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HomeMy WebLinkAboutENC2014-00086 • • (�� Print Form ) /,� CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No —1 �C / l_Xit/�ll/ DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File ( ��//70 North First Street right-of-way) Application Date Campbell,CA 95008 Issued 4/ I / I Application Expiration Date Ph. (408)866-2150 APN Fx. (408)376-0958 Permit Expiration Date /it 5 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.: 50 ' KQnn,e1r)..0__ Utility Trench Location: 5/{nn brno B. Nature of Work: ��V l/ 6" L)≤h ZC C t iC. L k t 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 �b 7e given to Public Works at least 24 hours before restarting any work. / Name of Applicant: � ` Telephone: 405.—�j_ ✓q( f O20 Address: KU-) 1_ `t✓I I (/1 C� E-Mail Address: ..e2MOkrnc�/)I, con-124-HOUR EMERGENCY PHONE NUMBER: Is this work being done by the property owners at their own residence? r YES r 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 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 inf a ion. t is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all damag s arising out he condition of any private improvements in the public right-of-way. Accepted: (Applicant Ffrmi ee (sign) Date 5er flit', ,INc, /OT►�rDa Y r' , ro st/%�1c (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. V . 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 SCHED LE FOR CURRENT FEES AMOU T RECEI°T Nn - a PERMIT APPLICATION FEE r $ "5 9.0 O Z5 K 3 1 PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT $ ,^ PLAN CHECK&INSPECTION FEE $ i D 15 Z9 3 EMERGENCY PERMIT FEE - $ APPROVED FOR ISSUANCE f I1 / For ity 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 resnonsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions. </(r//y Applicant Date: 47 e 4-40 /dC, ,9 mAQ't A2 r CO Wi' ' Contractor (Print Name) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.02/14 PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT,TRAFFIC & MISCELLANEOUS RECEIPT Effective July 1, 2013 TO: City Clerk ( lr iLt C(.\ PUBLIC WORKS FILE NO. PROPERTY ADDRESS 50(c--1 Kann ) fire, Please collect & receipt for the following monies: rr::AMOUNT ITEM I z ENCROACHMENT PERMIT Q 4722 Utility Encroachment Permit Application Fee $377.00 R-1 Encroachment Permit N/C Emergency Permits $107.00 Plan Check&Inspection Fee ') Minimum Charge Per Location $377.00 Conduits/Pipelines up to 500 Feet $2.50/ft Above 500 Linear Feet $1.55/ft Manholes/Vaults/Etc. $165.00/ea Pole Set/Removal $165.00/ea 4760 Storage Container Permit $153.00 4760 Project Plans &Specifications Project No. 4760 Standard Specifications& Details $1/Pg$15.50/Bk 4760 Engineering Maps& Plans Aerial Plot 24"x 36" $60.00 Aerial Print 8 1/2"x 11" $28.00 Map Research(includes max of two 24"x36"copies) $28.00 Maps and Plans 24"x 36" $14.00 4722 Penalties: Failure to restore public improvements $100/Calendar Day(Muni Code Sec. 11.34.010) 4722 Penalties: Failure to correct unsafe conditions $100/Calendar Day 4 Times Applicable Fee 4722 Work Without Permits p a �, Fir :rA a -� r a pan'n. tf K 'r Y� �`, .�!- �`s �,& "g �,. a`A'*ar:.ri.,...... ,^�Y,i�� i. < ,-1:117,x1 TRAF�JV °$`✓� uy2���r„¢ ' �ka"y',. `+�:..,.