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HomeMy WebLinkAboutENC2013-00062 ��--__11 Print Form, ENCROACHMENT PERMIT Permit No t V C 20(3 -�Gg 2 CITY OF CAMPBELL X-Ref.File DEPT.OF PUBLIC WORKS (for working within the public 70 North First Street right-of-way) Application Date if(Lf/I 3 Campbell,CA 95008 / r ' L Application Expiration Pate 600 4,/I Ph. (408)866-2150 Issued `T I I APN (. (� Fx. (408)376-0958 `7 1141)Permit Expiration Date LI- 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.) Came A. Work Address or Tract No.: /,")C7 E h.e i� A Utility Trench Location: B. Nature of Work: PO.(k Cm'At- O'Y\ Y 'ed- 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: 1Ci•k'D5 Cra,..5 e_ 3-\1l C2 4/) y Telephone: ' 5 a _ 15 37 Address: 10 L/5 COMA/1.27C k a I Cal- 5/k1.D 3051- E-Mail Address: AS C-to.}} Ick 1Jc Cry,,AJe,co"( 24-HOUR EMERGENCY PHONE NUMBER: y p/ 31 ‘- 7/6I Is this work being done by the property owners at th>?I"r own residence? r YES r NO The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell,its officers,agents,and employees free,safe and harmless from any claim or demand for damages resulting from the work covered by this permit. The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the infor ;tion. Applican is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and a da ag-s arising to e o dition of any private improvements in the public right-of-way. Accepted: i`/ 1/ / /3 (Applica e ittee) (sign) Date 30 k-)C441.c.1, ) Schott y/y / /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 $ 2 to 2_st 7(-,21 PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK&INSPECTION FEE $ 3-7O 'Z`t 7 6 11 EMERGENCY PERMIT FEE $ — 1 � f APPROVED FOR ISSUANCE L1 i Lt()3 For City Engineer Date Permit Expires 12 Months After Date of Issuance GENERAL PERMIT CONDITIONS 1. A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency call-out,overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. 3. Refund or the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. Submit project schedule 10(ten)days prior to proposed start of work.Special provisions may be required for work within City facilities and downtown Campbell. 5. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. 6. Maintain safe pedestrian and vehicular crossings and free access to private driveways,bus stops,fire hydrants,and water valves. 7. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures,detours,and street closures.This plan must be reviewed and approved prior to any lane closures. 8. A Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones,dated 1990,available at Caltrans. Traffic control equipment shall include Type II flashing arrow signs if required. 9. Replace as directed by the City Engineer any damaged or removed improvements in accordance with City Standards and Specifications at the sole expense of the Permittee. 10. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements. 11. Prior approval of inspector is required for any work done after normal working hours,on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 12. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost(including all labor and materials)against the cash deposit. 13. Compaction testing of subgrade,base rock,and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 14. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m.to 4:00 p.m. 15. No storage of materials or equipment will be allowed near the edge of pavement,the traveled way,or within the shoulderline which would create a hazardous condition to the public. 16. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a separate permit may be required,nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 17. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 18. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 19. Call back(call out)due to emeregencies regarding this permit shall be at the current overtime rate with a three(3)hour minimum charge per occurrence. 20. Pursuant to Chapter 14.02 of the Campbell Municipal Code,applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. 21. If the public interest requires a modification of,or a departure from the plans and specifications,the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made for City-owned or maintained facilities. 22. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and phone number. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions. G-kk ql Applicant i Date: Li/ Contractor Print Name) Date: • J:\FORMS\ m s\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.03/13 \ ` PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1,2012 G`, TO: City Clerk PUBLIC WORKS FILE NO. "1- 20 I 3 '" 00O16 2 PROPERTY ADDRESS Please collect&receipt for the following monies: ACCT. I ITEM I AMOUNT LAND DEVELOPMENT 4722 Encroachment Permit Application Fee Non-Utility Encroachment Permit Major≥$10,000 $370.00 Minor Encroachment Permit<$10,000 $210.00 2. (O Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $205.00 Street Tree Planting/Removal N/C 2203 ($500 per Tree Planting Deposit Required) $500.00/tree 2203 Plan Check Deposit 2%of Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Grading&Drainage Plan Review Single Family Lot $260.00 Site< 10,000 s.f. $780.00 Site≥ 10,000 s.f. <0.5 Acre $1,040.00 Site≥0.5 Acre $1,560.00 4722 NPDES Review(C3 Requirements) For projects not required to submit numeric sizing $150.00 For projects required to submit numeric sizing Impervious Area 10,000 Sq. Ft to 1 Acre $650.00 Impervious Area 1 Acre or more $850.00 Plan Check&Inspection Fee(Non-Utility) 3 7O 4722 Engr. Est. up to$250,000 14%of Engineer's Estimate **2203 Engr. Est. ≥$250,000 Actual cost+20%Admin Overhead (Min$35,000 Deposit) 2203 Emergency Cash Deposit 4%of Engr. Est.*($500 min/$10,000 Max) 2203 Faithful Performance Security(FPS) 100%of ENGR. EST.* 2203 Labor and Materials Security 100% of ENGR. EST.* 4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00 (Multi-Res$2,385.00) (All Other$2,650.00) 4722 Parcel Map(4 Lots or Less) $3,700.00+$80/lot 4722 Final Tract Map(5 or More Lots) $4,500.00+$110/lot 2203 Monumentation Security 100%of ENGR. EST. 4920 Parkland Dedication Fee(75%/25% Due Upon Cert. of Occupancy) 4722 Lot Line Adjustment(includes Certificate of Compliance) $1,750.00 4722 Vacation of Public Streets& Easements $2,340.00 4722 Certificate of Compliance $1,765.00 4722 Certificate of Correction $520.00 4722 Appeal Filing Fee $200.00 4722 Notary Fee(per signature) $10.00 4722 Assessment Segregation or Reapportionment First Split $830.00 Each Additional Lot $260.00 511.7424 Postage MISCELLANEOUS I Other(Please Specify) *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. �©, "*Actual Cost Plus 20%Overhead(Non-Interest bearing deposit) TOTAL $ CJ NAME OF APPLICANT klatOC:3 e RAN E 5e.3-- .� NAME OF PAYOR PHONE '/0e g/6 - 7/56 ADDRESS IONS C6`M -c C lQ T S )3 j s c_ ZIP qS/1 FOR RECEIVE B CITY CLERK ONLY Date LA Receipt# .,P APB' R13 Date Initials J,FORMS,Tempams,AdmimatrativeReceipl Form Land Dove,opment 12-13 » & » n 4 z \ n 0.�pm C. � '�^ ' &� ' #4 . n k ?p ^ a a k+R 4,0 ■ a e! � � _ c..- to. / m 2 @2 2& i m 4.p # Ra a�A �& ©�� a , &■ 4 /� TRAFFIC CONTROL PLAN - S 2ND STREET (E CAMPBELL AVE TO ORCHARD CITY DR), CAMPBELL R11-2 M4-9R ROAD DETOUR W1-4R W20-1 R3-2 i 20' 20' CLOSED [Sh ii '1 ' . I I a��..l t ',� I,t.......4.1`, 20' I 20 WORK T i 28"TRAFFIC CONES 15'MAX SPACING . AHEAD - 125'! I i' S. 2ND STREET ; • 235'TOW AWAY NO STOPPING ' I 125' 125' A \ ' <� Irt H . . . . .. . . .2. . . . . . . . • 90'SHIFTING TAPER <1L-l 20' R9-11R wuo N 20' 40' • • . - _ $ F CRANE o Ni II-; 20' =';> 125' �h._._._. �._._. 125' 125' 235'TOW AWAY NO STOPPING 1.i R1 i ST� R9.11AL R9.9 ) Ca ROAD ROAD DETOUR / / SIDEWALK WORK CLOSED n i CLOSED 125' i AHEAD AHEAD AHEADMt D! 125' t-,.�� / ' U 3ROAD / i Q W20-1 W20-3 W20-2 11 i 20' 20' WEAK / f Cr w AH 20' / 20'/ 2 I— ! �R3-1 (1 ' ®I W20-1 Cr 0 D . J M ' S.2ND STREET DES END DETOUR m a Z Ogil- m G P [DR _)_ TA DETOUR `pE`, / PREPARED BY: ROBERT SCULLY III[[[ S.3RD STREET HIGHWAY TECHNOLOGIES.INC. 1277 OLD BAYSHORE HWY. SAN JOSE CA.95112 (408)295-8210 (408) 939 FAX DETOUR ROUTE C-31 0.32 CONTRACTORS C-32 CONTRACTORS DC.796782 04/03/2013 7 : 25 : 59 PM -0500 FAXCOM PAGE 3 OF 7 80878 A'c'WR CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 4/32013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Construction&Real Estate Practice PHONE I FAX (A�,No): (866)358-1487 (A/C,No,Ext): Wells Fargo Insurance Services USA, Inc.-CA Lic#:OD08408 E-MAIL CertRequests@wellsfargo.com wellsfar o.com ADDRESS: q g 959 Skyway Road NSURER(S)AFFORDING COVERAGE NAIC I San Carlos,CA 94070 INSURER A: Zurich American Insurance Co 16535 INSURED INSURER B: Silicon Valley Crane,Inc.dba King Crane Service INSURER C: 10700 Bigge Avenue INSURER D: INSURER E: San Leandro,CA 94577 INSURER F: COVERAGES CERTIFICATE NUMBER: 5886525 REVISION NUMBER: See below 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 ADDLISUBW POLICY EFF POLICY EXP LTR TYPE OF INSURANCE .INSR WVD, POLICY NUMBER (MM/DDIYYYY) (MM/DD/YYYY) LIMITS GENERALUABILITY $ 1,000,000 A X GL0343693811 4112013 4/1/2014 EACH OCCURRENCE DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY 500,000 PREMISES(Ea occurrence) $ CLAIMS-MADE X OCCUR NED 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 -1 POLICY X PECOT- LOC $ A AUTOMOBILE LIABILITY X BAP369652511 4/1/2013 4/1/2014 (CEO MBIdNdEeDiSINGLE LIMIT $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED --'SCHEDULED BODILY INJURY(Per acddent) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accilent) UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I 1 RETENTION$ _ $ WORKERS COMPENSATION X WC STAN- OTH- A AND EMPLOYERS'LIABILITY Y/N X WC399167810 4/1/2013 4/12014 I TORY LIMITS I I FR ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more apace is required) RE:Jobsite:200 E.Campbell Avenue,Campbell,CA CA 20 48 