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ENC2016-00125Print Form CITY OF CAMPBELL R-1 ENCROACHMENT PERMIT Permit No.E%c�, DEPT. OF PUBLIC WORKS X-Ref File (Non -engineered work within the public right-of-way) / 70 North First Street ($_10,000 0 maxi um value of work) Application Date Cif Campbell, CA 95008 71711 7 % 9 Application Expiration Ph. (408) 866-2150 ISSUED: / / / L� Date Fx. (408) 376-0958 Permit Expiration Date: APN �� q APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, e) o`nn1 04. (Application expires in 6 months if the permit is not issued.) A. Work Address: B. Nature of Work:d-D _-n/ -� t �-,* -v ` A C. Attach three (3) copies of a drawing showing th location, extent and dimensions of the work. The drawing shall show the relation of the proposed work to existing improvements. When approved by the City Engineer, said drawing become apart 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 securities. NAME OF APPLICANT: KA-Z -mil ^1 Telephone: Address: E-Mail Address: ... ��l��i � ......... The Applicant hereby confirms that this work is being done by the property owner/applicant at their own residence. 9 �72 The Applicant hereby agrees by affixing their signature to this permit to hold the City of Campbell, City of Campbell Redevelopment Agency, 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 hereby acknowledges that �havand ur contractor(s) of the information. ACCEPTED: (Applicant/Permittee) (Sign) bgSl the front and back of this permit, and that they will inform their NOTES: All work shall conform with the attached approved plans and all applicable Campbell Standard Details and Conditions and applicable insurance requirements. The Contractor must have this permit and approved plans and must arrange to meet with the Public Works Inspector at the site at least two days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work. Per Section 4216 of the Government Code this permit is not valid for excavations until Underground Service Alert (USA) has been notified and the inquiry identification number (Ticket No.) has been entered hereon. USA Phone: 1-800-227-2600. Ticket No.: 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 design, installation or condition of private improvements in the public right-of-way. SPECIAL PROVISIONS 1. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right -of -Way, which shall be recorded. 2. 3. SECURITY FOR FAITHFUL PERFORMANCE R-1 PERMIT FEE STANDARD AMOUNT RE EI T N . (100% Of Engr's Est.) 19 $ APPROVED FOR ISSUANCE: `� — for City Engineer-' \t Parmit Fvnir,-c ti NAnnth c aft,-r flat,- of Ica mnra GENERAL PERMIT CONDITIONS 1. Payment of a security to insure faithful performance and completion of the work is required. This security is refundable upon completion of the work and written acceptance by the City. 2. A one-year maintenance period for all work is required. Such period will begin on date of acceptance by the City. It is the applicant's responsibility to remove and replace unacceptable improvements within the one-year maintenance period. 3. Refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. Submit project schedule 10 days prior to proposed start of work. Special provisions may be required for work within City facilities and downtown Campbell. 5. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. 6. Maintain safe pedestrian and vehicular crossings and free access to private driveways, fire hydrants and water valves. 7. 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. 8. Sawcut for all PCC and AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements. 9. Adequate signing and barricading is required on thejob site. Failure to provide such signing and barricading as specified by the City Engineer may result in the City's providing such signing and barricades and charging the cost to the Permittee. 10. The Contractor or Permittee will have a supervisory respresentative available for contact on the project at all times during construction. 11. This permit shall be kept at the site of work and must be shown to any authorized representatives of the City of Campbell or any law enforcement officer upon demand. 12. No storage of materials or equipment will be allowed near the edge of pavement, within the traveled way, or within the shoulderline, which would create a hazardous condition to the public. 13. 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. 14. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. is. This permit is -not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 16. 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. 17. 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. 18. 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. 19. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the mi injCirnal ctnrm drain system steal other than storm water. � Applicant shall adhere to the REST MANAGEMENT PRACTICES ecta b!icherl by _.. rp ._ _..___ - , the Santa Clara Valley Urban Runoff Pollution Prevention Program. Applicant shall be responsible f ensuring that all thos vidin ervices under the applicant are aware of and understand all ofthe above conditions. Applicant Date J:\FORMS\Templates\Encroachment Permits\R-1 Encroachment Permit STATIC form2.pdf Rev. 02/14 ®F C 4, r °kcrinKo CITY OF CAMPBELL Public Works Department August 17, 2017 Ms. Annie Alston 346 Esther Ave. Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2016-00125 346 Esther Ave. - FINAL INSPECTION AND ACCEPTANCE Dear Ms. Alston: The City of Campbell has made a final inspection of subject Public Works improvements and finds the work to be acceptable and in conformance with City standards. Accordingly, the City Engineer accepts the improvements. If you have any questions, please call me at (408) 866-2165. Sincerely, Syed Wahidi Public Works Inspector Cc: Permit File: Enc2016-00125 70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAX 408.376.0958 • TDD 408.866.2790 Of ' Carp U r CH NO CITY OF CAMPBELL Public Works Department August 16, 2016 Ms. Annie Alston 346 Esther Ave. Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2016-00125 346 Esther Ave. FINAL INSPECTION AND ACCEPTANCE Dear Annie: The City of Campbell has made a final inspection of subject Public Works improvements and finds the work to be acceptable and in conformance with City standards. Accordingly, the City Engineer accepts the improvements. The one year maintenance period stated in the permit begins as of this acceptance letter. The permittee is responsible for the repair and/or replacement of any defective work or failures that occur within one year. The City will inspect the improvements within one year and notify you, in writing, whether or not any repairs are required. Your Faithful Security Deposit in the amount of $2,000.00 is enclosed. If you have any questions, please call me at (408) 866-2165. Sincerely, Syed Wahidi Public Works Inspector Cc: Inspector /Suspense Files Permit File: Enc2016-00125 70 R1.,<1-1, i=:-r Cf. f . f a— t-11 C'nlifnrnin 050OR-14:t6 • -mi. 408 866.2150 - Fax 408.376.0958 • Tnn 408.866.2790 I Encroachment, Permit Final Sign Off Encroachment Permit#� 20l(0`- Oa125 Address: �Lt�N Date of Final Inspection and Acceptance: �rr0r( I, Inspected by: OK to release deposits: 100% 75°� Comments: ANNIE ALSTON 346 ESTHER AVE. CAMPBELL CA 95008 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR ONE YEAR MAINTENANCE ACCEPTANCE LETTER Encroachment Permit # ENC2016-00125 Property Address 346 Esther Ave. Date of Final Inspection: 7 29 16 Faithful Performance $2,000.00 Labor and Material $ Construction Cash Deposit to be released: $ Other overdue deposits to be released (Description): Processed by: Reviewed by: Reviewed by: Inspector Land-bevelopment Engineer slu,z, JAJoAnnaT\Deposit refunds\CHECKLISTS\Esther 346..doc (Rev. 10/11) ' TO: Finance PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective PUBLIC WORKS FILE NO. PROPERTY ADDRESS g Please collect & receipt for the following monies: ACCT., ',ITEM LAND DEVELOPMENT 4722 Encroachment Permit Application Fee Non -Utility Encroachment Permit Ma'or >_$10 000 $395.00 Minor Encroachment Permit <$to,000 $225.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $225.00 Inspection Fee Minimum Charge per Location $390.00 Street Tree Planting/Removal N/C 2203 ($500 per Tree Planting Deposit Required) $500.00/tree 2203 Plan Check Deposit 2% of Engineer's Estimate $500.00 min 4722 Utility and R-1 Permits Grading & Drainage Plan Review no deposit required Single Family Lot $275.00 Site < 10,000 s.f. $825.00 Site >_ 10,000 s.f. < 0.5 Acre $1,105.00 Site ? 