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ENC2015-00181Print Form REM AUGCITY OF CAMPBELL ENCROACHMENT PERMIT DEPT. OF PUBLIC WORKS (for working within the public 70 North First Street right-of-way) Campbell, CA 95008 public Wovlcs AIJmmistratlon Ph. (408) 866-2150 Issued C1 / 3 I Permit No L�P�� �C) j(z-or) i F X-Ref. File Application Date Application Expiration Date APN Fx. (408) 376 0958 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 Address or Tract No.: 2295 Winchester Blvd, Campbell CA Utility Trench Location: (1) El Caminito Ave; (1) Winchester Blvd -- - ---—-- ----------------=�-0 Zl-(c - =5-- - -L-`(Elul 1'7 B. Nature of Work: Utility potholes via air/vacuum excavation at 2 locations over water mains. 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 for this permit, listed below. Failure to abide by these conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2.) E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work. Name of Applicant: Bess Testlab, Inc. (Joshua Williams) Telephone: 408-988_0101 Address: 2463 Tripaldi Way, Hayward CA 94545 E-Mail Address: Joshua@besstestlab.com 24-HOUR EMERGENCY PHONE NUMBER: 909-225-0656 Is this work being done by the property owners at their own residence? F_ YES rl NO J The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers, agents, and employees free, safe and harmless from any claim or demand for damages resulting from the work covered by this permit. The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all damages arising out of the condition of any private improvements in the public right-of-way. Accepted: (Applicant Permittee) (sign) Date (Contractor) (Print Name) Date SPECIAL PROVISIONS: 1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be specifically approved by the Inspector prior to cutting. 2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A", unless otherwise approved by the Engineer. 3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public Works Department before starting work. 4. Per Section 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 has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO. 5. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right -of -Way, which shall be recorded. 6. Public Notification Requirements: 7 SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES PERMIT APPLICATION FEE PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS CONSTRUCTION CASH DEPOSIT PLAN CHECK & INSPECTION FEE EMERGENCY PERMIT FEE APPROVED FOR ISSUANCE AMOUNT $ 425 R CEI .,T NO '�`�' $ i O 2'2 a�9i?rr For City Engineer Permit Expires 12 Months After Date of Issuance Date GENERAL PERMIT CONDITIONS 1. A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency call -out, overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. 3. Refund or the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. Submit project schedule 10 (ten) days prior to proposed start of work. Special provisions may be required for work within City facilities and downtown Campbell. 5. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. 6. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants, and water valves. 7. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures, detours, and street closures. This plan must be reviewed and approved prior to any lane closures. 8. A Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated 1990, available at Caltrans. Traffic control equipment shall include Type II Flashing arrow signs if required. 9. Replace as directed by the City Engineer any damaged or removed improvements in accordance with City Standards and Specifications at the sole expense of the Permittee. 10. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements. 11. Prior approval of inspector is required for any work done after normal working hours, on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 12. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost (including all labor and materials) against the cash deposit. 13. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 14, The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m. 15. No storage of materials or equipment will be allowed near the edge of pavement, the traveled way, or within the shoulderline which would create a hazardous condition to the public. 16. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a separate permit may be required, nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 17. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 18. