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ENC2018-00231 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC 2018-00 231 Name: Summerhill Homes Property Address: Intersection of Burton Rd., and Los Gatos Blvd. Date of Final Inspection: On File: Bonds CD Cash Faithful Performance: $ Labor and Material: $ Construction Cash Deposit to be released: $ Other overdue deposits to be released (Description): Processed by: ak dmi 'strator Reviewed by: Inspector Reviewed by: Land Development Engine JAJoAnnaT\Deposit refunds\CHECKLISTS\l Checklist-Final Acceptance.doc(Rev. 10/11) YY) CERTIFICATE OF LIABILITY INSURANCEFDATE(MM/DDIYY DBlD3l2D 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 2 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT ADn Risk Services Southwest, Inc. NAME: ( Houston TX office " a"c°NN,Ext): (866) 283-7122 No.): (800) 363-0105 `y 5555 San Felipe E-MAIL —o suite 1500 ADDRESS: _ Houston TX 77056 USA INSURER(S)AFFORDING COVERAGE NAIC# INSURED - INSURERA: U.S, specialty Insurance CO 29599 DYnatest North America, Inc.. INSURERB: AXA Insurance Company 33022 Dynatest Consulting, 'Inc. 11415 Old .Roswell Rd., suite 100 INSURERC: Philadelphia Indemnity Insurance Company 18058 'Alpharetta GA 30009-2084 USA INSURERD: Tokio Marine Specialty Insurance Company 23850 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570072587768 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DDIYYYY MM/DDIYYYY LIMITS B X COMMERCIAL GENERAL LIABILITY PCS EACH OCCURRENCE $5,000,000 CLAIMS-MADE X❑OCCUR DAMAGE N $100,000 PREMISES Ea occurrence MED EXP(Any one person) $10,000 _ PERSONAL B.ADV INJURY _ $5,000,000 to GEN'LAGGREGATE LIMITAPPLIES PER: GENERALAGGREGATE $5,000,000 r- X POLICY ❑JET ❑LOC PRODUCTS-COMP/OPAGG $5,000,000 'OTHER: Deductible $35,342 0 n C AUTOMOBILE LIABILITY PHPK1770744 01/31/2 8 01/01/2019 COMBINED SINGLE LIMIT $1,000,000 Ea accident X ANYAUTO ^ ;� BODILY INJURY(Per person) 0 OWNED SCHEDULED �/, �' BODILY INJURY(Per accident) y AUTOS ONLY AUTOS ^ ' HIRED AUTOS NON-OWNED - ,\v\6 PROPERTY DAMAGE V ONLY AUTOS ONLY Per accident) X Coll Ded$1000 X Comp Ded$1000 :E D UMBRELLA LIAR. X OCCUR PUB616346 01/31/2018 01/01/2019 EACH OCCURRENCE $9,000,000 U X EXCESS LIAB CLAIMS-MADE AGGREGATE - DED RETENTION - WORKERSCOMPENSATIONAND PER OTH- EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? H N I A _ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT A E&o-PL-Primary, U551728132 10/31/2017 01/01/2019 Per Claim/Aggregate $2,000,000 Claims Made Deductible $35,000# DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) City of Campbell is included as Additional Insured in accordance with the policy provisions of the General Liability policy. A waiver of subrogation is ggranted in favor of City of Campbell in accordance with the policy provisions of the General Liability, rc- Automobile.LYability and umbrella Liability policies. CERTIFICATE HOLDER• CANCELLATION - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH.THE POLICY PROVISIONS. City Of Campbell AUTHORIZED REPRESENTATIVE - • 70 North 1st street Campbell CA 95008 USA ©1988-2016 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD A 08/07/ CERTIFICATE OF LIABILITY INSURANCE DATD/YYYY) 8/07/18 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 endorsements. PRODUCER CONTACT Aon Risk Services,Inc of Florida Aon Risk Services,Inc of Florida NAME: 1001 Brickell Bay Drive,Suite#1100 PHONE FAX Miami,FL 33131-4937 A/C,No,Ext:800-743-8130 A/C,Noy 800-522-7514 EMAIL ADDRESS: ADP.Col.Center@Aon.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: American Home Assurance Co. 19380 INSURED INSURER B: ADP TotalSource DE IV,Inc. 10200 Sunset Drive INSURER C: Miami,FL 33173 L/C/F INSURER D: Dynatest North America Inc INSURER E 11415 Old Roswell Road Alpharetta,GA 30009 INSURER F: COVERAGES CERTIFICATE NUMBER:2152210 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIMITS SHOWN ARE AS REQUESTED. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD MM/DD/YYYY MM/DD/YYYY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ El OCCUR DAMAGE TO RENTED CLAIMS-MADE PREMISES Ea occurrence $ MED EXP(Any oneperson) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 71PROJECTEILOC PRODUCTS-COMP/OP AGG $ OTHER $ COMBINED SINGLE LIMIT acc AUTOMOBILE LIABILITY Ea ident $ ANY AUTO BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEC RETENTION$ WORKERS COMPENSATION X PER OTH- A AND EMPLOYERS'LIABILITY Y/N WC 047018714 CA 07/01/18 07/01/19 STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED' N/A X E.L.EACH ACCIDENT $ 2,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 2,000,000 Ifs,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) All worksite employees working for DYNATEST NORTH AMERICA INC,paid under ADP TOTALSOURCE,INC's payroll,are covered under the above stated policy. WAIVER OF SUBROGATION IN FAVOR OF CERTIFICATE HOLDER AS RESPECTS OF JOB PERFORMED BY DYNATEST NORTH AMERICA INC AS REQUIRED BY WRITTEN CONTRACT. Re:100 feet north of the intersection of Burton Road and Los Gatos Boulevard CERTIFICATE HOLDER CANCELLATION City of Campbell SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 70 North 1st Street, THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Campbell,CA 95008 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE p ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 1 ® DATE(MMIDDIYYYY) '41`�R�' CERTIFICATE OF LIABILITY INSURANCE 08/07/18 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..lf 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 Aon Risk Services,Inc of Florida NAME: Aon Risk Services,Inc of Florida 1001 Brickell Bay Drive,Suite#1100 PHONE FAX Miami,FL 33131 A937 A/C,No,Ext:800-743-8130 A/C,No):800-522-7514 EMAIL ADDRESS: ADP.Col.Center@Aon.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: American Home Assurance Co. 19380 INSURED INSURER B: ADP TotalScurce DE IV,Inc. 10200 Sunset Drive INSURER C: Miami,FL 33173 UCIF INSURER D: Dynatest North America Inc INSURER E: 11415 Old Roswell Road Alpharetta,GA 30009 INSURER F: COVERAGES CERTIFICATE NUMBER:2152210 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIMITS SHOWN ARE AS REQUESTED. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR VIVID MMIDDIYYYY MM/DD/YYYY 47CA MERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED LIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any oneperson) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY F1 PROJECT❑LOC PRODUCTS-COMP/OP AGG $ OTHER $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident $ ANY AUTO BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEC I I RETENTION$ WORKERS COMPENSATION X PER OTH- A AND EMPLOYERS'LIABILITY Y/N WC 047018714 CA 07/01/18 07/01/19 STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ E.L.EACH ACCIDENT $ 2,000,000 N/A X (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 2,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) All worksite employees working for DYNATEST NORTH AMERICA INC,paid underADP TOTALSOURCE,INC's payroll,are covered under the above stated policy. WAIVER OF SUBROGATION IN FAVOR OF CERTIFICATE HOLDER AS RESPECTS OF JOB PERFORMED BY DYNATEST NORTH AMERICA INC AS REQUIRED BY WRITTEN CONTRACT. Re:100 feet north of the intersection of Burton Road and Los Gatos Boulevard CERTIFICATE HOLDER CANCELLATION City of Campbell SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 70 North 1st Street, THE EXPIRATION DATE THEREOF, •NOTICE WILL BE DELIVERED IN Campbell,CA 95008 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks.of ACORD INSURANCE REQUIREMENTS CHECKLIST Permit# CIP Project#.. Consultant/Contractor: � �GkeS �' � ���C-�— 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 o $1,000,000 general aggregate limit applying separately to'the project, or $2,000,000 general aggregate limit.- �(—Plolicy expiration date 1 \ utomotive Liability: "Any Auto" checked on certificate >d_" $1,0004000 per accident for bodily injury and property damage Policy expiration date 1 Workers' Compensation and Employer's Liability —7 ; Waiver of Subrogation clause V F;>[$1,000,000 per accident for bodily injur or,disease CC-t� ,/ �C � �Poiicy expiration date Course of Construction (if required in Special Provisions) Ei Completed value of the project - Ei Policy expiration date Required Endorsements to Generol Liability and Automobile Liability Policies Additional Insured Endorsement: 6` -6The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area should say: Should any of the above described policies be cancelled before the expiration date thereof,notice will 1� be delivered in accordance with the policy provisions. Workers' Compensation Insurance Sheet Submitted V For.General Contractor Eor Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev Jan 2018) Page 1 ' r Acceptability of lrisurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: �� �,ASf- CO - NAIC# Rating: Authorized in CA: Name: P`V'`�Q e&1&a. NAIC# Rating: Authorized in CA. Name: --k.nAer NSS`r NAIC# 1 R380 Rating: x Authorized in CA: Name: NAIC# Rating: Authorized in CA: ❑ Campbell Business License# Expiration: C®.