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ENC2006-00182
CITY OF CAMPBELL DEPT. OF PUBLIC WORKS 70 North First St. Campbell, CA 95008 (408) 866-2150 Fax (408) 376-0958 ENCROACHMENT PERMIT working within the public ng,tt-of-way) Issued ~ U Permit Expiration Date ~^~ APPLICATION -Application is hereby made for a Public Wotks Permit in accordance with Campbell Municipal Code, Section 11.04. months if the permit is not issued. ApplicationJFee is non-refundable.) A. Work address or tract# /~ / ~ ~~ ~,~~ ~~'C ,~ Utility trench B. Nature of work ~i' (Application expires in six (6) Perini+*,lo~fC~ ~~~' ~~~(~`~"- X-F `ile Application Date /Z~,/Gt .6 Applicat-i~o7n Expiration Date APN .C:.~ ~ -J ~ C~° ~~ C C. Attach four (4) copies of an engineered plan show 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 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 1 and 2.) E. The Contractor must have this 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 hou/~rs bef~ore~restarting any work. ! e Name of Applicant ~/ " "" C1,,5 ~ ~y ~ ~~ ~ Telephone (print name) Address~~~~ ~~~~ ~~~ V ~~ 24-HOAR EMERGENCY TELEPHONE NO. "~~ 9zj-$I R' ~ E-Mail Address 15 this work being done by the property owners at their own residence? _~Yes No The ApplicandPermittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, iLS officers, agents and employees free, safe and harmless from any claim or demand for damages resulting from the work covered by this permit. The ApplicandPetmittee 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 p~qub~lic rig~h't-of-way. ,~[ Accepted ~j~,41(/C! S L` tJ E7 (J ~ ~' r~~ / ~ /~L~/® (Applicant Permittee) (sign) -~Da~te Contractor (Print Name) Date _1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be specifically annroved by the Insaector prior to cuttine. _2. Pavement may be cut for underground installations and must be restored in accordance with the 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 ]-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. _G. Public Notification Requirements: 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES PERMIT APPLICATION FEE PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS CONSTRUCTION CASH DEPOSIT PLAN CHECK & INSPECTION FEE ~ APPROVED FOR ISSU AMOUNT~~11 RECEIPT N0. $~UU ~ sao~~~o ~~0 ~~~~ /U~ For City Engineer Date Permit Exnires 12 Months After Date of Issuance 1~ M` 9 ~ ~` 'I ~.%r -: ,G~Rt~D Bl': a"T~ (Attached aiaewalK ) 1~"• s~ ° ~ J:/Drawings!~--h~tai? ': SS's ~ i , . ..~ ~ ~• --.. C-~ ~ ,~ ~ _ _ ~... ~ __ ~.~ ~ ~ - - - 5 ...- r .. r 3 _. ., .~ ~ . i~---~- ' i •_ s ~ . ~, 777 2~ ~ , . .VY ~~. i '~4 ~ 1 ..~.... ~~ 7 ~ ~ ' ..S \ 1 ~~ `~ ~ ' i~~ C~ ~ ~' ~~ ~ '~ 4 v.. y f~~ ~ ~ ~y~f~~~ ~~ r~ ~_,~ rr ~~1 `1 ~ 5~ J ~t~ ~l ~ W.7 U ~~ ~ ~ ~ C ~` s j ~ ~ ~ i~ ~ ~ ~, ~~ ~ -~ ~ o~ ~ t '~ ~y, ," ~ t z ~ i 3 [7 ~"' } ., i ~; : . _:,,~ ~' ~, t\, ~ ~ ~ ~~ ~ .., .. 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W N b O 7 O Ref undnble Deposit Check Request To: Finance Director Check Payable To: Fransicso Guzman Address -Line 1: 1073 Ridgeley Drive Line 2: City: Campbell State: CA Zip: 95008 ~ Description: Refund Deposit Account Number: 101.2203 Amount: $2,000.00 Account Number: Amount: Account Number: 101.540.7448 Amount: (Finance Dept only) Interest Earned (Finance Dept only) Total Payable: $2,000.00 (Exact Amount) Purpose: Refund Construction Cash Deposit ($500.00) and Faithful Performance Security Deposit ($1,500.00) on 1073 Ridgeley Ave. Voucher #: Permit #: ENC2006-00182 192598 12/15/06 