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 19. Call back (call out) due to emeregencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence. 20. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. 21. If the public interest requires a modification of, or a departure from the plans and specifications, the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made for City -owned or maintained facilities. 22. 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. Applicant Contractor Date: Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev. 02/14 w / CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 8/14/2017 ✓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 CONTACT Sandy Brown Leavitt Pacific Insurance Brokers, Inc. PHONE(408) 288-6262 FAX X No): E-MAIL ADDRESS: sandy -brown@leavitt.com License #OD79674 INSURER(S) AFFORDING COVERAGE NAIC # 1330 S Bascom Ave INSURER A:Eyanston Insurance Company ! 35378 San Jose CA 95128 RECElvE® INSURED G INsuRERB:West American Insurance Company 144393 INSURERC:RSUI Indemnity Insurance Company 122314 Bess TESTLA13 INC. n11� �. 2463 Tripaldi Way till INSURERD:State Compensation Insurance Fund 135076 fNSURERE:Mount Hawley Insurance Company 37974 Hayward CA 94545 ��� y�QrksAdminiStr INSURERF:Columbia CasualtV Company , 31127 COVERAGES CERTIFICATE NUMBER:17-18 gl/au/um/wc 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 LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP MM/DD/YYYY MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE DAMAGE TO RENTED I $ 1,000,000 A ICLAIMS-MADE LX OCCUR j I PREMISES (Ea occurrence) $ 100,000 x Deductible 5000 X Y 3C21366 8/14/2017 8/14/2018 MED EXP (Any one person) I $ NC L PERSONAL 8 ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 —� PRO- POLICY � LOC JECT PRODUCTS - COMP/OP AGG I $ 2,000,000 Expenses Is h OTHER: �AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ ANY AUTO ALL OWNED i� SCHEDULED B AUTOS I AUTOS DAW56666963 8/14/2017 8/14/2018 I BODILY INJURY (Per accident) $ rPROPERTY DAMAGE Per accident Is NON -OWNED I HIRED AUTOS AUTOS is L , UMBRELLA LIAB X � OCCUR j EACH OCCURRENCE _� $ _ 5 , 000, 000 C x EXCESS LIAB 'CLAIMS -MADE AGGREGATE $ _ 5,000,000 DED RETENTION$ NHA243171 j 8/14/2017 8/14/2018 $ WORKERS COMPENSATION 'I' x PER OTH- STATUTE ER AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y �I E.L. EACH ACCIDENT 1,000,000 OFFICER/MEMBER EXCLUDED? N I A $ D (Mandatory in NH) y 907972316 i ll/21/2016 11/21/2017 I E.L. DISEASE - EA EMPLOYEE $ 1 , 000 , 000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 1 $ 1,000,000 i E (Pollution Liablity EGL0005093 8/14/2017 8/14/2018 5,000,000 F Professional Liab CE05091869087 I 12/27/16 12/27/17 IDed I I 5,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Campbell its officers employees and volunteers are named as additional insured per GL form CG2033 & CG2037 attached. Re:ltiaatClTe—st—er7*Bl7v--dWCMEp-be 1 CA Pemit o.: 2015-00181 Waiver of Subrogation applies & attached. 111111191afC11111IIaLoy-1117iLei AJa►L"a4WG\ILei ► City of Campbell 70 N First St Campbell , CA 95008 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ti ,E Fred Stafford/YWALD G� ACORD 25 (2014/01) INS 025 (201401) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 3C21366 COMMERCIAL GENERAL LIABILITY CG 20 33 0413 THIS ENDORSEMENT CHANGES THE POLICY.. PLEASE READ IT CAREFULLY. ADDITIONAL INSURE® - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRE® IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section 11 — Who Is An Insured is amended to include as an additional insured any. person or organization 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 or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured. However, the insurance afforded to such additional insured: 1. Only applies to the extent permitted by law; and 2. Will not be broader than that which you are required by the contract or agreement to provide for such additional insured. 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 additional exclusions apply: This insurance does not apply to: 1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of .the rendering of, or the failure to render, any professional architectural, engineering or' surveying services, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision, hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury" or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the failure to render any professional architectural, . engineering or surveying services. CG 20 33,04 13 1 © Insurance Services Office, Inc., 2012 Page 1 of 2 2. "Bodily injuryor "property damage"_occurring after: a. All 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 insured(s) at the location of the covered operations has been completed; or b. 