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ENC2018-00284
OF ' C4 -aa c C 0 °kcHnK�• CITY ®jF CAA4PBELL Public Works Department January 28, 2020 Thomas Harrington 105 Fremont Ave. #A Los Altos, CA 94022 SUBJECT: PERMIT NO. ENC 2018-00284 999 W. Hamilton Ave., Campbell, CA FINAL INSPECTION AND ACCEPTANCE Dear Mr. Harrington: The City of Campbell has made the final one year maintenance inspection of the subject Public Works improvements and finds that no remedial work is required. Your warranty requirements and any surety, therefore, are hereby released. AND The remaining 25% of your Faithful Performance Security deposit in the amount of $8,750.00 is enclosed. Sincerely, Syed Wa t 1 Public works Inspector Cc: Permit #ENC 2018-00284 70 North First Street Campbell, California 95008 TEL 408.866.2150 • FAX 408.376.0958 TDD 408.866.2790 Re'fundableQeposit .CheckRequesi' � , "'To' Finance,Director N ,.• Check Payable To T> homas Harrington'^ w • "Address- Line 1 -105 Fremont Ave.#A -Line 2:�° . - Stte ,CA 94022 City: Los Altos - Description:, :'NC2018-00284 999.W "Hamilton Av Account Number 101.2203 Amount 'i Sb'� -� , - , 'Account Number: 101.2203 , Amount: r Account Number: ' 101.5401448 Amount (Finance Dept only): "'"Interest Earned '(Finance-Dept only) t , Total Payable: x. 8,750.00 n (eXaccamounc) _r Purpose: Final25%,Deposit'refund - . Permit#! ENC2018.- 00284, - Receipt#:, 277865= Date 10/29/2018 I Receipt#, Date i , . - ,.• - - - e ues . - i R q ted by: City Inspector Date '1/16/2020 j .Syed hh'di Approved by Title`. Sr:Engineer: Date:" - .Roger rZ t :. s , Pate:' 1, r finance DeptAnly ," �•�� �v��ti��e - f Verified by.` . , Title:, Accounting Clerk II Date i Approved by Title: Accountant ' Date I Special Instructions: For Ha�ndli. � Check Mail As,is Mail,in Attached Envelope:; Interim-check I Needed By:, i Return To JoAnna,Thomason Public Works` _ 1 (Name) }(Department)m,. �, 3� GENERAL PERMIT CONDITIONS 1. The Permittee must provide evidence of insurance and Additional Insured Endorsements as required by the City.Insurance shall be maintained for the duration of the permit work. 2. A Construction Cash Deposit is required.Changes 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. 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. 5. Submit project schedule 10(ten)days prior to proposed start of work.Additional lead time may be required for work within City facilities and downtown Campbell. 6. The Permittee must request in writing a final inspection and acceptance of the work upon completion.Acceptance by the City will be made in writing to the Permittee. 7. Maintain safe pedestrian and vehicular crossings and free access to private driveways,bus stops,fire hydrants,and water valves. 8. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures,detours,and street closures.This plan must be reviewed and approved prior to any lane closures. 9. A Construction Traffic Control Plan shall conform to the 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 City Standards and Specifications at the sole expense of the Permittee as expeditiously as possible. 11. Sawcut for all PCC or AC removals.All PCC removals shall be to the nearest scoremark and new PCC shall be doweled to existing improvements. 12. Prior approval of inspector is required for any work proposed after normal working hours,on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 13. Work on arterials and collectors may require the use of changeable message boards.Adequate signing and barricading is required on the job site.Failure to provide such signing and barricading may result in the City's providing signing and barricades and'charging the cost(including all labor and materials)against the construction cash deposit. 