Loading...
HomeMy WebLinkAboutENC2014-00229 Print Form ('5?T P 1Y) CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No ��L (Lt—CIO 221 DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File 70 North First Street right-of-way) Application Date 12/9/ I`f Campbell,CA 95008 Issued O111/01 Application Expiration Date 6/9/(S Ph. (408)866-2150 APN ih Z\OC)L c Fx. (408)376-0958 Permit Expiration Date (2rf q '(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.: 2.(O 5 S P cc c cI AN-16- Utility Trench Location: 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: Telephone: Address: z Z __.�✓_._ rer%%A OZ,VA S Coro E-Mail Address: T �f, /A7/411/14 C,�R2 2� OUR EMERGENCY PHONE NUMBER: 1 t,ass-- /J p Is this work being done by the property owners at their own residence? IT YES (— NO AnNely 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 da ages arisi .out of the condition of any private improvements in the public right-of-way. Accepted: - f 2/' // ' - t Pe mittee) (sign) Date 2/6k-V, (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 $ -- PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT PLAN CHECK&INSPECTION FEE $ , EMERGENCY PERMIT FEE $ APPROVED FOR ISSUANCE (21I y /1L1 GENERAL PERMIT CONDITIONS 1. A Construction Cash Deposit is required.Charges will be made against this deposit if there is an emergency call-out,overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. 3. Refund or the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. Submit project schedule 10(ten)days prior to proposed start of work.Special provisions may be required for work within City facilities and downtown Campbell. 5. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. 6. Maintain safe pedestrian and vehicular crossings and free access to private driveways,bus stops,fire hydrants,and water valves. 7. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures,detours,and street closures. This plan must be reviewed and approved prior to any lane closures. 8. A Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones,dated 1990,available at Caltrans. Traffic control equipment shall include Type II flashing arrow signs if required. 9. Replace as directed by the City Engineer any damaged or removed improvements in accordance with City Standards and Specifications at the sole expense of the Permittee. 10. Sawcut for all PCC or AC removals.All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements. 11. Prior approval of inspector is required for any work done after normal working hours,on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 12. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost(including all labor and materials)against the cash deposit. 13. Compaction testing of subgrade,base rock,and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 14. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction.Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m.to 4:00 p.m. 15. No storage of materials or equipment will be allowed near the edge of pavement,the traveled way,or within the shoulderline which would create a hazardous condition to the public. 16. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a separate permit may be required,nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 17. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 18. This permit is not transferable.Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 19. Call back(call out)due to emeregencies regarding this permit shall be at the current overtime rate with a three(3)hour minimum charge per occurrence. 20. Pursuant to Chapter 14.02 of the Campbell Municipal Code,applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water.Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. 21. If the public interest requires a modification of,or a departure from the plans and specifications,the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made for City-owned or maintained facilities. 22. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and phone number. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions. Applicant Date: /C_ /2/e?A/ Contractor (Print Name) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC forrn2.pdf Rev.02/14 RAINO-1 OP ID:JV ,4c�oRv" 10/22 CERTIFICATE OF LIABILITY INSURANCE DATDWYW) 10122114 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 800-989-8712 CONTACT Bozzuto&Associates Insurance 408 29-8460 PHONE I FAX 34 S.Second St (AIC,No,EA): ,No): Campbell,CA 95008 ADDRESS: Linda Ellis INSURER(S)AFFORDING COVERAGE NAIC K INSURER A:North American Capacity Ins Co 25038 INSURED ROS,Inc.dba Rain or Shine INSURER B:California Automobile Ins Co 38342 Construction INSURER C:Financial Pacific Insurance Co 31453 PO Box 663 San Martin,CA 95046 INSURER D:Everest National Insurance Co. 10120 INSURER E:Peerless Insurance Company 24198 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBK POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MM!DD!YYYY) (MMIDOTYYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY X PNG000390805 07/01/14 07/01/15 DAMAGETORENTED 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 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 7 POLICY X jECT [1 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ B X ANY AUTO BA040000015955 07/01/14 07/01/15 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 C EXCESS LIAB CLAIMS-MADE 27303391 07/01/14 07/01/15 AGGREGATE $ 2,000,000 DED I I RETENTION$ $ ' WORKERS COMPENSATION X WC STATU- 1I0TH- AND EMPLOYERS'LIABILITY TORY LIMITS I l ER D ANY PROPRIETOR/PARTNER/EXECUTIVE YIN NIA X 7600001421141 03/01/14 03/01/15 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.LDISEASE-EAEMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 E Property Section CBP3576896 07/01/14 07/01/15 BPP/DED 16232/1000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: Permit #ENC2014-00229, Project Location 2105 S. Bascom Ave. , Campbell CA 95008; The City of Campbell, its officers, employees and volunteers are named as additional