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ENC2015-00143 2015-.06-25 09:19 6613930897 6613930897 » 4083760958 P 1/2 l JUN 25 2015 Print Form Public Works,AdministrattorlPermitNla a'CYdF CAhMELLENCROACHNIENTPERMir P1EPT.OF PUBLIC WOftV$ (for working w! M the.public X'Ref.FP 70 North First Street right-or-way) Application Date �r5l 1 Campbeii,C.A 95ooR l Application Expiration Ua e Ph.(409)$66.21SO Issued 5 .�,._ APN �,,..T � ON t rT Par. (409)376495E 8 f 4-LI/l e, PemlltExpliatlon pate �= • AppUCA7idN,AppReatfon,ls hereby made fora Public Works Permit 1n accordance with Campbell Municipal Co ft Section t 1.0+4. (Ap0Ildatlan expires fl 5b9 . (6)months If the permit is not issued.Application Fee It non-refundable.) A. Work Addras or Tract @to: +� '� .. __ UtitityTrenchWcatlon: - L.�►�,�..«�1.�.._`��.r7�_+.. .....��C;� �:s ,.... .,......._� . 8 Nature of wank �'e� G �wt tr A. w�-PR%0 r C. Attlsch four(4)coptps of an engineered plan showing the IO ftrj and ement of the work,and(our(°Tooples of the preliminary Engineers (stlmate ofwotk The plans shall show the relation of the proposed wort to&Mhgi surface and underground Inrpravenierts.Whcq approved by the Cky!ngiriear,saidplan becomesa part of this permit. 0� All workshafleonformto the CRY o(CampbellStanoardSpedleadonsandbetailsforpdhlic woea(;bn$mCdon,*ft General P,grmltConditlons Wed on the revs"slde,and the Spada[Provisions fof this'permh,lWad below. Falfure to ablds by Ehese conditions and provWon$m ftY MM t( in jab shutdown a{1d/orfyrfelturo of fawwul perf aonce Sdrei6 and oath daposits.(Sae Gorsr rai Pensth CondlUans 1 and 2.) E ThoCantm=rMwthavethisperreitandappmyedp4nsattheskeandroustno*thePuWlcWorksDepartmentatleasttwedaysbefog starting,work,Nodeer�ustbegiventoPublicWori4catleastxlihDlu3beforeresWKing7tnywork. ' NemeOAPp(lGeirtt: Address•. Matt addrrss5 9 iWercq�tob\t •� 7MFtDUR EMEi�iEfacYPHaNE NUMOEIi: f0 d �•7� Is this work belltg done by the PmPeg dwttetrs d their ow residence?' YES No '" The A,ppilCant/Permktce hereby egrets by*Wng.thdr signature to this pcmtlrty hold the City of Campbell,Its ofAbers,agents,and employees fiat,safe 'and harmless fromanydalril•ordeng4d for d6magas resulting fromtheworkcoveredbythisOWL' " Ilia AppRrarWperinthea hereby ado+owledgcs that thay hale mad ond undermhd both the front and back of this permit,and they will,Inform their c*rrtrador(s)of tips Iefa madon. Applicant It,�dv[sad that upon(sswce of this permit proPotty owner, or property owner's duccgssor3 shall he,' responsible four any ona ati dtimog"arWA9 out'af tltlIdgn of any private improvements to the public r(ght-of-way. (Appllotnt Permirree) �Styml Cery (Contractor) • T (4'rint Noma} Date cp rt 'egi-IMST —1. Strm shall not be open cut forundogroundinSWllatlons.Minimum cutibcbeallowed for connections or exploration holes.Suchcut;mvbc .fBPC�t"Ilvaaeravetl,�pr�ht+!rJSp�`i„rlrerlartacultin_a. 2 Pavement may be"for undotground installations and must be restored In accordance with the5tandard Details Trench Restar tlon Method 'A.unless otherwise approved by ft Engineer. _3. -Work to be staked bye licanvs d land Surveyor otavil Englneera6d two(2)copies of•lre cut shRt'ts sent to the Publle Works Department bifoea stordrvg work ' 4. Per Section 4216 of the Govgmmartt Code this permit Is not valid for excavations until Underground Service Alert(USA)has been notified and the iTtqufry idertdleatlan number has bra entered hereon.USA Phone.1.0*227 2500. USA'ft0 Ci'NO ' _5. Prior to anywork the prop¢rty owner shall execute an Agreement for Pdvate Improvements in the Public Right-or-Way,which than be roconied •__6. Public;NotNication Requlrem@rrts• ,. C p a erwl(1rOt71t5 FEE SCNF,Q�,t f t"Ak CURRt?NT�,FEFS AMOUNT ' RECEI(ri NCI PERMIT APPUCATIONFIX S -•' 'r+9 ..