0.5 Acre $1 655.00 4722 NPDES Review C3 Requirements) For projects not required to submit numeric sizing $160.00 For projects required to submit numeric sizing Impervious Area 10,000 S . Ft to 1 Acre $690.00 Impervious Area 1 Acre or more $900.00 4722 For projects sent to Consultant for review Consultant Cost +20% 4722 Additional treatment facilities $300 ea Plan Check & Inspection Fee(Non-Utility) 4722 En r. Est. < $250 000 14% of Engineer's Estimate 4722 Engr. Est. >_$250,000 and 5$500,000 $35,000 + 8% of Enqineers Estimate 4722 En r. Est. >$500 000 $55 000 + 7% of Engineers Estimate 2203 Emerqency Cash Deposit 4% of Enqr. Est.* ($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) $3,930.00 + $85/lot 4722 Final Tract Map (5 or More Lots) $4 775.00 + $116/lot 2203 Monumentation Security 100% of City's Monumentation Estimate 4920 Parkland Dedication Fee (75%/25% Due Upon Cert. of Occupancy) 4722 Lot Line Adjustment (Includes Certificate of Compliance) $1,856.00 4722 Vacation of Public Streets & Easements $2,480.00 4722 Certificate of Compliance $1,840.00 4722 Certificate of Correction $550.00 4722 Document Recording Fees $15.00/first page $3 ea. Additional 4722 Private Improvement in Public ROW $50.00 4722 Approved Plan Revision Fee $100/sheet 4722 Appeal Filing Fee $200.00 4722 Notary Fee (per signature) $10.00 722 ssessment Segregation or Reapportionment First Split $877.00 Each Additional Lot $275,00 511.7424 _Postage a Other (Please Speci ) *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $ NAME OF APPLICANT NAME OF PAYOR f�jn PHONE 2 ADDRESS ZlPA� FOR RECEIVED BY II,p t' CITY CLERK ONLY "�' Date Receipt # t.0 . "a" J:�FORMS1Templa .a ' ' - ' ;. .. rf&+©LQmGQa A »,a2 Kc - �. !. , nyp k7m;a6 q+«s m : ya>ki. »g79 1E:C6a A DESCRIPTION mg ,,,,z a{ %POSIT - m! TENDERED, DAk- mom: REF mR Tae m;+ AmA £,RCm ---------------- Ilk me p! 000.m bm ,S 2 lmGm m& �coR® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 7/5/2016 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 r7ay'reciuire an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). f (✓ PRODUCERCONTA ; HUCKABY INSURANCE SERVICES 1365 El Camino Verde Drive 4/(�A �v Lincoln, CA 95648b/,n 4. 062o,8 !r "Pols , CT NAME HON c,"Nc EM i (408)249-9397 (A/C. No): ADDRESS: rhuckaby huckabyins.com INSURER(S) AFFORDING COVERAGE NAICpply" INSURER A.t Wesco Insurance Co INSURED Romero Concrete 111 Lic# 936672 bj/61/o`% 1336 Old Bayshore HyWy 13585 Mammini Ct., San Martin, CA 95046 San Jose, CA 95112 INSURER 6: INSURERC: INSURER D. INSURER E : INSURER F COVERAGES CERTIFICATE NUMBER: 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 LTR TYPE OF INSURANCE INSD SUER VOID vD POLICY NUMBER (MMlDD/YYYY) (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE 11 OCCUR PREMISES (Ea ,occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES; PER: GENERAL AGGREGATE $ POLICY CI PEa CI LOC PRODUCTS- COMP/OPAGG $ $ OTHER: AUTOMOBILE LIABILITY (Ea accident)" G $ BODILY INJURY (Per person) $ ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ (Peraccideht) NON -OWNED, HIRED AUTOS AUTOS $ UMBRELLA LAID OCCUR EACH OCCURRENCE $ REXCESS AGGREGATE $ LIAB CLAIMS -MADE D RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/DIECUTIVE C1 OFFICER/MEMBER EXCLUDED? (Mandatory In. NH) N/A WWC3154434 8/24/2015 - /24/2016 X STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1 ,000,000 If yes. describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $ 1 ,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES -(ACORD'101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder is named Additional insured. City of Campbell Waiver of Subrogation in favor of City of Campbell applies to Worker Compensation. Anyinsurance caried by City of Campbell shall be excess of the above -referenced insurance coverage and non- contributory to such coverage. Waiver Endorsement to follow. The project address is: 344 Esther Avenue Campbell, CA 95008 ,CERTIFICATE HOLDER CANCELLATION City of Campbell 70 N. 1 st Street Campbell, CA 95008 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES"BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. © V8-2014 ACID CORPORATION. All rights reserved. D25(2014/01) The ACORD name and logo are registered marks of ACORD AC40R" CERTIFICATE OF LIABILITY INSURANCE GATE (MM/DDNYYY) I il._� 07105/2016 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 pollcy(les) must have ADDITIONAL INSURED provisions or 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 endorsements . PRODUCER CONTACT Rachel Silva Whitney Oaks Insurance Services Inc. PHONE