Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
ENC2011-00007
CITY OF CAMPBELL 'CROACHMENT PERMIT ~A~ DEPT. OF PUBLIC WORKS i No LC~L 2" f (° GC'L'G .7 .,r working within the public k-.,cT. File 70 North First St. right-of-way) Campbell, CA 95008 (408) 866-2150 Issued _ (~~L ~ ~ ~ ( Application Date (~~ ~ I Fax (408) 376-0958 Application Expiration Date ) Perini[ Expiration Date ` ~ ~ ~ 2 APN ~~ ~--+ ~,, APPLICATION -Application is hereby made for a Public Works Petmit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable.) A. Work address or tract # Utility trench B. Nature of work C. Attach four (4) copies of an engineered plan showing the location and extent of the work, and four (4) copies of the preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer, said plan becomes a pazt 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 be re restarting any work. Name of Applicant /~~ 3~ ~ L Telephone 1G~C71J `~~- . 1 j~ Address ~ y~-~ ~g (Prt name) .~'_C~ ~ 24-HOUR EMERGENCY TELEPHONE NO.,~~ ~~~=~ ~_ w (,~ E-Mail Address ~~ L~ ~ ~~ _ 11A. ~/ ~iSvS `~' Is this work being done by the property owners at their own residence? Yes ~,No The ApplicanUPermittee 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 tt}avvork cove~ye~ by this~pgrmit. The ApplicanUPermi[tee hereby acknowledges that th ha re and information. Applicant is advised that upon suanc of is p rmit, arising out of the condition of any private imp~vemen in he ,t,s~.~ both the front and back of this permit, and they will inform their contractor(s) of [he vner, or property owner's successors, shall be responsible for any and all damages v~Cro~ "( (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 he s ecificall a roved b the Ins ector rior to cuttino. _ ~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 1-800-227-2600. _5. Prior [o any work, the property owner shall execute an Agreement for Private Improvements in the Publ clRight-oft Way, which shall be recorded. _6. Public Notification Requirements: _7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT N0. PERMIT APPLICATION FEE PLAN CHECK DEPOSIT $ 3Sv Z LZ I SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $ CONSTRUCTION CASH DEPOSIT $ ~- PLAN CHECK & INSPECTION FEE $ i $~ 7 2'Z--. L I~ APPROVED FOR ISSUANCE For City Engineer L 1 Perrtut Expires 12 Months After Date of Issuance Date ~(~ S/t~/lS ~~ 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 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 vehicular 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 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. 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 al] PCC or AC removals. A]1 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 norntal working hours, on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. I1. 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 provide 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. 15. 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. 16. 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. l9 other than stormtwater0.2Applicantnshallladhererpolthe BESTIMANAGEMENTSPRACTICESrestablishedtbyathetSanta Clara Valle Urban Runoff 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. Contractor (Print Name) Date Applicant Date J\forms\pwperm Rev. 11 /9/0~ n?