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ENC2015-00179 rm CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No �i�rdC�-C(� ® �t-` �r� DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File 701North First Street right-of-way) Application Date Z S` Campbell,CA95008 Issued �/ 4 1lt`� Application Expiration Date_Q-025 1 Ph. (408)866-2150 APN Fx. (408)376-0958 / f' '6 Permit Expiration Date lt: 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.: Utility Trench Location: II SG_Est t��j'{ G!¢17r12/�2 *o 0 V l Lf7/N� B. Nature of Work: � ��jT/L/T�rc/ jcf(/.��/'r) ...................`.........._......................................................................._.__....._._.._.............................................................................................................._..__.......................................................... ......:................._.......................... C. Attach four(4)copies of an engineered plan showing the location and extent of the work,and four(4)copies of the preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improveynents. When approved by the City Engineer,said plan becomes a part of this permit. D. All work shall conform to the City of Campbell Standard Specifications and GG Details for Public Works Construction;the General Permit Conditions listed on the reverse side;and the Special Provisions for this permit,listed below. Failure to abide by these conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2.) E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work. Name of Applicant: (UAI LNG GBAI�f�(/Gfi[p-s� CO. Or— G+Z-/A*ZA//,0P+-I Telephone: OS 34 r—/7ro 7 Address: 24 $ J- Tdt- 4-1-4/`M fs0A1 d_f-� /ry ......................._............._....._.._._.._.........................................................._...._.__. —................................................................................_............... E-Mail Address: �2> '�D /lp/SSDhJ�(QM� CO-WI 24-HOUR EMERGENCY PHONE NUMBER: /70ZI— -- ........._.._................................................._...__......__._....._.._..._...__................................: Is this work being done by the property owners at their own residence? YESFjNO 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 mages resulting from the work covered by this permit. The Applicant/Permittee hereby ackno edgoadvise y have read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. Ap licantthat upon issuance of this permit, property owner, or property owner's successors, shall'be responsible for any and all damages arsing o nd• ion of any private improvements in the public right-of-way. Accepted: 2 r (Applica Pe itte (sign) Date PdC�!AIIf0 )1ZE (Contractor) (Print Name). Date SPECIAL PROVISIONS: 1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be specifically approved by the Inspector prior to cutting. 2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A",unless otherwise approved by the Engineer. 3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two(2)copies of the cut sheets serif to the-Public Works Department before starting work. 4. Per Section 4216 of the Government Code this permit is not valid for excavations until Underground Service Alert(USA)has been notified and the inquiry identification number has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO. 5. Prior to any work,the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way,which shall be recorded. 6. Public Notification Requirements: 7. SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT_ RECEIPT N PERMIT APPLICATION FEE $ ��� PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK&INSPECTION FEE $ ir) -� EMERGENCY PERMIT FEE $ APPROVED FOR ISSUANCE For City Engineer Date Permit Expires 12 Months After Date of Issuance GENERAL PERMIT CONDITIONS 1. ' A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency call-out,overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. 3. Refund or the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. Submit project schedule 10(ten)days prior to proposed start of work.Special provisions may be required for work within City facilities and downtown Campbell. 5. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. 6. Maintain safe pedestrian and vehicular crossings and free access to private driveways,bus stops,fire hydrants,and water valves. 7. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures,detours,and street closures.This plan must be reviewed and approved prior to any lane closures. 8. A Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones,dated 1990,available at Caltrans. Traffic control equipment shall include Type II flashing arrow signs if required. 9. Replace as directed by the City Engineer any damaged or removed improvements in accordance with City Standards and Specifications at the sole expense of the Permittee. 10. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements. 11. Prior approval of inspector is required for any work done after normal working hours,on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 12. Adequate signing and barricading is required on thejob site. Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost(including all labor and materials)against the cash deposit. 13. Compaction testing of subgrade,base rock,and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 14. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m.to 4:00 p.m. 15. No storage of materials or equipment will be allowed near the edge of pavement,the traveled way,or within the shoulderline which would create a hazardous condition to the public. 16. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a separate permit may be required,nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 17. