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ENC2011-00044
CITY OF CAMPBELL .1CROACHMENT PERMIT I _ ..fit No ~~ ~ 2G, I~ r UGG 1-f ~{ DEPT. OF PUBLIC WORKS (for working within the public X-Ref. File 70 North First St. right-of-way) Campbell, CA 95008 j ~ ~ ~ Application Date '~-~" ~ ~ (408) 866-2150 Issued ~ ~ ~ Application Expiration Date ~ 2 ( ~ r) I Fax (408) 376-0958 Permit Ex iration Date ~ ~ 2 ~ ~ ~' APN ty ~/~ p APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section ] 1.04. (Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable.) /~ ~ ~ - A ~ ~ 1 /~ ~ ~ p S '~ r 1 1 J I A. Work address or tract # ~ IOp~~ ~`' ~" w-~x~ ~ `1 v `^ V 0~ 1 CTA »~ ; TVA. Utility trench B. Nature of work ~~- ^ ~ C ~ O S L"P_ _ O '~ / `' / ~ S P ~ ~"` ~~ ^ / T ~/Q . 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 part of this permit. U. 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 I 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 he given to Public^W/orks at leas[ 24~^hours before restarting any work. LOvI~ t-r1e~~.~ ---7 Name of Applicant > V t.7 rC N' l t9e^`~ ^'~ N ~ i C ~~~ V" ' ~` ~ V ^ ~ ~•`^ e ~ , V ~ ~"s .. Tele hone ! ~ 7'~ ? 3 ~ - 0 3 (~ y P ~ ~ h print n. ~rt~e) ,5- Address~5 6 ~~`~'~` s• y C°`3°~'~`~ ~~• yV~'i'^, ~f y 524-HOUR EMERGENCY TELEPHONE NO. ~~~~ E-Mail Address I !M ~ r^e'~ ~ CC Ni~f-c -- ~ -" t ^ L . C +~ '^S Is this work being done by the property owners at their own residence? Yes No 7~7 - 73v-036t1 The ApplicandPermittee 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 ApplicanUPermittee hereby acknowledges [hat they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all damages arising out of the condition of any private improvements in t ublic right-of-way. (sign) (Print Name) Uate '~ `1 / .~ Date 1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be specifically 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 Meth«1 "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. 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: SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO PERMIT APPLICATION FEE $ ~~;~ 13~ ~ O PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK & INSPECTION FEE ==J= $;.LG ~_? ~.1! c__..... ~~ ~,, APPROVED FOR ISSUANCE ~_ ~ f ""3 ~I I For City Engineer Date Permit Expires 12 Months After Date of [ssuance C~~ S,i"I; S ~~ PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT & MISCELLANEOUS RECEIPT Effectiv e July 1, 2010 TO: City Clerk ~ 7 (, C ~ ~ ~ ' C'C' ~ y PUBLIC WORKS FILE N0. 1 PROPERTY ADDRESS ~ ~ ~{~~~ ~~ ~<-~, Please collect & recei t for the foltowin m onies: ..,.ACCT. ITEM AMOUNT EN CROACHMENT_ PERMIT 4722, Utility Encroachment Permit Application Fee $350.00 I ACC' R-1 Encroachment Permit N/C Emeroency Permits $100.00 ~I Plan Check & tnsoection Fee 4722 I Utilit < $50,000 ` ~ ~ ~ d' Minimum Charge Per Location $350.00 Conduits/Pipelines up to 500 Feet $2.40/ft Above 500 Linear Feet $1.45/ft i ManholesNautts/Etc. $150.00/ea _ I I Pole SeURemoval $150.OOlea *' 22031 Utilit ? $50.000 ' Actual Cost + 20°~0 " ~I minimum de osit $5.000 4760'. Storaoe Container Permit $150.00 ' 4760' Project Plans & S ecifications Pro ect No. 4760 ~ Standard S ecifications & Details $1/P $15.50/Bk 4760 ~! En ineerin Ma s & Plans Aerial Plot 24" x 36" $57.00 Aerial Print 8 1/2" x 11" $26.00 ' Ma Research includes max of two 24"x36" co ies $26.00 i Ma sand Plans 24" x 36" $13.00 47221 Penalties: Failure to restore ublic improvements ~1oo/caiendar oa /Muni code sec. ~ i sa o~o~ 4722 Penalties: Failure to correct unsafe conditions $100/Calendar Da _i 4722 Work WlthoUt PermltS 4 Times A olicable Fee I i MISCELLANEOUS - I 511.74241 Posta e Other Please S eci I 'Engineer's Estimate shall be as approved by the City Engineer an " d shall include all items of wo rk. ~ ~ ~~ Actual Cost Plus 20% Overhead (Non-Interest bearing deposit) TOTAL $ ~ NAME OF APPLICANT ~~~)~~,/~ J~ C(~"~Ml`'I C.`t/~J L Cr,~ ~~'~~`15 e~ NAME OF PAYOR ~) ~~Z (_'~-~~,U,i.C_~~ Z~N S .... PHONE ( ;~ "~ ~ J,3 ~ li ADDRESS ~~,~~ ti~>~I~~ ~IALL~ ~I~I~%I~.A'7 ~ i~~. ~r~ ~~~ ~~ _ ZIP ~ L' AS.~_ ~ t~~ D C7 n ~ '`~ FOR RECEIVED Y +~ ~ ;3= ' CITY CLERK ~ ' ~ r ~ ~ ONLY ..Date Recei t# ' ~: JIF ORMS\l emplatesWtlmm~sVaweW ecetp[ Form U\il~v Encioacnment L' Misc 1U-11 kev 1011 t' 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. G. 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 all PCC or AC removals. All PCC removals shall be to nearest scoremark and shalt be doweled to existing improvements. 10. Prior approval of inspector is required for any work done after normal working hours, on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. l L 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. 1 G. This permit does not release the Permittee from any liabilities contained i^ other agreements or contracts with the City and any other public agency. 17. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 18. Call back (call out) due to emergencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence. 19. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban 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 t~ll thos~jproviding services under the applicant are aware of and understand all of the above conditions. plicant nJ ~~ ~I Date Contractor (Print Name) Date J\forms\pwperm Rev. 11 /9/05 N N c~ t i '~t i^~S w ~~ n 1L ..~ ^~ it ~{ l~ P, ,tiLt{.t ~i` ;t1;-ice .. ~. (,t: yL~G~ ~_i ;.... i _ ,. , ,.1 liF {V~~Rt~ _~::.... 1 .,.zt7idt ~,-- f G `G ' ~ ~.. a .. c a~ O v ~ U ~ ~ N ~ W O L ~ ~, a °~ ~ ~ z _ ~ '~ 0 a~ 0 z mom m ~ U ~ ~ o ~ v U N n`. V ~ N ~ p d~ O a N~r~'`al II~TS~IR.AN~E. REQ~IIREMENTS CHECKLIST Permit ~ >/f~~C2C~(~ - C~C"~ Lf<~ 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 be~,in. These insurance requirements apply to wort: being perforl~ed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. 1.11111 tS Commercial General Liability for bodil}~, personal injur}~ and propert}~ damage: ,~ ~ L000.000 per occur-ence, and ^ X1,000,00(1 general aggregate limit applyin<~ separately to the project. or ~, ?,000,000 general aggregate limit. ~ Policy expiration date G~ I l Automotive Liability: ~i, "An}' Auto" checked on certircate pQ ~I,000,UOU per accident for bodily injw~~~~ and property dama~~e ~ Policy expiration date Cp ~2 I ~ i f Vv orkers~ Compensation and Employer's Liabiiity ~ Waiver of Subro~~ation clause %i ~ l .000,000 per accident for bodil ~ injury or disease ~, Policy expiration date '_ 1 I I Course~f=L o~ s~ truction (if in Special Pro~~isions) ^ ,E'ompleted value of the project ,i ^ Policy expiration date CA I~~li~j~( -~j ~~~L~_ 1,<<`19; C ,=~ i D~ :~ S t- 3 oK I ~~~3_~I,C~n2l ~~~-~~c~,z.