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HomeMy WebLinkAboutENC2013-00098 ( '; . + Print Form CITY OF CAMPBELL v 22 2 2 ENCROACHMENT PERMIT Permit No V L �v t3 l ( . ` DEPT.OF PUBLIC WORKS �p1 cfor orking within the public X-Ref.File 70 North First Street rks admtinistfa right-of-way) Application Date 5 -2? --‘3 Campbell,CA 95008 ;,ublic W� c�� / Application Expiration Date ‘l- Z7 -\3 Ph. (408)866-2150 Issued ��?L'( ' 3 APN e—\L LA`? S C:(u Fx. (408)376-0958 /� /) Permit Expiration Date ti- 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.: `(02 1 \o A-4-e- CAS 1 r/4 Q Utility Trench Location: VrbQ .� B. Nature of Work: IR2wuO(e �i 1 p p ev /40 6," 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: At� ,c..., Telephone: qcB. ? 377 , (cpl a Address: I OW 1 JGr_ \r mil/ l `1 -Mail Address: e,A-b e ,� co 24-HOUR EMERGENCY PHONE NUMBER: 4d6- Z I g - 0(055- , Is this work being done by the property owners�t their own l residence? r YES RNO 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. Applica is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any d I ma arisin t of ond' ion of any private improvements in the public right-of-way. 2 Accepted: G-,Z'13 (Applica t Permittee) (sign) Date q—v S c �-� of e.� c2z• t3 (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 $ 3 7(3 "),46 31 - PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK&INSPECTION FEE $ 7C "D.L{ -,i a_ EMERGENCY PERMIT FEEc_______ V $ c, APPROVED FOR ISSUANCE 7/20/1 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 name and phone number. Applicant shall be res onsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions. 5'2213 Applicant \ Date: Alo\ s5V(ie c,22Contractor (Print Nae) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.03/13 P., --`-Y-0 — off cf)1/4-:- 1 ---) I C\___li 11 1 4 r-0 ' 1 i kexC 1" a i ill � y w''! tfj 2 _t t 0 `44r- t .,, ef' --=-P_I 1't I m P- 1 ,_il 4 r 1 4 4 a .. 41 gN pi-_, 1 1 ..,,_ wr.i, i 1 __3(4.1-1 4t a 1 _c 41 r fi '6° 4 9 1 ..Ln--6. ,i, 11 1 1 .., i------,NA:fr 3 I I •-1 ---31 if j West Valley Sanitation District EL Y Yl l I f Li G i7 { q- ( S S ct,?C( 6 ; . 3/2 v/2•P t'3 John Hwang Construction Inspector II - n. et eV1 f G 6-. I i Gi` jhwang@westvalleysan.org 1 S L"t 100 East Sunnyoaks Ave. www.westvalleysan.org /11,17e9" Campbell,CA 95008-6608 s' �-N3.---Y 408.378.2407 Office ' 408.234.8844 Cell rt04,„,,,_„ ,. 408.364.1821 Fax ,-, �^\ ( ...„4,,,,:,-„,,,,,,- .....,,,..„ V "V 3 - '- .. ` ;::�?r "ce s. -V:4?e�`T i'N 9,3,1-1%,"-:".1'.--13f'e X'�f+�,r'r..,, "1**1-41—?,,,,:,... 40 iftiVtx 'f.. .-,.1, "' 37,-x w-w Y4'7' ,•'�X ,e6vt.� , 1N West Valley Sewer Connection Permit No: ," 4' Sanitation pistrt¢ SD Y Issue Date ?-,1!,.;11 s By: 1.i--/ 1' 1 OFFICE HOURS&CONTACTS: FEES: BACKFLOW PREVENTION: .f..) 1 7:30 a.m.to 4:30 p.m.Monday thru Friday Connection $ '� w 100 E.Sunnyoaks Ave.,Campbell,CA 95008 Capacity Field check required Processing ir.` ' A,t t- Basement 1 •Phone:(408)378.2407 Service Advance •Information Services Department ,, &;. { Check valve required:Yes 'No [ — LOCATION: APN .:, t ---?-> 3 * BUILDING SEWER CONNECTIONS: Sewer Map Book r Page Tract Lot Total Due: $ �s�a '` Total number of connections to this Project I I Assmt t '' property: t Address 1.1.,,--'4•1,i , 0 .,� .�_ .1,_4,',.-- Paid by Check No: I .. aa. P P Y 1. Lateral ID No. ''',"41:.'''''''' is located Hillside:Yes No Jurisdiction ' t ,; — 't feet of 1-it property, line, £ feet from main sewer and BUILDING TYPE: INSTRUCTIONS: feet deep. Single Family •Permit is invalid if not connected within 12 Condon own 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 P Industrial by the District. US MH Commercial,,a(,'r" a„-'•, •Obtain a building or plumbing permit from the Pipe Type 1 AI tr e Jurisdiction listed above. P yp f REMARKS: d -t� e t— •Street encroachmentpermit is required from ,,,,. V s a List any additional connections on •Keep 3'radius around cleanout clear of reverse side of this form. OLD PERMIT No. r"Sub No vegetation or obstruction. is Original—Applicant Pink—Accounting Yellow—City/County Bldg. Inspector Card—District File t ACCDREP CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDM/Y1) 5/1/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT ON All Spectrum Ins PHONE (408)739-8300 I FAX (866)826-6781 All Spectrum Insurance Brokers (Arc_Nn.Fxt) (Ac.Nol: 4300 Stevens Creek Blvd nuDREss:help@asibrokers.com Suite 100 INSURER(S)AFFORDING COVERAGE NAIC# San Jose CA 95129 INsuRERANational Fire Insurance Co of 20478 INSURED INSURERB:peerless Insurance Company 24198 Able Underground Construction, Inc INSURERC:St Paul Fire and Marine Ins Co 24767 Able Septic Tank Service INsuRERD:Everest National Insurance Co 10120 1020 Ruff Dr INSURERE: San Jose CA 95110 INSURERF: COVERAGES CERTIFICATE NUMBER:CL135100123 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-SUB- POLICY EFF POLICY EXP TYPE OF INSURANCE LTR INSR WVn POUCY NUMBER (MM/DDIYYYY) (MMIDD/YYYYI UNITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 300,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ A I CLAIMS-MADE X OCCUR X 2076630503 5/1/2013 5/1/2014 MED EXP(Any one person) $ 5,000 PERSONAL BADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE�� LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 7 POLICY I X 17,?- pi LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea acciden0 $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ B ALLOWNED SCHEDULED x BA8910289 7/20/2012 7/20/2013 BODILYINJURY(Peraccident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS _ AUTOS (Per accident) $ X UMBRELLA UAB OCCUR EACH OCCURRENCE $ 1,000,000 C EXCESS UAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED I X IRETENTION$ 10,000 ZUP14R6811012NF 5/1/2013 4/1/2014 $ D WORKERS COMPENSATION X I TORY LIAMITS I I0T AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? Y N/A 5/1/2013 5/1/2014 7600007280131 (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) RE: permist# ENC2013-00098 As required by written contract/agreement per attached endorsements G-140331-B (Ed. 01/09), AC01020308 the following is additional insured: City of Campbell, The City of Campbell Redevelopment Agency, its officers, employees and volunteers. \ cZ-k ry \\ \. te CERTIFICATE HOLDER CANCELLATION (408)376-0958 14083760958@myfax.COm SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Campbell 70 N 1st Street Campbell CA 95008 AUTHORIZED REPRESENTATIVE Dmitriy Lazarev/DIMAL �'--..--. ..-..-.:.....,..-i= `�- ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 Ontnnsi 01 Tha ArORn Hama and Innn ara ranictararl marke of APORrI Polcy#2076630503 G-140331-B CNA (Ed. 01/09) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE(OPTIONAL) Name of Additional Insured Person(s) Or Organizations (As required by written contract/agreement per Paragraph A. below.) Location(s)of Covered Operations (As per the written contract/agreement, provided the location is within the"coverage territory"of this Coverage Part.) (Coverage under this endorsement is not affected by an entry or lack of entry in the Schedule above.) A. Section II - Who Is An Insured is amended to in the performance of your ongoing operations include as an additional insured any person(s) or for the additional insured(s)or organization(s), including any person or c. "Your work" that is included in the organization shown in the Schedule above, whom "products-completed operations hazard" you are required to add as an additional insured on and performed for the additional insured, this Coverage Part under a written contract or but only if this Coverage Part provides such written agreement, provided: coverage, and only if the written contract or a. The written contract or written agreement was written agreement requires you to provide executed prior to: the additional insured such coverage. 