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ENC2013-00226
Print Form CITY OF CAMPBEL L NOV 2 5 2013 ENCROACHMENT PERMIT DEPT. OF PUBLIC ORKS (f VIor working within the public 70 North First Street right-of-way) Campbell, CA 9500J18 PUMC Works Adminipt(igoUi, U ILA `� Ph. (408)866-215U Permit No b-/ 6' 7,r71 J- .-,r 00 X-Ref. File Application Date Application Expiration Date APN is — \ —C)\1 Fx. (408) 376-0958 Permit Expiration Date L-', 5-`.S_ APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable.) A. Work Address or Tract No.: 1251 Llewellyn. Campbell, CA 95008 a� Utility Trench Location: B. Nature of work: Driveway improvements, add (1) street light C. Attach four (4) copies of an engineered plan showing the location and extent of the work, and four (4) copies of the preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer, said plan becomes a part of this permit. D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2.) E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work. Name of Applicant: Annajean Anderson Telephone: 408.335.1953 Address: �499 Loma Alta Ave. Los Gatos, CA 95030 E-Mail Address: ajandersoI. n@emg11 ff.org 24-HOUR EMERGENCY PHONE NUMBER: 408.218.9312 Is this work being done by the property owners at their own residence? ' YES NO The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers, agents, and employees free, safe and harmless from any claim or demand for damages resulting from the work covered by this permit. The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any gpd all damages arising out of the condition of any private improvements in the public right-of-way. Accepted: (ApplAnt Permittee) (sign) (Contractor) L Ve _5 ,� / (Print Name) Date Date r;94— SPECIAL PROVISIONS: 1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be specifically approved by the Inspector prior to cutting. 2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A", unless otherwise approved by the Engineer. 3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public Works Department before starting work. 4. Per Section 4215 of the Government Code this permit is not valid for excavations until Underground Service Alert (USA) has been notified and the inquiry identification number has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO. 5. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right -of -Way, which shall be recorded. 6. Public Notification Requirements: 7 SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES PERMIT APPLICATION FEE PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS CONSTRUCTION CASH DEPOSIT PLAN CHECK & INSPECTION FEE EMERGENCY PERMIT FEE /] APPROVED FOR ISSUANCE V J .. For City Engineer Permit Expires 12 Months After Date of Issuance RECEIPT b� r2i GENERAL PERMIT CONDITIONS 1. A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency call -out, overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. 3. Refund or the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. Submit project schedule 10 (ten) days prior to proposed start of work. Special provisions may be required for work within City facilities and downtown Campbell. 5. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. 6. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants, and water valves. 7. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures, detours, and street closures. This plan must be reviewed and approved prior to any lane closures. 8. A Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated 1990, available at Caltrans. Traffic control equipment shall include Type II flashing arrow signs if required. 9. Replace as directed by the City Engineer any damaged or removed improvements in accordance with City Standards and Specifications at the sole expense of the Permittee. 10. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements. 11. Prior approval of inspector is required for any work done after normal working hours, on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 12. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost (including all labor and materials) against the cash deposit. 13. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 14. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m. 15. No storage of materials or equipment will be allowed near the edge of pavement, the traveled way, or within the shoulderline which would create a hazardous condition to the public. 16. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a separate permit may be required, nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 17. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 18. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 19. Call back (call out) due to emeregencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence. 20. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. 21. If the public interest requires a modification of, or a departure from the plans and specifications, the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made for City -owned or maintained facilities. 22. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and phone number. Applicants ha I I be responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions. Yl- 4"401�� _h�� /1��6-- Applicant n Date: Contractor (Print Name) J:\FORMS\Templates\Encroachment Perm its\Encroachment Permit STATIC form2.pdf Rev. 03/13 4-/4-Ir 4- Date: PUBLIC WORKS ULPAK i MtN I LANUIJCVGLvr1V1Cw1 Effective July 1,2013 TO: City Clerk PUBLIC WORKS FILE NO. PROPERTY ADDRESS Please collect & receipt for the following monies: ACCT. ITEM .:. _ AMOUNT LAND DEVELOPMENT 4722 ncroachment ermlt Appllcatlon Fee Non -Utility Encroachment Permit Major >_$10,000 $377.00 ' 7 -7-7. 0 u Minor Encroachment Permit <$to,000 $215.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $209.00 2203 2203 Street Tree Planting/Removal N/C ($500 per Tree Planting Deposit Required) $500.00/tree Plan Check Deposit 2%D of Engineer's Estimate $500.00 min r• Utility and R-1 Permits no deposit required 4722 Gradinq & Drainage Plan Review Single Family Lot $265.00 Site < 10,000 s.f. $795.00 Site >_ 10,000 s.f. < 0.5 Acre $1,060.00 Site >_ 0.5 Acre $1,590.00 4722 NPDES Review (C3 Requirements) For projects not required to submit numeric sizing $153.00 For projects required to submit numeric sizinq Impervious Area 10,000 Sq. Ft to 1 Acre $663.00 Impervious Area 1 Acre or more $867.00 Plan Check & Inspection Fee (Non -Utility) 4722 Enqr. Est. up to $250,000 14% of Engineer's Estimate **2203 Enqr. Est. >:$250,000 Actual cost +20% Admin Overhead 2203 (Min $35,000 Deposit) Emerqency Cash Deposit 4% of Enqr. Est.* ($500 minl$10,000 Max) 2203 Faithful Performance Security (FPS) 100% of ENGR. EST.* 2203 Labor and Materials Security 100% of ENGR. EST.