> i-ir IYL.`.~, A Y'Y1 IJ ~,;'C '~ A ; ~V UK f~j;11C~iciyijc ~'A ira#Oi3i~.~ oK- P.equired Endorsements to Gencral Liability and Automobile Liability Policies Additional Insured Endorsement The City, the City of Campbell Redevelopment Agency, its officers. employees aril volunteers are named as additional insured. ~ The insurance coverage afforded to the Additional Insured is primary insurance. ~f Cancellation area of certificate edited to delete "endeavor to'~ and '`but failure to n1ai1 such notice shall impose no obligation or liability of any hind upon the company, its agents or representatives'. - Vl~orl<ers' Compensatioi uranee ~ 1 Submitted ~~n ~fxf ;. A~X~' `~ For General C ractor N ~ t L-~ ? ~ ~., 52 ^ per or Owner c_''' I r~ ~* ~`~ 3~-1" 3 -- Y Y 1 , ~ - ~~x ,~~U ~' ~ ~ r~~~-, . ~~ ~ . -''~rv~1~eS1- : ~ x~ Acceptability of Insurer(s) N -~ ~~ ~ Z I ~~;~7 ~~. A if ~ i~ ~> ;. ~ Insurer(s) has current A.M. Best Ratin~~ of A:VII and is autl7onzed' to trai~s~a'ct business in the State of Califorlia. ~ Campbell Business License ~_ ~ ~~~~`~~--~~ ~; ~ x ~ , z-~2_9~( Insurance Certificate Reviewed `E Dzr~ Copy of hlsurance Certificate placed in ticlaer file one month prior to expiration. .1.'~FORh1S',7~emE~lates,lnsutance kcquirements\Insurai~ce Requirenu ut, Claist.cloc (key 0~ 101 03.09;'2016 21:53 FAx C~j 002 ~~i~~ +~~ I~~DDrrn I N . 04 / ~ PROVUCeR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANO CONFERS NO RIGHTS UPON THE CERTIFlCATE SISEMORE INSURANCE SERVICES HOLDER. THIS CERTIFICAT£ DOES NOT AMEND, EXTEND OR 1631 LINCOLN AVE ALTER THE COVERAGE AFFORDED 8Y THE POLICIES BELOW. NAPA CA 94 5 5 8 COMPANIES AFFORDING COVERAGE COMPANY A COLONY INSURANCE COMPANY INSURED NORCAL COMMUNICATIbNS AND COMPANY e NATIONAL UNION FIRE INSURANCE CONS'I'RUC'~IQN, INC . COMPANY 1227 SWEETBRIAR DRIVE C NAPA., CA 9 4 5 S $ COMPANY D ~;. THIS lS TO CERTIFY THAT THE POLICIES OF INSURANCE L15TEd BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD NOTW{TMSTANGINO ANY REGIUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 70 WHICH THIS INDICATED , CERTIFICATE MAY BE 153UED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I$ SUBJECT TO ALI.7HE TERMS, EXCLUSIONS AND CONDITION8 OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, LTR TYPE OF INSURANCE POLICY NUMBER ~IB (~~ ~~~ (MM/DaYY)N LIMITS A Q>:N ENAL uABIUTY GENERAL AGGREGATE i 2, 0 0 0, O 0 X COMMERCIAL GENERAL uA61UTY PROOLICTS - OOMPJOP AGG i 2, O 0 O, O O C;WIM9 MADE ~ OCCUR GL 3 8 7 6 5 8 7 0$/ 12 / ~. 