Liability: USCG ^ "Any Auto" checked on certificate ~ ~ D~ ~S~S ~''n ~ ~~~ ~v $1,000,000 per accident f bodily injury and property damage Policy expiration date Workers' Compensation and Employer's Liability Waiver of Subrogation clause ~b $1,000,000 per accident for bodily injury or disease `~fj Policy expiration date ~ Y] Course of Construction (if required in Special Provisions) ^ Completed value of the project ^ Policy expiration date uired 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 ~_ :u~l ~ ^ For General Contractor ~n~,ln ~,~ ` ~uf~fY~, ~~ ~ L ^ For Developer or Owner ~~~~ ~h- ~ ~ ~ ~ ~~ ~~' ~ ~I I Acceptability of Insurer(s) SC ~ ~ JSUy~ ^ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact LJ ~rC:rY~~Lbusiness in the State of California. Insurance Certificate Reviewed /C~ ~-C.4 1 ~ ~--' ~~ ~D~ Initials Date ~Q, Copy of Insurance Certificate placed in tickler file for month of expiration. j:\forms\inscklst (rev 11/99) ,~ ~.~ ~ ~ D~ Z4' ~~~~ ~FAx TO: Kristin Findley Allstate Insurance 1375 Blossom Hill Road, # 17 San Jose, CA 95118 Phone (408) 445-7200 Fax Phone (408) 445-7203 i CC: Date 10/24/06 Number of pages including cover sheet FROM: Joanne D'Ambrosia City of Campbell 70 North First Street Campbell, CA 95008 Phone (408) 866-2701 Fax Phone (408) 376-0958 2 REMARKS: ^ Urgent ^ For your review ® Reply ASAP ^ Please Comment Insured: Vern Easthouse General Contractor Permit #: ENC2006-00030 Work Site: 189 S. Third Street, Campbell, CA In reviewing our files, we see that the auto liability insurance coverage shown on the insurance certificate we have in file for the above permit has expired. Please forward a new certificate showing updated insurance. You may fax the certificate to our office. A copy of the expired insurance follows for your reference. Please make sure the renewal certificate has the same wording and details as the originally approved certificate. Please call me if you have any questions. Thanks for your help. rln!~.-ia-ccl_I:_ rJl• wl I n~ll• You're in pool hands. ALl STATE 1NSURAN~E COMPANY laa~~e Ufti ca NorthbreUk, Illit^ois lrzsured: VERN & MART EA;THGIJSC (:i ty : LUS G.ATOS St IV•.Jl l~l I I I 'L~ ~- %z ~K~-- 5~ob Caier~dar Date: G3i16l200b Policy Number; 067U~3169Z 05 / 16 Address: i536~1 RGSI.L~~AF COURT CA Zip: 95032 Home: 40R - 356 - X3'(4 CHANGE OPERATCIR # ~ Name ; UCRN R EASTNS~IJSE Sex: M Relation to Ins: SA Birth: 10(31i193~3 Date Li1:;:10/1954 Marital SL: MA Occupl0esc: EM CONSTRUCTION Lic No rOF,8751a State L'~c: CA SSN; 566506585 ADO/CH(1NGE Cul'ER,AGF 1998 ZOUCI ~`~! 1. unit, AGUKU SILVERAD ~/~~~~ Bodi l }~ ' n~urx IOGUU00 / 1000000 X X Property Damage 100000(? X X veR ~ ~ 20p0 ,)SAGE AND RATE CI_ASSIrlt:l!~TIUN '~~M~Ns~~q~ l~Jyb %OOG T/O~y A%ORD SILUFRnDCi Est. Ann. Mies (000): 012 0'l2 Fri no.i pl e Use : '~Inrk/5ch 06 WCrki $rh U~~ Est ~ llsP by Oper 1 ~ 090 020 Est ~ Use by Oper• 2 010 080 THIS REQUCST IS ErFECiIVE ONLY I~ THE P01Ti:Y NU~ItQ ABOVE IS CURREPJTLY IN FORCE i~ffec*ive l}1 ~ 32 PM 03 ! 15 / 2006 'a ~ Cy er s . 