* 4721 Storm Drainage Area Fee Per Acre R-1 $2 120.00 (Multi -Res $2,385.00) All Other $2,650.00 4722 Parcel Map (4 Lots or Less) $3,775.00 + $82/lot 4722 2203 Final Tract Map (5 or More Lots) $4,590.00 + $112/lot Monumentation Security ' 100% of ENGR. EST. 4920 Parkland Dedication Fee 75%(25% Due Upon Cert. of Occupancy) 4722 Lot Line Adjustment (Includes Certificate of Compliance) $1,785.00 4722 Vacation of Public Streets & Easements $2,386.00 4722 Certificate of Compliance $1,764.00 4722 Certificate of Correction $530.00 4722 4722 Appeal Filing Fee $200.00 Notary Fee (per siqnature) $10.00 4722 Assessment Segreqation or Reapportionment First Split $846.00 Each Additional Lot $265.00 511.7424 Postage MISCELLANEOUS: Other (Please Specify) *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. **Actual Cost Plus 20% Overhead (Non -Interest bearing deposit) TOTAL $ NAME OF APPLICANT 6,01 Q �gfNtd(ZS fI1`0 NAME OF PAYOR ky lz4- l A&. M PHONE �D�- Zfk—�13f2 ADDRESS ;Ie5i L 1 eW r! h five, M ZIP 68 FOR ' $; x' RECEIVED B t f, CITY CLERK ONLY Date I 7i� Receipt# Date/ Initials° s u r Lfi- J.FORMS%Templatm%Admini:V,b,,k2 ipl Fam Lwd DIv Wmml 13-14 e: d 0 CITLOECAMPBELL CLERK 70 N FIRST ST LOWER LVL CAMPBELL, CA 95008 11/25/2013 16:16:40 MID: 000000000464180 TID:05167565 225180862990 CREDIT CARD + MC SALE CARD # XXXXMXXXM7604 'Y[ INVOICE 0005 Batch #: 000052 I.I Approval Code: 191640 i Entry Method: Swiped `0 rs Mode: Online 1 Tax Amount: $0.00 <<;; Cust Code: 120 SALE AMOUNT $811,00 �v T r " CUSTOMER COPY 0 PUBLIC Wi i DEPARTMENT LAND DEVELOPMENT Effective July 1, 2013 TO: City Clerk PUBLIC WORKS FILE NO. A 12-? -- fVT7T7 PROPERTY ADDRESS Please collect & receipt for the followina monies: A MOUNTh,_..... L-ANUDEVELQPMENT 4722 Encroachment Permit Application Fee Non -Utility Encroachment Permit Major �:$10,000 $377.00 Minor Encroachment Permit <sioxo $215.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $209.00 Inspection Fee Minimum Charge per Location $377.00 Street Tree Planting/Removal N/C 2203 ($500 per Tree Planting Deposit Required) $500.00/tree 22031 Plan Check Deposit 2% of Engineer's Estimate $500.00 min 4722 Utility and R-1 Permits no deposit required Gradinq & Drainage Plan Review Single Family Lot $265.00 Site < 10,000 s.f. $795.00 Site �: 10, 000 s. f, < 0.5 Acre $1,060.00 Site Z: 0.5 Acre $1590.00 4722 NPDES Review (C3 Requirements) For projects not required to submit numeric sizing $153.00 For projects required to submit numeric sizing Impervious Area 10,000 Sq. Ft to 1 Acre $663.00 Impervious Area 1 Acre or more $867.00 4722 Plan Check & Inspection Fee (Non-UtilitV) Enqr. Est. up to $250,000 14% of Engineer's Estimate **2203 Enqr. Est. 2�$250,000 Actual cost +20% Admin Overhead (Min $35,000 Deposit) 2203 2203 Emerciency Cash Deposit 4% of Enqr. Est.' ($500 min/$10,000 Max Faithful Performance Security (FPS) 100% of ENGR. EST.* ? el (2 - 2203 Labor and Materials Security 100% of ENGR. EST.* 4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00 (Multi -Res $2,385.00) All Other $2,650.00) 4722 Parcel Map (4 Lots or Less) $3775.00 + $82/lot 4722 Final Tract Map (5 or More Lots) $4,590.00 + $l 12/10t 2203 Monurnentation Security 100% of ENGR. EST. 4920 Parkland Dedication Fee (75%/25% Due Upon Cert. of Occupancy) 4722 Lot Line Adiustment (Includes Certificate of Compliance) $1,785.00 4722 Vacation of Public Streets & Easements $2,386.00 4722 Certificate of Compliance $1,764.00 4722 Certificate of Correction $530.00 4722 Appeal Filing Fee $200.00 4722 Notary Fee (per signature) $10.00 4722 Assessment Segregation or Reapportionment First Split $846.00 Each Additional Lot $265.00 511.74241 M19MLL Postage ...... . .. . . .. .. ....... EOVS Other (Please Specify) *Engineer's Estimate shall be as approved by the City Engineer and shall include all items. of work. **Actual Cost Plus 20% Overhead (Non -Interest bearing deposit) TOTAL C., NAME OF APPLICANT NAME OF PAYOR PHONE ADDRESS ZIP FOR R RECEIVED 'R CITY CLERK ONLY J:TORMS\T.,plates) dmi,iM,,I,l Iclipt Farm Land Development 13-14 ��1 ® CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) 04/04/2014 F 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 Aon Risk Insurance Services West, Inc. San Jose CA office CONTACT NAME: PHONE (866) 283-7122 FaX 800-363-0105 (A/C. No, Ext): A/C. No.): E-MAIL ADDRESS: 60 South Market street, Suite 1100 San Jose CA 95113 USA INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURERA: United Specialty Insurance Company 12537 INSURERB: Golden Eagle Ins Corporation 10836 Sierra View Company, Inc 4160 Douglas Blvd., suite 100 Granite Bay CA 95746 USA INSURERC: National Union Fire ins Co of Pittsburgh 19445 wsURERD: Everest National Insurance Co 10120 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570053412354 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. Limits shown are as requested INSLTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF MMIDDNYYY POLICY EXP MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY BTO 425 EACH OCCURRENCE $1, 000, 000 CLAIMS -MADE X]OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $50,000 MED EXP (Any one person) EXCI tided PERSONAL& ADV INJURY $1, 000, 000 LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $2,00POLICY EPRO ❑LOC JECT M'OTHER: PRODUCTS-COMP/OPAGG $2,000,000 Deductible $10 , 000 B AUTOMOBILE LIABILITY BA 5634729 02/01/2014 02/01/2015 COMBINED SINGLE LIMIT Ea accident $1, 000, 000 BODILY INJURY ( Per person) X ANYAUTO BODILY INJURY (Per accident) ALL OWNED SCHEDULED AUTOS AUTOS HIREDAUTOS X NON -OWNED X AUTOS PeOaccidengAMAGE C X UMBRELLALIAB OCCUR BE044784185 02/01/2014 02/01/2015 EACH OCCURRENCE $5,000,000 AGGREGATE $ 5 , 000 , 000 EXCESS LIAR H CLAIMS -MADE DED I X RETENTION 510, 000 D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ N 7600010796141 02/01/2014 02 01 2015 X PER STATUTE I OTTH- E.L. EACH ACCIDENT $1, 000, 000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N / A E.L. DISEASE -EA EMPLOYEE $1, 000, 000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $1, 000, 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Re: SVCI Job No. 14-005, EMQ Families First, 251 Llewellyn Avenue, Campbell CA 95008. The City of campbell, its officers, employees and volunteers are included as Additional insured in accordance with the policy provisions of the General Liability policy. General Liability evidenced herein is Primary and Non -Contributory to other insurance available to an Additional insured, but only in accordance with the policy's provisions. A Waiver of Subrogation is granted in favor of the City of Campbell in accordance with the policy provisions of the General Liability and Workers' Compensation policies. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Campbell AUTHORIZED REPRESENTATIVE Attn: JoAnna Thomason 70 N. First street Campbell, CA 95008 USA �y/�i� alln �c_fxjGtaxw yetvrl w �j� �i J'i ,fm IT U) M N V' 0 0 LO ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: BT01426594 COMMERCIAL GENERAL LIABILITY CG 20 26 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ® DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Persons Or Organization(s) As per written contract Information re uired to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s) or organ- ization(s) shown in the Schedule, but only with re- spect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 0 POLICY NUMBER: BT01426594 COMMERCIAL GENERAL LIABILITY CG 20 37 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS- COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anization s : Location And Description Of Completed Opera - tions As per written contract Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for ."bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products - completed operations hazard". CG 20 37 07 04 - © ISO Properties, Inc., 2004 Page 1 of 1 13 BT01426594 UNITED SPECIALTY INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY — PLEASE READ IT CAREFULLY USIC VEN 104 02 11 07 PRIMARY AND NON-CONTRIBUTORY WORDING This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART Any coverage provided to an Additional Insured shall be excess over any other valid and collectible insurance available to such Additional Insured whether primary, excess, contingent or on any other basis unless: 1) a written contract or written agreement specifically requires that this insurance apply on a primary and non-contributory basis;or 2) prior