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ENC2014-00025
Print Form CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No C-~ ~ Ze I ~ - ~ C? G 2~j DEPT. OF PUBLIC WORKS (for working within the public X-Ref. File 70 North First Street right-of-way) Application Date Campbell, CA 95008 ) r2 ~ ~~ ~ Application Expiration Date Ph. (408) 866-2150 Issued APN l~ '1. . F~`l J Z-1 • zi- ~ Fx. (408) 376-0958 ' Permit Expiration Date ~ 2 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 isnon-refundable.) A. Work Address or Tract No.: 1190 DELL AVE. Utility Trench Location: 11190 DELL AVE. B. Nature of Work: ANITARY SEWER LATERAL REPLACEMENT (VWSD) 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 Ciry 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: BLE SEPTIC TANK SERVICE Telephone: 08-377-9990 Address: 1020 RUFF DR. SAN J05E CA. 95110 E-Mail Address: ARK@ABLESEPTIC.COM 24-HOUR EMERGENCY PHONE NUMBER: ~-377-9990 Is this work being done by the property owners at their own residence? ~'"" YES r' 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 o4t of the condition of any private improvements in the public right-of-way. Accepted: (Applicant Permitfe~) (sign) ~'~ Date (Contractor) (Print Name) 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. 'r/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. 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. 6. Public Notification Requirements: 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEI T NO. PERMIT APPLICATION FEE $ 3 7 ~ ~7 I ~~ O PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK & INSPECTION FEE $ ~7 ~ 2 l ~' EMERGENCY PERMIT FEE $ APPROVED FOR ISSUANCE ~- '`_~~~~° J_ J~ 2~/ ('4 For City Engineer Date t Permit Expires 12 Months After Date of Issuance PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC: ~Ic MISC+tLLAIVtVUJ KCLaCIr 1 Effective July 1, 2013 TO: City Clerk ]~ PUBLIC WORKS FILE NO. ~~ ~ ~~~ t \ - UGC Z~j PROPERTY ADDRESS Please collect & receipt for the following monies: _ __ _-_ ___ ___ __ - - - AMOUNT' ACCT.'-~-- - ITEM ENCRQA PERMIT CHMENT __ , - - 00 lication Fee $377 it A t P h 7 4722 . pp erm men Utility Encroac rmit N/C t P h R 1 E men e ncroac - 00 $107 it P E . s erm mergency e ti F k & I on e nspec Plan Chec 00 Location $377 P Ch Mi i 7 ~ . er arge mum n 50/ft to 500 Feet $2 /Pi li i C . nes up pe ts ondu 55/ft Feet $1 500 Li Ab . near ove 00/ea $165 lt /Etc /V h l M . . au s an es o 00/ea val $165 t/R P l S . emo o e e 4 60 00 mit $153 i P C t St 7 4760 . ner er ora a on a ifications Pro'ect No. & S P t Pl ' 760 ans ec ro ec 50/Bk tions & Details $1/P $15 ifi d S St d 4 4760 . ca an ar ec s & Plans i i M E neer n a n 00 t 24" x 36" $60 l Pl A i . er a o l Print 8 1/2" x 11" $28.00 ri A e a arch includes max of two 24"x36" co ies $28.00 R M ese a 00 24" x 36" $14 d Pl M 4722 . ans a san Failure to restore ublic im rovements $100lCalendar Da Muni Code Sec. 11.34.010) P lti 4722 ena es: Failure to correct unsafe conditions $100/Calendar Da ltie P 4722 ena s: Work Without Permits 4 Times Applicable Fee _ _ _ TRAFFIC , 4728 Traffic Flow Ma Dail Traffic Volumes $35.00 4728 l Timin Information 73 Si n 4271 a ck Permits $16.00 er tri Tr 4728 u No Parking Signs $1 each or $25/100 - -- - -- lSCELLANEOUS 511.7424 Posta e Other Please S eci (~ ~/~ ~ TOTAL ~ 5 NAME OF APPLICANT \../' ~"~ Z ~~Yv C ~, v~ NAME OF PAYOR - b ~ ~- CJ~ ~~~ L PHONE ADDRESS ~ ~ . c`> ~~i~ %'~/-'~ c~ ;~ ~-' ~.e ZIP Gl I a-~ FOR RECEIVED BY CITY CLERK ONLY Date Recei t # ~. ,- M1: : ~... 6 ,'d. ., k ,. ,,.. ,., f .. ~ i ~ ~_ J:tFORMS\TampletesV+tlmmatnti.e\Receipt Form Utf9ty Encroachment 8 Mac 13-74 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 Ciry. 4. Submit project schedule 10 (ten) days prior to proposed start of work. Special provisions may be 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 Ciry 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 emeregencies 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. Permimee 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. / ~~--~ - ~ a ~~ ~ + y Applicant / Date: Contractor (Print Name) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev. 03/13 ~:ITY ;.?E .; `A;;f>;: t;:`?1L~E iJ;I?EF:sh,E:?l~ttii? 7L?i?i=~~`•~~ i?i'S~E« ~~2r','7 rr if9 t; i~TJltfi L?