1. The"bodily injury"or"property damage"; or 2. However, we will not provide the additional insured any broader coverage or any higher 2. The offense that caused the "personal and limit of insurance than the least of those: advertising injury" a. for which the additional insured seeks coverage Required by the written contract or written under this Coverage Part; and agreement; b. The written contract or written agreement b. Described in B.1.above; or pertains to your ongoing operations or "your c. Afforded to you under this policy. work"for the additional insured(s). 3. This insurance is excess of all other insurance B. The insurance provided to the additional insured is available to the additional insured, whether limited as follows: primary, excess, contingent or on any other 1. basis, unless the written contract or agreement The person or organization is an additional requires this insurance to be primary. In that insured only with respect to liability for "bodily event, this insurance will be primary relative to injury," "property damage," or "personal and advertising injury"caused in whole or in part by: insurance ewdict ed. the additionalilot insured as a named insured. We will not require a. Your acts or omissions;or contribution from such insurance if the written contract or written agreement also requires that b. The acts or omissions of those acting on this insurance be non-contributory. But with your behalf respect to all other insurance under which the additional insured qualifies as an insured or G-140331-B Includes copyrighted material of Insurance Services Office, Inc., with its permission Page 1 of 2 (Ed.01/09) cA (E .0 1/19) (Ed. 01/09) additional insured, this insurance will be An additional insured under this endorsement excess. will as soon as practicable: 4. The insurance provided to the additional (1) Give us written notice of an "occurrence" or insured terminates when your operations for the an offense which may result in a claim or additional insured are complete. But if the "suit" under this insurance, and of any claim written contract or written agreement specifies a or"suit"that does result; date until which this insurance must apply, then (2) Tender the defense and indemnity of any this insurance terminates: claim or "suit" to any other insurer or self a. On the date specified in the written contract insurer whose policy or program applies to or written agreement; or a loss we cover under this Coverage Part; b. When this policy expires or is cancelled, (3) Except as provided in Paragraph B.3 of this whichever occurs first. endorsement, agree to make available any other insurance the additional insured has C. With respect to the insurance afforded to the for a loss we cover under this Coverage additional insured, the following additional Part; and exclusions apply. (4) Send us copies of all legal papers received, This insurance does not apply to: and otherwise cooperate with us in the injury," roe damage," or "personal investigation, defense, or settlement of the 1. "Bodily "property rtY 9 P claim or"suit." and advertising injury" arising out of the rendering of, or the failure to render, any We have no duty to defend or indemnify an professional architectural, engineering, or additional insured under this endorsement until surveying services, including: we receive from the additional insured written notice of a claim or"suit." a. The preparing, approving, or failing to prepare or approve maps, shop drawings, 2. With respect only to the insurance provided by opinions, reports, surveys, field orders, this endorsement, the first sentence of change orders or drawings and Paragraph 4.a. of the Other Insurance specifications; and Condition is deleted and replaced with the following: b. Supervisory, inspection, architectural or engineering activities. 4. Other Insurance 2. "Bodily injury," "property damage," or "personal a. Primary Insurance and advertising injury" arising out of any This insurance is primary and non- premises or work for which the additional contributory except when rendered insured is specifically listed as an additional excess by this endorsement, or when insured on another endorsement attached to Paragraph b. below applies. this Coverage Part. E. The provisions of the written contract or written D. SECTION IV — COMMERCIAL GENERAL LIABILITY agreement do not in any way broaden or amend CONDITIONS is amended as follows: this Coverage Part. 1. The Duties In The Event of Occurrence, Offense, Claim or Suit condition is amended to add the following additional conditions applicable to the additional insured: G-140331-B Includes copyrighted material of Insurance Services Office, Inc., with its permission Page 2 of 2 (Ed. 01/09) BUSINESS AUTO AC 01 02 03 08 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO ENDORSEMENT FORM This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM A. CHANGES FOR TRAILERS AND FARM or organization qualifies as an "insured" un- EQUIPMENT der the Who Is An Insured Provision con- tained in Section II— LIABILITY 1. Under SECTION I -COVERED AUTOS, the following are added to Paragraph C. Certain COVERAGE of the Coverage Form Trailers, Mobile Equipment and Temporary D. REPLACED EXCLUSIONS Substitute Autos: The Expected or Intended Injury Exclusion 4. "Trailers" designed to be towed by a pri- IN SECTION II — LIABILITY COVERAGE is vate passenger type "auto" or a pickup, replaced by the following: panel truck or van if not used for busi- Expected or Intended Injury ness purposes, other than farming or "Bodily injury" or"property damage"which is ranching. expected or intended by the "insured". This 5. Farm wagons or farm implements while exclusion applies even if the resulting "bod- being towed by a covered "auto". ily injury"or "property damage": B. CHANGES FOR ADDITIONAL NEWLY a. is of a different kind, quality or degree ACQUIRED VEHICLES than initially expected or intended; or 2. Paragraph B.2 of SECTION 1 — COVERED b. is sustained by a different person, entity, AUTOS is replaced by the following: real property, or personal property than 2. If Symbol 7 is entered next to a cover- that initially expected or intended. age in Item Two of the Declarations, an E. ADDITIONAL EXCLUSIONS "auto" you acquire will be a covered The following exclusions are added to "auto"for that coverage only if: SECTION II - LIABILITY COVERAGE: a. We already cover at least one"auto" Damage to Named Insured's Property you own for that coverage or it re- Any claim or"suit"for "property damage"by places an "auto" you previously you or on your behalf against any other per- owned that had that coverage;and son or entity that is also a Named Insured b. You tell us within 30 days after you under this policy. acquire