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HomeMy WebLinkAboutENC2013-00151 Print Form Permit No `` C 20 13 - i 5 CITY OF CAMPBELL ENCROACHMENT PERMIT UG DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File / 70 North First Street right-of-way)riC� Application Date S/6/ 41 Campbell,CA 95008 Issued p/ 7 (3/ Application Expiration Date '2_4((�' Ph. (408)866-2150 ` APN Fx. (408)376-0958 Q 7 Permit Expiration Date V l[ APPLICATION-Application is hereby made for a Public Works Permit in accordance wit 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 Addressor Tract No.: 11 g` ,A bbo.4-I AVenue (Arrro4 del -I e4ikOCbve Mete Utility Trench Location: B. Nature of Work: FO-{-kolibet•Q 0.4 A66154 AVelel1 e C. Attach four(4)copies of an engineered plan showing the to on 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: 5ainc.c. ( ,^es ' Telephone:(Inc-• (4"o� 7)n- 21el3 Address: . Ca Ct","le r —t�30 •E-Mail Address: .1..�t'ACLAJll�C same , . 24-HOUR EMERGENCY PHONE NUMBER: J�Tek Is this work being done by the property owners at their own residence? r YES NO The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell,its officers,agents,and employees free,safe and harmless from any claim or demand for damages resulting from the work covered by this permit. The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all dama 'sing out of the condition of any private improvements in the public right-of-way. Accepted 8 (Applicant Permittee) (sign) Date • S0.NCO 'fit' < <Kc. ".4. DA,v (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 —7 RECEIPT NO. PERMIT APPLICATION FEE $ 377 7 2L f ((-3o PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK&INSPECTION FEE $ N% 4 — EMERGENCY PERMIT FEE $ e., t ecth c - 1©1tax)`-'-:- V C ' Lt 5 k APPROVED FoR ISSUANCE N7/ 3 For Ity ngineer Date Permit Expires 12 Months After Date of Issuance I n sr Fr. b-e" add e) 7-,:( 12-ey miff —A, S ir—ee p vCWs-tit 1• 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. a/C::>/MI , Applicant Date: C° 1:31 e (ti 611.4 D et vt`c{ Contractor (Print Name) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.03/13 .! PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1,2013 2 L 3 UD t5 TO: City Clerk PUBLIC WORKS FILE NO. -�C PROPERTY ADDRESS I I S( Ai36671- , Please collect&receipt for the following monies: ACCT. I ;ITEM I r AMOUNT i ; LAND DEVELOPMENT ' m c• 4722 Encroachment Permit Application Fee Non-Utility Encroachment Permit Major≥$10,000 $377.00 3�7 Minor Encroachment Permit<sio,000 $215.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $209.00 Street Tree Planting/Removal N/C 2203 ($500 per Tree Planting Deposit Required) $500.00/tree 2203 Plan Check Deposit 2%of Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Grading&Drainage Plan Review Single Family Lot $265.00 Site< 10,000 s.f. $795.00 Site≥10,000 s.f.<0.5 Acre $1,060.00 Site≥0.5 Acre $1,590.00 4722 NPDES Review(C3 Requirements) For projects not required to submit numeric sizing $153.00 For projects required to submit numeric sizing Impervious Area 10,000 Sq. Ft to 1 Acre $663.00 Impervious Area 1 Acre or more $867.00 Plan Check&Inspection Fee(Non-Utility) 4722 Enqr. Est. up to$250,000 14%of Engineer's Estimate **2203 Enqr. Est.≥$250,000 Actual cost+20%Admin Overhead (Min$35,000 Deposit) 2203 Emergency Cash Deposit 4%of Engr. Est.*($500 min/$10,000 Max) 2203 Faithful Performance Security(FPS) 100%of ENGR.EST.* 2203 Labor and Materials Security 100%of ENGR. EST.