-�^, r^tiM^.. s '�m�2'n.w�t �' .a 4728 Traffic Flow Map (Daily Traffic Volumes) $35.00 4728 Signal Timing Information 73 4271 Truck Permits $16.00 per trip 4728 No Parking Signs $1 each or$25/100 511.7424 Postage Other(Please Specify) ( _ TOTAL (-/_ NAME OF APPLICANT �7C, / �� PHONE NAME OF PAYOR ADDRESS 11 ALL _ ZIP )-S`t_tr'W j - 4 �kySx✓ rl���'l� �: '4N'5"ii`'+�' FOR RECEIV D BY ,t4 ° � m � ��r '�'��� 'x:�����^ � � CITY CLERK _;` % w ONLY rrr n r) k.x rn fly h hY . CD ill M Z t cr`h ,i r.Y i r7 d �''y Cry +-.-i 7[.i CD c--. O ,,,,C7.1 tv ,ems'.. - •. — x r +r r T Cry V -yT CD C O . • ri.`..7 43 1 . t.., rt� C7 C t C� ca r f. Ah. .a '" Y tv 1 iv C.4 #Y ,..,. GJ CD 1 ...3 r..1 .O CCD--.7.) CD iI �..i v r) CD PO I :T C.,7 O4 INSURANCE REQUIREMENTS CHECKLIST Permit# LN 2,O\ 6(e. CIP Project# Consultant/Contractor: L ckl 1�\w� -i-'c The following insurance is required of all consQaltants/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: )ef---$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. Policy expiration date Z-1/„ / 5 Automotive Liability: "Any Auto” checked on certificate x$1,000,000 per accident for bodil injury and property damage Policy expiration date '11 i Workers' Compensation and Employer's Liability o Waiver of Subrogation clause o $1,000,000 per accident for bodily injury or disease o Policy expiration date Course of Construction (if required in Special Provisions) o Completed value of the project o Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement: ��i The 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: 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 say: Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. o Workers' Compensation Insurance Sheet Submitted For General Contractor o For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 02 14) Page 1 Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: J\? Q\ae•luJit r iS NAIC# 6?:.3(6(6 Rating: `K�\ 1 Authorized in CA: Name: \14 Name: cE,ge NAIC# /944SRating: /Al Authorized in CA: Name: edeSt-4.1'c l NAIC# Rating: /4.c. /X"J Authorized in CA: Name: — - \,ekk' l yetkic# Rating: Authorized in CA: Campbell Business License # 07,5 61(0 • Expiration: 3/3 / 13 Insurance Certificate Reviewed Initials Date Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 02 14) Page 2 ....------oN t≥D DATE(MM/DD/YYYY) �J►�!2[7 CERTIFI�., rE OF LIABILITY INSURAN... _ 04/09/2014 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 Dan Ellsworth PRODUCER Adobe Insurance Brokers, LLC NAME: 18181 Butterfield Blvd #170 n/c°.No.Extl:855-236-2356 I (WC,No): 855-236-0001 E-MAIL Morgan Hill CA 95037 ADDRESS: dan@adobebrokers.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Mesa Underwriters Insurance Co 36838 INSURED Break Away Concrete Cutting, Inc INSURER B: National Union Fire Insurance 19445a P.O BOX 13037 INSURER C: Everest National Insurance Company 10120 COYOTE CA 95013 INSURER D: The Hartford 11000 INSURER E: Liberty Mutual 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 INSD VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED _ I CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $ 100,000 MED EXP(Any one person) $ A Y Y MP0081003000882 02/13/2014 02/13/2015 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X