4gna e 083505 CJM 41x8 ~J~~S 7.7.00 gen s ~ g a ure Agent # Location Agent's PhonF # SAK7C-2 -~-~ --fit ~ ~~ l to I p~ ~- ~~ ~ ~ ~~C 2~~ '~Db~O Rze~-, Page 1 of 1 Page 1 of 1 Joanne D' Ambrosia From: Syed Wahidi Sent: Tuesday, October 03, 2006 11:29 AM To: Joanne D' Ambrosia Subject: RE: 189 S. Third St/Vern Easthouse Const. This work has not started yet. I think we should inform them to update the insurance as they may start work all of a sudden and will face delays at that time. Syed From: Joanne D' Ambrosia Sent: Friday, September 29, 2006 8:51 AM To: Syed Wahidi Subject: 189 S. Third St/Vern Easthouse Const. Is this permit work done? The insurance has expired and need to know whether need to get renewal insurance. It was issued by AI Oxonian in 3/06. Joanne 10/3/2006 Fax o~ ~2 ~~ ~ Date 3/17/06 Nl. m Number of pages including cover sheet $ ` `~ TO: Michelle Costa FROM: Joanne D'Ambrosia Bozzuto & Associates City of Campbell 3425 S. Bascom Avenue #100 70 North First Street Campbell, CA 95008 Campbell, CA 95008 Phone (408) 377-8712 Phone (408) 866-2701 Fax Phone (408) 377-5741 Fax Phone (408) 376-0958 CC: REMARKS: ^ Urgent ^ For your review ® Reply ASAP ^ Please Comment Re: Insured: Vern Easthouse General Contractor. Permit #: ENC 2006-00030 Work Site: 189 S. Third Street, Campbell We have received the certificate of insurance for general liability for work the above insured will be doing in the City of Campbell right-of-way. In order to meet our minimum insurance requirements we must ask that the following changes be made to the certificate. 1. T ese endorsements/changes need to be added/done: - The City, the City of Campbell Redevelopment Agency, its officers, employees and volunteers are amed as additional insured. The insurance coverage afforded to the Additional Insured is primary insurance. - The cancellation area of the certificate is to be edited to delete "endeavor to" but failure to mail such /fiotice shall impose no obligation or liability of any kind upon the company, its agents or ~/ representatives". A copy of the certificate, as well as our insurance requirements, follow for your reference. You may forward the requested items to us by fax. Please call me if you have any questions. Thanks for your help. ACQRD CERTIFICATE GF LIABILITY INSURANCE OPID $ DATE(MMrDD/YYYYj v~~rrg-1 11 as/Ds PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bozzuta & Associates Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR One Almaden Blvd Suite 810 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. San Jase CA 95113 Fhone:8O0-989-8712 E'ax:408-288-7130 INSURERS AFFORDING. COVERAGE NAIL # INSURED IN,~LIr-~Eh ~ Lincoln t3eneral Insurance I~ L)(?EI~'~' Vern Easthouse General Contractor ,hti,l_iREE ~-, 16364 Roseleaf Court IrrouRERL Los t~atas CA 95032 I?,i~;LrEra e COVERAGES 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 CfRTIFiCATE MAY BE ISSUED OR MAY PERTAIN, THE INSI1RANf1F AFFC']RI]FI'] RY THE P(')I ICIFS I'IFSCRIRFf) HEREIN IS St IR.IFCT T(7.AI I THE TERMS, FXCI I ISI(~NS ANf] Cf)NnlTtt~NS (7F SI ICH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER I I17~ DATE MMJDDJYY ~~S7~Yl=~ i LIMITS DATE MMIDD GENERAL LIABILITY Ep~7; C,t;1uURRECd!