~1'C: ~~il~~i(~~ i:iir:' %~:Z?~ I.fEu~•6:I1-'TI:?i'i ~a'L? ' i r~. Lii?L^: s\ `a~:~~ft 4~ c ll, 3;:~ i i 4 i : , l~j~ L•(J[:~ E"~:i~i ~~ ~.,'~E~1?i~.% rlListili F ~~;37'7.l?t! Li~si ii?« f t; itL ~?iJE « F J3 . R.~~J I L)1L?CJtL ~t « ~ I vii ~ UL ( L: }~lYt ll. « V . {.fir West Valley ` t Sanitation Distri t i OFFICE HOURS & O TACTS: 7:30 a.m. to 4:30 p. M nday thru Friday 100 E. Sunnyoaks A e.,~Campbell, CA 95008. • Phone: (408) 378-2407 • Information Services Department LOCATION: APN~y O'-v9l Sewer Map Book Page S Tract Lot Project Assmt Ad~ess Vic. igu~,t,+t`j /-r9,-•n ~~~, l~ sa cry ~c'`" Jurisdiction (~?.~r~.®~~Gf,'Z%- BUILDING TYP Single Family Condo/Town House Multiple Dwelling Units Industrial Commercial ~ "' REMAR S: ~N.~ligG,;- ~'l~-~.-~~" OLD PERMIT No.38~ c~ Sub No. C~ !} FEES: Connection $ Capacity Processing ~'~~+ Service Advance BACKFLOW PREVENTION: Field check required ~ Basement Check valve required: Yes No _ ~~er - 2~'~~ ~-tf/c'~ BUILDING SEWER CONNECTIONS: Total Due: $ ~~li- ~-' A Paid by Check No: /.SGT, S %~~ Hillside: Yes_ No INSTRUCTIONS: • Permit is invalid if not connected within 12 months of issue. • Do not connect until the main sewer is accepted by the District. • Obtain a building or plumbing permit from the Jurisdiction listed above. • Street encroachment permit is required from L~~~ ~.-z~l~~~ • Keep 3' radius around cleanout clear of vegetation or obstruction. Total number of connections to this property: 1. Lateral ID No.~/G' ~ is located feet ,5 of property line, _ feet from main sewer and ~,~, 7' feet deep. Connection to Main SewerG~ feet US from DS MH ~ G/~~~~_ US MH ~-~.~/--~/ Pipe Type __ List any additional connections on reverse side of this form. ~~'f ~~ i~ Original -Applicant Pink -Accounting Yellow -City/County Bldg. Inspector Card -District File r, t it i~ 11t ~ it ie ~ '~ ~` ~ :: ~ x F~ O 0 ~ ,.~ . ,~ i ;'# ,~ t ~ ~~ ~~ ~. a,~ St r_ Y+~y 1~ ~.,t Yi. S ~ O .~ ~ ' M!'SR~ ~ ~ ~ J y . '!!'~~ '~ ~~ .~ ~.y~. 4 C ~l ~~1 „~V ~ ~ '~.'~ ~~> k,~ e. .rt "a.~ z T ~ D ~ nCO~ _ ~ ~G~ ' a r O ~ 0 ~ ~~~ ~ ~~~ ~ ~ O ~ ® ® ®®~ r QT~Z z ~< s ~+ ~~ s~ q d - Ol 3 ~ f+ ~ ~~ ~' r D ~ ' ^ ~ n °a ' <p ~ ~ o ~•~ o ~ ~ ~ ~ a ? c to o ~ ~ ~ C 3 a ~ Q ~ ~ `D ~ ~ ~ ~ o ~ ~ ~ cn = a ~ r7 I u, Z a ~D ~ z m j N ~ ~ ~ Q ` ~ ~ ~ ~ ~ ~ tl~ ~ rD S C ~ to Ao o ~ c ~ ~'~ ~ ,3 o d ~ ~ ~ ~ ~ ~ Q ~ ~ ° ~~_ ~.C o ~ - zo_o n ~ ao Q ~ ~ ~ ~ ~ ~ ~ ~~ 0~ z ~ °dR Ou 2 ~ 2 H to _ Z< o as aIN ~ 'p `" I m/ ~_\ 3 0 ~ ~' Sewer Connection Permit No: 1 1 Issue Date: ~/f~~~ By: AICOR~® DATE (MM/DD/YYY1'( `/ CERTIFICATE OF LIABILITY INSURANCE 7/17/2013 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, sutyect 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 certiflcate holder in lieu of such endorsement(s). PRODUCER NAMTA T All Spectrum Ins All Spectrum Insurance Brokers PHONE (4O8) 739-B3O0 FAX . (866)826-6781 4300 Stevens Creek Blvd '~( .help@asibrokers.com Sll]. to 100 INSURE S AFFORDING COVERAGE NAIC # San Jose CA 95129 INSURERANational Fire Insurance Co of 0478 INSURED INSURERB:Peerless Insurance Co an 4198 Able Underground Construction, Inc, DBA: Able INSURERC:St Paul Fire and Marine Ins Co 4767 1020 Ruff Dr INSURERDEverest National Insurance Co 0120 INSURER E San JOBe CA 95110 INSURER F envGeer_GC ccorclcerG w rur:>;GQ~cr.~ i77 ~nns3'I REVISION NIIIYIRFR~ 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 L TYPE OF INSURANCE POLICY NUMBER UCY EFF M POLK:Y EXP D LIMITS GENERAL LIABILITY EACH OCCURRENCE _ _ 5 1 , 000 , 000 X COMMERCIAL GENERAL LIABILITY p 1 S 300, 000 A CLAIMS-MADE ~ OCCUR X Y 076630503 /1/2013 /1/2014 MEDEXP An one S 5, 000 PERSONAL & ADV INJURY S 1 , 000 , 000 GENERAL AGGREGATE S 2 , 000, 000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG S 2 , 000 , 000 X POLICY PRO LOC S AUTOMOBILE LIABILITY Ea a udeD IN L LI I 1 000 000 B X ANY AUTO BODILY INJURY (Per person) S ALL OWNED AUTOS SCHEDULED X 8910289 /20/2013 /20/2014 BODILY INJURY (PeraccideM) E NON-0VUNED PROPERTY DAMAGE S HIRED AUTOS AUTOS P r ent TERRR S X UMBRELLA LIAB OCCUR EACH OCCURRENCE S 1 , 000 , 000 C EXCESS LIAB CLAIMS-MADE AGGREGATE S 1 , 000, 000 DED X RETENTIONS 10,00 UP14R6811013NF /1/2013 /1/2014 y D WORKERS COMPENSATION ' Y VJC STATU- OTH- ANDEMPLOYERS LUIBIUTY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT 5 1 000 000 ~ OFFICER/MEMBER ExCLUDED7 (Mandatory In NH) N ~ A 600007280131 /1/2013 /1/2014 E.L. DISEASE - EA EMPLOYE S 1 000 000 li yes, tlescribe under DESCRIPTION OF OPERATIONS below E.L DISEASE -POLICY LIMIT S 1 000 000 DESCRIPTION OF OPERATIONS / LOCATK)NS /VEHICLES (Atbch ACORD 101, Addltlonal Remarks Schedule, M more apaoa hti required) RE: permist~ ENC2013-00098 As required by rcritten contract/agreement per attached endorsements G-140331-B (Ed. 01/09), AC01020308 the follo~-ing is additional insured: City of Campbell, The City of Campbell Redevelopment Agency, its officers, employees and voltmteera. (408)376-0958 14083760958@myfax.com City of Campbell 70 N 1st Street Campbell CA 95008 25 (20101051 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE triy Lazarev/DIMAI+ ~~- - ,~-"°'-i-- ©1988-2010 ACORD CORPORATION. All righffi reserved. INS025 nn+ms~ m Tlsn Al:nRrl namo ~nrl Inns sro rai.:aMrod r-rarirc of 0(`nRrl :.I:1 `t~ Lf~~i:`L'C~L b;E i'vtis ~? i : C~;JHiErt i :7•-,c; -~,- . US:.~Juc:Ji is F`R ~'t~~:: t=:;~LE 't1~!IiEF';~~,r$l«~Ii t;E~t?.r7~lt~{ t1AiE: ~lii:jar!`i+ ttt.~',: a:::Zi~ Et~%;;< ,~ 5l1~tZf?4' r"il.?A'~ F ~u3i?,tnrt L'1lai IIj: Er~::~Cily-J~fi2~ E`tG~i ,~ Sli~tjilii zI~I~G F ~:3~7,GL~ l:EJSr Iii: ?kIT~L £!JE t $?;~+3. L"its L~tEf.}s i~~: tLb+~J TE;;IIiE~Ef+: ~ 7~~ . ~~ THlS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. POLLUTION LIABILITY -BROADENED COVERAGE FOR COVERED AUTOS -BUSINESS AUTO, MOTOR CARRIER AND TRUCKERS COVERAGE FORII~S This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. A. Liability Coverage is changed as follows: 1. Paragraph a. of the Pollution Exclusion applies only to liability assumed under a contract or agreement. 2. With respect to the coverage afforded by Paragraph A.1. above, Exclusion 6.6. Care, Custody Or ConVol does not apply. B. Changes In Definitions For the purposes of this endorsement, Paragraph D. of the Definitions Section is replaced by the following: D. "Covered pollution cost or expense" means any cost or expense arising out of: 1. Any request, demand, order or statutory or regulatory requirement; or 2. Any claim or "suit" by or on behalf of a governmental authority demanding that the "insured" or others test for, monitor, clean up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of "pollutants". "Covered pollution cost or expense" does not include any cost or expense arising out of the actual, alleged or threatened discharge, dispersal, seepage, migration, release or escape of "pollutants": a. Before the "pollutants" or any property in which the "pollutants" are contained are moved from the place where they are accepted by the "insured" for movement into or onto the covered "auto"; or b. After the "pollutants" or any property in which the "pollutants" are contained are moved from the covered "auto" to the place where they are finally delivered, disposed of or abandoned by the "in- sured". Paragraphs a. and b. above do not apply to "accidents" that occur away from premises owned by or rented to an "insured" with respect to "pollutants" not in or upon a covered "auto" if: (1) The "pollutants" or any property in which the "pollutants" are contained are upset, overturned or damaged as a result of the maintenance or use of a covered "auto"; and (2) The discharge, dispersal, seepage, migration, release or escape of the "pollutants" is caused directly by such upset, overturn or damage. CA 99 48 09 02 ® ISO Properties, Inc., 2002 Page 1 of 1 INSURED COPY 07/20/2012 8910289 NECLXJXA 2607 PGDM060D J05955 STACK09G 00000828 Page 73 Palsy # 20766~~.,~3 G-140331-B ~~ (Ed. 01 /09) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE (OPTIONAL) Name of Additional Insured Person(s) (As