14. Compaction testing of subgrade,base rock,and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 15. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction.Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m.to 4:00 p.m.and on weekends. 16. No storage of materials or equipment will be allowed near the edge of the pavement,the traveled way,or within the shoulderline which would create a hazardous condition to the public. 17. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a separate permit may be required,nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 18. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 19. This permit is not transferable.Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 20. Call back(call out)due to emergencies regarding this permit shall be at the current overtime rate with a three(3)hour minimum charge per occurrence. 21. Pursuant to Chapter 14.02 of the Campbell Municipal Code,applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water.Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. 22. If the public interest requires a modification of,or a departure from the permit,plans,special provisions and/or specifications,the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made. 23. Permittee 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 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. Said vault water shall not be discharged into the City of Campbell's storm drain system. See http://www.waterboards.ca.gov/water issues/programs/npdes/utilityvaults.shtml for more information. Applican ' e b esponsible for ens ' g that all hose providing services under the applicant are aware of and abide by all of the abo a conditi ns. Q Applican Date: Is Contractor (Print Na e) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.04/18 °F Imo• � Ca'A� � G "?CHAO CITY of CAMP13ELL Public Works Department January 7, 2019 Mr. Thomas Harrington 105 Fremont Ave., #A Los Altos, CA 94022 SUBJECT: PERMIT NO. ENC 2018-00284 999 W. Hamilton Ave. Campbell, CA FINAL INSPECTION AND ACCEPTANCE Dear Mr. Harrington: The City of Campbell has made a final inspection of subject Public Works improvements and-finds the work to be acceptable and in conformance with City standards. Accordingly, the City Engineer accepts the improvements. The one year maintenance period stated in the permit begins as of December 18, 2018. The permittee is responsible for the repair and/or replacement of any defective work or failures that.occur within one year. The City will inspect the improvements within one year and notify you, in writing, whether or not any repairs are required. 75% of your$35,000.00 Faithful Security Performance Deposit refund in the amount of $26,250.00 and your Construction Cash Deposit refund for$1,400.00 are being processed and will be sent to you under separate cover. The City will continue to hold 25% of your Faithful Performance Surety ($8,750.00) for the one-year maintenance period. If you have any questions,please call me at (408) 866-2165. tSic�'rely, S ed Wahidi Public Works Inspector Cc: Inspector/Susp'ense Files Permit File ENC2018-00284 70 North First Street • Campbell, California 95008-1436 TEL 408.866.2150 • FAX 408.376.0958 TDD 408.866.2790 Refundable -®ep®sit Check, Request To: Finance Director CheckPayable-To Thomas Harrington Address Line 1: '105 Fremont Ave.#A Line 2: City: Los altos State: CA Zip; 94022 Description: ''NC2018-00284 999.W:Hamilton Av Account Number: .101.2203 Amount: $26,250:0077 Account Number: 101.2203 - Amount: 1,400.00 `. Account Number:. 101.540.7448 Amount: (Finance Dept only). Interest Earned (Financ"e DeptonlO Total Payable. 