`F $ 1, Q Q Q Q Q Q A X X COM~MCR~fA:_GENEPP± uA.EIUT± 6320014352-02 11/02/0& 11j02/O7 I FREl~11SES~iEa ruar'er~~,:Nl ~ 100000 "CLAIMS M.4CSE ~ rt. t;I.JR. k~E-n EXr t,AnY .:n8 PE~ =.chl $ Cj Q Q Q _ i aERSCN;~,_~,n.[~v Inl~;.!Fw ~ 1000000 I :"':G,IChHL. .A:iC.~iCa:ATC f Q QQ Q Q d 0 GEN'L .AL GkE ~P.TE LIMIT ~F>=~UE.; F~EFc ~ FP.L?DU~~TS ~ C,uMFdC?F A~t<C~ $ Included X 1 F'~JL'Gi" ~ PE"OT ~ LCx_ AUT OMOBILE LIABILITY It,IVLE L !L~IT . a~ g ,hJ•dY ?1ST,'1 c1~1 nt) (: 3 ALL cr'/vr,~n,~.~rres I EUDILI INJUF Y SCHELLILEDAIJTOS . iP~rpe~s~^1 $ HIRED ALfi05 I QODILY IPdJUPa ' ,~ Nn1J-OWNED Alf)-O;> ar ~ cia~nti _ i~ ~,.., w F'P CiPERTY C~~MAGE ~ ~,.. ., p ig $ ar acN, i 4 n~ GARAGE LIABILITY ;U_fff? DNLY - EA P,i:S'IUi=tJT ANY AI_r7;~ i, ~ (~ ~ ! I V l1 Y ~ , } ^~ ~ ~ U IJ ~ '~ THER TMAN Et1 aCG ALi7n ~jNLY Ji=~, ~ EXCESSNMBRELLA LIABILITY LI AD VV ~S ryf ~,,,,, EAGrf nCCLIRREtdCE $ !JC ~:;L~' ~ : LAIMS MAG'E MINI TRATIOh . . A ATE: $ G $ i RETErm~N ~ ~ WORKERS COMPENSATION AND ' I ToRV LiIviIT~ ~~R - EMPLOYERS LIABILITY 4tG_tDENi i El E4 H -~ $ AN'f pRf~F'Rlc`Tt_+p./PAF?TNERIEX~EGLIT!VE _ , f~FFf~'tFIMEMRER EaE~LJDEDY (f i b n d i E L DISEASE- Ek.EMPLOYEE $ I yss; ascn au c ar SFEC,4LPF'~V75.ONSbaloGV ~ iEL DhEfi6E-?OL6~vLIM1T $ 07}{ER i OESCRIPTIOM OF OPERATIONS t IOCATION3 /VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS R~:Permit# ENC2006-00030 Driveway Approach @189 s.3rd St.,campbell,cA 95008 The City, the City of Campbell Redevelopment Agency, its officers, employees and volunteers are named as additional insured per endorsement to follow from carrier. The insurance coverage afforded to the additional. insured ie primary insurance. X10 days for nonpayment of premium /=- 7 ~ ~, {~ C ~ ~ L ~`" L~L~L 7~ CERTIFICATE HOLDER CANCELLATION City of Campbell Redevelopment Agency, Its officers employees and Volunteers 70 N. First Street Campbell CA 950.08 ~FB)".~iT1 ( SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOR£ THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL~ifJ' MAIL 3O * DAVS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, AUTHORIZED From: Betsv Hansen At: eozzuto & Associates FaxID: To: JoannelCity of Campbell Date: 11/8f2006 01:15 PM Paae: 1 of 2 8~2~~Ta N S U R A N C E S E R V I C E S One Almaden Blvd., Suite 810 San Jose, CA 95113 Phone: 408-947-3000 Fax: 408-288-7130 Fax From: Betsy Hansen To: Joanne/ City of Campbell Pages: 2 Fax: (408) 376-0958 Date: 1 1 /8/2006 01:15:44 PM Phone: ( ) - Subject: City of Campbell-Third St Campbell Message: Attached please find the certificate for our insured Vern Easthouse General Contractor. The original will follow in the mail. Thank you! cc: Vern Easthouse cc: City of Campbell 408-376-0958 r~HR:-1~,-~u~~ i71:.soF- ~fduri: iu:~,ri4rrr rod-•~ ~~IIIS1~a1~. You're in pond hands. AI_I ST11TE 1NSL'RANLE CCJMP/IPJY I-lode Ufficc Northbrook. Illinois lrz5ured: VERN & MARY >=ASTHGl15C Ci ty ~ LL'S G.ATOS St C4iendar Date: Q3,'16/200b Policy Numt3er : 057U~31BCa1 05 l 16 Address: 1ti;3F,~~1 f?[,;SFLEAF CUIRi~ CA Zip : ~35U3~ Home: 408 - 356 - r3I /4 CHF,NGE OPERATaR # 7 Narne ; UCRN R EAST!