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 other than. ' another contractor or subcontractor engaged . -in , performing operations for a principal as a part of .the same project. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement you have entered into with the additional insured; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 33 0413 POLICY NUMBER::3C21366 - : COMMERCIAL GENERAL LIABILITY CG20370704 - THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. 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 As required by written contract executed by both parties prior to loss. 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". CC 20 37 07 04 1 ©-.ISO Properties, Inc., 2004 Page 1 of 1 0 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART ..PROD,UCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following - is - added to .the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any. provision to the agreement that this insurance would be contrary:. primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and CG.20 01, 04 13 ©-Insurance Services Office, Inc., 2012 Page 1 of 1 POLICY NUMBER: 3C21366 COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 - WAIVER OF TRANSFER OF RIGHTS OF RECOVERY - AGAINST" OTHERS TO US .This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: As required by written contract executed by both parties prior to loss. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8_ Transfer Of Rights Of Recovery Against Others To Us of Section IV — Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising outof your ongoing operations or "your work" done under a contract with that person or organization and included in the "products - completed operations hazard". This waiver applies only to 'the person or organization shown in the Schedule above. CG 24 04.05 09 © Insurance Services Office, Inc., 2008 Page 1 of 1 " ENDORSEMENT AGREEMENT WAIVER OF SUBROGATION . BLANKET BASIS HOME OFFICE SANFRANCISCO EFFECTIVE NOVEMBER 21, 2016 AT 12.01 A.M. ALL EFFECTIVE DATES ARE AND EXPIRING NOVEMBER 21, 2017 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME BESS TESTLAB 2463 TRIPALDI WAY HAYWARD, CA 94545 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. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.00% OF THE TOTAL POLICY PREMIUM. 9079723-16 RENEWAL - NA 0-84-00-52 PAGE 1 OF 1 SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION BLANKET WAIVER OF FOR WHOM THE NAMED INSURED SUBROGATION HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERS IGNED• AND ISSUED AT SAN FRANCISCO: NOVEMBER 3, �20016 2572 AUTHORIZED REPRESENT /IVE PRESIDENT AND CEO SCIF FORM 10217 (REV.7-2014) OLD DP 217 m I� � N EX. EX. EX. EX D/W D/W EX. :HP GAS LINE CVR K. D/W S/W �+�{ I� ELEV. 299' \iAMIMITO A VE EX. 6' DICL TIE-IN (B3-007) Ln ��\\\ EX. 6' VCP 6.7' CVR \�7.q-v.- 4.09'CVRI \ ' I5_RCP 3.6' CVR R 3.5' CVR EX. 6' DICL (EB-025) 10 RETIRED Q EX. D/W S/W M N tt N 305-3 -039 3 l' WN o aAMl1/V O AVE I o m w :r > Y `lr I PARKING G sn 2rr 21 r =w C Q > > > - - O U U FIRE COMMERCIAL SERVICE & 1RR1G. 12' -' 11 cn J In U 16' a I p LA CD I > Q PROPOSED APN # 305-34-004 BUILDING 47' w w w 2295 S. WINCHESTER EL 92' I cy tf� rt .t{ PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MISCELLANEOUS RECEIPT Effective July 1, 2015 TO: Finance PUBLIC WORKS FILE NO. r-N C aoIS ^00 PROPERTY ADDRESS Lv. Please collect & receipt for the following monies: ACCT. I ITEM AMOUNT ENCROACHMENT PERMIT 4722 Utility Encroachment Permit Application Fee $425.00 2 R-1 Encroachment Permit N/C Emergency Permits $120.00 Plan Check & Inspection Fee Minimum Charge Per Location $390.00 3�d Conduits/Pipelines up to 500 Feet $2.75/ft Above 500, Linear Feet $1.65/ft Manholes/Vaults/Etc. $175.00/ea Pole Set/Removal $175.00/ea 4760 Storage Container Permit $160.00 4760 Project Plans & Specifications Project No. 4760 Standard Specifications & Details $1/Pg $15.50/13k _ 4760 Engineering Maps & Plans Aerial Plot 24" x 36° $61.00 Aerial Print 8 1/2" x 11" $29.00 Map Research (includes max of two 24"x36" copies) $29.00 Maps and Plans 24" x 36" $14.00 4722 . Penalties: Failure to restore public improvements $100/Calendar