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HomeMy WebLinkAboutENC2013-00059 • n Z Print Form CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No G 01 /- 8d0 59 DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File 70 North First Street right-of-way) Application Date '5-27- I'N Campbell,CA 95008 Issued Lit to) 3 Application Expiration Date Ph. (408)866-2150 APN Fx. (408)376-0958 Permit Expiration Date (f I i G I 1 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.: rtt*cit /4Q. /aoltz--- 6 S C{/, H LT0>v'c 1-Ve Utility Trench Location: w 'r,/,4N,/L-/ ( PA 1212-Y1.-L PC/V B. Nature of Work: /,C/erl/}7/fj dVD7Nfi 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: SUS/ Gf, -s evAIf7YC/cr4 "' ‘441- Telephone: ¢ 8 ;T /76 7 Address: Sal Gr f Q JAI" JOsv-- C 11-7 1 E-Mail Address: kRor Rs Q/eoQSOI`/ifovht—Celld1 24-HOUR EMERGENCY PHONE NUMBER: 4i$ 764- /3 flW- Is this work being done by the property owners at their own residence? 7 YES r NO The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell,its officers,agents,and employees free,safe and harmless from any claim or demand for damages resulting from the work covered by this permit. The Applicant/Permittee hereby acknowledges that they have read d unde tan both the front and back of this permit,and they will inform their contractor(s) of the information. Applicant is advised that upon ss ance .f th per 't, property owner, or property owner's successors, shall be responsible for any and all damages arising out of the condition of. y p"vate pr.vemes in the public right-of-way. r� Accepted: I Acs-r2-06 G -�' -77(1/(3 nt mittee (sig e CONXfrel/cT)'/ P, - Ho 1-1,01-,c/r! 3(1x//3 (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 4215 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 $ 31 0 2414i0 o PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK&INSPECTION FEE $ `L`+ EMERGENCY PERMIT FEE $ APPROVED FOR ISSUANCE L,/1 vi 13 For City ngineer ineer 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. 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. 5. Maintain safe pedestrian and vehicular crossings and free access to private driveways,bus stops,fire hydrants,and water valves. 6. 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. 7. 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. 8. 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. 9. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements. 10. 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. 11. 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. 12. Compaction testing of subgrade,base rock,and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 13. 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. 14. 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. 15. 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. 16. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 17. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 18. 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. 19. 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. 20. 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. 21. 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 sh be res•.nsib.for ensuring that all those providing services under the applicant are aware and understand all of the above conditions. C. f_.(2 7(1 Applican Date: A CoAl e"?(Efizeic-170V (37/1/, Contractor (Print Name) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.09/10 cxkiel 3 j PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT,TRAFFIC & MISC7LLANEOUS RECEIP Effective July 1, 2012 b1-0I,;f( 5R i 3 1 TO: City Clerk PUBLIC WORKS FILE N0. � 9i [Ai ��,�� PROPERTY ADDRESS r, Please collect & receipt for the following monies: AMOUNT ACCT. ,l ITEM ENCROACHMENT PERMIT 4722 Utility Encroachment Permit Application Fee $370.00 R-1 Encroachment Permit N/C Emergency Permits $105.00 Plan Check&Inspection Feed , Minimum Charge Per Location $370.00 OD C Conduits/Pipelines up to 500 Feet $2.45/ft Above 500 Linear Feet $1.50/ft ManholesNaults/Etc. $160.00/ea Pole Set/Removal $160.00/ea 4760 Storage Container Permit $150.00 4760 Project Plans&Specifications Project No — 4760 Standard Specifications&Details $1/Pg $15.50/Bk — 4760 Engineering Maps&Plans Aerial Plot 24"x 36" $58.00 Aerial Print 8 1/2"x 11" $27.00 _ Map Research (includes max of two 24"x36"copies) $27.00 Maps and Plans 24"x 36" $13.00 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 A..licable Fee TRAFFIC 'v ° � .:. _;� ��.;�g� �, P, 4728 Traffic Flow Map (Daily Traffic Volumes) $34,Q .._..