to a loss, you request in writing and we agree that this insurance shall apply on a primary and non-contributory basis. All other terms, conditions and exclusions under this policy are applicable to this Endorsement and remain unchanged. USIC VEN 104 02 11 07 Page 1 of 1 { POLICY NUMBER: BT01426594 COMMERCIAL GENERAL LIABILITY CG 24 0410 93 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. . WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: As per written contract (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV — COMMER- CIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work' done under a contract with that person or organization and included in the "products -completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 0410 93 , Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1 0 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 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 2% of the -California workers' compensation premium otherwise due on such remuneration. - SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE BLANKET WAIVER OF SUBROGATION NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER 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: 02/01/2014 Policy No. 7600010796141 Endorsement No. 001 Insured: Sierra View Company, Inc. Premium $ INCL. Insurance Company: Everest National Insurance Company Countersigned By: -1998 by the Workers' Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual -1999. ov, CA41 A `A ' ... • "$CHARD CITY of CAMPBELL Public Works Department May 15, 2018 EMQ Families First 499 Loma Alta Ave. Los Gatos, CA 95030 SUBJECT: PERMIT NO. ENC 2013-00226 251 Llewellyn Ave. Campbell CA FINAL INSPECTION AND ACCEPTANCE To Whom it May Concern: According to our records, there is a deposit refund due for the driveway improvements completed at 251 Llewellyn Ave. under Permit ENC2013-00226. The City of Campbell has made the final 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. A check for your deposit refunds totaling $2,796.00 is enclosed. And your Faithful Performance Bonds in the amount of $5.7,393.00 are also enclosed. Please let me know if you have any questions. Sine ely, Syed Wahidi Public Works Inspector Eric: Check # 267783, Bond #4393961 70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAX 408.376.0958 • TDD 408.866.2790 1 1 I i ------- --- - j oar.CAMPaBELL�... CHECK 05�14�18 XtE CHECR NO Z677b � U N�FifH FIRST STREET 420 MONfGOMERY STREET 1210 �""AMPBELL,CALIFORNIA 95008 saai FRxrrcxsco ca 9aio4 E t VQTD AFTE 9Q I TH�'USANn� "'� THE SUM,:OF TWO SEMEN HUNDRED NINETY SIX DOLTrARS c�C' � �,, �mI I E M,Q FAMILIES FIRST 499'LOMA ALTA AVE LOS GATOS CA 95030 r Premium Amount $1,435.00 BOND FOR FAITHFUL. PERFORMANCE We, the undersigned FamiliesFirst, Inc dba EMQ FamiliesFirst , (hereinafter "Principal ") and SureTec Insurance Companv I a corporation 'organized under the - laws of the State of Texas , and authorized to transact business ►n.the State of California, as Surety, are obligated to the City of Campbell, (hereinafter "City") a municipal corporation under the .laws of the State of California, in the sum of Fifty Seven Thousand Three Hundred Ninety Three and 701100 1 Dollars ($ 57,393.70 ) 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: Because the obligated Principal has, on 1�';19,1 w , 20entered into written Contract with the City for the Project, a copy of which contract is attached and made a part of this bond, for construction of Project Street Improvement Agreement for 251 Llewellyn Avenue Campbell CA 95008• APN: 30747-017 Now, therefore, if the Principal shall faithfully perform the work in accordance with the plans, specifications and contract documents during the original term, and any extensions of the contract 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 contract, and shall fully indemnify and save harmless the City from all costs and damages which it may suffer by reason of failure to do so, and shall 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 contract. If any legal action be filed upon this bond, it shall be filed within one year after final payment has been made under the Contract excluding the warranty period, if any, provided for in the Contract, 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 Contract or to the work to be performed under it ar the specifications accompanying it shall in any way affect its obligation on this bond, and it does by this means waive notice of any change, extension of time, alteration or addition to the terms of the Contract 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 March 4 20 14 (Principa FamlliesFirst Imcdba.J)Q F iliesFirst By r Titled t I;MG ('LtGttt�oCd �ii (Attach Acknowledgements) (Both Principal's and Surety's Attorney in Fact) (Surety) SureTec ins r nce Company a Julia Pitta B Attorney -in -Fact A i s of Surety: 1350 Carlback Avenue, Suite 200 Wal Creek, CA 94596 Surety's Bond Number 4393961 (Accompany this bond with Attorney-in-fact's authority from Surety to execute the bond, certified to include the date of the bond.) J:\FORMS\Templates\Capital Improvement Projects\Bond For Faithful Performance.doc (Rev. 03/08) POA #: 510013 SureTec. Insurance Company LIMITED POWER OF ATTORNEY . Know All Men by These Presents, That SURETEC INSURANCE COMPANY (the "Company"), a corporation duly organized and existing under the laws of the State of Texas, and having its principal office in Houston, Harris County, Texas, does by these presents make, constitute and appoint David Harris, Stephanie Worden, Heather Pate, Julia Pitta its true and lawful Attorney -in -fact, with full power and authority hereby conferred in its name, place and stead, to execute, acknowledge and deliver any and all bonds, recognizances, undertakings or other instruments or contracts of suretyship to include waivers to the conditions of contracts and consents of surety for: Five Million and 00/100 Dollars ($5,000,000.00) and to bind the Company thereby as fully and to the same extent as if such bond were signed by the President, sealed with the corporate seal of the Company and duly attested by. its Secretary, .hereby ratifying and confirming all that the said Atforney-in-Fact may do in the premises. Said appointment shall continue in force until 10/31/2013 and is made under and by authority of the following resolutions.ofthe Board of Directors of the SureTec insurance Company: 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 Attomey(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 of behalf of the Company, to execute, acknowledge and deliver, any and all bonds, recognizances, contracts, agreements or indemnity and other conditional or obligatory undertakings 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. (Adopted at a meeting held on 2e of April, 1999.) In.Witness Whereof, SURETEC INSURANCE COMPANY has caused these presents to be signed by its President, and its corporate seal to be hereto affixed this 17th day of October , A.D. 2012 . ,Mn�WkW4 SURETEC INS E C PANY By: wi w ;D3' John o Jr., resident 1 State of Texas ss: 7� .5 t< County of Harris On this 17th day of October , A.D. 2012 before me personally came John Knox Jr., to me known, who, being by me duly sworn, did depose and say, that he resides in Houston, Texas, that he is President of SURETEC INSURANCE COMPANY, the company described in and which executed the above instrument; that he knows the seal of said Company; that the seal affixed to said instrument is such corporate seal; that it was so affixed by order of the Board of Directors of said Company; and that he signed his name thereto by like order. o;�erFb�'•'" JFlCQUETYN IVIALl7d'NAI70 G .1': "=,• A. - •:� .: � ... (�� � i� "°•' NotaryPublic, State of Texas My Commission Expires . acq ely aldo ado, Notary Public May 18, 2013 y comet stun ex ' es May 18, 2013 I, M. Brent Beaty, Assistant Secretary of SURETEC INSURANCE COMPANY, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney, executed by said Company, which is still in full force and effect; and furthermore, the resolutions of the Board of Directors, set out in the Power of Attomey are is ,_fi!.11'force and effect. Given under my hand and the sal of said Company at Houston, Texas this 4th day of )`March 2014 , A.D. M. Brent Beaty, Assistant Secretary Any instrument issued in excess of the penalty stated above is totally void and without any validity. For verification of the authority of this power you may call (713) 812-0800 any business day between 8:00 am and 5:00 pm CST. ®i.