jE LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY ` COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) I X ANY AUTO BODILY INJURY(Per person) $ EALL OWNED SCHEDULED ABODILY INJURY(Per accident) $ X HIJR DSAUTOS X NON-OWNED N N 1076694 11/09/2013 11/09/2014 PROPERTOSTY DAMAGE $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 B EXCESS LIAB CLAIMS-MADE N N BE084763747 02/13/2014 02/13/2015 AGGREGATE $ 3,000,000 DED I X RETENTION$ 10,000 $ WORKERS COMPENSATION X STATUTE I'Fr - AND EMPLOYERS'LIABILITY CANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? N/A Y 7600006107131 10/01/2013 10/01/2014 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 D N N 57SBADO0645 02/13/2014 02/13/2015 1 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Reference Project Location - 506 Kenneth Ave. Campbell CA 95008, Permit #ENC2014-00086. The City, its officers, employees and volunteers are named as additional insured. This insurance coverage afforded to the Additional Insured is primary insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Campbell THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 70 N. First St. ACCORDANCE WITH THE POLICY PROVISIONS. Campbell, CA 95008 AUTHORIZED REPRESENTATIVE Joannat@cityofcampbell.com g61, ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT,TRAFFIC & MISCELLANEOUS RECEIPT Effective July 1, 2013 TO: City Clerk PUBLIC WORKS FILE NO. �( PROPERTY ADDRESS 30_(C) Kenn LA, ;()_/'re., Please collect & receipt for the following monies: AMouNT ACCT. I ITEM ENCROACHMENT PERMIT , <� ..,, .:.� 4722 Utility Encroachment Permit Application Fee e $377.00 ' R-1 Encroachment Permit N/C Emergency Permits $107.00 Plan Check&Inspection Fee r Minimum Charge Per Location $377.00 37�`()v Conduits/Pipelines up to 500 Feet $2.50/ft Above 500 Linear Feet $1.55/ft ManholesNaults/Etc. $165.00/ea Pole Set/Removal $165.00/ea 4760 Storage Container Permit $153.00 4760 Project Plans&Specifications Project No. 4760 Standard Specifications&Details $1/Pg$15 50/Bk 4760 Engineering Maps& Plans Aerial Plot 24"x 36" $60.00 Aerial Print 8 1/2"x 11" $28.00 Map Research (includes max of two 24"x36"copies) $28.00 Maps and Plans 24"x 36" $14.00 4722 Penalties: Failure to restore public improvements $100/Calendar Day(Muni Code Sec. 11.34.010) 4722 Penalties: Failure to correct unsafe conditions $100/Calendar Day 4722 Work Without Permits 4 Times Applicable Fee 4728 Traffic Flow Map (Daily Traffic Volumes) $35.00 4728 Signal Timing Information 73 _ 4271 Truck Permits $16.00 per trip 4728 No Parking Signs $1 each or$25/100 MISCELLANEOUS 511.7424 Postage Other(Please Specify) / TOTAL7- OU NAME OF APPLICANT 1(7) A4bS/e.: NAME OF PAYOR PHONE ADDRESS 5Z )(6', 1� �. t"l �I~N _ ZIP 'S L- --), FOR RECEIN DBYr , � �" � ��f '� CITY CLERK ONLY Date Rece # ' .;I IY OF CAI1/IPF3ELL Jy F CANFRELL , qag ,CASHIER ��� � y � * l� 4DIN h m& 0105025/L-931 Dat DATE: 04/06/14 +T- 54/58/14 DESCRIPTION Qom= 14:14 � � G6 ^&« ` ® m5 q; & GE q la KENNETH AVE ,t , .