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ENC2018-00115 CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No.: AC, 2-e DEPT.OF PUBLIC WORKS (for working within the X-Ref. File 70 North First Street public right-of-way) Application Date Campbell,CA 95008 Issued 5�2 � , _ Application Expiration Date «t I f/(t, Ph.(408)866-2150 Fx. (408)376-0958 APN l�C� ,fb o'�'O Permit Expiration Date, APPLICATION-Application is herebymadefora PublicWorks 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. WorkAddress: 1639 Walters AVa. Campbell, CA 95008 Nature of Work/Utility 1—nififf about 84 ,o I in.p'of Fi pe_for PGE roni Propose gas meter to PGB main'gas line across. e B. Trench Location: street in front of address 1626.Install about 35 ft.of 3 in.PGE approved conduit line from meter to PGE pull box located to front of the propert No Fee Permit for work related to City Project Project Name; 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 r3h€1w the rglatinn of the proposed work to existing surface and underlgrouPd improvements, When approved by the City Entainaer,said plan becomes a part of this permit. D. Allworkshalleonfqemto the City ofCampbeliStandard pecificatipnsar±dRetailsf4rPuttlieVyorksConstruer[on;thg eneralPermitOQnditions listed on the reverse side;and the Special Proyisiana for this pPrin[t,listed fElgw;F Illure tip abldP lIy these ,Qnditi©ns and provisipns may result injob shutdown and/orforfelture of F2lthfui Performance Sureties and cash deposits, E, The Contractor must have this permit and approved plans at tho site and must wifythe Public Works Department at[east two days before starting work. Notice must be given to Public Works at least 24 hours before restartft any work, Name of Applicant; Raul Martinez Telephone: 40877Z.6-792Q Address: 2040 a 7th eat,#300, San dose, CA 9511 E,Mail Address: service 24-HOUR EMERGENCY PHONE NUMBER 40$-667-9819 Is this work being done by the property owners at their own residence? Yes No The Appl[cant/Perm[ttee hereby agreeg by affixing their§ignatiare to this permit to held the City of Campboll,its officers,agePts,and employees free,safe and harmless from any claim or demand for damages resulting from the quark cQyered 4y this Permit, The Applicant/Permittee hereby acknowledges that they have read and understand broth the front and hook of this permit, and they will inform thoir cantractor(s) of the information,Applicant is advised that l?Pgn issuance of this P_rmit: property owner, or praPer#y Owner's suiucessnrg; shall he re5pomilale for any and all damages arising out of improvementsht�o eor._ d lc-r,•[ ,... ,f..�w.a.:y, cepted: Raul Martinez ` y.Ac — _ �:_--�--�----•_"�—.cam--.-..:,.._ _-._, (Applicant Permittga) -"(518n) Rate TrenehFree, Inc. Maul Martinez -4 Z?.p � (Contraetorj (Print Name) - Rate�T �. . 1. Street sha!l not be open cut for u ndprigrPund installations,Minimu rn cuts MUbe allowed for connections or exploration holes.Suchcut's e. 5pprif[r_ [[van rn%reri lift th€ I� ,n�zpecr nr nrinr tin rUYting. V 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 9 licensed Land Surveyor or Civil Engineer and two(2)copies of the cut sheets sent to the Public Works Department / before starting work. V 4. Per Section 4216 of the Government Code this permit Is not valid for excavations until Underground Service Alert(USA)has been notified and the inquiry identification number has been entered hereon. USA Phone: 1-800-222.2600. USA TICKET NO.X812100807 OOX 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: Tn -CAP>c 1,t er Paai`nzC u�y `rpi � P +nvc�, s�u�(L q1` eg w(7Ef w,a SLts St�L N,N `3v7H 51 f)E 5 (`i SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT PERMT APPLICATION FEE $_.