HomeMy WebLinkAboutENC2013-00079 Print Form
Permit No C 2-01-; 'GOO 79
CITY OF CAMPBELL ENCROACHMENT PERMIT
DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File
70 North First Street right-of-way) Application Date if-3c _I 3
Campbell,CA 95008 Application Expiration
'Date (�-3° 13
Ph. (408)866-2150 Issued ����i 3 f2 APN � .4 Zj-5-b O
Fx. (408)376-0958 /
Permit Expiration Date 5
1 tt
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.: \ -'?7C D LL /\\,1i-
Utility Trench Location:
B. Nature of Work: I N S'7/\1,1- S A \-z-A 2 y Li, LA%t f2/ L
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: K i t 1,,1 p)pt lrlhac S I N L Telephone: L I(c)--7`17- 2 di 1
Address: -,'-'76 C M I cc(c f CmT / _ 5 ( G ° l_1 J 2
E-Mail Address: k k‘ 1 cf1v)p `2e( '*c c5),6.J ,,,,t 124-HOUR EMERGENCY PHONE NUMBER: 41/5 7-(f.7 -2 °1 (
Is this work being done by the property owners at their own residence? r— YES r NO L1( - 7-2,6 $6'ef
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers,agents,and employees free,safe
and harmless from any claim or demand for damages resulting from the work covered by this permit.
The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their
contractor(s) of the information. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be
responsible for any and damages arising out of the condition of any private improvements in the public right-of-way. 3
Accepted: /" 6//3
(Applicant Permitt9 (sign) Date
(e—) 6r>C„"t A,^Ec,-.,-,./65, /mac 3c/)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 orior to cutting.
V 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 3 7C, RECEIP�O.
PERMIT APPLICATION FEE $
ti71 g-6
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $
CONSTRUCTION CASH DEPOSIT $PLAN CHECK&INSPECTION FEE $ 3 7v 2'- MS-6,
EMERGENCY PERMIT FEE $
APPROVED FOR ISSUANCE /I /1 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.
Applicant Date:
/ (A)61.)6,1'.-1/ (f/3//i
Contractor (Print Name) Date:
J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf
Rev.03/13
1
PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT
Effective July 1,2012
TO: City Clerk PUBLIC WORKS FILE NO. EN C 131 +- coo 79
PROPERTY ADDRESS I '7o Ic(1 4,--f-
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 37O
Minor Encroachment Permit<sio,000 $210.00
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 70
4722 Enqr. 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
Other(Please Specify)
*Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. "7 Q
**Actual Cost Plus 20%Overhead(Non-Interest bearing deposit) TOTAL $ !
NAME OF APPLICANT 1`1 Ai 6---1>Owt Pi (-'cc_.i-✓�/ IN L
NAME OF PAYOR K.I l...iC-,c?aw1 f, I'cc-,�Es�, /..-1 c PHONE /.//$ -77--76.797
L ADDRESS , //V I SS'C" ) r ≤(� ,j FE-4,-sic.(Sec, C� ZIP 9</1 L
FOR RECEIVED BY -^•
CITY CLERK , s i, ',_"
ONLY Date Receipt# `j
Date/ Initials
J:FDRMS\TemplaieAkdminislntiveS1ece,pl Fonn Land Devebpmen112.13
CI T1 1 OF CMNF'BELL
RECJ0 B'i: CASHIER 01000247986
PAYOR: KINGDOM PIPELINES
: TODAY'S DATE: 04/30/13
REGISTER DATE: 04/30/13 TINE: 14:03
DESCRIPTION AMOUNT
ENGR SUBDIV FILING F $370.00
CUST. ID: ENC 2013-00079
ENGR S SUBDIV FILING F $370.00
CUST ID: 1.000
TOTAL DUE: $740.00
CHECK 'PAID: $740.00
CHECK NO: 1712
TENDERED:: $740.00
CHANGE: $.00
a
eh West Valley Sewer Connection Permit , No: • `
VDSan;at,on District
Issue Date: By:
OFFICE HOURS&CONTACTS: FEES: .i, BACKFLOW PREVENTION: 1.: 11.7:30 a.m.to 4:30 p.m.Monday thru Friday Connection $
Capacity
100 E.Sunnyoaks Ave.,Campbell,CA 95008_ Field check required
...