27;P50.00 - , (Exactainount) Purpose.,; FPS•&Construction Cash.Debosit Refunds Permit#: ENC2018-00284 Receipt#._. :277865.._ Date: 10/29/201,8- - - Receipt# Date: Requested by Title`. City inspector Date 12/19/201.8" Syed•W6hidi Approved by:• Title; Sr..,Engineer ... Date .�Z Roger'Stori Date: - Todd Capurso P/W Director Finance Dept Only: Verified by Title: AIccounting:Clerk II. Date: . Approved by Title., Accountant "Date: 5- ecid . I 'strucl-io s � art lin :Ch ' ck _ Mall AS Is: Mail in Attached Envelope Interim GheCK: Needed By: Return To: JoAnna Thomason Public Works (Blame) (Department) PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1,2017 TO: Finance PUBLIC WORKS FILE NO. ENC2018-00284 PROPERTY ADDRESS 999 W Hamilton Ave Please collect&receipt for the following monies: ACCT ITEM LAND UEVEL•OPMENT' a AMOUNT 722 Encroachment Permit Application Fee Non-Utility Encroachment Permit Major>_ 10,000. $425.00 $425.00 `— Minor Encroachment Permit<gio 000 $240.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $240.00 Inspection Fee Minimum Charge per Location $420.00 Street Tree Planting/Removal ' N/C 2203 500 per Tree Planting Deposit Required) 500.00/tree 2203 Plan Check Deposit 2% of Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 47221 Grading& Drainage Plan Review Single Famil Lot $295.00 Site< 10,000 s.f. $885.00 Site? 10,000 s.f. <0.5 Acre $1 185.00 Site>0.5 Acre $1,772.00 4722 INPDES Review C3 Requirements) For projects not required to submit numeric sizing $175 00 For proiects required to submit numeric sizing Impervious Area 10,000 S . Ft to 1 Acre $740.00 Impervious Area 1 Acre or more $965.00 4722 For pro'ects sent to Consultant for review Consultant Cost+20% 4722 Additional treatment facilities 315 ea Plan Check&Inspection Fee (Non-Utility) 47221 En r. Est.<$250,000 14%of Engineer's Estimate $4 900.00 47221 En r.'Est.z 250 000 and 5 500 000 $35,000.00+8%of Engineers Estimate 47221 En r. Est. >$500 000 $55 000.00+7%of En ineers Estimate 1 • • • . 1 111MIL&AI=TMr l l 1 1 1 • 11' • • 111 11 � 22031 Labor and Materials Securit 100%of ENGR. EST.- 4721 Storm Drainage Area Fee Per Acre R-1 $2 120 00 (Multi-Res$2,385.00) All Other 2 650.00 4722 Parcel Ma 4 Lots or Less $4 200.00+ 90/lot 4722 Final Tract Ma 5 or More Lots 5 115.00+ 12411ot 2203 Monumentation Security 100%of Cit 's Monumentation Estimate 4920 Parkland Dedication Fee 75%/25% Due Upon Cert.of Occupancy) 4722 Lot Line Ad'ustment Includes Certificate of Compliance) 1 990.00 4722 Vacation of Public Streets &Easements $Z700.00 4722 Certificate of Compliance $1,970.00 47221 Certificate of Correction $590.00 47221 Document Recording Fees $15.00/first page 3 ea.Additional 4722 Private Improvement in Public ROW $100.00 4722 Approved Plan Revision Fee 100/sheet 4722 Appeal Filing Fee $200.00 730.4924 Notice of Improvement Obligation Pa ment 4722 Assessment Segregation or Reapportionment First Split $940.00 Each Additional Lot $295.00 511.74241 Postage 'MISCELLANEOUS — — ' Other Please Specify) / zmm-m1[M.RITT . .. - . `Engineer's Estimate shall be as approved by the City Engineer and shall include all ite s of work. TOTAL _ $41.725.Or NAME OF APPLICANT NAME OF PAYOR •� PHONE 0 • q4'l ad/ ADDRESS ex Vd Q zip FOR RECEIVED BY CITY CLERK NIL" r ONLY JZeceipt# ( I l:tl nnEUer\I'lan C.CcI Commenu\1-Specilc Prefec(r-ACGVC Prejert In ProgreSa\Nainig.n Ava Y!999(I Ae GrCenerJ(If cell!nef CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/21/2018 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: Imelda Orellana ONE Adlemi Trucking Insurance Services AICC,No,Et: 562-923-0333 aC No):562-923-8111 P O Box 2371 ADDRIESS: insurance@adlemi.net Downey, CA 