-y S�2 PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT PLAN CHECK$±INSPEC;TION,1sEE EMERGENCY PERMIT FEIF _ APPRQVEUFORI5SUANCE - ` — � ,Q —. _ . ,.: ._,-5 rb tiJ [' r [ty fPgineor Date ,J Permit Expires 12 Months After Rat(,of l5smopGe DEVELOPER NOTES N BEFORE BEGINNING SUBSTRUCTURE WORK, PLEASE CALL THE UNDERGROUND N gg N INSPECTOR AT LEAST 48 HOURS IN LEGEND 3 �0ADVANCE AT 725-2202 OR FAX — (408) 725-7773. (WORK NOT PROPERLY o r INSPECTED MAY BE REJECTED) IF THERE —yy— (1) - 3" PVC SERVICE DUCT BY APPLICANT ARE ANY CONFLICTS BETWEEN w SUBSTRUCTURES INSTALLATIONS AND a 0 LANDSCAPING CONTACT THE INSPECTOR PRIOR TO INSTALLATION. Ld _m o (MON j _N f+�j .UUd m ��I'7 # 1667 �� # 1655 # 1639 � � 1621 � V���Z-=zsna- w=W J g`g O U _ _J o 200 AMS U Lj z 20/240 V W La l Zo z 3 10 co _< w W V)J z w m Z M =5 J CL U : a 'L 17" X 30" X 30" FVT SECONDARY � C, U o ' ci SPLICE BOX TO BE INSTALLED Clrf M ON PM 31292468 F- UD o - - —"TOAL 2 - - - - - - c ) =a m y C3 DUCT 2468 (/) M WALTERS AVENUE f 250' HARRIET AVENUE �_ ¢ I Z N m 5' PT32047-1 NOTES N K O — — — — 1. APPLICANT TO TRENCH JOINT WITH ELEC, TELCO AND CATV (GAS IN SEPARATE TRENCH) ¢ 2. APPLICANT IS TO PROVIDE ALL ELECTRIC SUBSTRUCTURES AS SHOWN - cr w 3. APPLICANT IS TO PROVIDE MANDREL AND PERFORM MANDREL TEST WITH PG&E INSPECTOR STANDBY o 44 PAIAFETY 4. THE TOTAL NUMBER OF BENDS IN ANY SECONDARY DUCT RUN IN EXCESS OF 200 FEET Y SHALL NOT EXCEED 300 DEGREES. ANY SECONDARY DUCT RUN EQUAL TO OR LESS THAN r�00¢ z SAFETY PLEDGE 200 FEET IN LENGTH MAY CONTAIN UP TO A TOTAL OF 315 DEGREES IN BENDS. - �'-'lii O zp I ALWAYS PU SYtIY Mg. U N =Z 5. APPLICANT IS RESPONSIBLE TO ENSURE TRENCHING AND SUBSTRUCTURE w m z WOK FOR MDacr TO _ INSTALLATION MEET PG&E GREENBOOK STANDARDS. GREENBOOKS ARE AVAILABLE ED a H w RESOLVE UNSAFE SRUATIONS. AT YOUR LOCAL PG&E HEADQUARTERS OR CAN BE FOUND ON THE INTERNET ��o w m ¢a I NETS Ar+o ENCOURAGE 0 WWW.PGE.COM/GREENBOOK j a"U Q z CD g W oTNERs To An SAEFlY. 6. FLAME RESISTANT (FR) CLOTHING IS REQUIRED WHEN WORKING ON OR AROUND �}¢ w v¢icOTn� PG&E FACILITIES AND EQUIPMENT. SEE PG&E GREENBOOK FOR ADDITIONAL DETAILS M cD aY z O a 7. APPLICANT IS RESPONSIBLE TO COORDINATE WITH TELCO AND CAN z o G- FOR THEIR CONSTRUCTION REQUIREMENTS o m Lo¢ w a �ooEnoo� aolnlno.�c� i i PM 31335221 MAP 3474-A1 S7AFETy CPA 3412-32 60 PSIG 1639 WALTERS AVE CAMPBELL i 520 SCFH t I � f I 0 � 1 NEW PROPERTY LINE OI w =DONATED TO CITY - Q OLD PROPERTY LINE 327' 1 EDGE OF PAVEMENT 1 � 1 WALTERS AVE �o 1 r lom EDGE OF PAVEMENT s TIED— a G - G G C 2" HP7—1946 ® TIED PROPERTY LINE — OAS TAP HOLE 6701T UNDER GAS IMIN NOTES: * BUILDING CONTRACTOR TO TRENCH AND BACKFILL ALL. * BUILDING CONTRACTOR TO DIG GAS TAP HOLE AS SHOWN 6' X 4' X 18" UNDER GAS PIPE * BUILDING CONTRACTOR TO TRENCH APPROX. 84' TO GAS METER LOCATION * PG&E TO INSTALL PIPE ONLY * SEE ELECTRIC SUBSTRUCTURE PACKAGE FOR ELECTRIC TRENCH EST: John Gambucci CO: ADE: John Gambucci Gas Construction Sketch SD: SUR Erin Straub 1639 Walters Ave NOTIF: 112131796 REP: Chris BradleyOTHER: PLNR: Campbell SHT: SHEETS SCALE: D10'1717 PACIFIC GAS AND ELECTRIC COMPANY PM:31335221 REV. APPLICANT CHECKLIST ■ CONTACT UNDERGROUND SERVICE ALERT "USA" AT 1-800-227-2600 (OR "811" BY LANDUNE), AT LEAST 2 BUSINESS DAYS BEFORE EXCAVATION, TO HAVE EXISTING UNDERGROUND UTILITIES MARKED IN FIELD O OBTAIN CITY/COUNTY EXCAVATION PERMIT (IF APPLICANT TO TRENCH) ■ FOLLOW TRENCH INSTRUCTIONS ,(IF APPLICANT TO TRENCH) ■ APPLICANT TO BACKFILL IMMEDIATELY AFTER INSTALL. MINIMUM OF 4" OF SAND AND 8" OF NATIVE SOIL DAY OF CONSTRUCTION. ■ HAVE SUFFICIENT SAND ONSITE PRIOR TO FINAL INSPECTION, REFER TO GREENBOOK SECTION 2.3.4 ■ MAINTAIN 3' MINIMUM PARALLEL SEPARATION FROM WET FACILITIES (I.E. WATER, SEWER, STORM), REFER TO UO STANDARD S5453, EXHIBIT B ■ TRENCH MUST MEET PG&E STANDARDS (SHOWN BELOW) AND HAVE 2" OF PG&E APPROVED SAND ON BOTTOM OF TRENCH BEFORE FINAL INSPECTION. ❑ COORDINATE INSTALLATION OF TELEPHONE AND CABLE TV FACILITIES PER THEIR CONSTRUCTION REQUIREMENTS ■ CALL (408) 725-2202 OR FAX (408) 725-7773 FOR