insured per the attached endorsements. The insurance coverage afforded to the Additional Insured is primary insurance. Waiver of subrogation applies to workers compensation per the attached endorsement CERTIFICATE HOLDER CANCELLATION CITYOFC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Cam pbell ACCORDANCE WITH THE POLICY PROVISIONS. Public Works Department 70 North First Street AUTHORIZED REPRESENTATIVE Campbell,CA 95008-1423 ` @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD RAINO-1 OP ID:JV .4 10/22 L CERTIFICATE OF LIABILITY INSURANCE DATDWYY 10/22/14 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER 800-989-8712 CONTACT Bozzuto&Associates Insurance X 408-429-8460 roe,70.Extl: FAX,No): 34 S.Second St Campbell,CA 95008 ADDRESS: Linda Ellis INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:North American Capacity Ins Co 25038 INSURED ROS,Inc.dba Rain or Shine INSURER B:California Automobile Ins Co 38342 Construction INSURER C:Financial Pacific Insurance Co 31453 PO Box 663 San Martin,CA 95046 INSURER D:Everest National Insurance Co. 10120 INSURER E:Peerless Insurance Company 24198 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MMIDDIYYYY) (MMIDD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY X PNG000390805 07/01/14 07/01/15 DAMAGES( 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 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 7 POLICY n JECT [1 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1 000 000 (Ea accident) $ 1,000,000 B X ANY AUTO BA040000015955 07/01/14 07/01/15 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS - HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 C EXCESS LAB CLAIMS-MADE 27303391 07/01/14 07/01/15 AGGREGATE $ 2,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION X I TORY LIMITS I I ER AND EMPLOYERS'LIABILITY D ANY PROPRIETOR/PARTNER/EXECUTIVE YIN X 7600001421141 03/01/14 03/01/15 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? NI A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes.describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 E Property Section CBP3576896 07/01/14 07/01/15 BPP/DED 16232/1000 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) RE: Permit #ENC2014-00229, Project Location 2105 S. Bascom Ave. , Campbell CA 95008; The City of Campbell, its officers, employees and volunteers are named as additional insured per the attached endorsements. The insurance coverage afforded to the Additional Insured is primary insurance. Waiver of subrogation applies to workers compensation per the attached endorsement CERTIFICATE HOLDER CANCELLATION CITYOFC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Cam pbeli ACCORDANCE WITH THE POLICY PROVISIONS. Public Works Department 70 North First Street AUTHORIZED REPRESENTATIVE Campbell,CA 95008-1423 I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD INSURANCE REQUIREMENTS CHECKLIST L OZZ' CIP Project# z1� �Permit# ( 'l ��(�k \ —� Consultant/Contractor: 9-.. ---.3t 'IS\C_- AEN2-.. (2--c:., c,C sj ..n jL.—_ 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: ;8, $1,000,000 per occurrence, and ❑ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggregate limit. 4. Policy expiration date 1/ i/ i c Automotive Liability: "Any Auto" checked on certificate $1,000,000 per accident for bodily injury and property damage yks Policy expiration date 7/l)lc 1,�C�`orkers' Compensation and Employer's Liability p` Waiver of Subrogation clause $1,000,000 per accident for bodily injury or disease ❑ Policy expiration date 2) 11\\ 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: \V The City, its officers, employees and volunteers are named as additional insured. l� `-= (Reference Project Location/Permit Number) 0\1/(-)\\ 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 For General Contractor ❑ For Developer or Owner J:\F0RMS\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. y Name: I,.hsti%e+c.o, NAIL# I'„' Authorized in CA: Name: ( t- A,‘A0 • CO• NAIC# sc63i+Z Rating: /\\-N\\\ Authorized in CA: Name: ve4 rs r ►srl ..Ng- Co. NAIC# IOVLO Rating: /c c/7A/ Authorized in CA: Name: NAIC# Rating: Authorized in CA: 1 Expiration: ❑ Campbell Business License # � 1. 71 I3, 0. 3s 'w'' Contractors License #��`1V.b Class: " Expiration: 3k I I C&`/ Insurance Certificate Reviewed kqt Iy I r Is Date o Copy of Insurance Certificate placed in tickler e one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 RAINO-1 OP ID:JV ACORO DATE(MMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 10/22114 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 Bozzuto&Associates Insurance 408 29-8460 PHONE FAX 34 S.Second St (Arc,No.EA): (AIC,No): Campbell,CA 95008 E-MAIL Linda Ellis ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC/ INSURER A:North American Capacity Ins Co 25038 INSURED ROS,Inc.dba Rain or Shine INSURER B:California Automobile Ins Co 38342 Construction INSURER c:Financial Pacific Insurance Co 31453 PO Box 663 San Martin,CA 95046 INSURER D:Everest National Insurance Co. 10120 INSURER E:Peerless Insurance Company 24198 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR' POLICY EFF POLICY EXP LIMBS LTR INSR WVD POLICY NUMBER (MMIDDIYYYY) (MMIDDIYYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY X PNG000390805 07/01/14 07/01/15 DAMAGETO 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 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 7 POLICY n jECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,00%000 (Ea accident) $ B X ANY AUTO BA040000015955 07/01/14 07/01/15 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS {Per accident) UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 2,000,000 (� EXCESS LIAB CLAIMS-MADE 27303391 07/01/14 07/01/15 AGGREGATE $ 2,000,000 DED I I RETENTION$WORKERS COMPENSATION $ AND EMPLOYERS LIABILITY X TORY L MITS I ER D ANY PROPRIETOR/PARTNER/EXECUTIVE YIN X 7600001421141 03/01/14 03/01/15 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N 1 A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 