�i.�i�is�rci®ia-iri©isricnc�imiorr%®rmic+rarrmiarr7iorenorsracicri..�rmiwi/ccisrr<^�imrrri.�icimiE-rmrmrnici.^i ie%rmr®imrvrmia%rmim/tlicrimicsi.Fri®imimioitliarivicaor�%mini.�i�rcimimr.�rrmrsrErrmi�iwivrmicTrsior.�i..icsioi®ia� B 0 6, o CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT o Q G 0 0 0 - State of California SS. 'D County of Contra Costa ) o f, On March 4 2014, before me, H. A. Pate Notary Public, °a personally appeared Julia Pitta who proved to me on the basis of satisfactory evidence to be the person(-s) whose named is{� subscribed to the within instrument and acknowledged to me that o Wshe4e-y executed the same in his�her4heif authorized capacity(), and that by his/herAieir osignature() on the instrument the person{-s), or the entity upon behalf of which the person(s) 0. acted, executed the instrument. A I certify under PENALTY OF PERJURY under the laws _of the State of California that- the P foregoing is true and correct. o / WITNESS my hand and official seal. B H. A, PATE m ; : Commission # 1893980 z �v Notary Public - California z z "' Contra Costa County qC1 My Comm. Expires Jun 27, 2014 D, 0 (Signature) [SEAL] G A Q B 6 / r Q r 6 i 9 � '0 r / '%.-.�'/m/©/!✓/�l/L'/.9/�J/G'/G/!.�/lJ/G//1.�/.�/EJY6/®/6//EJ/2�/dCe9/tl/L✓/G!/n/LaYG%.'3/E9/LY/f9/m/�/n/,L�/®/6�/6i/CJ/iJ/®/!%d/©/m/6%fJ/<%G:'�/fI/L%n/v%fY/m/n/M/6i/6°/4/Fu%C/.G7/O/m/6Y/®/©/d/nlm/[�/.'➢/L!/m/fJ/m/l!/6%m/%l3/w©!3"/m/®/6/!S/m/E9/n/6%/A/n/Edi BOND FOR LABOR AND MATERUL We, the undersigned FarnlflesFirsL Inc dba EMQ FamillepFirst — (hereinafter "Principal") and SureTec Insurance Company - - , a corporation organized under the laws of the State of Texas , 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 Fifty Seven Thousand Three Hundred Ninety Three and 701400 Dollar. s($ 57.393.70 for the payment of which sum we obligate ourselves and our successors and assigns, jointly and severally bythe following provisions: The conditi )n of this obligation I . s that the Principal entered, or is about. to enter, into a certain written Contract with the City dated L C L 20 -A ---- which said Contract is hereby referred to and made a part hereof. The I ( . contract is entitled: Street Improvement Agreement for 251 Lteweflyn Avenue, Campbell, CA 95008; APN: 30747-017. Because Principal is required to furnish a bond in connection with the contract, providing that if Principal, or any of its subcontractors, shall fail to pay for any materials, or other supplies, or for any word or labor on the contracted work of any kind, or for amounts due under the unemployment insurance act with respect to any work or tabor 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. Now, therefore, we, FamillesFirst-tric dba F--MQ FarrilliesEirst -as, Principal, AND WeTecinsurance Company as Surety, are obligated to the City of Campbell, in the sum of 1 57,393-70 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 contracted to be done, or for amounts due tinder 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 ex, to expressly stipulated and agreed that this bond shall inure to the benefit of any and all persons, companies and corporations entitled 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, theft 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 Contract or in any plans and specifications referred to herein, and no forbearance on the part of the City -,hall 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 Mareh4 —,20 (Principal)FMilier.First,tn dba EMQ,F AlesFst By Title (Attach Acknowledgments Both Principal's and Surety's Attorney in Fact Surety's Attorney in Fact) (Surety) SureTec to ranee Company Julia Pitta Y*Aftomevw4n-Fact IX Nf - td dre, -s of Surety: 1350 Carlback Avenue, Suite 200 nukreek, CA 94596 Surety's Bond Number 4393961 (Accompany this bond with attorney-in-fact's authority from Surety to execute the bond, certified to include the date of the bond.) J:1FORMSNTemplate.,Xapita1 Improvement Pro*L-,FBond For Labor and Materialdoc (Rev. 03108) POA #: 510013 SureTec Insurance Company LIMITED POWER OF ATTORNEY Know All Men by These Presents, That SURETEC INSURANCE COMPANY (the "Company"), a corporation duly organized and existing' under the laws of the State of Texas, and having its principal office in Houston, Harris County, Texas, does ,by these presents make, constitute and appoint David Harris, Stephanie Warden, Heather Pate, Julia Pitta its true and lawful. Attomey-in-fact, with full power and authority hereby conferred in its name, place and stead, to execute, acknowledge and deliver any and all bonds, recognizances, undertakings or other instruments or contracts of suretyship to include waivers to the conditions of contracts and consents of surety for: Five Million and 00/100 Dollars ($5,000,000.00) and to bind the Company thereby as fully and to the same extent as if such bond were signed by the President, sealed with the corporate seal of the Company and duly attested by its Secretary, hereby ratifying and confirming all that the said Attomey-in-Fact may do in the premises. Said appointment shall continue in force. until 10/31/2013 and is made under and by authority of the following resolutions of the Board of Directors of the SureTec Insurance Company: 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 Attomey(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 of behalf of the Company, to execute, acknowledge and deliver, any and all bonds, recognizances, contracts, agreements or indemnity and other conditional or obligatory undertakings 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. (Adopted at a meeting held on 20'h of April, 1999.) In Witness Whereof, SURETEC INSURANCE COMPANY has caused these presents to be signed by its President, and its corporate seal to be hereto affixed this 17th day of October , A.D. 2012 . uRANC°"K SURETEC INS E C PANY ..qF0 By. a, w ; n John o Jr., resident State of Texas ss: 7� ,t �' !,z County of Harris On this 17th day of October , A.D. 2012 before me personally came John Knox Jr., to me known, who, being by me duly sworn, did depose and say, that he resides in Houston, Texas, that he is President of SURETEC INSURANCE COMPANY, the company described in and which executed the above instrument; that he knows the seal of said Company; that the seal affixed to said instrument is such corporate seal; that it was so affixed by order of the Board of Directors of said Company; and that he signed his name thereto by like order. W"' Notary Public, State of Texas , My Commission Expires acq elyn aldo ado, Notary Public May 18, 2013 y comm sion ex ' es May 18, 2013 I, M. Brent Beaty, Assistant Secretary of SURETEC INSURANCE COMPANY, do hereby certify that the above and foregoing is a true and correct copy of a Power of Attorney, executed by said Company, which is still in full force and effect; and furJtermore, the resolutions of the Board of Directors, set out in the Power of Attorney are in full.rorce and effect. Given under my hand and the seal ofsad Cor.