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ENC2015-00101
CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No .......... _. E .. 2-15-001 fl DEPT. OF PUBLIC WORKS (for working within the public. X-Ref. File_PJ._N201 A- A 70 North First Street right -of- ay) Application Date 5/19/2015 Campbell, CA 95008 Issued ` Application Expiration'Date........___ Ph. (408)BW2150 ..�_.1. _ APN �-a7 Fx. (406) 376-0958 "- Permit Expiration Date APPLICATION -Application is hereby, made for a Public. Works Permit in accordance with Campbell Municipal Code, Section 11.G4, (Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable:) A. Work Address or-rractNo,: 11291 Freda Court, Campbell, CA 95008 Utility Trench Location: B. Nature of work: Street Improvements on West Hacienda Avenue as required by Planning Permit C. Attach four (4) copies ofan engineered plan showing the location and extent of the work, and fou"r (4) copies of the preliminary Engineer's Estimate of work. The plans shall shave 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, Ail work shall conform to the City of Campbell Standard Specifications and. Details for Public Works Construction; the General Permit Conditions fisted 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. E. The'Contractor must have this permit and approved plans at fife site and must notify the PubiieWorks 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: Jason and Sylvia Cathy Telephone: 408-687-1133 Address; 11291 Freda Ct. Campbell Ca 95008 E-Mail Address:. sylviacathy@sbcglobal.rfet 24-HOUR EMERGENCY PHONE NUMBER: 408-687-0995 _- Is this work being done by the.property owners at theirown residence? J7 YES NO The ApplicanVPermittee hereby agrees by affixing; their signature to this pmrnit 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 ApplicantlPermittee hereby acknowledges that they have read and understand both the front and taaek of this permit, and they will inform their contractors) of the information. Appiicant'is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any, a d all damages arise a iorovements completed in the public right-of-way. ___ Accepted; r j / f / �' --: _..- ....- (Applicant Pemiittee) /J (sign) A 4:1 am 5PECIALPRt7ViSiO1NS:.� -��-- - _i. Street shall not be open cut for underground installations.. Minimum cuts maybe allowed for connections or exploration holes. Such cuts may _be sp�cific4_11y a_pprctv_e_c! by Inspector prior w crrttiing. ,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 421E 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 for Private Improvements in the Public Right of -Way, which shall r e recorded. _6. Public NotificationReouirements: — .................- _.. — ——.......__ -- -- -- — -- - .. - -- SEE.PUBLIC VJQRK4 !FUR CURRENT- E.ES. AMOUNT RECEIPT NO. PERMIT APPLICATION FEE s_— 385.00 258619 ��_-_--- PLAN CHECK DEPOSIT 5 ...__-_58I0 ..- 2 86..1_ SECURITY FOR FAITHFUL PERFORMANCEILABOft i& MATERIALS' S _._.-_90 , a I Bond N4. S�OO��q�jj� CONSTRUCTION CASH DEPOSIT S 1 ��`� :�� PLAN CHECK & INSPECTION FEE2- EMERGENCY PERMIT FEE APPROVED FOR ISSUANCE For City Engineer Date Permit Expires 12 Months After Date of Issuance GENERAL PERMIT CONDITIONS 1, The Permittee must provide evidence of insurance and Additional insured Endorsements as required by the City. Insurance shall be maintained for the. duration of the permit work. 2— 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. 3. Refund of the construction,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. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. Surety posted shall be equal to 25% of the original Faithful Performance Security. 5, Submit project schedule 10 (ten) days prior to proposed start of work. Additional lead time maybe required for work within City facilities and downtown Campbell. 6. The Permittee mustreque5it in writing a final inspection and acceptance ofthe work u pon completion. Acceptance by the City will be made in writing to the Permittee. 7. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants, and water valves. 8, A Construction Ttaffic. 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. 9. A Construction Traffic Control Plan shall (onform to the 2006 California Manual on Uniform Traffic Control Devices (MUTCD). 10. -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 as expeditiously as possible. 11, Sawcut forall PCC or AC rpmcivals. All PCC removals shall be to the nearest scoremark and new PCC shall be doweled to existing Improvements. 12, Prior approval of inspector is required for any work proposed after normal working hours, on weekends or holidays and may require reimbursement of inspection costs it the current overtime rate. 13, Work on arterials and collectors may requite the use of changeable message boards. -Adequate signing and barricading is required on the job site. Failure to provide such signing'and badicading may result in: the City's providing signing and barricades and charging the, cost (including all labor -and materials) against the ccinstruction'cash deposit 14, Compaction testing of subgrade, base rock, and asphait concrete by Permittee is required unless otherwise stated by the City Engineer. 15. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shali provide a phione, number at which they can be:cdnitacted, outside the hours of 6,,00 axil, to.4.00 p.m. and on weekends, 16. 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 17. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other we, k for whicha separate Permit may be required, nor does ii relieve the Permitteeof any obligation to obtain any other permit required by law. I& This permit does not release the Permittee from any liabilities contained In citheragreements or contracts with the City and any other public agency. 19. This permit isnot transferable. Work must be performed by the Per.mittee or his designated agent or contractor as specified thereon. 29. Call back (call out) due to cmerege�ricle5 regardingthis permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence. 21. Pursuant to Chapter 14.02 of the Campbell Municipal Co&, 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. 22. If the public interest requires a modification of, or a departure from the permit plans, special provisions and/or specifications, the City shall have the authority to require or approve any modification or depalure and to specify the.manner in Which the same is to be made. 32, 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. 7t is , hereby re oirensuring that all those providing services under the applicant arl-raware conditions. the Con,ractor (Print Name) I - Date: Ji\FORMSlreippla"es\Encroathment Pertnits\Encroachment Permit STATIC form2.pdf Rev.,05/14 J:1LeedDeJA Check C—.-.11-Spacifz Prajec6-AcN Projector P.,,—'FredaCt12911Fee7— Of cA,�, •CkCHAR�• CTI'Y OF CAMPBELL Public Works Department April 26, 2018 Jason and Sylvia Cathy 1291 Freda Ct., Campbell CA 950.08 SUBJECT: PERMIT NO. ENC 2015-00101 1291 Freda Ct., Campbell, CA FINAL INSPECTION AND ACCEPTANCE Dear Jason and Sylvia: The City of Campbell has made the final one year maintenance inspection of the subject Public Works improvements and finds that no remedial work is required. Your warranty requirements and any surety, therefore, are hereby released. Enclosed is your Faithful Performance of Maintenance Bond i#100279633. Sincerely, Syed Wahidi Public works Inspector Cc: Permit # ENC 2015-00101 70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAx 408.376.0958 • TDD 408.866.2790 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2015-00101 Name: Jason Cathy Property Address: 1291 Freda Ct. Date of Final Inspection: On File: Bonds CD Cash Faithful Performance: $ Labor and Material: $ Construction Cash Deposit to be released: $ Other overdue deposits to be released (Description): ¢F6c> IMP ��n enance z°01� - 51181M Processed by: �CZ dministrator Reviewed by: Inspector Reviewed by: Land Development Engine r J:VoAnnaT\Deposit refunds\CHECKLISTS\Freda 1291b.doc (Rev. 10/11) of cA'r yF O UkCHARO CITY OF CAMPBELL . Public Works Department June 28, 2017 Jason and Sylvia Cathy 1291 Freda Court Campbell, CA 95008 r- SUBJECT: PERMIT NO. ENC 2015-00101 1291 Freda Court FINAL INSPECTION AND ACCEPTANCE Dear Jason and Sylvia: Thank you for dropping off your Maintenance Bond in exchange for your Faithful Performance Bond. Enclosed are the original Faithful Performance Bond and your deposit refund check in the amount of $1,752.00. The City will make the final inspection on your improvements in April 2018 and inform you in writing whether or not any repairs are required. If you have any questions, please call me at (408) 866-2150 Eric: Faithful Performance Bond #100279633, Ck 9262583 Cc: Inspector /Suspense Files Permit File: ENC2015-00101 Roger Storz, Sr. Engineer 70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • Fax 408.376.0958 • TDD 408.866.2790 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2015-00101 Name: Jason and Sylvia Cathy Property Address: 1291 Freda Court Date of Final Inspection: 4/26/17 On File: Bonds CD Cash Faithful Performance: $ Bond for $29,312.46 Labor and Material: $ Construction Cash Deposit to be released: $1,172.00 Other overdue deposits to be released (Description): Plan Check Deposit $580.00 Processed by: Reviewed by: Reviewed by: istrator Inspector Land Development Engineer 2-7 J:VoAnnalADeposit refunds\CHECKLISTS\Freda 1291..doe (Rev. 10/11) ®V C911� - r v r •�kCHAR��. CITY OF CAMPBELL Public Works Department May 9, 2017 Jason and Sylvia Cathy 1291 Freda Court Campbell, CA 95008 SUBJECT: PERMIT NO. ENC 2015-00101 1291 Freda Court FINAL INSPECTION AND ACCEPTANCE Dear Jason and Sylvia: 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 April 26, 2017. 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 Construction Cash Deposit in the amount of $1,172.00, and your Plan Check Deposit in the amount of $580.00 will be sent under separate cover. Your Faithful Performance Security Bond (Continuation Bond) which will expire June 7, 2017, should be replaced with a Maintenance Bond for 25% of the original amount which is $7,328.12. If you have any questions, please call me at (408) 866-2165. Sincerely, Syed Wanidi Public Works Inspector Cc: Inspector /Suspense Files Permit File: ENC2015-00101 70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAX 408.376.0958 • TDD 408.866.2790 ........... ........... .. .. .. .. ... ...... . .... ........... ................ .... ...... .. - .......... ............ ............... ........... ............ ......... .. ............................ .................. ................. .......... ..................... ......................... CITY OF CAMPBELL VENDOR NO. 10014371 CHECK NO. 262583 CAMPBELL, CALIFORNIA 95008 SYLVIA CATHY 129.1 FREDA COURT CAMPBELL CA 95008 ENCRMENT PERMIT ISSUANCE CHECK LIf City of Campbell Encroachment Permit No. ENC ?,DIS --00 l C4 Department of Public Works Tract No. 0/k Address: A Czx.,k:�C__ ITEMS REQUIRED FOR PERMIT APPLICATION: 1. 93. Encroachment Permit Application complete, with applicant signature and date (front and back) 2. 95 Permit Application Fee paid $ ' ,�SkOQ - Receipt Number & Date 2 % b��'1� S �v� k S 3. V,-5- Plan Check Deposit Paid (2% of Engineer's Estimate, $500 min) $ 5b0,00 Receipt Number ZS S 4. Grading Plan Review Fee paid $. © -' eceipt Number & Date 5. City Engineer's Estimate Completed and Submitted 6. Four (4) Sets of Street Improvement Plans 7. Four (4) Sets of Grading and Drainage Plans 8. Check Lists (Grading and Drainage, Street Improvement) ITEMS REQUIRED PRIOR TO PUBLIC WORK CLEARANCE FOR BUILDING PERMITS 9. % Plan Check & Inspection Fee: Engineer's Estimate (EE) = $ '?q 1 `, `'Z.m ; ifEE is <$250,000, then fee is 14% ofEE. If EE > $250,000, fee is Actual Cost + 20%. $35,000 minimum deposit. Amount $ koz •CSC Receipt No. & Date 'Zsal 3 10. Security for Faithful Performance and Labor and Materials, 100% each of Engineer's Estimate, supplied or paid. Amount $ TA Form ZQIA� Receipt No. & Date t 00'Z-7151 11._b4 Security for Monumentation Amount $ Receipt No. & Date 12. Construction Emergency Cash Deposit: 4% of Engineer's Estimate. ($500 minimum , $10,000 maximum) Amount $_ i 112. ego ZSq 3� � Receipt No. & Date "7\ 3 Vs 13. Stle-orm Drainage Area Fee Amount $ �� :� Receipt No. &Date 15`13_� L� 77 11 14.(15 Street Improvement Agreement signed and notarized (proof of ownership submitted) 15.�1- Right of Way Documents Completed and Fees Paid. 16.P5, All other Public Works requirements listed in the Conditions of Approval of the development. 17.4& Other Fees, Payments, Deposits Amount $ Receipt No. & Date 18. SWPPP +NOI 19. JAJAPC3 Certification 20. Covenant Agreement 21. Geotech Letter 22. 4— Storm Water Management Plan ITEMS REQUIRED PRIOR TO ISSUANCE OF ENCROACHMENT PERMIT: 23. Contractor's signature added to the permit application (front and back) 24. Contractor's City of Campbell Business License # 25. Worker's Compensation Insurance Information Sheet received from Contractor. 26. Certificate of Insurance with Additional Insured's Endorsement received from Applicant or Contractor 27. One mylar set and six (6) or less sets of off -site plans signed by engineer, stamped APPROVED FOR CONSTRUCTION. _Contractor, _Inspector PW Superintendent (Service Center) EP File LD File _Signals & Lighting Supervisor (Service Center) 28. Permit signed by City Engineer. 29. INITIATE CHECK REQUEST FOR PLAN CHECK DEPOSIT REFUND WHEN ALL OF THE ABOVE ITEMS ARE COMPLETE, PERMIT MAY BE ISSUED. Issuer: Initial and date and file with permit Encroachment Permit Final Sign Off Encroachment Permit # 20 Address: 1 I P - C-T 2 ' Q `- Date of Final Inspection and Acceptance: Inspected by: vj OK to release deposits: 100% 75% Comments t�;`A� C ���.o a�S"��VC'��Q✓` l�a� Refundable Deposit..Check Request To- rinance Director l Check Pa able To: Sylvia }� \� - - . Y . C� a �I Lj Address" Line 1 . ` 1291 Freda Court i Line 2:. City: Campbell State: CA Zip: 95008 Description'." 1291 feeda Court _ Account Number: 101..2203_- _. Amount: $1,752.00., Account Number: - 101.2203 Amount: Account Number: 101..540.7448 Amount; (Finance Dept only) Interest Earned (Finance Dept only) Total. Payable: (Exact Amount) Purposes Construction Cash Depositend Plan Check.Deposit Refunds Permit #: ENC2015-00101 Receipt #: • 258619... Date: 3/14%2017 Receipt #: - 259374 , Date: _ _ 7/13/2015 ' Requesy ted.b, Title: Inspector Date: MO' R. 'Syed Wahidi Approved by: Title: Sr. Engineer Date: S Roger-storz Finance Dept Only;: Verified'by: Tithe:: Accounting Clerk , Date: -Approved by- Title: Accountant, Date: Sdecial, Instructions'.., For. H:andli Check Mail As Is: Mail in Attache—d noels e; Interim'.Check:.. Needed By: R- turn o: JoAnria Thomason Public Works (Name) (Department) Other:.Please return-check4o'JoAnna JoAnna Thomason From: Roger Storz Sent: Thursday, May 25, 2017 8:55 AM To: 'On -Site Construction, Inc'; 'Sylvia Cathy' Cc: Syed Wahidi; JoAnna Thomason Subject: 1291 Importance: High Good Morning, We are processing the paperwork and deposit refund of $1,752.00 for your project, but we first need to resolve the warranty bond issue. As part of your project, you are required to maintain a warranty bond in the amount of 25% of the original bond amount for a period of one year. You can either extend your current faithful performance bond for an additional year, or ask your bonding company to issue you a replacement warranty bond. One other option Is to put the warranty surety up as a cash deposit to the City, which we would refund at the end of the one year warranty period. Some customers prefer this option as it avoids dealing with another bond and the associated bond premium. Please let me know how you wish to proceed as soon as possible. Thank you, Roger Storz, PE City of Campbell (408) 866-2190 (direct) roaersna citvofcamobell.com Land Development Website .� ® Ac"R® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDfYYYY) 03/15/2017 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 Dicar Insurance Marketing 6976 Automall Parkway NAME: CT Edith Gonzalez PHONE 408 848-9085 (FAX, c No : 408 848-5125 Alc No Ext: ( ) ( ) ADD Liss: dicaredith@gmail.com INSURER(S) AFFORDING COVERAGE NAIC # - - INSURERA: CENTURY NATIONAL '15954 Gilroy CA 95020 INSURED - INSURER 6 : INSURER C : Amaya'S Concrete INSURER D: 15245 Murphy Ave INSURERE: INSURERF: San Martin CA 95046 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 I TYPE OF INSURANCE . . ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MMIDDIYYYI' POLICY EXP MMIDDM/YY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE E OCCUR DAMAGE l O R NTED PREMISES (Ea occurrence) $ MED EXP (Any one person) S PERSONAL & ADV INJURY I S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE PRODUCTS - COMP/OP AGG $ PRO- � LOC POLICY ❑ OTHER: I $ AUTOMOBILE LIABILITY EOalaccd.nl) LE LIMIT �$ 1,000,000 .BODILY INJURY (Per person) �ODILY INJURY (Per accident) I S Is A X ANY AUTO ALL OWNED SCHEDULED AUTOS - AUTOS NON -OWNED HIRED AUTOS AUTOS BAP0184145 - 04/12/2016 -4/1272 PROPERTY DAMAGE Per accident is $ UMBRELLA LIAB OCCUR EACH OCCURRENCE is RDED AGGREGATE $ EXCESS LIAB CLAIMS -MADE RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE cER OTH- ,.TATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ OFFICER/MEMBER EXCLUDED? ❑NIA (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below 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) J,t�7BfLOCAaTI,QNw>It1r29rIjFREDAYCfTCAMPBEL_LgCA�[9'5p0'8formit Nurniaer E. C20e17=0,00, THE CITY, IT'S OFFICERS, EMPLOYEES, AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSURED. INSURANCE COVERAGE AFFORDED TO ADDITIONAL TO THE INSURANCE IS PRIMARY INSURANCE GLK I H-IGA I t HULL)tK r wry THE CITY OF CAMPBELL 70 N. FIRST 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. AUTHORIZED REPRESENTATIVE --ORD 25 (2014/01) r U 1988-2914 AGURD GOKPUKA I IUN. All rignts reserved. The ACORD name and logo are registered marks of ACORD BOND NO. 100279633 PREMIUM: INCLUDED IN ENCROACHMENT . PERFORMANCE BOND BOND FOR FAITHFUL PERFORMANCE OF MAINTENANCE PERIOD ENCROACHMENT. PERMIT NO. ENC2015-00101 We, the undersigned JASON RICHARD CATHYAND SYLVIA DOLORES CATHY, TRUSTEE OF THE CATHY FAMILY LIVING TRU5erelnafter "Principal") and AMERICAN CONTRACTORS INDEMITY COMPANY , a corporation organized under the laws of the State of , and authorized to transact business in the State of California, as Surety, are obligated to the City of Campbell (hereinafter "City"), a municipal corporation under the laws of the State of California, in the sum of SEVEN THOUSAND THREE HUNDRED TWENTY EIGHT & 12/100 Dollars ($ 7,328.12 1 for the payment of which sum we obligate ourselves and our successors and assigns, jointly and severally by the following provisions: The condition of this obligation is that the Principal entered, or is about to enter, into a certain written Contract with the City dated t&gs<cyL �4 , 20k-1_ and entitled PUBLIC WORKS IMPROVEMENT AT 1291 FREDA COURT a one year maintenance period of the work described in said Contract, a true and correct copy of which is presently on file in the office of the City Clerk of the City of Campbell, which said agreement is hereby referred to and made a part hereof. And, the City requires a guarantee from the Principal against defective materials and workmanship in connection with that maintenance. Now, therefore, the Principal agrees that it shall make all repairs or replacements necessary during.the period of one-year from the date of acceptance of the contract work, by reason of defective materials or workmanship .in connection with the Contract. If those defective materials or workmanship occur within that period, the City shall give the Principal and Surety written notice of that defect within 60 days after discovery. When each replacement is made to the satisfaction of the City, the obligation of the Principal and Surety shall be discharged as to that replacement, otherwise to remain in full force and effect, with surety obligated to secure full and faithful performance of all of Principal's obligations under the above -referenced contract. Any repairs or replacements made under this bond shall in like manner be subj ect to the terms and conditions of it. No prepayment or delay in payment and no changes, extensions, addition or alteration of any provision of said Contract or in any plans and specifications referred to herein, and no forbearance on the part of the City shall operate to release the Surety from liability on this bond, and consent to make such alterations without further notice to or consent by the Surety is hereby given, and the Surety hereby waives the provisions of Section 2819 of the Civil Code of the State of California. In witness, the parties have executed this agreement as of JUNE 21 20 17 JASON RICHARD CATHYAND SYLVIA DOLORES CATHY, TRUSTEE OF THE (Principal) CATHY FAMILY LIVING TRUST (Attach Acknowledgements) (Both Principal's and Surety's Attorney in Fact) i T (Surety) AMERICAN CONTRACTORS INDEMNITY COMPANY By NHUNG H. SA ,ATTORNEY-IN-F 1- Address of Surety 801 S. FIGUEROA STREET LOS ANGELES, CA 90017 + - Surety's Bond Number 100279633 (Accompany this bond with Attorney-in-fact's authority from Surety to execute the bond certified,to include the date of the bond.) 7:\FORA4S\Templates\Encroachment PermitslEncroachment Permit Maintenance Bonddoc (Rev. 03/08) CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only.the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. STATE OF CALIFORNIA COUNTY OF SACRAMENTO } On 06/21/2017 before me, KATY TAYLOR Notary Public, Date (here insert name) personally appeared NHUNG H. 