-IC}USE Sex: M Reiatlon to Ins: SA 6~irth: IO/31i193~3 Data Li~~:10/1954 Marital SC: MA OccupJ0e5c: EM CONSTRUCTiCIN Lie fJo `-06803:3 State Li c: CA SSN; 566506585 ADGICHANGE C.ut,'ER,AGF 1~a98 L units ACU~tU Bndily '_n~ur~ 1OG0000 % 10000011 X Property Damage 100000(1 X '.JSAGE AND RAT>= CI_ASSIrIC,'tTION l~~t~8 :000 AC1.~RD SI~UrR/1UCi Est. Ann. Miies (000): U1l U12 Frin~.iple Use : Work!Sch 06 WorkiSch 01-> F.at `); Use by ~0per 1 ~ 090 0~0 Est ~ use by (~ier' 2 0~ 0 080 2000 S I L'd CRAG ~~~/'~ MAR 1 ~ ~~ p Z~~6 '~OM~Nj~ wogKs ~R4T/Oy THIS REQUCST TS E~~ECTIVE ONLY' I~ THE P01 Ti;Y PJUiED A~QVE IS CURRENTLY IN FORCF Effective 1?1 ~ 3c PM 03 / 15 / X006 'v ~ cy er s . i gna e y ~ 083506 CJM 4}8 415 77.00 gen s g~1a ure AgFnt # Lccat.iun Agent' PhnnF SARI C - ~ ~ . ~ ~ ~.ys _ -7 2 ~3 ~ ~ ~~ ~~~~ e ~~~~~ ~ I~ ~ ~~./ `~ C 2 ~ ~? ` ~ Db -emu R?.853-' ~~r3~e 1 CJf I ACORD.. CERTIFICAT' PRODUCER 'Bozzuto & Associates Insurance 3425 S Bascom Avenue #100 Campbell CA 95008 OF LIABILITY INSURANr ~ OPID M DATE (MM/DD/YYYY) _ VERVE-1 03 16 06 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. Phone:408-377-8712 Fax:408-377-5741 INSURED Vern Easthouse General Contractor 16364 Roseleaf Court Los Gatos CA 95032 INSURERS AFFORDING COVERAGE NAIC # INSURER A'. L1nCOln General Insurance INSURER B. INSURER C: INSURER D'. INSURER E. COVERAGES 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 MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER pgTEYMM/DD/YY E PDATE MM/DD/YY N LIMITS GENERAL LIABILITY EACH OCCURRENCE $ lOOOOOO A X X COMMERCIAL GENERAL LIABILITY 6320014352 11/02/05 11/02/06 PREMISES (Eaoccurence) $ 100000 CLAIMS MADE ~ OCCUR MED EXP (Any one person) $ 5000 PERSONAL&ADVINJURY $ lOOOOOO GENERAL AGGREGATE $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ Included }{ 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 NON-OWNED AUTOS ~~~~~ ~~ Per accident) $ ~ PROPERTY DAMAGE j ~±~ ~ ~ ~ Ld ~ ~ 6 (Per accident) $ GARAGE LIABILITY ~UBLIC W RKS AUTO ONLY - EA ACCIDENT $ ANY AUTO ADMINIS TION OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ~ CLAIMSMADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND TORY LIMITS ER EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIV't EL. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT /SPECIAL PROVISIONS RE: Driveway Approach @ 189 S. 3rd St., Campbell, CA 95008 City of Campbell listed as additional insured per endorsement to follow from carrier. *10 days for nonpayment of premium CERTIFICATE HOLDER CANCELLATION CAMPBEL 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 DO SO SHALL City of Campbell 70 N. First Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Campbell CA 95008 REPRESENTATIVES. AU IZED REPRES ATIVE ACORD 25 (2001/08) ~ ©ACORD CORPORATION 1988 1'rOfT: NL Cn OIe GOSia N[. tSOZZUiO & N560CIaTBS r'aY,I U; I-YUO-J/ /-O/H i I O. Vern Ca SIn OU Se ben of al L.OniraClvr Ua4C. JI I~/ivu0 V I.OO nvi rayC. i VI ~ ACORD CERTIFICA i c OF LIABILITY INSURANCE OPID M DATE;MMIDDM'YY) _ VERVE-1 03/16/06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bozzuto 6 Associates Insurance ~~ E i r~ HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 3425 5 Sascont Avenue #100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Campbell CA 95008 ~:~~ (~ Phone:906-377-8712 Fax:90B-377-5741 INSURERS AFFORDING COVERAGE ;NAIC~ L INSURED ~ IN::_REF' q L1aCOln C3@aeY81 In3uranCe --r-_ Vera Easthouse IMS_FFRE -- -----i--------- l3eaeral Contractor ; IN5_REe c 16364 Roseleaf Court I lrls REF o Los c3atos CA 95032 ' _ - --____.