�pany at Houston, Texas this 4th day of March 2014 , A.D. 4Z 1_�&A M. Brent Beaty, Assistant Secretary Any instrument issued in excess of the pepalty stated above is totally void and without any validity. For verification of the authority of this power you may call (713) 812-0800 any business day between 8:00 am and 5:00 pm CST. 1 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT State of California ) SS. County of Contra Costa _ ) On March 4, 2014, before me, H. A. Pate Notary Public, personally appeared Julia Pitta who proved to me on the basis of satisfactory evidence to be the person() whose names) ism subscribed to the within instrument and acknowledged to me that he/she4hey executed the same in his�her4hek authorized capacity(4es), and that by his/herA heir signatures) 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 is true and correct. WITNESS my hand and official seal. H. A. PATE Commission # 1893980 z@My Notary Public - Californiaz Contra Costa County (Signature) Comm. Expires Jun 27, 2014 [SEAL] CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR NOTICE OF RELEASE OF RECORDED STREET IMPROVEMENT AGREEMENT Encroachment Permit # ENC2013-00226 Property Address: 251 Llewellyn Date Street Improvement Agreement recorded 3/13/14 Ye�_v<Ae� Date of Final Acceptance Letter: Date of One -Year Maintenance Acceptance Letter: All deposits refunded (Date of last refund) Inspector's Encroachment Permit file merged with Main Permit File Date Permit archived in Permit Plan Processed by: Reviewed By: Inspector Reviewed by: Fl� f i /S. I l�r Land Development EWgineAir Date Check Request Submitted to Finance for Recording Fees/ I I r x Date Notice of Release sent for recording: J:UoAnnaT\Deposit refunds\CHECKLISTS\Llewellyn 251 SIA Release.doe (Rev. 10/11) +° TO BE RECORDED WITHOUT FEE SECTION 6103 GOVERNMENT CODE AT THE REQUEST OF CITY OF CAMPBELL Recording Requested by: ) City of Campbell ) When recorded mail to: ). City Clerk ) City of Campbell ) 70 North First Streei ) Campbell, CA 95008 ) DOCUMENT: 22543306 IIIVIIIflgIIIIIIIIIIIIOIIIIIIIIIIIIIIIIV �o`:p i .: REGINA ALCOMENDRAS SANTA CLARA COUNTY RECORDER Recorded at the request of City Pages: 11 No Fees RDE # 026 3/13/2014 2:58 PM APN: 307-17-017 (Space above this line for Recorder's use only.) ADDRESS: 251 Llewellyn Ave., Campbell, CA 95008 STREET IMPROVEMENT AGREEMENT RECITALS THIS AGREEMET T, identified by File No(s). PLN 2013-179, is entered into this d day of (1_ C �41 ) 2014, by and between FamiliesFirst, a California nonprofit public benefit corporation, hereunder referred to as "Owner," and the CITY OF CAMPBELL, a municipal corporation of the County of Santa Clara, State of California, hereinafter referred to as "City." On November 12, 2013 the Planning Commission granted approval for a modification to a previously approved Conditional Use Permit to allow the establishment of a youth crisis stabilization unit for that certain real property described in Exhibit A attached hereto and incorporated as though fully set forth herein, and commonly known as 251 Llewellyn Avenue, which property is hereinafter referred to as "said real property." TERMS AND CONDITIONS Now, therefore, in consideration of the above referenced approvals, and in satisfaction thereof, the parties to this Agreement shall 'comply with the following terms and conditions: (1) The Owner shall provide, construct and install at his/her own proper cost and expense, street improvements as described in Section 11.24.040 of the City Code within 12 months from the date first mentioned hereinabove; provided, however, that in the computation of said 12 month period, delays due to, or caused by acts of God, viz., unusually inclement weather, major strikes, and other delays beyond the control of the Owner or his/her successors shall be excluded. (2) If the Owner fails to complete the work required by this Agreement within the said 12 month period, the City, after giving ten (10) days written notice to the Owner, or his/her successors, may construct and/or install said improvements and recover the full cost and expense from the Owner, or his/her successors. STREET IMPROVEMENT PLANS (3) The Owner, shall cause to be prepared at his/her cost and expense street improvement plans for the construction and installation of said improvements prior to such construction or installation. Said plans shall be prepared by a civil engineer registered by the State of California and submitted to the City Engineer for examination and approval. (4), All of said improvements embraced in this Agreement shall be constructed and installed in accordance with the plans approved by the City Engineer and shall be made under the inspection and to the satisfaction of the City Engineer. Said construction and/or installation shall be in accordance with the existing ordinances and resolutions of the City of Campbell and all applicable plans, specifications, standards, sizes, lines and grades approved by the City Engineer, and all State and County statutes. Upon completion and acceptance of the improvements by the City, the Owner, shall provide reproducible as - built plans to the City Engineer. PLAN CHECK AND INSPECTION FEE (5) Prior to approval of the plans by the City Engineer pursuant to Section (3) of this Agreement, Owner, or his/her successors, shall pay the City for plan checking of improvement plans, field inspection of construction of improvements and all necessary expenses incurred by City in connection with said improvements, a sum calculated in accordance with Resolution No. 10494 as adopted by the City Council on May 3, 2005, or as may subsequently be adopted by the City Council. FAITHFUL PERFORMANCE SECURITY (6) The Owner, or his/her successors, shall file with City, prior to beginning construction, security acceptable to the .City in amount equal to the City Engineer's estimated cost of the street improvements to ensure full and faithful performance of the construction of all the aforementioned improvement work. Said security shall guarantee that Owner, and his/her successors, will correct any defects which may appear in said improvement work within one (1) year from the date of acceptance of the work by City and pay for any damage to other work resulting from the construction thereof, as well as pay the cost of all labor and materials involved. This security shall remain in effect until one (1) year after date of final acceptance of said improvements by City. Said security amount may be reduced by the City Engineer in his/her sole discretion after the date of final acceptance to not less than twenty-five (25) percent of its full value. (7) Upon final release of said security by City, the obligations of Owner, and his/her successors, contained in this Agreement shall be considered null and void, except as otherwise provided by applicable law, or Sections 12 or 13 of this Agreement. ORMATION OF A SPECIAL ASSESSMENT (8) The Owner, when called upon by City to do so, shall execute a petition for the formation of any special assessment district created pursuant to any special assessment act as provided in the Streets and Highways Code of the State of California created for the purpose of constructing and/or installing any or all of said