Receipt #: 192599 Date: 12/15/06 Requested by: -- ` ~ Title: PW Inspector Date: 7130/2007 ahi ' Approved by: ~ Title: City Engineer Date: 7/3012007 Michelle Quinney Finance Dept Only: Verified by: Title: Accounting Clerk II Date: Approved by: Title: Accountant Date: Special Instructions For Handling Check Mall As IS: Mail in Attached Envelope: Interim Check: Needed By: Return To: Joanne D'Ambrosia Public Works/City Hall (Name) (Department) Other: f/n: Forms/excel/chkreq - Revised O5/00 sENERAL PERMIT CONDITIONS 1. A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency call-out, overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. 3. Refund of the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. 5. Maintain safe pedestrian and vehiculaz crossings and free access to private driveways, bus stops, fire hydrants and water valves. 6. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures, detours and street closures. This plan must be reviewed and approved prior to any lane closures. 7. The Constmction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Conshuction and Maintenance Work Zones, dated 1990, available at Caltrans. Traffic control equipment shall include Type II flashing arrow signs if required. 8. Replace as directed by the City Engineer any damaged or removed improvements in accordance with City Standards and Specifications at the sole expense of the Permittee. 9. Sawcut for all PCC or AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements. 10. Prior approval of inspector is required for any work done after normal working hours, on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 11. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost (including all labor and materials) against the cash deposit. 12. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 13. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall pmvide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m. 14. No storage of materials or equipment will be allowed near the edge of pavement, the traveled way, or within the shoulderline which would create a hazardous condition to the public. I5. 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 he required, nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 1 G. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 17. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 18. Call back (call out) due to emergencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence. 19. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoft Pollution Prevention Program. 20. 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 departure and to specify the manner in which the same is to be made for City-owned or maintained facilities. 21. Permittee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by City prior to distribution and include dates of work and a contact name and phone number. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above conditions. G- Date L ate • ' - - Applicant ' ~" "~ ~ ~ Contractor ~ (Print Name) ~, , t ~• t~ J\forms\pwperm Rev. 11/9/05 ~ ~~ }(~y )'~1~1 4~ 1 q~t ~ h"1 'For Pkn Check and Cash Depositc, send yellow co r e ) -~ Dete/ InNials j:\(orms4eceipt brm 06-O7.xls 1 i. i f 7' ]r .' i i.iY1'tj-'~~iE1 t - ? ~H ~HTf~R: F~~ANCI~i.J tip{G'~tfit•: ~ TGI+q f ' i~ti±{Fj';~~~i`% ~ Its j E: ; ~; i _ ~ r R~~, rEF I ~hTE; -~ I{,`I;~r[„ TIME ~; ifE';~LF,'2'F' T I~tty : c{JG~ ,~ ,9tiltr~lrl F ~ ~ Ar~GttNT IL Its„ F ENGF,' ~~ ~Uhi+It' FILING F GTL+T; ~ ~ ~_'~:.u r r Ir% NI1J FFE F}~ - ~a ~`~ C J . j} } _ '- .1l LiA i./ . ~1+ ------ TUTr~L Ir1IE: ------ - - 11 ~~'' { ti'~t;Er,E,i; . ~.uti ~ ~; Rc~4'Ii Vi`i': ,ii;PdH ~#'i1U~+: i RA4dCI'~iu t9~tL~'I:i[a Gt6I'LiE;; If~iE: i~;'1;~;'C~b ?