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 18. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 19. Call back(call out)due to emeregencies regarding this permit shall be at the current overtime rate with a three(3)hour minimum charge per occurrence. 20. Pursuant to Chapter 14.02 of the Campbell Municipal Code,applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. 21. If the public interest requires a modification of,or a departure from the plans and specifications,the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made for City-owned or maintained facilities. 22. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and phone number. Applicant shall e r spon ible for nsuring that all those providing services under the applicant are aware and understand all of the above conditions. -2, Applicant Date: Contractor (Print Name) Date: J:\FORMS\Templates\Encroachment Perm its\Encroachment Permit STATIC form2.pdf Rev.02/14 ® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 12/28/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must 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 CONTACT NAME: AudreyBone Lovitt&Touche' Inc-Tempe PHONE FAX 1050 West Washington St,#233 fAI Lo Ext:602-792-2311 AIc No):602-956-2258 Tempe AZ 85281 ADDRESS: abone@lovitt-touche.com INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Lloyd's of London INSURED ROBSO-1 INSURER B:Charter Oak Fire Insurance Company 25615 Sun Lakes Construction Co. of CA Robson Homes, LLC INSURER c:Amerisure Mutual Insurance 23396 9532 East Riggs Road INSURER D: Sun Lakes AZ 85248 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:173061287 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 MMIDD/YYYY MM/DD/YYYY A X COMMERCIALGENERALLIABILITY Y Y CC1901002 1/1/2019 1/1/2021 EACH OCCURRENCE s10,000,000 DAMAGE CLAIMS-MADE FxIOCCUR -PRE M SESOEa occur ence $100,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $10,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $10,000,000 POLICY❑JECT PRO ❑ LOC PRODUCTS-COMP/OPAGG $10,000,000 X PRO- OTHER: Construction SIR $100,000 B AUTOMOBILE LIABILITY Y Y 8102F490211 1/1/2019 1/1/2020 COMBINED SINGLE LIMIT $1,000,000 Ea accident JX ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident $ A UMBRELLA LIAB X OCCUR Y Y CC1901059 1/1/2019 1/1/2021 EACH OCCURRENCE $10,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000 DED X RETENTION$ $ C WORKERS COMPENSATION Y WC207584808 4/1/2018 4/1/2019 PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) ELL. -EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The General Liability and Automobile Liability insurance evidenced above includes as insureds only persons or organizations that the Named Insured agrees by written contract or written agreement to add as insureds. The coverage provided to such insureds applies only to work performed for the Named Insured under such written contract or written agreement at the Named Insured's worksite. Waiver of subrogation included in policy form if waived in written contract prior to a loss. Madison Park of Campbell,LLC is an Named Insured. The City,its officers,employees and volunteers are named as additional insured if required by written contract as respects work at:280 Dillon Ave,Campbell, CA and Permit#ENC2015-00055 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Campbell 70 North First Street Campbell CA 95008 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD r ® DATE(MM/DDIYYYY) A `'ij CERTIFICATE OF LIABILITY INSURANCE Ill 1 12/22/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must 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 CONTACT NAME: Audrey Bone Lovitt&Touche' Inc-Tempe PHONE FAX 1050 West Washington St,#233 MAIL° Ext:602-792-2311 A/C. lC No:602-956-2258 Tempe AZ 85281 AbDREss: abone@lovitt-touche.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Lloyd's of London INSURED ROBSO-1 INSURER B:Charter Oak Fire Insurance Company 25615 Sun Lakes Construction Co. of CA Robson Homes, LLC INsuRERc:Amerisure Mutual Insurance 23396 9532 East Riggs Road INSURER D: Sun Lakes AZ 85248 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:513161905 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 SUER POLICY NUMBER MMIDDYIYYYY MM/DD/YYYY LIMITS LTR A X COMMERCIAL G ENERALLIABILITY Y Y CC1700234 1/112017 1/1/2019 EACH OCCURRENCE $10,000,000 DAMAGE To RENTED CLAIMS-MADE �OCCUR PREMISES Ea occurrence $100,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $10,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $10,000,000 POLICY❑ PRO ❑ LOC PRODUCTS-COMP/OP AGG $10,000,000 JECT X OTHER: Construction SIR $100,000 B AUTOMOBILE LIABILITY Y Y 810217490211 1/1/2018 1/1/2019 COMBINED SINGLE LIMIT $ Ea accident) 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS PROPER X HIRED X NON-OWNED PERTY DAMAGE $ IAUTOS ONLY AUTOS ONLY Per accident A UMBRELLA LIAB X OCCUR Y Y CC1700272 1/112017 1/1/2019 EACH OCCURRENCE $10,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000 DED I X I RETENTION$in nnn nnn $ C WORKERS COMPENSATION Y WC207584805 4/l/2017 4/1/2018 PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOR/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 I E.L.DISEASE-POLICY LIMIT $1,000.000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The General Liability and Automobile Liability insurance evidenced above includes as insureds only persons or organizations that the Named Insured agrees by written contract or written agreement to add as insureds. The coverage provided to such insureds applies only to work performed for the Named Insured under such written contract or