it that you want us to cover Abuse or Molestation it for that coverage. The most we will pay for Physical Damage "Bodily injury" or "property damage" arising Coverage for"loss" under this Coverage Ex- out of: tension is $100,000 per "auto", subject to a. The actual or threatened abuse or mo- the largest deductible applicable to any lestation by anyone or any person while "auto"for that Coverage. in the care,custody or control of any"in- C. BLANKET ADDITIONAL INSURED sured",or Any person or organization which you have b. The negligent: agreed to name as an additional insured in a 1) Employment; written contract, executed prior to an acci- 2) Investigation; dent, other than a contract for the lease or 3) Supervision; rental of a vehicle is an "insured"for Liability 4) Reporting to the proper authorities, Coverage, but only to the extent that person or failure to so report; or AC 01 02 03 08 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 3 with its permission. AC 01 02 03 08 5) Retention; b. "Loss" to TV antennas, awnings or ca- of a person for whom any"insured" is or banas. ever was legally responsible and whose c. "Loss" to equipment designed to create conduct would be excluded by Para- added living facilities. graph a. above. However, these exclusions do not apply if Abuse means an act which is committed Miscellaneous Personal Property Coverage with the intent to cause harm. is provided by endorsement to this policy. Explosives G. ACCIDENTAL AIRBAG DISCHARGE "Bodily injury" or "property damage" caused COVERAGE by the explosion of explosives you make, Under Paragraph B.3.a. of SECTION III - sell or transport. PHYSICAL DAMAGE,the following is added: Rolling Stores Mechanical breakdown does not include the ac- If a covered "auto" is a rolling store, "bodily cidental discharge of an airbag. injury" or "property damage" resulting from H. PHYSICAL DAMAGE LIMIT OF INSURANCE the handling, use or condition of any item Paragraph C. Limit of Insurance of SECTION III the "insured" makes, sells or distributes if - PHYSICAL DAMAGE INSURANCE is replaced the injury or damage occurs after the "in- by the following: sured"has given up possession of the item. C. Limit Of Insurance Wrong Delivery of Liquid Products 1. The most we will pay for "loss" in "Bodily injury" or "property damage" result- any one"accident"is the lesser of: ing from the delivery of any liquid into the a. The actual cash value of the wrong receptacle or to the wrong address, damaged or stolen property as or from the delivery of one liquid for another, of the time of the"loss";or if the "bodily injury" or "property damage" occurs after the delivery has been corn- b. The cost of repairing or replac- pleted. ing the damaged or stolen prop- Delivery is considered completed even if fur- ems' ther service or maintenance work, or correc- 2. An adjustment for depreciation and tion, repair or replacement is required be- physical condition will be made in cause of wrong delivery. determining actual cash value in the event of total"loss". Professional Services 3. The cost of repairing or replacing "Bodily injury": a. Resulting from the providing or the fail- may: . Be based on an estimate which ure to provide any medical or other pro- a fessional services. includes parts furnished by the original equipment manufacturer b. Resulting from food or drink furnished or other sources including non- with these services. original equipment manufactur- "Bodily injury" or "property damage" result- ers and ing from the handling of corpses. b. Include a deduction for better- F. MOTOR HOME CONTENTS COVERAGE ment for a part or parts that are 1. For a covered "auto" that is a motor home normally subject to repair or re- the following exclusions are added TO placement during the useful life SECTION III-PHYSICAL DAMAGE: of the "auto", such as, but not limited to tires and batteries. Motor Home Contents Betterment means the difference This insurance does not apply to: between the actual cash value of a a. "Loss" to the covered "auto's" contents, part immediately before the "loss" except equipment usual to trucks or pri- and the cost to replace that part with vate passenger"autos". a new part. Page 2 of 3 Includes copyrighted material of Insurance Services Office, Inc., AC 01 02 03 08 with its permission. AC 01 02 03 08 I. GLASS REPAIR—WAIVER OF DEDUCTIBLE An "employee" of yours is an "insured" while operating an "auto" hired or rented under a Under Paragraph D. Deductible of SECTION III PHYSICAL DAMAGE COVERAGE, the follow- contract or agreement in that "employee's" - added: name, with your permission,while performing induties related to the conduct of your busi- No deductible applies to glass damage if the ness. glass is repaired rather than replaced. B. Changes In General Conditions J. AMENDED DUTIES IN EVENT OF ACCIDENT, Paragraph 5.b. of the Other Insurance CLAIM, SUIT, OR LOSS Condition in the Business Auto Coverage The requirement in Loss Condition 2.a. Duties In Form is replaced by the following: The Even Of Accident, Claim, Suit Or Loss — of For Hired Auto Physical Damage Coverage, SECTION IV-BUSINESS AUTO CONDITIONS the following are deemed to be covered that you must notify us of an "accident", "claim", "autos" "suit", or"loss" applies only when the "accident", you own: "claim", "suit", or"loss"is known to: 1. Any covered "auto" you lease, hire, rent or borrow; and 1. You, if you are an individual 2. 2. Any covered "auto" hired or rented by A partner, if you are a partnership; your "employee" under a contract in that 3. An executive officer or the employee desig- individual "employee's" name, with your nated by you to give such notice if you are a permission, while performing duties re- corporation; or lated to the conduct of your business. 4. A member, if you are a limited liability com- However, any "auto" that is leased, hired, pany. rented or borrowed with a driver is not a K. UNINTENTIONAL FAILURE TO DISCLOSE covered"auto". HAZARDS M. EMERGENCY LOCKOUT - PRIVATE SECTON IV- BUSINESS AUTO CONDITIONS PASSENGER VEHICLES — B.2. is amended by the addition of the follow- We will reimburse you up to $50 for reasonable ing: expense incurred for the services of a locksmith If you unintentionally fail to disclose any hazards to gain entry into your covered "auto" of the pri- existing at the inception date of your policy, we vate passenger type subject to these provisions: will not deny coverage under this Coverage 1. Your door key or key entry pad has been lost, Form because of such failure. However, this stolen or locked in your covered "auto" and provision does not affect our right to collect addi- you are unable to enter such"auto" , or tional premium or exercise our right of cancella- 2. Your key or key entry pad has been lost or tion or nonrenewal. stolen and you have changed the lock to L. AUTOS HIRED OR RENTED BY prevent an unauthorized entry;and EMPLOYEES 3. Original copies of receipts for services of a If hired or rented "autos" are covered "autos" on locksmith must be provided before reim- this policy, the following provisions apply: bursement is payable. A. Changes In Liability Coverage The following is added to the Who Is An In- sured Provision in SECTION II—LIABILITY COVERAGE: All terms and conditions of this policy apply