90242 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: National General Insurance Company INSURED INSURER B Javier Rodriguez DBA Rodriguez Concrete INSURERC: 105 Sanchez Drive INSURERD: INSURER E Morgan Hill CA 95037 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE AI DOD ywp POLICY NUMBER MMIDDPOLICY EFF POLICY/YYYY Y MM DD/YYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMACLAIMS-MADE OCCUR PREMI O RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO JECT ❑LOC PRODUCTS-COMP/OP AGG $ OTHER: 1 $ A AUTOMOBILE LIABILITY X 2005729517 12/29/201712/29/2018 COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ x OWNED FXX SCHEDULEDBODILY INJURY Per accident $ AUTOS ONLY AUTOS ( )xHIRED NON-OWNED FIR ERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I ER ANYPROPRIETOR/PARTN ER/EXECUTIVE OFFICER/MEMBEREXCLUDED? ❑ N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) A - 2007 Volvo Tractor VIN#4V4NC9TG97N445641 Physical Damage $20,000 Deductible $1,000 - Non Owned Trailer 19__ ***CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED ON POLICY*** 1 CERTIFICATE HOLDER CANCELLATION City of Campbell SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 999 W. Hamilton Ave. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Campbell, CA 95008-1423 ACCORDANCE WITH THE POLICY PROVISIONS. Fax: 408-376-0958 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD A O® DATE IY(MM/DDYYY) (C> CERTIFICATE OF LIABILITY INSURANCE 1 1/1 912 01 8 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER;AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE FAX Automatic Data Processing Insurance Agency,Inc. AIc No EXt: A/c No): E-MAIL 1 Adp Boulevard ADDRESS: Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Markel Insurance Company 38970 INSURED INSURER B: RODRIGUEZ CONCRETE INSURER C: 1'05 Sanchez Dr. Morgan Hill,CA 95037 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1027830 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. I POLICY LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YYYY MM/DDIIYYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE F OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ECT LOC / PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Peraccident $ $ UMBRELLA LIAB .OCCUR EACH OCCURRENCE $ �EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OF EXCLUDED? ❑Y N/A Y MWC0052320-06 07/01/2018 07/01/2019 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1 000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Address:99 W Hamilton Ave,Campbell,CA,96008 This certificate has a blanket Waiver of Subrogation. __aC)e,- % CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE r THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Campbell ACCORDANCE WITH THE POLICY PROVISIONS. 70 North 1st Street Campbell,CA 95008 AUTHORIZED REPRESENTATIVE A©1988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD RODRI-1 ACORro" CERTIFICATE OF LIABILITY INSURANCE l DATE 11120/20/ YYy 11/20J2018 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 pollcy(les)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 858-874-0101 CONTACT Office Account NAME: Business Owner's Ins.Agency PHONE 858-874-0101 FAX 858-874-3801 Genesis Ins.Svcs USA,Inc. (AIC,No,Ext): (Arc,No): 3914 Murphy Canyon Rd.