written agreement at the Named Insured's worksite. Waiver of subrogation included in policy form if waived in written contract prior to a loss. The City,its officers,employees and volunteers are named as additional insured if required by written contract as respects work at:186 Dillon Ave,Campbell, CA and Perm' #EN �11s5 001179 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Campbell 70 North First Street Campbell CA 95008 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD WOkt ERS 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 Person or Organization Job Description ANY PERSON ORORGANIZATION REQUIRED BY WRITTEN CONTRACT OR CERTIFICATE OF INSURANCE 1 i This endorsement changes the policy to which it is attached and is effective on the date issued unless othenArise 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$ Sun Lakes Construction Company of CA Insurance Company Countersigned by WC 04 03 06 Hart Forme&Services (Ed.4-84) Copyright 1999 National Council on Compensation Insurance,Inc. Reorder No.14-2-120 .-- v�r�a erevro e esr d.erwe�e e e eero7ve�a-aeav� 3/14/2016 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 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 . CONT PRODUCER NAME:CT Elaine Leaman Lovitt&Touche' Inc-Tempe PHONE 602-956-2250 FAX No; 602-956-2258 1050 West Washington St,#233 E-MAIL Eleaman@lovitt-touche.com Tempe AZ 85281 D INSURERS AFFORDING COVERAGE NAIC# INSURER A:Lloyd's of London INSURED ROBSO-1 INSURER B:Charter Oak Fire Insurance Com an 25615 Sun Lakes Construction Co. of CA INSURERC:Alterra E&S Lines Insurance Company Robson Homes, LLC - INSURER D:Amerisure Mutual Insurance 23396 9532 East Riggs Road Sun Lakes AZ 85248 INSURERE: INSURER F COVERAGES CERTIFICATE NUMBER:867617920 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. rA POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DDIYYYY MMIDD/YYYY X COMMERCIAL GENERAL LIABILITY Y Y CHF15YF15CP01001 1/1/2015 1/1/2017. EACH OCCURRENCE . $10,000,000 DAMAGE TO RENTED CLAIMS-MADE X❑ OCCUR PREMISES Ea occurrence) $100,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $10,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $10,000,000 X POLICY PRO LOG PRODUCTS-COMP/OP AGG $10,000,000 JECT OTHER: Construction SIR $100,000 i11/2016 1/1/2017 COMBINED SINGLE LIMIT $1,000,000 B AUTOMOBILE LIABILITY Y Y g102F490211COF15 Ea accident X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED F AUTOS SCHEDULED BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ C UMBRELLA LIAB X OCCUR Y Y MKLS6GL0000579 1/1/2015 1/1/2017 EACH OCCURRENCE $10,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000 DED I I RETENTION$ $ D WORKERS COMPENSATION Y WC2096253 4/1/2016 4/1/2017 X STATUTE OER" AND EMPLOYERS'LIABILITY Y/N - ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $1.000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) The General Liability and Automobile Liability insurance evidenced above includes as insureds only persons or organizations that the Named Insured agrees by written contract or written agreement to add as insureds. The coverage provided to such insureds applies only to work performed for the Named Insured under such written contract or written agreement at the Named Insured's worksite. Waiver of subrogation included in policy form if waived in written contract prior to a loss. The City, its officers, employees and volunteers are named as additional insured if required by written contract as respects work at: 186 Dillon Ave, Campbell, CA and Permit#ENC2015-00179 CERTIFICATE HOLDER CANCELLATION 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 First 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 ........................................ ......... ................. ...................................... ............... ............. ......................... ....................................... ....................... ........... ............................................... 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B ALL U11LITY CLOSET co AC PAMNG ................................... . ..... .. . ............................. . ............................ ............ .......................................... ...................... ................................ .......... ............. ............ .................. ................................................... ............................................. ...........-......................... ...... 4 PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MISCELLANEOUS RECEIPT Effective July 1, 2015 TO: .Finance (� f r• J PUBLIC WORKS FILE NO. OQ l PROPERTY ADDRESS 'C Please collect& receipt for the following monies: ACCT. I ITEM AMOUNT ENCROACHMENT PERMIT 4722 Utility Encroachment Permit Application Fee $425.00 R-1 Encroachment Permit N/C Emergency Permits $120.00 Plan Check& Inspection Fee Minimum Charge Per Location $390.00 Conduits/Pipelines up to 500 Feet $2.75/ft Above 500 Linear Feet $1.65/ft Manholes/Vaults/Etc. $175.00/ea Pole Set/Removal $175.00/ea 4760 Storage Container Permit $160.00 4760 Project 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 $100/Calendar Day 4722 Work Without Permits 4Times Applicable Fee TRAFFIC 4728 Traffic Flow Map(Daily Traffic Volumes) $35.00 _ 4728 Signal Timing Information $73 per hour 4271 Truck Permits $16.00 per trip 4728 No Parking Signs $1 each or$25/100 MISCELLANEOUS 511.74241 Postage Other(Please Specify) TOTAL NAME OF APPLICANT NAME OF PAYOR > PHONE S / ADDRESS ZIP FOR RECEIVED B CITY CLERK A—vk YL I ) - � ONLY Date $1 Z-5 1 Receipt �(4J(/ p c� Au U C1 J1FORMS1TemplatesWdministmtive%Receipt Form Utility Encroachment&Misc 16-16.xls California Bank&Trust Stub Check No. 10005 MADISON PARK OF CAMPBELL,LLC _Loft Date 08125L15_---.