'SAEPHAN who proved to me on the basis of satisfactory evidence to be the person(.&) whose name(&_) is/afe subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by Ns/her/their signature(&) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signatu Description of Attached Document Title or Type of Document: Document Date: (Seal) .OPTIONAL INFORMATION Other: T 5 0, KATY TAYLOR U COMbl. # 207221'1 0, Zqb. , — o NOTARY PUBLIC- CALIFORN14 \- SACRAMENTO COUNTY C) mop . COMM. EXPIRES JULY 19.2018 Number of Pages: 'P 41 = ill Ill i q lli ilillulil' �ilii 'IIIIiIi'I — 1 1112 III III III — 1II- - OF ATT III,Ii I, II 4�IIIIIIIIIJI, III' (IIII Illii6:lll, _ _ _ _ AMERICAN CONTRACTORS INDEMNITY COMPANY TEXAS BONDING COMPANY ` UNITED STATES SURETY COMPANY U.S. SPECIALTY INSURANCE COMPANY KNOW-ALL MHN BY HESEumed PRESENATS ri ant erican Contractors Indemntl:ip ny, a -California corporationsexas _ _ A _ _—_p % i�l:l II IIII: iQl II III'4 IIIIII' _ -� dll III �cilactors"Indemnoat Dnte�cates Surety Company aMaryland cnrparahon=an [T Specialty In 'I II Ili hill III Ila I:I I� a corporatton� llec£� 1 he --`Coen aties"), do by thes�res_ents make3 III Ili a l'V!Ihll l 11 IIIIu II III — = - - =cons ttute attd appoint: — _ _ Eric J. Fedors, Sheryl Smith, Elizabeth A. Juarez, Nhung H. Saephan, Katy Taylor, or Daren Eiseman of Sacramento, California its true and>lawfkAttorney(s)-in-fact, each in the .sep-grate capacity if more th onel la1 ,a j bove, with full power -and authokit� III p IIIII here'rtty conferred m its name, placeatead, to execute, acknowledge.atl IIIIII 'ila y La �plp nds, recognizan_ces, undra _ or other instruments or contracts o- urefh_s i UN nblude riders, a It :� s , s .of surety, o lio f -e _ — *�** *** II!IIVI'.III;I IILIIIIIi I�IVlpllll'lllt'IIII�,IIVI DO11arS $�0000�0** _ �penalty does not exceed = Three Million ( D.. . This Power of Attorney shall expire without further action on December 20, 2017'. This Power of Attorney is granted under and by authority of the following resolutions adopted by the Boards of Directors of the Companies: Be it Resolved, that -the President, any, Vice -President, anfI Assis , III Il,ice-President; any Secretary or any AssistantSecretary shall be and :is`hereby vetted ��tl�'nll— I ea�uer atr fion��ppomt any one or m. e I b e is ey(s)-in-Fact tore rp esenttad actor nd o0ghalf of the Company sect -to_ he fo o . g IIIIII III i II � III Il III i I� �I III — — -- - -- - — d1.II,..I�II, - - lttirney�nctniaygiven full poweIllalnd a�}hrirlll .Iin'lll a ne of and on behf3he t0mpanxeeutecknowledge and delianx_andl bands - III :V Illlllin - recognizances, contracts, agreements or indemnity%'- d other conditional or obligatory uf�m�a ngs; including any and all consents forerelease of retained percentages and/or final estimates on engineering and construction contracts, andany land all notices and, documents canceling or terminating the Company's liability } thereunder, and any such instruments so executed by any such Aito_mey-in-Fact shall -be binding upon the Company as if signed by the President and sealed, and effected bythe•Corporate Secretary. Be=it Resolved, that -I ie si nature of anauthorized_=officerman"eal�he Company,_heretofore lol a ;I III d 01' power of attorney or any cortificatei lating g. y r r afte!'! l them bacsimile any power of attorreificafe beannsimile.signature or t� I�� al l�,1 i a d binding upon the.an�--wttt[Espt p'u IIpIU II ghl'j fl'I IIII IIIIIq, — a_ nond or undertakenio which it is attar — — — — _ IIIII'I I�;I I; I II� IIJiI i� �llllll1 II�� �I'II�I� IJIIII:,II:IIII�, II — !I IN WITNESS WHEREOF, The'Companies have caused this instrument to a signed and- .their corporate seals to beto> affixed,; this . Ist day of:December, 2014. . AMERICAN CONTRACT OR INDEMNITY"COMPANY TEXAS BONDING'COMPANY �c= or a eals UNITED STATES ANY U S. SPECIALTY INSURANCIr�OMPANY.. _ II!IIIIIIIIIIY I - -- �'1 SU f J� ��llj0 N N III � i1H lnsoragc - - _ r _ �� = - - �Y � 0 g. o— _W mcmronnTEo n r: i!,1111 yl.:. •�T o:; 9' t B}T� D.all jam— ..- y _ 9EFf 21 4990 K T1 e e , ', ... Agwlar;'Vice"Pr std ht �gUFp..... r rnn nnn� �� .nnnumP�.. rruumeP A notaryWubhe omther officer completiWhis_certi#tcate vies only the identity olf�thelilndivildual ll II ho'llsl�Red the — document to=lv7nch this certificate -is att d,�t -- oTMM_ II ness, accuracy, o Rl�rt i'I. II' fIIPIII IIII I III a,Il ltlli State oMhfom�a County of Los Angeles SS: = IIII Ill IIII } J, III — _ On this 1st day of December, 2014, before.me, Maria G. Rodriguez, Wong, a notarypublic, personally appeared "Dan P. Aguilar, Vice President of American Contractors Indemnity Company, Texas -Bonding Company, United States Surety and U.S. Specialty In Company who proved to me on the basis of satisfactory evidence to be the person whose name, subscribed to the within instrument and ael mo-ledged to me that he executed the same in - III htsuthort=ca�aet and that by his si ei t rn a person, or the en.oeha�vhite person acted, executed theanstrumen: -_, IIIIIII�ILIiI II 'IIIIII��IIII — — - - _ c rti finder RP NA Y OF PERJUl � $IIII II pl to I "f Califorma tha the aregmng-Tara us a and correct. MESS my hand and official seal. III III (IIII _ I IIII — MARIA G. RODRIGUEZ-WONG Commission # 2049771 Signature (Seal) Z :�_� Notary Public • California i Z Flli n a IIII Dun D = a I^ ty ul lliil'I' o trx 1il c;20.2017+ = = - - I, III I I I _ = _ = — _ Ili IILI �I IIIIII � 'I ! I I III,II�II'�— __ , =I, Kio DO, Assistant Secretary of Amerie-au�-ontcacta-r�Tdemni Company, Texa's!I� ti mg�l„Compa y United States Surety��n�nd�� Specialty Insurance Company, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney, executed by said Companies, which is still in full force and effect; furthermore, the resolutions of the Boards of Directors, set out in the Power of Attorney are in full force and effect. I I,� In Witness WhF- 5, I have , hc, eunto set my ha dl'jand Iaffixed the seals of said Coral = ,,IIIIIIIIIIIIII IIIIII! IIIIII Ill�ylll Illlllglllq,, ;, 2tJ�7.lI� I III I I �I III � � III I' II,I — IaI III j 'II 'l�'IlI'I I Iyit, Il'I III = - - Co orate Seals 1 ��� 7pRs/ 'CEg"S ll/�FT 00pSOINr, 00. ,\�V lnsu aar 3 I , y, V 1YGdtiY•MiEO z O �+= 1,U Bond No 1002796JJ' u 9ErT2 •aeo r. a� Y 7 Y --.� !� �b O 2.•3 a AgP.nC NO-: —7010 Y �A11 NAP — ��t —n qTE OFiE�'Py (�I I* i __ III I'II'I ill - I II' IIIIII nl 'II IIIIII I California this 21 q'r day Kio Lo, Assistant Secretary American Contractors Indemnity Company 11� G r . , wH C C 1610 Arden Way, Suite 145 Sacramento, CA 95815 h, r } o " main 916 568 7818 facsimile 916 568 7838 J -tit , -, , June 24, 2016 Continuation Certificate E>U�ltlrs� 4dtldidlir�6 4t.rc1/� Bond No. Bond Description Bond Amount Effective Date Expiration Date 100279633 - CLASS B CONTRACTS $29,312.00 07/07/2016 06/07/2017 - ALL OTHER CLASS B - [ALL OTHER CLASS B NOCI Principal: JASON RICHARD CATHY AND SYLVIA DOLORES CATHY, TRUSTEE OF THE CATHY FAMILY L 1291 FREDA COURT CAMPBELL, CA 95008 Obligee: CAMPBELL CITY PUBLIC WORKS DEPT (CA) 70 NORTH FIRST ST CAMPBELL, CA 95008 THIS BOND CONTINUES IN FORCE TO THE ABOVE EXPIRATION DATE CONDITIONED AND PROVIDED THAT THE LOSSES OR RECOVERIES IN IT AND ALL ENDORSEMENTS SHALL NEVER EXCEED THE PENALTY SET FORTH IN THE BOND AND WHETHER THE LOSSES OR RECOVERIES ARE WITHIN THE FIRST AND/OR SUBSEQUENT OR WITHIN ANY EXTENSION OR RENEWAL PERIOD, PRESENT, PAST OR FUTURE. ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED. SIGNED AND DATED THIS 24th DAY OF JUNE 2016 American Contractors Indemnity Company Ilillillllillilllllllll III II IIIIIIiI IIIIIIII IIIlilll Illillllllllllllll ���� � �-- �'°�--- NHUNG H. SAEPHAN , Attorney -in -fact Obligee: CAMPBELL CITY PUBLIC WORKS DEPT (CA) 70 NORTH FIRST ST sty CAMPBELL, CA 95008 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. STATE OF CALIFORNIA COUNTY OF SACRAMENTO On 06/24/2016 Date before me, KATY TAYLOR �• Notary Public, (here insert name) personally appeared NHUNG H. SAEPHAN , who proved to me on the basis of satisfactory evidence to be the person(e) whose name(&) is/are, subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/tI•ieir authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(&) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: Description of Attached Document Title or Type of Document: Document Date: (Seal) OPTIONAL INFORMATION Other: a"J�oYTAYORj nw#i NUTARYPUBLIC - CALIFORNIA (1) SACRAMENTO COUNTY a rroc COMM. EXPIRES 18 Number of Pages: t 11 I $ ,, * ! 