#A239 E-MAIL San Diego,CA 92123 ADDRESS: Office Account INSURERS AFFORDING COVERAGE NAIC# INSURER A:U.S.Specialty Ins.CO. INSURED RODRIGUEZ CONCRETE INSURERB: JAVIER RODRIGUEZ 105 Sanchez Drive INSURERC: Morgan Hill,CA 95037 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFYTHAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUB POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD MMIDDIYYY MMIDDIYYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE ®OCCUR y U15AC88161-03 07/07/2018 07/07/2019 PAEMAGETORENcED Ce $ 100,000 MED EXP(AnV oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY[X]JECT LOC PRODUCTS-COMPIOP AGG 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY Per accident $ HIRED N%OWED PROPERTYent DAMAGE AUTOS ONLY AUTOSo NLY Per accid $ A UMBRELLA LIAB X JOCCUR EACH OCCURRENCE $ 1,000,000 X EXCESS LIAB CLAIMS-MADE U15AC88161-03 07107/2018 07/07/2019 AGGREGATE $ 1,000,000 DED I X I RETENTION$ 0 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN TATUTE I I ER ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? N!A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The Cit of Campbell, its officers,employees and volunteers are named as addi ional insured for Project: 999 W.Hamilton Ave.,Campbel,Ca. Coverage is Primary and Non-Contributory if required by written contract per the attached endorsement. 10 days notice of cancellation if for nonp a mentJ30 days notice for all other reasons. I t 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 St. Campbell,CA 95008 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to-transact business in the State of California. TJ Name: �S, cj��-Cc�l�°� NAIC# ZRating: Authorized in CA: Name: a tKe'� 1J�S�f. Co NAIC# Rating: /� .-4v Authorized in CA: Name: W,I�ol � e�ca� NAIC# a3 7Z�S Rating: Authorized in CA: Name: �' NAIC# Rating: Authorized in CA: V,1 ZU 199, c1l�c�e ❑ Campbell Business License#,,,' Expiration: ❑ Contractors License A`� Olk-LO ♦ Class: Expiration: Expiration: Insurance Certificate.Reviewed In tials Date Copy of Insurance Certificate placed in tickler file one month prior to expiration,: l J:\FORMS\Templates\Insurance Requirements\Insu ran ce Requirements Cklist.doc (Rev 08 14) Page 2 KELLY'S CONCRETE & SOLD BY: BUILDING MATERIALS, INC. WEIGHED/ MEASURED AT: 44300 OLD WARM SPRINGS BLVD., FREMONT, CA 94538 PHONE: (510) 656-2368 (408)262-8630 TRUCK# DRIVER FAX: (510) 656-6359 n I 1 i"f'I••1 WE MAKE ALL DELIVERIES INSIDE CURB AND ON LOT AT CUSTOMERS RISK ONLY TIME LOADED AND ACCEPT NO RESPONSIBILITY FOR DAMAGES RESULTING FROM SUCH DELIVERY. 1 r;;%l� 1 'I F'i"'' fa tyl IT IS CUSTOMERS RESPONSIBILITY TO HANDLE THESE MATERIALS SAFELY AND ARRIVE JOB KELLY'S CONCRETE INC.! PROPERLY. �lt �7 WARNING: Materials are irritating to the skin and eyes because they contain Portland Cement,so wear rubber boots and START POUR gloves. Prolonged contact may cause burns. Avoid contact with eyes and prolonged contact with skin. In case of contact with with skin or eyes flush thoroughly with water. If irritation persists,get medical attention. Precaution must be observed because alkali burns occur with little warning and little heat is sensed. END QUR WEIGHMASTER CERTIFICATE Jf� THIS IS TO CERTIFY that the following described commodity was weighed,measured,or counted by a weighmaster,whose signature is on this certificate,who is a / ! recognized authority of accuracy,as prescribed by Chapter 7(commencing with Section 12700)of Division 5 of the California Business and Professions Code, ARRIVE PLANT administered by the Division of Measurement Standards of the California Department of Food and Agriculture. 1 WATER ADDED AT JOB: KELLY'S CONCRETE z,,, GALLONS DEPUTY WEIGHMASTER G.ttt°r- E TICKET CUSTOMER ID PHONE NUMBER JOB/P.O.NUMBER DAT SOLD TO DELIVER TO d.T:I�rF' €?!U _ ' t:w01,{C �1'� '_1 ►:� I•-iAl�`l.II_`t01'*.I —��l7li\1 70 rE • ry r P' LOAD# �SLUMP ��� '![/'1 7. QUANTITY QUANTITY PRODUCT PRODUCT UNITOF UNIT EXTENDED THIS LOAD DELIVERED CODE DESCRIPTION MEASURE PRICE PRICE I�`!l?! -), I IZ1 ��T � l�s �i h, •�' (J 1.•_'e1. 1<�IIJI 2 :a. 12)1f 1 00 1. Ic 0 EC,W F=E F EPd VTiRUMME-1,`-1� FEE, c cN "36. 