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ENC2016-00149
Print Form f` CITY OF CAMPBELL ENCROACHME-NT PERMIT Permit No DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File _. 70 North First Street ight- f-way) Application Date 7 _ Campbell,CA 95008 Application Expiration Date _ Ph. (408)866-2150 Issued APN — Fx. (408)376-0958 Permit Expiration'Date APPLICATION-Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code,Section 11.04. (Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable) A. Work Address or Tract No.: Lioa c Utility Trench Location: B. Nature of Work: X'V� �� � � C. Attach four(4)copies of an engineered plans owing 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 ofthe proposed work to existing surface and underground improvements. When approved by the City Engineer,said plan becomes a part ofthis 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. 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�WQorks at least 24 hours before restarting any work. Name of Applicant: ��/'fr �(1, SI�.V.✓ j (`� Telephone: /1u. " ._. 70,40 Address: —� _ . .1`? E-Mail Address: Dave, ff)b, �5 24 FLOUR EMERGENCY PHONE NUMBER: qDIf 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 ' advise At at upon issuance of this permit, property owner, or property owner's successors, shall be responsible f a and all damages aris}r ot+ ve ents completed in the public right-of-way. Accepted: (Applicant Per te ) (sign). Date 40 (Contractor) (Print Name) Date SPECIAL PROVISIONS: 1. Street shall not be open cutfor underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be specifically approved b t�lnspector 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 ofthe cut sheets sent to the Public Works Department before starting work. 4. Per Section 4216 ofthe Government Code this permit is not valid for excavations until Underground Service Alert(USA)has been notified and the inquiry identification number has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO. S. Prior to any work,the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way,which shall be recorded. 6. Public Notification Requirements: 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOrUNNT 2 RFCEIP`l�Q PERMIT APPLICATION FEE $ ` 0€ 3 L� '7(0,�#'� 1, PLAN CHECK DEPOSIT $ `— SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ 0 CONSTRUCTION CASH DEPOSIT $ Ur PLAN CHECK&INSPECTION FEE f" $ EMERGENCY PERMIT FEE $ APPROVED FOR ISSUANCE For"CiV Engineer D to Permit Ex fires 12 Months After Date of Issuance �i— GENERAL PERMIT CONDITIONS 1. The Permittee must provide evidence of insurance and Additional Insured Endorsements as required by the City.Insurance shall be maintained for the duration of the permit work. (2) A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency call-out,overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. Refund of the construction cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance J of the work by the City. 4. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City.Surety posted shall be equal to 25%of the original Faithful Performance Security. 5. Submit project schedule 10(ten)days prior to proposed start of work. Additional lead time may be required for work within City facilities and downtown Campbell. 6. 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. 7. Maintain safe pedestrian and vehicular crossings and free access to private driveways,bus stops,fire hydrants,and water valves. 8. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures,detours,and street closures. This plan must be reviewed and approved prior to any lane closures. 9. A Construction Traffic Control Plan shall conform to the 2006 California Manual on Uniform Traffic Control Devices(MUTCD). 10. Replace,as directed by the City Engineer,any damaged or removed improvements in accordance with City Standards and Specifications at the sole expense of the Permittee as expeditiously as possible. 11. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and new PCC shall be doweled to existing improvements. 12. Prior approval of inspector is required for any work proposed after normal working hours,on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 13. Work on arterials and collectors may require the use of changeable message boards.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 construction cash deposit. 14. Compaction testing of subgrade,base rock,and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 15. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m.to 4:00 p.m.and on weekends. 16. No storage of materials or equipment will be allowed near the edge of pavement,the traveled way,or within the shoulderline-which would create a hazardous condition to the public. 17. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other 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. 18. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency: 19. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 29. 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. 21. 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. 22. If the public interest requires a modification of, or a departure from the permit, plans, special provisions and/or specifications,the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made. 32. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and&indeates of work and a contact name and phone number. plicantisherebyresr ensuring that all those providing services under the applicant are aware of and abide by all of the above conditions. App is t Date: Contractor (Print Nam ) Date: JAFORMS\Templates\Encroachment Perm its\Encroach ment Permit STATIC form2.pdf Rev.05/14 _.__.W._..__.._ ....__....._..._...._...v._.....�....._.._..........._-..___..._.__..__... .__ ._._�.....�____.,__.._. ....,................__...........,.......,.._...................w._..,..._. _,... _._ _.._. a l.. ._.L.. �,..... ��.�.........._... .�_..._..... <<�•ul;h� 1 I III I C O 1 P/� q .J �..,.. B q ` ' ` y 1 `^ „y I Y11fIY14:lll Jn1151%:I 1, 1 11 !®O ae�6 V 1 = Ila, ' II I; III III'. { f I,1 111 �_� ............................. A;1'1'M Jv0 III 1 III q :7lrlrclxi III 6 ! C) 7� C � IlYlilll 1111117i1Y;1 III P C I III V III � b III {�a�y .°s/ � � •N i .,..� �i p .0 rye'':::1x � xUWJAk4u4 AY1diNW x'rv6mJlxvll y rn III V OPouO(�'•4Cr/(GIN WA4,4FtWU<rtW9lY}44h.14ha•IlWnt'katlY4Y,8M f/LM'M�.:4{!Y♦NIW!( ' } f��1"l.. 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II I• III 1 �` `• .� III ....._. _..�`,�,,•��`... ._....._.....,_.,�._,.,... t PUBLIC W( DEPARTMENT LAND DEVELOPMENT Effective July 1,2016 _ TO: Finance PUBLIC WORKS FILE NO. 1vC —6� PROPERTY ADDRESS '�Poq �AA_ Please collect&receipt for the following monies: _:`ACCT.� ITEM - AMOUNT. LAND'DEVELOPMENT 4722 Encroachment Permit Application Fee " Non-Utilit Encroachment Permit Major>_$10 000 $403.00 Minor Encroachment Permit<$to,000 $230.00 Initial R-1 Permit N/C Subse uent R-1 Permits within Two Year Period $230.00 Inspection Fee Minimum Charge per Location $398.00 Street Tree Planting/Removal N/C 2203 ($500 per Tree Planting Deposit Required) $500.00/tree 2203 Plan Check Deposit 2%of Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Grading&Drainage Plan Review Single Family Lot $281.00 Site< 10,000 s.f. $841.00 Site>_10,000 s.f. <0.5 Acre $1 127.00 Site>_0.5 Acre $1 688.00 4722 NPDES Review C3 Re uirements For projects not required to submit numeric sizing $163.00 For projects required to submit numeric sizing Impervious Area 10,000 S . Ft to 1 Acre $704.00 Impervious Area 1 Acre or more $918.00 4722 For projects sent to Consultant for review Consultant Cost+20% 4722 Additional treatment facilities $300 ea Plan Check& Inspection Fee(Non-Utility) 4722 Enqr. Est. <$250 000 14%of Engineer's Estimate 4722 Enqr. Est. >_$250,000 and<_$500,000 $35,000+8%of Engineers Estimate 4722 Enqr. Est. >$500 000 $55 000+7%of Engineers Estimate 2203 Emergency Cash Deposit 4%of Enqr. Est.*($500 min/$10,000 Max) DO — 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) $4009.00+$87/lot 4722 Final Tract Map(5 or More Lots) $4 871.00+$118/lot 2203 Monumentation Security 100%of Cit 's Monumentation Estimate 4920 Parkland Dedication Fee(75%/25% Due.Upon Cert. of Occupancy) 4722 Lot Line Adjustment(Includes Certificate of Compliance) $1,893.00 4722 Vacation of Public Streets&Easements $2,530.00 4722 Certificate of Compliance $1,877.00 4722 Certificate of Correction $561.00 4722 Document Recording Fees $15.00/first page$3 ea.Additional 4722 Private Improvement in Public ROW $50.00 4722 Approved Plan Revision Fee $100/sheet 4722 Appeal Filing Fee $200.00 47221 Notary Fee (per signature) $10.00 2 Assessment Segregation or Reapportionment First Split $895.00 Each Additional Lot $281.00 511.7424 Postage MISCELLANEOUS- Other - ._ . .. _..,. _.. ,__-_--._...._. ._-- _ :-._._"_ ..__ ---_ .._ ___.___._,-_--.