FAX 916 415-1930 Arc No): 916 415-1931 5800 Stanford Ranch Road, Suite 320 E-MAIL Rocklin, CA 95765 ADDRESS: csL@whitneyoaksinsurance.com License #: OF74432 INSURERS AFFORDING COVERAGE NAIC # INSURERA: U.S. Specialty Insurance Company — INSURED INSURER B : Joel Romero DBA: Romero Concrete INSURERC: 1336 Old Bayshore Highway INSURER D: San Jose, CA 95112 INSURER E: INSURER F : (tr)VPRA(;FC (tFRTIPlr ATF Ml IMRFR• MMMOn_dR543 RP1/IRIOKI MI IflARFR- R 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. IN jR TYPE OF INSURANCE ADDL SUBR POLICYNUMBER POLICY EFpp NIMIDDNYYY POLICY EXP MMIDDIYYYY LIMITS A X COMMERCIALGENERALLIABILITY CLAIMS -MADE FxIOCCUR U16AC92368-00 05/06/2016 05/06/2017 EACHOCCURRENCE $ 1 000 OOO DAMAGE Ra__occurR—TED ce MEDEXP (Any oneperson) $ 100,000 $ 6,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY❑ JEST LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OPAGG $ 2,000,000 $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY COMBINED SINGLE LIMIT $ BODILY INJURY (Per person) $ t BODILY INJURY Per accident) ( ) $ PROPERTY DAMAGE a accfde t S $ UMBRELLA LIAB EXCESS LIAB HCLAIMS-MADE OCCUR EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETORIPARTNERIEXECUTIVE OFRCERIMEMBER EXCLUDED? (Mandatory In NH) If Yes, describe under DESCRIPTION OF OPERATIONS below NIA PER OTH- E.L. EACH ACCIDENT $ E.L, DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) City of Campbell, It's officers, elected or appointed officials, employees, agents and volunteers are named additional insured. Waiver of subrogation applies to general liability. Physical Address: 346 Esther Ave. Campbell Ca. 95008 City of Campbell 70 North 1st Street Campbell, CA 95008 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Printed by RJS on July 05, 2016 at 10:55AM i ITY IMF 1 CAHPBELL 0 ut LA oLicenseNo. IPAYOP: j. ROMERT DRDS. CON TODAY'S MTE: SIC/Cla.ssode- REGISTER WITE: 07/05/16 TIM: DO:013 DESCRIPTION 4VIOUNIT FLAT FEE: $96.00 -UST 111:039174 BUSIVESS LICENSE - NE11.4 CITY OF CAMPBELL ---------------- 'PLICATION FOR AN OUT OF TOWN BUSINESS TOTAL DUE; 06.M TENDERED. uhhug u answered or designated not applicable (NIA), as appropriate. uired pursuant to City of Campbell Title 5. REF NUM. 551-5 under penalty of perjury., that the statements made herein are true. nts of the State Controller's Office under Revenue & Tax Code. Sec 19286.8, without this information. PLEASE TYPE OR PRINT ALI, INFORMATION 1. BUSINESS NAME: mo e n; Q,ti 1, " '!apsi -a --r�n (limited to 35 characters) 'p, ,Q- I !, 2. BUSINESS ADDRESS: 126�6�12 A h'. UA -- ( i ucl &' n. :L (Nutnber) (Street) J S"k- (S .. IeApr 9) late) (zip) 3. MAILING ADDRESS: (ff differentfrour above) (Vifi-nbe) (Street) (Statel"Ipt ) (city) (state) (zip) 4. BUSINESS TELEPHONE NUMBER: 5. DRIVER'S LICENSE#:, 5., FED EMPLOYER ID #: 7. SOCIAL SECURITY H: 6.'STATE EMPLOYER ID if 9. RETAIL, SALES TAX 4: 7 O'VIVNE R'S NAME: ---I L OWNER'S PHONE NO: �03) inq(04 (Limited to 35 1 03ch'a", , I 'LV1 8. OWNER'SADDRESS1fitZa lqi�-L t4 ',A - o- t (AtioTiber) (Street) (Apt 9) (City) (State) (Zip) 9. TYPE OF OWNERSHIP (Check one): Sole Proprietorship Partnership [y,),Corporation Trust f ] LLC 10. TYPE OF BUSINESS (Be Specific): I LCONTRACTOR STATE LICE' NSE NUMBER -%}Expiration date-' 3AJ— LIVerified DECLARATION RATION I DECLARE UNDER PENALTY OF PERJURY that the foregoing is. true and correct and ifcalled as a witness I could competently testify to the facts contained herein. Executed this day of 201 -in the Town/City of Q County of State of CR. S144131)-, VILE - FOR OFFICE USE ONLY: Receipt # State ADA Fee S 1,00 Amt Paid: Business Lic. Tax. '95.00 ---$ Jotal: $ 96.00 Date Paid: POLICY NUMBER: U16AC92368-00 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 Organization(s): Location And Description Of Completed Operations Any person or organization, when you and such parties have agreed in writing in a contract or agreement pertaining to "your work" performed during the policy period. This additional insured coverage does not apply to "excluded residential construction". "Excluded residential construction" means: a) the ground -up construction of any building whose units will be individually owned and titled; and, b) "your work" performed on the conversion of any building into a condominium ortownhome. Information required to complete 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 ❑ POLICY NUMBER: U16AC92368-00 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 Operations Any person or organization for whom you are performing operations during the policy period 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. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional exclu- organization(s) shown in the Schedule, but only sions apply: with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" "property damage" occurring after: caused, in whole or in part, by: 1. All work, including materials, parts or equip- 1. Your acts or omissions; or ment furnished in connection with such work, 2. The acts or omissions of those acting on your on the project (other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insured(s) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed; or nated above. 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 2010 07 04 0 ISO Properties, Inc., 2004 Page 1 of 1 0 POLICY NUMBER: U16AC92368-00 COMMERCIAL GENERAL LIABILITY HCS 040 06 1013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY AND BLANKET WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART A. PRIMARY AND NON-CONTRIBUTORY TO OTHER INSURANCE With respect to any person or organization that is an additional insured under this Coverage Part, the following is added to paragraph 4. of SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS: If you have agreed in writing in a contract or agreement that this insurance is primary and non- contributory relative to an additional insured's own insurance, then this insurance is primary and we will not seek contribution from that other insurance. For the purpose of this endorsement, the additional insured's own insurance means insurance on which the additional insured is a Named Insured. When this endorsement is attached to the policy it supersedes all other insurance conditions within. HCS 040 06 10 13 B. WAIVER OF SUBGROGRATION — BLANKET Under SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, The Transfer Of Rights Of Recovery Against Others To Us Condition is amended by the addition of the following: We waive any right of recovery we may have against any person or organization because of payments we make for injury or damage arising out of: a. Your ongoing operations; or b. "Your work" included in the "products - completed operations hazard". However, this waiver applies only when you have agreed in writing to waive such rights of recovery in a contract or agreement, and only if the contract or agreement: a. Is in effect or becomes effective during the term of this policy; and b. Was executed prior to loss. Page 1 of 1 Includes copyrighted material of Insurance Services Office, Inc., with Its permission. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 01-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS 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 0% of the California workers' -compensation premium otherwise due on such remuneration. Person or Organization City of Campbell Campbell, CA 95008 Schedule Job Description Concrete approach and sidewalk work This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated: (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 8/24/2015 Policy No. WWC3154434 Endorsement No. WC 04 03 06 Insured ROMERO, JOEL EFREN (AN INDIVIDUAL) Premium $ 5372 Insurance Company Wesco Insurance Company Countersigned by WC 04 03 06 (Ed. 01-84) DATE (MWDDIYYYY) ACOREP CERTIFICATE OF LIABILITY INSURANCE 07/01 /2016 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 CONTANAME: Ezequiel Marquez Deleon -Marquez Insurance Agency PHONE 408 266 8501 �qJC Not_ 408-266 8502 talc, Ne, Exs) .... ........ _.. . _ E-MAIL ...... ............. ADDRESS: Emarquez@allstate.com 1425 Foxworthy Avenue, Suite B INSURER(S].AFFO.RDING COVERAGE NAIC0 San Jose, CA 95118 INsuRERA: Allstate Insurance Company 19232 .. . INSURED INSURER e : J. Romero Bros, Construction, Inc. INSURER c 13585 Mamminin Court INSURERD: San Martin, CA 95046 -- INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 1 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. POLICY EXP -- - - - - LTR ; TYPE OF INSURANCE I iNsn wvn. POLICYNUMBER (MINDDIYYYY MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 5 i DAMAGE IOREF1Eb— ----._.. CI_AIh19-MADE 'OCCUR f : PREAA-ISE9 Ea„occupence) S I I MED EXP (Any one person) { S ' f j PERSONALE;ADVINJURY �5 j GEN'L AGGREGATE LIMIT APPLIES PER ( ! GENERAL AGGREGATE 15 PRO- t POLICY : JECT I I LOC ` I _. + ! PRODUCTS COMPiOPAGG S------- OTH_R S AUTOMOBILE LIABILITY I j COMBINED SINGLE LIMIT is 1,000,000 [Eaaccident).