}~~: 1a:::ti:~b ~. s Tt~=[,'''75'TIJt~ ~~f~~"{fit 1LJ )+1 iuT~it tS!`E• ~louflG.~ti ~+i.~ft1.JU i E's~I}E6:EI~: ~ ii; l 1,~{Hi~tx~ : 'I /ri. 4 WI i r u G~;~ ui~cL' -. i, ~. v1l•L1t+t ~~~ 9', t'~1GtR: Ft~;~,~~CI5CT1 Gili~i~f~ ?[II~F~f'a IiHTE: i~,''1~Jilc+ ii:JJ.1J ift"~C~'iE'7'ICi~t hME?!#t~T FEr IfEFL38ITS _2U1.:'n; ~5~JU.~f,~ cv~ i ~~ t:Nkt~GE: 3.GG lJ °i1 C-t,rZ (`~ z:~ ~~.. r INSURANCE REQUIREMENTS CHECKLIST Permit # ~ fi ~ ~~ ~ CIP Project # ~'D 7~ The following insurance is re uired 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 O $1,000,000 general aggregate limit applying separately to the project, and $2,000,000 general aggregate limit. ~ ~ ~ ~v ^ Policy expiration date i ~ -a 9_ ~, ~ Automotive Liability - "any auto" $1,000,000 per accident for bodily injury and property damage L~ Policy expiration date ~~ ~ /y - d .7 ~~~~~,~~~ Worker's Compensation and Employer's Liability T` /`'1 ~~`~ - ~~ ~~~ $1,000, 000 per accident for bodily injury or disease Policy expiration date f ~ - / v Course of Co coon (if requi ~ Special Pr ' ' ns) ^ ompleted v of the pro' ^ Policy' cation date Required Endorsement to General Liabilit<~ and Automobile Liability Policies Additional Insured Endorsement The City, the Cit of Campbell Redevelopment Agency, its officers, yee and volunteers are named as additional insured. ~u~ ~ '~ The insurance coverage afforded to the Additional Insured is primary insurance. [~ t Workers' Compensation Insurance Sheet Submitted ~~~(~'°"~ ^ For General Contractor ~• ~; Subrogation Clause ~-~J /j2 '~~~- D Insurance Certificate Reviewed / ~ Co Initials Date ~j Cop of Insurance Certificate placed in tickler file one month prior to expiration. ':\for inscklst 4/96 rev 6/96 ^"' J ~ ) ~ ( ~ ~~ ~/ ` oF~c~~ v ~~ ~~ ARCH A2~ CITY of CAMPBELL Public Works Department FAX TRANSMITTAL December 18, 2006 TO: Brajenovich Insurance Agency 280-1199 From The Desk Of.• Marlene Pomeroy Executive Assistant (408) 866-2776 fax (408) 376-0958 Acknowledging receipt of your fax re insurance for Fantasy Concrete. Joanne is on vacation this week, so I will be reviewing the certificate. There are a couple of changes that need to be made in order to satisfy our requirements so that Mr. Guzman can get his encroachment permit: ~'~1. The Worker's Compensation Insurance (through State Compensation Insurance Fund) needs a Waiver of Subrogation. ~2. The language under the Description of Operations should read, "All work in the public right-of--way at 1073 Ridgeley Drive, Campbell. 3. The Cancellation paragraph should read: "Should any of the above described policies be cancelled before the expiration date thereof, the issuing company will mail 30 days written notice to the certificate holder named to the left." All the language following should be eliminated (strikeover). We require 10 day notice for non-payment of premium. Please let me know if you have any questions. 