______._—_-__-__0 4728 Signal Timing Information $72.00/Hr 4271 Truck Permits $16.00 per trip 4728 No Parking Signs $1 each or$25/100 MISCELLANEOUS <w `. : r£ NVr ..:, , 511.7424 Postage Other Please S•eci TOTAL _� NAME OF APPLICANT CAki\-1....kkka.Onkcilk(eki-4---,‘5'N" ',art ` /, ,.� �j C NAME OF FAVOR f�C�1,`� �-'� `l'sHintk �y L LG PHONE �y 3�J- ADDRESS iJ 5 rvo Ii ck.' l ZIP r /26 FOR (RECEIVED Y ' � -7 `` f CITY CLERK ONLY Date 4 �L Receipt# Li ___.),..)O) I, t CITY OF CA'14PE!ELL RECVD BY: CASHIER 01000247701 PAYOR: PENNY LANE HOUSING TODAY'S DATE: 04/10/13 REGISTER DATE: 04/10/13 TIME: 11:36 DESCRIPTION AiOUNT ENGR R SUSDIV FILING F $740.00 CUST ID: 2013-00058 2013-00059 TOTAL DUE: $740.00 CHECK PAID: $740.00 CHECK NO: 10075 TENDERED: $7440.0 CHANGE: $.00 . • ,,,•/--,7 -1' ,,,,,IA. PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MIS, ELLANEOUS RCEIPT Effective July 1, 2012 "` Y '2•0/3-e16-056 -t- 2O13 -0z59 TO: City Clerk ,,�L�- PUBLIC WORKS FILE NO.PROPERTY ADDRESS &51 I..,•4, ibiri,.1f Please collect & receipt for the following monies: ACCT. i ITEM ( AMOUNT ENCROACHMENT PERMIT 4722 Utility Encroachment Permit Application Fee $370.00 X 2- 1 O R-1 Encroachment Permit N/C Emergency Permits $105.00 Plan Check&Inspection Fee -- Minimum Minimum Charge Per Location $370.00 Conduits/Pipelines up to 500 Feet $2.45/ft Above 500 Linear Feet $1.50/ft Manholes/Vaults/Etc. $160.00/ea Pole Set/Removal $160.00/ea 4760 Storage Container Permit $150.00 4760 Project Plans &Specifications Project No. _ 4760 Standard Specifications &Details $1/Pg $15.50/Bk 4760 Engineering Maps&Plans Aerial Plot 24"x 36" $58.00 Aerial Print 8 1/2"x 11" $27.00 Map Research (includes max of two 24"x36"copies) $27.00 Maps and Plans 24"x 36" $13.00 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 �4 ' ,„ 4728 Traffic Flow Map (Daily Traffic Volumes) $34.00 4728 Signal Timing Information $72.00/Hr 4271 Truck Permits $16.00 per trip 4728 No Parking Signs $1 each or$25/100 MISCELLANEOUS;'� .:.,:. 511.7424 Postage Other(Please Specify) TOTAL -12t0 NAME OF APPLICANT If\ Lo .- 'u&6 • NAME OF PAYOR r)�P,,\F�(1 L_(j�e t\- U , L I•-G PHONE 1 - aj4 5- 17 07 ADDRESS 2 l 95 to A-'(G-4,\pclo_ i ( r'1 ZIP ,5/ -(, /I MFOR RECEIVED BY CITY CLERK 1, ,, ., '? ONLY Date 2-11-r. Receipt#2 / -► t�1' - ' ., _f' 7,PTM._ \ : � X E � CITY OF CAMPBELL ; Q � $ RECVD BY: CASHIER 200«#9« « Sb PENNYEUE ASIA 7 . TODAY'S DATE: 03/27/13 REGISTER DATE: 3/27/13 2R; 1067 2 � gDESCRIPTION AMOUNT 9mam2ly FILING { $70.00 CUST S: 651 ! k«ETONly»SS9 TOTAL DUE: $740.0 CHECK PAID: !913 m n mE: wa !mq e «R 2.5 {! CHANGE; R, 2 c O w - o o o o - . E p / _ ` i\ / Cr \ \ . � � , k . � ' a," � l ® DATE(M A D o MIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3/25/2(1 3 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Leisa Youngman Lovitt&Touche'Inc-Tempe 1050 West Washington St,#233 PHONE E-MAIL E't1-602 956 2250 INC,FI No1:602-956-2258 Tempe AZ 85281 ADDREss:Iyoungman@lovitt-touche.com INSURERS)AFFORDING COVERAGE NAIC# INSURER A:National Union Fire Insurance 19445 INSURED SANTA26 INSURER B:Cincinnati Ins Company 10677 Sun Lakes Construction Co. of CA INSURER C: Penny Lane Housing, LLC INSURERD: Santa Clara Development, Inc 9532 E. Riggs Rd INSURER E: Sun Lakes AZ 85248 INSURER F: COVERAGES CERTIFICATE NUMBER:2141465215 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 LIMITS LTR INSR VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- JECT LOC B AUTOMOBILE LIABILITY CAP5191438 1/1/2013 1/1/2014 UUMHINED SINGLE LIMII (Ea accident) $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS BODILY INJURY(Per accident) $ AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS $ AUTOS (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ A WORKERS COMPENSATION Y/N Y 999123 4/1/2012 4/1/2013 TWC STATU-ORY LIMITS I OTH- AND EMPLOYERS'LIABILITYER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N N/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 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Evidence of California Workers Compensation Coverage WC Blanket waiver of subrogation applies if required in written contract. per WC040361 Evidence of Auto Liability. RE: Permit#BLD2012-00149 All work in public right of way 651-727 W. Hamilton Ave Campbell, CA See Attached... CERTIFICATE HOLDER CANCELLATION 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. 70 North First Street Campbell CA 95008 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are,registered marks of ACORD (3S- � A .• I Svc L,\KE. INSURANCE REQUIREMENTS CHECKLIST Permit# � � 7,O\3 "(1LSG5-6/ Zc --asA OP Project# L;•5 ,ti' lAc1wt \Nco The following insurance is required of all 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 - >a- $2,000,000 general aggregate limit. o Policy expiration date \I \ I \\-\ Automotive Liability: "Any Auto" checked on certificate $1,000,000 per accident for bodily injury and property damage o Policy expiration date \I\ /\' Workers' Compensation and Employer's Liability Waiver of Subrogation clause $1,000,000 per accident for bodily injury or disease o Policy expiration date u(\( 1 -5 Course of Construction (if required in Special Provisions) o Completed value of the project o Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement / The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) o The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: o Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR should say: Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. C:\Documents and Settings\joannat\Desktop\Insurance Requirements Cklist.doc (Rev 07/11) Page 1 of 2 ❑ Workers' Compensation Insurance Sheet Submitted ' For General Contractor ❑ For Developer or Owner 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: ,vc^4:c,.;Y,1 1;.n:,,,,, cat-, NAIC# Ic/ 45 Rating: /\ / Authorized in CA: Name: Q\ c \��v\cy\, vAS'(� NAIC# (0(017 Rating: f 7.\/ Authorized in CA: \(/„.. Name: (40 kS (.c-.1Ac--)`- NAIC # / Itz7 Z-Ra•ing:JL/ X\I Authorized in CA: Name: /-\\ \-e i'(c._ NAIC # 5-5ks 1 Rating: 0:.\./ Authorized in CA: V is----Campbell Business License # Suvk I c,Ke -- OZ,-1 a Z ExQ \Z(3 / 3 Insurance Certificate Reviewed 31 7/ I Initials Date Copy of Insurance Certificate placed in tickler file one month prior to expiration. C:\Documents and Settings\joannat\Desktop\Insurance Requirements Cklist.doc(Rev 07/11) Page 2 of 2 -\' T &• PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MISCELLANEOUS RCEIPT Effective July 1, 2012 7-o13_areg358 2013 -GtiS9 TO: City Clerk PUBLIC WORKS FILE NO. ! PROPERTY ADDRESS �2S/ V4, � I-k,,( five Please collect& receipt for the following monies: ACCT. ITEM I AMOUNT, ENCROACHMENT PERMIT 4722 Utility Encroachment Permit Application Fee $370.00 )( 1.10 R-1 Encroachment Permit N/C Emergency Permits $105.00 Plan Check&Inspection Fee � > Minimum Charge Per Location $370.00 —?o �L Conduits/Pipelines up to 500 Feet $2.45/ft Above 500 Linear Feet $1.50/ft ManholesNaults/Etc. $160.00/ea Pole Set/Removal $160.00/ea 4760 Storage Container Permit $150.00 4760 Project Plans&Specifications Project No. 4760 Standard Specifications &Details $1/Pg$15.50/Bk 4760 Engineering Maps&Plans Aerial Plot 24"x 36" $58.00 Aerial Print 8 1/2"x 11" $27.00 Map Research(includes max of two 24"x36"copies) $27.00 Maps and Plans 24"x 36" $13.00 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) $34.00 4728 Signal Timing Information $72.00/Hr 4271 Truck Permits $16.00 per trip 4728 No Parking Signs $1 each or$25/100 MISCELLANEOUS 511.7424 Postage Other(Please Specify) TOTAL zt.v NAME OF APPLICANT C `il CeC✓-fl 1" [lu' I • NAME OF PAYOR Pe4,14.