__ _____~__ ___ IRIS _F'EF' E' COVERAGES THc -! 4 CIEC , W=-UF'A~ : c Li >TcG B=L.Odd HH'+E bE~ ~ IS_UED '0 TH IfJ UkED CI~1~?.D AB07E FVR T-E POL f_ ~' REFICD ., F_.~I _C~ r. Twl l -BTANGINC. ., %E7U REMcfl-. ?ERM ~..F ., -I ~ iCr- ~!N ' .-: ,I ~:? ^F_ nnyEq ..J_LUlEI :? :,.-H F.E~FE -? r. wHL:H?H,> _EgrIEI~,,-E r,lp, 5E ,: L ~Er ,-~c, ^,1%- PtF AIF.I, THE f:SJRp. t E ~FFOR=EC °" THE F: ~I CIES :ESCRI©EC H°REI'J IS ,9UE J E~~T TO AL_ THE TERMS E<CLUBIGN_ ~~P1D'=OND h ION= ='F SUCH P%L IC IE5 =Gi;i^°G4TE L1+.,11T_ bHp•~Y!.I MA ~" H4 d? SEEN FEC~.~CED P~v PF. n C~L4F`-`~S '- ' _r 'SR AT/D CT LTR iNSRL'{ TYPE OF INSJRANCE POLICY NUMBER - ~~ ' DATE (MMfDDM!) DATE (MM/CDNY) -____-_ LIMITS I GENERAL LIAB!LRY ~ ~ ~ H ~~-~uR -- ` i g iQ ~~0~0 ~ or A K X ~~ ^~ ~,-iaL E F^ ~ EILJTY 6320D14352 11/02/05 ~ 11/02/05 ~i'~ET7TEC e RRRR r' -- - s 100000 F ~ a r,I~rduCF X~ '" 4- 7 ~ ~ I^1E(r~F1~r r I~r-1 --- _ 45000__ _ ~ - I ~ J ( ~F F ~NAI I' i-.P r- ~ 1~~0~00 -f-.___..__-__ _ _ _._. _.. ___ _ I ,, r EFL H Fr E _ _ III x_2000000 -.t_- - __ _.. -___ _ ~~~=FIL-1 t;~ E I~I~ P~FH Ic E= F ~ J ~ ~ I ~chr,~~~~_ r n~ ~r, ___ ~ 4 Included _ _ P L i~ ~ IF T ~ L ~' X .~T ~}~ Au-cmo~LEUASwIrY I ~ ne~~INEr 1= I!.;~T ~ t - i I I I ..L 'IJ.C HI 7 J. 7 ; I. ' BAR may) ~-w..f' F- _ ~ ~ _ H ~_ =F II r--I ~~ ~ ~ I I ~ ~ ~ ~~„ u - -- -~----- II- J r{IREC . _ ~: ~ ~ ~ P B ~ (,~ ~ ~ ~~ I c L ~r IN~ur ' - 4 I~ rJ ,.. r . ,- I--; ~QM~~C ~ ~ k rF I <<~JHrr - - -- ~ - -~ -------- -- I ~ ks ~ I I ~ rP 7 ~ 'I x ~ era _el arti GARAGE LIABILITY _ rd _,, ~ i P,UfC~0-1 ~_F~AI;CICENT '? E x - ' -~ _- ~--~ I : HFk T-i.N __._ ' ~. i -~.7i.) 'a ~ EXCESSIUMBRELLA LIABILITY _ ( E.~ I L~ IFFEIJCE -'- ¢ ^~[i?UR .__J CI .'I. S,a1~~DF i I r ~=r. rrE ~.tTE __- ~ 3~ ~~ I j ~~r IsLF ' i ~f g r_ I IrETE^'~;i~a ~' -._ ~ ~--- _._- ..- ~ WORKERS COMPENSATION AND EMPLOVERS'LIABILITY I j ^ I '~ ' - I fir.-'R , IIr,AIT-~ i_ F ~ F: +-_..-_.-__ vIJ PRCFFIrTURlF~4GT F4JF ~F~ U'vE ~ FF ER~ MBEF'E ~ i EC-. ~ ~ ~ j ' E F_I.CH A~ IGE ~T _ q ~____-_-_ O M ._l !_ f yE5 '~,~:f 112 LfICfEI' I t E_I F_ttAFL r F- E=i'( ----. PE.. v.. PFD I 'f c Dyl. vo E E,+: E f J~ C r Ilv i T I ~g OTHER ~ i i I I i I CESCRIPTIGN OF OPERATIONS f LOCATIONS 1 VEHICLES 1 EXCLJSIONS ADDED BY ENDORSEMENT /SPECIAL PRGViSIDNS RE: Driveway Approach @ 189 S. 3rd St., Campbell, CA 95009 City of Campbell listed as additional insured per endorsement to follow from carrier. +10 days for nonpayment of premium CERTIFICATE HOLDER CANCELLATION CAMPBEL ~ BHCULD ANY DF `HE ABOVE DESCRIBED POLICIES EE CANCELLED BEFORE THE EXP!R4TIDN DAT'c THEREOF THE ISSUING INSURER WILL ENDEAVOR TD MWL 3O * DAYS WRITTEN City of Campbell 70 N. First Street Campbell CA 95008 ACORD 25 NOTICE TO T~iE CERTIFICATE HOLDER !JAMED TO THE LEFT, BUT FAILURE TD DC SU SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANV KINC UPON THE INSURER. ITS AGEhi-S GR REPRESENTATIVES. ®ACORD CORPORATION 1988 From: Michele