+ G2 m J; }\FILING F ® +, • k w fa7y $377.50 TO DOE: FAG= '75430 CHECK += 2/ $724 TENDERED: CHANGE: ! • «m tm \ POLICY NUMBER:NIP 0 0 810 0 3 0 0 0 8 8 2 COMMERCIAL GENERAL LIABILITY CG 24 0410 93 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies Insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Any person or organization to which you are obligated by virtue of a written contract to provide insurance such as is afforded by this policy,but only with respect to(1)occurrences taking place after such written contract has been executed and(2)occurrences resulting from work performed by you during the policy period,or occurrences resulting from the conduct of your business during the policy period. (If no entry appears above,information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV—COMMER- CIAL GENERAL LIABILITY CONDITIONS)is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or"your work" done under a contract with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. CG 24 0410 93 Copyright,Insurance Services Office, Inc., 1992 Page 1 of 1• � • COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AMENDMENT - AGGREGATE LIMITS OF INSURANCE (PER PROJECT) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. The General Aggregate Limit under LIMITS OF INSURANCE(SECTION III)applies separately to each of your projects away from premises owned by or rented to you. CG 25 03 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 O 5 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy.We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2%of the California workers'compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR WHOM THE BLANKET WAIVER OF SUBROGATION NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 10/01/2013 Policy No.7600006107131 Endorsement No.001 Insured: Break Away Concrete Cutting,Inc. Premi INCL. Insurance Company: Everest National Insurance Compan' Countersigned By: -1998 by the Workers'Compensation Insurance Rating Bureau of California.All rights reserved. From the WCIRB's California Workers'Compensation Insurance Forms Manual-1999. POLICY NUMBER:MP 0 081003000882 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: Any person or organization to which you are obligated by virtue of a written contract to provide insurance such as Is afforded by this policy,but only with respect to(1)occurrences taking place after such written contract has been executed and (2)occurrences resulting from work performed by you during the policy period,or occurrences resulting from the conduct of your business during the policy period. Coverage provided by this policy to the Additional insured(s)shown In the Schedule shall be primary insurance and any other insurance maintained by the Additional Insured(s)shall be excess and non-contributory,but only if required of the Named Insured and by written contract. (If no entry appears above,information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement) WHO IS AN INSURED(Section II)is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of"your work"for that insured by or for you. • • CG 20 10 11 85 Copyright, insurance Services Office, Inc., 1984 Page 1 of 1 O l w ee `� _ v (' 145' PT12012-8 W AFETY W �J• z ,`tom Uej S Icy C\RE Ypo v' CAil‘ et 110 \C r.'") LA SUNNYBROOK CT.