__ X ANY AUTO BODILY INJURY (Per person) , S j .. -.._. ._.�... A ALL OWNED SCHEDULED X j 648537587 11/11/2015 11/11/2016 BODILY INJURY (Per acc de t)5 AUTOS # - NON-OAUTOSWNED NON-041TlED ! � � � -_-- - I PROPERTY DAMAGE - S HIREDAUTOS I AUTOS UMBRELLA LIAR OCCUR i EACH OCCURRENCE 5 ..._ _......... EXCESS LIAB .... 1 CLAIMS-MAOEI .... ........ _. ...__.............. I E AGGREGATE 5 DIED ! RETENTION S i i WORKERS COMPENSATION I ;U �e�'+ iy j PTAT i OTH- E S iAND EMPLOYERS' LIABILITY YIN I' g _ I LITEUTE ER -- IANYPROPRIETOH/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? ❑INIA E E.L.EAC}t ACCIDENT S - t (Mandatory In NH) q�y t 05 -Li ?9 I_E_L_ DISEASE EA EMPLOYEE If yes, describe under I JU • S _.. --- ---� -- - - � DESCRIPTION OF OPERATIONS below f E.A. DISEASE -POLICY LIMIT S i I Public VIP I I rks Admin stration DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, AddltionolRemarks Schedule, may be attached it more space Is required) The project locati n Is: 3M1G. 4st7 e1 uea�uc aT�lpbel1 LA 95008. L.tl<I Ir II+AIr- MUL-ULK CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Campbell ACCORDANCE WITH THE POLICY PROVISIONS. 70 North 1st Street Campbell, CA 95008 AUTHORIZED REPRESENTATIVE ©1988- 4 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered m s of ACORD POLICY NUMBER: 648537587 COMMERCIAL AUTO CA 20 48 10 13 THIS ENDORSEMENT CHANGES THE POLICY: PLEASE READ CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM SCHEDULE Name of Additional Insured Person(s) Or Organizations) Location(s) of Covered Operations: 346 ESTHER AVENIUE CAMPBELL, CA 95008 CITY OF CAMPBELL, IT'S OFFICERS, ELECTED OR APPOINTED OFFICIALS, EMPLOYEES, AGENTS AND VOLUNTEERS 70 N 1 sT ST CAMPBELL, CA 95008-1458. c Information required to complete this schedule, if not shown above, will be shown in the Declarations. A. Section 11— WHO IS AN UNSURED 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 damage" caused, in whole or in Part, by "your worn' at the location designated and Described In the schedule of this endorsement performed For that additional Insured and included In the "oroduces- IT IS AGREED THAT THIS INSURANCE IS PRIMARY AND ANY OTHER INSURANCE MAINTAINED BY THE ADDITIONAL INSURED SHALL BE EXCESS ONLY AND NON-CONTRIBUTING WITH THIS INSURANCE. CA 20 48 10 13 0 Insurance Services Office, Inc, 2011 Page i of 1 Permit # INSURANCE REQUIREMENTS CHECKLIST CIP Project # Consultant/Contractor: Qmyyn" r-b The following insurance is required of all consultants/contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or �4— $2,000,000 general aggregate limit. ❑ Policy expiration date \V Automotive Liability: \ -t- - e Cc�CCec� Any Auto checked on certificate �,. $1,000,000 per accident for bodily injury and property damaged _ (�� � Policy expiration date rkers' Compensation and Employer's Liabilit Waiver of Subrogation clause (� $1,000,000 per- accident for bodil injury or ease ❑ Policy expiration date _ ` �`U Course of Construction (if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement: The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) o The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: OV ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR should say: � Should any of the above described policies be cancelled before the expiration date thereof, otice will be delivered in accordance with the policy provisions. o'� ❑ Workers' Compensation Insurance Sheet Submitted • For General Con'ractor ❑ For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 02 14) Page 1 Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name NAIC #a Rating: x� Authorized in CA: ���2 C� a� H g Name:_��f.y�S�C. NAIC# QS-011 Rating: M1V Authorized in CA: / Name: A\\6�-tt_ NAIC # OZ,3Z Rating: %�C �� Authorized in CA: Name: NAIC # Rating: Authorized in CA: ❑ Campbell Business License # �� �� C'� Expiration: :C7 -� ❑ Contractors License # (o�a�l a. Class: C Expiration: 3� Insurance Certificate Reviewed Initials Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 a: d I ce Construction General Contractor . CCL # B782711 Ryan Coleman Office/Fax 408-374-2100 Owner yan@allianceconstructs.com Cell408-307-7779 www.alli6nceconstructs.com p .�.�3 ��: �O