^�`^,2�I GI PLAN Ct UK DEPOSIT S mcuRi y FOR 0AIY14FUL PERFDRMANCE&ASOit&MATCRIALS S CONSTRUC'190NCASHDEP05fT - PLAN CHECK&•1NSPECIt09 FM i e;M MENCY PERMff FEE APPROVED FOR ISSUANCE fo1 JAS C7hlof ah .3-0 '15 fke: ce 2x,1 —16 .re F' Yle+ 2015-06,-25 09:19 6613930897 6613930897 >> 4083760958 P 212 4 GENE$,gL POKE CON NUON5 I. AConstruetionCashDtposhlsrtsgotmd Chargc5wlQbemadeagaIM this&":iclfeliere Is,anamargenrycaliwut,overUmelnspecdonorwhonCity ordered barricading Is required.Anysuch costs Inexoass oftho doposir Will be billed to the parmittee, 2. A one-year maintenancee pariod and Simttyora required.Such period will begin on date orwrlttaaaccepram.bytho City. 1. Refund or thecash deposit balance and refund orcanCelli;don of the Faithful Podornwnco Suratywill be InlilbTed by the written acceptartea of the walk by the Clry. 4. Submit proJoctsdtadule Totten)days prior-to proposed ttartof work5pedal provlstons may be required for work within City facillties and downtown taardpbat. S. 'rho Permittee'must request In writing a tirtar mspccdon and acceptance of the work upon t ompledon,Acceptance by the City will be made In writing to the parmiitee. d, tttalnialnWepedestrianandvehicularcrossingsandfreeaccesstoprivatedriveways,busstops,ftrohydrsnis,andwatervaives. 7. A COMUCSIOn Traffic Control Plan and n Construction SChodute ale required for all lane closures,detours,and strvei closures.This plan must tm reviewed and approved prior to any Iona cto%urvs, 8 A ConitmWon Tmtfie Control Plan shell coo fr on to the CattransManual o(Traffie Controls for Con=;tlon and Maintenance Work Zones.dated 1990,avallable atColtrans.Traffk control equipment shall Include Type It flashing arrow signs it required. 2, Replace as dirmwd by the Oxy ftlneMrAnydamagodorremovedimprovementstoaccordancewithCityStandardsand5padflwdonsatthesose expanse of the.Pennirtee, , To. Sawcu t for all PCC or AC tomovals.All PCC removals sh all be to Vie nearest scoramarka rKI shall be doweled to eWsdila Improvements. 11, Pdorapprovbl of Inspector Is required for any work done after Tvannal witTIOng hour$.on weekand$or holIdAysind may require reirribursernot of lnipecdan costs as the current oveitimejute. ' 12. Adequate signing and bardeading Is required on the Job silo.Fallure to provide such 112nini)and barriradlnq may result in the Otis providing signing and barricades and charging thecost(Induding all labor and matorlais)against thetash do oslt 13. 4ompacdon testing or subgrade,base rock,a d ssohpltconaate by Permliteels required unless otherwisestawd by the Oty F,nglnter. 14. The Contractor or Parmitlee will haY*a,super-ASorl repreftnIA44 available for comw on the project at all t1mat during construction.corittacbror Pcrmlites shati provide a phone numberat which there can Ot contacit4 outside the hours 09:00.1mv.104,00 pm. 1s, Nostcragtofmotedolsorequlpmentwillbebllowednearthecdgeofpavement,thetraveledway,orwithintheshouldeillnewhichwouldaeawit haurdous condition to the public, 11i. This permitshall not bo Construed asauthorlsatlo0(crexcavation arid grading on prim piopertypdJacentto the workoranyotherwork(orwhfdta saparate permit may be required,nor does It relleve the PemtinrK►ornnyobligation toobtuln any other pvrmlt requlrcd by law. 17. Thh pt:Fmit clots not release the Perminee(torn noy flabilitics contained In otheragreemonts or contracu with the City and any odior pubilcageney. is, This permit Is nottrans(erable.WorkmostbeperrormedbythePermtttecorhisdatfm+atedagentofcontnctorasspedfledtiuicon. 