PG&E TRENCH INSPECTION — AT LEAST 2 BUSINESS DAYS ADVANCE NOTICE ■ PLUMB GAS HOUSELINE TO NEW LOCATION AND HAVE MUNICIPALITY NOTIFY PG&E THAT GAS HOUSELINE HAS PASSED INSPECTION ❑ GAS METER GUARDS PER GAS STANDARDS AND SPECIFICATIONS MANUAL SECTION J-95 ■ PAYMENT MUST BE RECEIVED BY PG&E, BEFORE CONSTRUCTION WORK CAN BE SCHEDULED TYPICAL JOINT TYPICAL MINIMUM SEPARATION AND SERVICE TRENCH GAS ONLY TRENCH CLEARANCE REQUIREMENTS 18° Z ¢ 12' G T T C S P MINIMUM COVER MIN. W MIN, r � W¢ G GAS — 12" 12" 12" 6" 12" 24"; 30" in street N BACKFILL , q Z T TELEPHONE 12" — 1" 1" 12" 12" 24"; 30" in street 39' MIN, N Q T TELEPHONE (DB) 12" 1" — 1" 12" 12" 24"; 30" in street D— C T 3' 28' MIN, BACKFILL N o C CAN 12" 1" 1" — 12" 12" 24"; 30" in street o SAND 12' M¢ S ELECTRIC SECONDARY 6" 12 12 12" — 3" 24"; 30" in street z 4' COVER MIN, P ELECTRIC PRIMARY 12 12" 12" 12" 3" — 30"; 36" in street of S . 6' MIN, . 0J4' SAND2' SL STREETLIGHT 6" 12" 17' 12" 1" 3" 24''; 30" in street SAND 2' SAND 2' GREENBOOK PG, 2-l0 GREENBOOK PG. 2-8 PER UO STANDARD S5453, EXHIBIT B 30' MIN. TO BUILDING CORNER THE MINMUM CLEARANCES DO NOT j APPLY TO FIXED WINDOWS THAT LENGTH 6' MIN. TO INSIDE ARE NOT DESIGNED TO OPEN. BUILDING CORNER EXISTING PIPE ELECTRIC 0 MIN. TO OUTSIDE o METER BUILDING CORNER 3 ELECTRIC 36° 36" SERVICE TEE/ METER 10, to, MIN. MIN, HOUSELINE 6' LENGTH X 4' WIDTH STEEL PIPE. O O MIN' MIN. BUILDING 4' LENGTH X 4' WIDTH PLASTIC PIPE. COMMUNICATIONS VENT Xx 36' 36' ENCLOSURE 75' MAX MIN, MIN, 77 66' PREFERRED SERVICE 26 48' MIN, TEE/HOUSELINE j BUT[ DINF, EXISTING PIPE 9° ® FINISHED GRADE VENT METER BUILDING 26' REGULATOR FINISH �g UNDER STEEL PIPE. VENT GAS RISER GAS VENT GAS RISER GRADE �Z" UNDER PLASTIC PIPE. GREENBOOK PG. 2-29 ELECTRIC SERVICE RACEWAY GREENBOOK PG, 2-30 GREENBOOK PG. 2-8 COMBUSTION 36' MIN, 36' MIN, COMBUSTION EXHAUST FAN EXHAUST FAN PAD-MOUNTED TRANSFORMERS„ ALL ELECTRIC EQUIP. AND GAS REGULATOR WIRING (E.G, CENTRA AIR, COMBUSTION D 26' EXHAUST FAN) COMBUSTION AIR-INTAKE VENTS VENT 91 AIR-INTAKE VENTS 8' MIN. METER SERVICE TEE/HOUSELINE GREENBOOK PG, 2-31 GAS RISER 8' MIN, EST: John Gambucci CO: ADE: John Gambucci Applicant Trenching Checklist so: SUPV: Erin Straub 1639 WALTERS AVE CAMPBELL MOTIF: 112131796 REP: Chris BradleyOTHER: �PLNR: Applicant Copy SHT: SHEETS SCALE: DATE: 10 P� REV. 18 17 ' PACIFIC GAS AND ELECTRIC COMPANY 31335221 1639 l , Z� `B2, - I CD 17"X30"X30"FVf SECONDARY ) � SPLICE BOX TO BE INSTALLED - ON PM 31292468 02 ,�EPAgED � i •� � 570P ,. +tHFAA.' ■ EDGE OF RALEMENT 100 ft POTHOLET0 o CHECK DEPTH A � y rn ;. OF EXISTING LINE 14 � T q'f �v to Soft - - .* § a t .. �Ml 100'ft.. [o0it SUREDGECIFPAVEMENT� m 3 m r € t IL r n ri LEGEND Ln >� C23Sing „; W20-4Sign /S� Existing Sewer Line ��� DrillDiredion � „ 4 �r��o to m * W3 4 Sign Sign Placement (;� Existing Gas Line 20 s C9A(CA)Sign ® Dig Area f /W� Existing Water Line J06# `_ 18-173 ME _ 1639 01, nz CD 17"X30"X30"FVTSECONDARYCD .. SPLICE BOXTO BE INSTALLED__ ____ _._I CBE t g i ON PM 31292468 ❑2 R� � y, Q, - s - x EDGEOPPAVEMENT _ SOft si0oft t0oft _ a r s ON _ f,. i Jr W D m s - s 'r11-s M 2x r) 70 SoW 4 s < fn Tilm pq s ¢ .., %. ;, ' 1 oft .SUft.. ;EDGECtFPAVEMENT -- G s., G G ---- s -----' 0Ein 71 A11D ff on[w, 8E4AREp rrox l x ROAtY..� GAS TAP HOLE m ." n m 6'X4'X18" �, D m LEGEND UNDER GAS MAIN ��` O Ln n C23 Sing W20 4 Sign S� Existing Sewer Line ���Drill Direction '~ D ova . Ln m W3-4 Sign Sign Placement �;� Existing Gas Liner A. �M . C9A(CA)Sign ® Dig Area /W� Existing Water Line 106# r 18 173 PUBLIC-WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MISCELLANEOUS RECEIPT Effective July 1, 2017 TO: _Finance PUBLIC WORKS FILE N0. PROPERTY ADDRESS �6•3 VYAL--etT4 Please collect& recel t for the followingmonies .�{-y iF 9 F17r1 i -:f i{ l V4 r' 'nilMOUN�'' 4t�ck i� 4 rev A.II✓T'.."