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HomeMy WebLinkAboutENC2014-00042 �n / Print Form CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No to V 1 f- GG 2 DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File 1� 70 North First Street right-of-way) Application Date 2 -2 Lt .. 1 Campbell,CA 95008 Application Expiration Date B-Ztt Ph. (408)866-2150 Issued APN Fx. (408)376-0958 Permit Expiration Date APPLICATION-Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code,Section 11.04. (Application expires in six (6) months if the permit is not issued. Application Fee is non-refundable.) A. Work Address or Tract No.: , 5 5 Utility Trench Location: 46-and cfP _/dens B. Nature of Work: nk 'yam/ 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. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction;the General Permit Conditions listed on the reverse side;and the Special Provisions for this permit,listed below. Failure to abide by these conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. (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: /./e -T.. �/e a /1 ie 6r Telephone(140 4)A�_97 Address: `/lot /stb r'Ti/ A/40 6/#---34/ /� /,,v/F-1 of g�✓ E-Mail Address: _ellyzieArt eA61000.44HOUR EMERGENCY PHONE NUMBER: 89/-e78- c.1/ Is this work being done by the property owners at their own residence? r YES The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell,its officers,agents,and employees free,safe and harmless from any claim or demand for damages resulting from the work covered by this permit. The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all da yes arising out he c • f any private improvements in the public right-of-way. Accepted: (Aplcant Perris ee) (sign) Date (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 sent 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 NO. PERMIT APPLICATION FEE $ 3 7 7 PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK&INSPECTION FEE $ 3-7 7 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 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 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 be respon ' le for ensuring that all those providing services under the applicant are aware and understand all of the above conditions. /X plicant Date: Contractor (Print Name) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.02/14 TRACTOR&DEVELOPMENT,INc. License#749728 Underground Pipeline.Tractor Service mercial&Residential Anthony Cox Owner/Operator 1112 N.Matt..#301 -Bus.(209)824-9007 Manteca,CA 95336 Fax (209)824-8481 actractor@hotmail.com Cel.(408)891-0983 Storms Mains,Custom Drainage Sewer Mains,Septic Systems HDPE Poly Fusion(State Certified) Pipe Bursting Water Mains, PG&E Joint Trench Demolition Serving The Entire Bay Area And Central Valley ------ - ------- ------------- ------ ------- `` DATE OF NOTICE: FEB 13 2014 900 Old River Road Bakersfield CA 93311-9501 CODE: 28A AT1 12 A 000359 oosa NOTE: PLEASE NOTIFY STATE FARM AT THE CITY ST OF CAMPBELL 70 N 1ST C� ADDRESS LISTED AT THE TOP, LEFT CORNER CAMPBELL CA 95008-1459F THIS PAGE REGARDING ANY CHANGE OF FEBFE 1781:17ADDRESS INFORMATION. Public Work Admir�istrailorr III1IIIItIIr1IIuIII lh14uiII1IIII1IrII1Ilrrll1Ilrr1Illrrrl,IIII O 0 O 0 ADDITIONAL INSURED'S NOTICE OF COVERAGE State Farm Mutual Automobile Insurance Company 7794-FAD3J NAMED INSURED: POLICY NO: 271 4266-C10-55C COVERAGE: o COX,ANTHONY L YR/MAKE/MODEL: NONOWNED AUTO BI AND PD LIABILITY N DBA AC TRACTOR& DEVELOPMENT VIN/CAMPER: $1 MIL/$1 MILD 1 MIL • 1112 N MAIN ST#301 AGENT NAME: SFO MANTECA,CA i MANTECA CA 95336-3208 AGENT PHONE: (209)823-0556 tc ENDORSEMENT NO: 6028BU POLICY EFFECTIVE 6164DL 6165CP FEB 07 2014 UNTIL TERMINATED N• POLICY MESSAGES: This policy shown above supersedes policy#2714266-55B. co • The policy includes a loss payable clause protecting the additional insured's interest in the described car to the extent of the