4411�111 III � Iil_I''14�t I,,. ' • ' . II { POWER OF ATTORNEY ANIERICAN CONTRACTORS INDEN'INITY COMPANY TEXAS BONDING COMPANY UNITED S'I'A'1'1sS SURF:7'Y COMI'ANY U.S. SPECIALTY INSURANCE COMPANY li 4 KNOW ALL MEN BY THESE'; PA6E0T i �jhaqije rnl -ican Contractors Indemnity Company, a California corporation, Texas Bonding Company, an assumed time of .Ame1 rcait Contractors Indemnity Company, United States Surety Company, a M aryland corporation and U.S. Specialty Insti'ian'ce Clotianp; a Texas corporation (collectively, the "Companies"), do by these presents make, constitute and appoint: Eric J. hedors, Sheryl Smith, Elizabeth A. Juarez, Nhung H. Saephan, Katy Taylor, or Daren Eiseman of Sacramento, California its true and lawful Attorn ev (s)- i n- fact, each in their separate capacity if ni��;e'�tal%.oiile, ►sinap d above, with full power and authority hereby conferred in its name, place and stead, to execute, acknowledge uid'�e�tv��; al tpid all btntls, recognizances, undertakings or other instruments or contracts of suretyship to include riders, an $l d n ts, and consents of surety, providing the bond penalty does not exceed *****Three Million***** Dollars ($ **3,000,000.00** ), This Power of Attorney shall expire without further action on December 20, 2017. This Power of Attorney is granted under and by authority of the following resolutions adopted by the Boards of Directors of the Companies: iPi s I Be it any, ghtthe President, ViQprPiiI �1�1si�tIi; Sn`nt nryor any i' and tshereby vested with ft�^to tlefflowing power ncut�rivtoa appoint one orJIeuo renand Assistant Secretary provisions: Atiorney-in-Pots may be given full power an'd` authority for and in the name of and on behalf of the Company, to execute, acknowledge and deliver, any and all bonds, recognizances, contracts, agreements or indemnity and other conditional or obligatory undertakings, including any and all consents for the release of retained percentages and/or final estimates on engineering and construction contracts, and any and all notices and documents canceling or terminating the Company's liability thereunder, and any such instruments so executed by any such Attorney -in -Fact shall be binding upon the Company as if signed by the President and sealed and effected by the Corporate Secretary. l II 11I r all Be it Resolved. that the signature of any authorized officer and seal of the Company, hcretot4letxhGkLiafterlfaft1Itec� ah�'power of attorney or any certificate relating thereto by facsimile, and any power of attorney or certificate bearing facsimile signature or apsfijlel� a) 911AI1 "bin, aM binding upon the Company with respect to any bond or undertaking to which it is attached. :,II III' 6:!I41,t ll G,: iN WITNESS WHEREOF, The Companies have caused this instrument to be signed and their corporate seals to be hereto affixed, this I st clay of December, 2014. AMERICAN Corporate Seals "ZApG...... „a„�. SEPT 15. 199J MNITY COMPANY TEXAS BONDING COMPANY MANY U.S. SPECIALTY INSURANCE COMPANY pY ins..... a':.. Daniel P. Aguilar, Vice President } III I;II � 414� A notary public or other officer completing this certificate verifies only the identd�'lfitte ut}r1tLYµ #�Iw�1 sued the document to which this certificate is attached, and not the truthfulness, accuracy o>ti 11�►g ofiltl>,at dbcih{tteta�'' fUe31a; Il,i:a:,n.. County of Los Angeles SS: On this I st day of December, 2014, before me, Maria G. Rodriguez -Wong, a notary public, personally appeared Dan P. Aguilar, Vice President of American Contractors indemnity Company Texas Bonding Comp a 1, Cjlt�d States Surety Company and U.S. Specialty Insurance Company who proved to me on the basis of satistactory evidence to be the p�rspt� w)}$s ml�lil 14bscribed to the within instrument and ackttowledged to me that he executed the same in his authorized capacity, and that by his stgnatt�rq op tit in curt;{2�7 tr@i d person, or the entity upon behalf of which the person acted, executed the instrument. I:,u ,i I i certify under PENALTY OF PERJURY �r�rder the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. MARIA G. RODRIGUEZ-WO—N-G i Commission M 2049771 Signature Seal < "ice Notar ,IPt h alifornia i b ( } Z • rlLtils /SnpP�Os quilt h ICu1 Q��h�ri`lt®SrD'Q't:20, 2017 I, Kio Lo, Assistant Secretary of American Contractors Indemnity Company, Texas Bonding Company, United States Surety Company and U.S. Specialty Insurance Company, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney, executed by said Companies, which is still in Hull force and effect; furthermore, the resolutions of the Boards of Directors, set out in the Power of Attorney are in full force and effect. In Witness Whereof, I have hereunto ari set m hdlalnd affixed the seals of said Comp anies at Los Angeles, California this 2_ day y li of i 11 t J 2U'l b Corporate Seals °"RpC70Rn as`S...R.,, oo NpING"'• "n lrsuri a•0�. ,.. it' .. •``"C : Tti..., a`�0; .• A •. O'., ° :i::........,,. a'cwPoanwo _�: ff//!1 ! �( Kill,1 Lo Assistant Secretary Bond No. Pi n ,m Y =X. SEvz - �'• _ � � ` > b _ .., � � a 6 O` may'` $I 1 .} Agency No. 6 ttf' •"i�AL;F00.Nr?c``�� ...* ',:,9jF O�Y�-F�• � I �� r* �• ,� ; k I , l AOJ7 ea__ G Pa-Sjr ct� Recording Requested by: City of Campbell When Recorded Mail To: City Clerk City of Campbell 70 North First Street Campbell, CA 95008 APN: See attached Exhibit ADDRESS: See attached Exhibit Regina Alcomendras 1 Santa Clara County - Clerk -Recorder 1 02/27/2017 03:57 PM Titles: 1 Pages: 4 RR 1V1jZ� APR 2Q011 CITY E , Fees: 0.00 Taxes: 0 Total: 10.00 ■III POOR WIN 'oaf 1#44-11A ZAI 111,01111,11111 (Space Above This Line For Recorder's Use) RESOLUTION VACATING THE LIGHT AND AIR / BUILDING SETBACK LINE EASEMENTS AS SHOWN ON TRACT MAP NO. 284, AND DIRECTING THE CITY CLERK TO RECORD THE RESOLUTION RESOLUTION NO. 12117 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF CAMPBELL VACATING THE LIGHT AND AIR / BUILDING SETBACK LINE EASEMENTS AS SHOWN ON TRACT MAP NO. 284, AND DIRECTING THE CITY CLERK TO RECORD THE RESOLUTION WHEREAS, an easement for light and air purposes was recorded May 13, 1946 on Tract Map No: 284 in Book 10 of Maps at Page 23 of Official Records, Santa Clara County; and WHEREAS, this easement is no longer required as it has been superseded by the requirements of the City of Campbell Zoning Code; and WHEREAS, it is the desire of the City of Campbell to remove this outdated encumbrance from the properties within the subdivision known as Tract No. 284 as shown on Exhibit A and more particularly described in Exhibit B; and WHEREAS, the easement vacation is to be made pursuant to Chapter 4, Summary Vacation, of Part 3 of Division 9 of the California Street and Highway Code. NOW, THEREFORE, BE IT RESOLVED that the City Council of the City of Campbell does hereby vacate the light and air / building setback line easement and directs the City Clerk to record this Resolution for the properties within Tract No. 284 as shown on Exhibit A and more particularly described in Exhibit B. PASSED AND ADOPTED this 21 st day of February, 2017 by the following roll call vote: AYES: Councilmembers: Waterman, Cristina, Landry, Resnikoff, Gibbons NOES: Councilmembers: None ABSENT: Councilmembers: None ATT T: -j . �' , 1j, & Wendy d, City Clerk APPRO ED. lizab th Gibbons, Mayor THE FOREGOING INSTRUMENT IS A TRUE AND CORRECT COPY OF THE ORIGINAL ON FILE IN THIS OFFICE. ATTEST: WENDY WOOD, CITY -CLERK ITY O C ELL, A BY DATED c a� LANDS OF S4LYAcoR *,=L- T. f64GNASCO LANDS Of ✓05E ses•sz•w 41175• - 027YAT/LO Sat/'Pipe- R + Set /'Ppa•i`' �'4 ;'se//•P:pc Bui/ding_•-'" -ao'Pp_ '4^I t 17Q;Q ^F Z Une -� 12 0 9� �• o I /3 -•Bui/a Line tic -52'C NB9 :Q'E 190.BB' I 00,07' 11 lot corners /1 I R V R I 14 sdcurva psinJs I .� )/ a/a//1Id a I NO •52' st with 2,5,3' 90.88E W wd. Stahes. 10 I m a M 15 0 I I p T e9•!2'r N89•]2E na.aB' f]aB • 0 I 0 B I 8 a7l 89'S2f I lsoes p 00 0 7 �I y �I a NB9-sre 1 /9o.Bs• C ,a o g e �1a NB9.52^C 19o.Ba' i 5 NB9•az'L p� lso.eB o° 4 W NB9•sz' /BO.BB' 9 gm O to I N • 2•E �"N 120.88• C q p 2 pp /9O.Oa �i h u a 1 o o � � NB9'1zE /Woo C a V yo I n �p� of ,r' a Jat /'Ppo 0 11 20 NB]^JZ'E � 0 20 o � o'er �� 190.e7' Y V 22 qp O B9•]Z' ° N 23 0 c AL I R --sag O /]O.B 24 1 NB9•s2G' C£RTIFICA TE OF ENOINEER !- Edward Cahalan Sleffanl, haroby certify that lam aregis/arad CAW fngir7eer of the State of Ca///ormo, /ha/ thls map cons/shr79 Of one shoal, correctly eaprosents o survay mode under my suparwlubn during /be month of March, 1546, that the survay,s true and complole os shown,• that al/ofthe monuman/s shown thereon actually argil onethe/r pos//ions are correctly shown and M./ sold monuman/s ore sufficlan/ to anob/e the survey to be ralraced. i�- CA5/5 OF BEAR/NGSNOTE 7h9 baorirag o/ /he Northerly Line a/ /he Sun-yoohs Tiac/as shown in Map Bo oh H at Paga 149, ?ocores of SonJo Caro Counly, State at Cot//ormo, was usados /he basis ofbeorii'gs shown upon lh/s map. All dislancas and dimensions am shown in /aaf anddaclrraals there./. The b/ua border ladle./as the boundor,es of/he land subdivided by this map. OWNERS CERT/F/GATE We hereby cer//fy lho! we arc the ownars oforhova soma right, title or 1r;farast in and to the real properly 1;7cfi ded within the subdivls/on shown upon IhMr mop, a wWal we are, The on/yµsrrae Whose consent /s necessary to pass o clear f/F/a to said proper/v arm we cans¢-/ to the mo/rrrya of solo mop and subdlvlsion as shown wi%hin The border /Ptad and heraby dodica/o /o ,OvAl* usa a//the Avenues shown upon sa/dmop within sold subdivision. fHao/so herebydedicofe lorpubh'c use easements./or/igh/ondoir urzhr, on or over Those eertoir7 strips of/and lyir7g balween The tines of Avanrres and The /fries each deslgnaled as bu//ding b;70, as shown on said mop wifhlh sold subdi wslon; such strips ./land to he hap/ open and floe from bu17.11nys ondaTrucfures of any Hind oxce'vM7.g h-iiga/ion one 5prh71f ing systems and appur/anances Thera/o. _,lL4C�CT_�11./ As Owners _________________ ACtrIVOWL £D4'MEN TS S/o/ of Co/r%rn,c' ss County ./SonM C/ono. On /h/s,zgtaoy o/J J946, before me,�lyle,,,,l <_ _ o Notary Public in end for said C`ounfy a/ Sonlo Cbro, 51010 Of COIIZOrn/o, roslo'ing /harem duly commiisionedondsm?rn pvsoro//yoppwrxrd 4—rr Garr/san,Ada 6oie4ra, his mib• Bair Vlill IM1aren. andOe/% hrlorerr hli wife, known to ma to ba The parsons whose names are suhscnbod /o /ha w ybh7 insfrumanf and echno w/edged /o me //lot they execu/ad /he sonTe. /N w/7N£SS WHEFi£Or / //a- helrun/a so/ my hond and offircemy off%Clol son/ /hc dayandyvar h7 /his cci/ificatc firs1 oba va writ/en. No/ r P / in and for /%xi Couri�y of onto C/ono, 51o1e of Co/i%rnia. .q'c,iiai'i esq�3 � P�00 AVE. Bat/'Pipe !•Sal /•P' _ /��P Oy' Monument J£ Gamer 1012 V 0Q ENGINEERS NOTE: Tharc,s no ewd nc¢ on the ground of fha e:xisf.nca old %flea or di%h - ghr of way /ho/ miyhf he .fang the rights of wayy gran/va for d//chea by✓.H. Henry to the S/o/ter Ditch C•ampony, by deed doled ✓una Z 1904 acid recorded ✓una /3 1004 in Vol. 2,60 of Deeds o/ 1%ac 304, RecoMi ofSan/a Clara County, S/ale OJCob%rnln and 6y ✓.H. Henry to Orch-f 01 y' 17t/on Company o Corpora%on by deed doled and recoreed Q; lobar 5 1904 in Vol. 283 of Deeds al fbge 125, Records of Son/o Clara Counly, Stole of CaMbrmi7. if is opporan/ thal These riyhls of way &ova lopsed because flong disuse. CERT/F/CAT£ OF COUNTY SURVEYOR I hereby carlily that! ha va eramh7oa`the Baal map of Tract No. 284; /hat the subdiwsion as shown !hereon /s subs/on/ia/ly the some as//appeared on the lanla//ve mop /hamal and any approved o/%rofibnsl that a// the pro visions of the Mop Act and of on y local ordirronce applicable of the pine of/he oppravo/ of the lenla/ive mop have boon comphed w %h, and Thal tom sofis/iad that said map 1J leehnkally eorrac% 92&rtB c&&u/-/ec-__ _ --- Counly Survcyo � 5n10 Clara Ooled_tYljY_4____--imo ,,coounty, Colifornhz By-//d25�—- 2ap717i------ CER TIF/CA TE OF CLERK OF BOARD OF SUPERVISORS It is oreeredlho/ the mop of Troc/Na 284 be one the same is haraby approved,• that a//s/reels, lanes, o//.ys, roads and other parcels of/and shown upon sorb mop and /honour of/erred for dedication bearrdthe some oreyl;r-V5ereby occepfea, for Jhe prrrooses for which the Some ore o/%rod her dedication. The p's/-p on Sannyaa4 Aae /s henrby acnp/ad. The C/erh of This Boards dracted To endorse upon the face ofso,dmop o copy offhib order outhen/icoled by the ry /of tho Baorrf a/Suparvlsors. Ibareby cep/i/y Mal the forrtyoi4 .roar was adopted by /ha oore olSupar vloors a/ o me. brag of soft Board he/d_ /ni i'L _.1946. Caun/y C/arfr and r-Olficla C/any o//hc Board of Supervisors Of/he Counly of C/pono�, State / Cah%rwi , Deputy CERT/FICATE OF COUNTY RECORDER Accepted for record and recorded Ira Booh_ ! o_of Maps; N Page Z�_, /r7 Jhe O/f/ce of /he Counly Recorder of the Counly 2 of Santo Clara fhh,-_3-doy of-'_"tay__ J946, 01_ '-s9 Ply, Chgs A. Poync _-- O Counly Recorder of Jhe County of P5': Sonla Clara. 