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ENC2006-00160CITY OF CAMPBELL DEPT. OF PUBLIC WORKS 70 North First St. Campbell, CA 95008 (408)866-2150 Fax (408)376-0958 R-1 N EE ENCROACHMENT PERMIT (Non-engineered work within the public right-of--way) ($10,000 maximum value of work) ISSUED ~U f ~ -1 O Permit Expiration Date I G ~ 7 O pit No ~~ ZoG~ -GG 16 O X-Ref. File Application Date 1 ~ 13 e6 Application Expiration Daate 4 IS~v~ APN 3~~' ~`7- c~53 APPLICATION -Application is hereby made for a Public Works Pemut in accordance with Campbell Municipal Code, Section 11.04. (Application expires in 6 monthsgif t/h~ e permit is not issu(e`d/~),~~ A. Work address I~~pO~. ,~ ~ `+r v~v ~ P~~u- ~ ~ B. Nature of bVork ~ ~v ~ ~ P1~Q~°~'cC ~') 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. 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 securities. NAME OF APPLICANT ADDRESS ~~ , C' E-MAIL ADDRESS TELEPHONE 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 acknowledges that they contractor(s) of the infoyrl~i lion. ACCEPTED read and understand both the front and back of this permit, and that they will inform their /'~ ~. l 3 ~- ~,~ (Sign) Date NOTES: All, k shall conform with the attached approved plans and all applicable Campbell Standard Details and Conditions and applicable i ranee 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: ] -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 any work, the property owner shall execute an Agreement for Private Improvements in the Public Right-of--Way, which shall be recorded. 3. SECURITY FOR FAITHFUL PERFORMANCE APPROVED FOR for City RECEIPT NO. (U/I 7/O~ Permit Expires 12 Months After Date of Issuance_ J:~formsUlpermit :~,,~ Revised 9.06 ~~V~~~l>;( ~~ ~, !; '\ STANDARD AMOUNT (100% OF EI~G. EST.) $__~~~ 0 ,~ N• ~_~ ` ~' W I ~ c V~ ~9 O ~ .~" ~C~ J BUG ='~ ~' • '~ ~~ ~~ ~ ~~d V~~ ~~ ~ O ~ ~~ ~., ~ v `s ?~- \ o \\`~ N ~ T ~`~ Q+~ ~3 SU ~ \ ~. V z J o~ `~ U Z J V ~ ti ~ ~ 3 :v ~ ~ ~ c~ w ra N_ 3( NI WEAKENED PLANE JOINT- OR CUT JOINT 1 /8" WIDE, 2" DEEP +10% MAX CONFORM` -WEAKENED PLANE JOINT OR CUT JOINT 1 /8' WIDE, 2" DEEP -6~ MAX .. .• .,..., ..,.••..: ~•.: •~: •: ••..:a;:~: •.•a::-:'••;.:a::-:'•~•a...-:• . 6" CLASS A CONCRETE, TYP. •' ~`'' ':~ t °' • • ~~• ' ` °: a::~ t ` ~°: ' ' 6.. 6" CLASS 2 AGGREGATE BASE, TYP. '~'•'''°''.~'"'~~~°'`~'"'~'~'`' SECTION A-A DOWEL NOTES 1. WHEN THE DRIVEWAY IS NOT POURED AT THE SAME TIME AS THE CURB AND GUTTER, 12" OF N0. 4 REBAR AT 4' INTERVALS SHALL BE INSTALLED AS SHOWN (REBARS TO BE BENT DOWN AND COVERED UNTIL USED). 2. SCORE MARKS SHALL NOT EXCEED 4'-0" O.C., AND USE MECHANICAL SEPARATOR AT EVERY OTHER SCORE MARK. 3. DRIVEWAY APPROACHES (EXCEPT SINGLE FAMILY) SHALL HAVE A 6"X6"X10/10 WELDED WIRE FABRIC 3" ABOVE BOTTOM OF CONCRETE. 