insurance • provided and subject to all policy provisions.The additional insured will be given 20 days notice if the policy is terminated. Until such notice u, is provided,it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of Pn any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. co ADDITIONAL INSURED'S NOTICE OF COVERAGE State Farm Mutual Automobile Insurance Company 7794-FAD3J NAMED INSURED: POLICY NO: 259 7871-B17-55H COVERAGE: COX,ANTHONY L& KATHY L YR/MAKE/MODEL: 1988 FORD FLAT BED BI AND PD LIABILITY DBA AC TRACTOR& DEVELOPMENT VIN/CAMPER: 1 FDMF60H4JVA26741 $1 MIL 1112 N MAIN ST#301 AGENT NAME: SFO MANTECA,CA $250 DED.COMP. MANTECA CA 95336-3208 AGENT PHONE: (209)823-0556 ENDORSEMENT NO: 6028BU POLICY EFFECTIVE FEB 11 2014 UNTIL TERMINATED POLICY MESSAGES: This policy shown above supersedes policy#2597871-55G. The policy includes a loss payable clause protecting the additional insured's interest in the described car to the extent of the insurance provided and subject to all policy provisions.The additional insured will be given 20 days notice if the policy is terminated. Until such notice - is provided,it shall be presumed that the required renewal premiums have been paid. The additional insured must notify us within 10 days of ° any change of interest or ownership coming to their attention. Failure to do so will render this policy null and void. ro .),L. 1)\°\ Co FRT ACTRACT-01 MATERAT AFRO. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 2/27/2014 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 Dawn Silver NAMEIOA Insurance Services-SAC PHONE (916)692-7000 FAX 473-1797 2180 Harvard Street,Suite 450 (AIC.No.Ext): (aC,No):(916) Sacramento,CA 95815 ADDRESS:Dawn.Silver@ioausa.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Mesa Underwriters Specialty insurance Company 36838 INSURED INSURER B: A C Tractor&Development INSURER C: 1112 N. Main Street PMB 301 INSURER D: Manteca,CA 95336-3208 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W LIMITS LTR INSR VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY X MP0081003001198 11/2/2013 11/2/2014 DAMAGES( RENTED 50,000 PREMISES(Ea occurrence) $ CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 X Blanket Additional PERSONAL&ADV INJURY $ 1,000,000 X Insured Endorsement GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS N BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (PER ACCIDENT) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE DED II $ RETENTION$ $ WORKERS COMPENSATION I TWC ORY A U- I I 0114- ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (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 (Attach ACORD 101,Additional Remarks Schedule,If more space is required) 2252 S Bascom Avenue,Campbell CA Permit No.ENC 2014-00042 City of Campbell,its officers,employees and volunteers are named as additional insured as respects to general liability,on a primary basis per written contract. 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. AUTHORIZED REPRESENTATIVE City of Campbell 70 N 1st Street I� 'Campbell,CA 95008 V(/ ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Page 1 of 1 JoAnna Thomason From: Anthony Cox[actractor@hotmail.com] Sent: Wednesday, February 26, 2014 5:53 PM To: JoAnna Thomason Subject: RE: Insurance for the City of Campbell The number for our Workers Comp. is 1-800-524-7024 Subject: FW: Insurance for the City of Campbell Date: Wed, 26 Feb 2014 16:13:38 -0800 From:joannat@cityofcampbell.com To: ACtractor@hotmail.com Hi Anthony, I am reviewing your insurance for the work you will be doing in Campbell. I need to have some additional information referenced on your Worker's Comp Certificate of Insurance. Do you have a contact name/number for them? Thank you, JoAnna JoAnna Thomason I Office Assistant Public Works Department Joannat@cityofcampbell.com 408.866.2150 I 45408.376-0958 (fax) 5,J 70.N.First Street I Campbell, CA 95008 