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Print®Ct 15 2®14 lA, , t 771( Form G Gi
CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No `+°`� w`O
DEPT.OF PUBLIC WORKS wrkg AdiY11111S'lsa\) (ror working within the public X-Ref.File
70 North First StreePUb11C right-of-way) Application Date tom\S ‘L_
Campbell,CA 95008 r(/ f 51( (1 Application Expiration Date
Ph. (408)866-2150 Issued l I 1 APN Lt '510D-7
Fx. (408)376-0958 Permit Expiration Date k vi(5 if-
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.) Pc:Q2.,4—Y'))
A. Work Address or Tract No.: 7kia
,/n1-2V\
Utility Trench Location: Gett
(65'
-
B. Nature of Work: 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. igen 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.
12, Name of Applicant: L01,4O Telephone: �0� t
510 Address:
FE-Mail Address: z v c4t,`0 cok 24-HOUR EMERGENCY PHONE NUMBER:gyp- kg 0.6) Z 70_ CO g O
M Illlll 7
Is this work being done by the property owne
p p y t t eir own residence? 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 improve nts in the public right-of-way.
p90 Accepted: w// i /�, j 5f/ / tr
(Applicant Permittee) (s' Date
�� C� �n�G��°� SOf�, t o, 117/ q
(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?) .) SS 110
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $
CONSTRUCTION CASH DEPOSIT _
PLAN CHECK&INSPECTION FEE $ 3'65 .�
EMERGENCY PERMIT FEE $
APPROVED FOR ISSUANCE ' ,OA s/I Lt
For City Engineer Date
hlL H f)4 �P^ %�) �� vvex 1
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.
/0/9--S o "yr
Applicant Date:
CO .wS7 .n/C. Y << v `� le I � / '(
Contractor (Print Name) Date:
J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC forrn2.pdf
Rev.02/14
PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MISCELLANEOUS RECEIPT
Effective July 1, 2014
TO: City Clerk
PUBLIC WORKS FILE NO. � �( - 0018c,
PROPERTY ADDRESS "176 S t}>ke_O4 Pi -MS
Please collect & receipt for the following monies:
ACCT. I ITEM AMOUNT
ENCROACHMENT PERMIT
4722 Utility Encroachment Permit Application Fee $385.00 -.3Qt57
R-1 Encroachment Permit N/C
Emergency Permits $110.00
Plan Check&Inspection Fee
Minimum Charge Per Location $385.00
Conduits/Pipelines up to 500 Feet $2.70/ft
Above 500 Linear Feet $1.60/ft
Manholes/Vaults/Etc. $170.00/ea
Pole Set/Removal $170.00/ea
4760 Storage Container Permit $156.00
4760 Project Plans&Specifications Project No.
4760 Standard Specifications& Details $1/Pg$15.50/Bk
4760 Engineering Maps&Plans
Aerial Plot 24"x 36" $61.00
Aerial Print 8 1/2"x 11" $29.00
Map Research(includes max of two 24"x36"copies) $29.00
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
TRAFFIC
4728 Traffic Flow Map(Daily Traffic Volumes) $35.00
4728 Signal Timing Information $73 per hour
4271 Truck Permits $16.00 per trip
4728 No Parking Signs $1 each or$25/100
MISCELLANEOUS
511.7424 Postage
Other(Please Specify)
TOTAL 770
NAME OF APPLICANT
NAME OF PAYOR PHONE
ADDRESS ZIP
FOR RECEIVE s =Y
CITY CLERK 1,0
ONLY Date 1(.1 � I Receipt#
J:\FORMS\Templates\Administrative\Receipl Form Utility Encroachment&Woo 14-15
•
INSURANCE REQUIREMENTS CHECKLIST
_ .(4,e\,..\ (mac;\ `M
Permit# f CIP Project #
` 'Consultant/Contractor: \ _, CC,(\SVk CA'
`C"�'
The following insurance is required of all consultants/contractors working in the City of Campbell
public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These
insurance requirements apply to work being performed under an Encroachment Permit and work
being performed under contract for Capital Improvement Projects.