- - --- ------ -•-- - . (Please Specify) *Engineer's Estimate shall be as approved by the ' City Engineer and shall include all items of work. TOTAL Y $ NAME OF APPLICANT C/ `G C, `aa NAME OF PAYOR PHONE_ ADDRESS . ZIP r r� - rye s 1 g CL SIP FOR RECEIVED.By [-Y t �� _� I PCITY CLERK . ONLY Date - Receipt#' - - •- - J T0RMS1Te,1 - pF C4� UftCHAR� CITY OF CAMPBELL Public Works Department December 14, 2018 Mr. Larry Schaddt PO Box 1368 Los Gatos, CA 95031 SUBJECT: PERMIT NO. ENC 2016-00149 400 E. Campbell Ave., Campbell, CA 95008 MAINTENNACE INSPECTION AND ACCEPTANCE Dear Mr. Schaadt: The City of Campbell has made the final maintenance inspection of the subject Public Works improvements and finds that no remedial work is required. Your warranty requirements and any surety, therefore, are hereby released. Sincerely, Syed Wahidi Public works Inspector Cc: 70 North First Street Campbell, California 95008-1436 • TEL 408.866.2150 FAX 408.376.0958 TDD 408,866.2790 Encroachment Permit Final Sign Off Encroachment Permit# Address: Date of Final Inspection and Acceptance: I2 f(5 Inspected by: C,�J OK to release deposits: 100% 75% Comments: U u •CRCHAR�• CITY OF CAMPBELL Public Works Department January 3, 2018 Mr. Larry Schaadt PO Box1368 Los Gatos, CA 95031 SUBJECT: PERMIT NO. ENC 2016-00149 400 E. Camp0bell Ave., Campbell CA FINAL INSPECTION AND ACCEPTANCE Dear Larry: The City of Campbell has made a final inspection of subject Public Works improvements and finds the work to be acceptable.and in conformance with City standards. Accordingly, the City Engineer accepts the improvements. _ The one year maintenance period stated in the permit begins as of December 12, 2017. The permittee is responsible for the repair and/or replacement of any defective work or failures that occur.within one year. The City will inspect the improvements within one year and notify you, in writing, whether or not any repairs are required. Your Faithful Security Deposit in the amount of$5,000.00 is enclosed. If you have any questions, please call me at(408) 866-2165. Sin erely, 4yeAWahidi Public Works Inspector Cc: Permit File ENC 2016-00149 70 North First Street • Campbell, California 95008-1436 TEL 408.866.2150 FAX 408.376.0958 TDD 408.866.2790 i L . I --------------------------------------- --------- -------- --- -- - - ---------------------------------------- ----- --------- --------- : CITY OF CAMPBELL-- VENDOR NO. 10014682 CHECK NO.' 265858 . ...Account ... ,..,. Purchase:Order ; Invoree Number..:..... : .:....Amount .....:....... . D¢scri'hon 1. . 101 2203 CR121817 5,000.00 400 'E CAMPBELL AVE } ! I \ / i 10014682 LARRY SCHAADT ` ---- -- - ',`� . HIM P CITY CAIVIPBELL i1-24, .; WELLS FARco Eaxx N A CHECK DATE CHECK NO MONPGOMERY STREET 2 6 5 8 5 8 1a10 -1 .7 Nt})fiTH,FIRST STREET ,CALIFORNIA 95008 iV :fit G}�MPBELI ^ sA�r a RANCISCO CA 94104 I UNT 5., 000 0 x ,r G 0 VOID AFTER 90 DAYS 0�I PAY`THE SUM'OF FIVE THOUSAND DOLLARS &. ZERO CENTS. m TO THE .LARRY {SCHAADT F i ORDER p O. . BOX 13.68is _ I � ¢-- ~' LOOS GATOS CA 9:5'031 � �r i �'. 2 6_5 8 5 80 t: L 2 L 0�0 0 2`,4 8�: 4 L 2 L 8 5�5 4 i 5 iI■ . : _ _._... _....._...._.......1 - r.. _ _....... _... _. ......_...._... -..---------_ _....__ .............._.__....... ......... .............__..._............... ..........................._._....... ..._...._............................. _.._......_.__....... .....___:__...__.. .. ....� _........__............. . 1 ! j ; ,1 I *See Re,, erse Side For Easy Opening Instructions* CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008. r , i 1 - i - I LARRY SCHAADT P.O. BOX 1368 LOS GATOS CA 95031 ! JoAnna Thomason From: Larry Schaadt <LSCHAADT@msn.com> Sent: Saturday, December 16, 2017 12:47 PM To: JoAnna Thomason Subject: Re: Refund check Hi JoAnna, The address is: PO Box 1368 Los Gatos, CA 95031 Thank you. Warm regards, Larry From:JoAnna Thomason <ioannat@cityofcampbell.com> Sent: Friday, December 15, 2017 12:52 PM To: 'Lschaadt@msn.com' Cc: Roger Storz Subject: Refund check Good evening Larry, I am preparing your deposit refund for the work at 400 E. Campbell Ave. Can you please give me your address so that I can mail it out to you when it's ready. Thank you, JoAnna oV•OMr�, JoAnne Thomason off. �E+C Office Specialist t� r C.'Jty ol'Ca mpbell l Public Works Deparime.nt a 0 70 N. First Street 1 Campbell, CA 95008 .c,it cal-c:r��_}?t�elLcom 1 409.866.21 50 *kc11AQ0 1 TO BE REWORDED WITHOUT FEE SEC`rION 6103 GOVERNMENT CODE - AT THE REQUEST OF CITY OF CAMPBELL 23824373 JAN 25 2018 Regina Alcomendras Recording Requested By: ) Santa Clara County — Clerk—Recorder,1� CLERK'S OFFICE City of Campbell ) 12/12/2017 08:05 AM 70 North First Street ) Titles: i Pages: 7 Campbell, CA 95008-1423 ) Fees: 10.00 0.00 Taxes: 0 After Recording Return To: ) Total: Mill KFM WN W611101051VI011fkNil�V1,41i 11111 City Clerk ) City of Campbell ) 70 North First Street ) Campbell, CA 95008-1423 ) APN: 412-07-038 (Space Above for Recorder's Use Only) Address:400 E.Campbell Avenue, San Jose,CA 95008 AGREEMENT FOR PRIVATE IMPROVEMENTS IN THE PUBLIC RIGHT-OF-WAY In consideration for granting permission to construct improvements in the public right-of-way, THE L.E.S. TRUST (property owner) enters into this Agreement with the City of Campbell. The improvements contemplated under this permit are for the benefit of the real property commonly known as 400 E. Campbell Avenue. The City of Campbell grants such permission to install four (4) decorative uplights within the public sidewalk under Encroachment Permit No. ENC2016-00149. All conditions of Encroachment Permit ENC2016-00149 remain in full force and effect. The property owner shall be solely responsible for maintaining the improvements in a good and safe condition at all times; and the property owner shall indemnify, defend, and hold harmless the City of Campbell, its officers, officials, agents, volunteers, employees and attorneys from any and all claims, actions, losses, liabilities and costs (including reasonably incurred attorney's fees) arising out of or connected with, or alleged to arise out of or be connected with the installation, design or condition of the improvements, except for any claims, actions;losses, liabilities and costs proximately caused by the sole negligence or willful misconduct of the City of Campbell, its officers, officials, agents, volunteers, employees or attorneys.' This provision is intended to be the dispositive of all rights of indemnity and contribution between the parties, and property owner waives and releases any and all rights to indemnity or contribution from the City of Campbell, in law or equity, arising out of, or connected with any and all claims, actions, losses, liabilities and costs (including reasonably incurred attorney's fees) for which property owner is obligated under this paragraph to provide indemnity or defense to the City of Campbell, its officers, officials,volunteers, employees or attorneys. The City, in its sole discretion, may revoke the rights granted under Encroachment Permit No. ENC2016-00149 and remove the improvements installed under Encroachment Permit No. ENC2016- 00149 at any time, without liability to the property owner, or require that the improvements be removed, and property owner shall have no right to compensation from City in any form. In the event that Owner fails to reimburse the City for the costs of removing the improvement ("default") as required by this Agreement, the City shall have and may execute the absolute right, at the City's option and without demand or notice to Owner, to claim and impose a lien, attached as Exhibit A J:\LandDev\Forms\2.AGREEMENTS-PIA SIA DEF SIA Maintenance Reimbursement Development\Private Improvements Agreements in ROW\Word Document\Campbell E 400.docx Page 1 of 5 and incorporated herein by this reference ("Lien"), on said real property (also referred to herein as "Collateral"). City's failure to exercise this option will not constitute a waiver of the right to exercise it in the event of any subsequent default. (a) Amount of Lien: The Lien shall be for the entire amounts then owing under this Agreement. (b) Recordation: City is authorized to record the Lien in the appropriate Recorder's Office(s). (c) City shall have full authority to perform all acts and things that City may consider necessary or advisable to impose, maintain and enforce the Lien. (d) Debtors' Warranty: OWNERS WARRANT that they are the owners of the Collateral and Owners have the right to make this Lien Agreement. (e) Debtors Covenants: Owners agree: (i) To pay City all amounts payable pursuant to this Agreement on or before the due date when due and payable, and to perform all terms of this Agreement; (ii) To defend the Collateral against claims and demands of all persons and entities; (iii) To keep the Collateral in good condition; to perform other acts that may be necessary to preserve the Collateral and protect the Collateral against unreasonable loss and all hazards, and; (iv) To immediately notify the City in writing when Owners become aware of any event that substantially affects the value of the Collateral, or the rights and remedies of City in relation to the Collateral. (f) Prohibitions: Without the prior written consent of the City, Owners will not permit any liens or security interests (other than the City's Lien) to attach to the Collateral; permit the Collateral to be levied on under legal process; dispose of the Collateral; or permit anything to be done that may impair the value of the Collateral or of the Lien, which is the subject of this Agreement. (g) Notices: Any notice, demand or request required hereunder, or by law, shall be given in writing(at the addresses set forth below) by any of the following means: (a) personal ser✓ice; (b) facsimile; (c) overnight courier or delivery service; or (d) registered or certified, first class U.S. mail, return receipt requested. J:\LandDev\Forms\2.AGREEMENTS-PIA SIA DEF SIA Maintenance Reimbursement Development\Private Improvements Agreements in ROW\Word Document\Campbell E 400.doex Page 2 of 5 Property owner agrees to maintain homeowners or general liability insurance with a limit of at least $100,000 for damages arising from the installation, design or condition of the improvements. This provision shall run with the land and be binding on the property owner's