required by written contract/agreement per Paragraph A. below.) Location(s) of Covered Operations (As per the written contract/agreement, provided the location is within the "coverage territory" of this Coverage Part.) (Coverage under this endorsement is not affected by an entry or lack of entry in the Schedule above.) A. Section II -Who Is An Insured is amended to include as an additional insured any person(s) or organization(s), including any person or organization shown in the Schedule above, whom you are required to add as an additional insured on this Coverage Part under a written contract or written agreement, provided: a. The written contract or written agreement was executed prior to: 1. The "bodily injury" or "property damage"; or 2. The offense that caused the "personal and advertising injury" for which the additional insured seeks coverage under this Coverage Part; and b. The written contract or written agreement pertains to your ongoing operations or "your work" for the additional insured(s). B. The insurance provided to the additional insured is limited as follows: 1. The person or organization is an additional insured only with respect to liability for "bodily injury," "property damage," or "personal and advertising injury" caused in whole or in part by: a. Your acts or omissions; or b. The acts or omissions of those acting on your behalf in the performance of your ongoing operations for the additional insureds) or c. "Your work" that is included in the "products-completed operations hazard" and performed for the additional insured, but only if this Coverage Part provides such coverage, and only if the written contract or written agreement requires you to provide the additional insured such coverage. 2. However, we will not provide the additional insured any broader coverage or any higher limit of insurance than the least of those: a. Required by the written contract or written agreement; b. Described in 6.1. above; or c. Afforded to you under this policy. 3. This insurance is excess of all other insurance available to the additional insured, whether primary, excess, contingent or on any other basis, unless the written contract or agreement requires this insurance to be primary. In that event, this insurance will be primary relative to insurance which covers the additional insured as a named insured. We will not require contribution from such insurance if the written contract or written agreement also requires that this insurance be non-contributory. But with respect to all other insurance under which the additional insured qual~es as an insured or G-140331-B Includes copyrighted material of Insurance Services Office, Inc., with its permission Page 1 of 2 (Ed. 01/09) additional insured, this insurance will be excess. 4. The insurance provided to the additional insured terminates when your operations for the additional insured are complete. But if the written contract or written agreement specifies a date until which this insurance must apply, then this insurance terminates: a. On the date specified in the written contract or written agreement; or b. When this policy expires or is cancelled, whichever occurs first. C. With respect to the insurance afforded to the additional insured, the following additional exclusions apply. This insurance does not apply to: 1. "Bodily injury," "property damage," or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering, or surveying services, including: a. The preparing, approving, or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and b. Supervisory, inspection, architectural or engineering activities. 