Day (Muni Code Sec. 11.34.010) 4722 Penalties: Failure to correct unsafe conditions $100/Calendar Day 4722 Work Without Permits 4 Times Applicable Fee TRAFFIC 4728 Traffic Flow Map (Daily Traffic Volumes) $35.00 4728 Signal Timing Information $73 per hour 4271 Truck Permits $16.00 per trip 4728 No Parking Signs $1 each or $25/100 MISCELLANEOUS 511.7424 Postage Other (Please Specify) NAME OF APPLICANT i S TOTAL NAME OF PAYOR S c / ® �— PHONE ADDRESS �'. j ZIP FOR RECEIVED B)(� 113 A CITY CLERK ONLY Date Receipt # �j �J li J %L + l Al Ira'I 'Ills l"oll g A-# a-r. J:\FCRMS\TemplatesVAdministrative\Receipt Form Utility Encroachment& Mist 15-16AS a� \S C,d\,nCV\.e S«( INSURANCE REQUIREMENTS CHECKLIST Permit # Consultant/Contractor: &S5 �tiG�J I TVA." -CNC aotS- ocy1,6 k 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: ,)n $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggregate limit. Policy expiration date ly lQ Automotive Liability: "Any Auto" checked on certificate 76— $1,000,000 per accident for bodily injury and property damage Policy expiration date (� _orkers' Compensation and Employer's Liability �� ❑ Waiver of Subrogation clause $1,000,000 per accident for bo ily injury or disease ❑ Policy expiration date-<< 21 s- 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: �p 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. 6 Cancellation area: ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liabilitv of anv kind upon the comoanv, its agents or representatives". OR should say: . Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. Workers' Compensation Insurance Sheet Submitted For General Contractor ❑ 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. 2 -7� Name:,�,�st �� _ NAIL # 353 Rating: A Authorized in CA: _ Name: )Me Or 4�cc,.— TD f, �. NAIC # 353 Rating: /�c Authorized in CA: Name: ctP - ram NAIC # 596-1Rating: Authorized in CA: 1/ Name: NAIC # Rating: Authorized in CA: nee�5 ❑ Campbell Business License # Expiration: _ ❑ Contractors License # 1>�1 �77� Class:Expiration: Insurance Certificate Reviewed Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. 8 ag rs- J:\FORMS\Templates\Insurance Requirements\Insurance Requirements &ist.doc (Rev 08 14) Page 2 A � V CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 8/12/2016 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 Leavitt Pacific Insurance Brokers, Inc. �' F �•+ License #OD79674 r1 _ CONTACT Sand Brown NAME: y PAHic NN .Ext: (408)288-6262 FAIAc No: (908)298-7635 E-MAIL sand —brown leavitt.com y ADDRESS:log INSURERS AFFORDING COVERAGE NAIC # 1330 S Bascom Ave San Jose CA 95128 INSURERA:Evanston Insurance Company 35378 INSURED INS.1�URERB:West American Insurance Com an 44393 Bess TESTA B INC. _ Pab1ir_, (i krfURERC:RSUI Indemnity Insurance Company 22314 INSURERD:State Compensation Insurance Fund 35076 INSURERE:Mount Hawley Insurance CompanV 37974 2463 Tripaldi Way 1 INSURERF:Columbia CasualtV CompanV 131127 Hayward CA 94545 COVERAGES CERTIFICATE NUMBER:1617 gl/au/um/wc 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 ADDL SUBR POLICY NUMBER POLICYEFF /YYYY MMIDDY EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE �X OCCUR DAMAGE TO PREMISESEa olccu".nce $ 100TED , 000 MED EXP (Any one person) $ NC X 3C21162 8/14/2016 8/14/2017 PERSONAL & ADV INJURY $ 1,000,000 LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY � Et° LOC Expenses $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 B X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS BAW56666963 8/14/2016 8/14/2017 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ (PROPER ccI AMAGE $ X OCCUR EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 C X EEENTION$ CLAIMS -MADE $ NRA240808 8/14/2016 8/14/2017 WORKERS COMPENSATION EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE PER STATUTE ERH XAND E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 D OFFICERIMEMBER EXCLUDED? ❑ (Mandatory in NH) N I A 907972316 11/21/2016 11/21/2017 E.L. DISEASE - POLICY LIMIT 1 $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E Pollution Liab EGL004355 8/14/2016 8/14/2017 5,000,000 F Professional Liab CS05091869087 12/27/15 12/27/16 Ded10000 5,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) City of Campbell its officers employees and volunteers are named as additional insured per GL form CG2033 & CG2037 attached. Re: 2295 Winchester Blvd Campbell CA Permit No.: 2015-001_81 Waiver of Subrogation applies & attached. 