7U North first Street Campbell, California 95008-1 436 T~II 408-866.2150 I,aX 408.376.0958 "I~UI) 408.866.2790 JAN-02-2007 16:08 From:BRAJENO''T`"H INS ACaCY 4082801199 12!1812006 ld:5F, 498376r;yS8 PUBLIC WLIRKS Q~~~~ •~~ ~i V. . ~. ,~ w ~~ ~~~ 4 dR ~,lrw0 ~S ,I aF C,A..MFBE~.L Pu~t[i~: Works f)epartmenc FAX December 18, ~OOd TO: Bxajenovich Insurance 28a-1.199 Acknowledging rCC~ipt of your v~catio~t this week, sa l will be ~ that need to be madt itl order u / hiR encroachment permit: "~ i . The 'Worlcear's Comperes pure!) needs s Waiver pf Subrog To: X3760958 P.1~5 PAGE 01/02 RECEiVE~ J/"tltl ® .G ~OO~ pUBUC WORKS q,pMIN18TRATION SMI (~8) fan re insurance for Fantasy eviewixtg the aertii~icatc. They sat~fy our requirements so Insurance (through $tah~ ~. The language under ibe Description oi' ~porataons ':;~ the public right-of-way at 1Q73~ 'dgeley Drive, Cannpbell. ,~ 3. The Cancellativa parag. ~~' policies he cancelled before tla~ 30 days written notice to the following should be eliminated of premium. Plc~se let rue know i£ you have ; 7U N„r~h I`vrst !+l•rcct tfRmr(~c11, t::nlllur,+~~ I3FC-18-2006 03:53PM From: 4083760958 ph should read: "Should atf~ expiratid~a daft thereof, the iuq xtiflcate holder named to the atrike<t~ei'). We require 1Q da questions. Ai, Fran: rhe!)erk O,f; Marlrnv Pomcmy Executive Assist<wt ifax(408)376-Q958 ;oncrete. Jofuuu is on are a coa~le of changes it Mr. ~itiTJ,178n can get Fnsuran.Ce read,, "All work in of the above described uing cbtripany will mail lCft," f#ll the language notice for non paynaettt rear, 1i:T, MiR-464,215r1 r~x 4CI~1.37fi.07yH 1'i,[i ena,yrr:,~79Q I~:BRAJENOVICHIINS AGCY Paee:001 R=95i JAN-02-2007 16:08 From:BRAJEN01"''H INS AGCY 4082801199 To: X3760958 P.2~5 PDIi Number: cs515661 Date Entered: 3/29/2005 ACORDTM CERTIFICATE OF LI BILITY INSURAN E ~ATEINIWDOnYYYI 12/15/2006 PRODUCER Srajenovich insurance Agency TN13 CERTIFICATE IS I SUED A$ A MATTER OF INFORMATION 1190 I,ir,caln Avenue, Ste 7 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE San do>ae, CA 95125 HOLDER. TH15 CERTIFI ATE DOES NOT AMEND, EXTEND OR ASTER THE COVERAGE AFFORDED 6Y THE PouclES BEI_ow- (aos)280-115a IN$URER$ AFFORDING C VERAGE NAIC # .. INSURED Fantasy Concrete, 7:nc. INSURCRA.NZC ZS'1013>:IAI'IOi C an .. ----- ~rancitsco Guzman JOge Ruvalcaba INSURERB~3tatQ Co_ ¢et'pn '[naurz+nce_Fund ___ 117 Seznal Road #70-280 INSURER C Financial Ind '_~ Company _ _ San Jose, CA 95119 INSURERD INSUHtH t' CffVERAf:FS THE PULIC;IES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO HE INSURE4 NAMED AOOVC fOR TFIE P LICY PERIOD INDICATED NO~f WI'I H$7 ANpIN(a ANY REQUIREMENT. TERM OR CONUI'I'ION ()F ANY CONTRACT OR OT ER DOCUMENT WITH RESPECT TO WI IIC I THIS CERTIFICATE MAY 8t ISSUtu UH MAY PERTAIN, THE INSURANCL Ar~ORDCD BY THE POLICIES DESCRI 17 HEREIN IS SUBJECT TO ALL THE TER &, EXGLt1SIQN$ ANA CONDITIONS Of SUCH POLICIES. AGUHtCiATE LIMITS SHOWN MAY HAVE BEEN REDl1CED 9Y PAIp CLAIMS INSR AOD'L .. .-- .._ . •4. POLICY NUMBER POLICY riPPHCTN2 POLICY E][PIRAT UNYT$ G ENERAL uABIUTY CACH OC:C:URRfNCF= $ 1 r OOO + OOO _ A X _ ~ GUMMtHGIALUENERALLIA8ILITY SF06CGL006179-00 11/29/2006 11/29/200 uAMAf3t TO RENTED PREMl,CS CBxhxenrn)_„ _ $60,000 CLAIMS MADE f ~I OCCUR MEO EXP (Ally One pni°ui) $ 5 , OOQ _ _ PERSONALBMV INJIfRV E 1 r GOO , OOO _ _ C,ENERnI Aff;ltl-i;alr S 2, 000, 000 GkML AUUHhUAIE LIMIT APPLIES PER PkppU01 S - CUMPfUP AGG $ 1 , OOO , OOO POLICY PRO• LOC C-T..... AUT ONX)BILE LIABILITY COMOINCD SINGLE LIMri OOO OOO 8 1 C _ nuvnllrn FCFICV12912'~1 10/10/2008 10/10/200 (Ensecitlonl} , , AI I nwNtu Au't'os BODM.Y INJURY 8 SCHtUULEO AUTOS INOf P°~^) HIRED AUTOS RUDILY INJURY $ NUN•~OVJNED AUTOS IPer BCCit1°nU ., .._ PROPERTY DAMAGE ~ (Pnr Rrr.Irf~M) GARAG! LIABWTY AUTO ONLY • CA ACCIDENT $ ANY AUTO OTI ICR TI IAN EA ACC S ... .- ._-..----~-~-- AUTn DNI Y AGG 3, EXCESSfUMBRELLA LIABILITY EACH OCCURRENCE $ __.._.. . 