02 99,WC 04 03 06(4-84),UGL1175ECW0412 City of Cambell,its officers,employees, and volunteers are named as additional insured as respects general liability and automobile liability per endorsements attached. CERTIFICATE HOLDER CANCELLATION City of Campbell SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 70 N.1st Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Campbell,CA 95008 AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) 04/03/2013 7 : 25 : 59 PM -0500 FAXCOM PAGE 4 OF 7 COMMERCIAL AUTO POLICY NUMBER: BAP369652511 ISSUE DATE: - - THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ 1T 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 modi- fied by this endorsement. This endorsement identifies person(s)or organization(s) who are"insureds" under the Who Is An Insured Provi- sion 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 70 N.1st Street Campbell,CA 95008 (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. City of Cambell, its officers, employees, and volunteers are named as additional insured as respects general liability and automobile liability per endorsements attached. CA 20 48 02 99 Copyright, Insurance Services Office, Inc., 1998 Page 1 of 1 04/03/2013 7 :25:59 PM -0500 FAXCOM PAGE 5 OF 7 WORKERS'COMPENSATION AND EMPLOYERS'LIABILITY INSURANCE POLICY WC 04 03 06 (Ed.4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following"attaching clause"need be completed only when this endorsement is issued subsequent to preparation of the policy.) This endorsement, effective on 4/1/2013 at 12:01 A.M. standard time,forms a part of (DATE) Policy No. WC3ss167810 Endorsement No. of the ZURICH AMERICAN INSURANCE COMPANY (NAME OF INSURANCE COMPANY) issued to Silicon Valley Crane, Inc.dba King Crane Service 9(4044.... Premium (if any)$ Authorized Representative 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 % of the California workers' compensation pre- mium otherwise due on such remuneration. Schedule Person or Organization Job Description ALL PERSONS AND/OR ORGANIZATIONS THAT ARE REQUIRED ALL CALIFORNIA OPERATIONS BY WRITTEN CONTRACT OR AGREEMENT WITH THE INSURED,EXECUTED PRIOR TO THE ACCIDENT OR LOSS,THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY FOR WORK PERFORMED BY YOU FOR THAT PERSON AND/OR ORGANIZATION WC 252(4-84) WC 04 03 06(Ed.4-84) Page 1 of 1 04/03/2013 7 : 25 : 59 PM -0500 FAXCOM PAGE 6 OF 7 0 Additional Insured —Automatic — Owners, Lessees Or ZURICH Contractors Policy No. Eff. Date of Pol. Exp. Date of Pol. Eff.Date of End. Producer No. Add'I.Prem Return Prem. GLO343693811 4/1/2013 4/1/2014 4/1/2013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured: Silicon Valley Crane,Inc.dba King Crane Service Address(including ZIP Code): 10700 Bigge Avenue San Leandro,CA 94577 This endorsement modifies insurance provided under the: Commercial General Liability Coverage Part A. Section II—Who Is An Insured is amended to include as an insured any person or organization who you are required to add as an additional insured on this policy under a written contract or written agreement. However, if you have entered into a construction contract or construction agreement with an additional insured person or organization, the insurance afforded to such additional insured only applies to the extent permitted by law. B. The insurance provided to the additional insured person or organization applies only to "bodily injury", "property damage" or "personal and advertising injury" covered under Section I — Coverage A— Bodily Injury And Property Damage Liability and Section I—Coverage B—Personal And Advertising Injury Liability, but 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, and resulting directly from your ongoing operations or "your work" as included in the "products-completed operations hazard",which is the subject of the written contract or written agreement. C. However, regardless of the provisions of Paragraphs A.and B.above: 1. We will not extend any insurance coverage to any additional insured person or organization: a. That is not provided to you in this policy:or b. That is any broader coverage than you are required to provide to the additional insured person or organization in the written contract or written agreement: and 2. We will not provide Limits of Insurance to any additional insured person or organization that exceed the lower of: a. The Limits of Insurance provided to you in this policy: or b. The Limits of Insurance you are required to provide in the written contract or written agreement. D. The insurance provided to the additional insured person or organization does not apply to: "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering or failure to render any professional architectural, engineering or surveying services including: 1. The preparing, approving or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders,change orders or drawings and specifications; and 2. Supervisory, inspection,architectural or engineering activities. U-GL-1175•E CW(04/12) Page 1 of 2 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. 