1 City of Campbell 70 N First St Campbell , CA 95008 l�N1VVCLL/i I IVR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE d Stafford/YWALD ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) INS025 (201401) The ACORD name and logo are registered marks of ACORD A ENDORSEMENT AGREEMENT BROKER COPY WAIVER OF SUBROGATION BLANKET BASIS HOME OFFICE SANFRANCISCO EFFECTIVE NOVEMBER 21, 2016 AT 12.01 A.M. ALLEFFECTIVE DATESARE AND EXPIRING NOVEMBER 21, 2017 AT 12.01 A.M. AT 1201 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME BESS TESTLAB 2463 TRIPALDI WAY HAYWARD, CA 94545 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. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.00% OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION BLANKET WAIVER OF FOR WHOM THE NAMED INSURED SUBROGATION HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER 9079723-16 RENEWAL NA 0-84-00-52 PAGE 1 OF 1 NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT AT SAy�N FRANCISCO. NOVEMBER 3, {2016J /�1�j (.v[/L- �✓ K• � l/!ii"�lN>ti .'tii �.tli7Z�f/lam AUTHORIZED REPRESENT 7VE PRESIDENT AND CEO SCIF FORK 10217 (REV.7-2014) 2572 OLD OF 217 / 1 ® ACoR" CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDNYYY) 9/22/2016 THIS CIERTIFICATE 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 Dorsey,Hazeltine & Wynne 1/ Wyn � � License # : 0281413 400 Seaport Court, Suite 1000 6 2p16 Redwood City CA 94063 CONTAA NAME: CT Pelayo Carranza PHONE (650)858-2375 FAX (650)856-1023 C N Ex A1C No E-MAIL ADDRESS: P cacranza@dhw-ins.com INSURERS AFFORDING COVERAGE NAIC # INSURERA:Rockhill Insurance Company k INSURED n`Sl� P.A. Lewis Construction, Inc. `r,'Q`KSr P.O. BOX 2003 ,) 161- V C Menlo Park CA 94026 INSURER B :Financial Pacific Insurance Compy INSURERC:State Compensation Ins. Fund 35076 INSURER D :CNA Surety INSURER E : INSURERF: rrn%i=oAr•=c rcRTIVIr_ATF NUMBER•16-17 GL/Umb Rnwl 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 ADDL SUBR POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP (ANDMI LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS -MADE �X OCCUR DAIE TO PREM SES Ea oocu ence $ 50,000 MED EXP (Any one person) $ 10,000 RCGLPGO114702 9/23/2016 9/23/2017 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 2,000,000 XPOLICY ❑PRO ❑ LOC JECT OTHER: AUTOMOBILE LIABILITY COMBINED$ Ea aociden SINGLE LIMIT $ BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1 000 000 AGGREGATE $ 1,000,000 B EXCESS LIAB CLAIMS -MADE DED RETENTION$ $ 2730361102 9/23/2016 9/23/2017 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000 000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 C OFFICER/MEMBER EXCLUDED? ❑ (Mandatory In NH) N I A 9138403-16 7/27/2016 7/27/2017 E.L. DISEASE - POLICY LIMIT $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below D Contractors License Bond 62127122 08/14/2014 08/14/2017 Bond Limit 15,000 DESCRIPTION OF OPEBAILONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space Is required) %E1, :,> ,-0' '6N00.118�1�'- 35 Dillon Avenue Ci'y of Campbell, its officers, employees and volunteers are named additional insured per attached General Liability endorsement form. Primary and non-contributory wording applies. Waiver of subrogation for General Liability and Workers' Comp are included. Notice of cancellation provided per policy condition form. UAN L, r LLA 1 IU SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Campbell THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: Dept. of Public Works ACCORDANCE WITH THE POLICY PROVISIONS. 70 N.-First St. Campbell, CA 95008 AUTHORIZED REPRESENTATIVE TSS/VSUNGA —� 011VOIS-LU14 Ak UKU 6UKrU1W I IUIV. imi rlgniti reserves. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD INS025 (201401) POLICY NUMBER: RCGLPGO1147-02 COMMERCIAL GENERAL LIABILITY CG 24 0410 93 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the f9ilp, "in COMMERCIAL GENERAL LIABILITY COVERAGE PART SCI-IED�t),(E-, Name ON" be Organ lzatld*,� h are obligated Oy!� 1&q of written contract ji , ide insurance Any person or organization to you q prrqyl such as is afforded by this; policy; bqtonly with respect to occurrences taking place such written co x pf work performed by you during the policy contract has executed and -urrences resulting fqT, ing,'f�pmihe conduct period,pToccurrencesresult of your Nslnes�s during the policy p (If no entry appears above, informaiibn'required to complete this endorsementwill be show,.n'in the Declarations as ,y ap applica!JI646this endorsement.) The TRANSFER OF RIGHTS .OF RECOVERY AGAINST OTHERS TO US Con dilion (Section IV COMMER&AL.GENERAL LIABILITY CONDITIONS) is amended by.the addition of the foflowlnq: person organization 'J�n 'A We wai*,�any 'jrlghj, of recovery W,!