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ENC2011-00061CITY OF GMPBELL DEPT. OF PUBLIC WORKS 70 North Plrst Street Campbell, CA 95008 Ph. (4081866.2150 ENCROACHMENT PERMIT (for working within the public right-of-way) Issued .~~ 5l~ l Print Form Permit No ~~ Cam. _bVG>~ X-Ref. File~___ _ _ _ ~~~~ _._ Application Date J/ ~7~ ~ ~ Application Expiration Date _ APN ~~~~..- v~ ~~ Fx. (40$1376-0958 ~ /1„/' 2 - Permit Expiration Date ( !~ -._ -- 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 is non-refundable.) A. work Addressor Tract No.: 580 McGlincy Lane ut;uty rrencn Location: ,McGlincy Lane and Campbell Technology Parkway B. Nature of Work: (Install 2, 4-inch Conduits for Telecommunications Connection between WVC Offices 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. 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 far 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: West Valley COnStfUCtlOn Company Telephone: Igt 6-240-2220 Address: 580 Mc Glincy Lane, Campbell, CA E-Mail Address: MikeC@wv-inc.com 24-HOUR EMERGENCY PHONE NUMBER: Is this work being done by the property owners at the{r own residence? (- YES rX' NO The ApplicanVPermittee 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 da s rise out f the~fi'ndi ' of any private ijmiprovements in the public r ht-of-way. 1 / _ __~~~ . r~ ~ ~ C f"t t G.. l^~ A ti (_ L~Pt7C- I ~ r T f Accepted: _ ~,_ ~~rC.. r _ "J_ S ( 1 I _ (Applicant Permitteel tsign) Date (Contractor) (Print Name) Date S_ PECIAL PROVISIONS: 1. Street shall not be open cut for underground installations. Minimum cuts maybe allowed for connections or exploration holes. Such cuts may be soecificallya~proved by the Inspector prior to cutting. 2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A", unless otherwise approved by the Engineer. 3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public Works Department before startiny work. _,.__4. Per Section 4215 of the Government Code this permit is not valid for excavations until Underground Service Alert {USA) has been notified and the inquiry identification number has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO. _______S. Prior to any work, the property owner shall execute an Agreement far 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 5 MOUNT 3 SO RECENT S ~ ` PERMIT APPLICATION FEE ___-__ ___ _--~ -~~ PLAN CHECK DEPOSIT 5 SECURITY FOR FAITHFUL PERFORMANCE/LA80R & MATERIALS 5 ____ CONSTRUCTION CASH DEPOSIT S PLANCHECK & INSPECTION FEF 5 EMERGENCY PERMIT FEE S 35C~ _~}'~~ '~ APPROVED FOR ISSUANCE ________ ______ __._____ ~_~__~~ ( For Ciry Engineer Date Permit Expires 12 Months After Date of Issuance GENERAL PERMIT CONDITIONS I. A Construction Cash Deposit is required. Charges wiA be made against this deposit if there is an emergency call-out, overtime inspecton 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 well begin on date of written acceptance by the City. 3. Refund or the cash deposit balance and refund or cancellation of the faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. 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. 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 I! flashing arrow signs if required. 8. Replace as directed by the City Engineer any damaged or renwved improvements in accordance with City Standards and Specifications at the sole expense of the Permittee. 9- Sawcut for all PCC or AC removals. AR PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements. 10. Prior approval of inspector is required for any work done aher normal working hours, on weekends or holidays and may require reimbursement of inspection costs at the current overtrme rate. 11. Adequate signing and barricading is required on thejob site- Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost (inducting 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 wilt have a supervisory representatwe 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 shouldedine which would create a hazardous condition to the public. t 5. 