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HomeMy WebLinkAboutENC2014-00215 Print Form ENCROACHMENT PERMIT Permit No �N C 20\It-O0 2(5 CITY OF CAMPBELL X-Ref.File DEPT.OF PUBLIC WORKS (for working within the public t 1 /( J' 70 North First Street right-of-way) Application Date51(e. I Campbell,CA 95008 Application Expiration Date 5/le./ (5 Ph. (408)866-2150 Issued 11/1-I///4 APN it kZZ � p�-1 Fx. (408)376-0958 /// Permit Expiration Date I I/ /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.: de U5- I1 PR lc O-c- Utility Trench Location: 7 6 B. Nature of Work: 1--e_p L+,C c O EL.-,4,O--k. 1 R w£w Pr( - Q 12 o,N-c C. Attach four(4)copies of an engineered plan showing the location and extent of the work,and our(4)copies of the preliminary Eng eer's Estimate of work. The plans shall show the relation of the proposed work to existing surface nd 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: ✓ l E ba -J . (.k p1J L C k.,`� Telephone: Q g L� g �Q S7S'IL Address: I ( 1 1 V e t� JOsI CA-. 1 E-Mail Address: C1.-e4E 4 R0 c£(i1lei 6/apt se. 24-HOUR EMERGENCY PHONE NUMBER: /�,��S 7— O 571 re" Is this work being done by the property owners at'tReir own residence? r YES )4 NO The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campb I,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/ e ittee,hereby acknowledges that they have read stand both the front and back of this permit, and they will inform their contractor(s) off t irtd ion. Applicant V advis that on issuance of is permit, property owner, or property owner's successors, shall be responsible for a and 311 da e i g of the ondit n of any pr' improvements in the public right-of-way. Accepted: t Vii'-749(4 (Applicant Permitte si Dal S4.t..11-" , -Z-7,---t CO N972 /0 l \ — (t -"Ze, ( Li (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. (?EPIhc'` Ey1ST1N Simv4ALt< WlT1-1 Ntw 5 FT WIDE- SIDkJA4: Ai-'f) New I71n/`( J Q)Z• SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO. PERMIT APPLICATION FEE $ PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT $( ...._.___, �y PLAN CHECK&INSPECTION FEE $ 44, c?;) , _ EMERGENCY PERMIT FEE $ Up l ./ /i APPROVED FOR 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 hone number. pelican h e res ' le for nsuring that all tho e providing services un the applicant are aware and understand all of the above conditions. 1 , Applicant Date: k (1- g- 2d Contractor (Print Name) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC forrn2.pdf Rev.02/14 • Pages 2 DOCUMENT : 12121 5 Recording Requested by ) Fees. . . . *D. No Fees IN CITY OF C,APBE ) p AMT PAID When Recorded Mail To: '`- RDE 026 City Clerk = REGINA ALCOMENQRAS RECORDER 12/04/2014 SANTA CLARA COUNTY 11 :20 AM City of Campbell ) Recorded at the request of 70 North First Street ) City Campbell, CA 95008 ) a��`O�S. APN: 412-12-003 (Space Above This Line For Recorder's Use) ADDRESS: 845 Apricot Avenue.Campbell,CA 95008 No Consideration Given GRANT OF PUBLIC SIDEWALK EASEMENT The Stephen J. Hanleigh Trust, dated September 18, 1980 and as Amended and restated by instrument dated October 13, 1987 hereby GRANT(s)to the City of Campbell,a municipal corporation,of the County of Santa Clara.State of California,an easement and right to construct and maintain a public sidewalk over,through and upon that certain real property within said City more particularly described as follows: The southerly three(3.0)feet of the property described in the Grant Deed recorded as Document No. 14033253.on January 30, 1998 in Book of Official Records at Pages Santa Clara County Records,being a strip of land 3 feet wide adjacent to and northerly of the northerly right of way line of Apricot Avenue.a distance of 20 feet from center line of said Avenue as depicted on that certain map entitled "Map of Orchard Villa Tract'tiled for the record in the office of the Recorder of Santa Clara County.luly 14th. 1924 in Book"S"of Maps at page 23. Said easement contains 270 square feet.more or less. • STATE OF CALIFORNIA )SS i \TED 0470, Z COUNTY OF SANTA CLARA -2U14 before me. >lthtary Public in and fo SIGNATURE said State,personally appear d S-�?tur J t�gV1ILt who proved to me on the basis of sat factory evidence to be the