4. DOWEL ALL NEW CONCRETE IMPROVEMENTS TO EXISTING CONCRETE IMPROVEMENTS. 5. AT LOCATIONS WHERE NEW SIDEWALK ENDS AND MEETS AN EXISTING SIDEWALK, THE NEW SIDEWALK SHALL TRANSITION TO MEET THE EXISTING SIDEWALK AS DETERMINED BY THE CITY ENGINEER. og cAyA CITY OF CAMPBELL REV. DATE BY SCALE: ,~-~ ~~, PUBLIC ~PORKS DEPARTMENT Residential N.T.S. •, ~ .. -. r .,4p9~`. ~ DRAI/N HY: DATE o2io4 Driveway Detail DETAIL "'°•~d'ei~' • CHECKED HY: DATE "s8 `ti~~ APPROVED HY: (Attached Sidewalk ) N0•~. °RcHA~o ~~ ~~~~R~ J:/Drawings/Std_Details/D15 ~ - 1 ~~,. INSURANCE REQUIREMENTS CHECKLIST Permit # '~~ 2 ~~ ~' o~ ~ ~~ 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.. i~ Policy expiration date ~.~''1/p ~ Automotive Liability: ^ "Any Auto" checked on certificate ~ ` ~~w~~ ~~~ $1,000,000 per accident for bodily injury and property damage /~ ~;~ Policy expiration date ~-~'7 Workers' Compensation and Employer's Liability ~'` c~`~,..` =7 ^ Waiver of Subrogation clause $1,000,000 per accident for b dily injury or disease ~ Policy expiration date ~~ J Course of Construction (if required in Special Provisions) ^ Completed value of the project ^ Policy expiration date _~ L ~~ ~ ql - -~ t ~ / ~ • ~ ~~ ~~ ~ Lt'1~ `~ ~ C " l 1. t' 6 I 1 e~% 1 _%/ v lr 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 + . Xv .~~~L. s~-I~ ^ For General Contractor ~~~~t ~ ~_ I ~~~~ ri t/1~~~ ~ ~ ~,~.,04'' ~30~ ~~L ~I I"S IIO~ ^ For Developer or Owner a22~~f3 ~v~-ru..2n ~~' ~ I~ A~'k Gk~ ..,~i C ~ . . Acce tability of Insurer(s) C~n~ ~t C. ~ Insurer(s) has current A.M. Best ~',~. ~~ ~ ~~~ business in the State of California. ~'3~ 1 ~In urance Certificate Reviewed 9J .0 ~ Rating of A:VII and is authorized to transact Initials Date _/ v ~u Copy of Insurance Certificate placed in tickler file for month of expiration. j:\forms\inscklst (rev 11/99) ~~ ~~. Fax TO: AMKlnsurance Agency 6855 Via Del Oro San Jose, CA 95119 Phone (408)224-9101 Fax Phone (408)224-9201 Date 10/2/06 Number of pages including cover sheet 9 FROM: Joanne D'Ambrosia City of Campbell 70 North First Street Campbell, CA 95008 Phone (408) 866-2701 Fax Plzone (408) 376-0958 CG REMARKS: ^ Urgent ^ For your review ® Re l ASAP p y ^ Please Comment Re: Insured: Valley Concrete dba: J C Concrete. Permit #: not yet assigned Work Site: 961 Campbell Avenue., Campbell, CA We have received the certificate of insurance 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. These endorsements/changes need to be added/done: Certificate we received appears to be a copy of one that was presented to the City of Santa Clara rather than the City of Campbell. We need to receive a certificate showing the certificate holder as the City of Campbell and also showing