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 maybe 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 contrails with the City and any other public agency. 1J. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. t 8. Call back (call out} due to emeregencies regarding this permit shall be at the urrrent overtime rate with a three (31 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. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and phone number. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions. "// `. / ~~/ ! ~s~lk , / plc mil- ~~ ~A t`-, ~-1 ."' L c `_-/~J L ~ _ ~ _ ) ~ / S' r ~~ ( , - -- Applicant - - Date -- ~>~ !. ~_-ter' ~ ~f~ ~ ~ -- _ . _ _ -- _ - Contractor (Print Name) Date: J:\FORMS1Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev. 09/10 o ci, N M ~ i '~ ~ ~ ~ N ~+..~ ~ ~ O 3° 0 b~ ~~ C~ N 0 "z w ~ ~ w ~ U 'J W V v A C D O G i A ro v iy V T Oa 0 00 °o °. 0 0 °~ O O ' O O V'1 V'1 M M 7 0 a.+ O [r O O N N V~1 ~ ~ ~ W W r-, `--, L 6r ~7 ~ ~ N N ~ ~ ~ O O O U M ~ Q ~ ~ O O h ~ C F U 0 A ~. 0 w ~ ~~ w °~ o '~ `~ U ~ ro °' a w a. d ~z ~~ ~~ ~~ W A N N O O ~ ~ v ~ ~ O O +..• .--~ c/1 A O O N N v~ ~n ~ ~ L~ N ,_, O U ~. v U w _o a~ PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT & MISCELLANEOUS RECEIPT Effective July 1, 2010 TO: City Clerk PUBLIC WORKS FILE NO. ~N ~ n ,, C~ ~ ~ '~ G ~U PROPERTY ADDRESS j ~ ~ (~c~(j1~Cy LV~1, Please collect & recei t for the followin monies: I _,-ACCT. ITEM AMOUNT ENCROACHIVIENT'PERMlT 4722 ~; Utility Encroachment Permit Application Fee $350.00 3~C] R-1 Encroachment Permit N/C Emeroency Permits $100.00 i Plan Check & Inspection Fee ~ 4722 Utilit < $50,000 ' 'i i I Minimum Charge Per Location $350.00 G I Conduits/Pipelines up to 500 Feet $2.40/ft Above 500 Linear Feet $1.45/ft _ I ManholesNaults/Etc. $150.OOlea ~, Pole Set/Removal $150.OOiea i `" 22031 Utilit ? $50,000 ` Actual Cost + 20°~ `" ~' i (minimum deposit $5.000) 74 60 Storaoe Container Permit $150.00 ~ _ 4760 ~ Project Plans & Specifications Pro ect No _, 4760~~ Standard S ecifications & Details $1 /P $15.501~b: ~' 4760 ~' En ineerin Ma s & Plans 1 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 4722 ~I Penalties. Failure to restore ublic im rovements $100/Calendar Da (Muni code sec. 11 3x.010) 4722'• Penalties: Failure to correct unsafe conditions $100lCaiencar Da _! 4722I~ Work Without Permits a Times A ohcable Fee MISCELLANEOUS 511.7424!. Postage Other Please S eci ~ ~ "Engineer's Estimate shall be as approved by the City Engineer an 'Actual Cost Plus 20% Overhead (Non-Interest bearing deposit) d shalt include all items of work. TOTAL $ 700 NAME OF APPLICANT `-" ~ l Vg's ~ 1 C~I~ S~• I NAME OF PAYOR PHONE ~ ~ ~ 2'~ G ^ZZZs ADDRESS ~ ~G ~~~ t hey ~-tn ~~ r ~ ~~~I ~~ ZIP ~ s ~ 7 i ~~ FOR RECEIVED BY ~`-'~= ~~ ~~ ~ ~ ,~~ ~'~ ~C' i CITY CLERK ONLY r ~ =°, ~ _; L _~ ~. :Date Recei t # -~ - {. J'\FORMS\l emoiatesWO minisirawe\keceml Form UUInV Encroachment g Mist 1(i-'I1 kev tU'~',. DIT'= DF iA~f~'I~ELL 4ECs1I: A'!: JAS. D3DDDL3559 i F'AYDFt: TEST ~.'ALLE~' CD~ST TDI+AY''S DATE: D5: D~l1! EGISTEF; IfATE: Db.Drf11 TI~#E: i5:L3 I~ESCf~IPTIDt~ A~DL~i~T E~lG(~ ~ SUHIaI~~ FILI*~G F ~35D.DD CJST IEF: E?~C Df;-DDDSz E3~Gk ~ 511t~ItI4' FILING F ~?SD.DD CL!GT IE~: 524 l~CGLINGY Lt~ TDTAL I1UE: ~iDD.;!%i C~!ECt~ FAIR: ~fiuD.DD CFsEDt: filD: 3 i~3P T E~tI~EF~LI+: ~?DD. DD L4AtvGE : ~ . DD ~T~TS~II;1~.1~1C~ ~EQ>`1~P`~'M[E1°~T'~'S ~~-~E~~L?ST Permit ~ a=1~"C2C~ I I - ~G~C~(ol ~'-I'~erfief,~t ~~© ~C ~~~i~~.~,~ v~l ~~t ~ ~ 11~ C ~~-tY--u:~ -Fi c~~Jv The following insurance is required of al] contractors workin~~ in the City of Campbell public ri;ht-of-way. lnsurance certificates must be accepted by City staff before work can he~rin. These insurance requirements apply to work beinvi perfoz7ned under an Encroachment Permit anti work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and propert~,~ damage: ,~ ~ l .000.000 per occurrence.