2. "Bodily injury," "property damage," or "personal and advertising injury" arising out of any premises or work for which the additional insured is specifically listed as an additional insured on another endorsement attached to this Coverage Part. D. SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows: 1. The Dutiss In The Event of Occurrence, Offense, Claim or Suit condition is amended to add the following additional conditions applicable to the additional insured: G-140331-B (Ed. 01 /09) An additional insured under this endorsement will as soon as practicable: (1) Give us written notice of an "occurrence" or an offense which may result in a claim or "suit" under this insurance, and of any claim or "suit" that does result; (2) Tender the defense and indemnity of any claim or "suit" to any other insurer or self insurer whose policy or program applies to a loss we cover under this Coverage Part; (3) Except as provided in Paragraph 6.3 of this endorsement, agree to make available any other insurance the additional insured has for a loss we cover under this Coverage Part; and (4) Send us copies of all legal papers received, and otherwise cooperate with us in the investigation, defense, or settlement of the claim or "suit." We have no duty to defend or indemnify an additional insured under this endorsement until we receive from the additional insured written notice of a claim or "suit." 2. With respect only to the insurance provided by this endorsement, the first sentence of Paragraph 4.a. of the Other Insurance Condition is deleted and replaced with the following: 4. Other Insurance a. Primary Insurance This insurance is primary and non- contributory except when rendered excess by this endorsement, or when Paragraph b. below applies. E. The provisions of the written contract or written agreement do not in any way broaden or amend this Coverage Part. G-140331-B Includes copyrighted material of Insurance Services Office, Inc., with its permission Page 2 of 2 (Ed. 01/09) POLICY NUMBER: C 2076630503 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s): Each of your construction projects located away from premises owned by or rented to you Information re uired to com lete this Schedule if not shown above will be shown in the Dedarations. ix A. For all sums which the insured becomes legally obligated to pay as damages caused by "occun'ences" under Section I -Coverage A, and for all medical expenses caused by accidents under Section I -Coverage C, which can be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. A separate Designated Construction Project General Aggregate Limit applies to each designated construction project, and that limit is equal to the amount of the General Aggregate Limit shown in the Declarations. 2. The Designated Construction Project General Aggregate Limit is the most we will pay for the sum of all damages under Coverage A, except damages because of "bodily injury" or "property damage" inducted in the "products-completed operations hazard," and for medical expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or "suits" brought; or c. Persons or organizations making claims or bringing "suits." COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 3. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the Designated Construction Project General Aggregate Limit for that designated construction project. Such payments shall not reduce the General Aggregate Limit shown in the Dedarations nor shall they reduce any other Designated Construction Project General Aggregate Limit for any other designated construction project shown in the Schedule above. 4. The limits shown in the Declarations for Each Occurrence, Damage To Premises Rented To You and Medical Expense continue to apply. However, instead of being subject to the General Aggregate Limit shown in the Declarations, such limits will be subject to the applicable Designated Construction Project General Aggregate Limit. CG 25 03 05 09 Copyright, Insurance Services Office, Inc., 2008 Page 1 of 2 8. For all sums which the insured becomes legally C. obligated to pay as damages caused by "occurrences" under Section 1 -Coverage A, and for all medical expenses caused by accidents under Section I -Coverage C, which cannot be attributed only to ongoing operations at a single designated construction project shown in the Schedule above: 1. Any payments made under Coverage A for damages or under Coverage C for medical expenses shall reduce the amount available D. under the General Aggregate Limit or the Products-completed