Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
ENC2013-00181
Print Fo/rm CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No~~~--f- DEPT. OF PUBLIC WORKS (for working within the public X-Ref. File _____ __ 70 North First Street ri ht-of-wa '1-(~*i g ;I- y) Application Date _____________ Campbell, CA 95008 .2 Application Expiration Date_ ~ " ~(~ `l Ph. (408) 866-2150 Issued ` ~~ ~l } APN f.T~~~~Z-~'-~ 5 Fx. (408)376-0958 ~ ----- - Permit Expiration Date APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 1 1.04. (Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable.) A. Work Address or Tract No.: ~~ ~ ~ I I 3.~___..~~'~ ~~~a~~ti ~~v C Utility Trench Location: >~~~ B. Nature of Work: ~ •~ n~t,l I ~ C~ ~ ~ ~i ,,~( _C,_,. , ~ ~ ~U~p\v (~ ~ }c-~(1,} O C. Attach four (4) copies of an engineered plan showing the location and extent of the work, and ff"our (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 hours before restarting any work. Name of Applicant: ~ ~O ~ ~S ~Zti-l Address: ~ 12 ~ 1 ~,~~ ~m.~r Telephone: ~~~ ~ }'~~_~U'~ v E-Mail Address: ''^^ ~ II ~ - w ~y/~,.rl ~ •~4-~~ R EMERGENCY PHONE NUMBER: ~!''~ ~ ~•~ ~~ C ~~CU r-~U i 1 r l/ Is this work being done by the property owners at th o 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 issuanc of . 's ermi , property owner, or property owner's successors, shall be responsible f%/ora,,~ny and all damages arising out of the condition of any priva i pr s in the public right-of-way. // Accented: l~U / f ~~E~ /f (Applicant Permittee) (Contractor) (Print Name) Date l~ Date SPECIAL PROVISIONS: 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 approved by the Inspector prior to cutting. 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 the Engineer. 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. _ _ ___S. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be recorded. __6. 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 EMERGENCY PERMIT FEE ~, APPROVED FOR ISSUANCE AM UNT 7 ~ EI~~ $ -~ ~ ~ For City Engineer Permit Expires 12 Months After Date of Issuance / ' ~ _ GENERAL 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 or 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. Submit project schedule 10 (ten) days prior to proposed start of work. Special provisions maybe required for work within City facilities and downtown Campbell. 5. 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 6. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants, and water valves. 7. 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. 8. A Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated 1990, available at Caltrans. Traffic control equipment shall include Type II flashing arrow signs if required. 9. 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. 10. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements. 11. 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. 12. 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. 13. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer 14. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m. 15. 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. 16. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a separate permit may be required, nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 17. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency 18. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 19. Call back (call out) due to emcregencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence. 20. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. 21. 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. 22. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the 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 and understand all of the above conditions. Applicant Contractor (Print Name) Dat q 6 Dat . J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev. 03/13 PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1, 2013 ~ -~ / TO: City Clerk PUBLIC WORKS FILE NO. ~ ~ r -J ./ PROPERTY ADDRESS ~ / " ~( Please collect & recei t for the followin monies: ACCT. ITEM AMOUNT LAND DEVELOPMENT ncroac ment ermit ication ee Non-Utility Encroachment Permit Ma'or ?