- and .. . a X1,000.000 ~aenera] aka<n-egatelimit applyin~a separately to the project. or ~~ ~?.U00.OOU ~~eneral a~~~-e<aate limit. ~ Police expiration date I b ~~ ~i I Automotive Liabiht~~: ~ "/~n~~ Auto" checked on certil`icatc ~,~ ~ l .000,000 per accident for bodily injur~~~ ~rnd~hrohcrty dama~++:- ~ Police expiration date 10 /i ~~ 1 ~ uId Re~~bi,c Gin Vvorkcrs~ Compensation and Emplcn~er~s Liability ~ Waiver of Subro~Tation clauso ~ S11.000.U0O per accident frn- bodily injury or disease ~ Policy expiration date I C.~~i /I I Course of Con - ~° wired in Special Pro ~sionsj ^ C Meted value; of the projec ~~ 'olicv expiration daft Ir1s Cori: NAiC~L'ii3~) CA~ig~--2 A. M ~ hest : A - x ~-.S~c~+t~ale Ins, C~:. ~;,a~c #4~2g1 CA= ~~/qs A, M. c~e~~t : A+xV Reouired Endorsements to Genera; Liabilir~~~ and Automobile Liability Policic~ Additional Insured Endorsement ,~ Thc~ City. the Cir~,~ of Campbell Redevelopment A~aencv, its officers. enlplo~~oc:; anti volunteers are named as additional insured. ~. The insurance coveral,~o afforded to the Additional Insured is primary insurance. ~ Cancellation area of certificate edited to de-lete "endeavor m~~ aild "but failure to mail Lk such notice shall impose no obli<=anon or liability of any hind upon the. comp~uw. its a~~ents or i°epre~sentatives". l~c~~ rd 25 (2009 /~9) WerC~ i nc~ v~se~1 i nSt~~ ~ . Workers' Compensatioi an ~ ~ eet Submitted f~ ^ For Genera] C raetor ~or Dever er or O~~~ner Acceptability of Insurer! sl ~{. Insurer(s) has cui7-ent P,.M. Best Ratin~~ of A:VII and is authorized to transact business in the State of Califonlia. Campbell Business Licenser ~Q r~ (~ 3 (~ 3~ ~ 2 Insurance Certificate Reviewed ~p Copy of insurance Certificate placed in ticlaer file one month prior to expiratiol.. l'~,FORMS~~Temuhtr~s,lnsurmicc kcquirementsUnsurlnc~Requirements CFaisi.doc (Re~~ (i~.10? ,;~j Q' 11 P~~c~~? `~~ l~ ~ Cn -e,{~~ ~' ~ db ,acoRV CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 06/14/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER LIC #0660864 1-925-671-5110 CONTACT Liz Boehmer NAME: Argo Insurance Group, Inc. PHONE 925-852-0401 FAX 925-852-0451 No Ext : AIC No ;_ _ - 2300 Contra Costa Blvd _._ ADDRESS: lizb®argoinsurance.com _ _ __.__ Suite 375 PRODUCER T MER D : ____ _ Pleasant Hill, CA 94523 ___._ __ INSURER(S) AFFORDING COVERAGE _ _ _ NAIC # _ _ _ INSURED CORP INSURERA: OLD REPUBLIC GEN INS 24139_ West Valley Construction Company, Inc. _ INSURERS: SCOTTSDALE INS CO 41297 580 McGlincy Lane INSURERC: _____ _ INSURER D : _ Campbell, CA 95008 - INSURER E INSURER F r`r1VFRA[:FS CERTIFICATE NUMBER: 21718947 REVISION NUMBER: 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DDIYYYY MM/DDIYYYY LIMITS A GENERAL LIABILITY X A1CG98621000 ! 10/O1/1 10/O1/11 EACH OCCURRENCE $ 1, 000, 000 X DAMAGE TO RENTED 100 000 COMMERCIAL GENERAL LIABILITY ii PREMISES Ea occurrence , $ CLAIMS-MADE ~ OCCUR MED EXP (Any one person) $ 10, 000 ~, PERSONAL & ADV INJURY $ 1, 000, 000 ~~ GENERAL AGGREGATE $ 2,000,000 '•, GEN'L AGGREGATE LIMIT APPLIES PER: ~ PRODUCTS -COMP/OP AGG $ 2 , 000 , 000 POLICY ' X PRO- X LOC $ A AUT OMOBILE LIABILITY ~ A1CA98621000 10/O1/1 10/O1/11 COMBINED SINGLE LIMIT $ 1,000,000 ~ '~~ (Ea accident) it ANY AUTO I i BODILY INJURY (Per person) ~ $ I ALL OWNED AUTOS ii Ali ~ BODILY INJURY (Per accident) j $ ' ~ SCHEDULED AUTOS I, I PROPERTY DAMAGE i HIRED AUTOS ~, (Per accident) $ ~ NON-OWNED AUTOS i $ B X UMBRELLA LIAB X OCCUR XL50069582 10/O1/1 10/O1/11 EACH OCCURRENCE $ 25, 000, 000 EXCESS LIAB CLAIMS-MADE ! i AGGREGATE $ 25, 000, 000 DEDUCTIBLE I I' $ RETENTION $ ~ $ A WORKERS COMPENSATION ' X A1CW98621000 ! 