1 UCGUH ~ CLAIMS MAUI ACGRCGATC .. $ $ -- DEDUCTIBLE $ RETENTION $ S WC STATU- OTH- WORKERS COMP[NSAYION ANO TORYlMl7: $ EMPLOYERS LIABILITY /2006 12/7 12/1/2007 F I. F.AC,H ACCIDENT $ 1, OOO, OOO - ANY PROPRIETORlPARTNERIEXECUTIVE fN'FIr.;FRlMEAIIgER EXCLUDED9 1813085-04 . ELDL°,EA.`,E-CACMPLUYCC $1,000,OOD Ity9e,deecrlDaundar 000 400 1 SPECIAL PROVISIONS tuNba E.L. D{SCASC • POLICY LIMIT , $ ~ OTHER DEbGRIPT1Ory QF OPERATIONS I LOCATIONS f VEHK:LES! EXCLUSIONS AOOED BY EN RBEM@NT! BPEgAL PROV19X7N9 A.1.]. work in the public right-of-way at: 1073 R dgley Arive, Campbell Ca. 95008 cenrlelrere uro neo I reelr¢I I eTlnAl SNOULD ANY OF THE A60VE DESC IBED POLK;IE$ BE CANC EL4,E0 BEFORE THE EXPIRATION City eyF C+~@y11e1,1 pAT@ TMfiR60P. TIiC ISSUING IN R NALLliptliAUOR'TO MNL10 DAYS WRRTiN Attn: Dept. of Public works NOTK:! TO THE CERTIrIGATE NO R NAMED TO THE LEFT, @l1T"PmM2Elb'Ob FfO~fu¢C 70 North Fi;St StY~~t 1NIPOS6~0-de>:iGm101rOR"D DF1WT'K11Y0'OTOIIr•I'11E1RSURE7t•TISAGEIITSOR CAnYpHtlll , CA 95008 1s1'~E~rJ,TIVF'gi _ i AUTMORItEC REPREbENTATNE ~ ACUKU 25 (20Q7/QJ9) ~ ~7~rORD CORPORATION 7895 JAN-02-2007 16:08 From:BRAJENC'"`~H INS RGCY 4082801199 To ?3760958 P.3~5 RTANT If the certificate holder is an ADDITIC7NAL~ INSURED, the policy(ies) must ~ endorsed A statement on this certificate does not Confer rights to th certificate holder in lieu of such en orsement(s). If SUBROGATION IS WAIVED, subject to he terms and conditions of the p licy, certain policies may require an endorsement. A statement on this certificate d4g8 not confer rights to the certificate holder in I~eu of such endorsement(s). The Certificate of Insurance on the revers side of this form does not eon itutc a contract between the issuing insurer(s), authorized represen ative or producer, and the certif cafe holder, nor does h affirmatively or negatively amend, extend p alter the coverage afforded by t e policies Ilsted thereon ACORD 25 (2001108) JAN-02-2007 16:08 From:BRAJENC' ~H INS AGCY 4082801199 To: '3760958 P.4~5 BLANKET ADDITIONAL INSUR~D~ OWNERS, LESS ES OR CONTRA TORS This endorserrrent modifies insurance provided u der the following. COMMERCIAL GENERAL LIABILITY COVE AGE PART SCHEDULE Policy Number SFOC~CGLOOi5179-00 Named Insured FANTASY CONCRETE, INC. Endorsement Effective: 1211 a. m. Courdersigned gy /~''a~ i ._ SC EDLILE Name of Person or oirganizatlon: THE CITY OF CAMPBELL; THE CITY 01= CAM BELL REDEVELOPMENT AG & EMPLOYEES 70 NORTH FIF2$T STREET CAMPBELL, CA 95DD8 ... _ _._ Location SIDEWALK APPROACH TO THE DRIVEWAY F A SINGES= FAMILY HOME LO RIDGELEY DRIVE, CAMPBELL CA (If no entry appears above, information required a complete this endorsement will as applicable to this endorsement.) A. Section II -Who Is An Insured is arr organizatron shown in the Schedule, b shown in the Schedule is held liable fc operations performed for that insured. B. Wlth respect to the insurance afforded added' 2. Exclusions This insurance does not apply to "t (1) All work, including materials work, pn the project (other tt or on behalf of the additions completed; or (2} That portion of "your work" c its intended use by any pert subcontractor engaged in pi project. C. Ttre words °you" and "your" refer to the D, "Your word' means work or operations or equipment furnished in connection ended to include as an insured t only to the extent that the pe your ants or omissions arising to these additional insureds, the ~dily injury" or "property damage" parts or equipment furnished in c ~n service, maintenance or repair insureds} at the site of the cover of which the injury or damage a or organization other than