~i `~ ,~ o '~ N N N "17 O O ~ ~ ` O_ _O C7 N N ~ ~ N °° ~, r ~o ~o O o ao 0 -+> -o x '~ y 0 .. m A A 0 0 0 0 -o a s~ 0 0 0 0 Q ..j a r- z 3 a z z v Nz~ ~ o ~. x~!~~ ... O ~x~ 0 ~, m n ~ w w v, <n 0 0 °o °o w w v, c.n 0 0 °o °o ~ ~ N N O O W W N N ~ ~ ~ O O O O ~ O O d ~~ a •c w s C m "'C G a n s A T. n z w o a ~. d e n b A~ ~ ~ ~ .. ~ C~7 ~ z n N r. O ~ ~ ~ ~,,, C ~! O ~C O ~ O O ~ N N N ~ 'OU O O I a T0: City Clerk PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT & TRAFFIC RtGtIF' I Effective July 1, 2010 PUBLIC WORKS FILE NO. _~~ ~__ ~Z`_l ~ ___ ~~~'~~ 7 ___ PROPERTY ADDRESS ~ ~ ~ 2 ~i ~~ ~P~ _ Please collect & recei t for the followin monies: _ ACCT.T ITEM LAND DEVELOPMENT AMOUNT.: 4T2~ ncroacFiment ermit A ication ee Non-Utility Encroachment Permit $350.00 5 Minor Encroachment Permit <$~o,ooo $200.00 Initial R-1 Permit N/C _ Subse uent R-1 Permits within Two Year Period $200.00 -_ 2203 Plan Check De osit 2% of En ineer's Estimate $500.00 min Utility and R-1 Permits no deposit required __. 4722 Grading & Drainage Plan Review Single Family Lot $250.00 Site < 10 000 s.f. $750.00 _. __ Site >_ 10 000 s.f. < Acre $1 000.00 _ _ _-_ Site ? 1 Acre $1 500.00 __ Pla n Check & Ins ection Fee Non-Utilit __ ~ SL' _ Engr. Est. up to $250,000 14% of Engineer's Estimate ___ _ __ 4722 En r. Est. ?$250 000 Actual cost +20% Admin Overhead __ (Min $35 000 Deposit) __ 2203 Emer enc Cash De osit 4% of En r. Esf.' $500 min/$10 000 Max __ 2203 Faithful Performance Security (FPS) __ 100% of ENGR. EST.` _ __ 2203 Labor and Materials Security 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) $3 600.00 + $80/lot ____ _____.___ __ 4722 Final Tract Map (5 or More Lots) $4 400.00 + $108/lot ____ _ 2203 __ Monumentation Securit 100% of ENGR. EST. __ _ _________ 4920 _4722 4722 4722 4722 4722 4722 4722 _ Parkland Dedication Fee 75%/25% Due Upon Cert. of Occupancy) Lot Line AdLstment $1 400.00 _ Vacation of Public Streets & Easements $2 250.00 Certificate of Compliance _ - $1 700.00 __ Certificate of Correction $500.00 A eal Filin Fee $200.00 Nota Fee er si nature $10.00 Assessment Segregation or Reapportionment -__ First Split ___ _ $800.00 ___ ~________ _ __ _.____. _-_____ _.- _ ____ _ Each Additional Lot $250.00 _. __ _ _ __ 511.7424 TRAFFIC 4728 _ _ Postage Traffic Flow Ma Dail Traffic Volumes $34.00 ___ 4728 __ Signal Timing Information $72.00/Hr _ 4271 Truck Permits $16.00/ er try _ 4728 No Parking Signs MISCELLANEOUS $1/each or $25/100 Other (Please Specify) ~ ____. "Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. ~'7 "Actual Cost Plus 20% Overhead (Non-Interest bearing deposit) TOTAL $__ / ~C _ ~tZ ~ _ __ 2~T- NAME OF APPLICANT ~ 2~j ~~rj GU~ ___ NAME OF PAYOR (~, ~~ ~-~-~ ~ _ _ _____ _ PHONE _-_-_ _ __ ADDRESS ~ 3 ~''l © ~~.~~~ ~ ~~ _~>7»»?~n~- ZIP cl ~ ~S ~ ~ --- - FOR CITY CLERK ONLY l- __ --_ I ,,~ - RECEIVED BY _ ~ C~--`~~ l~~~'-%!~~-'~~ - Date `~ Receipt # _L-~~~~ } ~'° __ *Focplan Check and Cash Deposits, send yellow copy to Finance. _ - Date/ Initials JIFORMS\TemplatesWEminislralrveW eceipt Form Land Oevelopmenl Tld111[ 10-111Rev O6/1 O:i c ef' ~T v aci I -p ~, ~ G~ E N ~ °% ~ ~ .a? q C m o Z ~ c6 a M ~, Z ~ ~ o -~ m ~' ~ ~ Q N ~ 0 U ~ Z :~ _O •~~ } Z o c ~O / v ~ F- U f6 N I d ~ Z ~ ~ Z ~ m E 3 ~ c > ~ .