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HomeMy WebLinkAboutENC2014-00088 Print Form 1` p CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No 2-Z T COO C�� DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File 70 North First Street right-of-way) Application Date f I /I L Campbell,CA 95008 Application Expiration Date (c/1'/I I If Ph. (408)866-2150 Issued f 1 O APN ti(&u�ZCP Fx. (408)376-095 • 8 Permit Expiration Date If 'lull J 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.: /3' Cam Utility Trench Location: /) L/ 'r s_a` B. Nature of Work: ( 'p 13 ca.c. S‘(- el°r ...5eJ.Jerif' /c f1 c ( C. Attach four(4)copies of an engineered plan showing the location and exterRt of the work,and hSur(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: 3eL Ie_S j Telephone: ( t3—C�'./V S 72 Address: /46'6, k ( 7 /j _,� C-r / Y vl , 9 E-Mail Address: sS,6O6Y 24-HOUR EMERGENCY PHONE NUMBER: `T eg 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 information. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all damages arising out of the condition of any private improvements in the public right-of-way. Accepted: (Applicant Permittee) (sign) Date ti`Crke.a-c Less �z ,t 4-7/ "/`-( (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 $ 37 7 252.'151 PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT $ 252_-(5 PLAN CHECK&INSPECTION FEE $ '377 EMERGENCY PERMIT FEE - $ 4 APPROVED FOR ISSUANCE _ ,, /kb/ 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 responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions. Applicant Date: 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 �� C 20 j -pro 88 PUBLIC WORKS FILE NO. PROPERTY ADDRESS 'i 35c C f)1 /J1= - Please collect & receipt for the following monies ACCT t . , ITEM .. .�rt�� � sew MOUNT010 ENCR©ACHMENTPERMIT 4722 Utility Encroachment Permit Application Fee $377.00 3 77 R-1 Encroachment Permit N/C Emergency Permits $107.00 Plan Check&Inspection Fee Minimum Charge Per Location $377.00 7—7 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 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 x k oftv✓;... A $Y•. 511.7424 Postage Other(Please Specify) TOTAL 7 5 / � -c NAME OF APPLICANT /34-5 A-re_ L(ec sL NAME OF PAYOR A-IL� +O- PHONE yO`�j �-S7-3 ' C ADDRESS /66 d Oct(t 6/e 0, L/L ).\h 1 ZIP j S D ? 7 / FOR RECEIVED BY �., .: CITY CLERKat " ON LY Date 4 1 cL Er Receipt# L;IfY OF CANIPt$c 1 r ^+n.,�a,1r4wIr+R West Valley Sewer Connection Permit No: 41.164 elsanitation District Issue Date: By: • ' •, / OFFICE HOURS &CONTACTS: FEES: BACKFLOW PREVENTION: ' h'1 7:30 a.m.to 4:30 p.m. Monday thru Friday Connection $ 100 E. Sunnyoaks Ave., Campbell, CA 95008. Capacity Field check required Processing Basement •Phone: (408)378-2407 Service Advance •Information Services Department Check valve required: Yes_No— LOCATION: APN BUILDING SEWER CONNECTIONS: Sewer Map Book • Page Tract Lot Total Due: $ Total number of connections to this Project Assmt property: Address Paid by Check No: . 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:'/j0// hz,,c,,_9r,:6 G •Street encroachment permit is required from j� C4'2,-)34-,,,,w_.z o To „G4��, List any additional connections on ii)/zit G3 ii7/-/Ay •Keep 3'radius around cleanout clear of reverse side of this form. OLD PERMIT No. • Sub No. vegetation or obstruction. &f V.,<;) Cc?/L.. /1W.V/Trd�- iet.