snot arming operations for a phncipa'~ Named Insured shown in the ormed by you or on your such work or operations, )6 - 11/29/07 12~D1 ~~ ,IT'S OFFICERS TED ~ 1073 shown in the Declarations person or or organization of your ongoing ng exclusion is ;currinc~ after mection with such to be performed by operations has been ices has been put to ier contractor pr as a part of the same aranons and materials, parts Prirnary Wording If requirr~d by wntten contract or agreement: S ch insurance as is afforded by this p liey shall be primary insurance, and any insurance or self-i suranCe maintained by the above ad itlonal insureds) shall be excess of the insurance a rded to the named insured and shall not contribute t~ it Waiver of S_ ubroaation ft required try written contract or agreement: a waive any right of r®covery we ay have against an entity ltr&t is an additional insured per the terms of this endorsement because of paym nts we make for injury or damage arising out of "your work" donA undAr a contract with that person or organi tion. ANF- ES 043 (512008) JAN-02-2007 16:09 From:BRAJENC ~"H INS AGCY 4082801199 To' X3760958 CE TH~LDER COPY STATE P.O BOX 42o8p7, SAN RANCISCa,CA 94142-0807 COMPENSATION ~NSURANGE CER7IFICAtE OF WORKER CdMPENSAtION 11N5URA CE P.5~5 I5SUE DATE: 12-18-2008 GROUP: POLICY NUMBER: 1813085-2008 CERTIFICATE ID: 3 CERTIFICATE EXPIRES 12-01-2007 12-01-2008 12-01-2007 CITY OF CAMPBELL NG JOB:ALL WORK IN THE PUBLIC RIGHT°OF-WAY AY: ATTN; DEPT. OF PUBLIC WORKS 1073 RiOGLEY DR VE 70 N 15T ST CAMPBELL CAMPBELL CA 95008-145$ CA 96~b8 This is to certify that wg havQ issued a valid Workers' C mppn5atipn insurance policy in a orm apprpvOd by the Galitornia Insurance Commissioner to the employer named below for the policy period Indic ted. This poliCY is net subject to cancellation by the Fund exC~epl upon iQ days advance written ~ notice to the employer, We win also givo you 10 days advance notice should this ppliCV be cancelled prior to Its n~rmal expiration. This certificate of insurance is not an insurance policy an daes not amend, extend or alter the coverage afforded by the policy listed herein- Nvtw~lhsianding any requireme t, term pr Condition of any contr t or other document wrth respect to which this certrf~cale of insurance may b issued Or t0 which It may pertai the insurance afforded by the policy described herein is subject to all he tgrmg, Qxclusions, and conditio s, of such polrcy. 1 THgRIZED REpRESENTATI PRESIOEN7 EMPLOYER'S LIABILITY LIMIT INCUIDING DEFENS COS'CS: 51,000,000 PER 0 URRENCE. ENDORSEMENT #1tiQ0 - FRANCISCO GLi2MAN PRESID NT - EXCLUDED. ENDORSEMENT #1600 - JOSE RUVALCABA SECRETAR TREASURER - ExcLUDED. ENDORSEMENT 1fx570 ENTITLED WAIVER OF SUBRO TION EFFECTIVE 2008-12-18 IS ATTACHED TO AND FORMS A PAft7 OF THIS POLICY THIRD PARTY NAME: CITY OF CAMPBELL EMPLOYER FANTASY CONCItE7E . INC 117 BERNAL ROAD ~ 70 - 280 SAN J05E CA 95117 [B11,NG~ IREV,2-051 PRINT D 1~-1$=x008 NG STATE COMPENSATION I N S U R A N C E Fu ni v AUGUST 3, 2007 CITY OF CAMPBELL ATTN: DEPT. OF PUBLIC WORKS 70 N 1ST ST CAMPBELL CA 95008-1458 A1C~ Q 6 207 F,~,guC Wp~KS o~pMlNl~`T10N IN REPLY REFER T0: CERTIFICATE OF WORKERS' ----------------------- COMPENSATION INSURANCE ---------------------- CANCELLATION WITHDRAWAL NOTICE ------------------------------ RE: CERTIFICATE DATED JULY 18, 2007 THE CANCELLATION HAS BEEN WITHDRAWN FOR THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW. THIS LETTER SUPERSEDES THE NOTICE OF CANCELLATION SENT TO YOU ON JULY 31, 2007. THIS EMPLOYER'S