•Phone:(408)378-2407 Processing Basement
Service Advance
•information Services Department f is ; Check valve required:Yes_No •
LOCATION:
APN 2,1. r. w , . BUILDING SEWER CONNECTIONS:
Sewer Map Book `- Page f?
Tract Lot Total Due: $ : , Total number of connections to this
Project f . r Assmt , property: 5
Address • . . ,,. Paid by Check No:
1.Lateral ID No. _ is located
Hillside:Yes No feet rka' of " property
Jurisdiction ,'... .•
line, . " feet from main sewer and
BUILDING TYPE: INSTRUCTIONS: - feet deep.
Single Family •Permit is invalid if not connected within 12
Condo/Town House months of issue. Connection to Main Sewer • feet
Multiple Dwelling Units •Do not connect until the main sewer is accepted US from DS MH
Industrial by the District. US MH
° Commercial • , . Obtain a building or plumbing permit from the Pipe Type
Jurisdiction listed above.
REMARKS:_ . r. •Street encroachment permit is required from
List any additional connections on
•Keep 3'radius around cleanout clear of reverse side of this form.
OLD PERMIT No.... • Sub No. vegetation or obstruction.
Original—Applicant Pink—Accounting Yellow—City/County Bldg.Inspector Card—District File 1„....
A`OR1 CERTIFICATE OF LIABILITY INSURANCE 4/29/220
•
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
DAYAL INSURANCE SERVICES INC N (650)599-3021 I FAX 650)58.9-7528
786 El Camino Real E•MAII cNe)
dayalinsuranceLaol.com
San-Francisco, CA 94080
INSURER@) AFFORDING COVERAGE NAMCI
0004804 IN>: A COLONY INSURANCE
INSURED 1IN84lREJt e: CENTURY NATIONAL INSURANCE
KINGDOM PIPELINES, INC IN C: STATE COP INSURANCE
5700 MISSION STREET INSURERD, TRAVELERS
SAN FRANCISCO , CA 94112 , INSURER E
415-7.47-2091 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED,ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
RON *COL- MAN 'POLICY EFF POLICY E)P
arp TYPE OF INSURANCE Mrs AM POLICY tweet (IONDO/YYTY) GAWDONYYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
X conameacw.GENERAL LIABILITY PREJAISES(Ea occurrence) I ...--- 50,000
CIAIMS-MADE [X OCCUR MEDEXP(Any one Parson) .`--- I ---- 5,000
A GL951285 01-15-13 01-15-14 pERsONALIADV'talky $ 1,000,000
GENERAL AGATE $ 2,000,000
GENE AGGREGATE UAW APPLES PER: PROOUCTs•mom*Ace 5 2,000,000
POLICY I he Fl L0c s
AUIOMOWLC LIABILITY couelriEn SINGLE LIMIT 1,000,000
(Ea accident) i
X ANYAUTO BODILY INJURY(Per person) $
— ALL Orrmee - ecN.ourio BAP 016 9 915 01-17-13 01-17-14
AUTOS AUTOS BODILY INARY(Per accident $
X HIrE0 Autos X D PROPERTY DAMAGE I
Autos Ter aeadee4 —
UMBRELLA LIAS X oclp FACN occtRRENCE s 4,000,000
A EXCESS UAB CLAIMS—AGE AG-RFGATE $ 4,000,000
GL951285 01-15-13 01-15-14
DED , RETENTION $ - $
WORKERS COMPENSATION X I INC;TTAT - I l TeR
AND EMPLOYERS'LABILITY Y 1871450-12 10-01-12 10-01-13
AMY Y NIA
El_EACH ACCICENT $ 1,000,000
C OFFlCEAAEI®ER Fmru FD
(Mandidoly In fer) EL asEABE-EA EMPLOYEE $ 1 000,000
If yes,aesrate uncles
DESCRIPTION OF OPERATIONS below EN DISEASE-POLICY LIMIT 5 1)000,000
SCHEDULED 318,000
D EQUIPEMENT 304X327 04-12-13 04-12-14 RENTED 100,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101.Additional Rented",Schedule.if mMS space Is required)
JOB: 1370 Dell Ave. The City, its officers, employees and volunteers are named
as additional insured. The insurance afforded to the additional insured is
primary insurance. Should any of the above.descirbed policies be cancelled
before expirationdate thereof, notice will be delivered in accordance with the
policy provisions - `� ���
C--- \ O\3
CERTIFICATE HOLDER CANCELLATION
CITY OF CAMPBELL
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ATTN: DEPT OF PUBLIC WORKS THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