0 Fyn - D -- Puffy �. TRACT No.284 GARRISON TRACT A SUBDIVISION OF PORTION OF LOT 2 SUNNYOAKS TRACT SANTA CLARA COUNTY, CALIF. APRIL 1946 SCALE I- too' F.E.PISANOA E.C.STEFFANI CIVIL ENGINEERS SANTA CLARA,CALIF. 10 23 Exhibit B Exhibit B - Vacation of Light and Air Easement Assessor Parcel Number Address Map Reference 404-30-012 945 Emory Avenue Tract No. 284, Lot #1 (portion) 404-30-011 927 Emory Avenue Tract No. 284, Lot #2 404-30-010 909 Emory Avenue Tract No. 284, Lot #3 404-30-009 881 Emory Avenue Tract No. 284, Lot #4 404-30-008 875 Emory Avenue Tract No. 284, Lot #5 404-30-007 855 Emory Avenue Tract No. 284, Lot #6 404-30-006 839 Emory Avenue Tract No. 284, Lot #7 404-30-005 819 Emory Avenue Tract No. 284, Lot #8 404-30-004 803 Emory Avenue Tract No. 284, Lot #9 404-30-003 783 Emory Avenue Tract No. 284, Lot #10 404-30-002 763 Emory Avenue Tract No.-284, Lot #11 404-30-001 745 Emory Avenue Tract No. 284, Lot #12 404-29-041 746 Emory Avenue Tract No. 284, Lot #13 (portion) 404-29-042 392 Waldo Road Tract No. 284, Lot #13 (portion) 404-29-037 764 Emory Avenue Tract No. 284, Lot #14 404-29-036 784 Emory Avenue Tract No. 284, Lot #15 404-29-035 804 Emory Avenue Tract No. 284, Lot #16 404-29-034 820 Emory Avenue Tract No. 284, Lot #17 404-29-033 840 Emory Avenue Tract No. 284, Lot #18 404-29-045 856 Emory Avenue Tract No. 284, Lot #19 404-29-031 878 Emory Avenue Tract No. 284, Lot #20 404-29-030 886 Emory Avenue Tract No. 284, Lot #21 404-29-029 910 Emory Avenue Tract No. 284, Lot #22 404-29-028 928 Emory Avenue Tract No. 284, Lot #23 404-29-027 946 Emory Avenue Tract No. 284, Lot #24 BOND NO. 100279633 PREMIUM: $879.00 ANNUALLY BOND FOR FAITHFUL PERFORMANCE ENCROACHMENT PERMIT NO. ENC2015-00101 JASON RKMARD CATHY AND SYLV IA DOLORES CA'rnY, We, the undersigned TRUSTEEOT THE CA17IY FAMILY LIVING TRUST , (hereinafter "Principal ") and AMERICAN CONTRACTORS INDEMNITY COMPANY a corporation organized under the laws of the State of CALIFORNIA _ and authorized to transact business in the State of California, as Surety, are obligated to the City of Campbell, (hereinafter "City") a mundeipal corporation under the laws of the State of California, in the sum of TWENTY NINE THOUSAND THREE HUNDRED TWELVE AND NO/100 Dollars ($ 29,312.00 ) for the payment of which sum we obligate ourselves and our successors and assigns, jointly and severally by the tbllowing provisions: The condition of this obligation is: Because the obligated Principal has, on t11�1 , 20 15" . entered into written Encroaclunent Permit with the City for the Project, a copy of which'Encroachment. Permit is attached and made a part of this bond, for construction of Project ENCROACHMENT WORD AT 1291 FREDA COURT, CAMPBELL, CA 95008 Now, therefore, if the Principal shall faithfully perform the work in accordance with the plans, specifications and permit documents during the original term, and any extensions of the permit which may be granted by the City, with or without notice to the Surety, and if it shall satisfy all claims and demands incurred under the permit, and shall fiilly indemnify and save harmless the City from all costs and damages which it may suffer by reason of failure to do so, and shalt reimburse and repay the City all outlay and expense which the City may incur in curing any default, then this obligation shall be void; otherwise to remain in full force and effect, with surety obligated to secure the full and faithful performance of all of Principal's obligations under the attached Encroachment Permit. If any legal action be Filed upon this bond, it shall be filed within one year after final payment has been made under the Encroachment Permit excluding the warranty period, if any, provided for in the Encroachment Permit, and venue shall lie, in the County of Santa Clara, State of California, and that surety, for value received stipulates and agrees that no change, extension of time, alteration or addition to the terms of the Encroachment Permit or to the work to be performed under it or the specifications accompanying it shall in any way affect its obligation on this bond, and it does by tlus means waive notice of any change, extension of time, alteration or addition to the terms of the Encroachment Permit or to the work or to the specifications, and thereby waives the provisions of Section 2819 of the Civil Code of the State of California. In witness, the parties have executed this agreement as of NLY 7 (Attach Acknowledgements) (Roth Principal's and Surety's Attorney in Fact) 20 15 (Principal) Title (Surety) By Z NHUNG AEPHA , ATTORNEY -IN -FACT Address of S ty: 601 S. FIGUEROA STREET, 91600, LOS ANGELES, CA 90017 Surety's Bond Number 100279633 (Accompany this bond with Attomey-in-faet's authority from Sinrety to execute the bond, certified to include the date of the bond.) J:11 ORMSI1'emplates\nicronohment Permits\Bond for Faithful Perfonnance.doo (Rev. 03/08) CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. STATE OF CALIFORNIA COUNTY OF SACRAMENTO } On 7/07/2015 before me, KATY TAYLOR Notary Public, Date (here insert name ) personally appeared NHUNG H. SAEPHAN , who proved to' me on the basis of satisfactory evidence to be the person(a) whose name(&•) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by Hs/her/their signature(s) on the instrument the person(&•), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: Description of Attached Document Title or Type of Document: Document Date: (Seal) OPTIONAL INFORMATION Other: KA Y "f °r°L09 0 COM.M. # 2072211 (5 NOTARY PUBLIC - CALIFORi dIA D SAC, MENTO COUNT ' 0 ljFOR � COMM. e;CPiRFS JUl.Y 19. 2318 Number of Pages: CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189 Ct..'�.{ C.T. _.��C�cJ.�i� �S�C�t_.�C c�Y't.aC�`•..�C��t/.: t�C/_: ...�5 S�C,c.S�•�•�C�S�Ss�C C .'C_a�•.�•s�C�C!�•.-S/.'CT�� _. �C A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California ) County of sc�,C\Nc _ On �Su_Ti a01 before me, Date Here Insert Name and Title of the bfficer personally appeared�I����� (°G��•�I C1\",(S Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS 71nd and official seal. 1, 4N I THOMASON Comridssion # 2110789 Z "my PMC - California Signature timed $ ft Clare C (2� ture of Notary Public IA Connr. Es ins iMa S 2019 Place Notary Seal Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document "ef�c_\ Title or Type of Document: as� �� �p0`S ko Document Date: Number of Pages: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: Signer's Name: ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual ❑ Attorney in Fact - Trustee ❑ Guardian or Conservator El Other: Signer Is Representing: 02014 National Notary Association - www.Nationa]Notary.org - 1-800-US NOTARY (1-800-876-6827) Item #5907 I NO. 100279633 PREMIUM: ENCLD IN PERFORMANCE BOND FOR LABOR AND MATERIAL NO ENCROACHMENT PERMIT NO. BOND �1 `� ��It JASON RICHARD CATHY AND SYLVIA DOLORES CATHY, We, the undersigned TRUSTEE OI'THE CATHY FAMILY LIVINGTRUST (hereinafter "Principal') and AMERICAN CONTRACTORS INDtiMNITl'CODIPANY -7 1 t a corporation organized under the laws of the State of CALIFORNIA and authorized to transact business in the State of California, as Surety, are obligated to the City of Campbell (hereinafter "City"), a municipal corporation under the laws of the State of California, in the sum of TWENTYNINE THOUSAND THREE HUNDRED TWELVE AND NO/100 Dollars ($ 29,312.00 ) for the payment of which sum we obligate ourselves and our successors and assigns, jointly and severally by the following provisions: The condition of this obligation is that the Principal entered, or is about t t i Pertain written Encroachment Permit with the Citydated �, v�` L��1t��`.5-isM � j \� , 20 � � ,which said Encroachment Permit No. is ereby referred to and made a pail hereof: Because Principal is required to furnish a bond in connection with the Encroachment Permit, providing that if Principal, or any of its subcontractors, shall fail to pay for any materials, or other supplies, or for any work or labor on the permitted work of any kind, or for amounts due under the unemployment insurance act with respect to any work or labor on this project; the Surety on this bond will pay for the debt, in an amount not exceeding the sum specified in this bond, and also, in case suit is brought upon the bond, a reasonable attorney's fee to be fixed by the court. JASON RICHARD CATITY AND SYLVIA DOLORES CATHY, Now, therefore, we, TRUSTEE OF THE CATHY FAMILY LIVING TRUST as Principal, AND AMERICAN CONTRACTORS INDEMNITY COMPANY as Surety, are obligated to the City of Campbell, and all contractors, subcontractors, laborers, material men and other persons employed in the performance of the aforesaid agreement in the sum of TWENTY NINE THOUSAND THREE HUNDRED TWELVE AND NOI100 Dollars ($ 29,312.00 ), lawful money of the United States, for the payment of which sums will and truly to be made, we the said Principal and Surety bind ourselves, successors and assigns, jointly and severally, by these provisions. The condition of this obligation is that if Principal, its successors or assigns, or its subcontractor, or subcontractors, shall fail to pay for any labor, materials, or other supplies, used in the performance of the work permitted to be done, or for amounts due under the unemployment insurance act with respect to this work or labor, then the Surety on this bond will pay for them, in an amount not exceeding the sum specified in this