Loading...
HomeMy WebLinkAboutENC2013-00105 Print Form CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No CNG ZO I3 -00 105 DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File 70 North First Street right-of-way) Application Date s/))1( 3 Campbell,CA 95008 Application Expiration Date Ph. (408)866-2150 Issued ��3 �� APN qt a. Os' 00 Fx. (408)376-0958 I Permit Expiration Date 5/9,1 1 t APPLICATION-Application is hereby made for a Public Works Permit in accordance with ampbell 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.: 11, E. n_ _ 4( 4v. Utility Trench Location: S. 41 C4r4.01s``r .4 4 ilurt.fi B. Nature of Work S _ I _ e C. Attach four(4)copies of an engineered plan showing the location and me extent of the ork,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 n i_ e. `,`G Telephone: Noc3)21.1_ilia Address: Loz' k) T ✓1 a As(/O E-Mail Address: r„1, ea G ^ _-,\ 24-HOUR EMERGENCY PHONE NUMBER: I4: .) 0?,. 1 1,'l11Is this work being done by the property owners at eir own residence? ' YES pa NO V 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 a d all damages arising out of he condition of any private im rovements in the public right-of-way. Accepted: ti (�j / �� � ) — (Applicant Permittee) (sign) Date AEce 5 - SP--/3 (Contractor) (Print Name) Date SPECIAL PROVISIONS: 1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be specifically approved by the Inspector prior to cutting. _,G`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 7O RECEIPT O. PERMIT APPLICATION FEE 2t is t? 451 PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT (' PLAN CHECK&INSPECTION FEE $ 3 7O 2`-t$ T.S-1 EMERGENCY PERMIT FEE ' $ APPROVED FOR ISSUANCE 11% 5AF j13 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. - S 3 I—13 plicant Date: 3 (- 1 Contractor (Print Name) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.03/13 PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MISCELLANEOUS RECEIPT Effective July 1, 2012 TO: City Clerk PUBLIC WORKS FILE NO. PVC 2-o l'" '0C)O5 PROPERTY ADDRESS Please collect& receipt for the following monies: ACCT. I ITEM AMOUNT ENCROACHMENT PERMIT 4722 Utility Encroachment Permit Application Fee $370.00 370 R-1 Encroachment Permit N/C Emergency Permits $105.00 Plan Check&Inspection Fee Minimum Charge Per Location $370.00 370 Conduits/Pipelines up to 500 Feet $2.45/ft Above 500 Linear Feet $1.50/ft Manholes/Vaults/Etc. $160.00/ea Pole Set/Removal $160.00/ea 4760 Storage Container Permit $150.00 4760 Project Plans& Specifications Project No. .l Standard Specifications & Details $1/Pg$15.50/Bk 4760 Engineering Maps&Plans Aerial Plot 24"x 36" $58.00 Aerial Print 8 1/2"x 11" $27.00 Map Research (includes max of two 24"x36"copies) $27.00 Maps and Plans 24"x 36" $13.00 4722 Penalties: Failure to restore public improvements $100/Calendar Day(Muni Code Sec. 11.34.010) 4722 Penalties: Failure to correct unsafe conditions $100/Calendar Day 4722 Work Without Permits 4 Times Applicable Fee TRAFFIC 4728 Traffic Flow Map (Daily Traffic Volumes) $34.00 4728 Signal Timing Information $72.00/Hr 4271 Truck Permits $16.00 per trip 4728 No Parking Signs $1 each or$25/100 MISCELLANEOUS - 511.7424 Postage Other(Please Specify) /� TOTAL 711-0 NAME OF APPLICANT A-5 LC NAME OF PAYOR o \z \\- PHONE � 1' 7j T 7-�[`Crt(7 ADDRESS l -2_oV�'F- i.IX ZIP Q�llO RECEIVED (riA> 9-- FOR CITY CLERK ,..4..,, it....67 ONLY Date -.73 Receipt# ' / 0 • - - - ----7'�" -"+ ,,.�,�., 7.7...7,77-7. - _-eJ'P'7 ;1..-;W7,117.rsJ - •r - "�."T 7'ryzy '.47.,4'-.';^ ^'4' pv. rz`n,.= r -.."• -�". ?� �£ '�� .,, v.1� ,t--.7:37.7 sir�A ay._: !":;•� �r S'�� �'- � f - West Valley Sewer Connection Permit ,No: r�' �J Sanitation District 4 Issue Date: LfigA 115 By: VS OFFICE HOURS & CONTACTS: FEES: BACKFLOW PREVENTION: 7:30 a.m. to 4:30 p.m. Monday thru Friday Connection $ Z1?!6C1'• Capacity fly Z.. t ' • Field check required 100 E. Sunnyoaks Ave., Campbell, CA 95008 Basement • Phone: (408) 378-2407 Processing � 1 t�. 00 • Information Services Department Service A r . .:.04), o .' Check valve required: Yes No LOCATION: APN 1 " `` BUILDING SEWER CONNECTIONS: Sewer Map Book Li Page 11 s pg Tract Lot G,i' ��F Oj`tiW $ 4 _51 • i. Total number of connections to this Project Assmt gOkuv:A` property: — Address li,1961,1% trmrr Paid by Check No: 4i ? 4t ,40,4c(14-It of Akoriiikhigi 1. Lateral ID No. 1 St.iii is located Hillside: Yes No , f t) L. feet $ of A../ property Jurisdictions P+e d3 ?