* 4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00 (Multi-Res$2,385.00) (All Other$2,650.00) 4722 Parcel Map(4 Lots or Less) $3,775.00+$82/lot 4722 Final Tract Map(5 or More Lots) $4,590.00+$112/lot 2203 Monumentation Security 100%of ENGR. EST. 4920 Parkland Dedication Fee(75%/25% Due Upon Cert. of Occupancy) 4722 Lot Line Adjustment(Includes Certificate of Compliance) $1,785.00 4722 Vacation of Public Streets&Easements $2,386.00 4722 Certificate of Compliance $1,764.00 4722 Certificate of Correction $530.00 4722 Appeal Filing Fee $200.00 4722 Notary Fee (per signature) $10.00 4722 Assessment Segregation or Reapportionment First Split $846.00 Each Additional Lot $265.00 511.7424 Postage MISCELLANEOUS ;. . I Other(Please Specify) *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. **Actual Cost Plus 20%Overhead(Non-Interest bearing deposit) TOTAL $ 3 77 NAME OF APPLICANT 54CLd►Cc• 1 t pekt /lu2 S t t v -- NAME OF PAYOR - �a.v%€a 4'' ''‘(306 (i eLec' �G . PHONE C ` �� �� 7- 2..193 ` ADDRESS Z1 Ut l.va t'v 14.4 Aire, LS C DC ZIP 1 co-30 FOR RECEIVE BY (-� 1, ,, , ,, CITY CLERK ' (-1 0 ONLY Date / Receipt# sAtis 3 Date/ Initials' CITY OF 14,elEu J:FORMs1T.mpWnaOmIMNr.a.'R.c.ipt Form WM Dewbpmeni 13.14 PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT Effective July 1,2013 OO t S TO: City Clerk PUBLIC WORKS FILE NO.Ec\C ,9.-r..)\- \- - . PROPERTY ADDRESS 1 \ 15 1 P0pk�p4- I_(_ Please collect&receipt for the following monies: ACCT.: 1 _ ITEM - ,.. 1 MOLD IT,4*, LAND DEVELOPMENT 4722 Encroachment Permit Application Fee Non-Utility Encroachment Permit Major≥$10,000 $377.00 Minor Encroachment Permit<$10,000 $215.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $209.00 Street Tree Planting/Removal N/C 2203 ($500 per Tree Planting Deposit Required) $500.00/tree 2203 Plan Check Deposit 2%of Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Grading&Drainage Plan Review Single Family Lot $265.00 Site< 10,000 s.f. $795.00 Site≥ 10,000 s.f. <0.5 Acre $1,060.00 Site≥0.5 Acre $1,590.00 4722 NPDES Review(C3 Requirements) For projects not required to submit numeric sizing $153.00 For projects required to submit numeric sizing Impervious Area 10,000 Sq. Ft to 1 Acre $663.00 Impervious Area 1 Acre or more $867.00 Plan Check&Inspection Fee(Non-Utility) 4722 Enqr. Est. up to$250,000 14%of Engineer's Estimate **2203 Enqr. Est. ≥$250,000 Actual cost+20%Admin Overhead (Min$35,000 Deposit) 2203 Emergency Cash Deposit 4%of Engr. Est.*($500 min/$10,000 Max) 2203 Faithful Performance Security(FPS) 100%of ENGR. EST.* 2203 Labor and Materials Security 100%of ENGR. EST.* 4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00 (Multi-Res$2,385.00) (All Other$2,650.00) 4722 Parcel Map(4 Lots or Less) $3,775.00+$82/lot 4722 Final Tract Map(5 or More Lots) $4,590.00+$112/lot 2203+ Monumentation Security 100%of ENGR. EST. 4920 Parkland Dedication Fee(75%/25% Due Upon Cert. of Occupancy) 4722 Lot Line Adjustment(Includes Certificate of Compliance) $1,785.00 4722 Vacation of Public Streets& Easements $2,386.00 4722 Certificate of Compliance $1,764.00 4722 Certificate of Correction $530.00 4722 Appeal Filing Fee $200.00 4722 Notary Fee(per signature) $10.00 4722 Assessment Segregation or Reapportionment First Split $846.00 Each Additional Lot $265.00 511.7424 Postage MISCELLANEOUS.,... a2p•3 I Other(Please Specify) G F13 n42.posit �c•••.+-,,,,,,,,.„,,1 s-ac‘a k,,e, Off .4 10)coo *Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. **Actual Cost Plus 20%Overhead(Non-Interest bearing deposit) TOTAL $ [t7 1000 NAME OF APPLICANTS _ NAMEOFPAYOR C(L\:\ -5.� `Qqs-\ \\-E'k ��",� ���� PHONE �)- -'aa-S- nutf�oZ ADDRESS 3o\ C c„�,n m €`Q �T �,,.„: _c.--� j ��.\.L\- 8`nZIP (01 Off. , .. r. � FOR RECEIVED BY CITY CLERK 1 Receipt# - � 1, . . . ONLY Date Date/ Initials J:WORMS\Te,w ..