+/G72"I47-7- 71- /2 4 -erel Original—Applicant Pink—Accounting Yellow—City/County Bldg. Inspector Card—District File K TE A oRo" CERTIFICA1 OF LIABILITY INSUF 4CE �04/0�20 4 t 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 ADDr11ONAL INSURED, the pollcy(les) 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 Phone: (916)209-5136 Fax: (916)409-0635 WhitehCMACTawk Insurance Solutions,Inc. WHITEHAWK INSURANCE SOLUTIONS,INC. PHONE x:,Nom: (916) TAIL.Not:209-5136 �A" (916)409-0635 1903 AVIATION BLVD L info@whitehawkinsurance.com LINCOLN CA 95648 PROREss: CUS 11461 CUSTOMER ID: Agency Lid':OH45179 INSURER(S)AFFORDING COVERAGE NAIC I INSURED IN.SIIRERA Colony Insurance Company BAY AREA TRENCHLESS CIO SEAN FRY INstIRERa : Wesco Insurance Company 16690 OAK GLEN AVE. INSURER State Compensation Insurance Fund MORGAN HILL CA 95037 INSURER 0: INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 73496 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 POUCHES TITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS *JCR ADM BURR POLICY EFF POLICY E]IP urn I TYPE OF INSURANCE INSR NI,D POLICY NUMBER R yn , Durr Yn LIMITS A GENERAL LIABILITY X X GL953227 03128/14 ' 03/28115 EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTEDPREMISES lEa omneal g 100,000 I I CLAIMS-MADE I�OCCUR 1 MED.EXP(My one person) S 5, _ PERSONAL 6 ADV INJURY S 1,000,000 A GENERAL AGGREGATE S 2.000,000 • GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG g 2,000,000 POLICY I JFCOT- LOC 15 B AUTOMOBILE LIABILITY X X WPA103044603 03/30/14 I 03/30/15 COMBWED SINGLE LIMIT 5 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) s ALL OWNED AUTOS GODLY INJURY(Par accident) s SCHEDULED AUTOS PROPERTY DAMAGE {I HIRED AUTOS (Per accident) S I NON-OWNED AUTOS 5 I S r t UMBRELLA LIAR I OCCUR EACH OCCURRENCE EXCESS LAB CLAIMS-MADE AGGREGATE DEDUCTIBLE s RETENTION S S C WORKERS COMPENSATION X 1958916-2014 01/01/14 01/01/15 X I I T AND EMPLOYERS' UABItm YIN ANY PROPRIETDIVPAR/NER/EXECUTIVE I EL EACH ACCIDENT S 1,000,000 orry in NH) EXCLUDED? NIA {Mandatory EL DISEASE-EA EMPLOYEE S 1,000,000 II yes.describe wider -- oesciePTION OF OPERATIONS below1 _.r". EL DISFASE-POUCY LIMIT g 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD lot.Additional Remarks Schedule,If more space Is required) The City,it's officers,employees and volunteers are to be covered as insureds with respect to liability arising out of automobiles owned, leased,hired or borrowed by or on behalf of the contractor,and with respect to liability arising out of the work or operations performed by or on behalf of the contractor including materials,parts or equipment furnished in connection with such work or operations. CERTIFICATE HOLDER CANCELLATION City of Campbell SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 70 N 1st Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Campbell,CA 95008 AUTHORIZED REPRESENTATIVE Attention: A\j/ Michael Short ACORD 25(2009/09) 2 0 D CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Additional Insured Person(s)or Organization(s): Location(s)of Covered Operations: CITY OF CAMPBELL 70 N. 1ST STREET AS REPSECTS TO ALL CALIFORNIA CAMPBELL, CA 95008 OPERATIONS AS REQUIRED BY WRITTEN CONTRACT OR PERMIT USE WITH THE NAMED INSURED A. SECTION II-WHO IS AN INSURED is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage"or"personal and advertising injury"caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to"bodily injury"or"property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project(other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance is amended and the following added: The insurance afforded by this Coverage Part for the additional insured shown in the Schedule is primary insurance and we will not seek contribution from any other insurance available to that additional insured. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. U2010P-1209 Includes copyrighted material of ISO Properties, Inc., Page 1 of 1 with its permission. ABA31526 SEAN FRY WPA1030446 03 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM TRUCKERS COVERAGE FORM SCHEDULE Name of Person or Organization: CITY OF CAMPBELL, ITS OFFICERS, EMPLOYEES & VOLUNTEERS 70 N 1ST STREET CAMPBELL CA 95008 Description of Operations or Services: Location: ALL WORK IN PUBLIC RIGHT-OF-WAY WAIVER OF SUBROGATION APPLIES Description of Covered"Autos": Per Schedule on file with company (If no entry appears In the Schedule above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) The WHO IS AN INSURED provision under LIABILITY COVERAGE is changed to include as an"insured" the person or organization shown in the Schedule, but only with respect to liability arising out of: 1. Your operations or services performed for that person or organization at the location shown in the Schedule; or 2. The ownership, maintenance or use of the covered"autos"described In the Schedule. A person's or organization's status as an additional insured under this endorsement ends when: t_ Your operations or services performed for that person or organization are completed;or 2. That person's or organization's interest in the described"auto"ends. CA990009 1004 Includes copyrighted material of insurance Services Office,Inc.. Page 1 of 1 with its permission. ADDITIONAL INSURED STATE ENDORSEMENT AGREEMENT BROKER COPY COMPENSATiOh WAIVER OF SUBROGATION IN ` JRA ".C = 1958916-14 FUND RENEWAL NF HOME OFFICE 5-55-67-28 SAN FRANCISCO PAGE 1 OF 1 ALL EFFECTIVE DATES ARE AT 12:01 AM PACIFIC EFFECTIVE MARCH 28, 2014 AT 12.01 A.M. STANDARD TIME OR THE AND EXPIRING JANUARY 1, 2015 AT 12.01 A.M. TIME INDICATED AT PACIFIC STANDARD TIME BAY AREA TRENCHLESS 16690 OAK GLEN AVE MORGAN HILL, CA 95037 ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING, IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND WAIVES ANY RIGHT OF SUBROGATION AGAINST, CITY OF CAMPBELL WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, BAY AREA TRENCHLESS IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE EMPLOYER. IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH EMPLOYEES SHALL BE INCREASED BY 03%. NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: APRIL 3 , 2014 2570 74141,411. AUTHORIZED REPRESENT IVE PRESIDENT AND CEO SCIF FORM 10217 IREU.1-2012) OLD DP 217 INSURANCE REQUIREMENTS CHECKLIST Permit # L lye, �b\� \`0001 CIP Project# Consultant/Contractor: 00,1 f ° The following insurance is required of all consultants/contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggregate limit. ❑� Policy expiration date :=,12`6//`) Aut motive Liability: \t' "Any Auto" checked on certificate - $1,000,000 per accident for bodily injury and property damage lit Policy expiration date 3 j 3O1 i 5-- Workers' Compensation and Employer's Liability Waiver of Subrogation clause z $1,000,000 per accident for bodily injury or disease rPolicy expiration date \ \1‘ 5� Course of Construction (if required in((Special Provisions) ❑ Completed value of the project o Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement: .The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) o The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: o Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR should say: Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. o Workers' Compensation Insurance Sheet Submitted >6-- For General Contractor o For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 02 14) Page 1 