0 0 6/ 12 / 11 PERJONAL 8 ADV INJURY ffi 1, O O O, O O OWNER'S 8 CpNTRACroR's PROT EACH OC~I~NCE i 1, O O O, O O FIRE oAAMOE (Any ona HIa) a 14 0 , 0 0 - -- Mm tXP IAnv ane aaroon) s 5 0 0 AUT OM091LELU1&LITY OOMBINED SINGLE uMIT ~ ANY AU•f0 ALL OWNEf] AUTOS BODILY INJURY $ SGI•IEOULEO AUTOS (~ pen3on) HIRED AUTOS aoolLY IwuFlr $ NON-OWNED AUTOS (Paraccrdenq _ - PROPERTY DAMAGE S GARAGE UA81LtTY AUTOONLY - @A ACCIOENI' ~ ANY AU'T'O OTHER THAN AUTO ONLY: EACH ACCIDENT i AGOR..GATE i EXCESS LIABILITY EACH OCCURREi~E S _ UM13MELLA FORM AGGR>GATE i OTHER THAN UM6RELLA FORM $ WORKERS COMPENSATM)N AND 3T'ATUTORY UMIT6 EMPLOYERS' LIA@IWTY EACH ACCIDENT S THE PROPRIE'I'OFV INCL DISEASE -POLICY LIMIT S PARTNF.F~lEXECUTIYE OFFICERS ARE; F'JCGL DISEASE • EACH EMPLOYEE f B vTHER EXCESS BU15469485 08/16/10 0$ f 16/11 $5, 000, 000 AGGREGATE LIABILITY SS,ODO,OOD OCCURREA7CE DESCRIPTION OF OPERATIONSILOCATIONSNEMICLE3/SPECIAL ITEMS ~ ~) '-) c ~ l '~ '! lODAYS NOTICE OF CANCELLATION FOR NON-PAYMEN'I'.CERTIFICA'TE HOLDER, ITS OFFICERS, EMPLOYEES AND VQLUNTEERS NAMED ADDTIONAL INSURED PER U156 (08/07}W/PRIMARY WORDING. WAIVER OF SUBROGATION PER U047(07/02) Ci=RTI~ICAfi~ HOL'~£R - .:. ~ -.. -.... CAWC~ItAYIOAI.....: _~.,, SHOULD ANT OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 'fFIE THE CITY DF CAMPBELL, THE CITY OF EXPInaTKSN DATE THEREOp. THE ISSUING COtVIPANY WILL ENDEAVOR TO MAIL CAMPBELL REDEVELOPMENT AGENCY' 3Q DAYS WRITTEN NOTICE ra THE CEATIPICATE MOLDER NAMED TO THE ~EFr, ATTN : DEPT OF PUBLIC WO12KS BUT FAILURE To MAR. SUCH NOTICE SMALL IMPOSE No OBLIGATION oR LIABILITY 70 ND~Z'x'Td FIRST STREF''T OF AN`/ KIND UPON THE COMPANY, ITS AGENTS oR PNYaNVE3- I ~+A ~ 5 0 ~ 8 AUT110RD~D RE ENTATIVE PQQ~T,A, 3 5 CAMPBELL, dcr3R>i ~s ~ a - .... Commercial Certificate of Insurance Agency lay Sisemare Name 1631 Lincoln Ave ~ Napa, CA 94558-4807 Address 707-252-2000 St. 95 Dist. 27 Agent 360 i FARM E R5 Issue llat.e (MM/DD/YY} ()q/26/2011- ~ i Ttds certificate is issued as a matter of information only and confers nn rights upon the certificate holder, This certificate does not amend, extend or alter the coverage afforded by the policies shown below. Companies Providing Coverage: Insured SEE E0002 Name • NURCAL COMMUNICATIONS & & 1227 SWEETBR[Alt DR Address • NAPA, CA 94558 Company A '['ruck Insurance T~.xchange Lefler company g Farmers insurance Exchange Lever company ~ Mld-Century Insurance Company I.etrrr (;ompa,y D Lcua Coverages ! This is to certify that the polities of insurance listed below have been issued to the insured named above for the puliry period indicated. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate may he issued or may pertain, the insurance '. afforded by the polities described herein is subject to all the terms, exclusions and conditions of such policies. Limi[s Shawn may have been reduced by i paid claims. Co. ~ Type of Insurance Ltr. General liability Commercial General Liability - Occurrence Version Contractual - lncldental Only Owners & Contractors Prut. C x Automobile Liability ~( All Owned Commercial Autos Scheduled Autos ~( Hired Aut~x }[ Nnn-Owned Autos Garage Liability Umbrella Liability Policy NumhPr ti04829b84 Policy Effective Policy Expiration Date MMIDn/YYJ Date tMMND/Yl~ 06/21 /2010 Workers' Compensation and ~ttlpl0yef5' Liability Description of OperatinnsNehicles/Restrictinns/Special items: Certificate Holder is Listed as Additional Insured per attached Endorsement. Encroachment Permit Number: ENC2011-00044 Project Address: 600 E. Hamilton Ave. Certificate Holder Cance do . City of Campbell Shout an n Name .Attn: Department of Public Works