improvements. Owner, or his/her successors, shall participate in and become a part of any special assessment ±WSTRUMENT IS A TRUE PJC CORPEUr COF), OF THE ORIGINAL 2 ON FILE IN THIS OFFICE. ATTEST: ANNE SYSEE, CITY CLERK PITY OF C:AI P EL , CA By _1L I , C� AATCl1 'II�IlL1 district as described in Section (8) of this Agreement. (9) The Owner's, or his/her successors' obligations contained in this Agreement that are accomplished to the satisfaction of said City Engineer by said special assessment district shall be considered to satisfy those obligations. RIGHT-OF-WAY ACQUISITION (10) Owner at his/her own cost and expense, shall acquire any easement and right-of-way within or without said real property necessary for the completion of the improvements shown upon aforesaid improvement plans. It is provided, however, that in the event eminent domain proceedings are required for the purpose of securing said easement and right-of-way, Owner, shall deposit or cause to be deposited with City a sum covering the reasonable market value of the land proposed to be taken and to be included in said sum shall be a reasonable allowance for severance damages, if any. It is further provided that in addition thereto such sums as may be required for legal fees and costs, engineering and other incidental costs shall be deposited with the City. (11) The Owner, shall carry out any and all negotiations with all interested parties and shall perform or cause to be performed at his/her own cost and expense and to the satisfaction of the City Engineer any and all work required to abandon, remove, raise, lower, relocate and otherwise modify irrigation lines within or without the boundary of said real property. INDEMNITY AND INSURANCE (12) The Owner, and his/her successors, to the fullest extent permitted by law, shall indemnify, defend and hold the City of Campbell, its agents, employees, attorneys, officers, officials and assignees harmless from any and all claims, actions, causes of action, liabilities, damages, losses and expenses, including, but not limited to, attorneys' fees, arising out of, or resulting from, or alleged to arise out of or result from any negligent or intentional act or omission (including misconduct) of said Owner, or his/her successors, or any subcontractor, or anyone directly or indirectly employed'by him, or anyone for whose acts any of them may be liable in the course of perfonnance of the Agreement, except for any claims, actions, causes of action, liabilities, damages, losses and expenses proximately caused by the sole negligence or willful misconduct of the City. (13) The Owner, and his/her successors, shall also indemnify, defend and hold the City of Campbell, its agents, attorneys, employees, officers, officials, and assignees harmless against and from any and all claims, actions, causes of action, liabilities, demands, losses, lawsuits, judgments, damages, costs and expenses (including, but not limited to, attorneys' fees and court costs, whether incurred at trial, appellate or administrative levels) which the City of Campbell may incur or suffer, or to which the City of Campbell may be subjected resulting from, or alleged to result from the failure of Owner, or his/her heirs, assignees, successors, grantees, agents, employees, subcontractors, or anyone performing services under him, to fulfill any of the obligations imposed under 3 this Agreement, except for any claims, actions, causes of action, liabilities, judgments, damages, costs and expenses proximately caused by the sole negligence or willful misconduct of the City. (14) The Owner and his/her successors shall also indemnify, defend and hold harmless the City, its agents, officers and employees from any claim, action, or proceeding against the City or its agents, officers or employees to attach, set aside, void or annul an approval of the City, its City Council, Planning Commission, Community Development Director, Public Works Director, Building Official, City Engineer, or other such City official concerning a subdivision, which action is brought within the time period provided for in California Government Code Section 66499.37. (15) In the event that this contract is subject to California Civil Code section 2782(b), the foregoing indemnity provisions shall not apply to any liability for the active negligence of the City. The foregoing indemnity provisions are intended to fully allocate all risk of liability to third -parties. No other rights of indemnity or contribution shall exist between the parties in law or in equity. The provisions set forth in this section shall survive the termination of this Agreement. (16) The City will promptly notify the Owner of any claim, action or proceeding to attack, set aside, void or annul any approval concerning a subdivision of said real property, and will cooperate fully in the defense. (17) Owner and his/her/its successors shall maintain insurance for injuries to persons or damage to property conforming to the following specifications: A. Minimum Scope of Insurance Coverage shall be at least as broad as: 1. Insurance Services Office (ISO) CGL form CG 00 01 11 85; and 2. ISO form G0009 11 88 Owners and Contractors Protective Liability Coverage Form — Coverage for Operations of Designated Contractor; and 3. Course of Construction Insurance covering all risks of loss; and 4. ISO CA 00 01 06 92 including symbol 1 (Any Auto); and 5. Workers' Compensation insurance as required by the Labor Code of the State of California and Employer's Liability insurance. B. Minimum Limits. of Insurance Owner shall maintain limits no less than: 1. General Liability: $1,000,000 combined single limit per occurrence for bodily, personal injury and property damage. If Commercial General Liability Insurance or other form with a general aggregate limit is used, 2 either the general aggregate limit shall apply separately to this project/location or the general aggregate limit shall be twice the required occurrence limit. 2. Automobile Liability: $1,000,000 combined single limit per accident for bodily injury and property damage. 3. Workers' Compensation and Employer's Liability: Workers' Compensation limits as required by the Labor Code of the State of California and Employer's Liability limits of $1,000,000 per accident. C. Deductible and Self -Insured Retention Any deductibles or self -insured retention must be declared to and approved by the City. At the option of the City, either: the insurer shall reduce or eliminate such deductibles or self -insured retention as respects the City, its agents, officers, attorneys, employees, officials and volunteers; or the Owner shall procure a bond guaranteeing payment of losses related to investigations, claim administration, and defense expenses. D. Other Insurance Provisions The policies are to contain, or be endorsed to contain, the following provisions: 1. General Liability and Automobile Liability Coverage: a. The City, its agents, officers, attorneys, employees,' officials and volunteers are to be covered as insureds as respects: liability arising out of activities related to this Agreement performed by or on behalf of the Owner, products and completed operations of the Owner, premises owned, occupied or used by the Owner, or automobiles owned, leased, hired or borrowed by the Owner. b. The Owner's insurance coverage shall be primary insurance as respects the City, its agents, officers, attomeys, employees, officials and volunteers. - Any insurance or self-insurance maintained by the City, its agents, officers, attorneys, employees, officials and volunteers