0IZ--I :,3cn. 00 Gam,, W' CHI I=I! << �-1 1-L.S.'I FIDE: Or i2. I>ll c, —{ry' `TOTAL NIINIJTES``• " -"AL''L0VVED'MINUTES '" CHARGED MINUTES SUBTOTAL STAND BY CHARGE r,3 IL - SALES TAX 11.il. IDS;, If buyer fails to pay the amount owed when due,buyer agrees to pay monthly service charges equal to 1 t/2%per month (18%per annum)of the outstanding balance of principal due as liquidated damages. A SERVICE CHARGE of$40 will be charged on any returned check. Necessary ATTORNEY FEES,COLLECTION AND SUIT COSTS will be STAND BY charged on any unpaid bills. } } Kelly's Concrete will not be held liable�r responsible for the removal or replacement of an material once it is accepted and laced at the'obsite. OTHER • E2V. Ay"":.i.i,.` i�J��...._. TOTAL READY MIXED SAN JOSE PLANT 'GILROY PLANT 93273 1404 SOUTH 7TH STREET 6475 AUTOMALL PARKWAY WARNING c 0 SAN JOSE,.CA 95112 GILROY,CA 95020 (408) 848-1560 IRRITATION TO THE SKIN AND EYES ACCOUNTING:(408) 947-0669 Contains Portland Cement.Wear Rubber Boots and Gloves.PROLONGED CONTACT MAY IJALITY col— TE CAUSE BURNS.Avoid Contact with Eyes and Prolonged.Contact With Skin.In Case of FAX:(408) 947-0434 MORGAN HILL PLANT Contact With Skin or Eyes,Flush Thoroughly With Water.If Irritation Persists,Get Medical Attention,KEEP CHILDREN AWAY.° DISPATCH: (408) 947-0159 199 MAST ST. FAX:(408) 947-0193 MORGAN HILL,CA 95037 SOLD TO: (408)779-2520 �Jj1�c r SHIP TO: t�;d TatArar tan1t x•!'.E''<-, ( :i a tt r.l L. i 116 3t.' _ �•1a:4 t t Et 4 s. i / t ...t._t;.,th't :�'i' � F'il:_4 I i', �tl "�.1%.p(',(9 ;, of f Y. 13,3 TIME FORMULA LOAD SIZE YARDS ORDERED USE DRIVER/TRUCK MAP COORDINATE PLANT TRANSACTION# il�t :r ai.'t', ` i` S•t(s1 1, .° J {:�c::/:i B"r +.{. DATE CHARGE C.O.D. LOAD# ~YARDS DEL, BATCH# WATERTRIM SLUMP TICKET NUMBER ii rTs... .+.t r� Cj -_' qq t ry...r^,,•,,, t r 5i I T"-sPF'Glil BT7 bl GAGE RELEASE WEIGHMASTE,R CERTIFICATE Excessive Watei is Detrimental,to Concrete Performance (TO AE SIGNED IF'17FLIV�Y TQ BE MAKE INSIDE CURB LINE) Deal Cusurin -The driver f this truck is or ti gihis RELEASE to youl'r your signature isof theopinion THIS IS TO CERTIFY thaf;ftie following described com- H 0 Added B Re uest Authorized B that the'sies and weight of his truck may posse cause ddfri age to the premises and/.,adjacent property a 2 Y Q Y if he places the material In this load where you desire It.It fs:uur wish to help you in every way that we can, modify was weighed,measured,or counted by a but in order to do this the driver is requesting that you sigg'dlhis RELEASE relieving his and his supplier tram fj, any respansibility from any damage that may occur to'ih"brsmisses and/or adjacent property,buildings, weighmaster,whose signature is on this certificate,who GAL sidewalkks,drive-ways;curbs,etc.,by the-delivery of this;111fififinnnaterial,and that you also a gee to help him remove mud from the wbeat,of his vehicle so that he will not litter the public street.Further,as additional is a recognized authority of accuracy,as prescribed by CONCRETE is a PERISHABLE COMMODITY and BECOMES the PROPERTY of the PUR- consideration,the undersigned agrees to indemnity and hold harmless the driver of this truck and this supplier Chapter 7(commencing with section 12700)of Division CHASER WHEN TRUCK IS LOADED.ANY CHANGES or CANCELLATIONS of ORIGINAL for any and all damage to the.premises and/or adjacent property which may be claimed by anyone to have arisen out of delivery of this order.Junsdictinn and Venue.Sellerand Buyeragree that exclusive jurisdiction and 5 of California Business and Professions Code,adminis- INSTRUCTIONS MUST be TELEPHONED to the OFFICE BEFORE LOADING STARTS. venue a rising out of