The City the City of Campbell Redevelopment A~encv their agents, officers attorneys employees officials and volunteers are as additional insured on a separate endorsement rather than just on the face of the certificate. The insurance coverage afforded to the Additional Insured is to be shown as rimar . The cancellation area of the certificate is to be 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 rights or representatives". 21~~The "any auto" box needs to be checked on the certificate under the auto liability section. 3. We also require that the Workers' Compensation and Employer's Liability include a waiver of subrogation clause. 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. Arr is and Supersedes Endorsement Num' THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED `This endorsement is EFFECTIVE August 3, 2006 *and is part of Policy Number: CT130339 `issued to: SBV Concrete dba Valley Concrete "Entry optional if shown in the Common Policy Declarations. If no entry is shown, the effective date of the endorsement is the same as the effective date of the policy. This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM With the respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. Name of Person(s) or Organization(s): City of Campbell, Department of Public Works 70 North 1st Street Campbell, California 95008 Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the Coverage Form. R~~~~ F'L/pLiC; '4'~MINISTRA17aty End. #16 T-418 (7/ 00) October 2, 2006 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Copyright, Insurance Services Office, Inc., 1998 Arr ids and Supersedes Certificate Dated 6~' ~'6 CERTIFICATE OF INSURANCE Northland INSURANCC This is to certify that we currently insure SBV Concrete dba Valley Concrete 1020 Ruff Drive, San Jose, California 95110 and that coverage is in force as indicated below. (ADDRESS) ^ AUTO LIABILITY -NON BUSINESS USE ONLY AUTO LIABILITY AUTO PHYSICAL DAMAGE ^ GENERAL LIABILITY (AUTOS DESCRIBED BELOW) (AUTOS DESCRIBED BELOW) POLICY NUMBER POLICY PERIOD POLICY NUMBER POLICY PERIOD CT130339 FROM: 4/4/2006 FROM: TO: 4/4/2007 TO: LIABILITY INSURANCE LIMITS OF LIABILITY PHYSICAL DAMAGE MAXIMUM INSURANCE LIABILITY DEDUCTIBLE BODILY INJURY $ ,000 Each Person COMPREHENSIVE $ $ $ ,000 Each Accident PROPERTY DAMAGE $ ,000 Each Accident SPECIFIED PERILS $ $ COMBINED SINGLE $ 1,000 ,000 Each Accident COLLISION $ $ x LIMIT MEDICAL PAYMENTS $ CARGO $ $ PERSONAL INJURY PROTECTION UNINSURED MOTORIST $ ,000 Each Person x INSURANCE $ 60 ,000 Each Accident GENERAL LIABILITY $ ,000 Per Occurrence $ ,000 General Aggregate DESCRIPTION OF AUTO(S): Item 1 -1999 Ford pickup truck, S#1 FDWF36F5XEC98558 Item 2 -1999 Sterling dump truck, S#2FZNNXYBXXAA03093 Item 3 - 2000 International crew truck, S#1 HTSCABM7YH241401 Item 4 - 2003 International flatbed truck, S#!HTMMAAL73H554004 Item 5 - 2001 Peterbilt tank truck, S#1XP5DB9X31D567091 (Effective 05/12/2006) Item 6 - 2000 Chevrolet van, S#1CGFG25R3Y1258480 (Effective 06/28/2006) Item 7 - 2006 Dragon end dump pull trailer, S#1UNSD28227C053210 (Effective 09101/2006) The City of Campbell, its officers, employees, and volunteers are named as additional insured. This certificate is issued as a matter of information only and does not amend, extend, or alter the coverage provided by the policy. Should any of the above described policies be cancelled before the expiration date, we wiit>ro~o mail 30 days advance written notice to you,xboxbdsdd~l>'eclald~ivcak~tlkia~rxx~ii+~tOta~o~c~x~~looy~dtlirt~txxx>t[xXx ~C Z~o(p ZSO~~° NAME AND ADDRESS OF CERTIFICATE HOLDER City of Campbell, Department of Public Works 70 North 1st Street Campbell, California 95008 DATE ISSUED October 2, 2006 ~~ Authorized Representative Glen A. Schuberg, Inc. TF-030 (2/94) 10f05l2006 01:32 4082876P95 VALLEY CONCRETE PAGE 01f05 OCT-02-006 MON 04:32 PM ha.;~ INSURANCE FAX N0, 408 ~~f 9201 P, 01/05 ~~k~CY~C~X~K~X~C~CM~~~~~%K~K~X~~X~XkC~c~~c~X~~~C~C~~:~~~~~K~~c#~K~K~:~c~C~C~~c~C~CMI~~c~~~~k~~c>x~k~~~~K~~:~K~c~RX~:~~c~C~~~K~~'~~c:K~~K~~~~~~~~K ~ P, O1 ~ ~ TRANSACTION REPORT ~ ~ OCT-~~2-e''.006 ITON 04 ~ 17 Ph1 ~ ~c ~c ~ FOR. AI's INSURANCE 408 224 8201 ~ ~ ~ ~ SEND ~ >K ~ ~ DATE START RECE I UER T'1{ TIME PAGES TYPE NOTE M~ DP ~ ~c - ~ ~c OCT-~02 04 c 15 PP1 3780958 1' S5a 5 I:AX T}{ 01{ 698 ~ ~ ~ ~ ~ ~ TOTAL ~ IM 55S PROFS; 5 ~ ~ ~ ~C~1k~C~~XIKX~MCIK~Y~~~>Ic~K~:K~C~X~k~lk~(~~~t~fJK~~~~7~~f 1k~~k~~~Xt~(~C~K:t~c:N~K~KY~K>I(~;~k~~K~K~(~f~f 1klk~klk~(~(~(~K~;~~~:~~~~~X;lK~(~(~9(~~(:KI~~~B~K~k~~~~ (~,l lildx IIS~[1RANC:~ 7~Or;West, i111C. J EDSS vIA AaL Otto ~Abl ~'CSF, CJI., 4 5119-13 1 9 LYC~Q$1~41~ t1/ (800)~3p•~SDS l4Dilaa~`a161 PAStcaoe~a~11.92fl1 l T4: T Ol r+l trf CR+~~P[SC~f~ FAX ~p•~rlLr~ d~5~ n~.TB: ~fZda e'7'OCo IF T135RS Is !RO!?~ES ATI TE~T9 8p~,g9IQLd, ar~nQa CALI, Akri T9~ i;R~E.R L1F PAt38s xo'G >~c~IVB t5 „~°~ .,,. ,t~rtc~i T1~CJ+®E3 RZIA T1dn8mM.TT'1`AL ' CE j („- vv ~~ n ~ °cr o ~ dt.~,, .~,~~~~ ~._._, l~s , _ 200s P C _- ~M N/S w~gKs ACGR', aF flR POLrCY 9i ..,~~~..-- M.~.r. T~TI ON M9SG11CCE To RECIPS~11'PC _, - ra ~bA1L.~7'{ ~clr 01uAi ,b6l,$t,.l~ ~~TifLle~"*~~~'~ . _l_~rr.i_ pta c~.da~•,- up~~r,.! z~r~s.~DY o.~ iae~YD L.rA+BIr17'Y P-1_~- ~' ~°J xa ~.+.au~ r,~ r~f,~'~'~~. TSB .i~iA~ rp,~ ~r~ek: guar-cam o~ a-+`~- li~:~~ . --~--- ~4er `f ~U ~reGti.e * ~rr.~S,~ !~~ ~c.e.Dy" rJaFS"r~~7~ ,~dx - io>s 10/05/2006 01:32 40$2876095 VALLEY CONCRETE PAGE 02!05 OCT,02-2006 MQN 04 ; 32 PM At I~ INSURANCE FAX NQ. 408 «~ 9201 P, 02/05 ' rr'r'.' ,~,.. .,>rr, I :'i~uu . 