} r A 4+C 4Y r 'n,� K"�4NEph t41�5 ., 7raM$ 4722 Utility Encroachment Permit Application Fee $455.00 Z15 R-1 Encroachment Permit N/C Emergency Permits $130.00 Plan Check&Inspection Fee Minimum Charge Per Location $420.00 �(zo Conduits/Pipelines up to 500 Feet $2.95/ft Above 500 Linear Feet $1.75/ft Manholes/Vaults/Etc. $190.00/ea Pole Set/Removal $190.00/ea 4760 Storage Container Permit(valid up to 60 days only) $170.00 4760 Project Plans&Specifications_ Project No.: -4760. Standard Specifications&Details $1/Pg$15.50/Bk.. 4760 Engineering Maps.&Plans ' Aerial Plot 24"_x 36" $66,00 Aerial Print 8 1l2"x 11" $32.00 Map Research (includes max of two.24"x36"copies) $32.00 Maps and Plans 24'`x 36". $1.5:00 4722 Penalties: Failure to restore.pub.lic imprgvements sloo/Caiendar'Day.(Muni Code Sec..1 1.34.010) 4722 Penalties Failure to correct unsafe conditions $100//calendar Day 4722 Work Without Permits 4 Times Applicable Fee/Min.$500 x� � �.y� _ �J �' i, �, t}i(°l J- � r4� 3 '`• Ev{ . � -� F '=x k j Y ri,r iEu 9 ...Iw d.7t,.u'_. Y._dad ..cH,i41,-+ ..S s-.rs� isR�1FICe ,3 Ott- 4728 . Traffic Flow Map (Daily Traffic Volumes) $35,00 4728 Signal Timing Information $73 per hour 4271 Truck Permits $16.0.0 per trip. 4728 No Parking Signs $1 each or$251100 r t r .aS,, r ' Fp s..`x`:.r,.P ':#' „L,, trzs.:'N MISCELI:ANEOU5 s.x„' „4" m,:a .,, �.s + 511.7424 Posta e Other(Please Specify) TOTAL NAME OF APPLICANTIA NAME OF PAYOR V 4eA^ C.c� i wv c PHONE �Zto- ► ADDRESS D aN ZIP G1, .y,� e eye f zc rl 1 wt sP i a r� 7 3 t t r FOR RECEIVED EY r ' CITY CLERIC T � � ��'F; ��x � �� '.• -s �.i '� e �>'rt P r u'>xt,'�.t {3s' ^r �" ONLY Dates Receipt#� f1 3 i� 1 £ t h t w ti {.Y+- y M {` .�' b r , L b`.�• f iL.'`-rs y. d A 48 ® 75/17/2018 (MM/DD/YYYY) ,�,co��o CERTIFICATE ®F LIABILITY INSURANCE ��. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Michelle Pelletier HUB International Insurance Services Inc. PHONE g16-480-4171 a/c No License License#0757776 A/C No Ext 3636 American River Drive, Suite 200 ADDRESS: Michelle.Pelletier@hubinternational.com Sacramento CA 95864 INSURERS AFFORDING COVERAGE NAIC# INSURER A: Ironshore Specialty Company 25445 INSURED JDPLUMB-02 INSURER B:American Fire and Casualty Company 24066 Trenchfree INSURERC:National Union Fire Insurance Co 19445 P.O. Box U San Jose CA 95112 INSURER D:Cypress Insurance Company 10855 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 163226253 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DDIYYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY Y AGS0078403 9/25/2017 9/25/2018 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea occurrence) ccurrence $50,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1.000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY�JE C LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY BAA58392290 12/16/2017 12/1612018 COMBINED SINGLE LIMIT $ Ea accident 1 000 000 rX ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS X AUTOS Per accident $ C UMBRELLA LIAB X OCCUR EBU023207624 9/25/2017 9/25/2018 EACH OCCURRENCE $3,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $3,000,000 DED I I RETENTION$ $ D WORKERS COMPENSATION Y JDWC909577 4/30/2018 4/30/2019 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE:Job#18-173, 1639 Walters Ave.,City of Campbell,CA 95008 Additional Insured:City of Campbell,its officers,employees and volunteers where required by written contract. Waiver of Subrogation in favor of City of Campbell, its officers,employees and volunteers where required by written contract. Form:CG2010 0413,WC990410B Nf� to l' 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 70 N. First St. Campbell CA 95008 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD THIS CERTIFICATE SUPERSEDES PREVIOUSLY ISSUED CERTIFICATE WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 04 1 OB (EdQ4 WAIVER OFOUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA BLANKET BASIS VVe have the right