person(s)whose name(s)is/are subscribed to the Stephen J.Hanleigh.Trustee within instrument and acknowledged to me that he/she/they PRINTED executed the same in his/her/their authorized capacity(ies). and that by his/her/their signature(s)on the instrument the person(s),or the entity upon behalf of which the person(s) acted.executed the instrument. I certify under PENALTY OF PERJURY under the laws of DAYNA L.SANTOS the State of California that the foregoing paragraph is true �,,,�; Commission# 2004582 a =f ��,. Notary Public -California `z and correct. z °". t '' Santa Clara County My Comm. Expires Jan 19,2017 WHITE ' v hand and otficial a ___ _ __ ___ _ _ __ _ . Signa ture Name 6611/1/0 / .301i1 41)5 (typed or printed) Place Notary Seal Above C:\Docwnents and Settings\ropers\Desktop\845 Apricot Sidewalk Easement.doc(Rev.03/08) ACCEPTED ON THIS 6 day of rOgUe/7` for and on behatf of the City of Campbell, a Municipal Corporation, of the State of California, pursuant to Resolution No. 749, recorded in Book 4509— 180 Santa Clara County Records. Anne Bybee, City Clerk City of Campbell, California Page 1 of 3 Syed Wahidi From: Roger Storz Sent: Monday, November 17, 2014 12:21 PM To: 'B Beck'; 'STEVEHANLEIGH@GMAIL.COM' Cc: Michelle Quinney; Syed Wahidi; Doris Quai Hoi Subject: RE: Hanleigh Deed on 845 Apricot Avenue Attachments: 845 Apricot Sidewalk Easement.pdf Thank you. At this point we just need to get Mr. Hanleigh to sign the attached easement, have his signature notarized and then return the original to us. We will process on our end and send for recordation at the County. At that point Mr. Hanleigh can pull a No-Fee Concrete Repair Encroachment Permit to reconstruct his sidewalk to be consistent with the adjacent property(i.e. a 5 foot wide sidewalk). Thank you, Roger From: B Beck [mailto:bbeckre@gmail.com] Sent: Monday, November 17, 2014 11:05 AM To: Roger Storz Cc: STEVEHANLEIGH@GMAIL.COM Subject: RE: Hanleigh Deed on 845 Apricot Avenue Hi Roger, If you will note that now the document number is on the "stamp"from the Recorder and the number of pages— there is no longer a "Book" or "Page" number registered in Santa Clara County (perhaps other counties, but not here). The forms are California generic that you are working with so you simply leave those spaces with a blank. (Having worked for Chicago Title before and having double checked with them just now...) Just " " for Book and Page Thanks for being thorough! Bonita Beck REALTOR Associate/Property Mgr. California BRE #00704368 Stephen J. Hanleigh, Owner/Broker 1262 E. Hamilton Ave., Ste 1C Campbell, CA 95008-0837 iit 408-377-8484 © 408-691-5334 From: Roger Storz [mailto:rogers@cityofcampbell.com] 11/18/2014 Page 2 of 3 Sent: Monday, November 17, 2014 10:37 AM To: B Beck Cc: STEVEHANLEIGH@GMAIL.COM Subject: RE: Hanleigh Deed on 845 Apricot Avenue Excellent! You wouldn't happen to know the book and page this was recorded in would you? The legal description we are preparing for the easement (see attached) needs the book and page. Thank you for your help, Roger From: B Beck [mailto:bbeckre@gmail.com] Sent: Monday, November 17, 2O14 1O:29 AM To: Roger Storz Cc: STEVEHANLEIGH@GMAIL.COM Subject: RE: Hanleigh Deed on 845 Apricot Avenue Hi Roger, Happy to do so. Attached please find the deed from himself to himself as trustee! B Bonita Beck REALTOR Associate/Property Mgr. California BRE #00704368 Stephen J. Hanleigh, Owner/Broker 1262 E. Hamilton Ave., Ste 1C Campbell, CA 95008-0837 it 408-377-8484 ® 408-691-5334 From: Roger Storz [mailto:rogers@cityofcampbell.com] Sent: Monday, November 17, 2014 9:55 AM To: bbeckre@gmail.com; STEVEHANLEIGH@GMAIL.COM Cc: Michelle Quinney Subject: RE: Hanleigh Deed on 845 Apricot Avenue Good Morning Bonita, The Parcel Map for the property next door shows a more recent document for 845 Apricot Avenue. It lists document 14033253 which was recorded in January of 1998. Could you please provide us with a copy of that more recent Grant Deed as well so that we can ensure we are using the latest document. 