----- Gross Discount Net 815.00 815.00 a C'? C:.l W3815.00 815.00 t1A t:J Lid C t:1 I:+- zn r�• i; , VS C,} ^.t. U1 LL! I^^ 4'J r•.c C'•J s•--: a i;9 •x ca ca 7Zl a� r- ,:ct 0"1 0') m •-,) .'. a�a co 4!J K7'7 C�:7 �Jy C`_Y •�: 41,1 LJ_ Ga 7 WA i•» c r,-s r' apcheckcbt__J— !iE apprn 4o3 U.S.PAT-t IT CIO.563P'<P0,5575508.56•?it93.518535?,5"s8A351.6030500 _.._................................................._.........................._...........-......... ...................................-...._._..........._.__........- _.._...__................._. .................. .. ................... ...................... ......................... .............................................................................................................. .. .... .................. ............................. .......... - ----- - 0 pp r-I- f� -� ` ► -9�.50TC�/ 9U9842TC L198.35TC 198.60TJ 198.48' `" 198.11T�� j19�.07TC``"'EX. 6" WATE � 19 198.26LIP 198.13L P EX. SDMH �1-9' 198.60 / AV V 98 RIM=198.29 �,---- 1 .42 nr ,— INV�191.01 IN(SE) EX IW=1.89.90 THRU 198.60TC 19��_0� 198.28TC 50�°"' 198.23LIP G 9 ,23 Pi C A97.84FL1 8.29TC 198.23TC 1 19 961-113 197.79%:' 198.15TC pp �0 7861. PI -' o 938 W _ , — 198.786� 785 10* PIST !� 198.46GRT 1°9€ i C, , EX. CO f - A RIM=198.58 f $ PG&E METER B L f f CONC�� 1-STORY DUI[ / i, u8 F UTILITY CLOSET ra AC PAVING � _...._.....................-.... ..--- �--...._..---- ---.. .__....._.._...........__.. .-.._...................._.................... _.......................-....._.__ �_._.._._.. . .__. . .._............._.. .._...... . ..... . ....__-..._.......... ..... ._........... . ...................................... ..................... ........................... ........................................... ........................................... .................................. ................................ ..............................................-7 ..................................... ................... (D ppe- W 9 L!Lo T-C ILgo-Z C`19�,3gTC 196,60T�j ,13LIP j ..� ` _ 9 /Af w 46TC 98. -(EX. 6" WA 19 LAUZTC_� L.�l_Mj TE 198.26LIP 19E EX. SDMH 1.57 P I-IM4 A It -E� 198.60 RIM=198.29 198.42 INV-r191.01 IN -EX' _ss INV=�l�W.90 THRU SD D 198.60TC 198.60TC 198.28T !00 pA SD 198.23LIPI G� Q.84ft 1.6-4 )8.29TC 198.23TC 197196L IN 1197.79 198.15TC J 786 1 PI TC Uqzw .................. 198.46bRT 17E5_1 7 7 71771 777,77 EX. CO R IM=l 98.58 PG&E METER sew B B CONc 1-STORY 0U4 UTILITY CLOSET AC PAVING ................................................................. ............ ............................... ........... ........... .............. .................... ..........- ............ ................... ............ ......................... ........... ...... ...................... ............ ........... FTO: inance UBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MISCELLANEOUS RECEIPT Effective July 1, 2015 PUBLIC WORKS FILE NO. I `� PROPERTY ADDRESS Please collect & receipt for the following monies: ACCT. I ITEM AMOUNT ENCROACHMENT PERMIT !, 4722 Utility Encroachment Permit Application Fee $425.00 R-1 Encroachment Permit N/C Emergency Permits $120.00 Plan Check& Inspection Fee Minimum Charge Per Location $390.00 Conduits/Pipelines up to 500 Feet $2.75/ft Above 500 Linear Feet $1.65/ft Manholes/Vaults/Etc. $175.00/ea Pole Set/Removal $175.00/ea 4760 Storage Container Permit $160.00 _ 4760 Project 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 $100/Calendar Day 47221 Work Without Permits 4 Times Applicable Fee TRAFFIC 4728 Traffic Flow Map(Daily Traffic Volumes) $35.00 4728 Signal Timing Information $73 per hour 4271 Truck Permits $16.00 per trip 4728 No Parking Signs $1 each or$25/100 MISCELLANEOUS - 511.74241 Postage Other(Please Specify) TOTAL(� — NAME OF APPLICANT NAME OF PAYOR � ra4 �, /, j ,C 'PHONE 44 ADDRESS FOR RECEIVED B?f CITY CLERK ONLY Date >`LrJ < Receipt# California Bank&Trust Stub Check No. 10005 MADISON PARK OF CAMPBELL,LLC _—_-_Date__08i25115.— .- Gross Discount Net ( I 815.00 815.00 j ----------- ----------- 815.00 i 815.00 I .,:` Y„] f b'") ).J �_•. ,a' }.._ 42:: CAI '.t : (C7 Cil Y�l :,Z, rs,, Y`.7 U' 4.0 -- t.t._ t=4 c-a i..,.! f. i,,l ex-, a checkcbt z o 1�✓` � V '� �Sx. .C'� p:�l J_V_0 8 s.. 1 o J, nor—e yes$From m a rn Ac3dre" '� -x.`� c� .�ram `.�.' r.• ' ps:� _ '�5.� C C:.J' 0 c) ro- l t I Z C>,( -os j ANR PAID CFIEF:IC I 3 _�. 0 hf !3klahJ(`E -�.-�—��-- ,hAf?NFI ORDER�� ��✓ - flu�a��w •z�� %REUtI tARU�- �� —_— --_.-. ---�—._,.—.— y Ir- y 1 t i ALC®®® DATE(MM/DD/YYYY) `./ CERTIFICATE OF LIABILITY INSURANCE 8/26/2015 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 endorsements. PRODUCER NAME:CONTACT Elaine Leaman Lovitt&Touche' Inc-Tempe PHONE(AIC No Fv[).602-956-2250 ��� Ne). 602-956-2258 1050 West Washington St,#233 E-MAIL Tempe AZ 85281 .Eleaman@lovitt-touche.