to recover our payments from anyone liable for an injury d by this policy. VVe will not enforce our right against the person ororganization named in the Schedule. (This agreement applies only to the mx1ont that you perform work under a written contract that requires you io obtain this agreement from us.) The additional premium for this endorsement shall be 296 of the total manual premium otherwise due on such remuneration. The minimum premium for this endorsement ia $350. This agreement shall not operate directly or indirectly to benefit anyone not named in the SGhedule. SCHEDULE BLANKET WAIVER Person/Organization Blanket Waiver—Any person o/organization for whom the Named Insured has agreed bywritten contract tufurnish th|awoiva,` Job Description All CA Operations This endorsement changes the policy hu which it Is attached and is effective on the date issued unless otherwise stated. (The information below&m required only when this endorsement kmissued subsequent to preparation uf the policy.) Endorsement Effective 04/30/2017 Policy No. JDyyC806723 Endorsement No. Insured JD Plumbing.Tnonohheo. Inc. Premium$ Insurance Company Cypress Insurance Company Countersigned by WC89041D8 (Ed.9-14) t POLICY NUMBER: AGS0078403 COMMERCIAL GENERAL LIABILITY CG20100413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED ® OWNERS, LESSEES O CONTRACTORS ® SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Locations Of Covered Operations As required by written contract. If required by your Any Location agreement with such Additional Insured. Additional Insureds shown in a written contract, or written agreement that includes primary and non-contributory wording where required. If anyone, other than the Additional Insured, provides similar insurance for the Additional Insured, then this insurance will apply as outlined in SECTION IV — COMMERICAL LIABILITY CONDITIONS, paragraph 4. Other Insurance, subparagraph c. Method of Sharing. The inclusion of one or more Insured(s) under the terms of this endorsement does not increase our limits of liability. All other terms and conditions remain unchanged Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to 1. The insurance afforded to such additional include as an additional insured the person(s) or insured only applies to the extent permitted by organization(s) shown in the Schedule, but only law; and with respect to liability for "bodily injury", "property 2. If coverage provided to the additional insured is damage" or "personal and advertising injury" required by a contract or agreement, the caused, in whole or in part, by: insurance afforded to such additional insured 1. Your acts or omissions; or will not be broader than that which you are 2. The acts or omissions of those acting on your required by the contract or agreement to behalf; provide for such additional insured. in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 B. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following additional Insurance shown in the Declarations; exclusions apply: whichever is less. This insurance does not apply to "bodily injury" or This endorsement shall not increase the "property damage" occurring after: applicable Limits of Insurance shown in the 1. All work, including materials, parts or Declarations. 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 2. 