Costa At: Bozzuto & Associates FaxID: 1-408-377-5741 To: City Of Campbell Date: 3/17/2006 04:26 PM Page: 2 of 2 ACORD„ CERTIFICATE OF LIABILITY INSURANCE OPID M DATE(MM~DDmwl VERVE-1 03/17/06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bozzuto ~ Associates Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 3425 S Bascom Avenue #100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Campbell CA 95008 Phone: 408-377-8712 Fax:408-377-5741 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA Lincoln General Insurance II'J UREP B: Vern Easthouse General Contractor INSURER ~_ 16364 Roseleaf Court . Los Gatos CA 95032 IIJ I IRER E, VJSURER F I:UVtKA(dE5 THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NS TYPE OF INSURANCE POLICY NUMBER DATE MM/DDlYY DATE MM/OOIYY N LIMITS GENERAL LIABILITY EA(r Cu_CURRENCE $ 1000000 A X X coMMEP~,.IAI_ ~ENEPFU_ui~Rll_Irv 6320014352 11/02/05 11/02/06 PREwIE oc,c_Irensei $ 100000 CLAIMS MADE ~ OCCUR MED EXP (Any one person) $ 5Q Q Q PERSOnIALBADV INJURY $ 1000000 _ „ „ ~G'~RE';,,^,,_ $ 2000000 GEN'L P.G~:;RE3HTE LIMIT~~PF'LIES FER. FRGDUCTS - CUMPiGF tt~.f> $ Included Pi1Lt(=~ n F~Q n LOC AUT OMOBILE LIABILITY P.NY AI,ITp ~'OMEII'dED SII'dGLE LIMIT (Ea accldentj $ ~ P,LL 4VVPIED P.UTr5 ~ ~ ~ EODILY INJURr $ SGHEGULEG AUTOc (I'er perer.'nl HIRED ALITOj "l~ ~- (~cc Br'i[iILY IfJJI IRV ~ NON-O'/uNED P1 Ri ~'.~ (F'af 3CC1~18r1C} 0~ ~4 PROPERTY DAMAGE n $ lFer AcrldA f) GARAGE LIABILITY AI.RG ONLY - EA A~~CIDENT $ AIVY AUTO EA ACC orHER TMAN $ AUTO OIVLV AC,- $ EXCESSNMBRELLA LIABILITY EA(=H Dt=CURREL`dC E OO~UR ~ SLA,IMS MADE AGGREGATE $ $ DECD i~~TBLE FICTEPITIOIV $ $ WORKERS COMPENSATION AND EMPLOYERS' LIA ~' Ts:~RY LIMITS F-P. BILITY P,r.ll' PP.(iPRIETOR/FAP.TNER/EXECUTIVE E L EACH P.C~~ IDEP~ -- $ GFFP~ERIMEMBER EXC:.LIJpEQ' If es describe • de E L DISEASE - EA I.MF'LGYEE $ y , ul ~ r SPECIAL F'RpV15101•.IS peb~w E L DISEASE - P9L P_ Y LIMIT $ OTHER DESCRIPTION OF OPERATIONS! LOCATIONS 1 VEHICLES !EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS RE:Permit# ENC2006-00030 Driveway Approach @189 S.3rd St.,Campbell,CA 95008 The City, the City of Campbell Redevelopment Agency, its officers, employees and volunteers are named as additional insured per endorsement to follow from carrier. The insurance coverage afforded to the additional insured is primary insurance. *10 days for nonpayment of premium GEK I IrIGATE HOLDER CeNCFI I erlnu CAMPS +L' L SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 8E CANCELLED BEFORE THE EXPIRATION Clty of Campbell Redevelopment DATE THEREOF, THE ISSUING INSURER WILL~MAIL 3O * DAYS WRITTEN Agency , ItS officers ,employees and Volunteers NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,~® 70 N. First Street Campbell CA 95008 AU IZED REPRES ATIVE D00' ACORD 25 {2001!08) O ACORD CORPORATION 1988 CERTHOLDER COPY STATE COMPENSATION INSURANCE FUND P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 09-2B-2006 CITY OF CAMPBELL 70 N 1ST ST CAMPBELL CA 95008-1458 GROUP: 000571 POLICY NUMBER: 0001057-2006 CERTIFICATE ID: 62 CERTIFICATE EXPIRES: 10-01-2007 10-01-2006/10-01-2007 THIS CERTIFICATE SUPERSEDES AND CORRECTS CERTIFICATE f{ 