4;r}; .iRi ~' ~ 'b~:R~ . ,DATE ilYN10GYYY) a'~ ~{ ~ r~,r { AC~R-~ IS,, 'r ~~ ~, ~ ~;,~I ~~}' ~p 10 t}2 j06 !~, .3 • i9i5S~ 'm ' ' }.. Y.4 • x'~w~eaarwf:ra~R~irna.:~«.x.:oNi~: ', ,''s.. •. ..~ M's~i ~ ~~3&fl~ .. ~. §~J~I ~ r'11' ~ , ... ~ ~. ~ .;. PROOaosa ~ 7H18 t;F,RT1FtGATi;•1tB D AS A MATTl=.F1 OF ItVFORMATIQN P.MIt INSURANCE AGENC'Y' ONLY ANO CONFERS NQ RtGM'I~ UPON TN~~ Ct'.RTIFlCATE tiaLDEFI. THIS C~InFICATE DOi;9 NOT At4E~ND DCTEND OR 1,~~~N9E $~Q$17017. ALYr=R TIiF COVEFiAG~ AFFORDED l3Y YN~ PO~.ICIFSS~LOW 6855 VIA ~7ET. ORO ,.. coMrANIES AFFQRpING oovelwC~ ..,....,..,..___ EAN JOSH CA 95119 coumAN~ A EVTrREST INDEMNITY INgtJRRlp -- - --~ - ~, ~~ COMPANY SBV coNC]~ETF INC ~ AMERI4AN EQUITY' DBA~ ~ VA1fI~EY CONC1~'TE cCUIPArn 7.aZ0 1tUFF DRIVE o .,.., SAN JQSE' CA 9513.0 COMPANY D r~t; :.. i '. ::,f, ~ ~ f ; +i ,~f,: £;. .,K, : , Sriv:' f;§: i r""' i ~)~ ` i E~ ~; ~ ..o rrr ~,.p ' :.r . D~ t7; ;,•::< . ~ Mo; ~ ~, ~' .: ~j;#" ~ f. ~kG;$~~ ~if~~PAS':J ' ~ » ' ~~~. ~' i:K ~ .1t;;~~.•~~E ~~~5`ii~~'~N"'vY6~ ' ~n~~ ~ rS'~5: a7. ~~0~ ~ f ; ~ ~O~t4~Fh i 1.'•'n I 7HlS (g TO CERTIFY TRAY THE PbL.ICIF.S pF INSL.IFIANCE L{STED RELdW HAVE SEEN 168LIEP TO TY.E INSURED NAMED A90~ FQR THE PQLI~`/ PERIOD • INDICATED, NOTWITHSTANDING ANY REQUIREM~IT, TeRM dR CONDITION QF ANY CQNTRACT OR OThIF~1 DOCUMENT YJITH RESPECT TQ WHICH rNlS CERTIFICATE MAY Bt ISSUED OR MAY PERTAIN, Tli[ IN6IJAANCE AFFORPF-P GY TFIC ~DLtCIL"'u• ~SCRiEI'R HEREIN IS SU&fECT Tp ALL TrIS TEAMS, CXCLU~NS ANp CONDITlPNS fJF SUCM POLIC{t:S• IJMiTS SHOWN MAY HAVE 9CF.N RI=RUGEp 9Y PAID CLAIMS, ~ TYPE GF INgLIRANCE POLICY NUMhRR POLIGI' FFF~Cr1v~ POLICY EXPIRRT}ON LJgITS QTR DATE {MwonnY) DATE (MMIPI1iYwt c~anAL c.IA91uTY 4 0 0 0 4 0 512 7. a G l 0 6 19 0 6 0 5 2 9 tJ 7 GBnl~u AGGREGA7L X 2, 0 0 Q~ a a a ~{ COMMCRCIAL GENERAL WABILITY PAGoE1CT9 • CbMP/~ AGG 1 ~+ r 0 0 0 , 0 O 0 CLAIIAS MADE ~ oaelm PERSOPIAL a nov Inuuav sl G,0 a a a D 0 awNSR•5 ~ ooNTiaAACroR~s PROr eACH occur;RENCE s1^~ 0 0 0 , 0 0 0 FlRF RAMA6G (AnY ane flte) S ~ a (~ 4 0 MED EXP (Aro One pe.aor}) r4. .r7 r 0 0 0 AU7QM09II.RLW3ILITY CT1303a9 a4 a4 a6 Q4/04 Q7 ~., 000, 000 COMBINED SINGLE LIMIT S ANY ALiTa ALL owNee AU7Q9 BODILY lN.ftIRY X &GFIEGCILIDAUTOS (POrparca}I S ~~ HIREp ?,U70R EC E 1 E ~ f~I~~;RY $ N~1-0WNED AUT03 PROPERTY DAMAGE S GARatllLIABILITY ~TO~• ADgDENT S PUBLIC W qKS °~R HA•A}lroONLY; ~' iSn•.S•:`•+.: •~•' ANY AUTO ;;`(:; MINIB TION EAC" T le^ ADOREfL1TP S EXC695 L}Aa1UTY EACH RraNCE S UMARELLAfORM A4aREBATE i 4n-I~a nihN LMA~fELLA FGRM S WOgKRRS CCMPNMSATIDN ANO FORY LIhT~AIT3 .i~; Sj;s;," •:~":'~ - R'M?