shall be excess of the Owner's insurance and shall not contribute with it. C. Any failure to comply with reporting provisions of the policies shall not affect coverage provided to the City, its agents, officers, attorneys, employees, officials, and volunteers. d. The Owner's insurance shall apply separately to each insured against whom claim is made or suit is brought except with respect to the limits of the insurer's liability. C. Coverage shall not extend to any indemnity coverage for the active negligence of the City in any case where an agreement to indemnify the City would be invalid under Subdivision (b) of Section 2782 of the California Civil Code. 5 2. Workers' Compensation and Employer's Liability Coverage: The insurer shall agree to waive all rights of subrogation against the City, its agents, officers, attorneys, employees, officials, and volunteers for losses arising from work performed by the Owner for the City. 3. Course of Construction Coverage: Course of Construction policies shall contain the following provisions: (a) the City shall be named as loss payee; and (b) the insurer shall waive all rights of subrogation against the City. 4. All Coverages: Each insurance policy required by this clause shall be endorsed to state that coverage shall not be suspended, voided, canceled by either party, reduced in coverage or in limits except after thirty (30) days prior written notice by certified mail, return receipt requested, has been given to the City. E. Acceptability of Insurers Without limiting Owner's indemnification provided hereunder, Owner shall take out and maintain at all times during the life of this contract, up to the date of acceptance of the work by the City, the policies of insurance listed in Paragraphs 12 through 16 of this Agreement. Insurance is to be issued by an issuer with a current A.M. Best Rating of A:VII and be authorized to transact business in the State of California, unless otherwise approved by the City. F. Verification of Coverage Owner shall furnish the City with, certificates of insurance evidencing coverage required by this clause. The certificates for each insurance policy are to be signed by a person authorized by that insurer to bind coverage on its behalf. The certificates are to be on forms provided by the City. Where by statue, the City Workers' Compensation related forms cannot be used, equivalent forms approved by the Insurance Commissioner are to be substituted. All certificates are to be received and approved by the City before work commences. G. Subcontractors Owner shall include all subcontractors as insured under its policies or shall furnish separate certificates by each subcontractor. All coverage shall be subject to all of the requirements stated herein. MUTUAL BENEFIT COVENANTS BINDING ON HEIRS. ASSIGNEES, SUCCESSORS, AND GRANTEES OF OWNER (18) It is acknowledged that the provisions of this Agreement constitute covenants for the improvement of the subject real property for the mutual benefit of Owner's property, commonly known as 251 Llewellyn Avenue, and the City's property, commonly described as Llewellyn Avenue and Latimer Avenue where it adjoins Owner's property. These covenants shall be considered to affect rights in the above -described real 0 properties, and shall be binding on the heirs, assignees, successors, grantees and agents of the Owner to said real property. UNVESTED INTERESTS (19) Nothing contained herein shall be construed to transfer any unvested interests in real or personal property for purposes of the rule against perpetuities. BREACH OF CONTRACT (20) The City, upon breach any of the terms, conditions, or covenants of this Agreement by the Owners, shall be entitled to recover from the Owner, in addition to any other relief available in law or equity, all costs and compensation incurred in attempting to obtain enforcement of the Agreement, including reasonable attorneys' fees and court costs. ENTIRE AGREEMENT BINDING (21) This is the entire Agreement between the parties, and there are no representations, agreements, arrangements or understandings that are not fully expressed herein. This Agreement can be executed in counterparts by the parties hereto, and as so executed shall consist of one agreement, binding on all parties. PRELIMINARY PLANS (22) Owner, shall provide and construct public street improvements per preliminary plans titled "STREET IMPROVEMENT PLANS — OFFSITE — 251 Llewellyn Avenue" which are subject to approval by the City Engineer, prepared by Ifland Engineers. 7 IN WITNESS WHEREOF, said City has caused its name to be affixed by its Public Works Director and City Clerk, who ate duly authorized by Ordinance 2059 adopted September 20, 2005, and said Owner has caused his/her name to be affixed the day and year first above written. FamiliesFirst FamiliesFirst CITY OF CAMPBELL Todd Capurso, Public Works Director City of Campbell (Notary Acknowledgment for above signator(ies) MUST be attached.) Attest: r� f; L- Anne Bybee, City Clerk State of California County of l it (/a' r7—j On �(; y -:,), 2—Cl Personally appeared ) . CERTIFICATE OF ACKNOWLEDGMENT before me, ��?? y��A ' %y r' '- (' Z /(heerre insert name and title of the officer) }"t Who proved to me on the basis of satisfactory evidence to be the person(4 whose name(sl is/aree subscribed to the within instrument and acknowledge to me that lab/she/they executed the same in hid/hedtl)e--�r authorized capacity), and that by hj-s/her/their signatures(') on the instrument the person(s), or the entity upon behalf of which the personal acted, executed the instrument. I certify under PENEALTY 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 "4' d` } RAUL VEGA Commission # 1934686 .� Notaf P q, �I'c - California i g��i t�ra County My Comm. Expires May 1, 2015 CORPORATE RESOLUTION OF THE BOARD OF DIRECTORS OF FAMILIESFIRST, INC. WHEREAS, at a meeting of the Board of Directors of FamiliesFirst, Inc. dba EMQ FamiliesFirst ("Agency"), held in accordance with the law and Agency by-laws on the 13th day of February, 2014, at which a quorum of the Board of Directors was present; BE IT RESOLVED that on February 13, 2014, the Board of Directors of FamiliesFirst, Inc. authorizes Darrell Evora, Chief Executive Officer/President, Jason Gurahoo, Chief Financial Officer, Craig Wolfe, Chief Clinical Officer. and/or Kathryn McCarthy, Chief Administrative Officer/General Counsel jointly or individually to negotiate and execute contracts and any and all documents pertaining to the contracts, and to submit claims for reimbursement and to file other financial reports required by said contracts. AND, FURTHERMORE, that the signatures recorded below are true and correct signatures of the designated individuals. Title: Chief Executive Officer/President Title: Chief Financial Wficer Name: Darrell Evora Name: Jason Guraho Signature �` gnature Title: Chief Administrative Officer/ General Counsel Kathryn Meier McCarthy cC, K,--, — Signature Title: Chief Clinical Officer Name: Craig volfe Signature ; CERTIFICATION I certify that I am the duly qualified and acting Vice Chair of FAMILIESFIRST, INC, a duly organized and existing 501(c)(3) non-profit organization. The foregoing is a true and correct copy of a resolution adopted by the Board of Directors of said organization, at a meeting legally held on February 13, 2014 and entered into the minutes of such meeting, and is now in full force and effect. Name: Michael Mcndrews Signature =Fs LievieIivI+ Ave ime. C'am 1beI!. (' 950,J6 -;il8.37 ;.� 90 ax 'i08. 64.401 www,enigf`(.org CALIFORNIA ALL-PURPOSE CERTIFICATE OF ACKNOWLEDGMENT State of California County of J r� On �\I�, .,tr`L` �v . 