Acceptability of Insurer(s) ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. p, Name: Q_O���`{ Z�5 NAIC# 3 tip Ratin Authorized in CA: -T g;�1L— Name: } eSC c INNS< Co� NAIC# ,)50\\ Rating:'"1-7k--V-1$ Authorized in CA: ✓ Name: S-kc-ANc C`-k&\0• NAIC# J Ik Rating: Authorized in CA: ✓ Name: NAIC# Rating: Authorized in CA: ❑ Campbell Business License # 1 1 Expiration: 7/31/ (1' Insurance Certificate Reviewed 14/l OP Initi Is 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 DATE pMMJODIVYYYI fC®JD" CERTIFICATE OF LIABILITY INSURANCE 04/01/2014 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 ADDfIIONAL INSURED, the policy(les) 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 Phone: (916)205-5135 Fax: (916)400-0605 CONTACT Whitehawk Insurance Solutions,Inc. rime VVHITEHAWK INSURANCE SOLUTIONS,INC. PHONE 91611 209-5136 11`'x (916)409-0635 Ia1C.12 Ea,- ( 1 IINC.Ho), 1903 AVIATION BLVD E-InAIL info@whitehawkinsurance.com LINCOLN CA 95648 PRDRESS PRODUCER 11461 CUSTOMER IC,: ----- - __-- Agency I.icO:0H45179 INSURER(S)AFFORDING COVERAGE __ NAIC II _ INSISTED INSIFERA . Colony Insurance Company BAY AREA TRENCHLESS INSURERa : Wesco Insurance Company C/O SEAN FRY 16690 OAK GLEN AVE. INsuRERC : State Compensation Insurance Fund MORGAN HILL CA 95037 INSURER O: INSURERE INSURER F : COVERAGES CERTIFICATE NUMBER: 73495 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 SI ICH POI IrjFS I IMITS SHOWN MAY HAVEBEEN RGDUCED BY PAID CLAIMS INSR ADo1 SUER POLICY EFT I POLICY EXP UNITS TYPE OF INSURANCE POLICY NUMBER_ LTR UNSR UND _ IMMIDI:=1 I� 0rc?YYl.-[ A CEN-AAL NEED r1Y X X GL953227 03/28/14 03/28/15 EACH OCCURRENCE 5 1,000,000 X I COMMERCIAL GENERAL LIAOILI Y DAMAGE TO RENTED 5 1 QO,000 PREMISES(Ea ecruairoe7 rdEo.EXP(Any One Person) $ 5,000 I I-1 CLAIMS-MADE 1 X I OCCUR 111}1 PERSONAL 6 ADV INJURY $ 1,000,000 A IM GENERAL AGGREGATE S 2,000,000 GENT.AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGO S 2,000,000 "1 POLICY I I PRO- i LOC S _—1 I B AUTOMOBILE LIABILITY X X WPA103044603 03/30/14 03/30/15 COMBINED SINGLE LIMIT s 1,000,000 (Ea aciden,) I ANY AUTO —1 BODILY INJURY(Per person) 5 }ALL OWNED AUTOS —' BODILY INJURY(Peraccidenl) S SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) 15 NON-OWNED AUTOS IS _ IS UMBRELLA IUAB I I OCCUR EACH OCCURRENCE-'-----'S EXCESS LAI I IMAMS-MADE AGGREGATE S DEDUCTIBLE S RETENTION S I S _ C WORKERS COMPENSATION X 1958916-2014 01/01/14 01/01/15 X 1 WC&TATu- I Mil S AND EMPLOYERS' LIABILITY TORY LIMITS Y t h E L EACH ACCIDENT 1,000,000 ANY PROPRIETORIPARTNER/IXEC(JTiVE �� � OFFiCER/MEMBER EXCLUDED? • I NIA EL DISEASE-EA EMPLOYEE 1,000,000 {Mandatory in NHI S II yes.dessoibc under DESCRIPTION OF OPERATIONS beta* i E.L DISEASE-POLICY LIMIT I S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES(Attach AGGRO 101,Additional Remarks Schedule,if morn space is required) The City,it's officers,employees and volunteers are to be covered as insureds with respect to liability arising out of automobiles owned, leased,hired or borrowed by or on behalf of the contractor;and with respect to liability arising out of the work or operations performed by or on behalf of the contractor including materials,parts or equipment furnished in connection with such work or operations. CERTIFICATE HOLDER CANCELLATION City of Campbell SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 70 N 1st Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Campbell,CA 95008 AUTHORIZED REPRESENTATIVE Cam° c O u -Ccc Attention: -)/A'j// MichBeI Short ACORD 25(2009109) C)1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD