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HomeMy WebLinkAboutENC2013-00078 Print Form CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No C(*3 L GG� DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File 70 North First Street 5-it Application Date 2-"2't-Z0(5 Campbell,CA 95008 Issued 5''i 0 .- t r 3 Application E iration Date Ph. (408)866-2150 APN (}r zLf60-')--6)1 Fx. (408)376-0958 !) - a-2-0Permit Expiration Date 14 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.: Public Works Maintenance Corporation Yard,290 Dillon Avenue Utility Trench Location: Existing stormwater catch basin at northeast corner of the corporation yard B. Nature of Work: Pothole for stormwater easement from 282 Dillon to exist.corp yard catch basin 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: Sun Lakes Construction Company of California Telephone: 408 345-1767 Address: 2185 The Alameda,Ste 150 San Jose, CA 95126 E-Mail Address: 24-HOUR EMERGENCY PHONE NUMBER: Is this work being done by the property owners at their own residence? r YES IT< 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/Permitter •reb ac .wledges that they have read and understand both the front and back of this permit,and they will inform their contractor(s) of the i for tion. A plicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any a r d all mages • isin out of the condition of any private improvements in the public right-of-way. / Accepted: (r-fA-r�� I C� '7-� (A licant Permittee) (sign) Date � p /icy— e•frt�.,,.Q '�/Z4 /f3 (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 RECE NO. PERMIT APPLICATION FEE $ '37D - 2'b J b5 PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK&INSPECTION FEE $ ?,70 - 7-4 3iF'� EMERGENCY PERMIT FEE $ APPROVED FOR ISSUANCE 0 ` 3 For City Engineer Date Permit Expires 12 Months After Date of Issuance GENERAL PERMIT CONDITIONS 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 me an hone number. Applicant shall be responsible for ensuring that all thos ro iding servi es under the applicant are aware and understand all of the above conditions. I2-/Gr Q `f/9-¢/i3 Applicant Date: !! Contractor (Print Name) Date: I J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.03/13 ® DATE(MM/DDIYYYY) ACORD CERTIFI ►TE OF LIABILITY INS '\NCE 4/17/2014 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 D PHONE Leisa Youngman Lovitt&Touche' Inc-Tempe F (A/C..No.Ext1:602-385-0528 IFAX(A/C.No):602-956-2258 1050 West Washington St,#233 EMAIL Tempe AZ 85281 APR 1'7 2014 ADDREss:loungman@lovitt-touche.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Lloyd's of London INSURED public v,pilinistration INSURER B:Alterra E&S Lines Insurance Company Sun Lakes Construction Co. of CA INSURER C:National Union Fire Ins Co of Pitts 19445 Robson Homes, LLC INSURER D Cincinnati Insurance Co 10677 9532 East Riggs Road Sun Lakes AZ 85248 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:393790976 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 W LIMITS LTRINSR VD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) A GENERAL LIABILITY Y CHF13NA13CP01005 4/1/2013 1/1/2015 EACH OCCURRENCE $5,000,000 X DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $100,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $5,000,000 I GENERAL AGGREGATE $5,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $5,000,000 PRO LOC Construction SIR $100,000 POLICY JECT D AUTOMOBILE LIABILITY CAP5191438 1/1/2014 1/1/2015 COM(Ea aB tINEDSINGLE LIMIT $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS _ AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS (Per accident) $ B UMBRELLA LIAB OCCUR Y MAX6GL0000451 4/1/2013 1/1/2015 EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I JI RETENTION$ $ C WORKERS COMPENSATION WC000999123 4/1/2014 4/1/2015 X I WC STATU- I IOTH- AND EMPLOYERS'LIABILITY Y/N TORY I IMITS ER 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) 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. Work Comp-Blanket Waiver of subrogation applies if required by contract per form WC040361. The City, its officers, employees a olunteers are named as additional insured if required by written contract as respects work at: 290 Dillon Ave,Campbell, CA and Pe t#ENC2013-00078. 