19, Call back(call out)due to omeragande;regarding this permit shall be At the wimnt a&brie rate with a three 0)hour minimum charge Per ascurrenca 20. Pur;uantto Chapter 14.O2 of the Cartlpball Municipal Code,applicant shaft not causato becilxhargod any material into the mixnicippi storm drain Worn other than storm water.Appgcant shall adhere to the OW MANAGNEWPWtCIOS estabushad by the Santa Clara veiny Udtan Runoff Pollution Prevention Program. 21. if the public inbuorrequtres a modification of,or a depwwre from the p"s and ypec)lleadons,the City stroll have the authority to a quire or approve any modification ordepartu►e and to specify the mannerin which tho lama Is to be chide forClty-owned or maintained(,!duties, 21. Pomimee must provide advance notification to all partiziburnayboaffected by1hopermilaCtivitic,.C.NWi11W1lpn shall berevirurcdbytheCllypilor to diftfttitlon and includedsto of work anti 4 Contact nameand phone number. Applicant shall he responsible for rnsudr j tgat all those pr&Adtng scnAces under the appllusnt rare awaro and mldarswnd aR of the above conditlons. Applicant i AN,: Contractor (print Name) Oats: 1III ORM5�lttopic,!a lEnarooehrnoneAcrmlrslEr►croadsmrrn:PcnnitSrATlCforrn1pdf Bev.t1T/l4 �® CERTIFICATE OF LIABILITY INSURANCE 2/2ATE(M /DD/YYYY) 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 endorsements . PRODUCER CONTACT NAME: Vicki Pratt Clifford,&.Bradford Ins Agency P"°NE 661-283-8100 FAX . 661-283-8111 1515 20th Street E-MAIL Bakersfield CA 93301 pratt@cliffordandbradford.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Pacific Compensation Ins Co INSURED SLATE-1 INSURER B:The Ohio Casualty Ins Co. 24074 Slater Plumbing&Mechanical, Inc. INSURER C:American Fire and Casualty Co. 24066 PO Box 10922 Bakersfield CA 93389 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:436307328 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 POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DDNYYY B X COMMERCIAL GENERAL LIABILITY BK057070069 2/2/2016 2/2/2017 EACH OCCURRENCE $1,000,000 CLAIMS-MADE �X OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $500,000 MED EXP(Any one person) $15,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY JECTPRO ❑ LOC PRODUCTS-COMP/OP AGG $2,000,000 PRO- OTHER: $ C AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT BAA57070069 C 2/ 16 2/2/2017 Ea accident $1,000,00o X ANY AUTO l BODILY INJURY(Per person) $ ALL OWNED SCHEDULED J BODILY INJURY Per accident $ AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ C UMBRELLA LIAB X OCCUR ESA57070069U 2/2/2016 2/2/2017 EACH OCCURRENCE $4,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WA00170400 8/1/2015 8/1/2016 X I STATUTE ERH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A _-__-__ . (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLE (AC f�4i ed 'dtli `na�l,ftr�,s'Schedule,may be attached if more space is required) FEB 0 9 2010 R LEC E 4 V C:-:,D Public WOrkS Atlminisfiratlu,, FEB 0 8 2090 CERTIFICATE HOLDER CANCELLATION Public MRSAdministration 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. Dept of Public Works _ 70 North First Street CA 95008 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD oa CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 5/12/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Verenice Valdez NAME: KIA Insurance Associates, Inc. PHO NE (661)835-4542 FAX (661)B35-4500 AICA/C No: License # 0415101 ADDRESS: P.O. BOX 11390 INSURER(S)AFFORDING COVERAGE NAIC# Bakersfield CA 93389-1390 INSURERA:Ohio Casualty Insurance Company 24074 _ INSURED INSURER B American Fire & Casualty 24066 Slater Plumbing, Inc. INSURER C:SecuritV National Insurance 19879 14213 Rosedale Hwy INSURERD: INSURER E: Bakersfield CA 93314 INSURER F: COVERAGES CERTIFICATE NUMBER:15-16 ALL REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYW MM/DDIYYW GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 