~ ~ o 1 o E cis ~ Q ~J ~ „° W me ~ ~ (~ ~ c a N ~ 3 ~~ ~ ~ .a 2 ~I~ ~° o 0 2 w o ° O LL W j ~° N O cw~ ~ J O > >, m I~ ~~~ m ~ a °' LL Y Z c~ '~- ~ a w u~i Y ~ p N ~ ~~~ ~ _ ~ rn U .c ~~ N~ c~~ Q U J O O ~ ~ ~~ h N W m ~ m ~a ~~~ Uppa Jd o ~ -.~ o ~ ~' ~ ~ ~' w E O r U ~ O L ~ a ~ ~. _~ 3 ~ ~ ~ a~i O 69 ~ ~ d N a N U ~..1 ~ M I ~ 'C _~ 'N O ~ W ~ l° c c G1 .Q ai o ~°, ~ ~vE ~c C ~ O O Z ~ Boa v.° ° Z ~ a .n ... v 2'i coc c~ O C > ~ U ~" C O -O N ~~ U ~ ~~ O .c N Za m ~"' may= N'O N ~ ~ h 3 ~cQ~•z -° ~ ~~Ny oo~°~ ~o O (0 O T7 = ._ L ~ m cv c WUUd.(~ c0 ~ ~€o c~'CN ~ ~~ ~ a ~ ~~ ~ ~ = za ~ o~ •~ ;w ~ a _ ~ O ~ Y ~ 0 T o U ~ ~ LL U aci Y m ~ I w U ~ n a o ~ Z o U O ~ N v `~ U ~ > w ~ Zi ~ Q N M d ~ M N ~ O C ipo ~q = V 1. ~ p C . ~ ~~ O C = n = 3N E c W c ( j o W a LL ch Q W ~ O ' \ d rn °' d Oa~~ ~ J Q. ~ o O a Z ~ Q ~ ~ '~ c>aa~~~~ OQ~--aQ J .~~. .~ ~~ ~ 4 0 \ T = .c O ~ C •E33 ~ ~ ~ tp O ° _. •U LL ~ O .N ~ Q a ~ '6 _a V) m N '= O ~ ~ O C7~U~ CU _Z J Q ~ ~ m !L I C z .O n~ '\ M O LLZ~ 1"~ w a J O m N 0 I U o` n c m m C O U ..~. U i 0 } ~ •~.. ~~ c ~ 'm (~j ~J U ~ Q i C a ~. `~~ C V m .U a a .~ Page 1 of 1 Joanne D' Ambrosia From: Sanchez, Joy [Joy.Sanchez@LibertyMutual.com] Sent: Wednesday, January 19, 2011 12:11 PM To: Joanne D' Ambrosia Subject: ARS Rescue Rooter/ City of Campbell Certificate and Endorsement Attachments: SKM253-01-011011915590.pdf Hi Joanne, I received the attached cent and end. revision for ARS Rescue Rooter. As for Item 1 , I can not amend any endorsements to show the following: -The insurance coverage afforded to the Additional Insured is rp imarKinsurance. Do you have a sample copy of an endorsement that shows this wording? As for Item 2, I am waiting for the broker to get back to me as I need his approval to add City of Campbell on Waiver of Our Right to Recover from Others endorsement. Item 3. I will amend the certificate of insurance to indicate "any auto. I will send the revised certificate and endorsement as soon as I hear back. from the broker. I apologize for the wait. a ,.~ ('ust~>mer,S'errnce (;nordi~nator Gi6erty '~Nutual ,13er.~er ~F~trm ~d. 1~gseCarrcC, :~'% 07068 ;r'~~ne: <Y00-900-4825 e.~t. 2026 5~1~9V 8-448-2026 I'a:~• 973-7~8-1493 jo~sanc(e~ (~?EiFer~t~!ruutuczGu~m °*r1'lrase het any Supert~isvrknou~ fio~u~ I am doing. r~incent.~i~aCleC?Ci~c:rtyrnutual;com *** eSafe 7 scanned this email for malicious content *** *** IMPORTANT: Do not opera attachments f..r..om urir.ecogni.zed sendex-s *** 1/19/2011 ~~~ ~. CITY OF CAMPBELL PUBLIC. WORKS DEPARTMENT ~~ ~~ 70 NORTH FIRST STREF,T ~~;~' CAMPBELL, CA 95008 FACSIMILE/EMAIL TRANSMITTAL SHEF,T TO: FROM: Joy Sanchez/Liberty Mutual Joanne D'Ambrosia, Office Specialist EMAIL DATE: 1/18/11 FAX NUMBER: TOTAL PAGES INCLUDING COVER: 1-973-758-1493 g PHONE NUMBER: SENDER'S EMAIL: 1-973-533-6509 joanned@cityofcampbell.com RE: PUBLIC WORKS FAX #: Certificate of Insurance 408-376-0958 ^URGENT^FOR REVIEW^PLEASE COMMENT X PLEASE REPLY ^ PLEASE RECYCLE NOTES/COMMENTS: Re: Insured: ARS Rescue Rooter Permit/Project #ENC2011-00007 Work Site: 1482 Ridgeley Drive We have received your certificate of insurance for the work your uisured will be doing in the City of Campbell. In order to meet our minimum insurance requirements, we still must ask that the following changes or additions be made to the certificate or information provided to the City. 1. The required endorsements to General Liability and Automobile policies are to show: -The insurance coverage afforded to the Additional Insured is primary insurance. 