\Adnin4lratiwWeupt Farm Land D.eopnwnt 13-14 CITY OF CAMPBELL RECVD BY: JAZ 01000249315 PRYOR: 0 R HORTON INC TODAY'S DATE: 07/30/13 REGISTER DATE: 07/30/13 TIME: 14:43 DESCRIPTION AMOUNT REF DEPOSIT - 101 $10.000.00 CUST ID: CFD DEPOSIT - 2013-00147 TOTAL DUE: $10,000.00 CHECK PAID: $10.000.00 CHECK NO: 4264S7 TENDERED: $10.000.00 CHANGE: $.00 1l-R•HOHTON ID I-1 I Aiffartca--" te4"41-e"P# RECEIV t7; JUL 26 2013 Public Works Administrai+uj, ilk 262013 woo jra FedEx edEx July 23, 2013 City of Campbell 70 North First Street Campbell, CA 95008 Attn: Lisa Petersen Re: Tentative Vesting Subdivision Map(PLN20112-132) 1181 Abbott Avenue Dear Lisa: D.R. Horton BAY, Inc. purchased the above referenced property from DUC Development and closed on July 11, 2013.We are in the process of preparing the final map and improvement plans for submittal to the City, and various agencies,for plan check which we anticipate within the next four weeks. Per the condition of approval number 32, we are hereby submitting a check in the amount of$10,000 representing the deposit for staff to establish the CFD. If you have any questions, please do not hesitate to give me a call at(925)413-9072. Sincerely, D.R. on B , Donald Babbitt Project Manger 5050 HOPYARD ROAD,STE. 180 PLEASANTON,CA 94588 TEL:(925)225-7400 FAX:(925)225-7402 I / : .20I I W V �o ss I 230.36 1 I 651 I WV 1 1 230.18 I I -l' -- - �'_, �;Ti 653 I III l ,� �q 1; �,-- / N I 71 230.46 I 1 I I 655 I V ---� �) � �� � x X30. 1 '. --( )-I , 230.32 I _._--__ 30 vl N `� I •OBA/CROL !: ' SSMH / (C�`_i/\I \ o, oo m - — 1S M i 1 N 230 / -�l� iI - - - _ h -6 I T7 '© ��P`; CTCR• EDCURkIEC /�a - _ �, — -moo. \ / EX 12" SDD- - L J — c� b crili137,1CKR. 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UTILITIES IN AREA. 11 �_ If\r7) I I _____ I CONTRACTOR TO VERIFY - --f _-- ________ j �I I -- I I I EXACT LOCAT ONS PRIOR TO 3 I I I \ / I J I'BEGINNING C NSTRUCTION a t.-L7 � I - I / 1 i 1 i < WIIIIIIMINNummumw 1: ) \-f '_ T5 II slielliy+-1' 1- ' " I ) i r' I / ,j I ��c.gC 4"r/;J c� W ~ Thr x I \ I Z — I m I I �) J ( a I (V....____ C) I 11 I LN (i) 7)> "/ ' : I: , t 4 1 / ) ,i ) , • -' LL I i= II I �' N . I \ I Ir .,.........mo, ® DATE(MM/DD/YYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE 08/06/2013 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 LIC #0726293 1-408-973-9500 CONTACT NAME: Arthur J. Gallagher & Co. PHONE FAX Insurance Brokers of California, Inc. (A/C.No.Ext): 408-973-9500 I(A/C,No): 408-257-2985 One Almaden Boulevard ADDRE ADDRESS: Suite #960 San Jose, CA 95113 INSURER(S)AFFORDINGCOVERAGE NAIL# INSURER A: Valley Forge Insurance Co. 20508 INSURED INSURERS: Zurich American Insurance Co. 16535 Sanco Pipelines, Inc. Starr Indemnity & Liability Co. 38318 INSURER C: _ 727 University Avenue INSURER D; AGCS marine Insurance Company 22837 INSURERE: Illinois Union Insurance Co. 27960 Los Gatos, CA 95032 INSURER F: COVERAGES CERTIFICATE NUMBER: 35100805 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) A GENERAL LIABILITY X GL 4034981857 04/01/13 04/01/14 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Es occurrence) $100,000 1 CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,000 X $25,000 Deductible PERSONALBADVINJURY $ 1,000,000 GENERAL AGGREGATE $2;000,000 GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMP/OP AGG $ 2,000,000 PR 7 POLICY X JFCOT LOC $ B AUTOMOBILE LIABILITY BAP5747431-00 04/01/13 04/01/14 COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per acadenl) $ PROPERTY DAMAGE $NON-OWNED (Per accident)X HIRED AUTOS R AUTOS $ C UMBRELLALIAB X OCCUR SISCCCL01775413 04/01/13 04/01/14 EACH OCCURRENCE $ 10,000,000_ X EXCESS LIAR CLAIMS-MADE AGGREGATE $ 10,000,000 DED RETENTION$NIL Prod-Compl Agg. $ 5,000,000 _ B WORKERS COMPENSATION X WC3504400-12 04/01/13 04/01/14 XITORYLIMITSI ICE-FY- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N --- (Mandatory In NH) I E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under __ 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ D Rented/Leased Equipment MXI 93049191 04/01/13 04/01/14 R/L Ded. $5,000 Included E Pollution CPY G27267762001 02/19/13 04/01/14 Limit 5,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: Sanco Job #R-13-08; 1181 Abbott Avenue, Campbell, CA. Additional Insureds (GL): The City of Campbell, and its officers, directors, employees, and volunteers. CERTIFICATE HOLDER CANCELLATION Sanco #R-13-08 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Campbell THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Dept. of Public Works ACCORDANCE WITH THE POLICY PROVISIONS. 