500 000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ A CLAIMS-MADE ®OCCUR X Yr BK056347367 /2/2015 /2/2016 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENI AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000 X POLICY PRO LOCI $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $_ 1�_000L000 B X ANY AUTO BODILY INJURY(Per person) $v ALL OWNED SCHEDULED X Y AA56347367 /2/2015 /2/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE Per accident) $ HIRED AUTOS AUTOS dent — ---- _ Medical payments $ 5,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4,000,000 DED I X RETENTION$ 0 SA56347367 /2/2015 /2/2016 $ C WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY —" ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ 11 000,000 OFFICER/MEMBER EXCLUDE U� SWC1050691 8/1/2014 8/1/2015 E.L.DISEASE-EA EMPLOYE. $_ 1 000 000 (Mandatory in NH) _ _ ,_�,__-___ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMP $ 1 000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) West Valley Sanitation District, City of Campbell, Town of Los Gatos, City of Monte Sereno, City of Saratoga and County of Santa Clara, it's officers and employees in their capacity as such, are included as additional insured as respects General and Auto Liability, per the attached endorsements. It is further understood that the contractor's insurance is to be primary to any other valid and collectible insurance available to the West Valley Sanitation District. Waiver of Subrogation applies to general liability and auto liability per attached endorsements. Waiver of Subrogation per Workers Compensation policy endorsment attached. i_1 r �;� ;" `�L{ \7.�� ti��✓�I� u� - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. West Valley Sanitation District 100 East Sunnyoaks Ave. Campbell, CA AUTHORIZED REPRESENTATIVE 95008-6608 Jim Hardy/VERENI ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025l,)nlnn51 ni Tho Ar`r1Rr1 namo anri Innn arc rcnictcrori morlrc of Ar r1Rr1 ACC ® CERTIFICATE OF LIABILITY INSURANCE DADD/YYYY) 5/12/22/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Verenice Valdez NAME: KIA Insurance Associates, Inc. PHONE . (661)835-4542 FAAI/C No;(661)835-4500 License # 0415101 E-MAIL ADDRE P.O. BOX 11390 INSURER(S)AFFORDING COVERAGE NAIC# Bakersfield CA 93389-1390 INSURERA:Ohio Casualty Insurance Company 24074 INSURED INSURER BAmerican Fire & Casualty 24066 Slater Plumbing, Inc. INSURER C:SecuritV National Insurance 19879 14213 Rosedale Hwy INSURERD: INSURER E: Bakersfield CA 93314 INSURERF: COVERAGES CERTIFICATE NUMBER 15-16 ALL 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 ADDTYPE OF INSURANCE INSR WVDSUBR POLICY NUMBER MMIDDIYYYYY MMIDDffYCY EYXYY LIMITS LTR GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 MIG X COMMERCIAL GENERAL LIABILITY PR SESOEa oi;cu REITED nce $ 500,000 A CLAIMS-MADE �X OCCUR X Y KO56347367 /2/2015 /2/2016 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 2,000,000 X POLICY PRO LOC $ CNEAUTOMOBILE LIABILITY EOa..ideDiSINGLE LIMIT $ 1,000.000 B X ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED X Y AA56347367 /2/2015 /2/2016 BODILY INJURY(Per accident) $ AUTOS AUTOS _ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident Medical payments $ 5,000 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000 B EXCESS LIAB CLAIMS-MADE - AGGREGATE $ 4,000,000 DED I X I RETENTION$ 0 SA56347367 /2/2015 /2/2016 $ C WORKERS COMPENSATION X WC STATU- I IOTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1 000,000 OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory in NH) SWC1050691 8/1/2014 8/1/2015 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) West Valley Sanitation District, City of Campbell, Town of Los