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Lloyd's of London INSURED ROBSO-1 INSURERB:Charter Oak Fire Insurance Company 25615 Sun Lakes Construction Co. of CA INSURERC:Alterra E&S Lines Insurance Company Robson Homes, LLC INsuRERD:Amerisure Mutual Insurance 2339 9532 East Riggs Road Sun Lakes AZ 85248 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1197715583 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 AUSUBIR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A x COMMERCIALGENERALLIABILITY Y Y CHF15YF15CP01001 1/1/2015 1/1/2017 EACH OCCURRENCE S10,000,000 DAMAGE CLAIMS-MADE X�OCCUR PREM SESOEa occurrDence $100,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $10,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S10,000,000 X POLICY D PRO- JECT LOC PRODUCTS-COMP/OPAGG S10,000,000 OTHER: Construction SIR S100,000 B AUTOMOBILE LIABILITY 8102F490211COF15 1/1/2015 1/1/2016 COMBINED SING LE LIMIT $ Ea accident 1.000.000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS Per accident s C X UMBRELLALAB X OCCUR Y Y MKLS6GL0000579 1/1/2015 1/1/2017 EACH OCCURRENCE $10,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000 DED I I RETENTION$ S D WORKERS COMPENSATION y WC209625301 4/1/2015 4/1/2016 PER OTH- AND EMPLOYERS'LIABILITY y/N X STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $1,000,000 D?OFFICER/MEMBER EXCLUDE (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below I I E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (A CORD 101,Additional Remarks Schedule,maybe attached if more space is required) The General Liability insurance evidenced above includes as insureds only persons or organizations that the Named Insured agrees by written contract or written agreement to add as insureds. The coverage provided to such insureds applies only to work performed for the Named Insured under such written contract or written agreement at the Named Insured's worksite. Waiver of subrogation included in policy form if waived in written contract prior to a loss. The City, its officers,employees and volunteers are named as additional insured if required by written contract as respects work at: 186 Dillon Ave,Campbell, CA and Permit#ENC2015-00179 CERTIFICATE HOLDER CANCELLATION 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 First 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 THIS CERTIFICATE SUPERSEDES PREVIOUSLY ISSUED CERTIFICATE 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 Person or Organization Job Description ANY PERSON OR ORGANIZATION REQUIRED BY WRITTEN CONTRACT OR CERTIFICATE OF INSURANCE This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 4/1/2015 Policy No. WC209625301 Endorsement No. Insured Premium $ Sun Lakes Construction Company of CA Insurance Company Countersigned by WC 04 03 06 lfart Forms i£Servires (Ed. 4-84) Copyright 1999 National Council on Compensation Insurance,Inc. Reorder No.14-2420 0 INSURANCE REQUIREMENTS'CHECKLIST Permit# a0ls CIP Project# Consultant/Contractor: �,c�.KeS sm\X 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: ,5= $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or L< $2,000,000 general aggregate limit. t�Policy expiration date_ 1 Automotive Liability: 4T "Any Auto" checked on certificate $1,000,000 per accident for bodily injury and property damage Policy expiration date \LQ Worke s' Compensation and Employer's Liability W. ver of Subrogation clause Exc-e5S ��� Y 1,000,000 per accident for bodily injury or disease O p�D co q` Policy expiration date Course of Construction (if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured,Enclorsemert: The City, its officers, employees and volunteers are named as additional insured. �(Reference Project Location/Permit Number) ❑ The insurance coverage afforded to the Additiolial 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 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. ❑ Workers' Compensation Insurance Sheet Submitted o 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 an is authorized to transact business in the State of California. Name: NAIC# Rat' g: Authorized in CA: Name: l_ �C�Sp �c1✓���/� NAIC# ��Z'Rat g Authorized in CA. �— Name: NAIC# "Z S 6(5Rating: / Authorized in CA: Name: rr� NAIC# Rating: -S Authorized in CA: Campbell Business License # � �--- Expiration: IK Contractors License# Class: 3a Expiration: Insurance Certificate Reviewed �Z I Initials 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 This endorsement effective, 15' January 2015 forms a part of Certificate No. CHF15/YF15CPO1/001 Issued to Robson Communities, Inc. issued by Certain Underwriters at Lloyd's' and International Insurance Company of Hannover THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. NOTIFICATION TO OTHERS OF CANCELLATION This endorsement modifies insurance provided under the: Contractors Liability Insurance Policy A. If we cancel this Coverage Part(s)by written notice to the first Named Insured for any reason other than non-payment of premium, we will mail or deliver a copy of such written notice of cancellation: 1. To the name and address corresponding to each person or organization shown in the Schedule below;and 2. At least 10 days prior to the effective date of the cancellation, as advised in our notice to the first Named Insured, or the longer number of days notice if indicated in the Schedule below. 6. If we cancel this Coverage Part(s)by written notice to the first Named Insured for non-payment of premium,we will mail or deliver a copy of such written notice of cancellation to the name and address corresponding to each person or organization shown in the Schedule below at least 10 days prior to the effective date of such cancellation. G. If notice as described in Paragraphs A. or B. of this endorsement is mailed, proof of mailing will be sufficient proof of such notice. SCHEDiTLE Name and Address of Other Person(s) Organization(s): Number of Days Notice: California Bank and Trust, and its successors and assigns 1900 Main Street, Suite 200 Irvine CA 92614 JP Morgan Chase Bank, N.A., and all subsidiaries as their interest may appear (ATIMA), its successors and/or assigns (ISAOA) 30 201 N Central Avenue Mail Code:AZ1-1009,14th Floor Phoenix AZ 85004 U.S. BANK NATIONAL ASSOCIATION d/b/a HOUSING CAPITAL COMPANY 1825 South Grant, Ste 630 San Mateo CA 94402 CHF-GL-0021 09 18 12 18 September 2012 Page 1 of 1 This endorsement effective, I't January 2015 forms a part of Certificate