$10,000 $377.00 Minor Encroachment Permit <$to,ooo $215.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $209.00 Street Tree Plantin /Removal N/C 2203 ($500 per Tree Plantin Deposit Required) $500.00/tree 2203 Plan Check De osit 2% of En ineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Gradin & Draina a Plan Review Sin le Famil Lot $265.00 Site < 10,000 s.f. $795.00 Site >_ 10,000 s.f. < 0.5 Acre $1,060.00 Site ? 0.5 Acre $1,590.00 4722 NPDES Review C3 Re uirements For projects not required to submit numeric sizing $153.00 For projects required to submit numeric sizing Impervious Area 10,000 Sq. Ft to 1 Acre $663.00 Im ervious Area 1 Acre or more $867.00 Plan Check & Inspection Fee (Non-Utilit ) 4722 Engr. Est. up to $250,000 14% of Engineer's Estimate _ **2203 Engr. Est. ?$250,000 Actual cost +20% Admin Overhead Min $35,000 De osit 2203 Emer enc Cash Deposit 4% of Engr. Est.* ($500 min/$10,000 Max 2203 Faithful Performance Securit (FPS) 100% of ENGR. EST." 2203 Labor and Materials Securit 100% of ENGR. EST.* 4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00 (Multi-Res $2,385.00) All Other $2,650.00 4722 Parcel Map (4 Lots or Less) $3,775.00 + $82/lot 4722 Final Tract Map (5 or More Lots) $4,590.00 + $112/lot 2203 Monumentation Security 100% of ENGR. EST. 4920 Parkland Dedication Fee 75%/25% Due U on Cert. of Occu anc 4722 Lot Llne Ad'ustment (Includes Certificate of Compliance) $1,785.00 4722 Vacation of Public Streets & Easements $2,386.00 4722 Certificate of Com liance $1,764.00 4722 Certificate of Correction $530.00 4722 A eal Filin Fee $200.00 4722 Nota Fee per si nature) $10.00 4722 Assessment Segregation or Reapportionment First Split $846.00 ___ Each Additional Lot $265.00 511.7424 Postage M ELLAN E U Other Please S ecif *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. **Actual Cost Plus 20% Overhead Non-Interest beari~n~d~e}po 't) ~~ TOTAL $ NAME OF APPLICANT C~ (S~ ~f-~C~- ~ , ~a NAME OF PAYOR PHONE -- ADDRESS ~ ~~ .~ ZIP k~ Tx 4j FOR RECEIVE BY ~ ~ ~ ~~ CITY CLERK ONLY E ,, ~ _i Date Recei t # ~ ~~ ~ - Date! Initials J:\FORMS1Templates\AdminrshaavMReseipt Fam Lamf Devtlopment 13-t4 ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION REP 06 9056329-13 NEW SP 5-39-12-54 PAGE 1 HOME OFFICE SAN FRANCISCO EFFECTIVE SEPTEMBER 16, 2013 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING MAY 11, 2 014 AT 12.01 A. M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDIGA7ED AT PACIFIC STANpAIiR TIME CHETAUD PRO BUILDERS 1201 PARKMOOR AVE APT 1315 SAN JOSE, CA 95126 P.N~'I'HING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF CAMPBELL V1lHICH MIGHT ARISE BY REASON OF ANY PAYMENT' UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, CHETAUD PRO BUILDERS IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES t1JHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY d3i. NOTHING 1N THIS ENDORSEMENT CONTAINED SHALL 8E HELD TO VARY, Ai.TER, WAIVE OR EXTEND ANY OF THE TERMS, CONDETIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITEON5, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT, COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: AUTHORIZED REPRE5EN"fA lVE SCIf- FORM 10217 IN EV.1-20121 SEPTEMBER 18, 20~13~_~ ~*L PRESIDENT AND CEC? 2570 OLD DP 217 .4coRO® CERTIFICATE OF LIABILITY INSURANCE ' DATE (MM/DDIYYYY) `,,.,~ 10/17/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: AL FEKE Primestate Insurance Agency, Inc. PAHONE gam , iA/c Not _ _ 23152 Verdugo Dr Ste 130 __ __ - E-MAIL ., ADDRESS: Laguna Hills, CA 92653 INSURER(S) AFFORDING COVERAGE _ ___ _ _NAI_C_#__ __ wsuRERA: UNITED SPECIALTY INSURANCE COMPANY ',12537 INSURED __ ___ __ ' 11770 INSURER B : UNITED FINANCIAL CASUALTY COMPANY CHETAUD & GENHO INC __ -- -- INSURER c : STATE COMPENSATION INSURANCE FUND 5076 DBA CHETAUD PRO BUILDERS ~ 1201 PARKMOOR AVE, #1315 INSURER D : ---- - SAN JOSE, CA 95126 INSURER E: _ _ ___ ___ ____ ___,~ _ INSURER F : I COVERAGES CERTIFICATE Nl1MRFRr REVISION Nl1MRFR• THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF MMIDD YYY POLICY EXP MMIDD/YYYY LIMITS GENERAL LIABILITY I I ~ EACH OCCURRENCE _ _ i $ 1 000 U00 -- - -- 6AMAGETO RENTED X COMMERCIAL GENERAL LIABILITY ~ ~ _ PREMISES (Ea occurrence) _ I $ _50,000_______,____ ~ CLAIMS-MADE ~ OCCUR ~MED EXP (Any one person) ~$ 5 000 _ , A CGD00001729 10/11/2013 10/11/2014 I pERSONALBADV INJUR Y i $ 1,000,000 Deductible: $5,000 _ _ GENERAL AGGREGATE __ $ 2,00 0,000 __ _ _ _ . _ __ _ GEN'L AGGREGATE LIMIT APPLIES PER: --- - PRODUCTS -COMP/OP AGG $ 2 000 000 __ r~ PRO- X ( ~ ~ __ _ $ POLICY I T LOC AUT OMOBILE LIABILITY C MBINED SINGLE LIMIT Ea accident $ 1,000,000 «_~ ANY AUTO BODILY INJURY (Per person) __ _ $ ~ ~ B , __~ ALL OWNED I SCHEDULED AUTOS ~ X I AUTOS '- 01728399-1 07/18/2013 07/18/2014 BODILY INJURY (Per accident) _ _ _ _ _ _ ___ $ I NON-OWNED j PROPERTY DAMAGE __ _ _ __ i_~ HIRED AUTOS AUTOS Per accident _ $ I __ ___ _ _ ___ _ _ $ UMBRELLA LIAB I OCCUR r ~ ~ EACH OC_CUR_RENCE ~ $ ~_ EXCESS LIAB _ ~I CLAIMS-MADE AGGREGATE __ _ $_ __.__ __ DED RETENTION $ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS' LIABILITY ._ ,TORY LIMIT ER _ _ C ~, / N ANY PROPRIETOR/PARTNER/EXECUTIVE ^ Y N/A ~ -. 8056329-2013 05/11/2013 05/11/2014 E.L. EACH ACCIDENT _ _ $ 1 000,0p OFFICE/MEMBER EXCLUDED? 1 __ __.___ (Mandatory In NH) E.L. DISEASE - EA EMPLOYE $ 1 000,000 If yes, describe under E.L. DISEASE-POLICYLIMIT ~ _ _ $ 1,000,000 i ~ I ~ Jr 1 DESCRIPTION OF OPERATIONS (LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER IS INCLUDED AS ADDITIONAL INSURED PER ATTACHED FORM USIC-CMGIA-0310 04/12. 10 DAYS WRITTEN NOTICE OF CANCELLATION FOR NON PAYMENT OF PREMIUM. The City, its officers, employees and volunteers are named as additional insured. Re. 1117 Hazelwood iS Permit ENC2013-00188 The insurance coverage afforded to the Additional Insured is primary insurance. Re. 1133 Hazelwood is Permit ENC2013-00181 CERTIFICATE HOLDER CANCELLATION CITY OF CAMPBELL Attn: JOANNA THOMASON 70 N FIRST STREET CAMPBELL, CA 95008 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN joannat@cityofcampbell.com ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ENDORSEMENT BLANKET ADDITIONAL INSURED This endorsement changes the policy. Please read it carefully. A. Section II -Who is an insured is amended to include as an additional insured any person or organization that the "Named Insured" has agreed in a written "insured contract" to name as an additional insured with respect to the general liability coverage provided under this policy. Such person or organization is an additional insured provided the "bodily injury" or "property damage" occurs subsequent to the execution of the written "insured contract." Such person or organization is an additional insured only with respect to liability for the "bodily injury" or "property damage" which is caused in whole by the negligence of the "Named Insured" during the policy term in the course of ongoing operations by the "Named Insured" for the additional insured. A person's or organization's status as an additional insured under this endorsement ends when the "Named Insured"'s work or operations for that additional insured are substantially completed or this insurance policy expires, whichever is earliest. The applicable limit of insurance provided under this insurance policy shall not be increased by the inclusion of any number of additional insureds. The coverage provided for the additional insured is only to the extent the additional insured is held legally liable for the negligence or strict liability of the "Named Insured". No coverage is provided for liability based upon the acts, errors or omissions of the additional insured. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to: 1. "Bodily injury" or "property damage" occurring after all work by the "Named Insured" including materials, parts, or equipment furnished in connection with such work, (other than service, maintenance or repair) at the site location of the covered operations has been substantially completed. 2. That portion of "your work," out of which the "Bodily Injury" or "Property Damage" arises, that has either been put to its intended use by any person or organization, or is used by another contractor or subcontractor engaged in performing work on the project. This endorsement does not modify the terms and conditions of the insurance policy, including all insuring agreements, except as specifically stated above. USIC-CMGIA-0310 Rev. 04/12 Policy Number Named Insured Effective Date CGD00001729 CHETAUD & GENHO INC DBA CHETAUD PRO 10/11/2013 BUILDERS Polic Number Named Insured Effective Date CHETAUD & GENHO INC CGD00001729 DBA CHETAUD PRO 10/11/2013 BUILDERS THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ENDORSEMENT BLANKET PRIMARY COVERAGE FOR ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE The primary coverage only applies to the person(s) or organization(s), but only if each person or organization listed in the above additional insured schedule qualifies as an additional insured under this insurance policy under an additional insured endorsement issued under this insurance policy and who have entered into a written contract with "you" prior to "your" commencement of work for the person(s) or organization(s) with whom "you" have entered into a written contract and such written contract specifically requires that "you" provide primary coverage. Such insurance afforded by this insurance policy to the additional insured under this insurance policy is primary insurance so long as the "occurrence" is caused in whole and exclusively by the "name insured" and takes place after the effective date of this endorsement and subject to the provisions of "your" insurance policy. Any other insurance or self-insurance maintained by the additional insured is in excess of this insurance. All other terms and conditions of the policy remain unchanged. $6,535.00 USIC- CMGIA-7820 Rev. 9/25/12 Polic Number Named Insured Effective Date CHETAUD & GENHO INC CGD00001729 DBA CHETAUD PRO 10/11/2013 BUILDERS ENDORSEMENT BLANKET WAIVER OF SUBROGATION Waiver of transfer of rights of recovery against others to "us" This endorsement modifies insurance provided under the following: commercial general liability This waiver only applies to the person(s) or organization(s) who have entered into a written contract with "you" prior to "your" commencement of work for the person(s) or organization(s) with whom "you" have entered into a written contract and such written contract specifically requires that "you" provide a waiver of subrogation but only if each person or organization who has entered into the contract with "you" and for whom "you" are performing work under the written contract qualifies as an additional insured under this insurance policy and so long as the "occurrence" takes place after the effective date of this endorsement and during the policy term. The transfer of rights of recovery against others to "us" condition under section IV -conditions, paragraph 12 -transfer of rights of recovery against others to "us" is amended by the addition of the following: "We" waive any right of recovery "we" may have against the person(s) or organization(s) who have entered into a written contract with "you" prior to "your" commencement of work for the person(s) or organization(s) with whom "you" have entered into a written contract and such written contract specifically requires that "you" provide a waiver of subrogation because of payments "we" make for "bodily injury" or "property damage" arising solely out of "your" ongoing operations done under an insured