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HomeMy WebLinkAboutENC2014-00190 RSCE,V"E Print Form OO 1 I5 2014 "' T1 TL( Permit No eA)Cao.L -OOYtO CITY OF CAMPBELL . ftOACHMENT PERMIT DEPT.OF PUBLIC WORKS rks pdmtl‘StJ r working within the public X-Ref.File 70 North First Street public right-of-way) Application Date t 0—..S�� Campbell,CA 95008 j, /( t I 5 I ( . Application Expiration Date Z Ph. (408)866-2150 Issued f APN Lk()LA OG1 Fx. (408)376-0958 Permit Expiration Date k 6/1 S I 1 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.: 14_1 SkGif�b� peLY1 5 Utility Trench Location: 6/) n u{-.q /n t.,C. . B. Nature of Work: 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: /j/7,S1:0/ � Telephone: toe ) 2 3.0 g X14, Address: g° 0/94 74 p)7 CA 44- _9d do U E-Mail Address: M E,Zak ctjis0 L47 24-HOUR EMERGENCY PHONE NUMBER:$ C_C.'OV Z 3`f 5?g 0 Is this work being done by the property own s 3t their own residence? [ YES fl 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 improveme in the public right-of-way. Accepted: /4f! 5 C L' 2t✓f f ( aj )c ) Lj (Applicant Permittee) (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. mil �� PERMIT APPLICATION FEE $ 3f35 off.'51 •' PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK&INSPECTION FEE $ `3 65 n C.;5—JI vLC EMERGENCY PERMIT FEE $ O` APPROVED FOR ISSUANCE (O/IS /r 4 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 responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions. (✓1, a vP g441'," /o/ /1;/ V Applicant Date: erk ,/4 c7 Car �/ QY1 re�' / / Contractor (Print Name) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC forrn2.pdf Rev.02/14 C) W .-. F- �� 2__.. _... __._. _ €. ICI z J .CI- I N (f) ° o 2 I l 73 p Q o II 2J o II J z E(7) v m / 8 < c I (n i I e IMIM MIM I ., N 0 I - 1 " PL_ DB (20') I s 4. v I o ( )LAURADR 60' 0 _ _ Ld F-- 1 } i i TYPICAL GAS ONLY TRENCH * BUILDING CONTRACTOR TO TRENCH AND BACKFILL ALL I-- 12" MIN--I * BUILDING CONTRACTOR TO DIG GAS TAP HOLE ' AS SHOWN 4' X 4' X 18" UNDER GAS PIPE 1_7_, k * BUILDING CONTRACTOR TO TRENCH APPROX. z 72' TO METER LOCATION N • ,k - k * PG&E TO INSTALL 72' OF 1" PLASTIC PIPE 31096240* GAS ONLY TRENCH m 6" SANDo 341-J3 * GAS LOAD 856 KBTU COVER M CPA: 3474-15 * SEE ELECTRIC SUBSTRUCTURE PACKAGE FOR y© MAOP 60 PSIG ELECTRIC TRENCH 1'EDDINc MATERIAL IN CAMPBELL EST: CARALEE CLARKE CO: ADE: JOHN GAMBUCCI Gas Construction Drawing SD: il SUPV: ERIN STRAUB 778 SHARMON PALMS LN APT A-D NOTIF: 107119778 REP: RALPH MCCALL OTHER: PLNR: Applicant and PG&E Inspector Copy SHT: SHEETS SCALE: DATE: p AND ELECTRIC COMPANY Pµ31096240 REV. 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NI C 2-4,.' 1 ti -©G ty V p PROPERTY ADDRESS 778 S h...w m w p4, wly Please collect & receipt for the following monies: ACCT. I ITEM I AMOUNT ENCROACHMENT PERMIT 4722 Utility Encroachment Permit Application Fee $385.00 .5••••?�c R-1 Encroachment Permit N/C Emergency Permits $110.00 Plan Check& Inspection Fee Minimum Charge Per Location $385.00 q.,5 Conduits/Pipelines up to 500 Feet $2.70/ft • Above 500 Linear Feet $1.60/ft ManholesNaults/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 170 NAME OF APPLICANT NAME OF PAYOR PHONE ADDRESS ZIP FOR RECEIVED =Y ��"' >; a, CITY CLERK ONLY Date tv�1 i + 'eceipt# �672t J'.\FORMS\Templates\Admeastrative\Receipt Form Utility Encroachment&Misc 14-15 DUPLICATE RECEIPT CITY OF CAMPBELL RECVD BY: CASHIER\ 01000255720 PAYOR: MASOUD EZATAGHA TODAY'S DATE: 10/16/14 REGISTER DATE: 10/16/14 TIME: 10:23 DESCRIPTION AMOUNT ENGR S SUBDIV FILING F $385.00 CUST ID: 778 SHARMON PALMS 14-189 ENGR & SUBDIV FILING F $385.00 CUST ID: 778 SHARMON PALMS 14-189 ENGR & SUBDIV FILING F $385.00 CUST ID: 778 SHARMON PALMS 14-190 ENGR & SUBDIV FILING F 3385.00 OUST ID: 778 SHARMON PALMS 14-190 TOTAL DUE: 31,540.00 CHECK PAID: 31,540.00 CHECK NO: 4027 TENDERED: 31,540.00 CHANGE: 3.00 INSURANCE REQUIREMENTS CHECKLIST —5 t.rnOt\ V. ' 3 Permit # CIP Project# Consultant/Contractor: ‘C(\\ S' C0'(4S�`CQC `O`er- 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 5/z (g- Automotive Liability: "Any Auto" checked on certificate $1,000,000 per accident for bodily injury and property damage o Policy expiration date Col(III 5- Workers' Compensation and Employer's Liability Waiver of Subrogation clause 7th $1,000,000 per accident for bodily injury or disease Policy expiration date °Or:3(i S Course of Construction (if required in Special Provisions) o 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) 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: ,9L 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 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. cNicl Name: .