11/18/2014 Page 3 of 3 Thank you for your help, Roger K. Storz, P.E. I Senior Civil Engineer City of Campbell I Public Works Department rogers@cityofcamPbell.com 408.866.219O 70 N. First Street.Campbell,CA 95008 From: B Beck [mailto:bbeckre@gmail.com] Sent: Wednesday, November 12, 2014 4:09 PM To: Michelle Quinney Cc: STEVEHANLEIGH@GMAIL.COM Subject: Hanleigh Deed on 845 Apricot Avenue Hi Michelle, Steve Hanleigh asked that I send this deed over to you to forward to the City Engineering Department as requested to change the front sidewalk. Please see that the person responsible receives it. Thank you so much for your assistance. B Bonita Beck REALTOR Associate/Property Mgr. California BRE #00704368 Assistant to Stephen J. Hanleigh, Owner/Broker 1262 E. Hamilton Ave., Ste 1C Campbell, CA 95008-0837 St 408-377-8484 m 408-691-5334 *** eSafe 8 scanned this email for malicious content *** *** IMPORTANT: Do not open attachments from unrecognized senders *** *** eSafe 8 scanned this •email for malicious content *** *** IMPORTANT: Do not open attachments from unrecognized senders *** 11/18/2014 ‘4.41P off iii ._ y1t 14 ll! . . .t. 1 . ,,-;','-'7,..i7-_ -:- �.. ..... .. 4 1,,,etehl‘ ' AIL,V 'Illillibillirvra .r4: Cam• - 'A ,7 u, a .�. .. jL 11. fix' '""„ `i i • oogic earth Go )gle earth feet 10 meters 3 , }'- .J'r~ eat r tom. , I '' d , ,,.. .. , iiiiirtiiii -........1D:" '- --T:::. ' t '''':, ;'cki f`,'-x:41',.f. ' , Is--- _ . ".' • oL -y t ► sk ,a 'RN. A. .11 9r GooIe earth feet 10 meters 3 INSURANCE REQUIREMENTS CHECKLIST Permit# C�1C aO\t-k o \s CIP Project # 7)k-VS- )P6C5t- Ok, Consultant/Contractor: 11\\1A u ZZ‘ CaNC-c ek Q-- 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: 4 $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or .,e $2,000,000 general aggregate limit. fik Policy expiration date .\ok I5-- (, _ Automotive Liability: "Any Auto" checked on certificate $1,000,000..per accident for bodily injury and property damage Policy expiration date 3/7 3( IS -. Workers' Compensation and Employer's Liability ❑ Waiver of Subrogation clause 41-. $1,000,000 per accident for bodily injury or disease ' Policy expiration date \b,\S,15 Course of Construction (if required in Special Provisions) ❑ Completed value of the project ❑ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement: The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) 7� The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR should say: Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. ❑ Workers' Compensation Insurance Sheet Submitted 'u 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. Name: ' ve,( 'S NAIC# 'AZU Rating: /yr I x\/ Authorized in CA: Name: ciCr �q'�° 1�1AIC#4P\ Rating: i cf X./ Authorized in CA: ✓ Name: NAIC# itzz °�2Rating: Authorized in CA: Name: NAIC# Rating: Authorized in CA: o Campbell Business License #O2.`0 ' Expiration: ( ( ) o Contractors License # ELM 5c1`‘ Class:C—'3 Expiration: 14 5°1((e Insurance Certificate Reviewed \17V 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 08 14) Page 2 • .. .. _ Date(mm/dd/y9 .:.... AC T F TE F LI#1E UT i 1�# t l E /14 11/7 Pro (408) 295-1195 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Solari & Sanfilippo ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. P.o. Box 471 THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. San Jose, Ca. 95103-0471 COMPANIES AFFORDING COVERAGE Company Allied Property & Casualty A Insurance Company Company Insured 3AANT01-XXX B J. A. Antuzzi Concrete Co. , Inc. Company And Antuzzi Designs, Inc. 333 N Montgomery Street C San Jose CA 95110 Company D THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY 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. POLICY POLICY CO TYPE OF INSURANCE POLICY NUMBER EFFECTIVE EXPIRATION LIMITS LTR DATE DATE GENERAL LIABILITY General Aggregate $ Commercial General Liability._ Products-Completed Ops Agg $ ,.. 