thereu ,the & 70 North First Strcct certifi to ho Address Campbell, CA 95008 Policy Limits General Aggregate I s Products-Comp/OPS Aggregate Personal & Advertising Injury Each Ucturrence Fire Damage (Any one fire) Medical Expense (Any one person) 06/21/2011 Combined Single Limit Bodily Injury (Per petvon~ Bodily Injury (Per accident) Property Damage Garage Aggregate Limit S S S s l,ooa,o0o S S S a S Statutory lEzch Accident S D15P.aSe • Each Employer. S Disease -Policy Lirnit S the above described ooticies be cancelled before the expiration datr. uing rnmpany will mai13U days written notice to the ter named to the left, tative 03:10%'2016 03:30 FAX f~j 006 Commercial Certificate of Insurance FARMER 5- Agency . Ray Sisetetore Name .1631 Lincoln Ave Issue Uate (Mtt+1/pD/YY) 04/26/201 t ~ ~ Napa, CA 94558-4807 Address ~ 707-252-20ti0 This certificate is issued as a matter of infatinalfon only and Conier~ na rights upon the certificate holder. This certl~flcate doe: oat amend extend or alter the St. ~~ ]7'esr. 27 Agent ~~ coverage afFarded by ttie politics shown below. Companies Ptavidir,g Cooerage Insured ~Y ~ Truck Insutanoe F~cctt8n~c ~ SEE: E0002 l etur Name . NORCAL COMMUtVICATlONS & ~ mp.ny B Farmers insurance Exchange & ~ 12Z7 SWEET'BR1AR DR t ~ company C Mid-Centrsry Insletance Company P APA, CA 94SSR Address ~+ ~y D Ldmr - - COVP.C~QS This b to certify that the poticlac of Insurance listed below have been issued t0 the Iruured erarraed afxwe for the policy period indicated. IVotvvithxtat~ding arty n.~gtrireineitt, term err condition of any cortttact err other dotamtor+t with respect to vrh[ch this oertiGeate may fie issued err may pertain, the itlsscrasrtx otded by the gollcks described herE4t is bttlrject la all 13te terms. exduslons and conditions of such patiaTes. i.irNts shaavrt may have bean reduo~ by paid claims. Co. Ltr. Tye of Trtsurarce _ Policy Nttenber ~j ~`y ~~ bad ~M~p~yyl Policy Limtrs General Liability General Ag~egate s Commercial General ~ Aggrzga~ 3 Liability • Oa~trs+ent~e Yersivn Advertising inJtuy 3 Connactual - [ncidrrtr~l ~~ ~ S Onty Flre 1]uttaga 44ny ere Orel s Owr~s & CcmUactoa Prot. Medial Expense _ Wcy t~ per) S C ~~ ~adY 6p4RZ9684 06/21/2010 06JZ1l2011 Cc~irmd Single t;otir s I 00a obo Ali Owned corrurterciai , , Autos ~ Injnry x Selr~eduled Autos lj ' s * Hind Auicx I 1>r,any ~.f~' ~~~ ~ x iVnn-C3nmed Autos I Garage Liebllity I p~Y S Gara®a ABBF48a~ S umbrella Liability Limit s A Tc Workers' C.ompensatitxt A19502826-00 07/Z1l21?10 07121!2011 ~~ ~.~h Accidmtt s t,ouo,OW ~ i> - ~ t s l aoo aoo Employ~s~ uabiuty e -Policy L[mR , , S t 000,400 _ 1]cscription oP Openbons/Vehictes/Restrictions/Speclal Items` Ceftif~ate holder Carloella . CITY 01= CAMPBELL Sltattid of above desa~e~d polldes be castcdled before the expiration dam Name ATTTJ: DEPARxMENT OF PL1$LIC WO thereoL Y vr[ll en~avar to malt 90 days aritfen natrce oa rho & 70 NORTH FIRST STREET' cerii$ca hard conned to the left„ but failure to mall sorb rtatke shah impose no Address NAPA, CA 9500$ tx " of any Idnd upon the txunpmy, its agptts err rrpresrartatives. Authotimd tative 03.1012016 03:29 FAX ~ 004 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TRANSFER