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 ---- I ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MISCELLANEOUS RECEIPT Effective July 1, 2012 TO: City Clerk 20 PUBLIC WORKS FILE NO. _ PROPERTY ADDRESS z, o . pi`)on Please collect & receipt for the following monies: ACCT. I ITEM I AMOUNT ENCROACHMENT PERMIT 4722 Utility Encroachment Permit Application Fee $370.00 �7� encroachment Permit 'l� Emergency Permits $105.00 Plan Check&Inspection Fee Minimum Charge Per Location $370.00 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 e 4 Times p licable Fee rf 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$25/100 MISCELLANEOUS 511.7424 Postage Other(Please Specify) TOTAL NAME OF APPLICANT ' 0199CY1 l 1"'1/1.��� �C NAME OF PAYOR V" PHONE ADDRESS �1 S Ike r�1ib `� ;\.) ZIP l 2-(p FOR RECEIVED BY . CITY CLERK { ONLY Date Receipt# `^ CITY OF CAM-1...$c„L.► +CHIC TE RE yT Gm OF COWDELL RRg : 2meGGw =mm ROBSON HOMES mes DATE: OZ g REGISTER DATE: 05'10'13 Q«: 1::41 DESCRIPTION AMOUNT gm & +RD SdmF lyGm OUST IRO G me SGLWw $mad CHECK PAID: !aG y CHECK q: 1127 TENDERED: Qw±e ROANGE: \ \, THIS CHECK 1S VZ °'6TWOU°"A GREEN A BLUE BORDER AND BACKGROUND PLED A KNIGHT&FIN REt95 .. aTA "Rs'x4ARiE C>Pl TNT x= k:K t-., _�T-� _ .�.7 Af California Bank 1 t Walnut Creek( 11-204/1210 11617 RO SON HOMES LLC 1277 Treat Blvd Suite 120 Walnut Creek,CA 94597 2185 The Alameda San Jose,CA 95126 Date Amount 05/06/13 $******740.00 Pay SEVEN HUNDRED FORTY AND 00/100 ******************************** *********** ***** Dollars To CITY OF CAMPBELL The 70 N FIRST ST Order CAMPBELL CA 95008-1458 Of u■ LL6L711' i: L2 LOO 2042i: L29009284LH' ROBSON HOMES LLC Califomia Bank&Trust Stub Check No. 11617 1-of-1 -------------Date----05/06/13 ------- • Invoice Number Inv Date Payment Advice Gross Discount Net 3142 050213 Encroachment/Inspection Fee 740.00 740.00 740.00 740.00 • Vendor No. Name 186108 CITY OF CAMPBELL apcheckcbt.___.._ REORDEP 903•U S PATENT NO.5530290,5575508.59941183,5785353,5384364,6030000 7 ® DATE(MM/DD/YYYY) ACCPRL' CERTIFI.:__ ATE OF LIABILITY INSI kNCE 3/31/2014 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 1050 West Washington St,#233 (A/C. Ext):602-385-0528 fA/C,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 Sun Lakes Construction Co. of CA INSURER c:National Union Fire Ins Co of Pitts 19445 Robson Homes, LLC INSURER D Cincinnati Insurance Company 10677 9532 East Riggs Road Sun Lakes AZ 85248 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1136457471 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR POLICY EFF POLICY EXP TYPE OF INSURANCE LTR ,INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYTY) LIMITS A GENERAL LIABILITY Y CHF13NA13CP01005 4/1/2013 1/1/2015 EACH OCCURRENCE $5,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY 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 PRO- Construction SIR $100,000 POLICY JFCT LOC D AUTOMOBILE LIABILITY CAP5191438 1/1/2014 1/1/2015 (EO BINEDISINGLE LIMIT $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE $ NON-OWNED 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 $5,000,000 DED I RETENTION$ Excess$5mil $ C WORKERS COMPENSATION WC0999123 4/1/2014 4/1/2015 x I WC STATU- Ix IOTH- AND EMPLOYERS'LIABILITY TORY I IMITS FR ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 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/LOCATIONS/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. Work Comp-Blanket Waiver of subrogation applies if required by contract per form WC040361. The City, its officers, employees and volunteers are named as additional insured if required by written contract as respects work at:290 Dillon Ave, Campbell, CA and Permit#ENC2013-00078. 