bond, and in case suit is brought upon this bond will also pay a reasonable attorney's fee; to be fixed by the court. Venue for any action arising out of this obligation shall lie in the County of Santa Clara, State of California. It is expressly stipulated and agreed that this bond shall inure to the benefit of any and all persons, companies and corporations entitled to file claims under Title 15 (commencing with Section 3082) of Part 4 of Division 3 of the Civil Code, so as to give a right of action to them or their assigns in any suit brought upon this bond. Should the condition of this bond be fully performed, then this obligation shall become null and void, otherwise it shall be and remain in full force and effect. No prepayment or delay in payment and no changes, extensions, addition or alteration of any provision of said Encroachment Permit or in any plans and specifications referred to herein, and no forbearance on the part of the City shall operate to release the Surety from liability on this bond, and consent to make such alterations without further notice to or consent by the Surety is hereby given, and the Surety hereby waives the provisions of Section 2819 of the Civil Code of the State of California. In witness, the parties have executed this agreement as of JTILY 7 120 15 (Principal) f i Bye Title Ot,017611- 17,Vec (Surety) B NITUNG AEPH ATTORNEY -IN -FACT Address of, ety: (Attach Acknowledgments 601 S. FIGUEROA STREET, #1600, LOS ANGELES, CA 90017 Both Principal's and Surety's Attorney in Fact) Surety's Bond Number 100279633 (Accompany this bond with attorney-in-fact's authority from Surety to execute the bond, certified to include the date of the bond.) J:\FORMSVI'emplateslEncroacliment Pem)itS\Bond for Labor & Materials.doc (Rev. 03/08) CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. STATE OF CALIFORNIA COUNTY OF SACRAMENTO } On 7/07/2015 before me, KATY TAYLOR Notary Public, Date (here insert name ) personally appeared NHUNG H. SAEPHAN , who proved to me on the basis of satisfactory evidence to be the person(e) whose name(&-) is/are subscribed to the within instrument and. acknowledged to me that be/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(&) on the instrument the person(&), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: Description of Attached Document Title or Type of Document: Document Date: Other. �- , •. KATY TAYLOR � U� COMM. 4 207221 ( ` r NOTARY PUBLIC - CALIFORNIA SACRAMENTO COUNIY 0 �4LIF011• COMM. EXPIRES JULY 19. 2018 Teal) V110 `I Number of Pages: IRA 1p HCC KNOW ALL MEN BY THESE PRESENTS: American Contractors Indemnity Company G01 S. Figueroa Street, Suite 1000, Los Angeles, California 90017 That American Contractors Indemnity Company of the State of California, a California corporation, does hereby appoint, NHUNG H. SAEPHAN its true and lawful Attorney -in -Fact, with full authority to execute on its behalf bond number 100279633 , issued in the course of its business and to bind the Company thereby, in an amount not to exceed Thirty thousand and 00/100 C $30,000,00 ). This Power of Attorney shall expire without further action on December 20 , 2017. This Power of Attorney is granted and is signed and sealed by facsimile under and by the authority of the following resolutions adopted by the Board of Directors of AMERICAN CONTRACTORS INDEMNITY COMPANY at a meeting duly called and held on the 1st day of September, 2011. Be it Resolved, that the President, any Vice -President, any Assistant Vice -President, any Secretary or any Assistant Secretary shall be and is hereby vested with full power and authority to appoint any one or more suitable persons as Attorney(s)-in-Fact to represent and act for and on behalf of the Company subject to the following provisions: Attorney -in -Fact may be given full power and authority for and in the name of and on behalf of the Company, to execute, acknowledge and deliver, any and all bonds, recognizances, contracts, agreements or indemnity and other conditional or obligatory undertakings, including any and all consents for the release of retained percentages and/or final estimates on engineering and construction contracts, and any and all notices and documents canceling or terminating the Company's liability thereunder, and any such instruments so executed by any such Attorney -in -Fact shall be binding upon the Company as if signed by the President and sealed'and effected by the Corporate Secretary. Be it Resolved, that the signature of any authorized officer and seal of the Company heretofore or hereafter affixed to any power of attorney or any certificate relating thereto by facsimile, and any power of attorney or certificate bearing facsimile signature or facsimile seal shall be valid and binding upon the Company with respect to any bond or undertaking to which it is attached." The Attorney -in -Fact named above may be an agent or a broker of the Company. The granting of this Power of Attorney is specific to this bond and does not indicate whether the Attorney -in -Fact is or is not an appointed agent of the Company. IN WITNESS WHEREOF, American Contractors Indemnity Company has caused its seal to be affixed hereto and executed by its President on this 1st day of December 2014. `\�Q�rtpnCiogs�q State of California =SK - AMERICAN CONTRACTORS INDEMNITY COMPANY INCOAPORATEA ••�' W' SEPT. 2S, 1990 ' = ,r Z s County of Los Angeles SS: '.`b.. .. By: �. 7---- %94ziFOR tpi`c Adam S. Pessin, President A Notary Public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached and not the truthfulness accuracy,or validity of that document. On this 1st day of December 2014, before me, Maria G. Rodriguez -Wong, a notary public, personally appeared Adam S. Pessin, President of American Contractors Indemnity Company, who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of CALIFORNIA that the foregoing paragraph is true and correct. MARIA G, RODRI M WRONG WITNESS my hand and official seal. ComrnleeloR 0 2049771 Nolary Public - C&iiternla Signature _� !ter (seal) LOSAngataecaufgr ��PR Go�wL'ae 20 2017 I, Michael Chalekson, Assistant Secretary of American Contractors Indemnity Company, do hereby certify that the Power of Attorney and the resolution adopted by the Board of Directors of said Company as set forth above, are true and correct transcripts thereof and that neither the said Power of Attorney nor the resolution have been revoked and they are now in full force and effect. IN WITNESS WHEREOF, I have hereunto set my hand this 7th day of July 2015 `��"�gACipj�sbi4 Bond No. 100279633 s�oa; gyp'EX Q_' '. Agency No. 7456 =a sEPT r`1iDUO < Michael Chalekson, Assistant Secretary HCCSZZ POAACIC 012015 CALIFORNIA ,• •;• • O S ,. _ C, c� .cu .cf .a.�..c�, sa ..n .w•_c�4.c� ,o�S _c>C. <�Y'<.c�..: a< .w• ci.C.�C.c� /'� a _c> .c�C P a<�� A..c�... a� .. C.a�R. s�C_ A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of -rx,(� C', cofC"_ On ��� ��i G 1 E> before me, Date Here Insert Name and Title of the 6fficer personally appeared Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. JOANN THOMASON CM"HSalon # 9110789 L Notary Public - California i Santa Clara County M Comm. Ex IreS Ma 9, 2019 I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature s Sr ature of Notary Public Place Notary Seal Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document q,)(� ., ACC_ Title or Type of Document: `l_L•n �r,� c�:���vt Document Date: Number of Pages: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General 0 Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian or Conservator ❑ Other: Signer Is Representing: Signer's Name: ❑ Corporate Officer — Titie(s): ❑ Partner — CI Limited ❑ General ❑ Individual I:1 Attorney in Fact Trustee 11 Guardian or Conservator ❑ Other: Signer Is Representing: -en :eri � •.✓: ei •er4� 4'ti4 U •Cl4'Q/ ei4�..i er rd4�O�„ a4 4 � 4'ar4'�.�•✓.4-ri4 4 Ar -m4'e 4'ev4'd' -¢r. 4-� @2014 National Notary Association - www.NationalNotary.org - 1-800-US NOTARY (1-800-876-6827) Item #5907 1 fhtnt'For� CITY OFCAMPBELL ENCROACHMENT PERMIT Permit NO DEPT.OF PUBLIC WOOtkS (foe working wltl)h) the 0.Ubfic x-fief. nle_2L.N2_01 :I3.a4_. 70 North FimtStreet rightofway) Application Data: Campbell, CA 95008 Ph, (409) 966-2150 Issued _ Application EXpira-iorri7stc__-___ — 074 Fx. (409) 376-0058 Permit Upitation Date APPLICAFION - Application is herebymadd for ,4,Puhllr' Works Permit In accordance with Campbell Municipal Code; Section 11.04. (Applii atii)n expires in six (G) 171uhths'if the permitls not issued Application F*pe, is hon-refundable:) A. Work Address orTract No,: 12�91 Fra Court; Campbell, CA 9500$ �"— ^�✓ Y Util'it4}'frenairLocation: €�._.._..� - - - •. "`-.,..- ...___�_ __�_.__.___._........ 4i• hlatureoftNork; Street Improvements on.WQst Hacienda Avenue as required by Planning Permit C: Atu< 6 four rl)rcopies rifign engineered, plan.shouing the )ocation and extent of the work, and f6ur (4) copies of the prefiminary Engineer's by1h,are ni'work. The, plans shall shovt the relation oftheprop'osed vrc.rk4to es lsting surface and underground improvements. When approved by file City Fnginef%r; said plan becomes a part of t#tis pormlt. D. All work shall conform to the City of Cttmpbe)i, Standard 5p� d6cationa.and.Details for Public Works €:o%lruclion; the General Permit Conditions listed on•the reverse side; and tht? Special Provisions for this peYrnit; listed below. Failure toabide by'thesc; conditions and provisions may result in Job shutdown and/or forfeiture of Faithful Ferform<iltce aurrades an¢ cash deposits. E. 1heCnntractorirnisthave 'this pemiirmclappttived.pla'risatttiesite.and must 'notify -the Pub iclNnrks Department at)easttwo days before starting work: Notice must be given to.Publie''tiiVoricS dCleast 7r.li�tity. before restarting any work Name of Applicant: Jason and Sylvia Cathy Tolephohe, i4{)81-b37 1133 Adcix!s-• IT29`I Freda.Ct.CarnpbellCa.J50o8"._.._..._____._�.�.__.„_.._._.._.____..__...._...,....�,....-_._........_.,._.._ .