unless modified by this endorsement. AC 01 02 03 08 Includes copyrighted material of Insurance Services Office, Inc., Page 3 of 3 with its permission. POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s): Each of your construction projects located away from premises owned by or rented to you Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. For all sums which the insured becomes legally 3. Any payments made under Coverage A for obligated to pay as damages caused by damages or under Coverage C for medical 'occurrences' under Section I — Coverage A, and expenses shall reduce the Designated 0 for all medical expenses caused by accidents under Construction Project General Aggregate Limit Section I — Coverage C, which can be attributed for that designated construction project. Such only to ongoing operations at a single designated payments shall not reduce the General construction project shown in the Schedule above: Aggregate Limit shown in the Declarations nor 1. A separate Designated Construction Project shall they reduce any other Designated Construction Project General Aggregate Limit General Aggregate Limit applies to each for any other designated construction project designated construction project, and that limit is z equal to the amount of the General Aggregate shown in the Schedule above. Limit shown in the Declarations. 4. The limits shown in the Declarations for Each 2. The Designated Construction Project General Occurrence, Damage To Premises Rented To Aggregate Limit is the most we will pay for the You and Medical Expense continue to apply. sum of all damages under Coverage A, except However, instead of being subject to the damages because of 'bodily injury' or 'property General Aggregate Limit shown in the damage' included in the 'products-completed Declarations, such limits will be subject to the operations hazard,' and for medical expenses applicable Designated Construction Project under Coverage C regardless of the number of: General Aggregate Limit. a. Insureds; IMMO b. Claims made or'suits' brought;or c. Persons or organizations making claims or bringing 'suits.' Ese CG 25 03 05 09 Copyright, Insurance Services Office, Inc.,2008 Page 1 of 2 B. For all sums which the insured becomes legally C. When coverage for liability arising out of the obligated to pay as damages caused by 'products-completed operations hazard' is 'occurrences' under Section I — Coverage A, and provided, any payments for damages because of for all medical expenses caused by accidents under 'bodily injury' or 'property damage" included in the Section I—Coverage C,which cannot be attributed 'products-completed operations hazard' will reduce only to ongoing operations at a single designated the Products-completed Operations Aggregate construction project shown in the Schedule above: Limit, and not reduce the General Aggregate Limit 1. Any payments made under Coverage A for nor the Designated Construction Project General damages or under Coverage C for medical Aggregate Limit. expenses shall reduce the amount available D. If the applicable designated construction project under the General Aggregate Limit or the has been abandoned, delayed, or abandoned and Products-completed Operations Aggregate then restarted, or if the authorized contracting Limit,whichever is applicable;and parties deviate from plans, blueprints, designs, 2. Such payments shall not reduce any specifications or timetables, the project will still be Designated Construction Project General deemed to be the same construction project. Aggregate Limit. E. The provisions of Section III — Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. Page 2 of 2 Copyright, Insurance Services Office, Inc.,2008 CG 25 03 05 09 POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s): Each of your construction projects located away from premises owned by or rented to you Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. For all sums which the insured becomes legally 3. Any payments made under Coverage A for obligated to pay as damages caused by damages or under Coverage C for medical 'occurrences' under Section I — Coverage A, and expenses shall reduce the Designated 0 for all medical expenses caused by accidents under Construction Project General Aggregate Limit Section I — Coverage C, which can be attributed for that designated construction project. Such only to ongoing operations at a single designated payments shall not reduce the General construction project shown in the Schedule above: Aggregate Limit shown in the Declarations nor 1. A separate Designated Construction Project shall they reduce any other Designated General Aggregate Limit applies to each Construction Project General Aggregate Limit designated construction project, and that limit is for any other designated construction project z equal to the amount of the General Aggregate shown in the Schedule above. Limit shown in the Declarations. 4. The limits shown in the Declarations for Each 2. The Designated Construction Project General Occurrence, Damage To Premises Rented To Aggregate Limit is the most we will pay for the You and Medical Expense continue to apply. sum of all damages under Coverage A, except However, instead of being subject to the damages because of 'bodily injury' or 'property General Aggregate Limit shown in the damage' included in the 'products-completed Declarations, such limits will be subject to the operations hazard,' and for medical expenses applicable Designated Construction Project under Coverage C regardless of the number of: General Aggregate Limit. a. Insureds; b. Claims made or'suits' brought; or c. Persons or organizations making claims or bringing'suits.' rm CG 25 03 05 09 Copyright, Insurance Services Office, Inc.,2008 Page 1 of 2 B. For all sums which the insured becomes legally C. When coverage for liability arising out of the obligated to pay as damages caused by 'products-completed operations hazard' is 'occurrences' under Section I — Coverage A, and provided, any payments for damages because of for all medical expenses caused by accidents under 'bodily injury' or 'property damage' included in the Section I—Coverage C,which cannot be attributed 'products-completed operations hazard' will reduce only to ongoing operations at a single designated the Products-completed Operations Aggregate construction project shown in the Schedule above: Limit, and not reduce the General Aggregate Limit 1. Any payments made under Coverage A for nor the Designated Construction Project General damages or under Coverage C for medical Aggregate Limit. expenses shall reduce the amount available D. If the applicable designated construction project under the General Aggregate Limit or the has been abandoned, delayed, or abandoned and Products-completed Operations Aggregate then restarted, or if the authorized contracting Limit,whichever is applicable;and parties deviate from plans, blueprints, designs, 2. Such payments shall not reduce any specifications or timetables, the project will still be Designated Construction Project General deemed to be the same construction project. Aggregate Limit. E. The provisions of Section HI — Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. Page 2 of 2 Copyright, Insurance Services Office, Inc.,2008 CG 25 03 05 09 • • • �. ill t'ri ci., Cam. U'7 - C.i7 rt X C7 e:� 1 r-t • t7.9 r.7 tc, .._i T. ...