�� ❑ Contractors License# Class: Expiration: Insurance Certificate Reviewed Initials Dat ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration.. ,t J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 i 0 ACO® DAT D(MMID201 ) 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 A certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Aon Risk Services Southwest, Inc. PHONE (866) 283-7122 FAX (800) 363-0105 Houston TX Office (A/C.No.Ext): A/C.No. 5555 San Felipe E-MAIL p suite 1500 ADDRESS: _ Houston TX 77056 USA i INSURER(S)AFFORDING COVERAGE NAIC s/ INSURED INSURERA: U.S. specialty insurance CO 29599 Dynatest North America, Inc. INSURERB: AXA Insurance Company 33022 Dynatest Consulting, Inc. 11415 Old Roswell Rd., suite 100 INSURERC: Philadelphia indemnity insurance Company 18058 Alpharetta GA 30009-2084 USA INSURERD: Tokio Marine specialty Insurance Company 23850 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570072587768 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER,DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested LTR TYPE OF INSURANCE IN'Sol WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS B X COMMERCIAL GENERAL LIABILITY PCS EACH OCCURRENCE $5,000,000 CLAIMS-MADE ❑X OCCUR PREMISES Ea occurrence) $100,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $5,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $5,000,000 m X POLICY ❑�E 0. LOC PRODUCTS-COMP/OP AGG $5,000,000 n OTHER: Deductible $351342 6 C PHPK1770744 01/31/2018 01/01/2019 COMBINED SINGLE LIMIT U1 AUTOMOBILE LIABILITY $1,OOO,OOO Ea accident X ANYAUTO BODILY INJURY(Per person) Z OWNED SCHEDULED BODILY INJURY(Per accident) y AUTOS ONLY AUTOS — HIRED AUTOS NON-OWNED PROPERTY DAMAGE ONLY AUTOS ONLY (Per accident Xy0—N „ Coll Ded$1000 X Comp Ded$1000 d D UMBRELLALIAB H OCCUR PUB616346 01/31/2018 01/01/2019 EACH OCCURRENCE $9,000,005 V X EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTION WORKERS COMPENSATION AND PER OTH- EMPLOYERS'LIABILITY Y/N STATUTE I ER ANY PROPRIETOR/PARTNER/EXECUTIVE El NIA EACH ACCIDENT OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT A E&O-P<-Primary Uss1728132 10/31/2017 01/01/2019 Per Claim/Aggregate $2,000,000 Claims Made Deductible $35,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of Campbell is included as Additional insured in accordance with the policy provisions of the General Liability polic A - waiver of subrogation is granted in favor of City of Campbell in accordance with the policy provisions of the General y � Liability, Automobile Liability and Umbrella Liability policies. 'Y1 r 3�G -- Oa 31 I .a. CERTIFICATE HOLDER CANCELLATION S SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE- POLICY PROVISIONS. _ City of Campbell AUTHORIZED REPRESENTATIVE • 70 North 1st street Campbell CA 95008 USA s ?V � r�JL - Jqc ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD V CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No,: I t_N c. DEPT.OF PUBLIC WORKS (for working within the x-Ref. File 70 North First Street public right-of-way) Application Date Ph.( belly CA 21SO issued-- Application Expiration Date �!511-f Ph.(4p8)86ti-2350 Fx. (408)376-0958 rU rG Permit Expiration Date APN��„�,_••� APPLICATION-App lication is hereby made fora Public W orks Permit in accordance with Campbell MunicipalCode,Section 11.04.(Application expires in six (6) months if the permit Is not Issued. Application Fee is non-refundable,) A. workaddress: 100 feet north of the intersection of Burton Road and Los Gatos Blvd. B Nature ofwork/Utliity Placement of traffic control devices along Los Gatos Blvd/Bascom Avenue for Trench Location: pavement coring in Los Gatos, _ ® No Fee Permit forwork related to city Project Project Name: North 40 C. Attach four(4)copies of an engineered plan showing the location and extent of the work,and four(4)copies of the preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground Improvements. When approved by the City Engineer,said plan becomes a part of this permit. D. Allworkshall conform tothe City ofCampballStan dardSpeclflcaticnse nd Details for Public Works Construction;the General Permit Con ditions 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 deposlts, E. The Contractor must have this permit and approved plans at the site and must notlfythe Public Works Department at leasttwo days before startingwork. Notice must be given to Public Works at least 24 hours before restarting any work. Name of Applicant: SummerHlll Homes Telephone: (650)842-2268 Address: 3000 Executive Parkway, Suite 4450, San Ramon, CA 94583 E-MallAddress: KEbrahimi@shhomes,com 24-HOUR EMERGENCY PHONE NUMBER: (650)842-2268 is this work being done by the property owners at their own residence? 