2. A waiver of subrogation clause is required in connection with the workers' compensation coverage. 3. We also require the "any auto" be indicated under auto liability on the certificate. A copy of our insurance requirements and your insurance certificates follow for your reference. You may forward the requested items to us by fax or email. cc: Syed Wahidi "t CII~,(:.~:'C lti ISSUED \S •\ ~fA ~. m a~..t ti i~OLIL1 A,ti t) UUE~ tiCl' :11 `t'his is to Certii'y that ( ARS Rescue Rooter ~ Branch #8128 3390 Keller St Suite B Santa Clara C.erGFlcatc of I:nsurauce S LISr6ll BELU\~I'OL; CY I.I'v1LILtSI \[(IENO!l..I`SSkrIIAN (Rust UE 1'v 'OR\1ATtlI\ tltv:.Y ? ~ lC'I: ~I )C l ~ TS I E ) Ht . [ ~\t~L- UFtDLD dY AI CIRAI_krd"IHC3(C X'tLi~P ii' ' ' ' . : . . . ED 3[L.ON r A4 C)1J7TIUNAI_ S:.HL3S11T)1 e'~i1T$ ti0"I LIS ~ NAME AND ~~~ t~ Liber ADDRESS t)F INSL,""RED tual ~Vl CA 95054 u Cond ttions~Urd i>.wt ahcredrtc m~~.e.Ia:r~nttn ~~tsm~~P'u~rxiitivlnt~hr.mr~on ~r.curotku dnct.n>i nt ttnl rspcctlr,driu~r it iii ~icrtatcatu~nt}~~~:urd ttn ill their :urns, eichstcns arc TYPE OF POLICY WORKERS CO~tPENSATK)N C'O~ili 1ERCIAI, GIiN'FRAL LIABILITY [.~ occuXke~cr :1UTO~iOBILE LIABILITY [/1o44~kD Q Ni)'N-i )14'ivil ~) ti1Rl?D O'7I{EN 10/1/2011 TB2-631-508631-020 10!1!2011 ~ AS2-631-508631-030 LIi17IT Oh LIABILITY ;.04 Lk( \i Y: 1 UfLI7FU t vDEN \4C E~1YL01'F.KS L.IAIIiI,ITY I„~« c71• Tk1 L, rul,:..O4vlrvc sr.\rrs~ Ail States except Monopolistic t;tidily Iniury by Acc,dcnt 1 000 000 rart~ at: ~x•~~~ 13adtly Injury k3y L)iscase 1 000.000 daddy Injury k3y Di;ea>r 1.000.000 , liene;::I :\ggrc~ate 4 000 000 I'rgdutits : Coinlaeted (7patoiions Aggres;ata 4 000 000 tact: Uccnrrcnce 2 000 000 Personal S: A9:enissng la}ury ~ O}~O{O OOO k'cr Pecs-un' Urgnnlr~ncn Ot, r r$eI ~,OCiO ~~,coo,ooo Each Accident-Single L:uut 2,000,000 13.1. And P D. C.om~med r..:ch :'erxun Each Accident ur ~)Gti:itTl ti':. Each Accident or Oce tur:;nce \t)Url'IUivAI, Cp3t41k:~]'S RE: BLDG2010-01129, 1482 RIDGELEY DRIVE. ALL WORK 1N PUBLIC RIGHT-OF-WAY. GITY OF CAMPBELL REDEVELOPMENT AGENCY, ITS OFFICERS, EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSUREDS AS RESPEGT LIABILITY PER CG 20 10 07 04 ;; Ltc cetll 6catc ~rp~artie. da~c is vnnuuouv r. exterdcd icrn. ~ u: ~a~d'. 6~ nclaled'.fc ri;,c ;s t,. nroateci or r 1; c d etme tha cmvheuc expiraUOn dntc l,ibert\' Dlufual Insurance Group 'SO CICF: 6E' CAC hi.1.11IUN: r;vt) l 111 LiC, Aka . IiNL] ~S 1 NNhlttl R UP C) l S ~ E~ti~i FR ) HLiL044'.1 3E U~t:: Tli ~I1TEp L\~:X:~rlO~. DATE: IH( CU`i t'1'~`t 14';[ Nt )`~ C\'~C F. (aRJA},1l Nt lKU~~ i?v Sl 2A%V C`E. AF r(7RD[) UNUGR 1~H k: At301`E PV LIC1ES tJ?7~nLAf LE:A..'h 3O Ut SUC H CANCELL.ATIOTv HAS E;: rh VLA[LED TiY _~~ CI1Y OF CAMPBELL Joy Sanchez ATTN: DEPT OF PUBLIC tNORKS Roseland G32~ AuTH(iLtiz.r.D Xr;'Xesrr,'rA rlvi - 3 Becker =arm Road Roselar.~d NJ U7G68 973-533-6509 1!1412011 70 NORTH FIRST STREE ( ~ orru e vHOtie DArL lssut.u y l CAMPBELL CA 95008 This certific;tt~ is executed by U}3EK [ Y ivlU'CU/~L IRSUKR?