7 �,\ q before me, (Here insert name and title of the officer) personally appearedQ� 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. �p JOANN THOMASON Commission # 1930682 W T�TESS my hand and official seal. Notary Public -California z. Santa Clara County M Comm. Mires Mar 28, 2015 (Notary Seal) Si natureb Notary Public ADDITIONAL OPTIONAL INFORMATION DESCRIPTION OF THE ATTACHED DOCUMENT (Title or description of attached document) (Title or description of attached document continued) Number of Pages Document Date (Additional information) CAPACITY CLAIMED BY THE SIGNER ❑ Individual (s) ❑ Corporate Officer (Title) ❑ Partner(s) ❑ Attorney -in -Fact ❑ Trustee(s) ❑ Other INSTRUCTIONS FOR COMPLETING THIS FORM Any acknowledgment completed in California must contain verbiage exactly as appears above in the notary section or a separate acknowledgment form must be properly completed and attached to that document. The only exception is if a document is to be recorded outside of California. In such instances, any alternative acknowledgment verbiage as may be printed on such a document so long as the verbiage does not require the notary to do something that is illegal for a notary in California (i.e. certifying the authorized capacity of the signer). Please check the document carefully for proper notarial wording and attach this form if required. • State and County information must be the State and County where the document signer(s) personally appeared before the notary public for acknowledgment. • Date of notarization must be the date that the signer(s) personally appeared which must also be the same date the acknowledgment is completed. • The notary public must print his or her name as it appears within his or her commission followed by a comma and then your title (notary public). • Print the name(s) of document signer(s) who personally appear at the time of notarization. • Indicate the correct singular or plural forms by crossing off incorrect forms (i.e. he/she/they— is /are ) or circling the correct forms. Failure to correctly indicate this information may lead to rejection of document recording. • The notary seal impression must be clear and photographically reproducible. Impression must not cover text or lines. If seal impression smudges, re -seal if a sufficient area permits, otherwise complete a different acknowledgment form. • Signature of the notary public must match the signature on file with the office of the county clerk. Additional information is not required but could help to ensure this acknowledgment is not misused or attached to a different document. Indicate title or type of attached document, number of pages and date. Indicate the capacity claimed by the signer. If the claimed capacity is a corporate officer, indicate the title (i.e. CEO, CFO, Secretary). • Securely attach this document to the signed document 2008 Version CAPA v12.10.07 800-873-9865 www.NotaryClasses.com J 7 V Ref undnb_I`e +De osit :Check` Request ToFinance, Director, , .o-,,-�, �_. .f: ,1.- :�" ,�'_ -,�":,�,1,I1;'rI:-.',,::.�, ,,"._,-- .-_ ,�.�I �,_i� I-�4�— l; , _�',�-_.r,,_ .-, .6� - 2,.-,,, �,_- _� .— C- ."," ,-I I, . 'I-'Z,...- , " �'._" . .;,�, , '" ,- I - , .., �-- I.�..',,�._ ,IL� :., - �:.'- �''.�'",. , -,�11- ,_, ,.'� ", . , ,, .,. ,- I.� ,i-Z, -,,,, ,-%I:_.,I".,,,,:.�,�.� ,,,�.',�",-_:rI _.,,� -'''�'.'I_ --.',' ,. , ...I ,,j -:-.-- , ,I�r " I_ .". %.". ., .o-,��� ,..', . L� : ,. . ,I ,, ., -.-,:"I"I,,,',, . �' . ` .. 'I"", .I.I..'c,'..I t, ..�II,. ! I... _ - _—,.,. - ,..'!. I � . 1�. � � % �:- ;' -I -i,` -i.,- . , .. -�', ,..", "_---- .��.,,-.._- y` Check Payable To EMQ Families First Y Address —Line 1 499 Loma Alta Ave: ti --.) Li . e,2 r r `1 -. I_II_—,1-�. _-',.I,.1��:.,, �," , �"--�,. .: ,-.�. 1..�)'...� ,,._f-: ,, I .,�,, �t-..j,. �`-,_ .. , City Los Gatos .„ State CA s Zip 95030 ;i Description IYn 251 Llewel r Ii Y _ _ - r ,f i. " . , _ 4 y AccountsNumber 101..2203 t Amount $2,7;96 00 Account Number h 101 2203 Amount , 101540.7444, Amount. Account Number _ i _'' "' (FInance Depf only)Interest' Earned (F Dept only), f m9nce Totiff Payable (", - c - mount)r , i _� "Purpose = Plan. Check,and Constructwn Deposit. Refunds ,{ `� Y J _ Permit# ENC20;13 00226 = ,A ,. Receipt # 2510;27 Date 11/25/2013: h. ;- ReceLpt',# 2521'3, , - t Date 2/14/2014 //'' Requested by -"�� 4 Title Inspector i _ Da`I�� - Syed Wahi`dl C ' , ` i •r _ Approved! by - Title Sr' tiEngmeer ' Date 3, b Roger Storz ) ,, - y.. ( - b ,1 ;,, , 'Finances , ept Only i :E Verlfietl,by Title Accounting Clerk ll:. Date _ `i Approved 6y ' IITitle Accountant Date ' ' , `'� - ,�• + .•' ,'� ,. it ]F , i d Special Instruction-s For Handling Check .T h r •' S I • ' J maii'as IS ,} mau in Attached Envelope : I; ! - 1. -, CK _ ` ,.. 1 Needed By - _< f ' ,'r _f { r Public Works ==h Return To J9A`nna Thomason i A" - (Name) ;Y (Department) -: - _ F ' < Other Please return cM, to JoAnne. ' , t _ _ .i , i. . i,. - . CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR ONE YEAR MAINTENANCE ACCEPTANCE LETTER Encroachment Permit # ENC2013-00226 Property Address 251 Llewellyn Date of Final Ins ection: 4/23/18 On File: Bon CD Cash 7-- Faithful Performance Bond $57,393.00 Construction Cash Deposit to be released: $2296.00 Ptc A cv, ec_v, 5-M --° Other overdue deposits to be released (Description): Processed by: Admin Reviewed by: Inspector Reviewed by: Land Development Engineer S� `fl ��- �( 0 J:UoAnnaT\Deposit refunds\CHECKLISTS\Llewellyn25 Ldoc (Rev. 10/11) 4/25/2018 ;� Fees Associated With 2:41:39PM CE�,!'� Case #: ENC2013-00226 'Fee,.,, . ° ` ' Start End j, Trans ,- Revenue _ Created V I ` '-T e. YP a, x Date, . s�,�. Date Dept Descr�ptian ode a . c a� Account Number =.' BY Date. Amount, Due AF05 7/1/2013 6/30/2014 PnntAppFee Utility Encr 101.730.4722 JT 12/6/2013 377.00 0.00 PCDP 7/1/2013 6/30/2014 OPdan-wChr'�c bep 101.2203 JT 12/6/2013 ogm 0.00 CASH 7/1/2013 6/30/2014 �C-DnstntcTio each%]DepB » 101.2203 JF 4/9/2014 W110-0070DW 0.00 PCII 7/1/2013 6/30/2014 Non-Util Plan Ck/Insp < $ 101.740.4722 JF 4/9/2014 8,035.00 0.00 Total Due: $0.00 .—bDc-\ c\S 0C1 Page 1 of I CaseFees..rpt July 7, 2014 Via Email dorisQh@cityofcampbell.com and U.S. Mail Doris C. Quai Hoi Asst. Engineer Public Works Department City of Campbell 70 N. First Street Campbell, CA 95008 Dear Doris: Enclosed please find and executed and notarized Agreement for Private Improvements in the Public Right -of -Way between EMQ FamiliesFirst and the City of Campbell, related to the property located at 251 Llewellyn Avenue. Please return a fully executed and recorded copy of the agreement once that process is complete. Please do not hesitate to call with questions. Thank you. Sincerely, 14�-,kO,,, Kathryn M. McCarthy Chief Administrative Of -ic r/G rneralounsel EMQ FamiliesFirst Enclosure: Agreement.for Private Improvement in the Public Right -of -Way Page Il 251 Llewellyn Avenue, Campbell, CA 95008 (408) 379-3790 Fax (408) 364-4013 www.emgffi.org �yed Wahidi From: Doris Quai Hoi Sent: Friday, July 11, 2014 8:57 AM To: Syed Wahidi Subject: 251 Llewellyn Attachments: SKMBT 50114071016210.pdf - 1� SKMBT 501140710 16210.pdf (21 K... Syed, The applicant signed a private improvement agreement to keep the water meter in the park strip. According to San Jose Water the cost to relcoate the WM would have been more than $30k. MQ ok'd it to stay in the park strip. Please make sure to have the contractor or engineer as built it or somehow we document the change. Also make sure the lids are not cracked or chipped. Thanks, Doris 1