www.CityofCampbell.com 2/27/2014 INSURANCE REQUIREMENTS CHECKLIST Permit# CIP Project# The following insurance is required of all contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: ❑ $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or ❑ $2,000,000 general aggregate limit. ❑ Policy expiration utomotive Liability: ❑ "Any Auto" checked on certificate ❑ $1,000,000 per accident for bodily injury and property damage ❑ Policy expiration date Workers' Compensation and Employer's Liability ❑ Waiver of Subrogation clause ❑ $1,000,000 per accident for bodily injury or disease ❑ Policy expiration date Course of Construction (if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date Re uire orsements to General Liabilit and Automobile Liabi ' 'es Additional Insured Endorsement ❑ The City, its officers, employees and volunteers are named as additional insured. ference Project Loc • ❑ The insurance coverage a or 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: C:\Documents and Settings\joannat\Desktop\Insurance Info\Insurance Requirements Cklist REV 3.13.doc(Revised 3.13) -1- ❑ Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. C:\Documents and Settings\joannat\Desktop\Insurance Info\Insurance Requirements Cklist REV 3.13.doc(Revised 3.13) -2- ❑ Workers' Compensation Insurance Sheet Submitted ❑ For General Contractor ❑ For Developer or Owner Acceptability of Insurer(s) o Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: NAIC# Rating: Authorized in CA: Name: NAIC# Rating: Authorized in CA: Name: NAIC# Rating: Authorized in CA: Name: NAIC# Rating: Authorized in CA: o Campbell Business License # Insurance Certificate Reviewed Initials Date o Copy of Insurance Certificate placed in tickler file one month prior to expiration. C:\Documents and Settings\joannat\Desktop\Insurance Info\Insurance Requirements Cklist REV 3.13.doc(Revised 3.13) -3- �,t/w.,✓ / (.cows./ crrt-Qf t�1Suf�,,tce, �� II ANTHLCO-01 BENI , COI?O CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 2/18/2014 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: Automatic Data Processing Insurance Agency,Inc PHONE r FAX 1 ADP Boulevard (A/c,No,Ext): I(A/c,No): Roseland,NJ 07068Z "o' E-MAIL IIr -��y-�- (� „' ADDRESS: tJv 1 INSURER(S)AFFORDING COVERAGE NAIC# _ INSURER A:Security National Insurance Company INSURED Anthony L Cox INSURER B: D.B.A A C TRACTOR AND DEVELOPMENT INSURER C: 1112 N Main Street Unit 301 INSURER D: Manteca, CA 95336 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR _ ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER IMM/DDIVYYY) (MWDD/YYYY) UMITS GENERAL UABILrTY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES SES(Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) S PERSONAL&ADV INJURY $ GENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S POLICY I PRO- JECT LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) -4 UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ WORKERS COMPENSATION WC STATU- 0TH- AND EMPLOYERS'LIABILITY X I TORY LIMITS I I ER A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N SWC 1027610 9/3/2013 9/3/2014 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE,$ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5 1,000,000 I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) This policy contains a specific waiver of subrogation in favor of the certificate holder 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. -2252 5-Baseom Ave- "10-V‘• V`'(S'' Campbell, CA 95008- AUTHORIZED REPRESENTATIVE © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD INSURANCE REQUIREMENTS CHECKLIST Permit# l= No -a0\k-k--"TjjOLkZ CIP Project# The following insurance is required of all 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: ,6.