11 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 Applirant/Permittee hereby acknowledges that they have read and understand both the,-front and back of this permit, and they will Inform their contractor(s)of the Information.Applicant is advised that upon Issuance of this permit, property owner, or property owner's successors, shall be responsible for a ny and all damages.arising out of rmprovemeW completeWn-tide pa5i c�rl�ht-of•wa , ate K Lam ON " (Contractor) (Print Name) Date SPECIAL PROVISIONS: _,t 1 Street shall not be open cut for underground installations.Minimum cuts maybe allowed for connections orexploration holes.Such cuts maybe enar�®ifiran%,. nvrri h the he Inc nr rip cto-ulting. 2. Pavement'may be cut for underground installatiuns and must be restored in accordance with the Standard Details irench Restoration Metl,od "A",unless otherwise approved by the F-nginr'er. 3. Work to be slaked by a licensed Land Surveyor or Civil Engineer and two(2)copies of the cut sheets sent to the Public Works Department before startingwork. 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: 1.800-227-26W. 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. 1 otifica' e nts `J 7• TC-P W It i 6 -GU el-IIQ if= 51Di✓WA%_ i5 CtoGE_t> 1:702 2 Rja/N I v�J PU IC WOR S SC DULE FOR C R T FEES AMOUNT L TNO PERMIT APPLICATION FEE PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCEILABOR&MATERIALS CONSTRUCTION CASH DEPOSIT $ PLAN CHECK&INSPECTION FEE $ 2G 7C� EMERGENCY PERMIT FEE f ` o APPROVED FOR ISSUANCE rorCity Engineer Date Permit Expires 12 Months After Date of Issuance GLUNE I PER yit�'ONDITION§.: J 1, The Permittee must provide evidence of insurance and Additlonai Insured Endorsements as required by the City.Insurance shall be maintained for the duration of tha permitwork, 2. A Construction Cash Deposit is required.Changes will he 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, 3. Refund of the construction 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, 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. S. Submit project schedule 10(ten)days prior to proposed start of work,Additional lead time may be required for workwith(n City fedlities 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 watervaives. S. A Construction Tragic 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 most recent version of the California Manual on Uniform Traffic Control Devices(MUTCD), 10. Replace,as directed by the City Engineer,any damaged or removed improvements In accordance with Cfty 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 seoremark and new PCC shall be doweled to existing Improvements. 12. Priorapproval of Inspector is required for any work proposed after normal working hours,an 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 resultin the Clty's providing signing and barricades and charging the cost(including all7abor 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 timesduring constructlon.Contractor or Permittee shall provide a phone numberat which they can be contacted outside the hours of 8:00 a.m.to 4:00 p.m.and on weekends. 15. No storage of materials or equipment will be allowed near the edge of the pavement,the traveled way,orwithin the shoulderline which would create a hazardous condition to the public, 17. This permit shalt not be construed as authorization for excavation and grading on private property adjacent to the work crony other work for which a separate permit maybe required,nor does it reileye the Permittee of any obligation to obtaln anyother permit required by law. 19, This permit does not release the Permittee from anyliabilities 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 ParmIttee or-his designated agent or contractor as specified thereon, 20. Call back(tail out)due to emergencies regarding this permit shall be at the current overtime rate with a three(3)hour minimum charge per occurrence. 