'Claims Made UOccur Personal&Advertising Injury $ Owner's&Contractor's Protective Each Occurrence $ Fire Damage(any I fire) 9 Medical Expense(any one person) $ AUTOMOBILE LIABILITY A IL Any Auto ACP7801260112 03/23/14 03/23/15 Combined Single Limit $ 1,000,000 All Owned Autos Bodily Injury Scheduled Autos (per person) $ Hired Autos Bodily Injury Non-Owned Autos Iper accident) Property Damage GARAGE LIABILITY Auto Only-Eacg Accident 9 _Any Auto Other Than Auto Only ........... ....... ............. Each Accident $ -" Aggregate 9 EXCESS LIABILITY Each Occurrence $ Umbrella Form Aggregate $ Other Than Umbrella Form $ WORKERS'COMPENSATION & 'Statutory Limit 'Other .................................... EMPLOYERS' LIABILITY EL Each Accident $ The Proprietor/ Inci EL Disease-Policy Limit $ Partners/Executive Officers are: Excl EL Disease-Ea Employee 9 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS The City, its officers, employees and volunteers are named as additional insured Re: 845 Apricot Way, Campbell, CA 95008 ERTIHCATE (2L E ` ;:':":::>':s: CAiUCELLi Tit?RI:,': 019 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL MAIL 3 0*DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, City Of Campbell Public Works Department � 70 N First StreetAuthorizedRepresentative Campbell CA 95008 , 7( CA 20 48 (02-99) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. SCHEDULE Name of Person(s) or Organization(s): City of Campbell, its officers, employees and volunteers (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the Coverage Form. Copyright, Insurance Services Office, Inc., 1998 CA 20 48 (02-99) ACP BA 78.0.1260112 LAHO 14030 CA2048029900 0240 78 0001707 JAANT-1 OP ID: CP AC'CPR CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 11/20/14 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 800-989-8712 NOMEACT Bozzuto&Associates Insurance 408 PHONE - IFAX -4298460 - 34 S.Second St (NC,No,Ext): — (NC,No): - Campbell,CA 95008 ADDRESS: Jennifer Anderson INSURER(S)AFFORDING COVERAGE NAIC INSURER A;Intl Ins Co of Hannover,plc AA112 INSURED JA Antuzzl Concrete Co.,Inc. INSURER B:Everest National Insurance Co. 10120 Antuzzi Concrete Designs,Inc. 333 North Montgomery Street INSURER C: San Jose,CA 95110 INSURERD: 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. ILTR TYPE OF INSURANCE ASR WVD POLICY NUMBER (MM(DIYYYY) (MMIDD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY X 1001200001303 10/01/14 10/01/15 DAMAGE TO RENTED $ ,50 000 PREMISES(Ea occurrence) CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEM_AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 -7 POLICY X JPE�CT- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS N BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE AUTOS $ HIRED AUTOS U _ TOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ _ WORKERS COMPENSATION X WC STATU- 0TH- AND EMPLOYERS'LIABILITY TORY LIMITS ER Y N B ANY PROPRIETOR/PARTNER/EXECUTIVE / X 7600009828141 10/01/14 10/01/15 EL.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? N IA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) Re: Project ® 845 Apricot Way, Campbell, CA 95008 (Permit ENC2014-00215) . The City of Campbell, its officers, employees and volunteers are named as additional insured. Insurance is primary. Waiver of Subrogation applies to the WC (to follow) . CERTIFICATE HOLDER CANCELLATION CITYOFC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Campbell THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN tY P ACCORDANCE WITH THE POLICY PROVISIONS. 70 North First Street Campbell, CA 95008-1423 AUTHORIZEEDREPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU (PRIMARY & NONCONTRIBUTORY This endorsement modifies insurance provided under the following; COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II -Who Is An Insured is amended to Include as an insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your po'icy. Such person or organization is an additional Insured 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. A person's or organization's status as an insured under this endorsement ends when your operations for that additional Insured are completed. B. With respect to the insurance afforded these additional insureds,the following additional exclusion apply: This insurance does not apply to; 1."Bodily injury", "properly damage", "personal and advertising injury"arising out of the rendering of, or the failure to render,any professional architectural, engineering or surveying services,including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications;or b. Supervisory, inspection,architectural or engineering activities. 2. "Bodily injury","property damage"occurring after; a. 