70 NORTH FIRST STREET ACCORDANCE WITH THE POLICY PROVISIONS.
CAMPBELL
CA 95008 AUTHORIZED REPRESENT NE
O1988-2010 CORD CORPORATION. All rights reserved.
ACnPn7c(2n1rvn5) The ACORD name and Imo are registered marks of ACORD
GL 951285
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION - COMPLETED OPERATIONS & ONGOING
OPERATIONS AS SCHEDULED
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s): Location And Description Of Operations
ALL PERSONS OR ORGANIZATIONS AS AS DESIGNATED IN WRITTEN CONTRACT WITH
REQUIRED BY WRITTEN CONTRACT 1MTH THE THE NAMED INSURED
NAMED INSURED
A. Section II—Who Is An Insured is amended to include the person(s) or organization(s) shown in the
Schedule(called additional insured), but only with respect to:
(1) Liability for "bodily injury" or "property damage" caused, in whole or in part, resulting from
"your work"at the location designated and described in the schedule of this endorsement per-
formed for that additional insured and included in the"products-completed operations hazard"
when you and such person(s) or organization(s) have agreed in writing in a contract or
agreement that such person(s)or organization(s) be named as an additional insured on your
policy.
(2) Liability for "bodily injury", `property damage" or "personal and advertising injury" caused, in
whole or in part, by resulting from:
(a)Your acts or omissions;or
(b)The acts or omissions of those acting on your behalf,
in the performance of your ongoing operations for the additional insured(s) at the location(s)
designated above.
B. Section IV—Commercial General Liability Conditions, 4. Other Insurance is amended and the
following added:
If you are required by written contract to provide primary insurance, the insurance afforded by this
Coverage Part for the additional insured shown in the Schedule is primary insurance and we will not
seek contribution from any other insurance available to that additional insured.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
U462-0310 Includes copyrighted material of ISO Properties, Inc., 2004 Page 1 of I
with its permission.
GL 951285
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
The following is added to Paragraph 8.Transfer Of Rights Of Recovery Against Others To Us of Section
IV—Conditions:
We waive any rights of recovery we may have against any person or organization because of payments we
make for injury or damage resulting from your ongoing operations or"your work"done under a contract with
that person or organization and included in the"products-completed operations hazard"if:
a. you agreed to such waiver;
b. the waiver is included as part of a written contract or lease; and
c. such written contract or lease was executed prior to any loss to which this insurance applies.
ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED.
U047-0310 Includes copyrighted material of ISO Properties, Inc., Page 1 of 1
with its permission.
UVKStMtN I ALiKttIVI N I
WAIVER OF SUBROGATION REP D8
STATE 1871450-12
.l.:M i _n5•:. V RENEWAL
I hf S U 4 V C E ITT
FUND 2-73-02-53
PAGE 1
HOME OFFICE
SAN FRANCISCO EFFECTIVE FEBRUARY 14, 2013 AT 12 .01 A.M.
ALL EFFECTIVE DATES ARE AND EXPIRING MARCH 8, 2013 AT 12.01 A.M.
AT 12:01 AM PACIFIC
STANDARD TIME OR THE
TIME INDICATED AT
PACIFIC STANDARD TIME
KINGDOM PIPELINES, INC.
5700 MISSION ST
SAN FRANCISCO, CA 94112
ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING,
IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND
WAIVES ANY RIGHT OF SUBROGATION AGAINST,
CITY OF CAMPBELL REDEVELOPMENT AGENCY
WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS
POLICY IN CONNECTION WITH WORK PERFORMED BY,
KINGDOM PIPELINES, INC.
IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN
PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION
OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE
EMPLOYER.
IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH
EMPLOYEES SHALL BE INCREASED BY 03%.
NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE
OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS
POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE
HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR
LIMITATIONS OF THIS ENDORSEMENT.
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO:
FEBRUARY 19, 2013 2570
)ORSEMENT AGREEMENT
WAIF OF SUBROGATION REP D8
STATE 1871450-12
COMPENSATION RENEWAL
I Nei U R A N C E NA
FUND 2-73-02-53
PAGE 1
HOME OFFICE
SAN FRANCISCO EFFECTIVE APRIL 29, 2013 AT 12 . 01 A.M.
ALL EFFECTIVE DATES ARE AND EXPIRING MAY 16, 2013 AT 12 . 01 A.M.
AT 12:01 AM PACIFIC
STANDARD TIME OR THE
TIME INDICATED AT
PACIFIC STANDARD TIME
KINGDOM PIPELINES, INC.
5700 MISSION ST
SAN FRANCISCO, CA 94112
ANYTHING IN THIS POLICY TO THE CONTRARY NOTWITHSTANDING:
IT IS AGREED THAT THE STATE COMPENSATION INSURANCE FUND
WAIVES ANY RIGHT OF SUBROGATION AGAINST,
CITY OF CAMPBELL DPW
WHICH MIGHT ARISE BY REASON OF ANY PAYMENT UNDER THIS
POLICY IN CONNECTION WITH WORK PERFORMED BY,
KINGDOM PIPELINES, INC.
IT IS FURTHER AGREED THAT THE INSURED SHALL MAINTAIN
PAYROLL RECORDS ACCURATELY SEGREGATING THE REMUNERATION
OF EMPLOYEES WHILE ENGAGED IN WORK FOR THE ABOVE
EMPLOYER.
IT IS FURTHER AGREED THAT PREMIUM ON THE EARNINGS OF SUCH
EMPLOYEES SHALL BE INCREASED BY 03%.
NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE
OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS
POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE
HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR
LIMITATIONS OF THIS ENDORSEMENT.
COUNTERSIGNED AND ISSUED AT SAN FRANCISCO: MAY 1 , 2013 2570
` - Flerybe___
AUTHORIZED REPRESENTA IVE PRESIDENT AND CEO
SCIF FORM 10217 (REV.1-2O12) OLD DP 217
� 1
1..
�� S C� Q\3 -" 0,00-‘(
- INSURANCE REQUIREMENTS CHECKLIST
Permit#_ V:610 c\` fk.1 e.- 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.
9L Policy expiration date (—\S -1-1
Automotive Liability:
3\ d ❑ "Any Auto" checked on certificate
\\�j $1,000,000 per accident for bodily injury and property damage
fit° Policy expiration date \ -- \'\— \y
Workers' Compensation and Employer's Liability
Waiver of Subrogation clause
$1,000,000 per accident for bodily injury or disease
A Policy expiration date \ \c-- \—
Course of Construction (if required in Special Provisions)
❑ Completed value of the project
❑ Policy expiration date
Required Endorsements to General Liability and Automobile Liability Policies
__4',O °J—c, Additional Insured Endorsement
b•e
(A -2 ❑ The City, its officers, employees and volunteers are named as additional insured.
th (Reference Project Location/Permit Number)
The insurance coverage afforded to the Additional Insured is primary insurance.
Cancellation area:
a Cancellation area of certificate edited to delete "endeavor to" and "but
failure to mail such notice shall impose no obligation or liability of any kind
upon the company, its agents or representatives".
OR should say:
XShould any of the above described policies be cancelled before the expiration
date thereof, notice will be delivered in accordance with the policy
provisions.
C:\Documents and Settings\joannat\Desktop\Insurance Requirements Cklist.doc(Rev 07/11) Page 1 of 2
pry .
❑ Workers' Compensation Insurance Sheet Submitted
❑ For General Contractor
❑ For Developer or Owner
Acceptability of Insurer(s)
❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business
in the State of California.