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 ACCPRE) CERTIFItATE OF LIABILITY INSuKANCE DATE(MM/DDNYYY) 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 FAX 1050 West Washington St, #233 EA A O.Fm602-385-0528 (A/c,No):602-956-2258 Tempe AZ 85281 ADDREss:Ioungman©lovitt-touche.com INSURER(S)AFFORDING COVERAGE NAIL# 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 LTRINSR WVD POLICY NUMBER I(MMIDD/YYYY) (MM/DD/YYYY) LIMITS A GENERAL LIABILITY Y CHF13NA13CP01005 4/1/2013 1/1/2015 EACH OCCURRENCE $5,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(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: PRODUCTS-COMP/OP AGG $5,000,000 POLICY PRO- IFCT LOC Construction SIR $100,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per $ AUTOS AUTOS accident) HIRED AUTOS NON-OWNED PROPERTY DAMAGE 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 $5,000,000 DED RETENTION$ Excess$5mil $ C WORKERS COMPENSATION `NC0999123 4/1/2014 4/1/2015 X I WC STATU- IX 0TH- 1000,000 AND EMPLOYERS'LIABILITY YIN TORY I IMITS 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 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 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD BLANKET WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT 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 12:01 AM 04/01/2013 forms a part of Policy No. WC 000-99-9123 Issued to SANTA CLARA DEVELOPMENT COMPANY, INC. By NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. We have a right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against any person or organization with whom you have a written contract that requires you to obtain this agreement from us, as regards any work you perform for such person or organization. The additional premium for this endorsement shall be 2.00 % of the total estimated workers compensation premium for this policy. WC 04 03 61 Countersigned by (Ed. 11190) Authorized Representative , Robson Communities, Inc. Policy # CHF11/NA11CP01/021 SECTION II-WHO IS AN INSURED 1. If you are designated in the Declarations as: a. An Individual, you and your spouse or domestic or civil partner are insureds, but only with respect to the conduct of a business of which you are the sole owner. b. A partnership or joint venture, you are an insured. Your members, your partners, and their spouses or domestic or civil partner are also insureds, but only with respect to the conduct of your business. c. A limited liability company, you are an insured. Your members are also insureds, but only with respect to the conduct of your business. Your managers are insureds, but only with respect to their duties as your managers. d. An organization other than a partnership, joint venture or limited liability company, you are an insured. Your"executive officers"and directors are insureds, but only with respect to their duties as your officers and directors. Your stockholders are also insureds, but only with respect to their liability as stockholders. e. A trust, you are an insured. 