�,rnay have against the p he �Schedule aboy . amage a r: i nj u ry or � d arising out of y because of 0yments we ma f' our ongoing operations or "your work" done and includ&dl h the "products-compldt6do p-e-iraition's hazard". This under a&6ntra* With that person or organization Walvefi t( ly 16 the person I a 6�g0olzatl6rishown int !,uea h.0`Sk`p'hq-'d I above. bo me. CG 24 0410 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 11 POLICY NUMBER: RCGLPGO1147-02 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS.:= ?(FORM B) This endorsement modifies insurance provided under the following: OOMMERbIAL `GENERAL LIA8ILITY''COVERAGE PART. ..SCHEdl.ULE'. Name of ,e" ir'`Organlzatlob ' Any pLLersori or organization thich you are obligated o„ by Virtue of a written contract to provide insurance suchas is aff.o,rOed by this 0046y,.,tot idnly with respect to, (1,) occur- rences taking place after such written .,contract has teen executed and (2} occurrences re- sultirglrom work performed by you during the policy period, or occurrences resulting from the conduct .o`f your bustnesE wring the policy petied A person or organ anon ghat guaiitres as sn ` insurg!under the above` paragt ph hi, Endgrsement; shall be an dditiorta1 insured solely ink fh respect to such additiona,I i,nsured's liability. for" "bodily ntui'y," 'property damage"' or "personal a.;ntl advertisrngpnlji�r "caused m, whole, or. in „part by -your acts .or omissions in the p11 e..r .ormance. of i your -or_k" ti or �tbe addi= tlonal,insuredfon,or at "eom�ne�eial�i;onstructio_n projedfs —.w , 1 , ctioredfnd"et" as thofthd"mcooeeu buitd,ings or structures corrstruct`ed, for comrnercral use end ;also include„apattrnecits, trote.ls. Home for the aged',, dormitories or barracks ."However, "commercial, coniruction projects'' shall nq include any puildirtg ar structure which, in whole ,or in part, contains individual bwhe occupied unit] dvVellit s.. (if no entry appears above,-mformaion required to complete this endorsement:will be shown ip tf�e Declarations as applicabl i,' othl'Siendorsement.) WHO,IS AN INSURED Section Ifs is amended to include.as<an'insured the person or organization shown in the Schedule, but=only with respect to liabiiityansing out of"your work" for that insured by_ or for..y'.ou. Coverage provided by this policy to the Additional Insured(s) shown in the Schedule_ shall be primary insurance and any other insurance maintained by the Additional Insured(s) shall be excess and non-contributory, but only if required of the Named Insured and by written contract. CG 20 10 1185 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 13 -COMMERCIAL GENERAL: IABI 'ITy 33 :07 98 THIS ENDOR ITCARE FULLY* �SFMENT CHANGES THE POLICY.. PLEASE . .. M ADDITIONAL INSURED - OWNERS'5 S LESSEES OR CO U W-H IE-,� �A 0 AT S CONTRACTORS - TOM IC,TAT $ REQUIRED IN CONSTRUCTION AGREEMENT WITRYOU his'endorsen pg r _pd '.insurance .om �(00-Un' following:. qqMMEKIAL:QEt+fERAL 41AB1j_jMr_ RPaI5 FART .A. Section 11 - Who., 'U, .Aw Insured is amended-tp, 1661 Ud ;&s an- lnsblhed'= persen or organiza lon foi "Ohl.you Oro P,0470M.fn operations haVe, pgreg writing Iie thpt Pi.. or :organization ba.addad aisan-additionai insured on -your policy., Such person ;-.',,or;organization is an ftfitloh6l- insured only '*'th,tespect to libbillt, ans Maw of P performe0 for MA in'.'$,U'r'qd. Age sbn'g gq insured under this endprellnent entls wharf yourL,.qpereitions'-forithdt-.,'insured-.are.corQpletiacfi7 ithrespect ,'to,the,insurance,afforcfeb"w e k 116nal -ins br, 'follow ft usion: A e bi iing additbri . ,,e This lh§'Uranc a d apply tdi Bodil 1pjury.11."prGperi:"yd damage" �ama,e M­persona and ;advertising injury' arisang dilt Adfithe if -""' Tendering of or :the faitu[e to refitlert n_ professional --i- J- d ,Ong n.00rmPwN*' 1 :$Omm, h0ftl_� I or hi- ......... -pprIpy.0; ilf'.9ps*, S. PR. IrMY- TIM. pJ_n.1P1A'-_'re- po : E field -bed s-'!­ b" drew[ngs end spa lf)pa ions, '464, 21, inspection, 0, 6g, Coverage p ON this policy 'p'611dy1dthe" Addirffib"bM finl"s..u...r.iedfshall e.: unary insu rance MdAh'y other lnsurancemaintained di'' lbfigl- Ib'§U?6d Sljall foe excess: esa.. antl ndhtddb"d CG 20 3107 98 Copyright ht, Insurance Services Office; Inc., 1997 Page 1 of 1 13