-..,.,..._,�._...._.._ E-MailArirlress: ISylviacath,yCSbeglobalriot 24-HOUREMERGENCY PHONE NUMBER; itOg_fig7-0g95 f is this work being don(; by the property owners ati heirown residt-nce? F YES NO The 8pplicant/Permittee hereby agrees by affixing than ,signatW0 to thra'pi:rinit to helot the City. of Campbell, its officer;, agi~nts; and employees free, safe and harmless from any claim err demand ford 6iarjes.resufting froth tfle w. ork.covered by this perrnit. The Appfitant_:Pcrinittee her( -by aeknawA x1ges that: they have read and .ohderstand bath the from anti back of 'this perrril:, and they will infurin their contractor(s) of the information. Applicant is advised that upon issuanirt of this permit property owner, or property o>vner's successors; shall be responsible for any dal! damages ansigp pt inrproyem rtts caiitpletpr1 in the public right-af-way. ftolicairi' Perri ttee) (sign) (Contractor) (PrirltName). Date SIDE 11L PijUVISigN5: Street ihall not tie ()pert r_c i! <gr; ridergraund installations.. Mihirrqurr :cuts ttmai ,,y be allowed for connections or ex fidoration holes: Such cuts rrray_be pg41f1scilik itpttrovt.41 f�the Inst�ectcl Pt9L3d tr�tlri�. Pavement may he cut for uitdergt-oil i7 install:i't,iran5 and musC fae ti5stotcri in dance with the Standard Details Tr'ncl Rc fora$' on Method ;:" �A", sin9r ss cat'ienNise.ap)raved:fiy-the Lngi:leer.; K_3. Work to be sf Wd by a licensed Land Surveyor or C(tii fitgins?erzind"two (2) copies of the cutsheeti sent toiler_ Public Works Department before starting work. 4, Per Section 4216 of the Govemrnent-Code that permit is not valid for c`CoaVgtl tn5 until Underground Service Alert (USA) has been notified and the inquiry Identification number has been entered hereon. USA Phone; 1-800-227-Wo. USA TICKET N0. _S Prior 10,:nY.wUrk, the property ownif shallexocute an Agreement f6 Private improvements in the Public Rigbt-of Vt+aye' 'hlch shall be recorded. G. PuhliGNotificationRec{ulrefnertts: _ _.. --- _ .... _...._.._.......... _..._;:.,_.................. ._.. Sf Ej�t'BLlC.1M1rOi2Ef5 FED SfHEPi)LEwFC1R.CLRP.Et+TFE,C5 AMOUNT RECTIPTNO. PERMIT APPLICATION FEE $ .__.._. 3,85.00 — __,___ 2J8'b1._ __... ._,...-_. PLAN CHECK DEPOSITs 2 6^1-, SECURITY FOR FAITHFULPERFORMANCE&LABOR&MA'FTAIJALS 5 Z9 3j7�8 _ liOtt{� €JS� S �VC3�,��jjj CONSTRUCTION CASH DEPOSIT s ...�1 PLAN r,HECIC& IF�SPECTlUN f�F.H• .. EMERGENCY Pf:siMIT FEE APPROUD FOR -ISSUANCE For city Engineyr Date hermit Expires 12 MontiisAftei Date of lsXuahce GENER'AAL PERMIT COND IL 1. The Perrttittee must provide evidence of insurance and Additional Insured Endorsefnents as required by the City: insurance shalt be maintained for the durarirratof the pernah work 2. A'Cansfruction Cash Dcposft ls,requirc dI Charges will be made against'this cle, posit if there is an emergency call-oul, overtime inspection or when City ordered barricadfruj is required: Any such costs in excess ofthe deposit will be billed to the I'ermittee. 3. Refund of the construction cash deposit:baiance and refund or cancellation of the Faithful Pe forman(zr Surety will Le'fNtlato by the vsritten acceptance of the work by the City. 4, A one year rnainw-ruirice period and sulmy are required: Such period will begin on date of written acceptance by the City, Surety posted shall be ecuai to 25^ra of die original Faiihf6l Perforr ance'$ect#ity, 5, Submit project schedule 10 (ten). days prior to proposed Starrofwork, Additional lead time may be required for we rk mithin City facilities and downtown Campbell, 11 The Permittee must request in writing a final inspretion End acceptance of the work upon comp efion. Acceptance by the City will be made in Writing to the Parinittee. 7" Maine err safe pz.dgstrian,,)nd vehicular crossings and free accesstooprhidw drivoways, bias stops, fire hydrants, and water valves: a. 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: 9. A constriv tion Triiftfc ronfrol Plan shall Conform to the 200 California Manual.on Uniform TrafficControl Devices (MUTO.). t o: Replace, as directed by the City finglueerrSny daniage.d of reniovo Improvements 'in accordance.trvith Qy5tandards and Specifications at the sole sxpenseof the Perrnittera as expedidopsty z5 per+`sabic". Saweut for al} PCt o,, AC removal?. All PCC rr:rtlo4ais'shail be to tPM nearest seoremark and new PGC Sltall be doweled to existing Improvements; 12, Prior approval of In pedor is required fo; any work proposed after normal worki ig:hours, on m5ekencI5 or holidays and may require reimbursement of imzection costs acthe currerlt� over m, raic. 13, work on arterials and collectpls may Yegvlire'the tune of chanyr.'ahlr rrtessacje boards: Adequate signing and bat'itadiny is requh'zd on the job site. Failure to provide such signing and barneading 'rnay fesult rh'tild t ity's providiriy si.461ng and b'arrtcades and charging the cot t (irzdudin,cd all labor and materials) against the construction cash dep6sit, 14, Colnpaction testing ofsubgrade btis6 ever., and Asiihalt.concrett by, Pprmittee is required unitssothervvfse'stattd by the City Engineer 15. TheContractoro Permltteewillhave. a-supervisoryrepresentative available forWritactonthe 'projectittall -times during constrtctian. tontAaetoror J'errnitte shall proyidie a phone nurilbor'A 'OTO. they can be contacted outside tihefioiirs of R-00a:rr.16.1i00 p.m. and on weekends. No storage of maie ials or equipmen'tvAll be allowed near the edge of pavement; the travefL.d way, or within the shoglderline wiiich would create a_ Iiazardov. eoitdtioiatnf.lizpublie, 17. This perittit sheli riot be construed as dtitfrvr9zrttign for.nucnvtrtiorr and tratrti n.g on private property aeilar a,'nt to the wttrk or any other work for whia a separate pt-,errit rnoy:Ibe'required, no¢ does,it relhive the Permitice of any obliynrion to obtain any nhter pot mit required by law. td: This pentticdoes not release'thc Perinitti elroraany liabilities.contained iti other acgeeemehts.orcontracts with the City and any other public agency. 1:9, Thispermltis hot T: khsfer9ble. Wdik'must be pertbrmed Uy di6 Permlltee or his designated agent orcorrtractnr :as specified thereon. 29. Calf ba k (railouti cive to erneregeacies regareding,this; pe;niitsti ii .br, at.th current overtime rate with athree (3) hour minim mt charge per occurrence.. 21., Pursuant:to Chapter'14,02 ofthe Campbell Murih3Ftgi'Ctide, liglleant Shall not cause to he discharged any material into the municipal storm drain ystem ot.Frcr thanstorm:water'. AppiieOrsfiall'ai6 rcto the BEST MANAGEMENT PRAG1 CFq established by211e.'Sanra Clara Valley Urban Runoff Pollution Preveritton Protimm, 22. if the public interest requites a modification of, or a departure from the permit, plans, special provisions andlor specifications, the City shall have the author ty to reyuirn or approve airy-ttodfGcatfan or departure a'nd to spocity alit manner• in which t to same is to be mach. 32, Perrrtrtttee must:providp advance: notifcatipt? to al! parti .$ tijat tray be affected by tfie:perrriiF.Sctiviifes. Notification shall be reviewed by tale City prior to distribution acid include dates of workando.cotitact nartte and,phone number. htis horeby rep Sssl forensuiing that allllhrase proivldI trd,services under the appiicant.ara awarelof'and aWde.1 all of the above conditions. ' Date: Contractor (Print.Nan:e) Date; J;F'dfshtSlTertaplatcslErtcroachtrerSt.Perr»itsiEncnsachmcrrit P( emit 5TATIC.form1pcif Rev. OSi t 4 INSURANCE REQUIREMENTS CHECKLIST v Permit # �'C ��� 5..�� CIP Project # Consultant/Contractor: O. 5 aq-,ct e:\e, 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 lZ\ \ Commercial General Liability for bodily, personal injury and property damage: C� $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggregate limit. p` Policy expiration date Automotive Liability: D- V .� Any Auto" checked on certificate _ $1,000,000 per accident for bodily injury and property damage �f-- Policy expiration date 1-Z . Workers' Compensation and Employer's Liability -z- Waiver of Subrogation clause �6— $1,000,000 per accident for bodily injury or disease ❑ Policy expiration date Cour5e,of Construction (if required in Special Provisions) ❑ Comp .value of the project ❑ Policy expira date Additional Insured Endorsement: The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) ,A The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: -annceIIati area of certificate edited to delete "endeavor to" and "but failure to mail such noti shall impose no obligation or liability of any kind upon the comoanv, its agents or presentatives'. 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. 0 Workers' Compensation Insurance Sheet Submitted -For General Contractor ❑ For Developer or Owner 1:\F0RMS\Temp1ates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 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. C� 2 Lk S Name:`` �- ��NAIC # J` Rating: A,K Authorized in CA: Name:MVO NAIC #5 ( ZO Rating: Authorized in CA: Name: Ste" NAIC # Rating: Authorized in CA: Name: NAIC # Rating: Authorized in CA: ❑ Campbell Business License fi 5 Expirations c3� ❑ Contractors License # 30 fi ?�^ Class:l. Expiration: Insurance Certificate Reviewed I Initials � Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. 1:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 AMAYCON-01 BROOKE �8CL7R,�" CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 3121120.17 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 License # 0504035 ONACT NAAME: Brooke Alarcon, CISR. Pacific Diversified Insurance, Inc. 15005 Concord Circle, Suite 110 408-842-2131 PHONE AIc No Ext : No): nDDRESs: balarcon@pdins.com Morgan Hill, CA 95037 INSURER(S) AFFORDING COVERAGE NAIC,# INSURER.A : Colony Insurance Company 39993 INSURED INSURER B:Security National Insurance CO 33120 Amaya's Concrete Jose Amaya 15245 Murphy Ave INSURER C : INSURERD : San Martin, CA 95046 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 FORTH E POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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 ALLTHE TERMS., EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN, REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSD WVO POLICY NUMBER (MMDDIYYYY)(MM DDNYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE T OCCUR X 103GLOO169187-00 11/22/2016 11/22/2017 EACH OCCURRENCE $ 1,000,000 PREMISES -{Ea ocwrrIL enbe�} $ 100iQ00 . MED EXP (Any ohs person) $ , 5,000 GEN'L PERSONAL&ADV INJURY $ 1,000,000 AGGREGATE LIMITAPPLIES PER: POLICY ❑ JECTPRO- LOC OTHER' GENERALAGGREGATE $ 2,000,000 X PRODUCTS- $ 2,000i000 $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY IWURY'(Perperson) 1 $ BODILY INJURY (Per accident) $ RO ER ,YDAMAG Peraccident) $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH. OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERJEXECUTIVE YIN .OFFICERfMEMBER EXCLUDED? Fy I (Mandatory in NH) Ifges, describe under DESCRIPTION OF OPERATIONS below NIA X WC1103346 04101/2016 04101/2017 PER OTH- X STATUTE ER 'E.L. EACH ACCIDENT $ 1,000000 E.L. DISEASE -EA EMPLOYEE $ 1.,000,000 E.L. DISEASE -POLICY LIMB $ 11000io00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if morespace is required) City of Campbell, its officers, employees, and volunteers, are hereby listed as additional insureds.in regards to the General Liability Policy where required by written contract. Insurance is primary and noncontributory. Waiver of Subrogation in favor. of the Workers Compensation. applies. %.r-rc i irra.ra i r- nvL-uorc City of Campbell Attn: Dept of Public Works 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 U 1988-2014 ACORD CORPORATION.. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD' 103 G L 0016187-00 'COMMERCIAL:GENERAL LIABILITY :CG; 20 U,04 13 THIS ENDORSEMENT CHANGES THE POLICY.. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement,modifies insurance provided under the following: COMMERCIAL .GENERAL. LIABI LITY COVERAGEPART A. Section. II — 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 "pers- onal 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" "personal 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" of "property damage" ,or the offense, which :caused .the "personaI.-and advertising injury'; Involved the rendering of or the, failure, to render any professional architectural; engineering or surveying services. CG 20 33 0413 0' Insurance Services Office,Inc.,,201-2` Pagel of2 103 GL 0016187-00 2. 'Bodily injury" or "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 04 13 9 WORKERS COMPENSATION AND EMPLOYERS LIABILITY' INSURANCE POLICY WC 04 03 08 (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 Specific Waiver per written contract 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 4/1/2016 Policy No. SWC1103346 Endorsement No. Insured Amaya, Jose Gilardo (An, Individual) Premium $ Insurance Company Security National Insurance Company Countersigned by WC 04 03 06 (Ed. 01-84) 2 12062 ,acoizo CERTIFICATE OF LIABIIJTY INSURANCE DATE (MNI/DD/YYYY) 03/15/2017 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($), 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 Dicar Insurance Marketing CONTACT NAAIE: Edith Gonzalez AHcNo Ext : (408) 848-9085 A/C No): (408) 848-5125 ADDRESS: dicaredith@gmail.com 6976 Automall Parkway INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: CENTURY NATIONAL '15954 Gilroy CA 95020 INSURED INSURER B : INSURER C : Amaya's Concrete INSURER D : 15245 Murphy Ave INSURER E : INSURERF: San Martin CA 95046 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 ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY -- LIMI"rS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS -MADE OCCUR [5AMAGE RENTED PREMISESO(Ea occurrence)S MED EXP (Any One person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑PRO ❑ LOC JECT PRODUCTS - COMP/OP AGG 5 5 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident S 11000,000 BODILY INJURY (Per person) S X ANY AUTO A ALL OWNED SCHEDULED AUTOS AUTOS BAP0184145 04/12/2016 04/12/2017 BODILY INJURY (Per accident) S PROPERTY DAMAGE Per accident $ NON -OWNED HIREDAUTOS AUTOS is UMBRELLA LIAB OCCUR EACH OCCURRENCE I $ AGGREGATE S EXCESS LIAB CLAIMS -MADE DED I i RETENTION $ S WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT s OFFICER/MEMBER EXCLUDED? ❑ NIA E.L. DISEASE - EA EMPLOYEE S (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) JOB LOCATION: 1291 FREDA CT CAMPBELL, CA 95008 Permit Number ENC2017-00075 THE CITY, IT'S OFFICERS, EMPLOYEES, AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSURED. INSURANCE COVERAGE AFFORDED TO ADDITIONAL TO THE INSURANCE IS PRIMARY INSURANCE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, ,NOTICE WILL BE DELIVERED IN THE CITY OF CAMPBELL ACCORDANCE WITH THE POLICY PROVISIONS. 70 N. FIRST STREET -- - AUTHORIZED REPRESENTATIVE CAMPBELL, CA 95008 ) 0198E-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD - Advjw. 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W C f-j _a Q) (D " = -- co :p . a " %.--a C I U) .0 0- .. a 6 6 f- = a - co -a a -,a -54-1 L- >1 11 b m C a 4- O -0 r- a :t:� .0 0 0 a 0 4;-0 -6mj CL 0 Q) W, Cl) 0 c Q> Z E . a 75 . -6.0 E 0 ,, -=#- 00 '-> (D a C-15 (D -C to 0 cn ,E . -0 .cn %,_, 5; cl) ;= -0 = = C: ID .c 2 . g� =� .>< >, , , �_ -a :-3 _ 0+ CL a- Cf) -0 0 w 0 . < 1 C�4 0 0 LO 00 a a >, ea - a- E 6 0 e-i r- 65 cD , 0 v- L- L) 1�- 0) L- L- 0 1 W_ C) .0-i 0 1 a -4-4 a) E -4-4 w 5 0 =a. �-, r- -- - IN 4) %+_0 .(D U >1_1 E a) 0 . ql-�� c 0 .2 c .,-% 4) a - " 01 -�c �� 2 00 *5 !�! 0 :3 = E o %I,- Q> E.- �5 ,,-� a = 0 :,;a_- -4- 0 a 0 N- 0- 0 C3 -,- c Q 0 .c .a (n 0 04 %- 0 --� 0 0 . v- Cl) 0) p a -W -�; *s: - c:> E > " U") ci:: -a a*-*- 0 C-3 Cl �! 0 U!) 0 V) r- = ;7�- - v) CD a- V) ,-: C4 t-i 4> = t =0 0 -W a- a .�! 0 C) U-1 :3 -1 C) 05 t'5f Cc: C) L- -�5 - >-. W %-- = L -*'-0 CA ** Q)s 0 0.0 0 O o 0 --a *5: . 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Q> - > - CO 0 -W 0. -5 , cn 0 %-� m 0 -0"0 0 = %- 0 0 a -0 ,-. Q) 0 " L- 0 Q 0 :3 W.0 a.- (A M 0 a - , L- L- 4%-, - '-a %+- .0 4-0, L- 0, 0 . 0 0 " -0 - Lf z uz 0 -C (n 1 .f.0 0 " rn 0 . > a L- w 0 -1�5 Z -1 C-) >,-4�O 0 "5 I" Q> C'+= C .cA 0 = w a -�g C.2 3: 0 a c >11 -+- c C) .0 cn 0 > - 4- 0 z 0 3:. 0 C 0 = c >,= -w E = " 0 Q> m a) 0 0 :Z -0 0--- CD E-0 Q) 100 --0%4 a - q-- w - (D 0 W 0 - .#,;i :3 - I- 0 O�-'-4 < Q> -C a -W -W cn 0 0 w 0 M -0 0 sw- 0 F: = -0 =) 4.- E E -0 6:� 0 -C a . cn - " - 0 -!a a 3: " 0 1 0 010 - a =, U� m 3: c %- -0 . 0 , 0 E 0 0 " :3 0 0 co a = 0 0 - 0 U- C:k--w %- .E a) g! 0 ,--.. - CO 0 *1� E Q> a-. .2 c . C (D >, 0 a 0 e C�, 0-'� .M . - 0 0 -�:: " , 0 (D Q) - ,%-j C: 0 -W W b >, :3 cn w 0 " co >11 -- - 0 -4Z -0 - 0 t5 Q Z-1 U-1 - �?- H " = 0 0 -0 0 " .0 0 � a a " w :�i 6 E <` - -> :3 04 V) = (n U- :5 M - :z -W w -+- M 04- a C) F- -W " . 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H 6- E 0>1 = 3: CD M 3: -0 a Q ,--, t- 4- Q a O �1: U) -0 r- > "O u.7 0 (D 0 9� w C) :p 0 -;c 0 v)-+., r- 0 4- U - 0 m =:) = 0) -A c - 0 i- 0) 0 '& :2 K I- � - - 16161.4 4-10 .a -F-j 0 (D C cm 0 0 0 :� 0 110, L- 0. 0 0 E IU) cj�: (n w 0 'a 02 w -#C` 0 �XE Q> a =3 -W M w fo- : 2'- 0 0 0 a -I-' '- 0 U- (D 0 " 0 a = V) Q z 0 IOM4 I U� >. -L ''I �� 0 . V) - I I I . r1, 11 11-1 I 0 , I 1� , I - N--11 0: 11 E-4 . 0) - 0 -a .s; 6 c �:: 0) . U) c .-- 4- �� a :;_- 0 - 0 $- 0 4) � I -0 -W V 0 0 .c -W (D =3 -C L: :t::: -+-j (D * F, 4- 0.1 CO rm"Mm" u C a 2 -1:1 40 = C (D -0 ,- 0 0) 'Q cn 0 O E! 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L- vo 2 - 0.0 - . �� -0 'C: 00, 0 a 0 C� 1-- 0 U. 0 - a I- 9! 0 >, , - 0 0 X-- r. �:: (D' -- w >-, w .=3 . . 0 V.% --% -4-j E - 6< 0 m= " 0 C d> 0 :p ::� - -+W-# (D (-> - * *5 �D -I �4 0 U- >11 " . !.- - 0 a " %.1; 0 14- 0 0 a - 0 E ,u o- Z' p., (D 0) -4, A (D cn 4- 2 ^ %- (D _a 0 cn 0� Q) -f-j - a- - I L- cn 0 :a 0 >" CL 0 - ,. +-? %4- -*--� U ,�cn -o- - L- 0 - -�- 0 I �, I 1 U V) w -W rn 0 > P q to co W � > -0 A= '0- -I.-, 42 -4--1 0 0 0 U.. 0 :3 a L- 3, (n 1%;-# %+- M ,4v :t:� 1-� C -5 = 11 I 1= a.- .-. 0 c u- -0 (n tvIN 0 " w C 2 0 10 L- = .:�: 0 Cl- " C: 0 e -C 0) E 4w--# .i5 %#,- -a . 0 L- rn se �� C-) =3 "a L- ? i. 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I a - 0 -4-0 < L- -a O g! .05 " O.� ?, 0- 0 --i 0 0 0 �;: Co 4) 4- c C W 0 - a c a -+.A -I�j -P 0 E 0 :3 " a d O.c �! w (n �:: 0 4-1 L- Q> 0 m -a w -0 4- C ca- cn a 0 -C E-4 -5 E c 0 a t .= Q 0-0 < 0 (D :p >_1 o 0 0 0 O- c -a- Q> -E� 0 C-) -1-� "' :3 0 0 W CD Cle- 3: 0 .- CL 0 cn :D -0 cn m < (n �1� a- a -j o 0 L- L- L- a a 0 >-, %- 0 0 0 a 0 04 :m m ,* 5 M CD -r r-, 04 :2 M '0 ,a < ---j W.0 -0 .c -a �- M 0::: CLQ- U ;� " - r� 0 - cn 0 ,1�4 uj " �- Ln a_ u u = r',� ry m U-0 ) Cm -0 0 V) cr- w �� m V) pq U-i 0 = 0 0 * 0 40 w 0 0 * e w z ry m r") C-1) m 0 w 0 0 0 =) I CD r'll 0 0 0 = cl- 10* < Q (n 0 w - co 0 . 0 E - I -- 4�- - I cn Z: w a- � cp "a " C: . 0 E .0 105- -,0j 0 0 < -j C) co . 0 -0 -5 m 0 x 0 Im I I 11 � I - -1,1' - = M -< 0 0"a . c Cm cl 0 0 O.- p -5 -4- -I, -a -- E 0) I --l" , , ,-, -1-11 ," - " - I C:) :z d� W U- -c = Q) C a (1) Cl) a) .� -4.w# ,a -a " a a - , I , I -11 - 11 , � I.- - � -- 111, 1, C� Z: :p - 0 U- a 0 V) Cp 'a.- , L- ---- � Z: - < 0 :� - 0) .?: � c L- -0 = 0 4� (D ''I', Admik F-- 0 f- Q> P 7p -0 C -+- 4) L- rn - --740w, -� " =) -J Zj 0 D " 0 - 4-f (1) a a te E Q> V 4., a , _ 0) CP I , "I" ,� �, � 11 1, 1, " �,-- - . __j 0 0 la- 010 to , ,�J: C: a - a- CD = . a- Q> -a Q> -C 0 .0 0 -5 0 111.1-, - I . 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Q> cn 0 01 , � -0 -2 E 5 Q> E Q>> -W 10 =3 L- "a -C L�-- -0-i I - """', -, �' a CO :L5 0 C; 4 b 2' ) " 0-5 (D &- -+l - "I - . -q!4 �- a 0 .ji C�,- a 0 (n . C: 'a * L w 1! E ,a3 * , L) Z (D 0 0 (f) 2 �5 00 o- a =Q> "a 4) L- I I . __j CD CIO v- CD = n w n 0 0 U) 0 0 V) CL ---5 -0 -Cwn n ui -0 w ,.O- , rn 1-1 I V) -s; = = U-1 V) t.,-------,, --A- CD ::D Z �< 0 0 0 * 0 0 m 0 0 0 e * 0 ", -.A m ". � - "I < __j Z� m < 'l4immi&bi6,, n1l I-- ui -1� V) z LLJ uj -,- --. 41 1��, I I - m 0 L�A IF � � � "I I , ,,, , I , , , e-- *** ", 11 - x , 11 -4,Al- I 11 M . � I --lil--- . ---, 0 a 0-0 " 2 c w 0 -+-j 0 a a 0 = 0 ?.: 0 -0 >:, a " zc Z: -0 (D q> -0 *5 a 0 2 w = 0 co M C. V) . G .c (n . G " L- -4--# (n 0 c 60 W 4-j 0 -v 0 :;z cl:� (D " 2 4-4 CL %.�- 0 a) 0 B1. C . M M - in 0 0 m Q 0 0 - -0-0 .0 -0 Q I co 0) --� -0 Cp * - W CO . 0 C eN -+-a - .�� :3 Ch C.0 0- a a ,;:: n Q:� - a C 4- cn�-.c a 0 :3 �1: = - I 0 i- < 0 cn � -- a> E? j= (0 a- " 4-- CO 0 a CL . 3.1 a) '-� C.D 0 . _ C 4"I a C:) 0 0. :3 a > 0 -0 -2 U� al -fj ,, al.a 0) :z . m 5 = a ,v co 0 L- 0 0 0 .0 E a - a) a: < -I- -#-J 0 C 0 a cn a- N M CL = CL E E 0 --- *C: o 0 t- 0 --I 0 CL 0 0 C� C- 0 0 0-w Q (n rl*t Z: < -j 0 0 0 = L- 4-- ,O -a 0 a -0 a) L- 0 .�5 -+-j 0- .c (6 1! (6 -0 0 0 4-a " a 0 M 0 (D 9! 0 = 0 : ,P cn 0 0 0 04--, �:: 4--F 0 . 9) - C71 .r-- m a -0 0-0 .+.,4 a - .0 -:�c L- - - 0 �:: -0 ( L) . -Sc -4-j 0 a 4a) a 0 3 �-' -6 p > �,, >-, " 0 " E -, L- 0 0 0.0 co 91 41�4 U- Cl) 0 0 �': . 0 Q-C) -t� :;,� L- -0 (a. Q) Q) - a 0 C (D 0 0 . 0 0- 0 0 �;: .a 0 -I�j = 4- E co ci) .c L- E a - 0 C" c- 0 "a . �0 0 -f-$ �:: E C e% .= 0 -0 .., E2 0 -4--j O .C: 0 - p ,-, ,�, 0-0 C.3- ',4 c 0 -1-i C: . U- c a c F" 9-.0 0 -a 4-i 0 = 0 04--f Z 3- 0 -.i r,-,N cn r-I 0) 0 0 0 L- >_1 0 L- -f-j Q. 9! 0 - 0- 0 C� -W 0 >-, 1p 0 . 0 I- :3 E 0 :t �:: -0 0 00 CD L- - a 4-4 0 ,- a I" r-q rl% ,,.,:t-' a . m -- - -- I *SONIMV�Rl (INV SWd 03onCIO�Jd3�J �JO/GNV ViVG DIN08iO3�3 KA 031�dHl K (13SS3�JdX3 Sl ,UI18VI-I 80 ,kiR81SNOdS3,\J ON 'SONIMV�10 (INV --- NOIS WNIDIK S30(13WONA0V KINO *ONI '!DNI�J33NPDN3 �IAI:D Si :�J3HIV`10SICI