58 DATED 10-01-2006 NG JOB:ALL CA OPERATIONS 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 30 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 UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPENSATION LAW. EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT N0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2006-10-01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF CAMPBELL ENDORSEMENT If2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-01-2006 IS -:,TTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT 1!2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2006-10-01 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF CAMPBELL OGT (~ y 2006 AOMWIg LURKS EMPLOYER ~nOHI .~~ 210-- ~ ~~ :~ EASTHOUSE, VERN NG 16364 ROSELEAF CT LOS GATOS CA 95032 NG [MPR,CN] (REV.2-05) PRINTED 09-26-2006 CERTHOLDER COPY NG STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 ~~~~~ b ~~ COMPENSATION INSURANCE ~~~ ~ ry 006 FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE r~UBL.IC wORKs ISSUE DATE: 03-16-2006 GROUP: 000571 ADMINISTRATION POLICY NUMBER: 0001057-2005 CERTIFICATE ID: 58 CERTIFICATE EXPIRES: 10-01-2008 10-01-2005/10-01-2006 THIS CERTIFICATE SUPERSEDES AND CORRECTS CERTIFICATE # 57 DATED 03-16-2006 CITY OF CAMPBELL NG 70 N 1ST ST CAMPBELL CA 85008-1458 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 upon30 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 UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPENSATION LAW. EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2006-03-16 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED: CITY OF CAMPBELL ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 03-16-2006 IS ~,t,TTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2006-03-16 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF CAMPBELL ~jUC 2 c7t3Co - OOd3a EMPLOYER EASTHOUSE, VERN NG 16364 ROSELEAF CT LOS GATOS CA 85032 [JCC,CN~ (RE V.2-05) PRINTED 03-16-2006 G3%^ E.:`~'E~~6 16:36 N0.693 D~[~:' PO':.ICYHOLDER COPT' NG ~AT~ P.O. SL7X 4208G7, SAN >=RAIVGISCO,CA 94142-0807 ~~~I~/~~I COM P EN 8 FtTI ON iNSU1lANCE V ~ Q CERTIFICATE GF WORKERS' COMPENSATION INSURANCE ~1~K ~ '~ ~~06 I55UE DATEr 03-1B-2006 GROUP: 000571 PUBLjC VV(7F3 PC1u'CY DUMBER= 0001 057-20pfi KS CERTIFICAT6ID; 58 ~ATjOIV CERT'.FICATE EXPIRES: 10-0,-2006 ,o-ol-zaofiilo-oi-2008 THIS CERTTFICATE SUPERSEDES ANb CORRECTS GERTIFTGATE M 57 GATED 03-16-2006 CITY OF CAMPBELL ~ 70 N 157 ST CAI~BELL CA 95008-1458 This is !G Certfy that we have issued a valid Warke>rs' Compensation insurance policy in a form app^oved by the Ca;ifcrnia insurance Commissioner t0 the ampl~~ISr named below far the policy Reriod indicated, This pCtlcy is not subject tp canceliatinn 6y the fund except upan30 days advance vvrren notice to the emplgyer. we will also give you 30 days advance notice should this policy b¢ cancelled prior to its normal expiration, lhi, certificate of insurance is not an insurance policy and does not amend, extend Or alter the coverage afforded by the policy iistet? he*ein. Notwithstanding aryl requirement, term ar Cgr!ditiAn 4t any Contra0t ar oth8r d~cum9nt with rospeet to vuFrrch