- ti line, feet from main sewer and • BUILDING TYPE: INSTRUCTIONS: 4` feet deep. Single Family • Permit is invalid if not connected within 12 Condo/Town House months of issue. Connection to Mein Sewer J 41 I feet Multiple Dwelling Units • Do not connect until the main sewer is accepted US from DS M -(64=. - Industrial by the District. US MH .. i 012,--c-)4 V Commercial stAoV'''rr`' • Obtain a building or plumbing permit from the Pipe Type 1i t;ix pi rl Jurisdiction listed above. REMARKS: :'LM rAL L., t. t.v4 f vdt,.,. • Street encroachment permit is required from re. c L•e.Ae4(A r. ,t eta} �� List any additional connections on : reverse side of this form. • Keep 3' radius around cleanout clear of OLD PERMIT No. 1'VV##t Sub No. 000 vegetation or obstruction. Original —Applicant Pink—Accounting Yellow—City/County Bldg. Inspector Card —District File r A CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DOTYYYY) 05/31/2013 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 Dmitriy Lazarev NAMEAll Spectrum Insurance Brokers �AHj�NE No, Ex1): (408) 739-8300 I „v No):(ace) 826-6781 4300 Stevens Creek Blvd nuoilss: dima@asibrokers.com Suite 100 PRODUCER CUSTOMER ID Able Underground Construction, Inc Saratoga CA 95129- INSURER(S)AFFORDING COVERAGE NAIC 6 INSURED INSURER A National Fire Ins Of Hartford 20478 Able Underground Construction, Inc INSURER B :Peerless Insurance Company 24198 Glen Gilbert, dba Able Septic Tank Service INSURER C :Everest National Insurance Co 10120 INSURER D St. Paul Fire & Marine Ins Co 24767 P.O. Box 24819 INSURER E : San Jose CA 95154- 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. INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MWEID/TYYY) (MMIODIYYYY) LIMITS A GENERAL LIABILITY 2076630503 05/01/2013 05/01/2014 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY / / / / DAMAGE TO RENTED PREMISES(Ea occurrence) $ 300,000 CLAIMS-MADE X OCCUR / / / / MED EXP(Any one person) $ 5,000 / / / / PERSONAL&ADV INJURY $ 1,000,000 / / / / GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: / / / / PRODUCTS-COMP/OP AGG $ 2,000,000 7 POLICY X JECT LOC / / / / $ B AUTOMOBILE LIABILITY BA8910289 07/20/2012 07/20/2013 COMBINED SINGLE LIMIT $ 1,000,000 / / / / (Ea accident) X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS / / / / / / / / BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS / / / / (Per accident) NON-OWNED AUTOS / / / / $ / / / / $ D X UMBRELLA UAB X OCCUR ZUP-14R6 8110-13-NP 06/01/2013 05/01/2014 EACH OCCURRENCE $ 1.000,000 EXCESS LIAR CLAIMS-MADE / / / / AGGREGATE $ 1,000,000 DEDUCTIBLE / / / / $ RETENTION $ / / / / $ WORKERS COMPENSATION 7600007280131 05/01/2013 05/01/2014 I WC STATU- OTH- C AND EMPLOYERS' LIABILITY X TORY LIMITS FR ANY PROPRIETOR/PARTNER/EXECUTIVE YIN / / / / E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? n N I A (MandatorylnNH) / / / / E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below / / / / E.L.DISEASE-POLICY LIMIT $ 1,000,000 / / / / / / / / DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Evidence of Insurance CERTIFICATE HOLDER CANCELLATION (408) 866-2150 (408) 376-0958 Public Works 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 AUTHORIZED REPRESENTATIVE Campbell CA 95008- ar ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(looms) The ACORD name and logo are registered marks of ACORD 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- 1. Under SECTION I - COVERED AUTOS, the tained in Section II — LIABILITY 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 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 wrong receptacle or to the wrong address, a. The actual cash value of the 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- erty. 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 Professional Services event of total "loss". 3. The cost of repairing or replacing "Bodily injury": 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 Motor Home Contents limited to tires and batteries. This insurance does not apply to: Betterment means the difference 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 Under Paragraph D. Deductible of SECTION III operating an "auto" hired or rented under a — PHYSICAL DAMAGE COVERAGE, the follow- contract or agreement in that "employee's" name, with your permission, while performing ing is added: 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 1. You, if you are an individual or borrow; and 2. A partner, if you are a partnership; 2. Any covered "auto" hired or rented by 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 re- corporation; or performing duties lated to the conduct of your business. 4. A member, if you are a limited liability corn- 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 pre- 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 If hired or rented "autos" are covered "autos" on 3. Original copies of receipts for services of a 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. 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" for which the additional insured seeks coverage a. 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. The person or organization is an additional basis, unless the written contract or agreement 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) • G-140331-B CNA (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 investigation, defense, or settlement of the 1. "Bodily injury," "property damage," or "personal 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 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) ,, 4 ciiii,' ; dolitA / Cf/ , -, - / u 4 il 4 g trt 4 i L _ cr. ?, A , ) 13: \ -NI 13 1 I 2 ufi 1,_ )cl s'-l- 1? (11 \ k r-Ti \ I ,,, c c-) • . I- -' E S. 44-'4 sit..to -i > - 41 D 14-- '5-1- --011 r c,, D a- J P- — L ji- 0. 4‘ T k �" CN1 ) c! IN 9 b ? Ott `L) 3 ' 1 't g '2 ",-) N.__. a ,----,2.) (R 6 I (A ' L.V. 01 cl. a • S L t.•k E-5-a- T3wo $ t <---- 2 2