E Property Section CBP3576896 07/01/14 07/01/15 BPP/DED 16232/1000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more apace is required) RE: Permit #ENC2014-00229, Project Location 2105 S. Bascom Ave. , Campbell CA 95008; The City of Campbell, its officers, employees and volunteers are named as additional insured per the attached endorsements. The insurance coverage afforded to the Additional Insured is primary insurance. Waiver of subrogation applies to workers compensation per the attached endorsement CERTIFICATE HOLDER CANCELLATION CITYOFC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Campbell ACCORDANCE WITH THE POLICY PROVISIONS. Public Works Department 70 North First Street AUTHORIZED REPRESENTATIVE Campbell,CA 95008-1423 @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: PNG0003908 -05 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - (FORM 6) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: Any person or organization to which you are obligated by virtue of a written contract to provide insurance such as is afforded by this policy, but only with respect to (1) occur- rences taking place after such written contract has been executed and (2) occurrences re- sulting from work performed by you during the policy period, or occurrences resulting from the conduct of your business during the policy period. A person or organization that qualifies as an "insured" under the above paragraph of this Endorsement shall be an additional insured solely with respect to such additional insured's liability tor "bodily injury," property damage" or "personal and advertising injury" caused in whole or in part by your acts or omissions in the performance of "your work" for the addi- tional insured on or at "commercial construction projects." For the purposes of this Endorsement, "commercial construction projects" are defined as buildings or structures constructed for commercial use and also include apartments, hotels, homes for the aged, dormitories or barracks. However, "commercial construction projects" shall not include any building or structure which, in whole or in part, contains individual owner occupied units or dwellings. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of"your work"for that insured by or for you. Coverage provided by this policy to the Additional Insured(s) shown in the Schedule shall be primary insurance and any other insurance maintained by the Additional Insured(s) shall be excess and non-contributory, but only if required of the Named Insured and by written contract. CG 20 10 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 O COMMERCIAL GENERAL LIABILITY CG 20 33 07 98 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II — Who Is An Insured is amended to B. With respect to the insurance afforded these addi- include as an insured any person or organization tional insureds, the following additional exclusion for whom you are performing operations when you applies: and such person or organization have agreed in This insurance does not apply to: writing in a contract or agreement that such person or organization be added as an additional insured "Bodily injury", "property damage" or"personal and on your policy. Such person or organization is an advertising injury"arising out of the rendering of, or additional insured only with respect to liability aris- the failure to render, any professional architectural, ing out of your ongoing operations performed for engineering or surveying services, including: that insured. A person's or organization's status as 1. The preparing, approving, or failing to prepare an insured under this endorsement ends when or approve, maps, shop drawings, opinions, re- your operations for that insured are completed. ports, surveys, field orders, change orders or drawings and specifications; and 2. Supervisory, inspection, architectural or engi neering activities. Coverage provided by this policy to the Additional Insured(s) shall be primary insurance and any other insurance maintained by the Additional Insured(s) shall be excess and non-contributory, but only if required of the Named Insured and by written contract. CG 20 33 07 98 Copyright, Insurance Services Office, Inc., 1997 Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 04 03 06 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an Injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION ANY PERSON OR ORGANIZATION FOR BLANKET WAIVER OF SUBROGATION WHOM THE NAMED INSURED HAS AGREED BY WRITTEN CONTRACT TO FURNISH THIS WAIVER This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The Information below Is required only when this endorsement Is issued subsequent to preparation of the policy.) Endorsement Effective O3-O3-2O14 Policy No, 76OOOO1421141 Endorsement No. 001 Insured ROS, 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 Foam Manual- 1999. INSURED COPY PLEASE POST IN A CONSPICUOUS PLACE NOT TRANSFERABLE BUSINESS LICENSE CITY OF CAMPBELL (408)866-2174 ESTABLISHED: 08/19/2014 EXP DATE: 07/31/2015 LICENSE NO. 028755 • LOCATION: 12860 LLAGAS AVE SAN MARTIN,CA 95046 BUSINESS: ROS INC a TYPE OF BUSINESS OWNER: JESSE MENDOZA CONTRACTOR-SPECIAL TRADE-OUT OF •{S ll r TOWN The person,firm,or corporation named above is granted this business license pursuant to the provisions of the City Business License Ordinances to engage in,carry on,or conduct the business,trade,calling,profession,exhibition,or occupation described above. Issuance of the license is not an endorsement,nor certification of compliance with other ordinances or laws, nor an assurance that the proposed use is in conformance with the city zoning regulations. This license is issued without verification that the licensee is subject to or exempt from the licensing by the State of California. Valid only within the City of Campbell city limits. CITY MUST BE NOTIFIED ON ANY CHANGE IN OWNERSHIP,LOCATION,OR CLOSURE. ANNUAL TAX PAYMENT DUE ON OR BEFORE THE EXPIRATION DATE.RENEWAL NOTICE NOT REQUIRED.