successors. Executed this f day of ���' , 2017. THE L.E.S. Larry chaadt, Trustee (Attach Notary Acknowledgment For All Parties) CITY OF CAMPBELL, a municipal Corporation Todd Capurso Public Works Director, City of Campbell ATTEST: Wendy�V od, City Clerk J:\LandDev\Forms\2.AGREEMENTS-PIA SIA DEF SIA Maintenance Reimbursement Development\Private Improvements Agreements in ROVWord Document\Campbell E 400.docx Page 3 of 5 Exhibit A Recording Requested By: ) City of Campbell ) When Recorded Mail To: ) City Clerk ) City of Campbell ) 70 N. First Street ) Campbell, CA 95008 ) APN: Space above this line for Recorder's use only Address: CLAIM OF LIEN 1, Todd Capurso, Public Works Director for the City of Campbell, a California Municipal Corporation ("City"), do hereby certify: A. On or about , 20_, ("Debtors") executed an Agreement for Private Improvement with the City of Campbell ("Agreement"). B. The Agreement was recorded in the Santa Clara County Recorder's Office on or about 20 Document Number C. The Agreement allowed the Debtor's to provide, construct, and/or install certain private improvements in front of their property at , Campbell, California, at their own costs and expense. Pursuant to the terms of the Agreement, the Debtors expressly agreed that if they failed to comply the work the Agreement, the City was authorized to remove said improvements and recover the full cost and expense thereof from the Debtors or their successors. D. The Debtors did not remove the improvements after being notified to do so. Therefore, the City removed said improvements. E. In , 20 , the City informed the Debtors about the improvements that would be removed pursuant to the Agreement. F. The City subsequently completed the work. On or about , 20_, the City sent the Debtors an invoice for said work in the amount of$ G. Pursuant to the terms of the Agreement, the Debtors expressly agreed that the City is authorized to, at the City's option and without demand or notice to the Debtors, immediately claim and impose a lien on the real property commonly known as , Campbell, California, APN Number , for the entire amounts then owing under, or incurred pursuant to, the Agreement, including without limitation, the entire unpaid principal amount. J:\LandDev\Forms\2.AGREEMENTS-.PTA SIA DEF SIA Maintenance Reimbursement Development\Private Improvements Agreements in ROW\Word Document\Campbell E 400.docx Page 4 of 5 WHEREFORE, the City of Campbell, A California municipal corporation, pursuant to the Agreement, hereby claims a lien upon the work of improvement and the land upon which it is situated, namely, the real property commonly known as Campbell, California, APN Number , in the amount of $ and said amount shall constitute a lien against said property until paid in full. IN WITNESS WHEREOF the City of Campbell, California, a California Municipal Corporation, has duly authorized the undersigned to execute this instrument in its name. Dated: By: for the CITY OF CAMPBELL, a California municipal corporation (Notary Acknowledgement Required for Signatures) J:\LandDev\Forms\2.AGREEMENTS-PIA SIA DEF SIA Maintenance Reimbursement Development\Private Improvements Agreements in ROW\Word Document\Campbell E 400.docx Page 5 of 5 ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of SANTA CLARA On f J/d2 before me, MEKIALA RAE TORREZ, NOTARY PUBLIC (insert name and title of the officer) personally appeared 14W4_,� 4cd�)1— , who proved to me on the basis of s tisfactory 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. 4 yiw MEKIALA RAE TORREZ WITNESS my hand and official seal. Commission #2139486 Notary Public - California Z Santa Clara County r My Comm. Expires Jan 8, 2020 , Signature-d/4& (Seal) CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE §1189 #�"�'s��,�n��`,a? �f'?.�i�=�'�5� .� 3; �,new"r,"sx �:"�' 3:zag��N,S��'fi;�=ss(sY� ?�.�s�'�:^3�3� ,r�."����}:�i ���•�"��,,,`'�� A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document. State of California County of On �lL(before me, T(� Date _ �I Here Insert Name and Title of the Offic�r personally appeared Name(s)'of Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s)whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s)on the instrument the person(s), or the entity upon behalf of which the person(s)acted, executed the instrument. '61I certify under PENALTY OF PERJURY under the JOANN THOMAS0 laws of the State of California that the foregoing Commission#21107B9 paragraph is true and correct. a"-c� Notary Public-California v z Santa Clara County WITNESS my hand and official seal. My Comm.Expires May 9,2019 Signature () \ � Place Notary Seal and/or Stamp Above Signature of Notary Public OPTIONAL _ Completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: \C-1 \r\A e vvy �uc Document Date: Number of Pages: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: Signer's Name: ❑ Corporate Officer—Title(s): ❑ Corporate Officer—Title(s): ❑ Partner— ❑ Limited ❑ General ❑ Partner— ❑ Limited ❑ General Q Attorney in Fact _ ❑ Individual El Attorney in Fact ❑ Trustee ❑ Guardian of Conservator 0 Trustee- -- 6sasdiao.of Cnmarva+nr ❑ Other: ❑ Other: Signer is Representing: Signer is Representing: "�n*''3'..`_�oe��i::::`�'l_'�".',^.'izs�'✓"t,F�'i��•Fr.'`�"-_'�;3:=:�''Biz`�s+,•.... `,-'fu't,��c.`�,:3m�_.o"���`�^� ?-`.nx<`"s'�`.� -_'�'£3`,^�•` -Ci�'`'.�o'� .,Y.'tv."^t'��r�'.'�'�:�"���y.-�..a�`.�..;pro�=�'ruti: 02017 National Notary Association Syed Wahidi From: Roger Storz Sent: Friday, October 06, 2017 1:23 PM To: IIschaadt@msn.com' Cc: Daniel Fama;Amy Olay; Syed Wahidi Subject: 400 E. Campbell Avenue &394 E. Campbell Avenue Attachments: Campbell E 400.pdf Good Afternoon Larry, I am following up on a couple of your projects and the required Private Improvement in the Public Right-of-Way Agreements. • 400 E. Campbell Avenue (Growers National Bank)—the recently installed uplighting within the public sidewalk can remain, however we will need you to execute an "Agreement for Private Improvements In the Public Right- of-Way"to document your ownership and responsibility for these improvements. Until this agreement is executed and recorded we cannot close the encroachment permit nor refund the associated $5,000 security deposit. • 394 E. Campbell Avenue (The Vesper)—per the Conditions of Approval for PLN2017-71 approved on March 14, 2017,you are required to execute an "Agreement for Private Improvements In the Public Right-of-Way" to allow the existing fire service mounted to the face of the building and extending into the public right of way to remain. I have attached a sample agreement already prepared for the 400 E. Campbell Avenue project,the agreement would be almost identical for the 394 E. Campbell Avenue project. To complete the agreements, I still need property ownership information for each property, and the name and title of who will be signing each agreement. I appreciate your timely assistance in resolving these matters. Regards, 'oV•CA,yo Roger Storz, PE .4• ;!P Senior Civil Engineer U r City of Campbell I Public Works Department 0 o 70 N.First Street I Campbell,CA 95008 www.cityofcampbell.com 1408.866.2190 •CRCHAR9 1 METHO-1 OP ID:VC ACOR®® Ft7/2016 M/DD/YYYY) CERTIFICATE OF 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 have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lley_of such endorsements . PRODUCER U00 (A6 4114"000NTACT Veronica Castro NAME: MISSION COUNTIES INS AGCY INC PHONE 408-979-8160 FAX 408-978-6801 License#0544474 A'Hr (A/C,No,Ext): (A/C,No): P O Box 6717 Lin ® '`r V ADDRESS: SAN JOSE,CA 95150 Veronica Castro INSURERS AFFORDING COVERAGE NAIC# (3AI30a)3 INSURER A:Kinsale Insurance Company INSURED Method Construction,Inc. INSURERB:Liberty Mutual P O Box 2702 INSURER C,Midwest Employers Casualty Co Gilroy,CA 95021 TOPA Insurance Company INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUB POLICY NUMBER POLICY EFF POLICY EXP LIMITS L D MMIDD/YYYY MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY / EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 0100045859-0 12/30/2016 12/30/2017 DAMAGE TO RENTED 300,000 X X PREMISES(Ea occurrence) $ MED EXP An one person) $ S,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY�X PRO-- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY COMBINEeD SINGLE LIMIT $ 1,000,000 X ANYAUTO X X BAW56780305 08/05/2016 08/05/2017 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ X HIRED IX NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ D UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 X EXCESS LIAB CLAIMS-MADE X16607596-01 12/30/2016 12/30/2017 AGGREGATE $ 5,000,000 DED RETENTION$ $ C WORKERS COMPENSATION '—` X PER OTH- AND EMPLOYERS'LIABILITY Y/N BNUWC0137522 08/01/201�' 08/01/2017 T ATUTE R 1,000,000 OFFICER MEANY IMBER EXCLUDED?ECUTIVE ❑ N/A X E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ p�SCRI TON OF P TIONS/ CATIONS/VE ICLES (ACOR 101 Add tional Remarks Sched e,may be attached if more space Is required) Gity o �amp�ie its oft%ers,emp�oyees an�PvoI n�eers are name as additional insured.The insurance coverage afforded to the additional insured is primary insurance.All work in the public right-of-way at: 400 Campbell Ave,Campbell,Ca 95008 C= CERTIFICATE HOLDER CANCELLATION CAMPCIT 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 Street Campbell,CA 95008-1039 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD METHO-1 OP ID:VC ACORN® DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/27/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 408-979-8160 CONTACT Veronica Castro NAME: MISSION COUNTIES INS AGCY INC PHONE 