and related to the subject matter of this credit application and any sale ofgoods from Seller to tered b the Division of Measurement Standards of the The'undersigned promises to pay all costs;Including reasonable attorneys'fees, Buyer shall lie in the Superior Court of the State of California.County of Santa Clara. y incurred in collecting any sums owed. SIGNED California Department Of Food and Agriculture. All COD-s not paid at time of delivery will be charged a$50.00 Service Charge and bear n interest at the rate of 10%per annum. r r r r WEIGHMASTER Not responsible for Reactive Aggregate or Color Quality.No Claims For Such Allowed r r r •r 'r, r, r,• Unless Made at Time Material is Delivered. r r All _ A$50.00 Service Charge and Loss of Cash Discount will be Collected on all Returned LOAD RECEIVED BY:I LL=. 7-it_.i.' i Si I�.I., Checks- ExcessDelay Time Charged®$2.00/per minute QUANTITY CODE DESCRIPTION UNITPRI'CE EXTENDED PRICE :t`la :itc;t3{i . �� (1.t !, .';;!'.:l 1 .(':A 41-:-ft :?_V 0 1,. ,11;'a l:',r I'=.S.I f; I�'';)I'YY:t.. !`.I'-tiil i,I�:L1l,(e°li,.L!'.�Is-'i1�. ('.•{,:.i�, t?_..., ' r ' , P e "THERE WAS NO CONCRETE OR CEMENTITIOUS MATERIAL LEFT IN STREET OR STORM DRAIN BY STAR CONCRETE X RETURNED,TOPLANT LEFT JOB FINISH UNLOADING DELAY EXPLANATION/CYLINDERTEST TIMEALLOWED is fD; :c I� 1.JOB NOT READY 6.TRUCK BROKE DOWN T � , 2.SLOW POUR OR PUMP 7,ACCIDENT 3.TRUCK AHEAD ON JOB 8.CITATION LEFT PIANT ARRIVED.JOB STARTUNLOADING 4.CONTRACTOR BROKE DOWN 9.ADDRESS,, TIME DUE )( LI I Il L`=d 1 p,- 5.ADDED WATER 10.OTHER ADDITIONAL CHARGE 1 t'� • L� j, ERROR IN PRICE,EXTENS ION AND ADD ITION SU BJ CT TO(34-REf TIO N. TOTALROUNDTRIP TOTALATJOB UNLOADTIME DELAY TIME �ADDITIDNAL CUSTOMER COPY SUGGESTIONS FOR PLACING CONCRETE SLAB TO MINIMIZE RANDOM CRACKING WHAT YOU DO WHY YOU DO IT STEP 1. Level and compact sub grade, place 4" of STEP I. The sand.provides a cushion for the concrete damp sand and grade so concrete and good drainage. poured is a consistent depth. STEP'_. Separate your new concrete from all STEP . The felt separates your new concrete fro ni existing concrete with 1/2" felt. Felt must existing, so it may shrink, expand, move up match the depth of your new slab. or down without a detrimental affect. sTEP3. Screen off your concrete. STEP 3. Make sure there are no low spots. STEP 4. Roller bug your concrete. STEP4. Once over the Surface, it helps vibrate, con- solidate and give you a better finish. S 1'EP 5. Float concrete with wood.bull float only. STEP 5. Wood keeps the surface open and allows the concrete to bleed preventing water entrapment and discoloration and/or plastic cracking. STE P 6. Cut control joints perpendicular from edge STEP 6. These joints should allow the concrete to crack 1/4 the depth of the slab, using appropriate in the joint taking the path of least resistance. spacing. 4" slab would be 8'x8'. STEP 7. STE 117.S Allow all bleed water to evaporate from the If you do not wait for all bleed water to surface, then you can. finish the concrete evaporate, you end tip troweling your bleed with metal trowels. water back into the surface, drainatically changing your water/cernent ratio, on ffie surface, causing a weaker.surface. STEP S. When.surface is finished,spray with a concrete STEP 8. This protects the concrete from wind, heat cure, if the concrete is colored you must use a and allows your slab-to cure on its own cure formulated for colored concrete. giving you a much better finished product. STEP9. Never add water or dry cement to the STEP 9. These two things also change water/cement surface of your slab. ratio on the surface and can rui-n your slab. 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