>.OYEg9r LIA8IIJTV r-Le,+cF+AfSaroeNr x 7116 rRDPRIE70W iNCL ~ l EAiiFPOLIGY LINlT PAPTNO35~EXECLiTIVE •"'•'" OFFICfiRB ME: ;%CL pL df9EA5E•EA EMPLOYE s OTHEA DES#IIP'TfQN PFOPERA~IONSILOCA714N4NEFh6L~`916PEGALREMS (N9UR6Q AK.4s A~J.B UNAFRGROC7N10 CONSTRUCTION INC. RR WaRK SITR: 9bi CA1HA13P,LL AvF,NUt:, CAMPi31?IrL, CA. Af..L WQ.RK M PUDLIC RfGhiT QF W/LX. THfi CITY OF CAMF$;q[.L, THE CITY OF GAMPSELL REDEv~iLOPf=,!}!I.Si~T AGLNG'Y, ITS OPFiCBRS, BMPI.OYT'ES ~ VOi.LINTPF?A,8 A~.B NA1vIS17 ADIyTTIONAL 1N$URED PSR ATFACHF.D l~vnORSI?IUENT. Po[.iCt>;S ARE PRIMARY aVfR ANY QTIiFR COLLE'CTIBLIi lNSURANC.]i, ray foHb11L4 ANY DF THE A60YE CFSCRIP~Q POLICIES BE CANCELLED ~fCflll THE y+7~' C7CTY OF C~+MI?~ELL EKPIRATKKM1 PATE T1fERE0Yi THE {SSUING C4AAPANY WILL aMMMfBW.~T~'1~EAIL DEPAR'r'M~NT 0l' PUBI.iT C ~~~~ 3 ~ DAYS WRI'R7f~N NOTICE TO THE CEFfCM'ICATL HOLDSq NAhlm TO THE LEFT, 70 NfJRTH FIRST STREET CAMPBELL CP,: 95008 AUTttoRtao• ATIVE :~'~~ .i^#' .....L~T!4Af I~ r'F•17; ~.fIYE!c::A~~!•R.:;:~!S!~,M,'F• .$; ~~: ' •~'~. .. ~4i4'I~~ "d':.... 10105/2006 01:32 4082876095 VALLEY CONCRETE PAGE 03105 OCT-02-2006 MOH 04:33 Phi h,,,. INSORANCE P~~ ~0. 408 ~~~ 9201 P, 03/Q5 POLICY NUMI~>=fit: q~0000Q51210-61 CvMMEiRCtRL GCN~RAL LIABIUTY c~~alalr~a~ THIS ENDDRS~MENT CHANCES THE l~QL,i~Y, P~f=ASE REAP IT C,AR~Ft~~LI~• ADDITl4N,~1,L, INSURED -~ O'VItNERS, ~,ESSEES OR C~NTRAUT't]RS -- SCHEDULED PER.S~N OR ORGAN 1~1"CI~N ~ ~ .~ . Phis endorsement madifros insurance provided under the following: nu. woax rN P[.fBLEC Eucti'r oE; w,~v. rHL crrY of CAMPHbLL, THE C]TY E)F G,,AerBEr.L REDEVELOPP]vtENi' AGENCY, Tr9 COMMERCIAk, GEIVS=RAL LIABILITY C01fERAGE PART °~'cfl~' ~~~~ ~`~~~~~NM~1~ ADDrE'fONAI. ENSIJLZE'sD ESF.tt ATTACHED h"NDOEk,SP.I~lENT. 1s0E,dCFfiSAREPRIMARYO~P.RANVOTHEs~tCOLLfiCTI$L~ SCH~D1Jt.tw [NSt1EtANCfi. Namc of Person ar Organlzdtion: CETY OF CAMPBELL , DEPARTMENT OF PUBLIC wflRKS 70 NORTH E~ STRETT Any parson or organjzat3Crt that is: Cr,M7'BELL CA 95008 1. An owner of real ar personal property an which you are performing Cperatians, or A contractor on whose behalf you are performing operations, but only at the Specific written request by that person nr orgpnization~to you, and only ik: 1. That request is made prior to ttte date your operations for that pecswt er organization commenced; and 2. A certificate of Insurance evidencing that request is on file wig, or received by, us prior to sixty days after the end of the policy period for this insurance, (If na entry appears above, irtfarmation requirod to complete ~tls endorsement will be shown in the DeClaratlonS as 2ppll~aUle to ti-Eis endorsement,) A Section II r Who Is An Insunod is s~mend®d to (1) Alt work, including rrEaterlals, parts or lncludt as arE insured tho person Or «rganizatian equipment furnished In connection with shown in the Schedule, buk only with respect to ~ such work, >yn the