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: If coverage provided to the additional insured, is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 0413 INSURANCE REQUIREMENTS CHECKLIST Permit# CIP Project# Consultant/Contractor: VN The following insurance is required of all consultants/contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These -insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: $1,000,000 per.occurrence, and -- - 0—$-100"00-gener-al aggregate-limit applying--separ-at-ely�-o-thp project,-or---- ------------ - — $2,000,000 general aggregate limit. Policy expiration date Automotive Liability: Y—"Any Auto" checked on certificate ,b� $1,000,000 per accident for bodily injury and property damage d—,Policy expiration date Z l(Pt ­10 Workers' Compensation and Employer's Liability Waiver of Subrogation clause $1,000,000 per accident for bodily injury or disease ❑y`Policy expiration date Course of Construction (if required in.Special`Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies o�- Additional Insured Endorsement: The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) \� The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area should say: Should any of.the above described policies be cancelled before the expiration date thereof,notice will be delivered in accordance with the policy provisions. Workers' Compensation Insurance Sheet Submitted For General Contractor ❑ For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev Jan 2018) 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. ZS'.yLk, S � Name: j.co,/\Spa%(<—' NAIC# Rating: Authorized in CA: Name: Aw\,.i ,(- ,,,`. NAIC# Zq-0(fRating: )C\l Authorized in CA: Name: C-J�� NAIC# 10 5 S Rating: 4Yt 1C Authorized in CA: Name: NAIC# Rating: Authorized in CA: Campbell Business License# q d Z(o 0 Expiration: 3 A--Contractors License#<Z�_l `O Class: Expiration: 3 31 I dC7 Insurance Certificate Reviewed S- &A 9 nitia Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 I ® DATE(MM/DD/YYYY) ,a�on CERTIFICATE OF LIABILITY INSURANCE 4/30/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME; Michelle Pelletier HUB International Insurance Services Inc. I­ PHONE FAX License#0757776 C No Ext:916-480-4171 A/C No:916-993-7271 3636 American River Drive, Suite 200 Av 201� A/V6. E-MAIL ADDRESS: Michelle.Pelletier@hubinternational.com Sacramento CA 95864 tratiotl INSURERS AFFORDING COVERAGE NAIC# orkInlic" s Adminis INSURERA:Ironshore Specialty Company 25445 INSURED JDP INSURER B:American Fire and Casualty Company 24066 Trenchfree P.O. Box U INsuRERc:National Union Fire Insurance Co 19445 San Jose CA 95112 INSURER D:Cypress Insurance Company 10855 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1252011721 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 I ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY Y AGS0078403 9/25/2017 9/25/2018 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence $50,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY PEC LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY BAA58392290 12/16/2017 12/16/2018 COMBINED SINGLE LIMIT $1,000,000 Ea accident X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OX HIRED AUTOS X AUTOS ED PR cZI DAMAGE $ C UMBRELLA LIAB X OCCUR EBU023207624 9/25/2017 9/25/2018 EACH OCCURRENCE $3,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $3.000,000 DED I I RETENTION$ $ D WORKERS COMPENSATION Y JDWC909577 4/30/2018 4/30/2019 X PER TOE TH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) RE: Work performed by the named insured under written contract for the certificate holder. Additional Insured: City of Campbell,its officers,employees and volunteers where required by written contract. Waiver of Subrogation in favor of City of Campbell, its officers,employees and volunteers where required by written contract. Form: CG2010 0413,WC990410B 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 70 N. First St. Campbell CA 95008 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 0410B ' (Ed.9-14) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA BLANKET BASIS We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) The additional premium for this endorsement shall be 2% of the total manual premium otherwise due.on such remuneration. The minimum premium for this endorsement is $350. This agreement shall not operate directly or indirectly to benefit anyone not named In the Schedule. SCHEDULE