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 b, 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;or c. 'Property Damage"which manifests after expiration of the Policy. If required by written contract or agreement,such insurance a 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. ALL OTHER TERMS, CONDITIONS AND EXCLUSIONS REMAIN UNCHANGED. TMGL 172 1011 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY Additional Insured-Owners,Lessees or Contractors-Completed Operations (PRIMARY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART: Name of Additional insured Person(s)Or Organization. Location and Description of Completed Operations: We shall name person(s)or organlzation(s)as additional insured(s)to this insurance as required under a written contract with the Named Insured entered into before the claim or loss for which this policy applies. No coverage,Indemnity and/or defense obligations shall be provided under this endorsement to any persons)or organization(s)claiming to be additional Insured(s)for claims or losses which do not arise from the Named insured's work or operations under a written contract and completed during the policy period. The Named Insureds mere presence at a work site shall not be deemed sufficient cause to require coverage,indemnity and/or defense to any person(s) or organization(s)claiming to be an additional Insured under this endorsement There shall be no coverage,indemnity,and/or duty to defend any person(s)or organization(s)claiming to be an additional insured under this endorsement if the claim or loss does not arise,in whole or in part,from the negligence and/or fault of the Named insured. Information required to complete this Schedule,if not shown above,will be shown in the Declarations. 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"or"property damage"caused,in whole or in part, by"your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and including in the"products-completed operations hazard." . 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. ALL OTHER TERMS,CONDITIONS AND EXCLUSIONS REMAIN UNCHANGED. TMGL 175 10 11 Additional Insured-.Owners,Lessees or Contractors Completed Operations(PRIMARY APARTMENT INCLUSION) This endorsement modifies the insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE: Name ofAddi ional Insured Person(s)Or Location and Description of Completed Operations: OrAanizatton(s), As required by mitten contract. No coverage Is provided under this endorsementfor single and multi family dwelling units,except for apartments. Information required to complete this Schedule,if not shown above,will be shown in the Declarations, 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" or"property damage"caused, in whole or in part,by"your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and including in the "products-completed operations hazard.". 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, ALL OTHER TERMS CONDITIONS AND EXCLUSIONS REMAIN UNCHANGED. TMGL 176 1011 ..�,� JAANT-1 OP ID: CP A T CPRCP CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 11/20/14 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 800-989-8712 CONTACT 33ozzuto&4 S.Second St 408-429-8460 Insurance 408-429-8460 NC..Nro.EA): FAX 34 Campbell,CA 95008 E-MAADDRESS: Jennifer Anderson INSURER(S)AFFORDING COVERAGE NAIC I INSURER A:Intl Ins Co of Hannover,plc AA112 INSURED JA Antuzzi Concrete Co.,Inc. INSURER B:Everest National Insurance Co. 10120 Antuzzi Concrete Designs,Inc. 333 North Montgomery Street INSURERC: San Jose,CA 95110 INSURERD: 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 ADL SUBR POLICY EFF POLICY EXP UNITS LTR INSR WVD POLICY NUMBER (MMIDDIYYYY) IMM/DDIVYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY X IG01200001303 10/01/14 10/01/15 pREMSES EaEoccurrence) $ 50,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 -I POLICY X JECT LOC $ AUTOMOBILE LIABILITY (Ea COMa INdEeD nt)SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS N BODILY INJURY(Per accident) NON-OWNED S PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTIONS $ WORKERS COMPENSATION X I TORY UMITS I IOER AND EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNER/EXECUTIVEY/N X 7600009828141 10/01/14 10/01/15 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Re: Project Q 845 Apricot Way, Campbell, CA 95008 (Permit ENC2014-00215) . The City of Campbell, its officers, employees and volunteers are named as additional insured. Insurance is primary. Waiver of Subrogation applies to the WC (to follow) . CERTIFICATE HOLDER CANCELLATION CITYOFC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Campbell THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P ACCORDANCE WITH THE POLICY PROVISIONS. 