408-979-8160 FAX 408-978-6801 License#0544474 (A/C,No,Ext): (A/C,No): P O Box 6717 E-MAIL ADDRESS: SAN JOSE,CA 95150 Veronica Castro INSURERS AFFORDING COVERAGE NAIC# INSURER A:Kinsale Insurance Company INSURED Method Construction,Inc. INSURER B,Liberty Mutual P O Box 2702 INSURERC:Midwest Employers Casualty Co Gilroy, CA 95021 TOPA Insurance Company INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTRIN SD WVD MM/DD/YYYY MM/DD/YYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE [X] OCCUR X X 0100045859-0 12/30/2016 12/30/2017 PA MAGE T O _gQcu e $ 300,000 MED EXP(Any oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY[XI PRO- LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ B AUTOMOBILE LIABILITY EeMBINEDtSINGLE LIMIT $ 1,000,000 X ANY AUTO X X BAW56780305 08/05/2016 08/05/2017 BODILY INJURY Per erson $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Paraccident $ D UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 X EXCESS LIAB I CLAIMS-MADE X16607696-01 12/30/2016 12/30/2017 AGGREGATE $ 5,000,000 DED I I RETENTION$ $ C WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY BNUWC0137522 08/01/2016 08/01/2017 T E 1,000,000 OFFICER/MEMBOER EXCLUDED?PROPRIETOR/PARTNER/EXECUTIVE F7 N/A X E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ fiSCRIP 10)J OF O FiATIQN /LO ATIONS EHIC (_S (A O D 101, d iopal Ro�a rks Schedule,may be attached if more space Is required) vifor�lc In pu�iFllc rlgnt-o-way. he�Ity o �ampse�`�, Its oTTlcers employees and volunteers are named as additional insured as respects liability per CG2010 04 13 form. CERTIFICATE HOLDER CANCELLATION CAMPCIT 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. 1 st Street Campbell,CA 95008-1039 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD POLICY #0100045859-0 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS SCHEDULED PERSON OR ORGANIZATION Attached To and Forming Part of Policy Effective Date of Endorsement Named Insured 0100045859-0 12/30/2016 12:01AM at the Named Insured Method Construction Inc address shown on the Declarations Additional Premium: :1!�$o Premium: $0 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person(s)or Organization(s): Location(s)of Covered Operations Blanket,as required by written contract Information required to complete this Schedule,if not shown above,will be shown in the Declarations. A. Section 11 —Who Is An Insured is amended to include B. With respect to the insurance afforded to these as an additional insured the person(s) or additional insureds,the following additional exclusions organization(s) shown in the Schedule, but only with apply: respect to liability for "bodily injury", "property This insurance does not apply to "bodily injury" or damage" or "personal and advertising injury" caused, "property damage"occurring after: in whole or in part,by: 1. All work, including materials, parts or equipment 1. Your acts or omissions;or furnished in connection with such work, on the 2. The acts or omissions of those acting on your project (other than service, maintenance or behalf; repairs) to be performed by or on behalf of the in the performance of your ongoing operations for the additional insured(s) at the location of the covered additional insured(s) at the location(s) designated operations has been completed;or above. 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. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. CG 20 10 07 04 0 150 Properties, Inc.,2004 Page 1 of 1 POLICY #0100045859-0 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS Attached To and Forming Part of Policy Effective Date of Endorsement Named Insured 0100045859-0 12/30/2016 12:01AM at the Named Insured Method Construction Inc address shown on the Declarations Additional Premium: Return Premium: $0 1 $0 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person(s)or Organization(s) Location and Description of Completed Operations Blanket,as required by 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 desig- nated and described in the schedule of this endorse- ment performed for that additional insured and in- cluded in the"products-completed operations hazard". ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. CG 20 37 07 04 0 ISO Properties, Inc.,2004 Page 1 of 1 POLICY #0100045859-0 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PRIMARY AND NON-CONTRIBUTORY ENDORSEMENT Attached To and Forming Part of Policy Effective Date of Endorsement Named Insured 0100045859-0 12/30/2016 12:01AM at the Named Insured Method Construction Inc address shown on the Declarations Additional Premium: Return Premium: $0 $0 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE ENVIRONMENTAL CONTRACTING AND PROFESSIONAL SERVICES LIABILITY COVERAGE PRODUCTS POLLUTION LIABILITY COVERAGE The insurance provided to Additional Insureds shall be primary and non-contributory with respect to any other valid and collectible insurance available to the Additional Insured,provided that the written contract specifically requires that this insurance apply on a primary and noncontributory basis. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. CAS5003 0110 Page 1 of 1 POLICY #0100045859-0 THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHER TO US-BLANKET Attached To and Forming Part of Policy Effective Date of Endorsement Named Insured 0100045859-0 12/30/2016 12:01AM at the Named Insured Method Construction Inc address shown on the Declarations Additional Premium: Return Premium: $0 1 $0 This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE SECTION IV—CONDITIONS,8.Transfer of Rights of Recovery against Others to Us is amended by the addition of the following: We waive any right of recovery we may have against persons or organizations because of payments we make for injury or damage arising out of"your work" done under a written contract with that person or organization wherein you have agreed to provide this waiver. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. CAS4002 0110 Page 1 of 1 METHO-1 OP ID: RY ,a►c'e�Ro. CERTIFICATE OF LIABILITY INSURANCE PATE(MMIDDrrrM ��. 10124120.17 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE:POLICIES BELOW. THIS CERTIFICATE OF INSURANCE ,DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) 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: Veronica"Roni" Castro The J. Morey Co., Inc. PHONE FAX License #0655907 wN No Ext:408-280-5551 (Arc No): 408-280-:1368 184 Jackson Street EMAIL ADDRESS: San Jose,CA 95112 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:West American Insurance.Co. INSURED Method Construction, Inc. INSURER e:Midwest Employers Casualty Co. P.O. Box 2702 INSURER C Gilroy,CA 95021 : INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 1 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM'OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR SD WVD POLICYNUMBER MMIDD MM/DD COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ D AGE TO RENTE7 CLAIMS-MADE17 OCCUR PREMISES Ea occurrence $ MED EXP{Any one person) $ PERSONAL&`ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident 1,000,00 A X ANY AUTO BAW581.97122 08/05/2017 08/0512018 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTO S AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER B ANY PROPRIETORIPARTNER/EXECLrnVE Y!N BNUWC0137522 08/01/2017 08/01/2018 E.L.EACH ACCIDENT $ 1,000,00 OFFICERIMEMBER EXCLUDED? N!A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is.required) Re:All work in the public right-of-way at 400 Campbell Avenue, Campbell, CA 95008. Note: Only the authorized-representative can issue or modify this certificate of insurance which is effective on the date shown.. CERTIFICATE HOLDER CANCELLATION CITCA02 SHOULD ANY OF THE ABOVE DESCRIBED'POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE. WILL' BE DELIVERED IN City of Campbell ACCORDANCE WITH THE POLICY PROVISIONS. 70 North 1 st Street 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 POLICY NUMBER: BNUWC0137522 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed.04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT CALIFORNIA(Blanket) We have the right to recover our payments from anyone liable for an injury covered by this policy.We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 0.020000 %of the California workers'compensation premium otherwise due on such remuneration. Schedule State Description CA Any party with whom the insured agrees to waive subrogation in a written contract. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Date: . Policy Number: BNUWC0137522 Endorsement No.: Insured Name: Method Construction,Inc. Insurance Company: Midwest Employers Casualty Company Countersigned 6y Ali L' ✓ S udl® i 1230...mead Pke B 303 ]J09BJ]n�yaafe08' 6.2996 I�FIRE SPRINKLER 1 �iAIA49AM1'` EXIT �J nlob�wd z,et k'RODN RETAIL AREA T S ` HALLWAY - Y WAITING AREA r STORAGE i, I -� / NN [[ Q�Q[ i V r L ME R00N iEsTR00N RECEPTION 1 i'�_ ..I1.TT 1 .�,7 ' }'NkA If I' Mobn n�n i ENTRY x jI I i t —i= ® ncl�n//Qq `.:'BAR ARE, no1 III' �_ — - �I Q o❑ o {f Z a f� Q UJ MnD J PROPOSED 1ST FLOOR PLAN 1 /16", 2 nn�nnnn Q Q I• I f ;: � (� � o r-- I` ST�I WA4 E%li O].26.16 ISG'JE1 FOR PLAN CHECK A / i HALLWAY 7c,,, PL ON ANNIVG CVENTSL INE UNISDINING ARFAh x z -1t _ DINING AREA DINING ROOM OPEN TO BELOW 1 L.ill� PROJEC-_10.:12-4630 ICI .� BAA sERV¢E dRE�- - —-- —— ;LIVE ENTEAiAINNENT' r1 �— STAGING AR EA s?GTu� .- - T PROPOSED FLOOR PLANS I I I r'-. A 1.0 FLOOR PLAN LEGEND y PINBALL MACHINE "- ARCADE MACHINE � .�' HIGH TOP TOTAL=4 pp = O (E)COLUMN TO TOTAL 3 T TAL-18 REMAIN I.