No. CHF151YF15CP01l001 Issued to Robson Communities, Inc.issued by Certain Underwriters at Lloyd's and International Insurance Company of Hannover THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Alameda County 43885 S.Grimmer Blvd Fremont CA 94537 Additional Insured;Alameda County Water Water District District Arizona Water 3805 North Black Phoenix AZ 85038- Arizona Water Company is additional insured if Company Canyon Highway 9006 required by written contract, California Bank& 1900 Main St,,Ste200 Irvine CA 92614 California Bank&Trust&ISAOA are additional Trust,ISAOA insured and loss payee as respects their interest in Lots 1-9 Tract 8052,Fremont,CA Loan #9557000505-1 California Bank& Att;Colette Kirste 1900 Main Street, Irvine CA 92614 As respects property located at 2400-2450 Trust,ISAOA Ste 200 Durham Road,Fremont,CA,48lots single family units for Solstice Homes,LLC-California Bank& Trust,ISAOA are additional insured for General Liability and Excess liability.loan#9557000504-1 &9557000504-2 California Bank and 1900 Main Street,Suite Irvine CA 92614 RE;Loan 49557000505-3 Trust,and its 200 42425 Mission Blvd Fremont,CA 94539 Borrower successors and Name;ROBSON HOMES,LLC assigns Mortgagee/Loss Payee;California Bank&Trust, and its successors and or assigns Additional Insured;California Bank&Trust,and its successors and or assigns r This endorsement effective, 15r January 2015 forms a part of Certificate No. CHF151YF15CP01/001 Issued to Robson Communities, Inc.issued by Certain Underwriters at Lloyd's and International Insurance Company of Hannover THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. California Bank and 1900 Main Street,Suite Irvine CA 92614 RE:Loan 99557000505-2 303 HACKAMORE Trust,and its 200. LANE,FREMONT,CA 94539—35 SINGLE FAMILY successors and RESIDENCES Borrower Name:ROBSON HOMES, assigns LLCMortgagee/Loss Payee:California Bank& Trust and its successors and or assigns(as to COC/Builder's Risk/All Risk coverage)Additional Insured:California Bank&Trust,and its successors and or assigns(as to general and excess liability coverage), CIT Technology c/o ABIC Specialty P,O.Box 979220 Miami FL 33197- CIT Technology Financing Services,Inc.is loss Financing Services, Services,5th Flr 9220 payee as respects their interest in equipment Inc, leased to the insured.Value$15,581 lease# 9000186946000 City of Campbell 70 North First Street Campbell CA 95008 The City,its agents,officers,attorneys, employees,officials and volunteers are named as additional insured if required by written contract as respects yard Right-of-Entry Agreement, City of Campbell 70 North First Street Campbell CA 95008 RE: Permit#BLD2012-00149 All work in public right of way 651-727 W.Hamilton Ave Campbell,CAAdditional Insured:City of Campbell, its agents,officers,attorneys,employees,officials and volunteers City of Campbell 70 North First Street Campbell CA 95008 The City,its officers,employees and volunteers are named as additional insured if required by written contract as respects work at:290 Dillon Ave,Campbell,CA and Permit#ENC2013-00078, This endorsement effective, 15t January 2015 forms a part of Certificate No. CHF151YF15CP01/001 Issued to Robson Communities, Inc.issued by Certain Underwriters at Lloyd's and International Insurance Company of Hannover THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. City of Fremont 3300 Capitol Ave Fremont CA 94538 Additional Insured:City of Fremont City of Fremont 3300 Capitol Ave Fremont CA 94537- City of Fremont is additional insured for Tract 5006 8092 Hackamore City of Fremont 3300 Capitol Ave. Fremont CA 94538 City of Fremont is additional insured. City of Goodyear 195 N 145th Ave, Goodyear AZ 85338 City of Goodyear is additional insured, City of Mountain Attn:Public Works Dept- PO Box 7450 Mountain CA 94039 City of Mountain View is an additional insured, View Land Development View City of Mountain 500 Castro Street Mountain CA 94039 City of Mountain View is additional insured where View View required by written contract, City of Mountain Att:Public Works Dept. P.0,Box 7450 Mountain CA 94039 City of Mountain View,its officers,officials, View Land Development View employees and volunteers are additional insured if required by written contract. City of San Jose 200 E,Santa Clara St, 2nd FI Wing San Jose CA 95113 City of San Jose,its officials,employees,angents and contractors are additional insured if required by written contract as respects Any and All Jobs, JP Morgan Chase 201 N,Central Ave,AZ1- Phoenix AZ 85004 JP Morgan Chase Bank,NA,ISAOA are additional Bank,NA,ISAOA 1009 insured. This endorsement effective, I't January 2015 forms a part of Certificate No. CHF151YF15CP01/001 Issued to Robson Communities, Inc.issued by Certain Underwriters at Lloyd's and International Insurance Company of Hannover THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. JPMorgan Chase Real Estate Banking, 201 N Central Phoenix AZ 85004 1P Morgan Chase Bank,N,A,,and all subsidiaries as Bank,N,A,,and all Attn:Nicole Troll Avenue Mail their interest may appear(ATIMA),its successors subsidiaries as their Code:AZ1- and/or assigns(ISAOA)are additional loss payee interest may 1009,14th Floor as respects their interest as mortgagee, appear(ATIMA),its successors and/or assigns(ISAOA) JPMorgan Chase Real Estate Banking, 201 N Central Phoenix AZ 85004 Certificate holder is loss payee and mortgagee as bank,NA.,any and Attn:Nicole Troll Ave,Mail Code: respects their interest, all subsidiaries as AZ1-1009114th their interests may Floor appear(ATIMA),its. successors and/or assigns(ISAOA) PG&E Corporation 1 Market Spear Tower San Francisco CA 94105 PG&E Corporation is additional insured, Pinal