(4 � .s'ie LVG PHONE 1 - 345- /7(07 ADDRESS 2(25 ---11Ae A-0-,,yieda I a7 s- ZIP "5/Z(o FOR !RECEIVED BY CITY CLERK i ONLY Date Z-\ l 6Receipt# ' / 70t/ CITY OF CAMP tt_i, r H a 4 H O O z CITY OF CO.PBELL c) r-- E RECV'D uY: CASHIER 0:;000247480 6 PA'YOR: PENNY LANE HOUSING TODAY'S DATE: 03/27/13 REGISTER DATE: 03/27/13 TIDE: 10:17 DESCRIPTION AMOUNT ENGR & SUBDIV FILING F $740.00 COST ID: 651 W HAMILTON 13-0581059 TOTAL DUE: $740.00 CHECK PAID: $740.00 CHECK NO: 10063 0 TENDERED: $740.00 CHANGE: $.00 ft Cj 0 A O O O O O O 0 O J z o 0 w z o o O 0 T o O 0 o 0 � il / ® CERTIFICATE OF/ � L�/ABILITY INSURANCE DATE(MMIDDIYYYY) ACORO L� hi 3/25/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMA7AON/'bNLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVED AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT G3''STITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Leisa Youngman Lovitt&Touche' Inc Tempe PHO(A/C.No.Ex-0:6_02-885-0528 1(AA/C,No):602-956-2258 1050 West Washington St,#233 AooREss:Iyoungman@lovitt-touche.com AZ 85281 l youngman@lovitt-touche.com INSURER(S)AFFORDING COVERAGE NAIC# ' INSURERA:LLOYD'S OF LONDON INSURED ROBSO-1 INSURERB:ALTERRA E&S LINES INS CO Penny Lane Housing, LLC INSURERC ASPEN UK INSURANCE LTD Sun Lakes Construction Co. of CA INSURER D:SWISS RE Robson Communities, et al — 9532 East Riggs Road INSURER E: Sun Lakes AZ 85248 INSURER F: COVERAGES CERTIFICATE NUMBER:307838208 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 LTR INSR_WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDIYYYY) LIMITS A GENERAL UABILITY Y CHF11NA11CP01021 1/1/2012 1/1/2014 EACH OCCURRENCE $5,000,000 X COMMERCIAL GENERAL LIABILITY PRMGE TO RENTED PREMISES(Ea occurrence) $1,000,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $excluded X OCIP PERSONAL&ADV INJURY $5,000,000 GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $5,000,000 POLICY PRO Construction SIR $100,000 X .IFCT LOC AUTOMOBILE UABILJTY COMBINED SINGLE LIMI I (Ea accident) S ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident $ AUTOS AUTOS ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) $ B UMBRELLA LIAB X OCCUR Y MAX6XL0000316 1/1/2012 1/1/2014 EACH OCCURRENCE $5,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED , RETENTION$ Excess$5mi1 $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'UABILITY Y I N TORY LIMITS I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N IA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Cr, Follow Form Excess of$10mil K08938012A0A 1/1/2012 1/1/2014 Occurrence/Aggregate 15,000,000 Follow Form Excess of$25mi1 MH918201 1/1/2012 1/1/2014 Occurrence/Aggregate 15,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) The General Liability insurance evidenced above includes as insureds only persons or organizations that the Named Insured agrees by written contract or written agreement to add as insureds. The coverage provided to such insureds applies only to work performed for the Named Insured under such written contract or written agreement at the Named Insured's worksite. RE: Permit#BLD2012-00149 All work in public right of way 651-727 W. Hamilton Ave Campbell, CA Additional Insured: City of Campbell, its agents,officers,attorneys,employees,officials and volunteers CERTIFICATE HOLDER CANCELLATION 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. 70 North First Street Campbell CA 95008 AUTHORIZED REPRESENTATIVE I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD DATE®ACC)R CERTIFICATE OF LIABILITY INSURANCE M/DD/YYYY) N 3/25/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Leisa Youngman _ Lovitt&Touche' Inc Tempe INC. o.Ext):602-956-2250 FAX inlc,Nd1:602 956 225$ 1050 West Washington St, #233 E-MAIL Tempe AZ 85281 l Y 9man oun lovitt-touche.co @ m INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:National Union Fire Insurance 19445 INSURED SANTA26 INSURER B Cincinnati Ins Company 10677 Sun Lakes Construction Co. of CA INSURER C: — Penny Lane Housing, LLC INSURER D: Santa Clara Development, Inc 9532 E. Riggs Rd INSURER E Sun Lakes AZ 85248 INSURER F: COVERAGES CERTIFICATE NUMBER:2141465215 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 ADDLTYPE OF INSURANCE INSR SUER (MM/DDPOLICY/YYYYI (MMID ) LTR INSR WVD POLICY NUMBER LIMITS GENERAL LIABILITY EACH OCCURRENCE $ _ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ CLAIMS-MADE OCCUR MED EXP(My one person) S PERSONAL Si ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGGPR $ 7 POLICY PECDT LOC $ B AUTOMOBILE LIABILITY CAP5191438 1/1/2013 1/1/2014 COMBINED SINGLE LIMI f (Ea accident) $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS -HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION y 999123 4/1/2012 4/1/2013 WC STATU OTH- AND EMPLOYERS'LIABILITY Y I N I TORY LIMITS I I ER ANY PROPRIETOR/PARTNER/EXECUTIVE - E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N NIA (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 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Evidence of California Workers Compensation Coverage WC Blanket waiver of subrogation applies if required in written contract. per WC040361 Evidence of Auto Liability. RE: Permit# BLD2012-00149 All work in public right of way 651-727 W. Hamilton Ave Campbell, CA See Attached... CERTIFICATE HOLDER CANCELLATION 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. 70 North First Street Campbell CA 95008 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD DATE Ac c) CERTIFICATE OF LIABILITY INSURANCE 3/31/2 014 .-. 2.....-•"" 3131/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Leisa Youngman Lovitt&Touche' Inc-Tempe PHONE 1 1050 West Washington St,#233 (NC No Fxt):602-385-0528 (AAic,No):602-956-2258 Tempe AZ 85281 ADDREss:Iyoungman©lovitt-touche.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Lloyd's of London INSURED ROBSO-1 INSURER B:Alterra E&S Lines Insurance Company Penny Lane Housing, LLC INSURER C:National Union Fire Ins Co of Pitts 19445 9532 East Riggs Road INSURER D: Sun Lakes AZ 85248 INSURER E: _ INSURER F: COVERAGES CERTIFICATE NUMBER: 1045962112 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 LIMITS LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A GENERAL LIABILITY Y CHF13NA13CP01005 4/1/2013 1/1/2015 EACH OCCURRENCE $5,000,000 DAMAGE TO RENTED PREMISES COMMERCIAL GENERAL LIABILITY (Ea occurrence) $100,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $excluded X OCIP PERSONAL&ADV INJURY $5,000,000 GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMP/OP AGG $5,000,000 X- POLICY PRO-.IFC:T LOC Construction SIR $100,000 AUTOMOBILE LIABILITY 1 COMBINED SINGLE LIMIT (Ea accident) i ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS I NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) $ B UMBRELLA LIAB X OCCUR Y MAX6GL0000451 4/1/2013 1/1/2015 EACH OCCURRENCE $5,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 I DED RETENTION$ Excess$5mil $ C WORKERS COMPENSATION WC0999123 4/1/2014 4/1/2015 X I WC STATU- X 1OTH- 1,000,000 AND EMPLOYERS'LIABILITY Y/N TORY I IMITS I FR ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/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 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Certificate holder is additional insured as respects their interest in operations of the insured and as mortgagee per form CG 20 18 11 85 attached. .../...-, RE: Permit# BLD2012-00149 All work in public right of way G\� 0COs \.�G 651-727 W. Hamilton Ave Campbell, CA - . `���"' Additional Insured: City of Campbell, its agents, officers, attorneys, employees,officials and volunteers (0`) `` CERTIFICATE HOLDER CANCELLATION 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. 70 North First Street Campbell CA 95008 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD • CNA (E G-1 5028-A(Ed. 08/89}/89)THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LOSS PAYABLE PROVISIONS This endorsement modifies insurance provided under the following: COMMERCIAL INLAND MARINE COVERAGE FORM SCHEDULE Provisions Applicable Location Description Loss Payee Loss Lender's Contract (If Applicable) of Property (Name &Address) Payable Loss Payable Of Sale REFER TO INLAND MARINE LOSS PAYEE SCHEDULE A. When this endorsement is attached to your a. We will pay for covered loss or damage to Commercial Inland Marine Coverage Form the term each Loss Payee in their order of Coverage Form in this endorsement is replaced by precedence, as interests may appear; the term