04/03/2013 7:25 : 59 PM —0500 FAXCOM PAGE 7 OF 7 E. The following is added to Paragraph 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit of Section IV — Commercial General Liability Conditions: The additional insured must see to it that: 1. We are notified as soon as practicable of an "occurrence"or offense that may result in a claim; 2. We receive written notice of a claim or"suit"as soon as practicable;and 3. A request for defense and indemnity of the claim or "suit" will promptly be brought against any policy issued by another insurer under which the additional insured may be an insured in any capacity. This provision does not apply to insurance on which the additional insured is a Named Insured, if the written contract or written agreement requires that this coverage be primary and non-contributory. F. For the coverage provided by this endorsement: 1. The following paragraph is added to Paragraph 4.a.of the Other Insurance Condition of Section IV—Commercial General Liability Conditions: This insurance is primary insurance as respects our coverage to the additional insured person or organization, where the written contract or written agreement requires that this insurance be primary and non-contributory with respect to any other policy upon which the additional insured is a Named Insured. In that event, we will not seek contribution from any other such insurance policy available to the additional insured on which the additional insured person or organization is a Named Insured. 2. The following paragraph is added to Paragraph 4.b.of the Other Insurance Condition of Section IV—Commercial General Liability Conditions: This insurance is excess over: Any of the other insurance, whether primary, excess, contingent or on any other basis, available to an additional insured, in which the additional insured on our policy is also covered as an additional insured on another policy providing coverage for the same"occurrence", offense, claim or"suit". This provision does not apply to any policy in which the additional insured is a Named Insured on such other policy and where our policy is required by written contract or written agreement to provide coverage to the additional insured on a primary and non- contributory basis. G. This endorsement does not apply to an additional insured which has been added to this policy by an endorsement showing the additional insured in a Schedule of additional insureds, and which endorsement applies specifically to that identified additional insured. All other terms and conditions of this policy remain unchanged. u-GL-1175-E CW(04/12) Page 2 of 2 Includes copyrighted material of Insurance Services Office.Inc.,with its permission. 04/03/2013 7 :25 : 59 PM -0500 FAXCOM PAGE 2 OF 7 • Construction&Real Estate Practice Wells Fargo Insurance Services USA,Inc.-CA Lic#:0D08408 959 Skyway Road San Carlos,CA 94070 To: City of Campbell From: Jeff Evenson(408-452-1537 Extension 6605) Fax: 408-376-0958 Subject: Certificate Of Insurance on behalf of(Silicon Valley Crane,Inc.dba King Crane Service) Comments: This is your requested certificate of insurance. CID:280878, SID:5886525 This certificate was sent to you using CyberSure,Wells Fargo Insurance Service's client portal. This message may contain confidential and/or privileged information If you are not the addressee or authorized to receive this for the addressee,you must not use,copy,disclose,or take any action based on this message or any information herein. If you have received this message in error,please advise the sender immediately by reply fax and delete this message.Thank you for your cooperation. w • (00 U . Cp,,,,,,o Ak ���. . INSURANCE REQUIREMENTS CHECKLIST Permit# CIP Project# 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 $2,000,000 general aggregate limit. 7� Policy expiration date L1-\ tLk Automotive Liability: 4 "Any Auto" checked on certificate $1,000,000 per accident for bodily injury and property damage g Policy expiration date L->,- -t 4 Workers' Compensation and Employer's Liability Waiver of Subrogation clause ,a $1,000,000 per accident for bodily injury or disease Policy expiration date u- \—VA 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) N--lo___: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 rate 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 'i.--„ Workers' Compensation Insurance Sheet Submitted For General Contractor o For Developer or Owner 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. Name: 2L).f \LNi\ �w\�y�C��v� NAIC# h5 5) Rating; 1\.-\f <\/ Authorized in CA: Name: NAIC# Rating: Authorized in CA: Name: NAIC# Rating: Authorized in CA: Name: NAIC# Rating: Authorized in CA: ❑ Campbell Business License # Insurance Certificate Reviewed Initials Date o 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