County Department of Public PO Box 727 31B Florence AZ 85132 RE:Unit 46A Works Final St,Bldg F Additional Insured:Pinal County Santa Clara Valley 5750 Almaden San Jose CA 94118 Santa Clara Valley Water District,its Directors, Water District Expressway officers,agents,employees,and volunteers are additional insured. Town of Los Gatos 110 E,Main Street Los Gatos CA 95031 Town of Los Gatos is additional insured, Town of Sahuarita 375 W Sahuarita Center Sahuarita AZ 85629- Robson Ranch Arizona Construction Company, Way 8487 Town of Sahuarita is additional insured, This endorsement effective, 1't January 2015 forms a part of Certificate No. CHF151YF15CP01/001 Issued Io Robson Communities, Inc.issued by Certain Underwriters at Lloyd's and International Insurance Company of Hannover THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY, U.S,BANK 1825 South Grant,Ste San Mateo CA 94402 Tract 10110 Los Gatos CA Loan#1920D309 NATIONAL 630 U.S,Bank National Association dba Housing ASSOCIATION d/b/a Capital Company is additional insured as respects HOUSING CAPITAL their interest in loan#19200309 and 4192OR for COMPANY location:Tract 10110 Los Gatos CA U,S,Bank National 1825 S.Grant St,, San Mateo CA 94402 U,S,Bank National Association dba Housing Association dba Ste 630 Capital Company is additional insured as respects Housing Capital their interest in loan#1965-03-09 for location: Company ISAOA, Hamilton Avenue,Campbell,CA ATIMA U.S.BANK Att:Heidi P Elrich 825 S Grant St San Mateo CA 94402 As Respects Loan#1900,4190OR and#1900M at NATIONAL Suite 630 Los Coches Subdivsion,Milpitas CA.Robson ASSOCIATION dba Homes LLC,is included as a named insured and as_ Housing Capital an owner for the additional insured.U.S,BANK Company NATIONAL ASSOCIATION d/b/a HOUSING CAPITAL COMPANY is additional insured US Bank National 1825 South Grant St,, San Mateo CA 94402 Re:Loan Number 2224 Association dba Ste 630 Location:Tract 10194,137 Easy Street,Mountain Housing Capital View,CA Company Additional Insured and Loss Payee:US Bank National Association dba Housing Capital Company US Bank National 1825 South Grant St,, San Mateo CA 94402 Re:Loan Number 2126 Association dba Ste 630 Location:655&651 W.Hamilton Ave,Campbell, Housing Capital CA Company Additional Insured:US Bank National Association dba Housing Capital Company This endorsement effective, 15t January 2015 forms a part of Certificate No. CHF151YF15CPO1/001 Issued to Robson Communities, Inc.issued by Certain Underwriters at Lloyd's and International Insurance Company of Hannover THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. US Bank National 1825 South Grant St,, San Mateo CA 94402 Re;Loan Number 22241-ocation;Tract 10194,137 Association dba Ste 630 Easy Street,Mountain View,CA Additional Housing Capital Insured and Loss Payee;US Bank National Company Association dba Housing Capital Company US Bank National 1825 South Grant St,, San Mateo CA 94402 Re;Loan Number 1985 Association dba Ste 630 Location;3111-3191 Mowry Ave,Fremont,CA Housing Capital 94538 Company Mortgagee and Lender Loss Payable;US Bank National Association dba Housing Capital Company US Bank National 1825 South Grant St,, San Mateo CA 94402 Re;Loan Number 1985 Association dba Ste 630 Location;3111-3191 Mowry Ave,Fremont,CA Housing Capital 94538 Company US Bank National Association dba Housing Capital Company is an additional insured if required by written contract. US Bank National 1825 South Grant St,, San Mateo CA 94402 Re;Loan Number 1965&196SR Association dba Ste 630 Location;655&651 West Hamilton Ave., Housing Capital Campbell,CA Company Additional Insured;US Bank National Association dba Housing Capital Company Additional Named Insured;Penny Lane Housing, LLC Policy Number:CHF15YF15CP01001 So long as the above conditions are met, attorneys' fees incurred by us in the defense of that indemnitee, necessary litigation expenses incurred by us and necessary litigation expenses incurred by the indemnitee at our request will be paid as "defense expenses". Our obligation to defend an insured's indemnitee and to pay"defense expenses" ends when we have used up the applicable limit of insurance for the payment of judgments or settlements or the above conditions set forth above,or the terms of the agreement described in Paragraph f.above, are no longer met. SECTION II—WHO IS AN INSURED 1. If you are designated in the Declarations as: a. An Individual, you and your spouse or domestic or civil partner are insureds, but only with respect to the conduct of a business of which you are the sole owner. b. A partnership or joint venture, you are an insured. Your members, your partners, and their spouses or domestic or civil partner are also insureds, but only with respect to the conduct of your business. C. A limited liability company; you are an insured. Your members are also insureds, but only with respect to the conduct of your business. Your managers are insureds, but only with respect to their duties as your managers. d. An organization other than a partnership, joint venture or limited liability company, you are an insured. Your "executive officers" and directors are insureds, but only with respect to their duties as your officers and directors. Your stockholders are also insureds, but only with respect to their liability as stockholders. e. A trust, you are an insured. 