{ :C1 .'C7 U':e .v.: .. r .e t:1 co -4ry 1> t;.�i C7 ]x. • CZ C... t-' ..' "'' p... a 1 W.: .rr —i rn C:1 I 1 F.,.. „t J. C: t•,7 ., `pi .. 1,,""r,," f.0 M.3 t.... G —"t C:7 1-.• C 1 1::, 1- ..Z LA ..... j r� M, CA 1^-i CI') C.f'1 Mt f rt t t— ire rd R'.t t.... y.3 t-.-7 r3 •• wt :e: i:i ;s:: PO CO C., • i '-'1.,. CD C..7.1 G'3 CO C y] 00. 'r�i -.1 en -n ,,.. f,,1 rry r c...! .1:71 tfl• 40 J> j•; r T . , 7 e .r;7 .T..:. 1 f et in., _ 1.wt Y.1 c.:.:‘ 6 -..Arn t.•. rZ C.. C.7 ." = CJ re. 4.O ..O f..) l C...1 Ce.t " CO r;„1 Mt t•..7 4:a C , CD .La S`. ABLE UNDERGROUND CONSTRUCTION,INC. 21136 CITY OF CAMPBELL 5/22/2013 . PERMIT-ENCROACHMENT- '7 c� . ,.. : . . .. . :., , .. . . . . : . . . . . „:.... - . , , , . . .. _ .. .. . . . . . , , . ., . , ., .. . . . . : . . , WELLS FARGO-9981 0 PERMIT-ENCROACHMENT PERMIT j Page 1 of 1 JoAnna Thomason 6,e3r- -' �� From: JoAnna Thomason Sent: Thursday, May 23, 2013 2:32 PM 5N\ To: 'katrina@ableseptic.com' r Subject: RE: Able Underground Construction, insurance certificate l/ Attachments: SKMBT_50113052313250.pdf Hi Katrina, the certificate you just sent shows Marvin Davis Construction as the Certificate Holder, not City of Campbell. I am attaching a copy of a certificate I received in the mail back on May 1st, and it looks correct including a Waiver of Subrogation. It would just need the permit number ENC2013-00098 added to the Description of Operations section. JoAnna Thomason I Office Assistant Public Works Department Joannat©city.ofcampbell.com lit 408.866.2150 I A 408.376-0958 (fax) ,E' 70.N.First Street I Campbell, CA 95008 www.CityofCampbell.com \F--- ( CA\ --A ' \\& _ From: Katrina Durbin [mailto:katrina@ableseptic.com] Sent: Thursday, May 23, 2013 12:01 PM To: JoAnna Thomason Subject: Able Underground Construction, Inc, ZUP14R6811013NF Good morning JoAnna, The last certificate of insureance did not have the right company name on it. Our insurance company made a mistake. I have attached the correct one. Please call me at our office if you have any questions. Thank you! Katrina Durbin Able Underground Construction, Inc. 1020 Ruff Drive San Jose, CA 95110 408-377-9990 http://www.ablesewer.com/ i 2 trMPFF'fd't7im. 'iA≥k(MC *** eSafe 8 scanned this email for malicious content *** *** IMPORTANT: Do not open attachments from unrecognized senders *** 5/23/2013 aC�® DATE(MMIDD/YYYY) • (✓ CERTIFICATE OF LIABILITY INSURANCE 5/1/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT All Spectrum Ins NAME: p All Spectrum Insurance Brokers (A/PHONE No.Est): (408)739-8300 I(A/C.No):(866)826-6781 4300 Stevens Creek Blvd Wass, p hel @asibrokers.com Suite 100 INSURER(S)AFFORDING COVERAGE I NAIC# San Jose CA 95129 INsuRERANational Fire Insurance Co of 20478 INSURED iNsuRERB:Peerless Insurance Company 24198 Able Underground Construction, Inc INSURERC:St Paul Fire and Marine Ins Co _24767 Able Septic Tank Service INsuRERD:Everest National Insurance Co 10120 1020 Ruff Dr INSURERE: San Jose CA 95110 INSURERF: COVERAGES CERTIFICATE NUMBER:CL135100123 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PR PREMISES EM TO RENTED (Ea occurrence) $ 300,000 A I CLAIMS-MADE X OCCUR X 2076630503 5/1/2013 5/1/2014 MED EXP(Any one person) $ 5,000 PERSONAL&ADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO .IFf:T LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 B X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED X 5A8910289 7/20/2012 7/20/2013 BODILYINJURY(Peraccident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS _ AUTOS (Per accident) X UMBRELLALIAB OCCUR EACH OCCURRENCE $ 1,000,000 C EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 DED I X IRETENTIONS 10,000 ZUP14R6811012NF 5/1/2013 4/1/2014 $ D WORKERS COMPENSATION X I ORY LIMITS I 'W- AND EMPLOYERS'LIABILITY Y/N ANY OFFICER/ME EXCLUDED? Y N/AIMBEER PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) 7600007280131 5/1/2013 5/1/2014 EL.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) RE: permist# ENC2013-00098 As required by written contract/agreement per attached endorsements G-140331-B (Ed. 01/09), AC01020308 the following is additional insured: City of Campbell, The City of Campbell Redevelopment Agency, its officers, employees and volunteers. c--Z \e?\\ � . CERTIFICATE HOLDER CANCELLATION (408)376-0958 14083760958@myfax.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Campbell 70 N 1st Street Campbell CA 95008 AUTHORIZED REPRESENTATIVE Dmitriy Lazarev/DIMAL ACORD 25(2010/05) (D1988-2010 ACORD CORPORATION. All rights reserved. INS025 oninnct ni The.ArORn narn.and Innn ara ranictarari niorkc of Aroizn Polcy#2076630503 G-140331-B CNA (Ed. 01/09) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE (OPTIONAL) Name of Additional Insured Person(s) Or Organizations (As required by written contract/agreement per Paragraph A. below.) Location(s) of Covered Operations (As per the written contract/agreement, provided the location is within the "coverage territory"of this Coverage Part.) (Coverage under this endorsement is not affected by an entry or lack of entry in the Schedule above.) A. Section II - Who Is An Insured is amended to in the performance of your ongoing operations include as an additional insured any person(s) or for the additional insured(s)or organization(s), including any person or c. "Your work" that is included in the organization shown in the Schedule above, whom "products completed operations hazard" you are required to add as an additional insured on and performed for the additional insured, this Coverage Part under a written contract or written agreement, provided: but only if this Coverage Part provides such coverage, and only if the written contract or a. The written contract or written agreement was written agreement requires you to provide executed prior to: the additional insured such coverage. 1. The "bodily injury"or"property damage"; or 2. However, we will not provide the additional insured any broader coverage or any higher 2. The offense that caused the "personal and limit of insurance than the least of those: advertising injury" a. Required by the written contract or written for which the additional insured seeks coverage under this Coverage Part; and agreement; b. The written contract or written agreement b. Described in B.1. above; or pertains to your ongoing operations or "your c. Afforded to you under this policy. work"for the additional insured(s). 