Operations Aggregate Limit, whichever is applicable; and 2. Such payments shall Designated Construction Aggregate Limit. not reduce any Project General When coverage for liability arising out of the "products-completed operations hazard" is provided, any payments for damages because of "bodily injury" or "property damage" inducted in the "products-completed operations hazard" will reduce the Products-completed Operations Aggregate Limit, and not reduce the General Aggregate Limit nor the Designated Construction Project General Aggregate Limit If the applicable designated construction project has been abandoned, delayed, or abandoned and then restarted, or ff the authorized contracting parties deviate from plans, blueprints, designs, speafications or timetables, the project will still be deemed to be the same construction project. E. The provisions of Section III -Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. Page 2 of 2 Copyright, Insurance Services Office, Inc., 2008 CG 25 03 OS 09 COMMERCIAL AUTO GOLD ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies Insurance provided under the following: BUSINESS AUTO COVERAGE FORM SECTION II -LIABILITY COVERAGE A. COVERAGE 1. WHO IS AN INSURED The following is added: d. Any organization, other than a partnership or joint venture, over which you maintain ownership or a majority interest on the effective date of this Coverage Form, if there is no similar insurance available to that organization. e. Any organization you newly acquire or form other than a partnership or joint venture, and over which you maintain ownership of a majority interest. However, coverage under this provision does not apply: (1) If there is similar insurance or aself-insured retention plan available to that organization; or (2) To "bodily injury" or "property damage" that occurred before you acquired or formed the organization. f. Any volunteer or employee of yours while using a covered "auto" you do not own, hire or borrow in your business or your personal affairs. Insurance provided by this endorsement is excess over any other insurance available to any volunteer or employee. g. Any person, organization, trustee, estate or governmental entity with respect to the operation, maintenance or use of a covered "auto" by an insured, if: (1) You are obligated to add that person, organization, trustee, estate or governmental entity as an additional insured to this policy by: (a) an expressed provision of an "insured contract", or written agreement; or (b) an expressed condition of a written permit issued to you by a governmental or public authority. (2) The "bodily injury" or "property damage" is caused by an "accident" which takes place after: (a) You executed the "insured contract" or written agreement; or (b) the permit has been issued to you. 2. COVERAGE EXTENSIONS a. Supplementary Payments. Subparagraphs (2) and (4) are amended as follows: (2) Up to $2500 for cost of bail bonds (including bonds for related traffic law violations) required because of an "accident" we cover. We do not have to furnish these bonds. (4) All reasonable expenses incurred by the "Insured" at our request, including actual loss of earning up to $500 a day because of time off from work. Includes copyrighted material of Insurance Services Offices, Inc. with its permission GECA 701 (01/07) Page 1 of 3 INSURED COPY 07/20/2012 8910289 NECLXJXA 2607 PGDMO60D J05955 STACK09G 00000796 Page 41 SECTION III -PHYSICAL DAMAGE COVERAGE A. COVERAGE The following is added: 5. Hired Auto Physical Damage a. Any "auto" you lease, hire, rent or borrow from someone other than your employees or partners or members of their household is a covered "auto" for each of your physical damage coverages. b. The most we will pay for "loss" in any one "accident" is the smallest of: (1) $50,000 (2) The actual cash value of the damaged or stolen property as of the time of the "loss"; or (3) The cost of repairing or replacing the damaged or stolen property with other property of like kind and quality. If you are liable for the "accident", we will also pay up