-- $1,000,000 per occurrence, and O $1,000,000 general aggregate limit applying separately to the project, or A $2,000,000 general aggregate limit. Policy expiration date Ni,\\y Automotive Liability: \\:ste O„Aos , S-`^p �ke& a '(\Or-\-pw-(ve o "Any Auto" checked on certificate . t.. $1,000,000 per accident for bodily injury and property damage 4 Policy expiration date `I-4\11 1 .q(V4 / 3(qpI14 \ `0 ( iy Workers' Compensation and Employer's Liability Waiver of Subrogation clause $1,000,000 per accident for bodily injury or disease — ( clot)- - Z.tt—'?O A1( o Policy expiration date (AI 5(Ii Course of Construction (if required in Special Provisions) ❑ Completed value of the project o Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement (Description of Operations Area) ,� The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location & Permit Number) •A The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation Area: o 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 Read Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. C:\Documents and Settings\joannat\Desktop\Insurance Requirements.doc(Rev 03/13) Page 1 of 1 ❑ Workers' Compensation Insurance Sheet Submitted ❑ For General Contractor ❑ For Developer or Owner Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: 4\1\ c, NAIC # 3(A 5 Rating: Authorized in CA: Name: # DS( Rating: Authorized in CA: Name: ScC..)- l N\\ iv\54 NAIC# Rating: Authorized in CA: Name: NAIC# Rating: Authorized in CA: /Campbell Business License # )`°�� a S G Links-- Insurance Certificate Reviewed Initials Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. C:\Documents and Settings\joannat\Desktop\Insurance Info\Insurance Requirements Cklist REV 4.12.doc(Rev 07/11) Page 2 of 2 INSURANCE REQUIREMENTS CHECKLIST Permit# CIP Project# The following insurance is required of all contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: ❑ $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or ❑ $2,000,000 general aggregate limit. ❑ Policy expiration date Automotive Liability: ❑ "Any Auto" checked on certificate ❑ $1,000,000 per accident for bodily injury and property damage ❑ Policy expiration date Workers' Compensation and Employer's Liability ❑ Waiver of Subrogation clause ❑ $1,000,000 per accident for bodily injury or disease ❑ 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 Endorsement ❑ The City, its officers, employees and volunteers are named as additional insured eference Project Location/Permit Number) —� ❑ The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR should say: C:\Documents and Settings\joannat\Desktop\Insurance Info\Insurance Requirements Cklist REV 3.13.doc(Revised 3.13) - 1- West Valley Sewer Connection Permit No: 41561 Sanitation District �`w Issue Date: 1 f qltA By: -'`.': OFFICE HOURS &CONTACTS: FEES: BACKFLOW PREVENTION: 7:30 a.m.to 4:30 p.m. Monday thru Friday Connection $ 100 E. Sunnyoaks Ave.,Campbell, CA 95008. Capacity Field check required •Phone:(408)378-2407 Processing Basement Service Advance •Information Services Department P De-"A o Check valve required: Yes_No— LOCATION: APN BUILDING SEWER CONNECTIONS: Sewer Map Book Page Tract Lot Total Due: $ [y Total number of connections to this Project Assmt property: Address `I_.'Sn —1.1 '"14. Paid by Check No: IA q i 1. Lateral ID No. is located Hillside: Yes No - Jurisdiction • — — feet of property line, feet from main sewer and BUILDING TYPE: INSTRUCTIONS: feet deep. Single Family •Permit is invalid if not connected within 12 Condo/Town House months of issue. Connection to Main Sewer feet Multiple Dwelling Units •Do not connect until the main sewer is accepted US from DS MH Industrial by the District. US MH Commercial •Obtain a building or plumbing permit from the Pipe Type Jurisdiction listed above. REMARKS: ...;..- •Street encroachment permit is required from } List any additional connections on •Keep 3'radius around cleanout clear of reverse side of this form. OLD PERMIT No.i?E Sub No. vegetation or obstruction. Original—Applicant Pink—Accounting Yellow—City/County Bldg. Inspector Card—District File ACTRACT-01 SILVERD ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 2/21/2014 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). CONTACT PRODUCER License#0E67768 NAME: Julia Baldwin IOA Insurance Services-SAC PHONE FAX 2180 Harvard Street,Suite 450 (ANC,No,Ern):(916y 692-7000 (,,O Ne 916 473-1797 Sacramento,CA 95815 EMAIL L_Z ADDRESS:Juha.Baldwin@ioausa.com INSURER(S)AFFORDING COVERAGE NAIC a INSURER A:Mesa Underwriters Specialty Insurance Company 36838 INSURED INSURER B A C Tractor&Development INSURER C: 1112 N.Main Street INSURER D PMB 301 Manteca,CA 95336-3208 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR ADOL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POUCY NUMBER (MMIOD/YYYY) (MMIDD/YYYY) LIMITS GENERAL UABILITY EACH OCCURRENCE 3 1,000,000 A X !COMMERCIAL GENERAL LIABILITY X MP0081003001198 11/2/2013 11/2/2014 DAMAGE TO RENTED PREMISES(Ea occurrence) $ 50,000 I CLAIMS-MADE I X OCCUR MED EXP(Any one person) S 5,000 X Blanket Additional PERSONAL li ADV INJURY $ 1,000,000 X Insured Endorsement GENERAL AGGREGATE 5 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS.COMP/OP AGG S 2,000,000 X POLICY )EI LOC LRY Ea dEerDit)Pita-0141T -_— AUTIOMOBILE LJABYJTY ANY AUTO BODILY INJURY(Per person) $ I ALL OWNED ! SCHEDULED BODILY INJURY(Per accident $ ,AUTOS AUTOS NON-OWNED (PER O ACC IDENT) DAMAGE S ... _. HIRED AUTOS AUTOS _ S UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE' AGGREGATE S ..{. CFO RETENTION S WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E L EACH ACCIDENT S (Mandatory in NH) E L DISEASE-EA EMPLOYEE $ It yes,descnbe under -- DESCRIPTION OF OPERATIONS below E L DISEASE•POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) City of Campbell,its officers,employees and volunteers are named as additional insured as respects to general liability per written contract. 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. AUTHORIZED REPRESENTATIVE City of Campbell 70 N 1st Street Campbell,CA 95008 ' ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD INSURANCE REQUIREMENTS CHECKLIST Permit # CIP Project # The following insurance is required of all contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggregate limit. ❑ Policy expiration date Automotive Liability: ❑ "Any Auto" checked on certificate ❑ $1,000,000 per accident for bodily injury and property damage ❑ Policy expiration date Workers' Compensation and Employer's Liability ❑ Waiver of Subrogation clause ❑ $1,000,000 per accident for bodily injury or disease ❑ 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 Endorsement ❑ The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) Z z,S-Z S. ry c PeJw � GNP H` O' �Z ❑ The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: sk,A 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: C:\Documents and Settings\joannat\Desktop\Insurance Info\Insurance Requirements Cklist REV 3.13.doc(Revised 3.13) - 1- 3 tulle Q RUFTCAT IS *SUED AS A MATTER Of INFORINATION ONLY AW CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRAIATIVUY OA NEGATIVELY ARE ND, EXTEND Oft ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE t S NOT CONS—MUTE A CONTRACT RET KEEN THE ISSUING INSURER*I. AkFTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER INN OiRTAl1T: E der thc*a braider Is NI ADDITIONAL*SUM, the Colic riee!remit be endereed:ITIOTINOCIATTON 1$1N'AIVIII,sauLtect In 1!w trams Crud cdncerbani eit its'Kitty,cartilin emcee no"'rebuke an tiodereenrierm A eistsenont dpi Ude C **Pc KIT carter rigs tts Fp Um Qer1lEtcelis CIer in Ow Of even*Pde Breen el• t+ a Ku**NettirtS a Ik In , ` '"Iii,,pj, IAA, 4i$420-4— i?rt't ,CA 953 Statism ee�. reitAtept 4 State Faun Genera!Itmen=ie a ny ettel ! a Anthony I&Kathy I COX 083,Y.RFR_o _a.._ .. - ,_. O A A C Tyr iS rtt �,� I 1112N Mate 14 01 IN@i'Tily Manteca,CA 95336 'wousurt F. t, THIS a TO CERTIFY Tt*,+4T THE POLICES OE ITIEARANGE ItSTEO 64 LOW HAVE EEEm