3. This insurance is excess of all other insurance B. The insurance provided to the additional insured is available to the additional insured, whether limited as follows: primary, excess, contingent or on any other 1. basis, unless the written contract or agreement The person or organization is an additional insured only with respect to liability for "bodily requires this insurance to be primary. In that event, this insurance will be primary relative to injury," "property damage," or "personal and insurance which covers the additional insured advertising injury"caused in whole or in part by: as a named insured. We will not require a. Your acts or omissions; or contribution from such insurance if the written contract or written agreement also requires that b. The acts or omissions of those acting on this insurance be non-contributory. But with your behalf respect to all other insurance under which the additional insured qualifies as an insured or G-140331-B Includes copyrighted material of Insurance Services Office, Inc., with its permission Page 1 of 2 (Ed. 01/09) CNA (E G-140 331-B (Ed. 01/09)additional insured, this insurance will be An additional insured under this endorsement excess. will as soon as practicable: 4. The insurance provided to the additional (1) Give us written notice of an "occurrence" or insured terminates when your operations for the an offense which may result in a claim or additional insured are complete. But if the "suit" under this insurance, and of any claim written contract or written agreement specifies a or"suit"that does result; date until which this insurance must apply, then (2) Tender the defense and indemnity of any this insurance terminates: claim or "suit" to any other insurer or self a. On the date specified in the written contract insurer whose policy or program applies to or written agreement; or a loss we cover under this Coverage Part; b. When this policy expires or is cancelled, (3) Except as provided in Paragraph B.3 of this whichever occurs first. endorsement, agree to make available any other insurance the additional insured has C. With respect to the insurance afforded to the for a loss we cover under this Coverage additional insured, the following additional Part; and exclusions apply. (4) Send us copies of all legal papers received, This insurance does not apply to: and otherwise cooperate with us in the 1. "Bodily injury," "property damage," or "personal investigation, defense, or settlement of the p p y g p claim or"suit." and advertising injury" arising out of the rendering of, or the failure to render, any We have no duty to defend or indemnify an professional architectural, engineering, or additional insured under this endorsement until surveying services, including: we receive from the additional insured written notice of a claim or"suit." a. The preparing, approving, or failing to prepare or approve maps, shop drawings, 2. With respect only to the insurance provided by opinions, reports, surveys, field orders, this endorsement, the first sentence of change orders or drawings and Paragraph 4.a. of the Other Insurance specifications; and Condition is deleted and replaced with the following: b. Supervisory, inspection, architectural or engineering activities. 4. Other Insurance 2. "Bodily injury," "property damage," or "personal a. Primary Insurance and advertising injury" arising out of any This insurance is primary and non- premises or work for which the additional contributory except when rendered insured is specifically listed as an additional excess by this endorsement, or when insured on another endorsement attached to Paragraph b. below applies. this Coverage Part. D. SECTION IV — COMMERCIAL GENERAL E. The provisions of the written contract or written LIABILITY CONDITIONS is amended as follows: agreement do not in any way broaden or amend this Coverage Part. 1. The Duties In The Event of Occurrence, Offense, Claim or Suit condition is amended to add the following additional conditions applicable to the additional insured: G-140331-B Includes copyrighted material of Insurance Services Office, Inc., with its permission Page 2 of 2 (Ed. 01/09) BUSINESS AUTO AC 01 02 03 08 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUSINESS AUTO ENDORSEMENT FORM This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM A. CHANGES FOR TRAILERS AND FARM or organization qualifies as an "insured" un- EQUIPMENT der the Who Is An Insured Provision con- tained in Section II— LIABILITY 1. Under SECTION I - COVERED AUTOS, the following are added to Paragraph C. Certain COVERAGE of the Coverage Form Trailers, Mobile Equipment and Temporary D. REPLACED EXCLUSIONS Substitute Autos: The Expected or Intended Injury Exclusion 4. "Trailers" designed to be towed by a pri- IN SECTION II — LIABILITY COVERAGE is vate passenger type "auto" or a pickup, replaced by the following: panel truck or van if not used for busi- Expected or Intended Injury ness purposes, other than farming or "Bodily injury" or"property damage"which is ranching. expected or intended by the "insured". This 5. Farm wagons or farm implements while exclusion applies even if the resulting "bod- being towed by a covered "auto". ily injury"or"property damage": B. CHANGES FOR ADDITIONAL NEWLY a. is of a different kind, quality or degree ACQUIRED VEHICLES than initially expected or intended; or 2. Paragraph B.2 of SECTION 1 — COVERED b. is sustained by a different person, entity, AUTOS is replaced by the following: real property, or personal property than 2. If Symbol 7 is entered next to a cover- that initially expected or intended. age in Item Two of the Declarations, an E. ADDITIONAL EXCLUSIONS "auto" you acquire will be a covered The following exclusions are added to "auto"for that coverage only if: SECTION II—LIABILITY COVERAGE: a. We already cover at least one"auto" Damage to Named Insured's Property you own for that coverage or it re- places an "auto" you previously Any claim or "suit" for"property damage" by owned that had that coverage; and you or on your behalf against any other per- son or entity that is also a Named Insured b. You tell us within 30 days after you under this policy. acquire it that you want us to cover it for that coverage. Abuse or Molestation The most we will pay for Physical Damage "Bodily injury" or "property damage" arising Coverage for"loss" under this Coverage Ex- out of: tension is $100,000 per "auto", subject to a. The actual or threatened abuse or mo- the largest deductible applicable to any lestation by anyone or any person while "auto"for that Coverage. in the care, custody or control of any"in- C. BLANKET ADDITIONAL INSURED sured", or Any person or organization which you have b. The negligent: agreed to name as an additional insured in a 1) Employment; written contract, executed prior to an acci- 2) Investigation; dent, other than a contract for the lease or 3) Supervision; rental of a vehicle is an "insured"for Liability Coverage, but only to the extent that person 4) Reporting to the proper authorities, or failure to so report; or AC 01 02 03 08 Includes copyrighted material of Insurance Services Office, Inc., Page 1 of 3 with its permission. AC 01 02 03 08 5) Retention; b. "Loss" to TV antennas, awnings or ca- of a person for whom any "insured" is or bangs. ever was legally responsible and whose c. "Loss" to equipment designed to create conduct would be excluded by Para- added living facilities. graph a. above. However, these exclusions do not apply if Abuse means an act which is committed Miscellaneous Personal Property Coverage with the intent to cause harm. is provided by endorsement to this policy. Explosives G. ACCIDENTAL AIRBAG DISCHARGE "Bodily injury" or "property damage" caused COVERAGE by the explosion of explosives you make, Under Paragraph B.3.a. of SECTION III - sell or transport. PHYSICAL DAMAGE, the following is added: Rolling Stores Mechanical breakdown does not include the ac- If a covered "auto" is a rolling store, "bodily cidental discharge of an airbag. injury" or "property damage" resulting from H. PHYSICAL DAMAGE LIMIT