#3 EGULAR TABLE 'm _.. ���yyyggqj E FSR \ ! („ HALLWAY 0 0d10 c 1nD eeemcea R 3O3 055 PROVIDE MIN 44 CLEAR ASLIE SPACE THRU OUT y �'n lo6s40 2.nel 4 }. (E)STORAGE ('} [�'`^�`�,�� 1 F'� i ('^s ('"` V 7l -e, i - { WONEN'S ,a' �P,• - ril }.. ..1.,..'� i Q-(..4 �� �-'t,-_I. LI r � 1.:..4 0 �k?.11 L I� 1fi0 I`- _ (E)STAIR TO a'. � t( D1 MENS 17 "' IENCL09U E � PROJECT AREA S.M.,+, C I I t1 TI �� � Ii '. Q ; a O eIk❑ i o OoC 1 LIQUOR DINING ORYFOOD STORAGE I I fl 130 .. ; 190 i .M 8 ti5 t L(E)WHEELCHAIRIFT 2ND STAIR TO .... .. _I. �_ : w4 - BAP O' O S LS & ORDERING a 140 / e KIT'OEN rE) AIR TO . . � .� R \ nln LJ 2a i�_ �I a Y®, a tJ❑ � - Ir� � DO Q Q (E)BUILDING WALL na PROPOSED LAYOUT PLAN 1/4" 1 nnn V (E)103'-2" LJ (E) 18'-5- (E)84'-9' O '=:-ia<w .,.S,.+I4'e4 _.. S ,'$.S; 3e& s .•x�`.fit $s ,is t 4, t.z`Fxa.o s'sia ..'L.>`- „5 nz_ WA �n-.. i.r g p � 09.09.16 ISSUED FOR C.U.P.APPUCADON E%IT 41 1 £< - _ __ WALL SCHEDULE� \ 1 O " •i ENLARGED PLAN 'ENLARGED PLAN dx NEW FULL-HEIGHT WALL OCC MAXIMUN OCCUPANT LOAD SIGN A (SEE 1/A7.3 FOR DETAIL) ISq PROVIDE INTERNATIONAL I I EXIT TO EXIT 0 NEW PLUMBING FURRED J SYSMOL OF ACCESSIBILITY AT I - WALL 16'ABOVE T.O. THIS LOCATION.SEE 4/AO.1 '? COUNTER. FOR REQUIREMENT .I 0 EXISTING BUILDING WALL E%IT TACTILE SIGN WORDING.REFER TO A0.1 n j e •i 'SIGNAGE/BRAILLE'.PER SEC 1011.4 4'-11' 5'-0' • 6-1' 1 A{A m 34'-2" A60 10'-0" 1 7 n C 3at6 ISA OCC � 7• 2' S' 3' 7" 3' 0" 4' 11• t fi PROJECT NO.:16-5470- vl Id ie,1 /y; - e\ FLOOR PLANS x •i I 29-4"OPEN BELOW TO FIT BACKBAR EQUIPMENT 9-0'UNDERCOUNTE (E)25' 2' 8'-7' 1-' PROVIDE d'CON C PLATFORM WITH QUARRY TILE FINISH 4.-9- SHELVING 25'-3" A1.0 OPEN BELOW i DIMENSIONED FLOOR PLAN 1/4" 2 COPrfi(cHT;�2o}��.s umQ 02,Inc. - _:LI:W4Au_..JY i '- ZN0 FLOOR TOTAL FLOOR AREA= 3.178.22 SF TOTAL OCCUPANT LOAD FOR 2ND FLOOR=31 PPL I EXIT _ udio O 1i 0°4m e°tl 0. .........._. ._............ sunnrinle. 9US i 730.BB77 (nn 4p. 6.2996 W MEN' ' MEN'S Lu ' t � OPEN OFFICE Lgu a.. i a � Q o � o CC J 1 W Q v L c moo = PROPOSED 2ND FLOOR PLAN - TOTAL OCCUPANCY = 31 1/4" 2 1ST FLOOR TOTAL FLOOR AREA 3,189.40 5F OCCUPANCY O COMMON LOBBY=38 PPL OCCUPANCY IN RECEPTION AREA=30 PPL UJ OCCUPANCY IN RESTAURANT= 100 PPL _ TOTAL 1ST FLOOR OCCUPANCY= 168 PPL �� co........ ___-_____--_ FIRE SPRINKLER TYa'r'� '.`*? Kal L..�. F=..0 L..ct G 5 .. iR00M ''�'' �' . ._t; x...a 1 �m?w:.. EXIT i i 11i ra .,ll .._.. Y -_....__ il.. fjALLWAY ..... - -j-- - ISSUED FOR PUNN . 07.06.13 0 LNG 09.01.16 PUNNING REVISION .— ,.}., WOMEN'SI MEN S IIID JilE y_ D L�T�ENTRY ti ..., •• - — --LOUNGE AREA- — k ' m f � � T 1 � ._) COMMON LOBBY { RECEPTION DESK Lzl -= DATE:07.D6.13 t flT 71 1"1 PROJECT NO.: 12-4330 It 7- ' •+ o 0 - ` A PROPOSED FLOOR PLANS -' a-D NAI LNG AR REA _ I KITCHEN ELECTRICAL EXIT PROPOSED 1ST FLOOR PLAN - TOTAL OCCUPANCY = 168 1/a" 1 CAPYRicdT�2a15`.'S7 DIO o2,Inc. Ref.undable Deposit Check Request , •� To Finance Di�ecttir - - � ;� � - . Check Fajrable To Larry Schaadt : ....... Address Line,4 - . Line. City State: CA 'Zip _ Description: 400'E. CampbellAve Accouiafi Nurnbet }- 1,01,2203 Amount $5,000 00. ; Account'Number 1012203 Arnount Account Number 101 540 7448 ' Amount (Finance Depf.only,)' 7nterestEarned ,(Fin nte'Dept on Total'.Payable (E . t> xact Amoun ) Purpose 400E Campbell Ave.FPS refund = Kermit#: . ,'ENC2016-001'49- Rece pt-# 265221 Date:.` 814/2016 Receipt-# ' Date Requested byr Title Inspector Date � ( h ' Approved byTitle Sr.,;Engmeer Date i Roger Stgiz d , Finance'Dept Only Verified by.. ;.._ Title Accounting,lerk.11; Date I.Approved,by ,Title Accountant bate-. a Special :Instructions :For Hanidlinc� Check i v. IYlall'F1S IS' Mell InAttat:netl Envelope interim uneCK "- i Needed By Return Yo - JoAnna Thomason Public or77 (Name) (Department) Y ' Othei^ Please return check to JoAnna _ .. i TO BE RECORDED WITUOUT FEE SECTION'➢}{R ,QUIS'r OFR CINMF TY Of AlytpOBELL DE 23324373 Santras a Clara County — Clerk—Recorder Recording Requested By: ) 12/12/2017 08:05 art City of Campbell CONFORMED COPY 70 North First Street Campbell, CA 95008-1423 ) Copy ynof ot been ent reedrwith original. Hasar After Recording Return To: ) City Clerk ) City of Campbell ) 70 North First Street ) Campbell, CA 95008-1423 ) APN: 412-07-038 (Space Above for Recorder's Use Only) Address:400 E. Campbell Avenue, San Jose, CA 95008 AGREEMENT FOR PRIVATE IMPROVEMENTS IN THE PUBLIC RIGHT-OF-WAY In consideration for granting permission to construct improvements in the public right-of;-way, THE L.E.S. TRUST (property owner) enters into this Agreement with the City of Campbell. The improvements contemplated under this permit are for the benefit of the real property commonly known as 400 E. Campbell Avenue. The City of Campbell grants such permission to install four (4) decorative uplights within the public sidewalk under Encroachment Permit No. ENC2016-00149. All conditions of Encroachment Permit ENC2016-00149 remain in full force and effect. The property owner shall be solely responsible for maintaining the improvements in a good and safe condition at all times; and the property owner shall indemnify, defend, and hold harmless the City of Campbell, its officers, officials, agents, volunteers, employees and attorneys from any and all claims, actions, losses, liabilities and costs (including reasonably incurred attorney's fees) arising out of or connected with, or alleged to.arise out of or be connected with the installation, design or condition of the improvements, except for any claims, actions, losses, liabilities and costs proximately caused by the sole negligence or willful misconduct of the City of Campbell, its officers, officials, agents, volunteers, employees or attorneys. This provision is intended to be the dispositive of all rights of indemnity and contribution between the parties, and property owner waives and releases any and all rights to indemnity or contribution from the City of Campbell, in law or equity, arising out of, or connected with any and all claims, actions, losses, liabilities and costs (including reasonably incurred attorney's fees) for which property owner is obligated under this paragraph to provide indemnity or defense to the City of Campbell, its officers, officials, volunteers, employees or attorneys. The City, in its sole discretion, may revoke the rights granted under Encroachment Permit No. ENC2016-00149 and remove the improvements installed under Encroachment Permit No. ENC2016- 00149 at any time, without liability to the property owner, or require that the improvements be removed, and property owner shall have no right to compensation from City in any form. In the event that Owner fails to reimburse the City for the costs of removing the improvement ("default") as required by this Agreement, the City shall have and may execute the absolute right, at the City's option and without demand or notice to Owner, to claim and impose a lien, attached as Exhibit A JALandDevToimsU AGREEMENTS-PIA SIA DEF SIA Maintenance Reimbursement DevelopmentTrivate Improvements Agreements in ROW\Word Document\Campbell E 400.docx Page 1 of 5 and incorporated herein by this reference ("Lien"), on said real property (also referred to herein as "Collateral"). City's failure to exercise this option will not constitute a waiver of the right to exercise it in the event of any subsequent default. (a) Amount of Lien: The Lien shall be for the entire amounts then owing under this Agreement. (b) Recordation: City is authorized to record the Lien in the appropriate Recorder's Office(s). (c) City shall have full authority to perform all acts and things that City may consider necessary or advisable to impose, maintain and enforce the Lien. (d) Debtors' Warranty: OWNERS WARRANT that they axe the owners of the Collateral and Owners have the right to make this Lien Agreement. (e) Debtors Covenants: Owners agree: (i) To pay City all amounts payable pursuant to this Agreement on or before the due date when due and payable, and to perform all terms of this Agreement; (ii) To defend the Collateral against claims and demands of all persons and entities; (iii) To keep the Collateral in good condition; to perform other acts that may be necessary to preserve the Collateral and protect the Collateral against unreasonable loss and all hazards, and; (iv) To immediately notify the City in writing when Owners become aware of any event that substantially affects the value of the Collateral, or the rights and remedies of City in relation to the Collateral. (f) Prohibitions: Without the prior written consent of the City, Owners will not permit any liens or security interests (other than the City's Lien) to attach to the Collateral; permit the Collateral to be levied on under legal process; dispose of the Collateral; or permit anything to be done that may impair the value of the Collateral or of the Lien, which is the subject of this Agreement. (g) Notices: Any notice, demand or request required hereunder, or by law, shall be given in writing(at the addresses set forth below) by any of the following means: (a)personal service; (b) facsimile; (e) overnight courier or delivery service; or (d) registered or certified, first class U.S. mail, return receipt requested. J:iLandDev\F0rms\2.AGREEMENTS-PIA SIA DEF SIA Maintenance Reimbursement Development\Private Tmprovements Agreements in ROMword Document\Campbell E 400.docx Page 2 of 5 Property owner agrees to maintain homeowners or general liability insurance with a limit of at least$100,000 for damages arising from the installation, design or condition of the improvements. This provision shall run with the land and be binding on the property gwner's