this certificate of Insurance may be issued Cr to which it may pertain, the insurance afforded by the policy described herein is Subject to aH the terms. exC~uSions, and conditions, of each policy. W i/ J'~•~ f'G1X~~4'`' 'HORIZED REPPtESENTAT'~ PRESiGENT t1NLE53 INpICAT'f0 OTHERWESE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY pECLARATIONS AS AN INDTYIDLlAL EMPLDYpi OR A HUSBAND ANO WIFE EMPLOYER; CALIF0~1 A~YfVORKERS~NCOMPENSATIONSSENEFITS E; IIPLOYEES EKCL DED LINDEROCALIFORNIA~MORKERIS~` COMPENSATION LAW. ~+EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 51,000.000 PER OCCURRENCE. ATTACHSEDETO ANp1FORN5 ALPARTDOFTTH~ISALPOMLICy~ONAMELOFEADOITIONALEINOSU~REp3-16 IS CITY OF CA~p6ELL -...~.e:TTAt~,EDE~ SAND FORMSIALpARTEOFITHISTPOrL~iCY~~/ NICE EFFECTIVE 03-f6-2006 IS ATTACH DETD AND7FORMSIALPARTAOFETHIS PDSULI~~TTHIRDFPARTYVNAME~-03-t8 IS CITY OF CAMPBELL EMPLOYEE EASTHOUSE, YERN HG 16364 ROSELEAF CT LOS 6ATOS CA 95032 [JCC.Ch1] PRINTED 03-,6-2046 N",EV.:-061 G;;i i 6:~ ~~p6 16:36 hJ~J . 6°3 D[]tl3 ~~~~~~ Mq R I ; 2006 r WAIVER CF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance an which the certificate holder required a waiver of subrogation: 1. Please be advised that a waiver of subrogation requires that a 3°lo surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3°~o surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work an jab/s far the certificate holder who has the waiver. The payroll retards are subject to verification by an auditor. Example: Payroll far job: Sample Rate Regular Premium equals: Surcharge: Additi©nal Waiver charge: Total premzum equ~.ls $ J r 0 Q ~ U V 13.30 $ 665.00 3.OQ~ $ 19.95 $ 6g~.95 f,665.OQ + 19.951 From Michele Costa AY Bozzuto & Associates FaxID~ 1-408-377-5741 To' City Of Camobell Fax Date' 3/172006 0426 PM Pace' 1 of 2 From: Michele Costa To: City Of Campbell Pages: 2 Fax: (408) 376-0958 Date: 3/17/2006 04:26:12 PM Phone: ( ) - Subject: R1 Cert, City of Campbell Message: Joanne, Here is the revised certificate. Thank you Michele cc. Vern Easthouse cc. City of Campbell Phone: (408) 377-8712 ext. 17 Fax: (408) 377-5741 -,- ~ "' ;~ ~ ~- - ` w ~ ~ __ - ~ -~ ~ ~ _ ,~= ~ -- ~ ~ ~ ~ .~ " ~' - ~ r, _ ' ' -- - ~ _ ~ ... ". _ ~ ' ~ ' } r b ,-~ ~„ ~ ~` t i ~ q ~i ~^ f .~. yn - ` +~ "~ ~ _ ~ i~ u~ ~* ~ Fr'" ' ,,.d ~ - _ t x `4.. ~ ~. °~ `~,.. ~"' q ~ w^ ,mss ~ ~ _ +.~P ~ _, . ~. ~ ~ ~ g { e ~3.~ i6.'~'~p6 16:36 r,r . 6U3 oc~~ ,I MAR Y ry 2006 ~11(A1V~R OF SUBRaGATIC~N N~TIC~ Enclosed is your copy of a certificate of insurance an which the certificate holder required a waiver of subrogation: 1. Please be advised that a waiver of subrogation requires that a 3°lo surcharge wi{l be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certifiroli on th t job, who requested the waiver. (Nate: if you have no employee pay then there is no charge,) 2. To apply the 3°~o surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work an jab/s far the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job: $5,000.00 Sample Rate: J_' 1j_30~ Regular Premium equals: $ p~3.00~ Surcharge: ___ Additional Waiver charge: $ 14.95 68.95 f,665.OQ + 19.951 ^'otal premium equals $