Limits
Commercial General Liability for bodily, personal injury and property damage:
_. $1,000,000 per occurrence, and
o $1,000,000 general aggregate limit applying separately to the project, or
o $2,000,000 general aggregate limit.
Policy expiration date 5/Z 'l
Automotive Liability:
slic "Any Auto" checked on certificate
\ $1,000,000 per accident for bodily injury and property damage
o Policy expiration date (-1-71(I115
Workers' Compensation and Employer's Liability
7la Waiver of Subrogation clause
7(tr-, $1,000,000 per accident for bodily injury or disease
Policy expiration date 5"
Course of Construction (if required in Special Provisions)
o Completed value of the project
t 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)
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
o For General Contractor
• For Developer or Owner
J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 02 14) Page 1
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. o�
r1 /
Name: Wit\ \---INN\ Co-..1--AS , NAIC# ►�� Rating: h/ � Authorized in CA:
Name: C`,,,,\,M�,kle. viesk- 1ST(.NAIC# i 3;&( Rating: ty >CT Authorized in CA: '/
Name: 1-\,,,-te Co.-.nO - NAIC# Rating: Authorized in CA:
Name: NAIC# Rating: Authorized in CA:
Campbell Business License # Z_2 Expiration: 4 -3( '-c`j\ S—'
54 Contractors License # `hC64 3 3 Class: - Expiration:cl3 1
4Insurance Certificate Reviewed ,-------- \�l\\l.
l Itia�'s� Date
o Copy of Insurance Certificate placed in tickler file one month prior to expiration.
J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2
S-7 R c• '5 >
AC�J/zo® CERTIFICATE OF LIABILITY INSURANCE DA1ai32014"
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 NAME: Alex
Alex Arash Eshraghi PHONE FAX Nn 40884 1074
"IA/C.No.EXti:408-963. 378 _ (Ac._.J.:
DBA:Bayshield Insurance • E-MAIADDRESS:alex@bayshieldinc r»m
155 E CAMPBELL#213 PRODUCER
CUSTOMER ID S: _...... _..�..._.._,.
CAMPBELL,CA 95008 JtISURER(S)AFFORDING COVERAGE NAICM
INSURED INSURER A:Security National Insurance Company
MASOUD EZATAGHA INSURER B:Commerce West Insurance
DBA:M S CONSTRUCTION INSURER c:State Compensation Insurance Fund 35076
80 DARRYL DRIVE
INSURER D:
CAMPBELL,CA 95008
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 ADM SUBR POUCY EFF POLICY EXP
LTR IN SR WVD POUCY NUMBER (MWDD/YYYY) (MMIDDJYYYY) LIMITS
A GENERALLIABIUTY NA102543001 05/28/2014 05/28/2015 EACH OCCURRENCE $ 1.000,000._
DAMfAOE icYI&LNiI O
X I COMMERCIAL GENERAL LIABILITY r 1 PREMISES(ES occurrence) $ 100 ODD,
1 I CLAIMS-MADE OCCUR MED 1� ! MED EXP(Any cane person) $ .... 5,000--I
PERSONAL&ADV INJURY 5 MO JA
' ! GENERAL AGGREGATE I 5 2 000,000
GEM.AGGREGATE LIMIT APPLIES PER: , PRODUCTS-COMP/OP AGG I S 1,000,000_
X I Poucv I 'PROT I km i $
B AUTOMOBILEUABILITY CVA4003309 06/11/2014106/11/2015 COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
ANY AUTO 1 1 `BODILY INJURY(Per person) $ _...__
ALL OWNED AUTOS ✓I BODILY INJURY(Per accident) S
X SCHEDULED AUTOS PROPERTY DAMAGE f
1 X HIRED AUTOS (Per accident)
X_ NON-OWNED AUTOS 1 I E _..."_.
f
,.UMBRELLA LIAR — OCCUR , EACH OCCURRENCE ...� f
htEXCESS UAB �CLAIMS-MADE rir )AGGREGATE S
DEDUCTIBLE j I $
RETENTION f f
WORKERS COMPENSATION 08/08/2014 08/08/2015 WCSTATU- I0T I H-
C AND EMPLOYERS"LIABILITY Yf N 9108981-14 TORT UAII(Ts ER _.._._.