successors. Executed this day ofP« 7 - , 2017. T13E L.E.S_, Larry chaadt, Trustee �— (Attach Notary Acknowledgment For All Parties) CITY OF CAMPBELL, a municipal Corporation Todd Capurso Public Works Director,City of Campbell ATTEST: Wendk, City Clerk J:\LandDev\Forms\2.AGREEMENTS-PIA SIA DEF SIA Maintenance Reimbursement Development\Private Improvements Agreements in ROW\Word DocumentlCampbell E 400.doex Page 3 of 5 Exhibit A Recording Requested By: ) City of Campbell ) When Recorded Mail To: ) City Cleric ) City of Campbell ) 70 N. First Street ) Campbell, CA 95008 ) APN: Space above this line for Recorder's use only Address: CLAIM OF LIEN 1, Todd Capurso, Public Works Director for the City of Campbell, a California Municipal Corporation ("City"), do hereby certify: A. On or about , 20 ("Debtors") executed an Agreement for Private Improvement with the City of Campbell ("Agreement"). B. The Agreement was recorded in the Santa Clara County Recorder's Office on or about 20_Document Nurnber C.. The Agreement allowed the Debtor's to provide, construct, and/or install certain private improvements in. front of their property at , Campbell, California, at their own costs and. expense. Pursuant to the terms of the Agreement, the Debtors expressly agreed that if they failed to comply the work the Agreement, the City was authorized to remove said improvements and recover the full cost and expense thereof from the Debtors or their successors. . D. The Debtors did not remove the improvements after, being notified to do so. Therefore, the City removed said improvements. E. In , 20 , the City informed the Debtors about the improvements that would be removed pursuant to the Agreement. F. The City subsequently completed the work. On or about , 20_, the City sent the Debtors an invoice for said work in the amount of$ G. Pursuant to the terms of the Agreement, the Debtors expressly agreed that the City is authorized to, at the City's option and without demand or notice to the Debtors, immediately claim and impose a lien on the real property commonly known as , Campbell, California, APN Number , for the entire amounts then owing under, or incurred pursuant to, the Agreement, including without limitation, the entire unpaid principal amount. J:\LandDev\Forms\2.AGREEMENTS-PIA SIA DEF SIA Maintenance Reimbursement DevelopmentTrivate Improvements Agreements in ROW\Word Document\Campbell E 400.docx Page 4 of 5 WHEREFORE, the City of Campbell; A California municipal corporation, pursuant to the Agreement, hereby claims a lien upon the work of improvement and the land upon which it is situated, namely, the real property commonly known as , Campbell, California, APN Number , in the amount of $ and said amount shall constitute a lien against said property until paid in full. IN WITNESS WHEREOF the City of Campbell, California, a California Municipal Corporation, has duly authorized the undersigned to execute this instrument in its name. Dated: By: for the CITY OF CAMPBELL, a California municipal corporation (Notary Acknowledgement Required for Signatures) DLandDevlFormsU AGREEMENTS-PIA SIA DEF SIA Maintenance Reimbursement DevelopmentTrivate Improvements Agreements in ROW\Word Document\Campbell E 400.doex Page 5 of 5 ACKNOWLEDGMENT A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of SANTA CLARA On 1,2�d$/�� before me, MEKIALA RAE TORREZ, NOTARY PUBLIC (insert name and title of flie officer) personally appeared 4 — who proved to me on the basis of s tisfacto y 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. !` m MEKIALA RAE TORREZ t' WITNESS my hand and official seal. ""`' Commission #2139486 •�: Notary Public-California z F; Santa Clara County r A My Comm: Expires Jan 8, 2020. , Signature its,& 10,64 (Seal) >CALIFORNIA ALL--PURPOSE NACKNOWLEDGMENT a.� � CIVIL CODE 1189 ti5..i+ i�a�..YF�u�'+V1ti»i..�y.1�:��vm•!t_ ���.,t N�iiY�]'vn _Y1 �;}yK y+,yyr. .... f{�r/ ,��.y . •'q��,{2, �t Jfi'R'iv y v'34aZ+JotiYt±'J+"a.�'h 347�'v� 3/•_ LT4��}(i3+i: K'Jili'[��LY�Cn1V.yut:�a'�'alS1"t'YU[�.fA��.�F. -i�S4�Y'y � A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document. State of California l County of �r •" �. �� �� On \ ?-) (before me, Date _ Here Insert Name and Titik of the Offic r personally appeared Nome(s)'df Signer(s) who proved to me on the basis of satisfactory evidence to be the person(s)whose name(s) is/are subscribed to the within instrument and acknowledged to,me that he/she/they executed the sarr.e 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 JOANN THOMASCN laws of the State of California that the foregoing " ' Commission#2110789 a -eri Notary Public-California n. paragraph is true and correct. z ` . •® Santa Clara County WITNESS.my hand and official seal.. My Comm,Expires May 9,2019. _ Signature Place Notary Seal and/or Stamp Above Sign ure of Notary Public OPTIONAL Completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title or Type of Document: -(Z Document Date: Number of Pages: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: Signer's Name: ❑ Corporate Officer-Title(s): ❑ Corporate Officer- Title(s): ❑ Partner- ❑ Limited ❑ General ❑ Partner- ❑ Limited ❑ General ❑ individual ❑ Attorney in Fact ❑ Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian of Conservator ❑ Trustee ❑ Guardian of Conservator ❑ Other: ❑ Other: Signer is Representing: Signer is Representing: i'`x,.,3'7:''vu=Ei:;' .�:st. .^.k``w;'.' _sS,:FB'.t�� U" '.:?C:.';.k"? ?. is. �[ `c'':a1x`:14'b+2�',�..'Y'r.rLli`• �r c f �..-x : 02017 National Notary Association CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit*: ENC 2016-00149 Name: Larry Schaadt Property Address: 400 E. Campbell Ave. Date of Final Inspection: On File: Bonds CD Cash Labor and Material: Construction Cash Deposit to be released: Faithful Security Deposit: $5,000.00 Other overdue deposits to be released (Description): Processed by: Administrator Reviewed by: 12-M f -7 Inspector Reviewed by: Nil--s Land Development Engineer , I JAJoAnnaT\Deposit refunds\CHECKLISTS\Campbe11400..doc(Rev. 10/11) Encroachment Permit Final Sign Off Encroachment Permit# 94C Address: LtvU C/Wd? r--LL � Date of Final Inspection and Acceptance: t� 'Inspected by: w OK to release deposits: 100% 75% Comments'. Syed Wahidi From: Amy Olay Sent: Friday, February 17, 2017 8:25 AM To: Syed Wahidi; Roger Storz Subject: RE: Uplighting in the ROW? Let's not sign off on it just yet. If there were already two lights on public ROW,any reason why we shouldn't allow two additional?Since the work was done without permit,we could ask them to remove but is that reasonable in this scenario. My concern is that the plans are incorrect in that they are missing information.Also, since these lights are on public ROW, who is responsible in maintenance, ie, where's the maintenance agreement. We should regroup on this today. Amy C. Olay, PE City Engineer City of Campbell Public Works Department 70 N. First Street Campbell, CA 95008 Office: 408.866.2150 1 Fax: 408.376.0958 amyo@cityofcampbell.com -----Original Message----- From: Syed Wahidi Sent: Friday, February 17, 2017 8:03 AM To: Roger Storz;Amy Olay Subject: RE: Uplighting in the ROW? Fyi, the permit is not closed out yet. Meaning, we gave occupancy but not officially signed off/accepted the project yet as it was sitting on JoAnna's desk to be closed out. Syed Wahidi I Public Works Inspector City of Campbell I Public Works Dept. syedw@cityofcampbell.com s 408.866.2165 1 (408.376-0958 70. N. First Street I Campbell, CA 95008 www.CityofCampbell.com -----Original Message----- From: Syed Wahidi Sent: Friday, February 17, 2017 7:59 AM To: Roger Storz;Amy Olay Subject: RE: Uplighting in the ROW? Found plans but they don't show old or new lights. After talking to contractor who installed sidewalk,the lights in r.o.w were always there and they just changed the fixtures before pouring concrete and taped them to protect concrete splatter. And that's why probably got overlooked during inspection. i Old Google pics confirm that there were two existing lights in r.o.w and definitely two more added in this project. Syed Wahidi I Public Works Inspector City of Campbell I Public Works Dept. syedw@cityofcampbell.com s 408.866.2165 1 (408.376-0958 - 70. N. First Street I Campbell, CA 95008 www.CityofCampbell.com -----Original Message----- From: Syed Wahidi Sent:Thursday, February 16, 2017 3:55 PM To: Roger Storz;Amy Olay; Doris Quai Hoi Subject: RE: Uplighting in the ROW? I found the encroachment permit file (ENC 2016-149) but the plans are not in it. Contractor says these lights were always there and they just changed the fixtures before pouring concrete. Google earth shows two lights were there in public right of way for years. Apparently they added two more in the r.o.w. Doris, can you please retrieve plans from LD files? Syed Wahidi I Public Works Inspector City of Campbell I Public Works Dept. syedw@cityofcampbell.com s 408.866.2165 1 (408.376-0958 70. N. First Street I Campbell, CA 95008 www.CityofCampbell.com -----Original Message----- From: Roger Storz Sent:Thursday, February 16, 2017 2:53 PM To: Daniel Fama;Todd Capurso; Syed Wahidi; Amy Olay Cc: Reina Antonio; Cindy McCormick; Doris Quai Hoi Subject: RE: Uplighting in the ROW? Daniel,these lights were installed in the right-of-way without a permit. No one spoke with Public Works about placing these lights in the public right-of-way. At this point we would like them removed and the right-of-way restored. Thank you, Roger Storz, PE City of Campbell (408) 866-2190 (direct) rogers@cityofcampbell.com Land Development Website -----Original Message----- From: Daniel Fama Sent:Thursday, February 16, 2017 9:59 AM 2 To: Roger Storz;Todd Capurso; Syed Wahidi Cc: Reina Antonio; Cindy McCormick Subject: RE: Uplighting in the ROW? There is no approval for the lighting in the ROW as far as I'm aware. However,there's a long history with this property and I don't know what may have been discussed in the past before I was involved. In any event, as I mentioned earlier, is it possible to legalize this with a private improvement agreement?This'is a great feature that will highlight this very important building. -----Original Message----- From: Roger Storz Sent:Thursday, February 16, 2017 8:26 AM To: Daniel Fama;Todd Capurso; Syed Wahidi Cc: Reina Antonio Subject: RE: Uplighting in the ROW? Do we have any approvals for this? Historic Downtown building, shouldn't there be some type of review and approval for this type of element? You consider it a form of fagade improvement, at least when it is dark outside. Thank you, Roger Storz, PE City of Campbell (408) 866-2190 (direct) rogers@cityofcampbell.com Land Development Website -----Original Message----- From: Daniel Fama Sent: Wednesday, February 15, 2017 8:42 AM To:Todd Capurso; Roger Storz; Syed Wahidi Subject: RE: Uplighting in the ROW? It is 400 E. Campbell Avenue. Can the property owner execute a private improvements in the ROW agreement to allow the lighting. If any building should be uplit, it's this one. -----Original Message----- From:Todd Capurso Sent:Tuesday, February 14, 2017 4:48 PM To: Roger Storz; Syed Wahidi; Daniel Fama Subject: Re: Uplighting in the ROW? Looks like the Grower's Bank building. Is that 400? Todd Capurso Public Works Director City of Campbell Original Message From: Roger Storz Sent:Tuesday, February 14, 2017 4:45 PM 3 To:Syed Wahidi; Daniel Fama Cc:Todd Capurso Subject: FW: Uplighting in the ROW? Is this at 400 E Campbell Ave? Thank you, Roger Storz, PE City of Campbell (408) 866-2190 (direct) rogers@cityofcampbell.com Land Development Website -----Original Message----- From: Todd Capurso Sent:Tuesday, February 14, 2017 4:36 PM To: Cindy McCormick; Roger Storz Subject: Fw: Uplighting in the ROW? Hello. Not sure who this is from, but it maybe worth looking at.Thanks. Todd Capurso Public Works Director City of Campbell Original Message From: Dawn <gonedawning@yahoo.com> Sent:Tuesday, February 14, 2017 4:16 PM To: Cindy McCormick;Todd Capurso Subject: Uplighting in the ROW? This is new.... Were you all aware that uplighting was being installed within the PROW? 4 METHO-1 OP ID:VC CERTIFitoHTE OF LIABILITY INSURAN%,� DATE 07/2s1201 YY) 7/22o1s Tq�s�ERTIFICATE 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 MISSION COUNTIES INS AGCY INC NAME: Veronica Castro License#0544474 A/CNN Ext.408-979-8160 A/c No):408-978-6801 P O Box 6717 E-MAIL SAN JOSE,CA 95150 ADDRESS: Veronica Castro INSURERS AFFORDING COVERAGE NAIC# INSURER A:Catlin Specialty Ins.Company INSURED Method Construction, Inc. INSURER B:Liberty Mutual Ins.Co. P O Box 2702 INSURER C:Midwest Employers Casual Co Gilroy,CA 95021 — INSURER D:TOPA Insurance Company INSURERE:American Zurich Ins.Co. INSURER F: T —1 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT DR 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. ILTR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP IN SD I MD POLICY NUMBER MM/DD/YYYY)I(MMfDDIYYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00d CLAIMS-MADE OCCUR X X GLS905086-1216 12/30/2015 12/30/2016 DAMAGE ( RENTED PREMISESS Ea 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 POLICY FX]PRO-- ❑ LOC ECTPRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,OOd,OdU B X ANY AUTO X X BAWS6780305 08/05/2016 08/0512017"BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 D X EXCESS LIAB CLAIMS-MADE X16607596 12/30/2015 12/30/2016 AGGREGATE $ 5,000,000 DED I X I RETENTION$ 0 $ WORKERS COMPENSATION _ AND EMPLOYERS'LIABILITY X STATUTE ER H C ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N X BNUWC0137522 08/01/2016 f)870s1lZ01'7 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in If yes,describe under E.L.DISEASE-EA EMPLOYEEJ $ 1,000,000 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 It more space Is required) / All work in public right-of-way.The City of Campbell, its officers �� S employees and volunteers are named as additional insured as respects liability per CG2010 0413 form. J CN CERTIFICATE HOLDER CANCELLATION CAMPCIT 'v SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE' WILL BE DELIVERED IN City of Campbell ACCORDANCE WITH.THE POLICY PROVISIONS. 70 N. 1 st Street Campbell,CA 95008-1039 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ° ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD METHO-1 OP ID:VC DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE oE(MMID IYY 16 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 CONTACTNAME: Veronica Castro MISSION COUNTIES INS AGCY INC ✓p y PHONE 408-979-8160 FAX c No:408-978-6801 License#0644474 ✓ A/c No Ext P 0 Box 6717 ADDRIESS: SAN JOSE,CA 95150 �F Veronica Castro y f INSURER(S)AFFORDING COVERAGE NAIC# G- INSURERA:Catlin Specialty Ins.Company INSURED PMethod O Box 2702truction,lri \�\S' 'a'�\�t\ INSURER 8:Liberty Mutual Ins.Co. Gilroy, 2 02 V�pC�s P INSURERC:State Comp Ins Fund INSURERD:TOPA Insurance Company INSURER E:American Zurich Ins.Co. INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFF POLICY EXP IN R TYSR PE OF INSURANCE AD p U p POLICY NUMBER MMIDDIIYYYY MM DDNYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR X X GLS905086-1216 12/30/2015 12/30/2016 PREMISES Ea occurrence $ 300,000 MED EXP(Any one person) $ 5,000 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JERCOT- LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident B X ANY AUTO X X BAW56780305 08/05/2015 08/05/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 D X EXCESS LIAB CLAIMS-MADE X16607596 12/30/2015 12/30/2016 AGGREGATE $ 5,000,000 DED I X I RETENTION$ O $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE YIN X 9065163-15 08/01/2015 08/01/2016 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 E Builders Risk ER0938617 07/05/2016 01/05/2017 500,000 $2500 De DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) - City of Campbell, its officers,employees and volunteers are named as additional insured.The insurance coverage afforded to the additional insured is primary insurance.All work in the public right-of-way at: 400 Campbell Ave,Campbell,Ca 95008 CERTIFICATE HOLDER CANCELLATION CAMPCIT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Campbell ACCORDANCE WITH THE POLICY PROVISIONS. 70 N.First Street Campbell,CA 95008-1039 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD i I 4 POLICY NUMBER:GLS-905086-1216 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 i 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: I COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Locations Of Covered Operations Blanket as per written contract. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following additional organization(s) shown in the Schedule, but only exclusions apply: with respect to liability for"bodily injury", "property This insurance does not apply to "bodily injury" damage" or "personal and advertising injury" pp y y or caused, in whole or in part, by: "property damage occurring after: 1. Your acts or omissions;or 1• All work, including materials, parts or equipment furnished in connection with such 2. The acts or omissions of those acting on your work, on the project (other than service, behalf, maintenance or repairs) to be performed by or in the performance of your ongoing operations for on behalf of the additional insured(s) at the the additional insured(s) at the location(s) location of the covered operations has been designated above. completed; or However: 2. That portion of "your work" out of which the injury or damage arises has been put to its 1. The insurance afforded to such additional intended use by any person or organization insured only applies to the extent permitted by other than another contractor or subcontractor law;and engaged in performing operations for a 2. If coverage provided to the additional insured is principal as a part of the same project. required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 10 0413 ©Insurance Services Office, Inc.,2012 Page'I of 2 C..With respect to the insurance afforded to these 2. Available under the applicable Limits of i additional insureds, the following is added to Insurance shown in the Declarations; t Section III—Limits Of Insurance: whichever is less. I E If coverage provided to the additional insured is This endorsement shall not increase the required by a contract or agreement, the most we applicable Limits of Insurance shown in the will pay on behalf of the additional insured is the Declarations. amount of insurance: 1. Required by the contract or agreement; or j t i i Page 2 of 2 ©Insurance Services Office, Inc., 2012 CG 20 10 04 13 q I I POLICY NUMBER:GLS-905086-1216 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 I THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL - i INSURE® OWNERS, LESSEES O CONTRACTORS -® COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations Blanket as per written contract. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. Section II —Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III—Limits Of Insurance: with respect to liability for "bodily injury" or If coverage provided to the additional insured is "property damage"caused, in whole or in part, by required by a contract or agreement, the most we "your work" at the location designated and will pay on behalf of the additional insured is the described in the Schedule of this endorsement amount of insurance: performed for that additional insured and included in the "products-completed operations 1. Required by the contract or agreement; or hazard". 