10/O1/1 10/O1/11 X WC ST~U- iOTH- LIABILITY AND EMPLOYERS ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1, 000, 000 ^ OFFICER/MEMBER EXCLUDED? N (Mandatory In NH) N I A . E.L. DISEASE - EA EMPLOYE $ 1, 000, 000 If yes, describe under DESCRIPTION OF OPERATIONS below I E.L. DISEASE -POLICY LIMIT 1, 000 , 000 $ DESCRIPTION OF OPERATIONS (LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) The City of Campbell, and its respective officers, agents and employees are added as additional insureds when required by written contract per the language provided in the attached CG2010 0704 & CG2037 0704. RE: All jobs pertaining to the work performed under contract by the above named insured. Automobile Liability is Primary per the policy. General Liability is Primary per the language provided in the attached CGENGN0029 0906. Waiver of Subrogation applies to Workers Compensation per the language provided in the attached WC04 0306. rcorfctrATC unl n~o CONCFI I ATI(DN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Campbell THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Public Works Department ACCORDANCE WITH THE POLICY PROVISIONS. ' 70 North First Street AUTHORIZED REPRESENTATIVE Campbell, CA 95008 USA U -'"-"' DoraenA U 198H-2009 ACORD GVRPVRATIVN. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD 21718947 OLD REPUBLIC GENERAL INSURANCE CORPORATION CHANGES ADDITIONAL INSURED PRIMARY WORDING SCHEDULE THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS ENDORSEMENT MODIFIES INSURANCE PROVIDED UNDER THE FOLLOWING: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Name of Additional tnsured Person(s) Or Organization(s): Location(s) of Covered gperations As required by written contract: information required to complete this Schedule, if not shown above, will be shown in the Declarations. The insurance provided by this endorsement is primary insurance and we will not seek contribution from any other insurance of a like kind available to the person or organization shown in the schedule above unless the other insurance is provided by a contractor other than the person or organization shown in the schedule above for the same operation and job location. If so, we will share with that other insurance by the method described in paragraph 4.c. of Section IV -Commercial General Liability Conditions. All other terms and conditions remain unchanged. Named Insured West Valley Construction Co. , Inc. Policy Number Aicc9ee2iooo Endorsement No. Policy Period io/l/lo - io/i/ii to Endorsement Effective Date: Producer's Name: Producer Number: ORIZED REPRESENTAT ~o/r/y DATE CG EN GN 0029 09 06 401d Republic Insurance Company 42010 Vertafore, Inc. Ali Rights Reserved. POLICY NUMBER: Aicc9s6aiooo COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 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 : Locations Of Covered O erations Where required by written contract Information re uired to com lete this Schedule, if not shown above, will be shown in the Declarations. A. Section II -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 insureds) at the location(s) desig- nated above. B. 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 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. CG 20 10 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 ^ POLICY NUMBER: Aicc9a6ziooo COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -COMPLETED OPERATIONS 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 And Descri tion Of Com leted O erations Where required by written contract but only Where required by written contract but only when coverage for Completed Operations is when coverage for Completed Operations is specifically required by that contract. specifically required by that contract. Information re uired to com lete this Schedule, if not shown above, will be shown in the Declarations. Section II -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" or "property dam- age" caused, in whole or in part, by "your work" at the location designated and described in the sched- ule of this endorsement performed for that additional insured and included in the "products-completed operations hazard". CG 20 37 07 04 ©ISO Properties, Inc., 2004 Page 1 of 1 ^ WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84} WAIVER OF OUR RIGHT TO RECOVER FROM OTIiERS ENDORSEMENT-CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered 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 due on such remuneration. Person or Organization of the California workers' compensation premium otherwise Schedule Job Description Notes: This endorsement may be used to waive the company's right of subrogation against named third parties who ma responsible for an injury. 