70 North First Street Campbell,CA 95008-1423 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 040306 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 5 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION CITY OF CAMPBELL CONCRETE WORK 70 N. FRIST STREET PERMIT # ENC2014-00215 CAMPBELL CA 95008 845 APRICOT WAY CAMPBELL CA 95008 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 11-20-14 Policy No. 7600009828141 Endorsement No. 001 Insured JA ANTUZZI CONCRETE CO. , INC. Premium $ INCL. Insurance Company EVEREST NATIONAL INSURANCE COMPANY 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. INSURED COPY ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS — AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU (PRIMARY & NONCONTRIBUTORY This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A, Section II -Who Is An Insured is amended to Include as an insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your po'icy, Such person or organization is an additional Insured only with respect to liability for"bodily Injury","property damage" or"persona!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. A person's or organization's status as an insured under this endorsement ends when your operations for that additional Insured are completed. B, With respect to the insurance afforded these additional insureds,the following additional exclusion apply: This insurance does not apply to: 1."Bodily injury", 'property damage', "personal and advertising injury"arising out of the rendering of, or the failure to render,any professional architecture!, engineering or surveying services,including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications;or b. Supervisory, inspection,architectural or engineering activities. 2, "Bodily injury","property damage"occurring after: a, 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 b. 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;or c. "Property Damage"which manifests after expiration of the Policy. If required by written contract or agreement,such insurance a 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, ALL OTHER TERMS, CONDITIONS AND EXCLUSIONS REMAIN UNCHANGED. TMGL 172 1011 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY Additional Insured-Owners,Lessees or Contractors-Completed Operations (PRIMARY) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART: Name of Additional insured Person(s)Or Organization.f Location and Description of Completed Operations: We shall name person(s)or organization(s)as additional Insureds)to this Insurance as required under a written contract with the Named Insured entered into before the claim or loss for which this policy applies. No coverage,indemnity and/or defense obligations shad be provided under this endorsement to any person(s)or organization(s)claiming to be additional insured(s)for claims or trams.;which do not arise from the Named Insured's work or operations under a written contract and completed during the policy period. The Named Insured's mere presence at a work site shall not be deemed sufficient cause to roquire coverage,Indemnity and/or defense to any person(s) or organization(s)claiming to be an additional Insured under this endorsement. There shall be no coverage,indemnity,and/or duty to defend any person(s)or organizations)claiming to be an additional Insured under this endorsement If the claim or loss does not arise,in whole or In part,from the negligence and/or fault of tho Named insured. Information required to complete this Schedule,If not shown above,will be shown in the Declarations. 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"or"property damage"caused,in whole or in part, by"your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and including in the"products-completed operations hazard." 