GF RIGHTS OF RECGVERY AGAINST G1`HERS TQ US This endorsemen# modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SECTION IV -COMMERCIAL GENERAL LIABILITY CONDITIONS, 8, Transfer of Rights Of Recovery Against Others TQ Us is amended and the following added: We waive any rights of recovery we may have against any person or organization because of payments we make for "bodily injury" or "property damage" caused by or resulting from your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard" if: a. you agreed to such waiver; and b. the waiver is included as part of a written construction contract or lease; and c. such written contract or lease was entered into prior to any claim to which this insurance applies. ALL OTHER TERMS AND GONDITIONS OF THE POLIGY REMAIN UNGHANGED. U047-0702 Includes copyrighted material of ISO Properties, Inc., Page 1 of 1 with its permission. 03%iJ9%2016 21:54 FAX [~p03 ENDQRSEMENT N~. 21 COLONY YN'SUR.ANCE COMPANY AT'I'ACHEf~ TO AND ENDORSEMENT EFFECTIVE FARMING APART OF fS7ANDARD TIMEI POLICY NUMBER MO. DAY YR, 12:01 INSURED PRODUCER AND CODE A.M. ~70RCAL COMMUNICATIONS AND 001040 CONSTRI:TCTTON, INC. SISEMORE INSURANCE GT 38'76587 D4 25 11 aC SERVICES TN CONSIDERATION Ok' THE PREMIUM CHA,RGED,TT IS HEREBY DATDERSTOOD AND AGREED THAT THE FOLLOWING IS ADDED AS AN ADD2TIONAL INSURED PER FORM U156(OB/D7): 'THE CITY Ol+ CAMPHELL,THE CITY OF CAMPBELL REDEVELOFMENT AGENCY,zTS OFFICERS, EMPLOYEES AND VfDI,t1NTEERS AT'T'N ~ DEpT OF PUBL I C WQRTCS '!0 NORTH FIRST STREET, CAMPBELL, CR 95008 IT zS FUR'Y'T-IER AGREED TT~,'Z' THIS INSURANCE SF3ALL BE PRIMARY ,A~TD lvO1V-CONTRIBUTORY, BUT ONLY IN THE EVENT OF THE NAMED INSL7RED'S 50LE NEGLIGENCE. TT IS FURTHER .AGREED A WAIVER OF' SUBROGATION AS PER FORM U047 (07/02), TRANSFER 01F RIGHTS OF RECOVERY' AGAINST OTHERS TO US, I5 GRANTED TN FAVOR OF THE ABOVE NAMED ADDI'Z'YRNAL INSURED. ALL OTHER TERMS AND CONDITL0~35 OF' THIS POLICX REMA2N UNCHANGED. i SISEMORE INSURANCE SERVICES - 001040 C ~. `~F'~~"`~""~' DATE 04-26-11, Countersignature .7F - INSURED - MONNA I 0~-0912016 21:54 FAX ~ 004 THIS ENDORSEMENT GRANGES THE POLIGY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS -SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following= COMMERCIAi_ GENERAL LIABILITY COVERAGE PART SCHI:DUCE me or of THE CITY OF CAMPBELL,THE CITY OF CAMPBELL REDEVELOPM NT AGENCY,ITS pFFICERS,EMPLOYEES AND VOLUNTEERS ATTN:DEPT OF PUBLIC WORKS 7Q NORTH FIRST STREET CAMPBELL, CA 95008 VARIOUS PROJECTS THIS INSURANCE SHALL BE BE PRIMARY A D NON-CONTRIBUTORY, BUT ONLY IN THE EVE T OF THE NAMED INSURED'S SOLE NEGLIGENC . A. SECTION ll -WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such 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 ar 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 insureds) at the location(s) designated above. A person's or organization's status as an additional insured under this endorsement ends when your operations for that additional insured are completed. B. With respect to the insurance afforded to these additional insureds, the following addftional exclusions apply: This insurance does not apply to: Additional insured Contractual Liability "Bodily injury" or '"property damage" for which the "additional insured(s)" are obligated to pay damages by reason of the assumption of liability in a contract or agreement. Finished Operations at Work "Bodily injury' or "property damage" occurring a#ter: 1. Ail work, including materials, parts or equipment 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 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization. Negligence of Additional Insured "Bodily injury" or "property damage" directly caused by or resulting from the negligence of the "additional in5ured(s) . ALL QTHER TERMS AND CONpITIONS OF THE PQLICY REMAIN UNCHANGED. U156-0807 Includes copyrighted material of ISO. Properties, Inc., Page 1 of 1 with its permission. Attach to your poiic~ ~ the same policy number shown an this Effective Date ~4/26/Z011 ENDORSEMENT ADDITIONAL INSURED CA02480299 .orsetnent. 60482-96-84 Policy Number of the Company designated in the Declarations THE CITY OF CAMPBELL, Ti3E CITY OF CAMFBELL REDEVELOPMENT AGENCY, ITS OFFICERS, EMPLOYEES AND VOLUNTEERS ARE LISTED AS ADDITIONAL INSURED. AND THE INSURANCE COVERAGE AFFORDED THE ADDITIONAL INSURED IS PRIMARY. This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is otherwisr~ sub)ect to all other farms of the policy. COUNTERSIGNED {Date) /. ~ TRUCK INSURANCE ^ FARMERS INSURANCE ^ MID-CF~ITURY EXCHANGE EXCHANGE INSU ~E COMPANY S 90268 NCCI CO. N0. 18244 NCCI CO. NO. 17744 NCCI ~ .. NO. 12998 CALIFORNIA 2nd Edition WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY Named NOR CAL COMMUNICATIONS & CONS Agent Insured DBA: NORCAL COMMUNICATIONS & CONSTRUCTION, INC 1227 SWEETBRIAR DR 95-27-360 A19502826-00 NAPA, CA 94558 2010 Policy Number Policy of the Company Year Effective 4/26/2011 Date WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -CALIFORNIA We have the right to recover our payments from anyone liable for an injury coverd by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 3 % of the California Workers' Compensation premium otherwise due on such remuneration. Minimum Charge: $250.00 Schedule Person or Organization Job Description CITY OF CAMPBELL TO BE DETERMINED FOR ALL CALIFORNIA OPERATIONS ATTN: DEPARTMENT OF PUBLIC WORKS 70 NORTH FIRST STREET CAMPBELL, CA 95008 This endorsement policy. Countersigned _ is rt of our/~olic~y. Jt~supersede an o trots nything to the contrary. It is otherwise subject to all the terms of the 4f~~' `' Authorized Representative 90-9026 2ND EDITION 7-94 (WC 04 03 O6 -Edition 4-84) RECEIVED MAY n ~ ~~~d PUBLIC WORKS A~iMIMIU~TRgT1C?t~ 03~10!201t3 Oa:30 FAX ~ 007 '~ TRUCK INSURANCE © FARMERS INSURANCE Q MItJ-CENTURY EXCHANGE EXCHANGE INSURANCl;COMPANY S 9268 NCCI CO. NQ. 18244 NCCI CO. Nil, 17744 NCCI CO. NO.12998 G~al,IFORNIA 2nd ~pteron WORKERS' COMPENSATION AND EMPLOYERS' LIAt31LITY INSURANCE POLICY Named , NOR CAL COMMUNICATIONS ~ CONS Agent Insured D13A: NORCAL COMMUNICATIONS & CONSTRUCTION, INC " 1227 SWEETBRIAR t)R 95-27-360 • NAPA, CA 94558 effective 4/26/2011 Rafe A19502826-00 Policy Numt~er of the Company WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENpOR$EMENT -CALIFORNIA Zola Policy Year We fiave the right to recover our payments from anyone 1'iabfe for an injury