22. Pursuant to Chapter 14.02 ofthe Campbell Municipal code,applicant shall,not cause to be discharged anymeterfal Into the municipal storm drain system otherthan 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 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 spectfy the manner in which the some Is to be made. 23, Perm(ttee must provide advance notification to,all parties that maybe affected by the permit activities,Notification shall be revlawed by the City priorto distribuuon and include dates ofwork and a contact name and a phone:number, 24. Applicant shall remove water from utility vaults In accordance with the requirements of state Water Resources control Board Water Quality order WQ 2014-0174- DWQ,Sold voultwater shall not be discharged Into the City of Campbell's storm drain system. See htto:Nwww.waterboardsca.sey water issues(programs/npdesluu(ityvaults.shtml,for more information. Applicant Is hereby responsible for ensuring that all th a providing se under the applicant are aware of and abide by all of the above conditions, 8/3/2018 Applicant Date: S merHill Kew rahimi 8/3/2018 Contractor (PrintName) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2,pdf Rev.04/18 TRAFFIC CONTROL PLANS CORING LARK AVE & LOS GATOS BLVD LOS GATOS, CALIFORNIA CITY OF CAMPBELL c^may \ • /J�RrgL o0'r/ '►/ owe ply, � 9t�' s,�o CONTRACTOR Gin yob CONSULTANT crn or crn'or o WORK LOCATION ' 00 - ALM E DAR I Z SAMARITAN DR CONTACT: IAN McCREERY ALMENDARIZ CONSULTING,INC. PHONE" (408)215-7007 1136 SUNCAST LN STE 9 EL DORADO HILLS,CA 95762 Di N (888)306-1211 OFFICE (888)768-7022 FAX Theselmg'1co(hwellansarebeingprovidedtoyo CI hlldr request Thelnformationcontained herelnistheexduslve prpperty of A tolpla, CA C31 LIC"979806 k�LF m m,`I O Consehing,lnc(herein after referred to as'ACI'1.ACl holds the exclusive rightto reproduce distribute,and tlisplay[hese tnKcce,fg,[an;aswell ^ Fy as the exduslve right to prepare work Eased upon Ne tlesign depicted.ConsWttipn plans,hlueprints,and computer-gene rateddeslgnlmagazare A � spZ the S.At tetlender Wlled 5 Py6copyrigM1[slaws.TM1e rightwprepare works based upon there[onsvuRion plans is spttifirally protetted under the US.ArNitecwal Works CapydgM1t ProteNon Act. Z CFRLTGN^JF __. 9y attepting lhese-ffic control plan;you agree that you will notreproduce,distribute,or display them in any way(except as agreed),and will not REVISIONS PRO.IECT NO. ISO93S pmpareany derivative works based upon the design depitted,prcau...ny derivatives works be created based upon the design depltted to be v prepared by a third Party. ¢��,OFz� DRAWN CJV 'O DESIGNED JEL AnY Party who reproduces,dirtributes,or displaystM1ese[mffic control plans,orprepares anywork based upon the design depicted,wihout the CHECKED CAA expres;written[Down[ofAClmay be rublecttalegalproceedingifor,fiet.ht infringementandbreacho(mntractaz wel—twl phi ,rith.ul theelvtolalion t ropydght,resulting in liability for monetary damage;floes,and jail time.Any work createtl from these mns[ruc[ion plans without the expres;written consent of ACI may be sublet[to a court ordertp stop work DATE wC JULY 9,2019 SHEET NO. I OF 3 CITY GENERAL NOTES 1. NOTHING ALLOWED IN THE BUFFER AND TRANSITION AREAS AT ALL TIMES. - TABLES CHART-2014 MUTCD(REV 3 2. SIGNS ARE ONLY SHOWING TO THE PUBLIC WHEN IN USE. 3. SIGNS AND CHANNELIZING DEVICES MUST BE RETROREFLECTIVE OR ILLUMINATED DURING NIGHT OPERATIONS. Te Mini...no,L,,QffiS Maxlmum 4. SIGN PANEL SIZES: 36"X36" MIN.ON ROADS<50mph,48"x48"ON ROADS 2 50mph. posted Taper(L) Buffer 10• 11• 12' 'Cone spacing Sign Spacing 5. SIGNS ARE SPACED PER THE CA 2014 MUTCD(REVISION 3)MANUAL. Speed F-1. Spam Offset offset onset - L 112L 1KIL L 1/2L 113E L 12L 113L @ @ @ rar sectia� 6. CHANNELIZING DEVICES SPACING AND TAPER LENGTHS ARE BASED ON THEIR RESPECTIVE CHARTS. (SEE CHARTS Memo Shm Shoulder Memo Shift Shoulder Me me Shift Shoulder Ta er Tan en1 Conflict L 6C.oa THIS PAGE) 25 159 104' 57 35' 116 Sr 38' 125' 63' 42' 25' 1 50' 12' 109.200' = 7. NOTIFY THE LOCAL LAW ENFORCEMENT,FIRE,AND AMBULANCE COMPANIES WITHIN 72 HOURS BEFORE 30 L 200' 150• 7S 50' 166 83' SS 180' 90' 60' 30' 1 60' ts• 120'-240'35 250 204' 102' 68, z s 117 75' 245' 123' 82' 3s• 70' 1T 140'-280' CONSTRUCTION BEGINS. 40 305' P67' 13T 89' 293' 147' 98' 320' 160' 10T 40' 80' 20' 160'-320' 45 360' 4 1 a 4 1 5 1804 90 6 - 8. CONTRACTOR TO MAKE SURE ALL TRAFFIC CONTROL EQUIPMENT MEETS ALL AGENCY REQUIREMENTS. so 425' 600' 250' 16]' 550' 275' 183' 600' 300' 200' so, 100, 25' 400'-600' 9. REMOVE ALL CONFLICTING MARKINGS FOR LONG TERM OPERATIONS 3 DAYS OR LONGER). ss L=WS 49s' sso' z7s• lea• fins 303' 202' fi60' 330' 220' S0' 100' 2s' 440'-660' ( ) 60 570 600' 300' 200' 660' 330' 220' 729 360' 240' 5T 1go' 25 a80'-]20' 10. THE LOCATION OF THE SIGNS AS SHOWN ON THE ILLUSTRATIONS ARE GUIDELINES AND ACTUAL LOCATIONS WILL 65 645' 650. 