OF INSURANCE the handling, use or condition of any item Paragraph C. Limit of Insurance of SECTION III the "insured" makes, sells or distributes if - PHYSICAL DAMAGE INSURANCE is replaced the injury or damage occurs after the "in- by the following: sured" has given up possession of the item. C. Limit Of Insurance Wrong Delivery of Liquid Products 1. The most we will pay for "loss" in "Bodily injury" or "property damage" result- any one"accident" is the lesser of: ing from the delivery of any liquid into the a. The actual cash value of the wrong receptacle or to the wrong address, or from the delivery of one liquid for another, damaged or stolen property as if the "bodily injury" or "property damage" of the time of the"loss"; or occurs after the delivery has been corn- b. The cost of repairing or replac- pleted. ing the damaged or stolen prop- Delivery is considered completed even if fur- ems' ther service or maintenance work, or correc- 2. An adjustment for depreciation and tion, repair or replacement is required be- physical condition will be made in cause of wrong delivery. determining actual cash value in the event of total "loss". Professional Services "Bodily injury": 3. The cost of repairing or replacing may: a. Resulting from the providing or the fail- ure to provide any medical or other pro a. Be based on an estimate which fessional services. includes parts furnished by the original equipment manufacturer b. Resulting from food or drink furnished or other sources including non- with these services. original equipment manufactur- "Bodily injury" or "property damage" result- ers and ing from the handling of corpses. b. Include a deduction for better- F. MOTOR HOME CONTENTS COVERAGE ment for a part or parts that are 1. For a covered "auto" that is a motor home normally subject to repair or re- the following exclusions are added TO placement during the useful life SECTION III-PHYSICAL DAMAGE: of the "auto", such as, but not limited to tires and batteries. Motor Home Contents Betterment means the difference This insurance does not apply to: between the actual cash value of a a. "Loss" to the covered "auto's" contents, part immediately before the "loss" except equipment usual to trucks or pri- and the cost to replace that part with vate passenger"autos". a new part. Page 2 of 3 Includes copyrighted material of Insurance Services Office, Inc., AC 01 02 03 08 with its permission. AC 01 02 03 08 I. GLASS REPAIR—WAIVER OF DEDUCTIBLE An "employee" of yours is an "insured" while operating an "auto" hired or rented under a Under Paragraph D. Deductible of SECTION III -PHYSICAL DAMAGE COVERAGE, the follow- contract or agreement in that "employee's" ing is added: name, with your permission, while performing duties related to the conduct of your busi- No deductible applies to glass damage if the ness. glass is repaired rather than replaced. B. Changes In General Conditions J. AMENDED DUTIES IN EVENT OF ACCIDENT, Paragraph 5.b. of the Other Insurance CLAIM, SUIT, OR LOSS Condition in the Business Auto Coverage The requirement in Loss Condition 2.a. Duties In Form is replaced by the following: The Even Of Accident, Claim, Suit Or Loss — of For Hired Auto Physical Damage Coverage, SECTION IV- BUSINESS AUTO CONDITIONS the following are deemed to be covered that you must notify us of an "accident", "claim", "autos"you own: "suit", or"loss" applies only when the "accident", "claim", "suit", or"loss" is known to : 1. Any covered "auto" you lease, hire, rent or borrow; and 1. You, if you are an individual 2. 2. Any covered "auto" hired or rented by A partner, if you are a partnership; your "employee" under a contract in that 3. An executive officer or the employee desig- individual "employee's" name, with your nated by you to give such notice if you are a permission, while performing duties re- corporation; or lated to the conduct of your business. 4. A member, if you are a limited liability com- However, any "auto" that is leased, hired, pany. rented or borrowed with a driver is not a K. UNINTENTIONAL FAILURE TO DISCLOSE covered "auto". HAZARDS M. EMERGENCY LOCKOUT - PRIVATE SECTON IV - BUSINESS AUTO CONDITIONS PASSENGER VEHICLES — B.2. is amended by the addition of the follow- We will reimburse you up to $50 for reasonable ing: expense incurred for the services of a locksmith If you unintentionally fail to disclose any hazards to gain entry into your covered "auto" of the pri- existing at the inception date of your policy, we vate passenger type subject to these provisions: will not deny coverage under this Coverage 1. Your door key or key entry pad has been lost, Form because of such failure. However, this stolen or locked in your covered "auto" and provision does not affect our right to collect addi- you are unable to enter such"auto" , or tional premium or exercise our right of cancella- 2. Your key or key entry pad has been lost or tion or nonrenewal. stolen and you have changed the lock to L. AUTOS HIRED OR RENTED BY prevent an unauthorized entry; and EMPLOYEES 3. Original copies of receipts for services of a If hired or rented "autos" are covered "autos" on locksmith must be provided before reim- this policy, the following provisions apply: bursement is payable. A. Changes In Liability Coverage The following is added to the Who Is An In- sured Provision in SECTION II—LIABILITY COVERAGE: All terms and conditions of this policy apply unless modified by this endorsement. AC 01 02 03 08 Includes copyrighted material of Insurance Services Office, Inc., Page 3 of 3 with its permission. POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 25 0305 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s): Each of your construction projects located away from premises owned by or rented to you Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. For all sums which the insured becomes legally 3. Any payments made under Coverage A for obligated to pay as damages caused by damages or under Coverage C for medical 'occurrences' under Section I — Coverage A, and expenses shall reduce the Designated for all medical expenses caused by accidents under Construction Project General Aggregate Limit 0 o Section I — Coverage C, which can be attributed for that designated construction project. Such only to ongoing operations at a single designated payments shall not reduce the General construction project shown in the Schedule above: Aggregate Limit shown in the Declarations nor 1. A separate Designated Construction Project shall they reduce any other Designated General Aggregate Limit applies to each Construction Project General Aggregate Limit designated construction project, and that limit is for any other designated construction project z equal to the amount of the General Aggregate shown in the Schedule above. Limit shown in the Declarations. 