2. Available under the applicable Limits of However: Insurance shown in the Declarations; 1. The insurance afforded to such additional whichever is less. insured only applies to the extent permitted This endorsement shall not increase the applicable by law; and Limits of Insurance shown in the Declarations. 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. CG 20 37 04 13 ©Insurance Services Office, Inc.,2012 Page 1 of 1 i COMMERCIAL GENERAL LIABILITY CG 24 04 05 09 WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Blanket as per written contract. Information required to complete this Schedule, if not shown above,will be shown in the Declarations. The following is added to Paragraph 8.Transfer Of Rights Of Recovery Against Others To Us of Section IV—Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising 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 04 05 09 0 Insurance Services Office, Inc.,2008 Page 1 of 1 POLICY NUMBER: GLS-905086-1216 COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s): All Projects: Each construction project described in a separate written contract. if multiple construction projects are grouped together under one written contract, all such projects will be considered one project and subject to a single general aggregate limit for that contract. Designated Construction Project General Aggregate Limit-As shown in the Commercial General Liability Declarations, SAGL 001 0208. General Aggregate for All Projects Combined-$5,000,000, Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. For all sums which the insured becomes legally 3. Any payments made under Coverage A for obligated to pay as damages caused by 'occur- damages or under Coverage C for medical rences" under Section I-Coverage A, and for all expenses shall reduce the Designated Con- medical expenses caused by accidents under struction Project General Aggregate Limit for Section I - Coverage C, which can be attributed that designated construction project. Such only to ongoing operations at a single designated payments shall not reduce the General Ag- construction project shown in the Schedule gregate Limit shown in the Declarations nor above: shall they reduce any other Designated Con- t. A separate Designated Construction Project struction Project General Aggregate Limit for General Aggregate Limit applies to each des- any other designated construction project ignated construction project, and that limit is shown in the Schedule above. equal to the amount of the General Aggregate 4. The limits shown in the Declarations for Each Limit shown in the Declarations. Occurrence, Damage To Premises Rented To 2. The Designated Construction Project General You and Medical Expense continue to apply. Aggregate Limit is the most we will pay for the However, instead of being subject to the sum of all damages under Coverage A, ex- General Aggregate Limit shown in the Decla- cept damages because of "bodily injury" or rations, such limits will be subject to the appli- "property damage" included in the "products- cable Designated Construction Project Gen- completed operations hazard", and for medi- eral Aggregate Limit. cal expenses under Coverage C regardless of the number of: a. Insureds; b. Claims made or"suits"brought; or c. Persons or organizations making claims or bringing"suits". CG 25 03 05 09 ©Insurance Services Office, Inc., 2008 Page I of 2 B. For all sums which the insured becomes legally C. When coverage for liability arising out of the obligated to pay as damages caused by "occur- "products-completed operations hazard" is pro- rences" under Section I -Coverage A, and for all vided, any payments for damages because of medical expenses caused by accidents under "bodily injury" or "property damage" included in Section I - Coverage C, which cannot be attri- the "products-completed operations hazard" will buted only to ongoing operations at a single des- reduce the Products-completed Operations Ag- ignated construction project shown in the Sche- gregate Limit, and not reduce the General Ag- dule above; gregate Limit nor the Designated Construction 1. Any payments made under Coverage A for Project General Aggregate Limit. damages or under Coverage C for medical D. If the applicable designated construction project expenses shall reduce the amount available has been abandoned, delayed, or abandoned under the General Aggregate Limit or the and then restarted, or if the authorized contract- Products-completed Operations Aggregate ing parties deviate from plans, blueprints, de- Limit,whichever is applicable; and -signs, specifications or timetables,the project will 2. Such payments shall not reduce any Desig- still be deemed to be the same construction nated Construction Project General Aggre- project. gate Limit. E. The provisions of Section III Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. Page 2 of 2 ©Insurance Services Office, Inc., 2008 CG 25 03 05 09 i' I i THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. I I PRIMARY ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM This endorsement modifies insurance provided under form number CG2010 0413 to include the following: For any person or organization you have agreed in writing in a contract or agreement to add as an additional insured, the insurance afforded by this coverage part for that additional insured is primary insurance and we will not seek contribution from any other insurance available to that additional insured All other terms,conditions and exclusions remain unchanged. Schedule of Primary Additional Insureds: Blanket as per written contract. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: Policy No.: Endorsement No. Insured: Premium: Insurance Company: Authorized Signature: SAGL 403 0713 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 1 with its permission iNLvnjEMENT AGREEMENT iOKER COPY COMPENSATION WAIVER OF SUBROGATION REP 06 INSURANCE BLANKET BASIS 9065163-15 FUND RENEWAL NA HOME OFFICE 2-81-58-53 SANFRANCISCO EFFECTIVE AUGUST 1, 2015 AT 12.01 A.M. PAGE 1 OF 1 ALL EFFECTIVE DATES ARE AND EXPIRING AUGUST 1, 2016 AT 12.01 A.M. AT 12:01 AM PACIFIC STANDARD TIME OR THE TIME INDICATED AT PACIFIC STANDARD TIME METHOD CONSTRUCITON PO BOX 2702 GILROY, CA 95021 WE HAVE THE RIGHT TO RECOVER OUR PAYMENTS FROM ANYONE LIABLE FOR AN INJURY COVERED BY THIS POLICY. WE WILL NOT ENFORCE OUR RIGHT AGAINST THE PERSON OR ORGANIZATION NAMED IN THE SCHEDULE. THIS AGREEMENT APPLIES ONLY TO THE EXTENT THAT YOU PERFORM WORK UNDER A WRITTEN CONTRACT THAT REQUIRES YOU TO OBTAIN THIS AGREEMENT FROM US. THE ADDITIONAL PREMIUM FOR THIS ENDORSEMENT SHALL BE 2.00% OF THE TOTAL POLICY PREMIUM. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION BLANKET WAIVER OF FOR WHOM THE NAMED INSURED SUBROGATION HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS . WAIVER NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAANFRFRANCISCO: JULY 31, 2015 AUTHORIZED REPRESENT IVE PRESIDENT AND CEO 2572 SCIF FORM 10217 (REV.7-2014) OLD DP 217 INSURANCE REQUIREMENTS CHECKLIST Permit# CIP Project# Consultant/Contractor: `��L �/tc7� �i1 �5���)C��o✓� The following insurance is required of all consultants/contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment -Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: $1,000,000 per occurrence, and. ❑ $1,000,000 general aggregate limit applying separately to the project, or >'6 $2,000,000 general aggregate limit. >(, Policy expiration date �Z1,?�C',! I l0 Automotive Liability: ` , -"Any Auto" checked on certificate §41 $1,000,000 per accident for bodily injury and property damage E3,4-Policy expiration date Workers' Compensation and Employer's Liability ;4 Waiver of Subrogation clause $1,000,000 per accident for bodily injury or disease q� Policy expiration date_ "('5 -- `: i Course of Construction (if required in Special Provisions) Q lL ❑ Completed value of the project t ❑ Policy expiration date Required Endorsements to General Liability and Autornubile Liability Policies Additional Insured Endorsemnrt: The City, its officers, employees and volunteers are named as additional insured. 6,/(Reference Project Location/Permit Number) The insurance coverage afforded to the Additional Insured is primary insurance. ancellation area: Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company its agents or representatives". OR should say: ❑ Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. �d--Workers' Compensation Insurance Sheet Submitted For General Contractor ❑ For Developer or Owner J:\FORMS\Ternplates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 0214) Page 1 Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: � -\CL�'�-, NAIC# Rating: �� Authorized in CA: _fix Name: NAIC# Z3 OLt3 Rating: /X- ✓ Authorized in CA: i Name: 6 0.0 NAIC# Rating: ��'` Authorized in CA: e/ Name: NAIC#350 7f� Rating: Authorized in CA: .Campbell Business License # �-��D Expiration: 3 t Contractors License# �� Class:✓ Expiration: Insurance Certificate Reviewed ) Snitia� Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. 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I, V &rn � /� } -A- A A- A A A A A A A A A A A;�� �1A A A A rj��J�M�J A/ �_ A A . /��� L�1 Y e �C/�-� � �b � 1 ?//T /lJJ1ll//<GGr1ttJJnCC � A A 20 ( CGS ���� ? � _ j cp.� DR-A � � \1 �� Z � aCA , � OY u'�%V ls— kcvVc C���� LO �ilcz 1-ql J 5v oul