70 North First Street AUTHORIZED REPRESENTATIVE Campbell, CA 95008 Cam- 4 I USA ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD slweis 35100805 G-140331-C CNA Named Insured: Sanco Pipelines, Inc. (Ed. 10/10) Policy Number: GL 4034981857 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - WITH PRODUCTS-COMPLETED OPERATIONS COVERAGE This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE (OPTIONAL) Name of Additional Insured Persons Or Organizations (As required by"written contract" per Paragraph A. below.) Locations of Covered Operations (As per the"written contract,"provided the location is within the"coverage territory"of this Coverage Part.) A. Section II - Who Is An Insured is amended to 2. We will not provide the additional insured any include as an additional insured: broader coverage or any higher limit of 1. Any person or organization whom you are insurance than the least that is: required by "written contract" to add as an a. Required by the "written contract"; additional insured on this Coverage Part; and b. Described in B.1. above; or 2. The particular person or organization, if any, scheduled above. c. Afforded to you under this policy. B. The insurance provided to the additional insured is 3. This insurance is excess of all other insurance limited as follows: available to the additional insured whether on a primary, excess, contingent or any other basis. 1. The person or organization is an additional But if required by the "written contract," this insured only with respect to liability for "bodily insurance will be primary and non-contributory injury," "property damage," or "personal and relative to insurance on which the additional advertising injury"caused in whole or in part by: insured is a Named Insured. a. Your acts or omissions; or 4. The insurance provided to the additional insured does not apply to "bodily injury," b. The acts or omissions of those acting on "property damage,"or"personal and advertising your behalf injury arising out of: in the performance of your ongoing operations a. The rendering of, or the failure to render, specified in the"written contract"; or any professional architectural, engineering, c. "Your work" that is specified in the "written or surveying services, including: contract" but only for "bodily injury" or "property damage" included in the (1) The preparing, approving, or failing to prepare or approve maps, shop "products-completed operations hazard," drawings, opinions, reports, surveys, and only if: field orders, change orders or drawings (1) The "written contract" requires you to and specifications; and provide the additional insured such coverage; and (2) Supervisory, inspection, architectural or engineering activities; or (2) This Coverage Part provides such b. Any premises or work for which the coverage. additional insured is specifically listed as an G-140331-C Includes copyrighted material of Insurance Services Office, Inc.,with its permission Page 1 of 2 (Ed. 10/10) G-140331-C CNA Named Insured: Sanco Pipelines, Inc. (Ed. 10/10) Policy Number: GL 4034981857 additional insured on another endorsement We have no duty to defend or indemnify an attached to this Coverage Part. additional insured under this endorsement until we receive from the additional insured written C. SECTION IV — COMMERCIAL GENERAL notice of a claim or"suit." LIABILITY CONDITIONS is amended as follows: 2. With respect only to the insurance provided by 1. The Duties In The Event of Occurrence, this endorsement, the first sentence of Offense, Claim or Suit condition is amended P to add the following additional conditions Paragraph 4.a. of