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. ALL OTHER TERMS,CONDITIONS AND EXCLUSIONS REMAIN UNCHANGED. TMGL 175 10 11 Additional Insured-Owners,Lessees or Contractors- Completed Operations(PRIMARY APARTMENT INCLUSION) This endorsement modifies the insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE: Name of Addi ional insured Person(s)Or Location and Description of Completed Operations: Organization(s), As required by written contract No coverage is provided under this endorsement for single and multi family dwelling units,except for apartments. Information required to complete this Schedule,if not shown above,will be shown in the Declarations. 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"or"property damage" caused, in whole or in part,by "your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and including in the"products-completed operations hazard.". 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. ALL OTHER TERMS CONDITIONS AND EXCLUSIONS REMAIN UNCHANGED. TMGL 1761011 ACC)RO CERTIFICATE OF LIABILITY INSURANCE ` Date lmm,dd/yy) _ ,:. 11/19/14 Pro er ,19 5 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION (4029 1 Solari & Sanfilippo C ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. P.o. Box 471 i';, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE San Jose, Ca. 95103-0471 COVERAGE AFFORDED BY THE POLICIES BELOW. NQV 24 2014 COMPANIES AFFORDING COVERAGE Company Allied Property & Casualty Public Works Adminlst,- ,uA Insurance company Company Insured 3AANT01-XXX B J. A. Antuzzi Concrete Co. , Inc. Company And Antuzzi Designs, Inc. 333 N Montgomery Street C San Jose CA 95110 Company D COVEiAGE THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY 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. POLICY POLICY CO TYPE OF INSURANCE POLICY NUMBER EFFECTIVE EXPIRATION LIMITS LTR DATE DATE GENERAL LIABILITY General Aggregate $ Commercial General Liability Products-Completed Ops Agg $ ... 'Claims Made IllOccur Personal&Advertising Injury S Owner's&Contractor's Protective Each Occurrence S Fire Damage(any 1 fire) S Medical Expense(any one person) S AUTOMOBILE LIABILITY A Any Auto ACP7801260112 03/23/14 03/23/15 Combined Single Limit $ 1, 000, 000 All Owned Autos Bodily Injury Scheduled Autos (per person) $ Hired Autos Bodily Injury Non-Owned Autos (per accident) $ Property Damage $ GARAGE LIABILITY Auto Only-Eacg Accident $ ........................................ _Any Auto Other Than Auto Only Each Accident S Aggregate S EXCESS LIABILITY Each Occurrence Umbrella Form Aggregate S Other Than Umbrella Form WORKERS' COMPENSATION 8 'Statutory Limit I 'Other EMPLOYERS' LIABILITY EL Each Accident $ The Proprietor/ Ind EL Disease-Policy Limit S Partners/Executive — Officers are: Excl EL Disease-Ea Employee $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS The City, its officers, employees and volunteers are named as additional insured Re: 845 Apricot Way, Campbell, CA 95008 - bt")D` S� CERTIFICATE ''OLDER C1NCEL.LATION 019 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL EWEN=MAIL 3 0* DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, B City Of Campbell Public Works Department 70 N First StreetAuthorizedRepresentative Campbell CA 95008 iarr;)("4( AC0RD 25-${01/95! Sy Ineurenc5 VrsrQn9 Ine, ACORD CORPORATION 1988 . CA 20 48 (02-99) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM MOTOR CARRIER COVERAGE FORM TRUCKERS COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply un►ess modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" under the Who Is An Insured Provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. SCHEDULE Name of Person(s) or Organization(s): City of Campbell, its officers, employees and volunteers (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to the endorsement.) Each person or organization shown in the Schedule is an "insured" for Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured Provision contained in Section II of the Coverage Form. Copyright, Insurance Services Office, Inc., 1998 CA 20 48 (02-99) ACP BA 78-0.1260112 LAHO 14030 CA2048029900 0240 78 0001707