�< 1 N-‘\ (0 NAIC# 1 Rating: h/XS- Authorized in CA: Name: Co,,.,‘yv\3Jce. viost-1S( NAIC# I3j(G( Rating: /2y ><At, Authorized in CA: Name: Co.-.At? ' NAIC# Rating: Authorized in CA: ✓ Name: NAIC# Rating: Authorized in CA: Campbell Business License # ) Expiration: �( D\ 5' Contractors License # `h`6`{ 3 3 Class: Expiration:�I ' Insurance Certificate Reviewed _� \LA.\\L"\ I itia�3'� Date ❑ 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 AC R® CERTIFICATE OF LIABILITY INSURANCE DATE(M /2014YY) �� 10!13/7.014 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: Alex Alex Arash Eshraghi PHONE FAX (NC,No.Ert):408-953-6378 _... lA/C Ne.):408484-1074 DBA:Bayshield Insurance AE-MAIL alex@bayshieldiTA OW 155 E CAMPBELL#213 PRODUCER CAMPBELL,CA 95008 CUSTOMER ID 1: _ _ INSURER(S)AFFORDING COVERAGE NAIC N INSURED INSURER A:Security National Insurance Company MASOUD EZATAGHA INSURER e:Commerce West Insurance ^ M DBA:M S CONSTRUCTION INSURER c:State Compensation Insurance Fund 35076 80 DARRYL DRIVE -" CAMPBELL,CA 95008 INSURER O: 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 SUER' `POLICY EFF POLICY EXP I '-- --- LTR TYPE OF INSURANCE I INSR WVD POLICY NUMBER (MWDOIYYYYJ (IIWDD/YYYY) LIMTS GENERAL LIABIUTY A NA102543001 05/28/2014 05/28/2015 EACH E I OR LN I L t $_______1210.000_ X I COMMERCIAL GENERAL LIABILITY r J PREMISES IORLNIEU I I In. I PREMISESSEaoccurrence) $ 100J10Q CLAIMS-MADE OCCUR I MED EXP(My one person) 5 _ 5,000_/ --1 .....-_ PERSONAL&ADV INJURY S 1 000,000 ._..._ _.._ �GENERALAGGREGATE _ S 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG I S 1,400,000_ ECr f POLICYI LOC S B AUTOMOBILE LIABIUTY COMBINED SINGLE UNIT S CVA4003309 06/11/2014 106/1112015 (Ea accident) 1,000,000 ANY AUTO 1 F I BODILY INJURY(Per person) S ALL OWNED AUTOS I BODILY INJURY(Per accident) S X SCHEOULEDAUTOS PROPERTY DAMAGE I HIRED AUTOS (Per accident) S X NON-0WNED AUTOS I _ S S L_,UMBRELLA LIAR OCCUR ' EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE --(" .. ....._ _. J J (AGGREGATE S F ± EDUC11BLE 1' ,s RETENTION $ S WORKERS COMPENSATION INC STATU- I IOTH- C 08/08/2014 08/08/2015 AND EMPLOYERS'LIABILITY YIN 9108981-14 TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE r EL.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? Y NIA i 1,000,000 (Mandatory in NH) V'EL.DISEASE-EA EMPLOYEES 1 000./ under If yes,desonbe der ,SPFC:IAI PROVISIONS helnw E.L.DISEASE-POLICY LIMIT t 1 000 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if 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. AZ C6 \/\Oo4•4•€\•:>.'" Pc,\w,s ( CNG ly-O° 'zIck ankL_. -r,<<) ' ot o 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 /l ^ v c 8-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) 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 970244.04 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 contract or 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 07 11 May Include Copyrighted Material of Insurance Services Offices, Inc. Page 1 of 1 Used with permission STATE ENDORSEMENT AGREEMENT BROKER COPY WAIVER OF SUBROGATION REP 06 91O8981-14 FUND NEW NA HOME OFFICE 5-08-75-8I. 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 MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS POLICY IN CONNECTION WITH WORK PERFORMED BY, MASOUD EZATAGHA DEA: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 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 OH LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR LIMITATIONS OF THIS ENDORSEMENT. 09/03/2014 COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: 2570 fiervw__ AUTHORIZED REPRESENT IVE PRESIDENT AND CEO SCIF FORM 10217 (R0v.1.2012) OLD OF 217