tWitlEO TO THE FNSattFIED%AMU)ABOVE FOR 11 PO=Y PERO INDICATED NO1 MTHSTANDIND ANY NE'DUIREitENT, TERI*OR COROT]OOR OF ANY CONTRACT OR OTHER itif9't ;Atilt RF?PCCT TO INHICH THIS CERTtICATE MAY EE ISSUED OR MAY PEP"'AIN.THE INSURAIC E A FT OR DEO BY THE PC4i CI ES DESC RSf! REl$IS IIWECT TO AO. THE TERMS EXCL1J O4S AN4J GONDITDOMS De,SUCH POLIES.LM S SHOW MAY Ina$V OLEN RLOO ,D U`9 CI.AdA int tYFEOF AN�iCs ' '.. . _ I *Wil rt r r rs ' OCOTVE Cit*L IFENERAL UANII tY tete to..toeseCrr r ,t I v s. I 'L"K`cu ''r PC L jilt 11 1 a *AO";� I. r ""s. ,y CEWL.DORSGATELeiff MINESPER rF F a4c r. srb — Mum[71 ri stet .stwWtt&Lso 4 i A far w arq Y MI T871-017 55i^a 02'171'2'14 ITW1T i1♦I � t IA:aside a4MY Niro doper ewer sa'.cmis+a S , —, t--H,,. M 4\i 6O4 l:.lEd a '-BOORiTP'WOW' x-,T4e1J i tH D 271 42.5-C10-s ' it# .r2O14 01O,'Td11 . ;:»� ,..., , , t# AUTOS � NU? i?Pt0t is D&V14t kli Mtl,__..__. 1., !! LL st — - di. lietiMetilt.tArrti •— Ot cter I i�! OD;VITRL1f t $_ LwAT f GWvii6_At+ E T .,. DEE{t.,L, ra'E'sAtRiflrl t._� t kitO l on:As L*OUT! yew . - �^ aurerenrprcldar*ArsCnestarrtvt *tit CA. r� T 4dolidArtnry ltaip 'V,1:446.046 SA aaJPU 4 et*NIX Ic rs,X4rya#OV.k at , E,L. -*wort -f '4WT 1 s } CESCRITTICeOFCRUM1)W11rLTIC11lTe0WtV'Widda Es lot,Atl*t4NtRwialt; osrr+ti left******41m4414144 to moire* ENC,7D14-OO42 Lncaean-7'.252 S Rai:me AreR,Cane,CA IRROOI Al work in a public ri ei-cd4MaX. City c4 Campbell,to°ECG+rr7w employees and votunteers No nomad as edtatione ire eted. The Neely coveraige wedded by a Sim Farm ado paltry is pennant w t t-e pact to detrne arlasirg cut at the operation oll Me oescred wed*t i wil usually bet tome**vtiTh nesp*Ct to e covered non-owned sir. ND special endorsemert 4 try tar wade)to make average p1pirraryrsetdl reSp4,1 CO e cy I y artt'1!rw r►•caoiretkAoiy wit respects to c1this arisna out or the k'rierostt d arMirtianaf Insureds.Our I weeks tar itsatatl This tr•s..rarvaa is opener crtlte descnbed weetllril CERITFTCATE HOLDER CANCELLATION sate+air of Irk Attool eticibmap Poucits in coctuotb Iltr prrti City of C.mpbea THE E14PtWikTeON DATE THEREOF, NOTtCer waL DE DELIVERED at TO N 1 al Stole ACCORDANCE vrrrH THE POLICY FROM t]**. Campbell,CA O50011 outmosatiorrariti .., 1 714 ACt7 0AATl0N,AN tight*resdnielt ACOND2S1014`)1) The ACORD newt.and logo see negexteted rn,1rWielnon 10111486 1328 o a14 Page l of l JoAnna Thomason From: JoAnna Thomason Sent: Wednesday, February 26, 2014 4:09 PM To: 'Julia.baldwin@ioausa.com' Subject: Insr for A C Tractor Attachments: SKMBT_50114022616040.pdf Hi Julia, I am reviewing the COI for AC Tractor for work being performed in The City of Campbell. I will need additional wording referenced in the Description of Operations in regards to the primary insurance coverage for The City of Campbell. I will also need the job location (2252 S. Bascom Ave., Campbell CA) and the permit number (ENC2014-00042) referenced. When completed, please email the revised COI to me. I am attaching a copy of the insurance requirements for your reference. Please let me know if you have any questions. Thank you, JoAnna JoAnna Thomason J Office Assistant Public Works Department Joannat@cityofcampbeli.com V 408.866.2150 I ,A 408.376-0958 (fax) PZ 70. N.First Street j Campbell, CA 95008 www.CityofCampbell.com aLAcc_ ,O'/\ 2/26/2014 Page 1 of 1 JoAnna Thomason From: JoAnna Thomason Sent: Wednesday, February 26, 2014 4:14 PM To: 'ACtractor@hotmail.com' Subject: FW: Insurance for the City of Campbell Hi Anthony, I am reviewing your insurance for the work you will be doing in Campbell. I need to have some additional information referenced on your Worker's Comp Certificate of Insurance. Do you have a contact name/number for them? Thank you, JoAnna JoAnna Thomason I Office Assistant Public Works Department Joannat@cityofcampbell.com 'it 408.866.2150 I d4408.376-0958 (fax) ,O 70.N.First Street I Campbell, CA 95008 www.CityofCam pbell.corn 2/26/2014