coverd by khis policy. UVe will not enforce our right against the person or arganizalon named in the Schedule. (This agreement applies only to the extent that you perform work under a written contrail chat requires you to obtain this agreement ftom us.) You must maintain payroll records aoeurately segregating the remuneration of your employees while engaged In the work dasalbed in the Schedule. The additional premium for this endorsement shelf bs 3 % of the Callfornfe Workers' Compensation premium otherwise due on such remuneration. Minimum Cfiarge: $250.00 5ohedule Person or Qrganrrallon ~ Jpb pesarlplJon C1TY OF CAMPSELI. TO BF DE-f'EIiMiNED FOR ALL CALIFORNIA OPERATIONS ATTN: DEPARTMENT OF PUBLIC WORKS 7Q NORTH FIRST STR~Ef CAMPBELL, CA 95008 This endorsement is rl of our fly, ~tsuperaed an trots nything to the contrary. It is oUtervulse subject to all the terms o~the A~Y• Countersigned Authorized Representative BaB026 2ND EDITION 7.94 (WC 04 03 OB • Edi9lon 4.84) Page 1 of 1 Jeanine Grundman From: Jeanine Grundman Sent: Wednesday, April 27, 2011 1:02 PM To: 'kristi@norcal-inc.com' Subject: Insurance for Encroachment Permit Attachments: Insurance Requirements.pdf Hi Kristi, We recently received the certificate of insurance for NorCal Communications and Construction, Inc. There are additional items required for us to accept their insurance certificate for the project: 1. Automotive Liability Insurance is required with "Any Auto" is checked on the certificate. 2. Automobile Liability Certificate needs Additional Insured Endorsement: The City, the City of Campbell Redevelopment Agency, its officers, employees and volunteers are named as additional insured and the insurance coverage afforded the additional insured is primary insurance. 3. Please use the new Acord 25 form or the cancellation area of the certificates needs to be edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents, or representatives". 4. Reference the Encroachment Permit number, ENC2011-00044 and project address, 600 E. Hamilton Ave. on the updated certificates. I have attached the the necessary Insurance Requirements for the City of Campbell Department of Public Works that may be helpful to you or to forward to your insurance company or producer. Thank you very much, Jeanine Jeanine Grundman City of Campbell Public Works Department 70 North First Street Campbell, CA 95008 408-866-2150 4/27/2011 03110!2016 03:28 FAX 2656 Napa Valley Corporate Drive Napa, CA 94558 Phone: 707-294-2051 Fax: 707-294-2052 Cell:7[}7-319-9982 Ivisti ~ norcal-a~c.COm Fau ~dJ 0 01 To' City of Campbell Dept. of Public Warks l:rvm: Kristi Haines Fax: 408-376-U958 Pages: ~ a pt~a+e; Date: 4/27/2Q1 ~ Re: COI cc: ~ Urgent D For Revlew ^ Please Comment ~ Please Reply ^ Please Recycle • Comments: ~,~C~k ~GlG1Y-ass : (~ ~ C~ ~ . ~to~i~ ~~rjYr Thank you, Kristi Raines kristi Qnarcahinc,com ,-_- L~~ A S1 s ~. ~ -1' -- ~ < `_' r y~ _ -a-~. Zs/~ ~ ~rA ~. ~i ` T S 3 c-, 5 '~C r ~ ,~ s i I 4 ~~ i ~~ ~ i ~ I t ~ I ;f r t~ 0 ~M~ a ~- n r ~~ ~.~.~~~ ~_~, Z~- t- uD~tS __ ___ ~ ~ , ' 3 ~~~ ., ~ E t j ~ ~ ~ ~ r• ~ /G~~~~. v ~ I . ~ ~ ~../ ii I t - ~ ~ ~ ~ ..,. l s ~ ` ~ ~ ~'~~~ I~ ~:~~ '' r ' ~ ~~~1 ` # i n '~ ! -___ ~ ~~ Y