Gatos, City of Monte Sereno, City of Saratoga and County of Santa Clara, it's officers and employees in their capacity as such, are included as additional insured as respects General and Auto Liability, per the attached endorsements. It is further understood that the contractor's insurance is to be primary to any other valid and collectible insurance available to the West Valley Sanitation District. Waiver of Subrogation applies to general liability and auto liability per attached endorsements. Waiver of Subrogation per Workers Compensation policy endorsment attached. !%{� _"3.�\5-U \ QVAz CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN West Valley Sanitation District ACCORDANCE WITH THE POLICY PROVISIONS. 100 East Sunnyoaks Ave. Campbell, CA 95008-6608 AUTHORIZED REPRESENTATIVE Jim Hardy/VERENI !-� !' ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 l7ninn.m nt Tho Ar npn name nnrl Innn urn runic+crnrl mnrlrc of Arr)pn Additional Named Insureds Other Named Insureds Edward P. Slater Additional Named Insured C I r OFAPPINF(02/2007) COPYRIGHT 2007,AMS SERVICES INC WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 (Ed. 4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT—CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration.of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2%of the California workers' compensation premium otherwise due on such remuneration. Schedule Any person or organization as required by written contract. $854.00 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Endorsement Effective 8/1/2014 Policy No. SWC1050691 Endorsement No. WC040306 Insured Slater Plumbing Inc(Corporation) Premium$ 27003 Insurance Company Security National Insurance Company Countersigned by 7 Forming a part of Policy Number: CBP8891150 Coverage Is Provided In PEERLESS INSURANCE COMPANY-A STOCK COMPANY Named Insured: Agent: SLATER PLUMBING MECHANICAL INC KIA INSURANCE ASSOCIATES INC Agent Code: 4295065 Agent Phone: (661)-835-4542 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location(s) Of Covered Operations Or Organization(s): WEST VALLEY SANITATION DISTRICT, CITY OF CAMPBELL, TOWN OF LOS GATOS, CITY OF MONTE SERENO, CITY OF SARATOGA AND COUNTY OF SANTA CLARA, ITS OFFICERS AND EMPLOYEES 100 EAST SUNNYOAKS AVE, CAMPBELL, CA 95008-6608 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 include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for"bodily injury", "property damage" or "personal and advertising injury"caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury"or"property damage"occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs)to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 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. ©ISO Properties, Inc.,2004 CG 20 10 07 04 Page 1 of 1 02/02/2014 8891150 NEUSXMMW601 PGDM060D J26418 GEONLYST 00000758 Page 71 0 ©tom INSURANCE REQUIREMENTS CHECKLIST Permit# CIP Project# Consultant/Contractor:' �)Vv W\n S, A�A,4 The following insurance is required of..Al 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: r/�1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or iW- $2;000,000 general aggregate limit. rC Policy expiration date Automotive Liability: Any Auto" checked on certificate 0-_ �- $1,000,000 per accident for bodily injury a.nd property damage � --Policy expiration date orkers' Compensation and Employer's Liability Waiver of Subrogation clause $1,000,000 per accident for bodily injury or disease 1r4- Policy expiration date_ S— Course of Construction (if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automubile Liability Policies Additional Insured Endorsement: The City, its officers, employees and volunteers are named-as additional insured. (Reference Project