~EC E GRC)l~N a~ res}~aec; such nsuran. e its is uf~orded by those C~mpanics N31'1 772 07-1 t) ^ coNTLULotrs POLICY Nt~tl7BER ^ ti\'I1NDEll ® t'CLiCI' TURD W C7-631-508631-010 10/1/2011 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -SCHEDULED PERSON OR ORGANIZATIt)N This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL UA811_ITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anizatian s Location(s) Of Covered Operations City of Campbell Where required by written contract or written Attn: Dept. of Public Works agreement 70 North First Street Campbell, CA 95008 i Information required to complete this Schedule. if not sho wn above, will be shown in the Declarations. A. Section li -Who Is An Insured is amended to B include as an additional insured the person{s} or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and adver#ising injury" caused, in whole ar in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalfi in the performance of your ongoing operations for the additional insured{s) at the locations} desig- nated above. With respect to the insurance afforded to these additionat insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, maintenance or repairs} to be performed by or on behalf of the additional insureds} at the location of the covered operations has been completed; or CG 20 10 07 04 O ISO Properties, Inc., 2004 Page 1 of 2 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. This endorsement is executed by the Liberty Mutual Fire Insurance Company Premium S Effective Date 1010112010 For attachment to Policy No Audit Basis Expiration Date 10/01/2011 TB2-631-508631-020 Issued To American Residential Service Investment Holdings, LLC Countersigned by __ __ .. __. .__ Authorized Representative Issued Sales Office and No. End. Seriat No. 0324 Page 2 of 2 ©(SO Properties, Inc., 2004 CG 20 10 07 04 INSURANCE REQUIREMENTS CHECKLIST Permit # ~~ 2'~f~ ~ , p if ,.~~ ~~ -~~ ~/ 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 worl: 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: /JET $1,000,000 per occurrence, and ,~ ^ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggregat li it. Policy expiration date ~ I (,~ ~ ~ Automotive Liability: p ^ "Any Auto" checked on certificate ~~ ~~'~ I ~~ ~ ~ ~~ ~~ ~ ! ~~ ~b $1,000,000 per accident or bo ily injury and property damage ^ Policy expiration date ~~ - ~ ~~) Workers' .. 1, ~ ~~ ~ .~ y~ Compensat>on and Employer's L>abil>ty ' °'~ ^ Waiver of Subrogation clause ~ ~ $1,000,000 per accident for b d'ly injury or disease ~i Policy expiration date ~ ~ ~~ ' ~ ~~ ~ ~~~ Course of Construction (if required in Special Provisions) ^ Completed value of the project ^ Policy expiration date Re aired Endorsements to General Liabilit and Automobile Liabilit Policies Additional Insured Endorsement The City, the City of Campbell Redevelopment Agency, its officers, employees and volunteers are named as additional insured. ^ The insurance coverage afforded to the Additional Insured. is primary insurance. ~°l, ~ . ~~ ~ ^ Cancellation area of certificate edited to delete "endeavor to" and " such notice shall impose no obligation or liability of any kind upon the etome ao ~~~ is agents or representatives". p~ Y~ ^ Workers' Compensation Insurance Sheet Submitted ^ For General Contractor ^ For Developer or Owner -~- -Acct-ab-ility of Insurer(s) ~'~~ l~ lnsurer(s) has current A.M. Best Ratin of A:VII g and is authorized to transact business in the State of California. Insurance Certificate Reviewed Initials Date ^ Copy of Insurance Certificate placed in tickler file one month prior to expiration. 