Policy. b. The Loss Payee has the right to receive B. LOSS PAYABLE loss payment even if the Loss Payee has started foreclosure or similar action on the The following is added under the Loss Conditions section of the Commercial Inland Marine Covered Property; Conditions, Paragraph E. — Loss Payment: c. If we deny your claim because of your acts or because you have failed to comply with For Covered Property in which both you and a Loss Payee shown in the above Schedule have an the terms of the Coverage Form, the Loss insurable interest,we will: Payee will still have the right to receive loss payment if the Loss Payee: 1. Adjust losses with you; and (1) Pays any premium due under this 2. Pay any claim for loss or damage jointly to you Coverage Form at our request if you and the Loss Payee, as interests may appear. have failed to do so; C. LENDER'S LOSS PAYABLE (2) Submits a signed, sworn proof of loss within 60 days after receiving notice 1. The Loss Payee shown in the above Schedule is a creditor (including a mortgageholder or from us of your failure to do so; and trustee)with whom you have entered a contract (3) Has notified us of any change in owner- for the sale of Covered Property, whose interest ship, occupancy or substantial change in that Covered Property is established by such in risk known to the Loss Payee. written contracts as: All of the terms of this Coverage Form will a. Bills of lading; then apply directly to the Loss Payee. b. Financing statements; d. If we pay the Loss Payee for any loss or c. Chattel mortgages. damage and deny payment to you because of your acts or because you have failed to 2. For Covered Property in which both you and a comply with the terms of this Coverage Loss Payee have an insurable interest: Form: G-15028-A Page 1 of 2 (Ed. 08/89) CNA G-15028-A (Ed. 08/89) (1) The Loss Payee's rights will be 4. If we do not renew this policy, we will give transferred to us to the extent of the written notice to the Loss Payee at least 10 amount we pay; and days before the expiration date of this policy. (2) The Loss Payee's rights to recover the D. CONTRACT OF SALE full amount of the Loss Payee's claim 1. The Loss Payee shown in the Schedule is a will not be impaired. person or organization you have entered a At our option, we may pay to the Loss contract with for the sale of Covered Property. Payee the whole principle on the debt 2. For Covered Property in which both you and the plus any accrued interest. In this event, Loss Payee have an insurable interest we will: you will pay your remaining debt to us. 3. If we cancel this policy, we will give written a. Adjust losses with you; and notice to the Loss Payee at least: b. Pay any claim for loss or damage jointly to a. 10 days before the effective date of you and the Loss Payee, as interests may cancellation if we cancel for your non- appear. payment of premium; or 3. The following is added under the Loss b. 30 days before the effective date of Condition section of the Commercial Inland cancellation if we cancel for any other Marine Conditions, Paragraph F. — Other reason. Insurance: For Covered Property that is the subject of a contract of sale, the word "you" includes the Loss Payee. G-15028-A Page 2 of 2 (Ed. 08/89) . POLICY NUMBER: COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MORTGAGEE, ASSIGNEE, OR RECEIVER This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Designation of Premises: (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) 1. WHO IS AN INSURED (Section II) is amended to include as an insured the person(s) or organization(s) shown in the Schedule but only with respect to their liability as mortgagee, assignee, or receiver and arising out of the ownership, maintenance, or use of the premises by you and shown in the Schedule. 2. This insurance does not apply to structural alterations, new construction and demolition operations performed by or for that person or organization. CG 20 18 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 O i 1 z, LL {{ tl asa�e� aF as in a a n � F U O A w-� trJ Hw �� C\2 :�. 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