325 21T 716 358' 238' 780' 390' 260' 50' 100 25' szo•-7eo DEPEND UPON ALIGNMENT,GRADE,LOCATION OF STREET INTERSECTIONS AND 85%TILE POSTED SPEED LIMITS. 70 730' 700' 350' 233' T70' 385' 257' 840' 420' 280' S0' 100, 25' Sfi9-840' 11. WHILE CROSSING INTERSECTIONS DURING MOBILE WORK,WORK MUST FOLLOW THE FLOW OF TRAFFIC AND Both are based on. L=Taper Length 'Cones shown on the templates are Illustration p,mosm only. 1.)85th%Tile or If not available,then use S=Speed Exact number of mnes required shall be based on cone spacing, PROCEED ON A GREEN LIGHT. Posted Speed Limit(PSL) W=Width(Offset from path of travel teper lengths.actual field mndidar,at,.. 12. FULL COMPLIANCE IS REQUIRED WITH THE CITY AGENCY. The mnmci spacings nanbousedonhatermodlateandShan- ma 13. PEDESTRIAN ACCESS MUST BE MAINTAINED AS PER THE CA 2014 MUTCD(REVISION 3)STANDARDS AND ADA pr.,-far tape,and ungentSemions.nem them amno REQUIREMENTS. pavement markings or he.there IS a conflict between existing pavement markings and cheuneliz- 14. C30SIG SPACIIGNS NG PERMITTED IN BUFFER AREAS. CA MUTCD 2014 TABLE 6C-� 15. SIGN SPACING IS PROVIDED IN THE CA MUTCD 2014 EDITION(REVISION 3),PART 6.TRAFFIC SPEEDS ARE BASED UPON RADAR MEASUREMENTS OF MOTORISTS.THE MUTCD ALLOWS FOR A"RANGE"IN SIGN PLACEMENT AND WILL BE MEANING OF LETTER CODES ON TYPICAL APPLICATION DIAGRAMS PROVIDED BY DOT.THE 85%TILE IS USED WHEN AVAILABLE TO PROVIDE A MORE ACCURATE REPRESENTATION OF DISTANCE BETWEEN SIGNS MOTORISTS SPEEDS. ROAD TYPE A e C 16. ANY WORK WITHIN 200 FT OF A SIGNALIZED INTERSECTION WILL REQUIRE CONTACT AND COORDINATION WITH CITY URBAN(LOW SPEED)-25 MPH OR LESS 100 FEET 10o FEET 100 FEET AGENCY PRIOR TO ANY WORK. URBAN(LOW SPEED)-MORE THAN 25 MPH T040 MPH 250 FEET 250 FEET 250 FEET 17. QUALITY STANDARD TO MEET REQUIREMENTS OF SECTION 1A-2 OF THE CALIFORNIA MANUAL ON UNIFORM TRAFFIC URBAN(HIGHSPEED)-MORE THAN40 MPH 350 FEET 350 FEET 350 FEET RURAL 500FEET 500FEET 500FEET CONTROL DEVICES. EXPRESSWAY/FREEWAY 1,000 FrEl 1,500 FEET 2,640 FEET 18. ALL TRAFFIC CONTROL DEVICES INCLUDING:SIGNS,BARRICADES,VERTICAL PANELS,DRUMS,WARNING LIGHTS, ARROWBOARDS,CHANGEABLE MESSAGE SIGNS,CONES AND TUBULAR MARKERS THAT MEET THE REQUIREMENTS OF AMERICAN TRAFFIC SAFETY SERVICES ASSOCIATION(ATSSA).CA MUTCD 2014(REVISION 3)SHALL BE USED ON THIS PROJECT/THIS WORK. 19. THE NCHRP REPORT 476 PROVIDES GUIDELINES FOR DESIGN AND OPERATION OF NIGHTTIME TRAFFIC CONTROL FOR HIGHWAY MAINTENANCE AND CONSTRUCTION.SEE TYPICAL APPLICATIONS NWTA-1 THROUGH NWTA-7.COMPLY WITH ANSI 107-2004 FOR APPAREL.HIGHWAY CONSTRUCTION WORK LIGHTING SHALL BE PER CONSTRUCTION SAFETY ORDER 1523(CALIFORNIA CODE OF REGULATIONS TITLE 8,DIVISIONI,CHAPTER 4,SUBCHAPTER 4,ARTICLE 3, SECTION 1523-ILLUMINATIONS). 20. SIDEWALKS AT THE CONSTRUCTION LOCATION MAY BE CLOSED WITH ADEQUATE DETOURS.SIDEWALKS MAY ONLY BE CLOSED TO THROUGH TRAFFIC AND SHALL NOT PREVENT LOCAL PEDESTRIANS ACCESS.DETOURS SHALL NOT INCREASE THE PATH OF TRAVEL BY MORE THAN 500 FT.DETOUR ROUTES SHALL BE LIMITED TO EXISTING SIDEWALKS, PRIVATE PROPERTIES(SEE BELOW REQUIREMENTS)AND CROSSINGS AT ROADWAY INTERSECTIONS.TO THE MAXIMUM EXTENT FEASIBLE,THE ALTERNATE CIRCULATION PATH SHALL BE PROVIDED ON THE SAME SIDE OF THE STREET AS THE DISRUPTED ROUTE.WHERE IT IS FEASIBLE TO PROVIDE A SAME-SIDE ALTERNATE CIRCULATION PATH AND PEDESTRIANS WILL BE DETOURED,SECTION 6D.02 OF THE CA 2014 MUTCD(REVISION 3)SPECIFIES THAT THE ALTERNATE PATH PROVIDE A SIMILAR LEVEL OF ACCESSIBILITY TO THAT OF THE EXISTING DISRUPTED ROUTE.THIS MAY INCLUDE THE INCORPORATION OF ACCESSIBLE PEDESTRIAN SIGNALS(APB),CURB RAMPS,OR OTHER ACCESSIBILITY FEATURES. 21. PEDESTRIANS MAY BE DETOURED ONTO PRIVATE PROPERTY ONLY IF WRITTEN PERMISSION FROM THE PROPERTY OWNER IS OBTAINED ALONG WITH DOCUMENTATION INDICATING THAT THE CITY WOULD NOT BE LIABLE(HOLD HARMLESS)IN THE EVENT OF AN ACCIDENT. 