project (other ~,en Ijability arisjng out pf your otlgQlftg operations por- service, maintenance or repairs) to b® formed for that insured- performed t:y or on behalf of the sddi- s. With respect to tt+e insurance afforded to those tiCnal insrarert(s) 8t the Stte of the coV- ared operatf4nS has been completed: additional Insufeds, the following exclusion is or added: ~ (2) That portlrm Qf'yraur work° Cut of which 2. ~xclw-isions the' injury or damage arises has been This insurance does not gpply to "bodily jrn put to its intended use by any person or jury" or "property damage" occurring after: ~ organization other than another con- tractor 4r subcontractor ®nQeped in performing operations far a principal as, a part of the same project. CG 201E)10 Qi ~ ISO Properties, 1rtc:, 2(100 Pdga 1 of 14 f 10/05/2006 01:32 4082876PQ5 OCT-02-20D8 MON D4:33 PM A~~~ INSURANCE VALLEY CONCRETE FAX N0, ~Da t~~ 920i PAGE 04105 P, D4/05 coMla>=RCIAI. o~w~I~nL Lu~BI~,IT~r c~ ~m o4 ho sia THIS ENDORSEMENT CHA[~IGES THE POLICY. PLEASE I~AD IT Cp17EPULLY. wAlv~l~ of T~NS~~~ of R~Gr~TS o~ R~cav~l~~r AGAINST aTHERS TO US This endarsetnerrt modifies insurance provided under the following: G©MMERCIAL GENERAL. LIABILITY COVERAGE PART SCHEDULE Name of Perebn ar Organia~atien: Any person or organization that is: 1. An owner Ofi real pr personal properly on which you are perForrning operations, Out only at the specific turitten request by that person ar organization to you, and only fi a. 7tiat request is made prior to the date your operations 'Far that psrs4n or organization commenced; and b. A Certificate of Insurance ®videncing that request has been issued by your authorized insurance agent ar broker: or 2. A contractor an whose behalf you are performing operations, but only at the specific wmten request by thlR person or organzation to you. and only if: a. That request is made prior to the d~rte your operations far that person or organiza~en commenced; and b. A Certificate aF insurance evidencinl~ that request has been issued by your authorized insurance agert# or broker, (1f no entry appears above. information required to complete #his endorsement will be Shown in the Declarations as applicable to this endorsement) The TRANSFER OF RIGHY'S OF RECOVERYACAkNSTOTHERS TU US C.andition (Section IV- G(~MMERcIAt. GENERAL LIABILITY CQN1~ITlGNS) is amended by the addition ofi th@ following: . Wt waNe any right qfi recovery we may have against the person or organization shouun to the Schedule above because of payments we make inr inNN or damage arising out of your ongoing operations or 'yrour work" don® under a eontractwith that person or organization and included in the'products~comAleted operatibns hazard". This Waiver applies only to the person or organization sfiown in the schedule above. CG 24 Q410 93 Copyright. Insuraance SeMces Office, Inc., 1992 Page 1 of 1 10105/2006 01:32 40828761x95 UALLEV CONCRETE DCT-02,2006 MO~f 0433 PM n.