WORKERS' COMPENSATION INSURANCE COVERAGE CONTINUED UNINTERRUPTED. EMPLOYER: FANTASY CONCRETE, INC 117 BERNAL ROAD # 70 - 260 SAN JOSE, CA 95117 POLICY 1813085-06 CUSTOMER SERVICE REPRESENTATIVE CUSTOMER SERVICE CENTER (877) 405-4545 1275 Market Street • San Francisco, CA 94103- 1410 Mailing Address: P.O. Box 420807 • San Francisco, CA 94142-0807 SCIF 19102 STATE COMPENSATION I N S U R A N C E Fu ni v AUGUST 3, 2007 CITY OF CAMPBELL ATTN: DEPT. OF PUBLIC WORKS 70 N 1ST ST CAMPBELL CA 95008-1458 IN REPLY REFER T0: CERTIFICATE OF WORKERS' ----------------------- COMPENSATION INSURANCE ---------------------- CANCELLATION WITHDRAWAL NOTICE ------------------------------ RE: CERTIFICATE DATED DECEMBER 18, 2006 THE CANCELLATION HAS BEEN WITHDRAWN FOR THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW. THIS LETTER SUPERSEDES THE NOTICE OF CANCELLATION SENT TO YOU ON JULY 31, 2007. THIS EMPLOYER'S WORKERS' COMPENSATION INSURANCE COVERAGE CONTINUED UNINTERRUPTED. EMPLOYER: FANTASY CONCRETE, INC 117 BERNAL ROAD # 70 - 260 SAN JOSE, CA 95117 POLICY 1813085-06 CUSTOMER SERVICE REPRESENTATIVE CUSTOMER SERVICE CENTER (877) 405-4545 1275 Market Street • San Francisco, CA 94103- 1410 Mailing Address: P.O. Box 420807 • San Francisco, CA 94142-0807 SCIF 19102 License Detail t7ecemk DISCLAIMER A license status check provides information taken from the CSLB license data base. Before on this information, you should be aware of the following limitations: . CSLB complaint disclosure is restricted by law (B&P 7124.6). If this entity is subject tc complaint disclosure, a link for complaint disclosure will appear below. Click on the lin button to obtain complaint and/or legal action information. . Per B&P 7071.17, only construction related civil judgments reported to the CSLB are disclosed. . Arbitrations are not listed unless the contractor fails to comply with the terms of the arbitration. . Due to workload, there may be relevant information that has not yet been entered ont Board's license data base. Extract Date: 12/18/2006 * * * Business Information * * * FANTASY CONCRETE INC 6885 IVEGILL COURT SAN JOSE, CA 95119 Business Phone Number: (408) 921-5188 Entity: Corporation Issue Date: 09/22/2004 Expire Date: 09/30/2008 * * * License Status * * * This license is current and active. All information below should be reviewed. * * * Classifications * Class Description C-8 CONCRETE * * * Bonding Information * * * CONTRACTOR'S BOND: This license filed Contractor's Bond number 495403 in the am• $10,000 with the bonding company Page 1 of 2 http://www2.cslb.ca.gov/CSLB_LIBRARY/License+Detail.asp?LicNum=847364 12/18/2006 License Detail CALIFORNIA CONTRACTORS STATE LICEN Contractor License # 847364 License Detail Page 2 of 2 SURETY COMPANY OF THE PACIFIC. Effective Date: 08/31 /2004 BOND OF QUALIFYING INDIVIDUAL(1): The Responsible Managing Officer (RMO) FRAI JAVIER GUZMAN certified that he/she owns 10 percent or more of the voting stock/equit~ corporation. A bond of qualifying individual is not required. Effective Date: 09/22/2004 * * * Workers Compensation Information This license is exempt from having workers compensation insurance; they certified that they employees at this time. Effective Date: 08/31/2004 Expire Date: None Personnel List License Number Request Contractor Name Request Personnel Name Request Salesperson Request Salesperson Name Request ©2006 State of California. Conditions of Use Privacy Policy http://www2.cslb.ca.gov/CSLB_LIBRARY/License+Detail.asp?LicNum=847364 12/18/2006 Page 1 of 1 