1:\~OIZMS\TemplatesUnsm'ance RequiremcntsUnsurance Requirements Cklist.doc (Rev. 03/08) TX Result Report P t 01/21/2011 14:22 Serial No. Ao2EDllo042s2 TC: 451572 Destination Start Time Time Prints Result Note 17083760958 01-21 14:21 OO:OD:56 000/007 No Ans omc cr75e tX. BnUi oUb e-s~~edaeint~ingAOireccinnl sPi sPecia~ ori~inai.FF000id ~FPCOdBC. RTX: Re-TX. RLY• RelaS1 HB Conf~denCiai. BUL: BU11eGin. S P: S p FaX. IPADR: IP Address FdX. I FAX: n erne Fax Result OK: Communication OK, S-OK: Stop Communication, P14-OFF: Power Switch OFF, TEL: RX from TEL, NG: Other Error, Cont: Continue, No Ans: No Answer, Refuse: Receipt Refused, Busv: Busv, M-Full:Memorv Full, LOUR: Receiving length Over, POUER:Receivins pace Over, FIL:File Error, DC: Decode Error, MDN:MDN Response Error, DSN:DSN Response Error. ~~E~~.IVED F'USLIC WORKS AD M I N I STR r~lTl6.~iIV L;<bc~-ty Mutual. Liberty Mutua] C3raup Fax Covor Staeet Attn: Jo q n» 6 ,Q ~ fj`+'1 ~+RO.4 i "q Date: 0/f ~I ~2°~/ Cornpany/D ept.: Fax Number: - y0 sT-37L -09'~S From: JOY S/~NCF-!EZ I Fax Number: 973-758-1493 I 12e: fire F./-r'~rro °~ in6trtaw oe ~ Er-a<<Ker.s~..nts R~.QS .2ea~u r; Roa /ct Pe~erre it, A¢ojec/ ~Y F~VG701~ - a aoo 7 ovaas,.~ - i~Qa n.~y,~ /fir ~R.vG .~dq„~ ~ , P/e+os6 /et me know -r yam ~d~ ~y.t.,,,,y -r~R~2 . ~----~~ Number of pages to follow: G if th c- following pages arc not recrived, contact: Nam o: JOY Phone: 2-80~-~00-4875 (OPT'SON Sj ~xt 2026 T ]~'~ 7'~. ' ~+ ~ A_~ ~ ,y qt f~ E Liberty Mutual Group Fax Cover Sheet Attn: Jo q n r- ~ ~ ~ f} e~ 62051.9 Date: t~~/ ~I ~~l/ Company/Dept.: Fax Number: ~l p g_ 3 7L, ~b~.S $ From: JOY SANCHEZ Fax Number: 973-758-1493 Re: ~'eeh~'icafc AI lnsu~unGC .~ ~c~(5'em~'!ts ~QS a~swc '~~°~~ RECEI Peen, ~t~ P2of'PC~ # ~Vrxn/~ - a o00 7 JAS ~ ~ wo~s,~ ~ 1y~a >z,d9~i~ ~OR,ve ~~~~~~ w ~~-~INIFrT ~logn~ e , Pl~rtse /et me knb~ ~~ yon deed Qny~r~hy -~~ ~a . Number ofpages to follow: ~ If the following pages are not received, contact: Name: JOY Phone: 1-80C?-900-4875 (OPTION 1) ext 2026 VET ~~~fi ARKS ~1TIQ(~ Certificate of Insurance PHIS l'CiRTIFICATE IS ISSUC;D AS A A1A'f"CEK OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER. TFIIS CERTIFICATE IS NOT AN INSURANCE POLICY AND DOES NOT AMEND, EX'f~Np, OR ALTER TIIE COVERAGE AFFOR DGD BY THR NOI"IC'IHS LISTED DE•,LOW. POLICY LIMITS AKE NO LOSS "rHAN'fHOSIi LISTED .ALTHOUGH POLICIES MAY INCLUDE ADDITIONAL SUBLIM1?I'I'/LIMIT'S NOT LISTED BELOW. This is to Certify that ARS Rescue Rooter Branch #8128 3390 Keller St NAME AND ~'~ Liber ADDRESS Suite B OF INSURED Santa Clara CA 95054 Mutual® is, at the issue date of this certificam, msumd by the Company under ttre pohcy(ies) hsmd below, l~he insurnme affonled by th Condiuons and is not altered by env reouirrmenl. ter,,, r,r rnnd,,,n„ ~r a,,.,,•,.,...:,~, ,.. ,.,t.... ,t--..T-_, ,..:,,..,.__.._.._ ...~,_,..,. e listed pohcyUcs) u subJcot to nil their terms, exclusions and : _ _ _..