ANY PROPRIETOR/PARTNER/EXECUTIVE EL.EACH ACCIDENT E 1,000.000_
OFFICER/MEMBER EXCLUDED? Y N f I- ^
(Mandatory in NH) 'I/ EL DISEASE-EA EMPLOYEE E _ 1,Q0Q.000/
If yes,describe under
SPFrIAI PROVISIONS MN-pm E.L.DISEASE.POLICY LIMIT f 1.000.000
FE
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required)
All Work in public Right-of-Way.City of Campbell,Its Officers,employees and volunteers are named as additional insured as respects liability per CG2009.
\l ct 0 5 si Y\O,-Th P L\' \� C-NC- k� -OO l B°\
(
o rAL, —r•-)r") N.cI d
CERTIFICATE HOLDER CANCELLATION
City of Campbell SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
70 N 1St Street POLICY PROVISIONS.
Campbell,CA 95008 AUTHORIZED REPRESENTATIVE
c 8-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY
BLANKET ADDITIONAL INSUREDS -
OWNERS, LESSEES OR CONTRACTORS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE _
Policy Number: NA102543001 Endorsement Effective: 10/13/2014 12:01 a.m.
Named Insured Countersigned By:
MASOUD EZATAGHA
M S CONSTRUCTION 94444, {#044.SCHEDULE
Name of Person or Organization:
THE CITY OF CAMPBELL, ITS OFFICERS,EMPLOYEES AND VOLUNTEERS
70 N 1TH STREET
CAMPBELL CA 95008
Location:
778 SHARMON PALM, CAMPBELL CA 95008
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement)
A. Section II—Who Is An Insured is amended to include as an insured the person or
organization shown in the Schedule, but only to the extent that the person or organization
shown in the Schedule is held liable for your acts or omissions arising out of your ongoing
operations performed for that insured.
B. With respect to the insurance afforded to these additional insureds, the following exclusion is
added:
2. Exclusions
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 site 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. The words"you"and"your" refer to the Named Insured shown in the Declarations.
D. "Your work" means work or operations performed by you or on your behalf; and materials, parts
or equipment furnished in connection with such work or operations.
Primary Wording
If required by written contractor agreement: Such insurance as is afforded by this policy shall be
primary insurance, and any insurance or self-insurance maintained by the above additional
insured(s)shall be excess of the insurance afforded to the named insured and shall not contribute
to it.
Waiver of Subrogation
If required by written contract or agreement: We waive any right of recovery we may have against
an entity that is an additional insured per the terms of this endorsement because of payments we
make for injury or damage arising out of "your work" done under a contract with that person or
organization.
49-0108 0711 May Include Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 1
Used with permission
STATE ENDORSEMENT AGREEMENT BROKER COPY
C,MhEnSITic. WAIVER OF SUBROGATION REP 06
FUND 91O898144
NEW
NA
HOME OFFICE 5-08-75-81
SAN FRANCISCO PAGE 1 OF 1
ALL EFFECTIVE DATES ARE
AT 12:01 AM PACIFIC
STANDARD TIME OR THE
TIME INDICATED AT
PACIFIC STANDARD TIME
MASOUD EZATAGHA
DBA:M S CONSTRUCTION
80 DARRYL DRIVE
CAMPBELL,CA 95008
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 CAMPBEL,ITS OFFICERS,EMPLOYEES AND VOLUNTEERS.
WHICH NIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS
POLICY IN CONNECTION WITH WORK PERFORMED BY,
MASOUD EZATAGHA DBA:M S CONSTRUCTION
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 8E 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.
09/03/2014
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 2570
/e-L,.. /EZ/41-
AUTHORIZED REPRESENT IVE PR
ESIDENT AND CEO
.t,C1F FORM 10217 RE V-1-20121 OLD DP 277