contract with that person or organization. This waiver applies only to the person(s) or organization(s) who have entered into a written contract with "you" prior to "your" commencement of work for the person(s) or organization(s) with whom "you" have entered into a written contract and such written contract specifically requires that "you" provide a waiver of subrogation and only if each person or organization for whom you are performing work under the written contract qualifies as an additional insured under this insurance policy. "W e" retain "our" right to seek recovery from all other responsible person(s), organization(s) and/or entities. All other terms and conditions of the policy remain unchanged. $6,535.00 USIC-CMGIA-7830 Rev. 09/12 BUSINESS LICENSE CHANGE REQUEST FORM ~ Z ' ~ ~~ %~ ~t ld~ S BUSINESS NUMBER BUSINESS NAME ^ C1oSe: Out of Business • Sold • Moved out of City of Campbell Deceased (Circle one) • No Job in City at this time Other Change: New Business Name (Ltn:ited to 35 CltaractersJ NeW BUSIRCSS~~A/dd~iCCSS (No P O Boxes nr priva(e arait box address) ~7`I l~r New Mailing Address '•~ New Owner's Name ~•. New Owner's Address New Telephone #: Area Code Business Area Code Home Change Cntcgory to: / ~ Change to in town: Number of Employees Authorize Number of Units Other ,~~~ ~ti,`;~ r° r , ~', ,,!'~~ d by: ;,~ °::°~ ~ Date: %~~~ / ~~t* ~ ~~ Cashier: Reissue License: _~ (If applicable) Yes ~~~~ r~r'~~.'~ 1-,~~jg Fee: ~lT !~i~~~ No ~ ~ Receipt #: ~-~ ~~ ~~ File name: Word-Bstatus Zc~ \?~ - p~~~ ~ INSURANCE REQUIREMENTS CHECKLIST Permit # ~~~~~~~(`~~ \~~ CIP Project # The following insurance is required of all contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: $1,000,000 per occurrence, and ^ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggregate limit. Policy expiration date ~O (~1 ~ 1 Automotive Liability: ^ "Any Auto" checked on certificate %~ ~ $1,000,000 per accident for bodily injury and property damage `C,~ ^ Policy expiration date ~ - ~~~c-\`~~ ~.i ~~ ~,~~'~y ~~ Workers' Compensation and Employer's Liability ~!+-_ Waiver of Subrogation clause ~ $1,000,000 per accident for bodily injury or disease y~ Policy expiration date Course of Construction (if required in Special Provisions) ^ Completed value of the project ^ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement (Description of Operations Area) The City, its officers, employees and volunteers are named as additional insured. jReference Project Location & Permit Number) The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation Area: ^ 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". OR Should Read ~y~ Should any of the above described policies be cancelled before the expiration date C thereof, notice will be delivered in accordance with the policy provisions. C:\Documents and Settings\joannat\Desktop\Insurance Requirements.doc (Rev 03/13) Page 1 of 1 ^ Workers' Compensation Insurance Sheet Submitted For General Contractor ^ For Developer or Owner Acceptability of Insurer(s) ^ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. / Name: ~~~-\c~l ~{z~C~~~\~~1 NAIC # ~Z~3~}'Rating: Authorized in CA: V Name: ~~,~;,~ e d ~;.c~,,nr'~c. \ NAIC # ~Z~Rating:~~_ Authorized in CA: Name: Cc.Svc`~i~y NAIC # Rating: Authorized in CA: Name: ~-~c~t~ C~ f~~~ NAIC # Rating: ~I f 1~Authorized in CA: per.`-1 z °t -1 ^ Campbell Business License # p Insurance Certificate Reviewed ~Z ~„ Initi~s ~ Date Copy of Insurance Certificate placed in tickler file one month prior to expiration. C:\Documents and Settings\joannat\Desktop\Insurance Info\Insurance Requirements Cklist REV 4.12.doc (Rev 07/11) Page 2 of 2 rIT~ OF E:~t^r'rE~E REC!.I+ FY: OASrIE+~: 0000<<OCi;~%, rAYDR: k ;,~?ETAtiIt TOIi~'f'S Iti;TE: OS;;bi.'. ~:uGISTEf~ Ii~iTE: ~~,''15: #3 TIDE: i5:f4 UESC~II'TIO-~! R~Olit~1T, E~l+~"'N. ~ SUBIti!: FILi~e r X377.00 CL!ST IIi: ENE~it13-OOt3f ----------------- TOTs~~ IiilE.: $377.01? TE~lI!EREIt: X377.00 isNANGE: :.00