-.. EXP DATE ~ CONTINUOUS TYPE OF POLICY ^ EXT'ENllEU POLICY NUIVIBER LIMIT OF LIABILITY ® POLICI' TERM WORKERS 10/1 /2011 WC7-631-508631-010 covERAC,E AFFORDED uNDER we LA W OF THE FOLLOWING S'1' T Eh1YLOY[:RS LIABILITY COMPENSATION A t:S: All Slates except Monopolistic IT dtl o y Injury by Accident 1 000 OOOe.,~nnr~„i"„ Hodily Injury By Piscasr 1 000 000 > Hodily lnJury By Dtscasc 1 OOQ OQO COMMERCIAL 10/1/2011 T82-631-508631-020 Grnrral Aggregate GENERAL LIABILITY 4 000 000 OCCURRGNCI Products / Cmn leted O ti A p pera ons ggregate ^ 4 QQQ QQQ CLAIMS 1vIADE Each Occurrence 2 0 00 RE1'It0 PATE Personal Sc Advertising Injup~ n 'z OVO OQO Prr Prison / GrganiZn110n O bar, 000, 000 5 Oll~e{0, 000 AUTOMOBILF, LIABILITY 10/1 /2011 AS2-631-508631-030 Each Accident-5mgle Lnnrt 2,000,000 E3.1. And P D, Combined OWNEU Each Parson NUN•OWNEU l~ IJ HIRED Each Accident or Occurrence Each Accident or Uccurtrner OTIIF.R JANZIL Allll1TIONAL COhIMEN7S RE: BLDG201 0-01 1 29, 1482 RIDGELEY DRIVE. ALL WORK IN PUBLIC RIGHT-OF-WAY CITY OF CAMPBE~~MIiNIsaT . REDEVELOPMENT AGENCY, ITS OFFICERS, EMPLOYEES AND VOLUNTEERS ARE NAMED A5 ADDITIONAL INSUREDS AS RESPECT LIABILITY PER CG 20 10 07 04 and LA 20 70 05 08. Automobile Liability Covered Autos - Any "Auto" (Symbol 1 on the policy) ....._ __.....-_.. _..r.._.._.. ..-._ ._ ,,,........,,,., ,,. ,.......,..~., ..., ..,, ram„ ...,. ~~ na,u,ru a coverage Is Icmm~alca or reuucra netorr Ihr cerdllcatc expiration date. Liberty Mutual NOTICE Ob' CANCELLATION: (NOT APPLICABLE UNLESS A NUA?BER OP DAYS IS ENTERED BELO\V.) Insurance Group BEFORE THE ST'A'fliD EXPIRATION DATE THE COMPANY WILL NOT CANCEL Uft RGDUCE TIIE INSURANCE AFFORDED UNDER THE A[3UVE POLICIES UNTIL AT LEAST 30 DAYS NOTICE OF SUCH CANCELLATION HAS BEEN MAILED TO~ ~TY OF CAMPBELL ATTN: DEPT OF PUBLIC WORKS ~ Joy Sanchez Roseland 0324 AUTt10R1ZEU REI'KfiSENI'A~fIVG i = 3 Becker Farm Road ~ 70 NORTN FIRST STREET Roseland NJ 07068 973-533-6509 1/21/2011 l CAMPBELL CA 95008 ~ °FI'Ir~L PfIGNE DATE IssueD This certificate is executed t?y LII3EKTY MU"fUAL INSURANCE GROUP as respects such insurance as is afforded by those Companies NM 772 07-10 /E~ ;.. X11 RKS ITION THIS ENDORSE~•fENT CHANGES TFiE POLICY, PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -COMPLETED OPERATIONS W1TH PRlMARYAND NON-CONTR]BUTORY WORDING This endorsement modibes insurance provided under the following. CO'~il\fERCL~tL GEIvE]U1L LL•1gILITY C(7t/1:R.r1GE PART SCHEDULE JAN ~ ~ :~~'`''~ F'UB><IC VVOf,f ~,®MINr~Tr~,~rfani Name Of Additional Insurcd Person(s) Location And Description Of Coutplrtcd Operations Or Ort;anization(s}; City of Campbell Attn: Dept. of Public Works 70 North First Street Campbell, CA 95008 to this Schedule, if not shown above, u111 be shown in the Dcclara ~1. Sccdon I[ -Who [s ran Insurcd is amended to Inc}tide as an additiona3 insured the person(s) or organization(s) shown s the Schedulq but only with respect to liability for "bodily injury' or "property damage" caused, in whole or in part, by "your wotk" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". 6Iowever, this provision: I. rtpplics only to covcragc and limits of insurance required by the written agreement, but in no event exceeds either the scope of covcragc or the limits of insurance provided by this policy; and Z. Does not apply to any person, organization, or state, for whom you have procured separate liability insurance while such insurance is in effect, regardless of whether the scope of coverage or limits of insurance oC this policy exceed those of such other insurance or whether such other insurance is valid and eolleeeible. LA 20 70 45 48 Page 1 ot2 ~• ~~/}tere you have agreed in writing to provide IiabiGry insurance for person or organizavon shown in