2. Each of the following is also an insured under Coverages A, B and C: a. Your "employees", other than either your"executive officers" (if you are an organization other than a partnership, joint venture or limited liability company) or your managers (if you are a limited liability company), but only for acts within the scope of their employment by you or while performing duties related to the conduct of your business. However, none of these "employees" is an insured for: (1) "Bodily injury"or "personal and advertising injury": (a) To you, to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability company), or to a co-"employee" while that co- "employee" is either in the course of his or her employment or performing duties related to the conduct of your business; (b) To the spouse, domestic or civil partner, child, parent, brother or sister of that co- "employee" as a consequence of Paragraph (1)(a) above; (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraphs (1)(a)or(b)above; or (d) Arising out of his or her providing or failing to provide health care services for which a professional designation or licensing is required by governmental authorities. (2) "Property damage"to property: (a) Owned, occupied or used by; CHF-GL-0001 2 2 Includes Copyrights material of Insurance Services Office, Inc. Page 16 of 36 (b) Rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by you, any of your "employees", any partner or member (if you are a partnership or joint venture), or any member(if you are a limited liability company). b. Any person (other than your "employee"), or any organization while acting as your real estate manager. C. Any person or organization having proper temporary custody of your property if you die, but only: (1) With respect to liability arising out of the maintenance or use of the property; and (2) Until your legal representative has been appointed. d. Your legal representative if you die, but only with respect to duties as such. That representative will have all your rights and duties under this policy. 3. Any person or organization that you have agreed by written contract or written agreement to add as an insured under this policy is an insured. However: a. Coverage under Coverage A and Coverage C, is limited to liability which: (1) Arises out of your ongoing operations; or (2) Arises out of"your work" performed by such person or organization for the Named Insured. b. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you entered into that written contract or written agreement; G. Coverage B does not apply to: (1) "property damage": (a) To that particular portion of "your work" performed on your behalf by the person or organization you have agreed by written contract or written agreement to add as an insured; and (b) That occurred before you entered into that written contract or written agreement. (2) "repair costs" for "Home Performance Failure(s)" taking place before you entered into that written contract or agreement. d. Coverage C does not apply to "personal and advertising injury" arising out of an offense committed before you entered into that written contract or written agreement; 4. Any organization you newly acquire or form, other than a partnership, joint venture or limited liability company, and over which you maintain ownership or majority interest, will qualify as an Insured if there is no other similar insurance available to that organization. However, with respect to the coverage afforded to any such organization: a. Coverage A does not apply to "bodily injury"or"property damage"that occurred before you acquired or formed that organization,- b. Coverage B does not apply to: CHF-GL-0001 2 2 Includes Copyrights material of Insurance Services Office, Inc. Page 17 of 36 (1) "repair costs" arising out of "Home Performance Failure(s)" in "homes" sold, given away or abandoned by that organization before you acquired or formed that organization; or (2) "property damage" to "your work" that occurred before you acquired or formed that organization;and C. Coverage C does not apply to "personal and advertising injury" arising out of an offense committed by that organization before you acquired or formed that organization. The coverage with respect to such organization is afforded only until the 90th day after you acquire or form the organization or the end of the policy period, whichever is earlier. SECTION III—LIMITS OF INSURANCE 1. The Limits of Insurance shown in the Declarations and the rules below fix the most we will pay regardless of the number of a. Insureds; b. Claims made or"suits"brought or"Requests for Repairs under a Home Performance Agreement", or C. Persons or organizations making claims or bringing "suits" or making "Requests for Repairs under a Home Performance Agreement". 2. The General Aggregate Limit is the most we will pay for the sure of: a. Damages under Coverage A, except damages because of "bodily injury" included in the "products- completed operations hazard",- b. Damages under Coverage C; and C. Damages under the Silica Each Occurrence/Offense Limit. 3. The Products-Completed Operations Aggregate Limit is the most we will pay for the sum of: a. Damages under Coverage A because of "bodily injury" included in the "products-completed operations hazard"; b. "Repair costs"under Coverage B because of"Home Performance Failure(s)"; and C. Damages under Coverage B because of "property damage" as a result of a "construction occurrence". 4. Subject to 2. above, the Personal and Advertising Injury Limit is the most we will pay under Coverage C for the sum of all damages because of all "personal and advertising injury" sustained by any one person or organization. 5. Subject to 2. or 3. above, whichever applies, the Each Occurrence/Construction Occurrence Limit is the most we will pay for damages under: a. Coverage A because of all "bodily injury' and "property damage"arising out of any one "occurrence"; or CHF-GL-0001 2 2 Includes Copyrights material of Insurance Services Office, Inc. Page 18 of 36