Joanne D' Ambrosia From: Joanne D' Ambrosia Sent: Tuesday, January 02, 2007 4:11 PM To: Syed Wahidi Subject: Fantasy Concrete/1073 Ridgeley/Francisco Guzman/ENC2006-00182 I now have all the correct insurance for this permit. I called Mr. Guzman after I received it today as he was in this morning asking about it. I told him we would have to wait until Wednesday for you to issue it (as I can't find the permit application on your desk). The only thing he needs to do it get a business license. Joanne 1 /2/2007 ~~ OF C~1n~r u r =s '' ~ v ARCH A0.0 CITY of CAMPBELL Public Works Department Date: August 13, 2007 TRANSMITTAL FROM THE PUBLIC WORKS DEPARTMENT TO: Francisco Guzman 1073 Ridgeley Drive Campbell, CA 95008 FROM: Joanne M. D'Ambrosia, Office Specialist SUBJECT: 1073 Ridgeley Drive, Campbell, CA 95008 Encroachment Permit #ENC2006-00182 Enclosed is a check in the amount of $2,042.68, representing refunds of your Construction Cash Deposit and Faithful Performance Surety, plus accrued interest, in connection with the above property. Joanne M. D'Ambrosia Office Specialist Enclosure 70 North First Street Campbell, California 95008- 1436 TEI_ 408-866.2150 FaX 408.376.0958 ruU 408.8662790 i _ --- - - CITY OF CAMPBELL VENDOR NO Account Yttrchase Order Invoice Number Arrwttnt Deseri lion 101 2203 101.540 7448 CR07302007 CR07302007 2,000.00 42.68 REFUND DEPOSIT INTEREST EARNED 10008074 FRANJIS(:U UUL.MAN 1 / / / / ~ 1 1 , 1 / / 1 1 / ' pC'C~A CITY O~ CAMPBELL K oe AMERICA u-as CHECx DATE CHECK NO. 70 NORTH FIRST STREET ~~~• , ~~ caeneaErn ocPlcE i2io 0 0 TH2 PRUNEYARd 08/13/07 211399 ' r ~ M t"" CAMPBELL, CALIFORNIA 95008 p o 2 'can,Pesta., ca 95008 AMOUNT ~ *****2 042.68* ~ ~ 'gym ~ , ~ `~ ~eclieao .~ VOID AFTER 90 DRYS ~ PAY THE SUM OF TWO THOUSAND FORTY TWO DOLLARS & 68 CENTS m~ f o TO THE FRANSISCO GUZMAN i m ~ ORDER 1073 R'IDGELEY DRIVE ~ ~~~ ~ ~ ,~~ ~-- ., \ ~ .CAMPBELL CA 95A08 ~ ,) lI __ / i ~~' 2 L i 399~i• ~; L 2 1000 358x;000 6 2 2080 2 4-9~~' __ ,__ _ _ ~ 10008074 cHECx No. 211399 'c. :n ~. 0 *See Reverse Side For Easy Opening fns#ruc#ions* CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 FRANSISCO GUZMAN 1073 RIDGELEY DRIVE CAMPBELL CA 95008 ,~ of c,y~~n~~ u ~ y ~~ °RCnr,~o CITY of CAMPBELL July 30, 2007 Public Works [:)apartment Francisco Guzman 1073 Ridgeley Drive Campbell CA 95008 SUBJECT: PERMIT NO. ENC2006-00182 LOCATION: 1073 Ridgeley Drive FINAL INSPECTION AND ACCEPTANCE Dear Mr. Guzman: The City of Campbell has made a final inspection of subject Public Works improvements and finds the work to be acceptable and in conformance with City standards. Accordingly, the City Engineer accepts the improvements. The one year maintenance period stated in the permit begins as of the date of this acceptance letter. The permittee is responsible for the repair and/or replacement of any defective work or failures that occur within one year. The City will inspect the improvements within one year and notify you, in writing, whether or not any repairs are required. Refunds of your Construction Cash Deposit of $500.00 and Faithful Performance Security of $1,500.00, plus any interest due, are now being processed and will be sent to you under separate cover. If you have any questions, please call me at (408) 866-2165. Sincerely, Syed Wahidi ''''P``ublic Works Inspector X~^'' MQ cc: Suspense - 11 months Permit #ENC2006-00182 Inspector File h:\word\permits\2006_182fin (jd) ;0 North First Su~ect Campbell, California ~i5008-143 r, TEt -~o&-SaE,2~~o IFlx 4(~s.3io.o95B rnn 4(lA.rio6.~,7~N~