22. DURING WORK HOURS,AT LEAST ONE WORKER SHALL BE ASSIGNED WITH THE RESPONSIBILITY TO ESCORT ELDERLY, DISABLED OR ANY OTHER PEDESTRIANS IN NEED OF ASSISTANCE THROUGH THE CONSTRUCTION SITE.A WORKER ASSIGNED WITH THIS RESPONSIBILITY MAY ALSO PARTICIPATE IN OTHER CONSTRUCTION ACTIVITIES;HOWEVER,THE ASSIGNED WORKER SHALL BE AWARE OF HIS OR HER RESPONSIBILITIES FOR PROVIDING THIS ASSISTANCE. MEASURES THAT SIMPLY CLOSE THE SIDEWALK,WITH THE EXCEPTION THAT PEDESTRIANS WILL CROSS SOMEWHERE ELSE DOES NOT ADEQUATELY SATISFY PEDESTRIAN ACCESS.PEDESTRIANS SHOULD NEVER BE DIRECTED/ EXPECTED TO CROSS A MULTI-LANE ROADWAY AT ANY LOCATION OTHER THAN AT A SIGNAL(OR ALL-WAY STOP). ACCOMMODATIONS SHOULD BE MADE ON THE SAME SIDE OF ROADWAY AS WORK. REVISIONS PROJECrNO. 180935 EEa mrar Las DRAWN CJV a DESIGNED JEL ' v,N SHEET a,NovEpW e CHECKED CAA DATE o eovrwaW0NnTEwni0r ENonnacorvsul .os. JULY9,201S SHEET NO. 2 OF 3 LOCATION H-11 Htj Lu I r ! 0 CITY OF 1,03 GATOS I CITY OF L'11 PDLLL \ � W a ` D �i � O%. 1 r \ N C r I \ � 1 yBUFFER': 11 v li O 'ti 50' ME h E TAPER Z 4` V I t ; ,a;215. TANGENT MERGETAPER�(V Q WORKAREA ` Pvi \* i l 1 3 .,' rI 245' M Pi H-11 CLOSED is LOS GATOS BLVD ° fP ' I W \ i po` ix T `� .t \ t 21 -- ----- _----- __ -� z ' >C11 tx cLol""se0 ' 7 ( Q 'x \ 02 \ \ CITY OF \ SAN JOSL SYMBOLLEGEND s � �• S'y,� ` 'ice`\�\ � xs i p,'',. i O \\S 1 8\ ze wxe 1 �r it�S1\ NOTES MATCHLINE B - SHEET 3.2 • CONTRACTOR SHALL MAINTAINIPROVIDE ACCESS TO ALL DRIVEWAYS AFFECTED BY THE WORK AREA • CONTRACTOR SHALL ASSIGN A WORKER TO ASSIST t•1 rvvE niaw PEDESTRIANS AROUND WORK AREA • CONTRACTOR SHALL MAINTAIN A MINIMUM 4'PATH OF TRAVEL FOR PEDESTRIANS. • W20-7(ROAD WORK AHEAD)S IGNS SHALL BE PLACED ON ® E rosEPuceozzxouuwwvaxcE ALL S10E STREETS BETWEEN THE WORK AREA AND THE FIRSTSIGN ENCOUNTERED BY TRAFFIC ON THE HWY. Las 100 0 SO 100 MAXIMUM CHANNELONG DEVICE SPACING FOR ALL ra�c axvawewvosrery • SPEEDS ON DOWNSTREAM TAPERS IS 20'. FAS CONST.HOURS: 9:00AM-3:00PM MON-THU REVISIONS ALMENDARIZ LOCATION LOS GATOS BLVD,LOS GATOS,CALIFORNIA PRCIIECTNO. 180935 --- ROAOS<50MPH: ROADS250 MPH. DRAWN CJV r ra11-1xac,P—OVLascnioa cae zo�v.or.lz 4E) MINIMUM 3ESIGNPANELS _,MINIMUM 40'SIGN PANELS 48-SIGNS MAY BE USED '^ G-E DESIGNED JEL seraMovty uca.Las,arvl ( ) •'% CONTACT:IAN M-11RY CHECKED CAA 1196 SUNCAST LN STE 9 � . PHONE' (40S12i"r]M1] —IMx txEusEOPaKYACCo7ExT. LL UORAUO HILLS CA 90 G2 DATE E erEurzPuts�TwC1UDEOWna9PAx , (SBS)306-121I OFFICE (888)76S-722FA% m # L'CI EXC2Lt?f:CB s CA C31 LIC•97980G - - JULY 9,2018 SHEET NO.3.1 OF 3 LOCATION H-11 SYMBOLLEGEND NOTES CONTRACTOR SHALL MAINTAIN/PROVIDE ACCESS TO ALL ei- consmucrwu sNH DRIVEWAYS AFFECTED BY THE WORK AREA • CONTRACTOR SHALL ASSIGN A WORKER TO ASSIST FlnacER PEDESTRIANS AROUND WORKAREA. • CONTRACTOR SHALL MAINTAIN A MINIMUM d'PATH OF TRAVEL FOR PEDESTRIANS. ` to cuvE� W20-1(ROAD WORK AHEAD)SIGNS SHALL BE PLACED ON - ALL SIDE STREETS BETWEEN THE WORKAREA AND THE FIRST SIGN ENCOUNTERED BY TRAFFIC ON THE HWY. • MAXIMUMCHANNELIZING DEVICE SPACING FOR ALL MATCHLINE B - SHEET 3.1 w-I TVPE1�Ps SPEEDS ON OOWNSTREAM TAPERS IS 20'm e aq `,1 II a t 1 M ¢runcM BrFAiCeoE I Kry x'j' ® T_FAS PIA�EorzHonR�ovAwN.cE rusrenc Nwoweoa+nswn �� lk 1 250 ROAD EXPECT M (NS)�JI; @F- (M250S) (NTS)� -r HUFAa%o EU,xS IIUTn.iES1) S JP/C M/SA FLASH FLASH2 H3 W � NE `t LA SPA _ FSHI FLASH2 FLASH3 25' GIN 1 <* (n I , 9CONES �3� "N° s 255PACING 1 Q --- PCMS r - -- - - __-----__-_- __ i--------- z ---=------------------------ ------------------------- ----_ S BASCOM AVEip I I 35 p N2 cn p m 100 0 50 100 CONST.HOURS: 9:OOAM-3:OOPM MON-THU REVISIONS AL��N®��la OCATION LOSGATOSBLVD,LOSGATOS,CALIFORNIA PROJECT NO. 180935 ROADS<50 MPH' ROADS t 50 MPH: DRAWN CJ\' I Moo WORKHRS.PERLTYOFILSGATOS w. zolaoT.ls in vwo¢.MINIMUM 36'SIGN PANELS �.` MINIMUM 48'SIGN PANELS . ,,. DESIGNED JEL K1uc5,a H-I tea' (4W SIGNS MAYBE USED) TM� z HETVPuxsHEETs w•OvsOE awls wrem.ls ^ CHECKED CAA ) 1130 SUNCAST LN STE 9 CONTACT:IAN McLREERV L` PHONE' NN)21,-RM7 E ussaFurcAccwENr, EL UOKADOHILLSCA 9a752 u�(` DATE aINEUOnR¢coNsuLTlrvo ncnxotnEOGEs No aESPOns�e urcIN1H - vuuHvoROEnrHoccuRaHoouauwrrvsus9aPrHESEPuns lB881306-12110FFICE 1998)769-7022 FAX ' Purl AT HOTTOSEouFucnrED=,StlYANV ON Normc�wEOw OO—Ot ....... naC{ "GL'IiEfIG+.,"'.'.,.,,.. JULY 9,2019 of ngoaow�a. CA O3I LIC•979e06 - Y SHEET NO.32 OF 3 Summelr ill Const(SHN40)LLC CITCAM01 CITY OF CAMPBELL <I?gFE' INVOICE,NO �"'DESCRIPTION "INVOICEAMOUNT ;`,DEDUCTION BALANCE—". ". 8-07-18`CKREQ080718 393 .01 N 40 ENCROA 660.00 660.00 ' CHEC RECK DATE K 8-08-18 ,..