to $500 per "accident" for the actual loss of use to the owner of the covered "auto". c. Our obligation to pay for, repair, return or replace damaged or stolen property will be reduced by an amount that is equal to the amount of the largest deductible shown for any owned "auto" for that coverage. However, any Comprehensive Coverage deductible shown in the Declarations does not apply to "loss" caused by fire or lightning. d. For this coverage, the insurance provided is primary for any covered "auto" you hire without a driver and excess over any other collectible insurance for any covered "auto" that you hire with a driver. 6. Rental Reimbursement Coverage We will pay up to $75 per day for up to 30 days, for rental reimbursement expenses incurred by you for the rental of an "auto" because of "loss" to a covered "auto". Rental Reimbursement will be based on the rental of a comparable vehicle, which in many cases may be substantially less than $75 per day, and will only be allowed for a period of time it should take to repair or replace the vehicle with reasonable speed and similar quality, up to a maximum of 30 days. We will also pay up to $500 for reasonable and necessary expenses incurred by you to remove and replace your materials and equipment from the covered "auto". If "loss" results from the total theft of a covered "auto" of the private passenger type, we will pay under this coverage only that amount of your rental reimbursement expenses which is not already provided under paragraph 4. Coverage Extension. 7. Lease Gap Coverage If a long-term leased "auto" is a covered "auto" and the lessor is named as an Additional Insured - Lessor, In the event of a total loss, we will pay your additional legal obligation to the lessor for any difference between the actual cash value of the "auto" at the time of the loss and the "outstanding balance" of the lease. "Outstanding balance" means the amount you owe on the lease at the time of loss less any amounts representing taxes; overdue payments; penalties, interest or charges resulting from overdue payments; additional mileage charges; excess wear and tear charges; and lease termination fees. B. EXCLUSIONS The following is added to Paragraph 3 The exclusion for "loss" caused by or resulting from mechanical or electrical breakdown does not apply to the accidental discharge of an airbag. Includes copyrighted material of Insurance Services Offices, Inc. with its permission GECA 701 (01107) Page 2 of 3 INSURED COPY 07/20/2012 8910289 NECLXJXA 2607 PGDMO60D J05955 STACK09G 00000797 Page 42 ~~ ~~ t < ~.. ti, ~ '~ ~: ~ ~: j 1 ~ a~ ~ ~ z~ n, ~`- ~~ ,~;a~ ._- ____ _l ! ir 'r ~` ~ ~-~''~ ~ ~ ~~ } -_ _ _ r_ ~F ~ xi + T A 4 ~\ , ~~ a$ ~~ z ~~ ~ ~ ~- .,, ~: n ~. r- ~` ~„ ~ r ?•- ~ ~ ~ '' ~. , r.~ ,~ ~ u~ ~, T ~ ~- ~ ~., ,~ ~- .r~a~ ~~ ~J~ ~~ ~, G A oR CERTIFICATE OF LIABILITY INSURANCE ~;i;;2o°is 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(les) must tte 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 certiflcate holder in lieu of such endorsemerrt(s). PRODUCER NAME T All Spectrum Ins All Spectrum Insurance Brokers PHONE (406) 739-8300 FAX . (866)826-6781 4300 Stevens Creek Blvd '~1 .help@asibrokera.com S111 to 1 O O INSURERS AFFORDING COVERAGE NAIC a San Jose CA 95129 INSURERANational Fire Insurance Co of 0478 INSURED INSURERB:Peerless Insurance CO an 4198 Able Underground Construction, Inc, DSA: Able INSURERC:3t Paul Fire and Marine Ins Co 4767 1020 Ruff Dr INSURERDEverest National Insurance Co 0120 INSURER E San Jose CA 95110 INSURER F COVERAGES CERTIFICATE NUMBERCI.1371"~ous:~~ r~vw~vn nvwrocn. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED . 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 L TYPE OF INSURANCE POLICY NUMBER M UCY EFF PO pCY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE b 1 , 000 , 000 X GENERAL LIABILITY R g ~ E 300, 000 A CIAL COMME MADE a OCCUR CLAIMS X Y 076630503 /1/2013 /1/2014 MEDEXP Any one person b 5,000 - PERSONAL 8 ADV INJURY E 1 , 000 , 000 GENERAL AGGREGATE E 2,000,000 REGATE LIMIT APPLIES PER: ' PRODUCTS - COMP/OP AGG E 2 , 000 , 000 L AGG GEN X POLICY PRO LOC N L u l a we b 1 000 000 AUTOMOBILE LUIBIUTY nt E X ANY AUTO BODILY INJURY (Per peroon) b B ALL OWNED SCHEDULED X 8910289 /20/2013 /20/2014 BODILY INJURY (Peraccidenl) b AUTOS NON-0WNED PROPERTY DAMAGE b P r ent HIRED AUTOS AUTOS TERRR b X UMBRELLA LIAR UR EACH OCCURRENCE E 1 , 000 , 000 EXCESS LIAR OCC MADE CLAIMS AGGREGATE b 1 , 000 , 000 C - DED X RETENTIONS 10,00 UP14R6811013NF /1/2013 /1/2014 b D WORKERS COMPENSATION Y WC STATU- OTH- ANDEMPLOYERS' LIABILITY TNER/EXECUTIVE Y E.L. EACH ACCIDENT E 1 000 000 ~ ANY PROPRIETOR/PAR OFFICER/MEMBER EXCLUDED? NSA 600007280131 /1/2013 /1/2014 E.L. DISEASE - EA EMPLOYE b 1 000 000 (Mandatory in NH) If yes, desaiUe under E.L DISEASE -POLICY LIMIT E 1 000 000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 101, Additlonal Remarks Schedule, It more space b required) RE: permist$ ENC2013-00098 reemen~ per attached endorsements G-140331-B (Ed. 01/09), AC01020308 n contract/a itt d b g y wr e As require the following ie additional insured: City of Campbell, The City of Campbell Redevelopment Agency, its officers, employees and volunteers. IC (408)376-0958 14083760958@myfax.com City of Campbell 70 N 1st Street Campbell CA 95008 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATVE triy Lazarev/DIID-L ~- c~ 191ta_2010 ACORD CORPORATION. All righffi reserved. AI.VKU La ILVIVrVa) INS025 r~mnnF~ n~ Tiro Ar`~1Rr1 name ~nA Innn ano roniee•ororl marina of Ar_ARfI /`-A ~ ti~ ~ `~' ~J ~~ ~~ J yy zw. M s G ~ d ~. "~ q~ ((( `p ~x -x- !5 Cn,, ",.1. ;,, r' ,~ ~~ ~ T \`~ -Y 3 ,.~~ ~~.' ~1 i .~ ~a x ~ - p x < I y~ N y I ` 1 1 l ~~a yti ~i ___ ~~ ~ ~.^ ~~ iSa 1 J ~ '~, t 1tj---^~ ----<- -- 'It r -~ ~~ ~~- C + _{ .L `' ~' .;J n, westvaney ~ Sewer Connection Permit No: 1 " 1 Sanitation Distn t `~ Issue Date: ~yGj ~ By: _ OFFICE HOURS &~~O ~TACTS: FEES: 7:30 a.m. to 4:30 p. ~. M nday thru Friday Connection $ 100 E. Sunn oaks A~e'~ Cam bell, CA 95008. Capacity y p Processing `7 /c:s' `~' • Phone: (408) 378-2407 Service Advance • Information Services Department ~7~.%aTt~-, '~ , c`G LOCATION: APN ~~- ©"- O~~ Sewer Map Book { Page f_S~ >,c> ~/~ '"~ Tract Lot Total Due: $ , Project Assmt Ad ess f ~Sc~r etc. ~cs~./rJG`i Paid by Check No: ~~~~.:, _'S ~T ~, ° ` Hillside: Yes_ No ~ ; - Jurisdiction ~ ~.vGc BUILDING TYPE: INSTRUCTIONS: • Permit is invalid if not connected within 12 Single Family months of issue. Condo/Town House Multiple Dwelling Units • Do not connect until the main sewer is accepted Industrial by the District. Commercial • Obtain a building or plumbing permit from the ` / _ REMAR S: /N.=l'.•~~x- G~ `' ~+5~`9'~~-~G- Jurisdiction listed above. • Street encroachment permit is required from • Keep 3' radius around cleanout clear of OLD PERMIT No.1~~ Sub No. ~'.R'~ vegetation or obstruction. BACKFLOW PREVENTION: Field check required Basement Check valve required: Yes No _ '} H ~~ /'..o.v~k LrF/ ~ BUILDINGr-SEWER CONNECTIONS: Total number of connections to this property: 1. Lateral ID No.~7/~ • is located ~,~" feet ..S` of ~_ property line, feet from main sewer and S'. 7 feet deep. Connection to Main Sewer© feet US from DS MH ~-CJf~`~e%~ US MH ~~~/=--~'/ Pipe Type List any additional connections on ~ reverse side of this form. ~~ Original -Applicant Pink -Accounting ~° ~ a~. , 5~ ~ ~ ~. ~ r 3 ~ tr" it v~ r. 4 „~ Yellow -City/County Bldg. Inspector N .A O f-+ O lp ;. ~~ ~ .,~ `f ~ at~~, .. ~ ~ ~ ~ ~~ ~ ~~Y.: ~. ~ M tg~ s r rr~ ~ T ~ ' if, ~ + - '° ~R i ,. •: ~ A ~ ~ ~ • ';..sin ~. - -. I ! j~ ..: ~!'I Ir Z T ~ r 0 ~, r 0, fND ~ r O ~~' a ~a_ 04 O O ~l: ~' ~ ~ ~ ~ 0° ~ ® ®~ ®~ T n T ~ Z `~ ~~S ~d~ ~ p~j r+ ~~Os ~ ~ ~ ~: ~ ~ u I (zif Tt ~ ~ ."~ a i i O n U! O' =• Q C ~ d- ~ fD ~ ~ ~ in p rh Z N ~~z~ ~ 3 ? ~ ~ ~ O O ~ 4 s ~. ~ a 4 ~ O_ f1 0 ~ rl' c a ~, a o~~ A =~ o ~ ~, ~, o E~ ~ o r+ ,,. C zynZ ~~ ~ tias .. a ~ o ~ ~ ~ N ~~. _ ~~ ro z< i3= aIN A"' ~ 3 o a ~^ _ t- rc- .~r j `' V t f r~ i ~~ ~ ': `~ ~~` i.~ ~ a / ~ s s ~, ~ r ~~ .._ ........~... n.._........ _.,., ~~~ _____ ~~~~ C` ~,: '~ r r~ n D~ ~ ~ ~F ~ x i°~b~ ~ ~ ~~ ~~ ~ J '"~" ~I i ~!-'~ J~ . , ~i ~' ~.-