the schedule, and such written agreement ccquires you ro provide liability instttance on a primary, excess, contingent, or any other basis, this policy will apply solely on the basis required by such written agreunenc and Item 4. Other Insurance of SECTION IV oC this policy will not apply, regardless oC whether the person or organization (for whom the insured has agreed to writing to provide such insurance) has available other valid and collecdblc insurance. lYlltere the applicable wcit[en agreement does nor specify on what basis the Gability insurance will apply, the provisions of Item 4. Other Insurance oC SECTION IV of this policy will govern. RE~~ ~.~, f~~ >, ~~ :~~ A~A,BI'~jl~ ~~Rk' This rndrusemau is ececuted by the LIRER7Y MUIUAL FIRE INSURANCF. COMPANY Prrmium >; P,ffccdvc Datc IU/U11'It10 Pnr altachmmt to Ibticy Nn. Audi[ Raxis E~pintion Datc f0/UI/~11 T82-631-508631.020 Issued Tn flmerican Residential Service Investrnrnt T•Ioldings, f,L,C and as per Endorsement t Crwrtrrs~gned b~ Isavcd Srda Office and Nn. Ro>eiand, N) 03?4 sECRGTARY' PRH.9D8NT Authonzcd kryrocnazi~t Gnd. Serial No. 1.A 20 7p 05 08 Page 2 of 2 THIS ENDORSEMENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -- OWNERS, LESSEES OR CONTRACTORS -SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anization s Location(s) Of Covered Operations City of Campbell Where required by written contract or written Attn: Dept. of Public Works agreement 70 North First Street Campbell, CA 95008 Information re wired to com fete this Schedule, if not shown above, will be shown in the Declarations. A. Section 11 -Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2, The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured{s) at the location(s) desig- nated above. With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insureds) at the location of the covered operations has been completed; or ~E~~IVd~ PUBLIC WC{RKB ADMINISTRATION CG 20 10 07 04 ©lS0 Properties, Inc., 2004 Page 1 of 2 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. This endorsarnenl is executed by the Liberty Ntutuai Fire Insurance Company Premium $ Effective Date 10!01/2010 For attachment to Policy No. Audit Basis Expiration Date 10/01/2011 T82-631-508631-020 Issued To American Residential Service Investment Holdings, LLC l`~-~-~ ~. ~j1 SI'CIiICI'.\AY I Countersigned by Issued Sales Office and No. 0324 R~ ~ ~ , JAS ~ l ;~:~ P~BUC ~,;,, . ~~?MINI ~.p ' Y r - . , Authanzed RepresenlaUve End. Serial No. Page 2 of 2 ©ISO Properties, inc.. 2004 CG 20 10 07 04 WAIVER OF OUR RIGMT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enlorce our righ! against the person or organization named in the Schedule. (This agreement applies only to the extent that you pertormwork under a written contract that requires you io obtain this agreement from us,) This agreement shalt not operate directly or indirectly to benefit anyone not named in the Schedule. Not applicable in NJ Schedule City of Campbell .~ ~ ' 2~1 t='UREIC V~-`t^±RK: ADMINISTt-~.__ ~ IOha This endorsement is executed by the Liberty Iriaurance Corporation Prem(urn 3 Efleaivepate 10/01/2010 ExprattonDate 10/01/2011 For anachmem Io Poticy No. WC7 - 631 •50 8631 - 010 Courrtersigned Authorized Rapreaanlatlvo Enq. Serial No. WC txl 03 13 Ed. 4/1/1984 Copyright 1983 National Council on Compensation insurance,