3 � "
Name: 0G`f��' i(S/l-° NAIC# 3 4 ``,Rating: #1 iy\\ Authorized in CA: V`
/� "'` 10$"—Rating: , Authorized in CA: "/
Name: L.�/\�4v1� lit\ NAIC# 7_b /-�� I�
Name: � .-\t° ec-r\f-O NAIC# Rating: Authorized in CA: V
Name: —rsk c.J e`-e\(S- NAIC# Rating: i / X\./ Authorized in CA: V
Campbell Business Licene,,# O),-1.-O I 571/I`t
Insurance Certificate Reviewed .,... _ 13n 1 I I
In'tials ate
XL
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
n
a _r
i
No--. S
i ..4..
u0
o 2 � " OVERHEAD POWER AND p 1
v
TELEPHONE LINES. DO
`�' s • NOT DAMAGE ..= w I
aaam ) N C
a
I �, I CO . Ci itc
r:mom d N o
d
35.0' u
1 21•
Sy SfAH ..... 336TH "x:,W
l/ !� 2WALE S 3�56 SWALE WALL TC%FC __ � x
x 235.02 - 234 4, •
- r 5 0s� IU I v �� .,
TC/FC TC/Fv' � SWA U1 2 ..1,3 •.»,_� :� 4
tll
CONNECT T�+ E = A .1�4.6 ��,. RAN .. d
INV 222.0 . 4 _ _ -43 S ,a0 E
l ._ __.2.`4.8 r e U
CONTRACTOR' T• E' 3 •OIN H
4.68 8 4 L+ O
VERIFY IN 'iT
� . "PVC ,..� .< 61 Ac . � .6V �_
AND LOCA N 281F-6_(� s ,A ,7p�. �� I un"
o SS S- Qa32 �• �6. . 234.'6 d w
T F � 3 "` 35.05 10 F .
xwv
.�:3 � SSCO /` ARP PIV G� tl In
x wv.8s L�11�1 1 • 1=Q a
IN 23 .86 ' � .. , •� • P• SDAD
`" 3 �2 •I. :� :�: RIM 235.96`
36. ►••..1...
''e.vu ti.40
Cr); = 10 F� �'.s-. � t ► .5 • ' •
• P--^G35.4
i'•: INV 233.46
a 1 "E LF I►,� *VOA— `y 23 .w�.,� _ — -�_ ,a35,49
r
Sign.005 \'• ''•I PERFORATED
C N EC TO ` 'ST. SD S-0.003
W ' LL . . 2Eg6'C-0 x 235.54
D"AI AGE .►• 65 p ':�: . 60
23 •6i - 23 .« : RIM 235.
O
(f) : � •` LV4 :
c� I��Jd L �II�'hI • ; ••I, 2 .»235.60 735.60
10 iF A► '• V 233.57
D • r S35 4
IGN I t 2�j�Ji
x!D A SD c �zG� 3 iRIM 23 :•`�
"TC/FC I i1�. G 235.60
T' I�� 233.62
214Y x 235.60
M.IIE36LF-4"PVC
�, � tt,, � I• _ _ � _ TED
1100 '
,•.�:\1 .r2 3 = 35.53
•Øt1jiø2
�CI � � � :,
• °°
3 3
` �►•► 4.4-1 C AFC ��-7 ,rz
(9 P. <2.8F15
EP 234. 111471.13
'IVI/ �73i6 5EP\
(n P TC5.5 rl I I V SD S#0 0
..20 234.85 234.43
23W 7
AC 234.93 e
� ___:;:T.(...+I► sr .$ EP 235 34 __.__�
TC jFC
( nn r/� P
/ ( ,V z Z 235.10
35.84 C,r� • 23 25 . z�.,..,., 35 a5
DUN ►C •� EP 5.50• pOhNC PA S R.A,C`',e•` C ` .__x�
2x3`..11 J
o, I . I G� �SE a! 3NC6PAD
w-T-Q 1 E -AI N' 5 23614
44EP
4 1235.65
235.78
x TC/FC Cr)CO x', F 1
I
O h
'7C
lU