~n INSURANCE FAK N0. 408 ~~4 9201 10~n2~2oo8 iS:Sa F~ 805 d~ld 6~5~ Glen ~ schubers Inc -- AIItI{-SJ Amends ditd supersedes Erldorst:rrrent Number ~ ~CMiS ENI~RS>=~IENT CH~AA{GES THIr POLICY, PLEAa~ READ lT CAREFULLY. ADDITIaNAL INSURED "This endarsemerd' i& f+FF>e;CTIYP Au9uSt 3, ZQ06 "and is part of Palley Number' 'issuaC to: S6V Concrete dha Valley GenerCte PAGE 05105 P, 05/05 ~ aoz CT730339 "Entry optiaroal if shoum in the Common Policy Deaiaratians, If no antrY fe ~ttt]Wt1, the effective 4ate of the endorsmmelrtds tnn same 8s the effectve draca ar: the pa6oy. This antiors.ment modifies insurance provided t,nder the fallowing: BUgIN1=SSAUYb CCVEFZAGE FORM QAiZAGE GQVERA4E FORM with the respeet to epvarag9 provided by this entlorSampnt< the provialons of tha Caverags Form apply unless madifiad by this endOr~rntXtt. ThVs erldotsantent Identlfle5 person(s) of organiztnian(a) who are "insurt~u under the Who Is An insured Provision at'the Coverope Fenn. Thin endorsement axes nol altar coverage provided In the Coverage Form, Name ai Person(s) ar Orpanizstan(s). fifty of Campbell, Department of Public Warlcs TO North let Steeet campaell, caAfomla 95006 fEaGh person or orp8nixetion shown in the 8rhed.,lb is an "ineuredy far t.iebliry Caveraga, but only to the extent Chat peralbn 4r orZenizetinn goal"Ifies as an'Insured" render the Who Is An Insured Provision cor>tained in Sactlpn ll of the Covanlge Porn. end. t'!'15 OctoC>er 2, zag6 7.x11! tr(Ot7} ~~ ~~~ "~~ °r Induranre Sorriays ptpra, Ira, wrgs Ito psrmiiclon. copuriQny uvuranrrSel+dnas t~Aem, Ina., leas POLICYHOLDER COPY NG STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142,-0807 COMPENSATION ICN SLJRANCE FUN ^ CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 07-20-2006 GROUP: 000713 POLICY NUMBER: 0016450-2005 CERTIFICATE ID: 11 CERTIFICATE EXPIRES: 07-01-2007 07-15-2006/07-01-2007 CITY OF SANTA CLARA NG BUILDING & PUBLIC WORKS DEPT PO BOX 12010 HEMET CA 92546-8010 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. VVe 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 #f2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-20-2006 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER ~~~~~ ._ ~ (~ ~ co0 SBV CONCRETE, ING DBA; VALLEY CONCRETE NG 1020 RUFF DR SAN JOSE CA 95110 [RRC,CNj PRINTED 07-20-2006 IRe V.2-05) Sta?e Ot Cali~ornia ,::~_,,, CONTRACTORS STATE LICENSE BOARD aim} <_; 6w~"'„ ACTIVE LICENSE '~m~, Cuuaumcr ;1fluin ~-~ ;r ~.,~,:r~~,~.~~, 830778 E,,.,., iN~iv d,,,,,_ „~;,,. VALLEY CONCRETE -~• ~~.~~ C-8 C61/D06 I' ~ ~'