• � „„iiiti., ,..... cD '' o o CD O 1 o NOTE G GcL �' °� p� © o , x ° e:5. ,E I4 ' �� Vow �,3 U Cl) z O Cl) 1:1- CONTACT U.S.A. C� 1 -800-227-2600 AT LEAST 48 Q � 4r JDERR[ 1ND SERVICE ALERT HOURS IN ADVANCE BEFORE DIGGING. CONTACT is i pi •t €�`` Lei,/ 0 INSPECTOR 48 HOURS IN ADVANCE TO MAKE 1 ♦ ���' -1-- _ \ ._---1-800-��7- 600 >-- PG&E STAND-BY ARRANGEMENTS WHEN WORKING WITHIN G - 7f _� % Z Q 5' OF ENERGIZED FACILITIES. ` L-59.08; \� I 1 ,,L i 0 IMPORTANT! DEVELOPER GENERAL CONTRACTOR ! p Ir \ / 11 A \ I( �� iJ ELECTRICAL CONTRACTOR, PLEASE NOTE: / % r _ '--- PG&E INSPECTOR TO VERIFY �' w - BEFORE BEGINNING SUBSTRUCTURE WORK, PLEASE CALL THE ! uj K AND MARK RISER QUADRANT W U (y PG&E UG INSPECTOR 48 HRS IN ADVANCE AT (408) 725-2202 I a �'(1�' � 'irl'P ' IN THE HELD. Q (WORK NOT PROPERLY INSPECTED MAY BE REJECTED) .�_ / ' ', >'' r " '; C C� IF THERE ARE ANY CONFLICTS BETWEEN SUBSTRUCTURE , , \‘ / i;):,-%-', " b �� x''' II (W/) W INSTALLATIONS & LANDSCAPING (SPLICE BOXES, TRANSFORMER , , , 4 200A MS f �� PROPOSED W = PADS, BERM TREES, BUSHES, ETC.) CONTACT UNDERGROUND >g ` 1 ` :`` 120/240 V \ ....� C� L,j I i 'f.',<':;, RISER QUADRANT = w INSPECTOR PRIOR TO INSTALLATION. % \ �, T/,, 3W, 10 \ Z m ii 1 \ \ 1 G: _- \--- 3" BEND BY APPLICANT E� J Z m n 4 il\ -- WI ! MIN. 3' SEPARATION MUST BE woo Q '` . p..._I_ tVi MAINTAINED BETWEEN ANY "WET" - �, 1 ` r �>; 1 -.:%8,. I L FACILITIES & PG&E FACILITIES. Lu Q LEGEND ✓~ N , � I I PG&E TO INSTALL SERVICE RISER ��-- w<'5 m�I = '�' �s 3 6 0 0 S Q FT I —sv APPLICANT TO INSTALL 1-3" PVC SERVICE CONDUIT 1, \ , ,� ti' , '' I I' U r21 = APPLICANT TO INSTALL 17X30 X26 INCIDENTAL VEHICULAR TRAFFIC SERVICE PULL BOX \-'11 , --', /,.:y..,-,,,,, ,zo,, le\ ,i 3 I — �r I, ,1_ NOTES ; 1 1 1- I - ` `. I CL 1. APPLICANT TO TRENCH AND BACKFILL FOR ELECTRIC, PHONE, CATV. \ (1) c a 'Fp 2. APPLICANT TO PROVIDE ALL ELECTRIC SUBSTRUCTURES AS SHOWN. /� \ \�� Ag 1 1 3. APPLICANT TO PROVIDE MANDREL AND PERFORM MANDREL TEST ,H str;5'_.- 'A� 1 Ibl'i N WITH PG&E INSPECTOR STANDING BY. nt \ , t l � I J' I y IIE 4. TOTAL NUMBER OF SWEEPS IN DUCT RUN SHALL NOT EXCEED \, !' �P 1 \t \ ILL__-_ J I , % 33O' INCLUDING THE SWEEP AT THE FEED-IN LOCATION. " 5. APPLICANT IS RESPONSIBLE TO ENSURE TRENCHING AND 1 �, 7sy -`\ ' ,- ,rrTit SUBSTRUCTURE INSTALLATION MEETS PG&E GREENBOOK STANDARDS. oa \ 1% ` 1 `q sere�cx N GREENBOOKS ARE AVAILABLE AT YOUR LOCAL PG&E OFFICE OR �T"S \ ?/ �" I, may - -�� , ONLINE AT WWW.PGE.COM/GREENBOOK. , �� \ -- \ O.S L o 6. ALL TRENCHING AND SUBSTRUCTURES MUST BE INSPECTED BY PG&E. ��_ I N z = ~ Q PG&E WILL NOT INSTALL FACILITIES IN A TRENCH THAT HAS NOT _ BEEN INSPECTED OR A CONDUIT THAT HAS NOT PASSED A "r`"-ITit 5,'t,�,_ �' '84 I M�p. H 1524 Z o __ VI f=1 a MANDREL TEST WITH A PG&E INSPECTOR PRESENT. 1 L \,:'' %' i oli a CLA t 3 AREA Q Y m 7. IF THERE ARE ANY CONFLICTS BETWEEN SUBSTRUCTURES AND Q E >- >- LANDSCAPING, MOUNDS, BERMS, TREES, ETC., CONTACT THE PG&E 1 =', S G j % .� To 1 LB INS. DISTRICT z _, _ INSPECTOR PRIOR TO INSTALLATION. I OJ z w Q _ o 8. ELECTRIC TRENCH LINE CANNOT BE IN, AND MUST MAINTAIN A t L..60.78� MmoY 1 LKV A, S.C. v o N Q Z N MINIMUM OF 3' PARALLEL TO, THE SEWER, STORM, OR WATER TRENCH. \,,. r 23 -- - - CCT=SARAT GA 1 109 •• .. W 9. APPLICANT IS RESPONSIBLE FOR COORDINATING WITH TELCO AND CATV '\ > l J FOR THEIR DESIGN AND INSTALLATION REQUIREMENTS. 1, 4 tit \ i`1,.- - _'A SSD=FUSE 31087 ; o = w 3 U W Q N a_ N