BLANKET WAIVER Person/Organization Blanket Waiver--Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver. Job Description Ali CA Operations This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 04/30/2017 Policy No. JDWC806723 Endorsement No. Insured JD Plumbing,Trenchfree, Inc. Premium$ Insurance Company Cypress Insurance Company Countersigned by WC 99 041013 (Ed.9-14) POLICY NUMBER: AGS0078403 COMMERCIAL GENERAL LIABILITY CG20100413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Locations Of Covered Operations As required by written contract. If required by your Any Location agreement with such Additional Insured. Additional Insureds shown in a written contract, or written agreement that includes primary and non-contributory wording where required. If anyone, other than the Additional Insured, provides similar insurance for the Additional Insured, then this insurance will apply as outlined in SECTION IV — COMMERICAL LIABILITY CONDITIONS, paragraph 4. Other Insurance, subparagraph c. Method of Sharing. The inclusion of one or more Insured(s) under the terms of this endorsement does not increase our limits of liability. All other terms and conditions remain unchanged Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to 1. The insurance afforded to such additional include as an additional insured the person(s) or insured only applies to the extent permitted by organization(s) shown in the Schedule, but only law; and with respect to liability for "bodily injury", "property 2, If coverage provided to the additional insured is damage" or "personal and advertising injury" g required by a contract or agreement, the caused, in whole or in part, by: insurance afforded to such additional insured 1. Your acts or omissions; or will not be broader than that which you are 2. The acts or omissions of those acting on your required by the contract or agreement to behalf; provide for such additional insured. in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: CG 20 10 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2 B. With respect to the insurance afforded to these 2. Available under the applicable Limits of additional insureds, the following additional Insurance shown in the Declarations; exclusions apply: whichever is less. This insurance does not apply to "bodily injury" or This endorsement shall not increase the "property damage" occurring after: applicable Limits of Insurance shown in the 1. All work, including materials, parts or Declarations. 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 2. 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: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or Page 2 of 2 © Insurance Services Office, Inc., 2012 CG 20 10 0413 ' ® DATE(MM/DD/YYYY) �c�Ro CERTIFICATE OF LIABILITY INSURANCE 9/26/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Michelle Pelletier HUB International Insurance Services Inc. PHONE g16-480-4171 AX No License License#0757776 A/C No Ext 3636 American River Drive, Suite 200 ADDRESS: Michelle.Pelletier@hubinternational.com Sacramento CA 95864 INSURERS AFFORDING COVERAGE NAIC# INSURERA:Evanston Insurance Company 35378 INSURED JDPLUMB-02 INSURER B:American Fire and Casualty Company 24066 Trenchfree INSURER C:National Union Fire Insurance Company of Pittsburg19445 P.O. Box U San Jose CA 95112 INSURER D:Cypress Insurance Company 10855 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1407882959 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 ADDLSUBRTYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY POLICY LTR MM DD/YYYY M /D/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y 2C21968 9/25/2018 9/25/2019 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADEF5q occurrence $300,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRO- LOC PRODUCTS-COMP/OP AGG $2,000,000 POLICY� OTHER: $ B AUTOMOBILE LIABILITY BAA68392290 