Location/Permit Number) ?6. The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no o"bligation 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. ❑ Workers' Compensation Insurance Sheet Submitted ii For General Con!ractor ❑ For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 02 14) Page 1 Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: _ ������ >�e NAIC #���'� Rating: 1`� Authorized in CA: i Name: !A'-NAIC# __� OLDRating: A / V✓ Authorized in CA: Name: NAIC# Rating: Authorized in CA: Name: NAIC# _Rating: Authorized in CA: r� Campbell Business License ##���'� �— Expiration: Contractors License # ���3 �5 Class: C3� Expiration: ':M O Ke Insurance Certificate Reviewed �q 1—S)"CaSr Initia date Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 Syed Wahidi From: Syed Wahidi Sent: Thursday, August 20, 2015 12:05 PM To: 'Ed Slater'; 'kturner@valleywater.org' Cc: 'George Blossom'; 'Eddie Slater'; 'HURTADO, Bill N - G6 HOSPITALITY'; 'Lisa Storey'; jpicado@westvalleysan.org'; 'Ho, Tran' Subject: RE: 1240 Camden Ave Fyi, This permit still not issued as we are waiting for the contractor to getlyYliasinessMrerse Fees has been paid, insurance has been approved. Syed Wahidi I Public Works Inspector City of Carnpb€ll I Public Works Dept. svedwQ)citvol'camnbell.com 0, 08.866.2165 408.376-0958 70. N. First Street iCampbell,CA 95008 www.CitvofCampbeli.com From: Ed Slater [mailto:ed(a)slaterplumbing.com] Sent: Thursday, July 16, 2015 4:18 PM To: kturnerCa)valleywater.org Cc: George Blossom; Eddie Slater; HURTADO, Bill N - G6 HOSPITALITY; Lisa Storey; jpicado@westvalleysan.org; Ho, Tran; Syed Wahidi Subject: FW: HI Kathrin Kathrin Hi Kathrin Please see #1 at manhole we will be excavating a 6'W x 101 x 8'D area, with excavator. #2 we will be saw cutting a 4'x 4' area,then with a vacuum to pot hole existing 19" water main. Other will be excavating sidewalk of a 6'x 8'area,then vacuum other utilities for potholing. As you can see the existing sewer main we will be pipe bursting a 4"vitrified clay pipe with a 6" HDPE which adds 2" Outer dimensions to existing piping. Please contact me on any questions Ed Slater 1 PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT,TRAFFIC & MISCELLANEOUS RECEIPT Effective July 1, 2014 TO: City Clerk PUBLIC WORKS FILE NO. 1' I O o I`*3 PROPERTYADDRESS veN Please collect & receipt for the following monies: GCT.. ITEM AMOUNT A ENCROACHMENT PERMIT 4722 Utility Encroachment Permit Application Fee $385.00 R-1 Encroachment Permit N/C Emergency Permits $110.00 Plan Check& Inspection Fee Minimum Charge Per Location $385.00 3 Conduits/Pipelines up to 500 Feet $2.70/ft Above 500 Linear Feet $1.60/ft Manholes/Vaults/Etc. $170.00/ea Pole Set/Removal $170.00/ea 4760 Storaqe Container Permit $156.00 4760 Pro'ect Plans &Specifications _ Project No. _ 4760 Standard Specifications&Details $1/Pg $15.50/13k _ — 4760 Engineering Maps & Plans Aerial Plot 24"x 36" $61.00 Aerial Print 8 1/2"x 11" $29.00 Map Research includes max of two 24"x36"copies) $29.00 Maps and Plans 24"x 36 $14.00 4722 Penalties: Failure to restore public improvements $100/Calendar Day(Muni Code Sec.11.34.010) 4722 Penalties: Failure to correct unsafe conditions $1oo/Calendar Day 4722 Work Without Permits 4 Times A licable Fee u : TRAFFIC... ... '` 4728 Traffic Flow Map (Daily Traffic Volumes $35.00 4728 Signal Timing Information $73 per hour 4271 Truck Permits $16.00 ertri 4728 No Parkin Si ns $1 each or$25/100 MISCELLANEO US. 511.74241 Postage Other Please S ecif ff r� TOTAL 776 NAME OF APPLICANT1(.Z�� NAME OF PAYOR ( lu 'aJ� PHONE ADDRESS ZIP 13 3 FOR RECEIVED:BY CITY CLERK ONLY Date' Recei t# 4a CITY OF CAMPbEiLk J:\FORMS\TempletesWdminisUetiv.\R...ipl Form Utility Encroachment&Mi..1415 1