2. Each of the following is also an insured under Coverages A, B and C: a. Your"employees", other than either your"executive officers" (if you are an organization other than a partnership, joint venture or limited liability company) or your managers (if you are a limited liability company), but only for acts within the scope of their employment by you or while performing duties related to the conduct of your business. However, none of these"employees"is an insured for: (1) "Bodily injury"or"personal and advertising injury": (a) To you, to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability company), or to a co-"employee" while that co- "employee" is either in the course of his or her employment or performing duties related to the conduct of your business; (b) To the spouse, domestic or civil partner, child, parent, brother or sister of that co- "employee"as a consequence of Paragraph(1)(a)above; (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraphs (1)(a) or(b) above; or (d) Arising out of his or her providing or failing to provide health care services for which a professional designation or licensing is required by governmental authorities. (2) "Property damage"to property: (a) Owned, occupied or used by; (b) Rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by you, any of your "employees", any partner or member (if you are a partnership or joint venture),or any member(if you are a limited liability company). CHF-GL-0001 09 19 11 Includes Copyrights material of Insurance Services Office, Inc. Page 16 of 34 b. Any person (other than your "employee"), or any organization while acting as your real estate manager. c. Any person or organization having proper temporary custody of your property if you die, but only: (1) With respect to liability arising out of the maintenance or use of the property; and (2) Until your legal representative has been appointed. d. Your legal representative if you die, but only with respect to duties as such. That representative will have all your rights and duties under this policy. 3. Any person or organization that you have agreed by written contract or written agreement to add as an insured under this policy is an insured. However: a. Coverage under Coverage A and Coverage C, is limited to liability which: (1) Arises out of your ongoing operations; or (2) Arises out of"your work" performed by such person or organization for the Named Insured. b. Coverage A does not apply to"bodily injury"or"property damage"that occurred before you entered into that written contract or written agreement; c. Coverage B does not apply to: (1) "property damage": (a) To that particular portion of "your work" performed on your behalf by the person or organization you have agreed by written contract or written agreement to add as an insured;and (b) That occurred before you entered into that written contract or written agreement. (2) "repair costs" for "Home Performance Failure(s)" taking place before you entered into that written contract or agreement. d. Coverage C does not apply to "personal and advertising injury" arising out of an offense committed before you entered into that written contract or written agreement; 4. Any organization you newly acquire or form, other than a partnership, joint venture or limited liability company, and over which you maintain ownership or majority interest, will qualify as an Insured if there is no other similar insurance available to that organization. However, with respect to the coverage afforded to any such organization: a. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed that organization; b. Coverage B does not apply to: (1) "repair costs" arising out of "Home Performance Failure(s)" in "homes" sold, given away or abandoned by that organization before you acquired or formed that organization; or (2) "property damage" to "your work" that occurred before you acquired or formed that �....1.._ _..__._.... organization; and. ......