12/16/2017 12/16/2018 COMBINED SINGLE LIMIT $ Ea accident 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS Per accident $ $ C UMBRELLA LIAB X OCCUR EBU03541397 9/25/2018 9/25/2019 EACH OCCURRENCE $3,000,000 X EXCESS LIAB I CLAIMS-MADE AGGREGATE $3,000,000 DED I I RETENTION$ $ p WORKERS COMPENSATION Y JDWC909577 4/30I2018 4/30/2019 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $1,000,000 OFFICERIMEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,OOD If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE:Job#18-173, 1639 Walters Ave.,City of Campbell,CA 95008 Additional Insured:City of Campbell,its officers,employees and volunteers where required by written contract. Waiver of Subrogation in favor of City of Campbell, its officers,employees and volunteers where required by written contract. Form:CG2012 0509,WC990410B (✓� q Z� l _ 00 S� L/ 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 70 N. First St. Campbell CA 95008 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD COMMERCIAL GENERAL LIABILITY CG 20 01 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance (2) You have agreed in writing in a contract or Condition and supersedes any provision to the agreement that this insurance would be contrary: primary and would not seek contribution Primary And Noncontributory Insurance from any other insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and 1 CG 20 01 04 13 O Insurance Services Office, Inc., 2012 Page 1 of 1 " POLICY NUMBER: 3C21968 COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURE® - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON CAR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL..GENFRAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Or anization s : Locations Of Covered Operations As agreed to by written contract or agreement All Locations Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section II — Who Is An Insured is arnended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional exclu- organization(s) shown in the Schedule, but only sions apply": with respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or darnage" or "personal and advertising injury' "property damage' occurring after: caused, in whole or in part, by. 1. All work, including materials, parts or equip- 1. Your acts or omissions; or ment furnished in connection with such work. 2. The acts or omissions of those acting on your on the project (other than service, maintenance behalf; or repairs) to be performed by or on behalf of in the performance of your ongoing operations for the additional insureds) at the location of the the additional insured(s) at the location(s) desig- covered operations has been completed: or nated above. 2. That portion of "your work' out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a par of the same project. CG 20 10 07 04 O ISO Properties, Inc.. 2004 Page 1 of 1 ❑ WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 0410B (Ed.9-14) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA BLANKET BASIS 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 appl les only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) The additional premium for this endorsement shall be 2% of the total manual premium otherwise due on such remuneration. The minimum premium for this endorsement is $350. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. SCHEDULE BLANKET WAIVER Person/Organization Blanket Waiver—Any person or organization for whom the Named Insured has agreed by written contract to furnish this waiver: Job Description All CA Operations This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is Issued subsequent to preparation of the policy.) i Endorsement Effective 04/30/2017 Policy No. JDWC806723 Endorsement No. Insured JD Plumbing,Trenchfree, Inc. Premium$ Insurance Company Cypress Insurance Company Countersigned by WC 99 04106 (Ed.9-14)