�uMBER 1064 TOTAL> 660.001 660.00 " PLEASE DETACH AND RETAIN FOR YOUR RECORDS SummerHill Const(SHN40)LLC CITCAM01 CITY OF CAMPBELL DATE INVOICE NO: DESCRIPTION INVOICE AMOUNT DEDUCTION BALANCE 8-07-18 CKREQ080718 393.01 N 40 ENCROA 660.00 660.00 r DATE CHECK 8-08-18 NUMBER CHECK 1064 TOTAL> 660.00 660.00 PLEASE DETACH AND RETAIN FOR YOUR RECORDS .3a BY. qr PAga G¥Smw gbea DATE- mdym REGISTER k£; 0R4wG SM ; RkgelG A E mS 2:D g q61 Seam»& FILING $24600 TEST 3:mc+ 2, a gmam2y SQOF ' wm.m --------- q»Lme $kam TORGm km.m m77: wm tam » ° ' !ws m F me 1064 • . PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1,2017 TO: Finance PUBLIC WORKS FILE NO. `C 2 �� - GG 2?j PROPERTY ADDRESS Pct. `— Please collect&receipt for the followin monies Fr ti Lfill(w} '+.rf 2+zl .$. —4. •�. S qT i"rkF '^ i Y+� L aACICT ' ITEM s _ _ Y t� r L AMr)l�tT r LAND DE1/ELOP..;MENT. Y r ° 1 R. t�. 1? r �?: kT- -4722 Encroachment Permit Application fee Non-Utility Encroachment Permit Major>_$10 000 $425.00 Minor Encroachment Permit<sio,odo $240.00 v Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $240.00 lns ection Fee.Minimum Charge per Location $420.00 20 Street Tree Planting/Removal N/C 2203 ($500 per Tree Plantinq 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 4722.1 Grading&Drainage Plan Review - Single Family Lot $295.00 Site<10 000 s.f. $885.00 Site?10,OOD s.f. <0.5 Acre $1' 185.00 " Site'a 0.5 Acre $1 772.00 4722 NPD.ES Review C3 Requirements) For projects not required to submit numeric sizing $175:00 For projects required to submit numeric sizing Impervious Area 10,000 S .Ft to 1 Acre $740.00 Impervious Area 1 Acre or more $985.00 4722 For proiects.sent to:Consultant for review Consultant Cost+20% 4722 Additional treatment facilitie's .$315 ea _ Plan Check-&Ins ection Fee`Non-.Utili 47221 En e.Est.<$25000D 4%of'Engineer's Estimate 47221 En.gr. Est.>_$250,0.00'and:5$500,00.0 $35,000:00+'8%of Engineers Estimate 47221 En r. Est. >$5D0 000 $55 000.D0+7%of Engineers Estimate 2203.1 Emerqency Cash Deposit 4% cif Engr. Est.*($500 min/$10,0Do Max 22031 Faithful Performance Securi FPS 10D%:of ENGR. EST.* 22031 Labor and Materials Security 100%of EN.GR. EST.* 4721 Storm Drainage Area Fee Pet Acre R71 $2,120.00 . (Multi=R.es$2,385.0b) (All:Other$2,650.DO) 4.722_ Parcel Map.(4 Lots or Less) $4,200.0:0+:$90/1ot . .4722 Final`Tract'Map(5..or More Lots) .$5,115:00+$124/lot 2203 Mondmentation'Security 100✓0 o'f.C'itV's Monumentation Estimate 4920 -Parkland Dedication Fee 75%0/25%Due Upon Celt: of Occupancy) -4722 Lot Line Adjustment(includes Certificate OfCompliance) $1,99.0.0,0 4722 Vacation of Public Streets & Easements $2,700..00 4722 Certificate of Compliance $1,97.0.0.0 4722 Certificate of Correction $690.00 4722 Document Recording Fees $15.DD/first page$3 ea.Additional 4722 Private improvement in Public RDW $100.'00 4722 Approved Plan Revision Fee $100/sheet 4722 Appeal Filing Fee $200.00 730:4924 Notice of Improvement Obligation Payment 22 Assessment'segregation or Keapportionment First Split $940.00 Each Additional Lot $295.00 511.74241 Postage VtISCELL=AN I RCIt,S ;_ ;: ,.;.�+.,, _ c.•:;: ,. _.>.,�.�.'� ......_.�_,.. NP .... .rw > .tip..<„ �x ,,�:.w Win_ _:....Y.:�ti c _,.•r•m Other(PleaseSpecify) 'Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. TOTAL $ C 6 C) NAME OF APPLICANT Nl�'1Li•�lL j�1.�`� NAME OF PAYOR -�jt�i�t�(`�2ii'i(�. ( O 1�� PHONE 4DDRESS �x C v M1� lCt�� Z(56 S'��, RA rvt vL,\ ZIP ti. � `.f - r c 9.. -t -y` ,,,, c` +z �-�. i } l_ T7..,�1 3 t..4-u t ^TS�t G �Y FOR RECE1VED`°BY Z .. .r�`�_ ? ti.�,� v 2 _c _. s �� � u. � . a.�''_k s��z +. •1.+ r; 'F [. :ITYCLERK .� �`�� `k CnNi v .Date _ �:..... -��_r., � Rscetpt+# �+,,.•.: h, r W, x, 'r..,i_a j -*�,�` � � � ,,� � x '" s WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT-CALIFORNIA This endorsement changes the policy to which it is attached effective on inception date of the policy unless a different date is indicated below. (The following"attaching clause"need be completed only when this endorsement is issued subsequent to preparation of the policy). This endorsement. Effective on 08/07/2018 at 12:01 AM,forms a part of Policy No.WC 047018714 Issued to: ADP TotalSource DE IV, Inc. By: American Home Assurance Co. 10200 Sunset Drive Miami, FL 33173 L/C/F Dynatest North America Inc 11415 Old Roswell Road Alpharetta, GA 30009 Premium: N/A 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 Additional Premium Percent%of the California workers'compensation premium otherwise due on such remuneration. Schedule Person or Organization City of Campbell 70 North 1 st Street, Campbell,CA 95008 WC 04 03 06 Countersigned by (Ed. 4-84) Authorized Representative J LL r i y L - � r c J i