_ _ ..._._. CHF-GL-0001 09 19 11 Includes Copyrights material of Insurance Services Office, Inc. Page 17 of 34 f S_:),(\ (---(-\\k- s Ci_o4-\ - ,k uc_A \o--/ -- INSURANCE REQUIREMENTS CHECKLIST 2qc) \,. \\\per 1\,e____ ,, Permit# (�' JLi )('/ .3 -(;(301 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 ,\y/ $1,000,000 general aggregate limit applying separately to the project, or u 2,000,000 general aggregate limit. X Policy expiration date M \ \ Automotive Liability: c), ' >6_ "Any Auto" checked on certificate 4" $1,000,000 per accident for bodily injury and property damage . Policy expiration date \-- l -\� \L . Workers' Compensation and Employer's Liability iver of Subrogation clause $1,000,000 per accident for bodily injury or disease _ �X�\�� SA S��j iv ,�e\( A Policy expiration date Lk--..�-- .\-. 1 �- �(kliy d C— C 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 K-------- o The/City, its officers, employees and volunteers are named as additional insured. Reference Project Location/Permit Number) - \oCc ; , - Ze-CC, 6\\w/ tt\\)e- . ❑ 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: OI\\' 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 � r • o Workers' Compensation Insurance Sheet Submitted ❑ For General Contractor o 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. 1 11 ' - tIZ1ZZ5� Name: l� c�S Lb„v\ok/k.--PIAIC # . Rating: / / Authorized in CA: Name: ic\tes(V0,• NAIC # 3-i1et Rating: utWorized in CA: —Rating::� Authorized in CA: Name: N�\ v,`:0� F�e_. NAIC# �tC.l4S g Name: ::. C�na(��. .1. ..`C. a NAIC # (0x07-7 Rating: tz top, Authorized in CA: \-/v r� Campbell Business License #S,JY1 OL1 S Z Z C )(‘CD (Z/1 I L3 Insurance Certificate Reviewed --` / 30 f Initi 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 • JoAnna Thomason From: JoAnna Thomason Sent: Wednesday, January 30, 2013 4:03 PM To: 'Leisa Youngman' Subject: RE: NAIC Insurance Information Thank you Leisa ! JoAnna Thomason I Office Assistant Public Works Department joanna@cityofcampbell.com ( 408.866.2150 17 408.376-0958 (fax) * 70. N. First Street I Campbell, CA 95008 www.CityofCampbell.com Original Message From: Leisa Youngman [mailto:lyoungman@lovitt-touche.com] Sent: Wednesday, January 30, 2013 4:00 PM To: JoAnna Thomason Subject: RE: NAIC Insurance Information Hi JoAnna, Lloyds has several syndicates. Following are the NAIC numbers for this policy: NAIC Number Syndicates 1225 AA-1127225 L‘0"- S y,A� \Z-1 Syndicate 33 AA-1126033 A__Syndicate 4020 AA-11200 75 Ac/x\/ LEISA YOUNGMAN 7 Lovitt & Touché, Inc. Sr. Commercial Account Manager Construction 800.417.2756 : main 602.385.0528 : direct 602.956.2258 : fax lyoungman@lovitt-touche.com Website: http://www.lovitt-touche.com/ Facebook: http://www.facebook.com/lovitttouche Twitter: http://www.twitter.com/lovitttouche LinkedIn: http://www.linkedin.com/company/lovitt-&-touche-inc. CONFIDENTIAL AND PRIVILEGED This email (including attachments) is covered by the Electronic Communications Privacy Act, 18 USC Sections 2510-2521. It is confidential and privileged. If you are not the intended recipient, any retention, dissemination, distribution or copying of this communication is strictly prohibited. Please refer to the sender if you have received the message in error and then delete it. Thank you. Please consider the environment before printing this e-mail. Original Message From: JoAnna Thomason [mailto:joannat@cityofcampbell.com] 1 i • WORKERS' COMPENSATION INSURANCE INFORMATION The following worker's compensation insurance information is required for all Applicants and Contractors. One of the following items for each Applicant and Contractor must be submitted prior to working under a Public Works permit or contract. WORKERS' COMPENSATION INFORMATION: Name of Contractor/Applicant $2. ' 4-, c' �dd✓c1'/ZGe-=(10-./ c-', Ul c.