2. The sentence in () is optional with the company. It limits the endorsement to apply only to specific jobs of the in<, and only to the extent that the insured is required to obtain this waiver. This endorsement changes the policy to which it is attached and is effective on the date unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 1o/o1/IO Policy No. Alcw9s62looo Endorsement No. Insured Insurance Company West Valley Construction Co., Inc. Old Repub~l,ic/ General Insurance Corp. Countersigned By _ c~~~__l~f~~''""~ m 1998 by the Worker's Insurance Rating Bureau of Califomia. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual ©2001. ©NCCI Holdings, Inc. ©2010 Vertafore, Inc. All Rights Reserved. Jeanine Grundman From: Doreen Alexander [DoreenA@argoinsurance.com] Sent: Tuesday, June 14, 2011 12:30 PM To: Jeanine Grundman Cc: 'Liz Boehmer' Subject: RE: West Valley Construction Company, Inc. - City of Campbell (REVISED) Jeanine, We did not have an Automobile Primary wording endorsement after all, but it is part of the policy, so I put the wording in the description of operations. I hope this works. Thank you, Doreen Alexander Argo Insurance Brokers, Inc. 2300 Contra Costa Blvd. #375 PO Box 232017 Pleasant Hill, CA 94523 Direct Phone: (925) 852-0435 Direct Fax: (925) 852-0485 e-mail: doreena@argoinsurance.com Please visit our website at www.argoinsurance.com ***COVERAGE CANNOT BE ALTERED OR BOUND VIA E-MAIL OR VOICEMAIL WITHOUT CONFIRMATION*** The information in this E-mail message, and any files transmitted with it, is confidential and may be legally privileged. It is intended only for the use of the individual(s) named above. If you are the intended recipient, be aware that your use of any confidential or personal information may be restricted by state and federal privacy laws. If you, the reader of this message, are not the intended recipient, please notify the sender and delete the material from any computer. Thank you. P Save paper, trees, and money: Please print this email only if necessary -----Original Message----- From: Jeanine Grundman [mailto:jeanineg@cityofcampbell.com] Sent: Monday, June 13, 2011 3:12 PM To: doreenaCargoinsurance.com Subject: RE: West Valley Construction Company, Inc. - City of Campbell (REVISED) Hi Doreen, I just quickly reviewed it. One change: The primary insurance needs to apply to both the General and Automobile Liability Insurance. Thank you so much, Jeanine Jeanine Grundman City of Campbell Public Works Department 70 North First Street Campbell, CA 95008 408-866-2150 -----Original Message----- From: certificates@prod.certificatesnow.com 1 [mailto:certificates@prod.certificatesnow.com] Sent: Monday, June 13, 2011 2:59 PM To: Jeanine Grundman Subject: West Valley Construction Company, Inc. - City of Campbell (REVISED) This insurance document was sent to you from Doreen Alexander mailto:doreena@argoinsurance.com ) (Phone: 1-925-852-0435) via CertificatesNow. This document was brought to you by CertificatesNow. If you have questions regarding the content of this document, please contact the Producer/Agent listed on the certificate of insurance or the Insured listed on the notice of cancellation/reinstatement. To find out how you can send and receive all of your certificates of insurance either by email, high speed fax or standard mail, email customercare@confirmnet.com or visit our website at www.confirmnet.com cc The attachment is an Adobe Acrobat PDF file. To open the PDF file, you need Adobe Acrobat Reader, which can be easily downloaded by going to http://www.adobe.com/prodindex/acrobat/readstep.html. After completing Adobe's simple 3-step process, just double-click on the file to open it. 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