4. The limits shown in the Declarations for Each 2. The Designated Construction Project General Occurrence, Damage To Premises Rented To Aggregate Limit is the most we will pay for the You and Medical Expense continue to apply. sum of all damages under Coverage A, except However, instead of being subject to the damages because of 'bodily injury' or 'property General Aggregate Limit shown in the damage' included in the 'products-completed Declarations, such limits will be subject to the operations hazard,' and for medical expenses applicable Designated Construction Project under Coverage C regardless of the number of: General Aggregate Limit. a. Insureds; b. Claims made or'suits"brought;or C. Persons or organizations making claims or bringing'suits.' CG 25 03 05 09 Copyright, Insurance Services Office, Inc.,2008 Page 1 of 2 B. For all sums which the insured becomes legally C. When coverage for liability arising out of the obligated to pay as damages caused by 'products-completed operations hazard' is 'occurrences' under Section I — Coverage A, and provided, any payments for damages because of for all medical expenses caused by accidents under 'bodily injury' or 'property damage' included in the Section I—Coverage C,which cannot be attributed 'products-completed operations hazard'will reduce only to ongoing operations at a single designated the Products-completed Operations Aggregate construction project shown in the Schedule above: Limit, and not reduce the General Aggregate Limit 1. Any payments made under Coverage A for nor the Designated Construction Project General damages or under Coverage C for medical Aggregate Limit. expenses shall reduce the amount available D. It the applicable designated construction project under the General Aggregate Limit or the has been abandoned, delayed, or abandoned and Products-completed Operations Aggregate then restarted, or if the authorized contracting Limit,whichever is applicable;and parties deviate from plans, blueprints, designs, 2. Such payments shall not reduce any specifications or timetables, the project will still be Designated Construction Project General deemed to be the same construction project. Aggregate Limit. E. The provisions of Section III — Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. Page 2 of 2 Copyright, Insurance Services Office, Inc.,2008 CG 2503 05 09 • POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 25 03 05 09 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED CONSTRUCTION PROJECT(S) GENERAL AGGREGATE LIMIT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designated Construction Project(s): Each of your construction projects located away from premises owned by or rented to you Information required to complete this Schedule, if not shown above,will be shown in the Declarations. A. For all sums which the insured becomes legally 3. Any payments made under Coverage A for obligated to pay as damages caused by damages or under Coverage C for medical 'occurrences' under Section I — Coverage A, and expenses shall reduce the Designated 0 for all medical expenses caused by accidents under Construction Project General Aggregate Limit Section I — Coverage C, which can be attributed for that designated construction project. Such only to ongoing operations at a single designated payments shall not reduce the General construction project shown in the Schedule above: Aggregate Limit shown in the Declarations nor 1. A separate Designated Construction Project shall they reduce any other Designated General Aggregate Limit applies to each Construction Project General Aggregate Limit designated construction project, and that limit is for any other designated construction project 3 equal to the amount of the General Aggregate shown in the Schedule above. Limit shown in the Declarations. 4. The limits shown in the Declarations for Each 2. The Designated Construction Project General Occurrence, Damage To Premises Rented To Aggregate Limit is the most we will pay for the You and Medical Expense continue to apply. sum of all damages under Coverage A, except However, instead of being subject to the damages because of 'bodily injury' or 'property General Aggregate Limit shown in the damage' included in the 'products-completed Declarations, such limits will be subject to the operations hazard,' and for medical expenses applicable Designated Construction Project under Coverage C regardless of the number of: General Aggregate Limit. a. Insureds; b. Claims made or'suits' brought; or c. Persons or organizations making claims or bringing 'suits.' CG 25 03 05 09 Copyright, Insurance Services Office, Inc.,2008 Page 1 of 2 B. For all sums which the insured becomes legally C. When coverage for liability arising out of the obligated to pay as damages caused by 'products-completed operations hazard' is 'occurrences' under Section I — Coverage A, and provided, any payments for damages because of for all medical expenses caused by accidents under 'bodily injury' or 'property damage' included in the Section I—Coverage C,which cannot be attributed 'products-completed operations hazard'will reduce only to ongoing operations at a single designated the Products-completed Operations Aggregate construction project shown in the Schedule above: Limit, and not reduce the General Aggregate Limit 1. Any payments made under Coverage A for nor the Designated Construction Project General damages or under Coverage C for medical Aggregate Limit. expenses shall reduce the amount available D. If the applicable designated construction project under the General Aggregate Limit or the has been abandoned, delayed, or abandoned and Products-completed Operations Aggregate then restarted, or if the authorized contracting Limit,whichever is applicable;and parties deviate from plans, blueprints, designs, 2. Such payments shall not reduce any specifications or timetables, the project will still be Designated Construction Project General deemed to be the same construction project. Aggregate Limit. E. The provisions of Section III — Limits Of Insurance not otherwise modified by this endorsement shall continue to apply as stipulated. Page 2 of 2 Copyright, Insurance Services Office, Inc.,2008 CG 25 03 05 09 (0-y e\\ ,--N,\ . INSURANCE REQUIREMENTS CHECKLIST Permit# EL caltY 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. c Policy expiration date -,S H - I Automotive Liability: "Any Auto" checked on certificate ,tir, $1,000,000 per accident for bodily injury and property damage rg Policy expiration date 7 2c1 i 3 Workers' Compensation and Employer's Liability —9 Waiver of Subrogation clause $1,000,000 per accident for bodily injury or disease Policy expiration date 5-I Course of Construction (if required in Special Provisions) o Completed value of the project o Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement The City, its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) o The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR should say: yt.,,.Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. C:\Documents and Settings\joannat\Desktop\Insurance Requirements Cklist.doc (Rev 07/11) Page 1 of 2 o Workers' Compensation Insurance Sheet Submitted o For General Contractor o For Developer or Owner Acceptability of Insurer(s) o Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: W\\ '1`(\CQ,.1 O• NAIC # ayTgRatin •g. • Name: QeP�c\e S �r� . CD • NAIC # 2L11°l$ Rating: . 4 Authorized in CA: / Authorized in CA: Name: S\. „\ NAIC #2tk1 1 Rating: c /-A\/ Authorized in CA: Name: �,1-63.Ce9'c— t \k\ NAIC# 10120 Rating: t c/)tJ Authorized in CA: Campbell Business License # k.VA NP 513 i liLt Insurance Certificate Reviewed $ -`-L\ 1 Z 'nit Is 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