„4-, ❑ A Certificate of Consent to Self-Insure issued by the Director of Industrial Relations: OR A Certificate of Workers' Compensation Insurance Insurance Co. 1V4f'274— //y'( 7'( 1 Ilk Policy No. / %44 S' Expiration Date g(/ /, : OR ❑ A signed Certificate of Exemption from the Workers' Compensation laws as printed below. CERTIFICATE OF EXEMPTION I certify that in the performance of the work for this contract, I shall not employ any person in a manner so as to become subject to the Workers' Compensation Laws of California. Signed Date Title NOTICE TO APPLICANT/CONTRACTOR: If after signing this Certificate of Exemption, you should become subject to the Workers' Compensation provision of the Labor Code, you must forthwith comply with such provisions or the permit or Contract will be cancelled or revoked. J:\FORMS\Templates\Insurance Requirements\Workers Comp Informationsheet_doc(Rev 9/11) °p D 4 CO `79,,.., - ! / cam, `` cs ca eg 8 6E$ eg /'' ----..............---\ se ge tom',° ' O. 6 JmB �yPO///�'y�/ w cJ C' y •V • , �� GRAPHIC SCALE � _ °4 G `,$ 4.°P• \ \ L IN FEET)=MOMINIasIIII 6.4,0„. /�� / �C�_'�{t �•" ?, 64 1 inch r 20 N. r : ., 4.?> NFU. t ` EtL yc� 6 F °g \ , • G J `' wNR° C°'IT s�JB \r-----IIIIIIII fT-6 ''''''7 x 6 N ,B C40v 70.. w 0,„,�' 4,...•:•.....-; '.."--' , 5g„,,,, \ \ 1 'kg 1— : T �� >/— 7 -0 :F%',' '\4.:33 3S— i \ s I: c�S , * s3 J • / °- °:• \ cy�$'7> � ', m 6 ETk�1rT\ `� ` Z41 0 \ Cw \ w p A, \ � ?r , vV RCN C`kY'7' 199.-5k, 7p: <g5., c; (7,°,r o °.;, \ ♦♦ �°p ri aCpV 6� O` %. BUILDING •.O`G , 996 E„nF„ . 9_�� • 'CS-.OF'''. , Fry V ,' ._�L. W000 FlUC \\ 11., 0 2 51I O. *SO \ 97e 9b.9_- �§�. p 1NE '�„7 J'• P.m, -' �. L3? \'.:r - Y� BU'LO NG M. d\J' ..1°„�'..,..: 6 `\ '�1�7� �liar[ >Y••'� 171�� ..s9 1� \9z> ,,,N., w9•!.•�y9s . «i w a q— w K'. _ .:� . , '' ' i,i ja. p w S, coTc �4it •g\� .t',F.6, . . � -Ts•1111� ,� - -i�S..=r Ya'S\y�y���. St�/•::� - \9. �."-9�9 E' �/f//� BE'i' Y 'a.".�`�\ ,. �/Ff • '��' ����r+�T r,\0 �OMI{ c�'•_" , 9g.'�9cr,�°OT , ire ��� I •\ e. /.� — _--�'r. �F.ir��:.-; I}'� .T i'i•. \\ • `•. ' /SQL r /'Se1L 19, ,>� l� - ♦v r. °f$ mss, °E°° "; �tii �I �'�_+� �� ' 6T q µa�� fX W5 \gz„-, +��\ P UET PLAN TYPE 2 TYPE 2 PLAN TYPE 1 PUN TYPE 2 PLAN TYPE 2 PLAN TYPE PLAN TYPE 3 'g7l �lr�' „�i '• ye _—"�' �j s•. fro, Nc+' r 1 L1,q 4b\+r _sz n s ,c, —. _ l �'o-} ►��\ wi`•rA, ,-. v Oz'Fa =918 EF.= F.F. FF.=1932 FF.=910 F.F.=928 .F=1926 iVF aN , PAD=9263 PAD=926 'AD=9813 19221jLu •y1 Vr' �' _ Lot 6� I9+ '.Il ` '°J ::-Tr.,ts� a yY.e ,a^'e�'°a Il. a O ILI G aP G •e.?iEF gy gg`R�i eE°Y , Q �\ \ V .. w a . ° ..J 14 ',, 13 16 1 j FLAN TYPE 3 ° � OFF.190.2 „c4A--1 d } 191.. -,t!), P F-190.63T� a _� ,�'' \ ` ; ; PLAN TYPE 1 PLAN 2 PUN TYPE 2 PLAN TYPE 1 PLAN TYPE ,•za V$ 9a's' W = _ DUET PLAN TYPE 2 PLAN T1•P�r� `J3 x 4''ej' 2CC \ rjy ' / f $ Mh - .1 ° - P.y 999 per'�w O • R- S'�� y 7 91W o 19x0 9• \ Ur ate ti "' 7\ry 41'7>0 e�- f CCSS 3-�•��S+f� YY ••/� - C ST.SSW PRIVATE S7REET •'� Zr!INN= ```\ ° .n J z sit,t, I O 1[ .•.. A W / gib -1111f— 1 \\` 'C'r W 3� ar �onN yL PRAM 99N. �� nP,. M- ,...,___,... INY- �u < J =a _, D FOR RUCTION _ ___ City of Campbell 0 I PUN- 3 PLAN TYPE 1 PLAN TYPE 2 PLA�' PE 2 PLAN TYPE 1 PLAN TYPE 3 A Z ` a 2, �J .,� y E PLAN TYPE 2 PUN TYPE PUN TYPE 3 P F.1� ply :;u�►Iio Works Permit No 2 cal ,�w`'a-59 �� FF 1 'r I z O 2 01 J- VV V 1iC °� P "'-'6:-' @ ® 31 3© 33 Q 4\ 243 A g IL Contractor must here these plans _ I NV B6,13 --_ on the jab site during construttionl �\ �.T pBJ „e• reyes-e�4.� ------�- - '= ' rnar w Wdr- DATE APR.19,13 13 — —_ �, 9n1,. +, T a she s-a _ - --- - ae -----''— _s-.''''' r B Sr 0.222-- -- .E Y ® '1'- -- �' 0S^.E' , DESIGNED J.G.;ri _ teA SHEET - _-_ - ,� rz Pot)-!OLi c 3 II a SHEETS