the Other Insurance applicable to the additional insured: Condition is deleted and replaced with the following: An additional insured under this endorsement 4. Other Insurance will as soon as practicable: a. Primary Insurance (1) Give us written notice of an "occurrence" or an offense which may result in a claim or This insurance is primary and non- "suit" under this insurance, and of any claim contributory except when rendered or"suit"that does result; excess by endorsement G-140331-C, or when Paragraph b. below applies. (2) Except as provided in Paragraph B.3 of this endorsement, agree to make available any D. Only for the purpose of the insurance provided by other insurance the additional insured has this endorsement, SECTION V - DEFINITIONS is for a loss we cover under this Coverage amended to add the following definition: Part; "Written contract" means a written contract or (3) Send us copies of all legal papers received, written agreement that requires you to make a and otherwise cooperate with us in the person or organization an additional insured on this investigation, defense, or settlement of the Coverage Part, provided the contract or agreement: claim or"suit"; and 1. Is currently in effect or becomes effective during (4) Tender the defense and indemnity of any the term of this policy; and claim or "suit" to any other insurer or self 2. Was executed prior to: insurer whose policy or program applies to a loss we cover under this Coverage Part. a. The "bodily injury"or"property damage"; or But if the "written contract" requires this insurance to be primary and non b The offense that caused the "personal and contributory, this provision (4) does not advertising injury" apply to insurance on which the additional for which the additional insured seeks coverage insured is a Named Insured. under this Coverage Part. G-140331-C Includes copyrighted material of Insurance Services Office, Inc.,with its permission Page 2 of 2 (Ed. 10/10) WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY WC 04 03 06(Ed.4-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT- CALIFORNIA This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. (The following"attaching clause"need be completed only when this endorsement is issued subsequent to preparation of the policy.) This endorsement,effective on 04/01/2013 at 12:01 A.M. standard time,forms a part of Policy No. WC 3504400-12 Endorsement No. of the Zurich American Insurance Co. issued to Sanco Pipelines, Inc. "It "'''''' Premium (if any) $ oriz presentative We have the right to recover our payments from anyone liable for ati injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be % of the California workers' compensation pre- mium otherwise due on such remuneration. Schedule Person or Organization Job Description ALL PERSONS AND/OR ORGANIZATIONS THAT ARE ALL CALIFORNIA OPERATIONS BY WRITTEN REQUIRED CONTRACT OR AGREEMENT WITH THE INSURED, EXECUTED PRIOR TO THE ACCIDENT OR LOSS,THAT WAIVER OF SUBROGATION BE PROVIDED UNDER THIS POLICY FOR WORK PERFORMED BY YOU FOR THAT PERSON AND/OR ORGANIZATION WC 252(4-84) Page 1 of 1 WC 04 03 06(Ed.4-84) DATE SUPPLEMENT TO CERTIFICATE OF INSURANCE 08/06/2013 NAME OF INSURED: Sanco Pipelines, Inc. Additional Description of Operations/Remarks from Page 1: Additional Information: Forms Incldued Where Required by Written Contract: General Liability: Additional Insured - Ongoing & Completed Ops per attached form G-140331-C (10-10) Insurance is Primary & Non-Contributory per attached form G-140331-C (10-10) Workers Compensation: Waiver of Subrogation per attached form WC 04 03 06 (4-84) C+ SUPP(05/04) __4SURANCE REQUIREMENTS CHECKLI Sc\c-tp p2 \\(\eS Permit # C c�v\�J' CCU\5 \ 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: if $1,000,000 per occurrence, and xf $1,000,000 general aggregate limit applying separately to the project, or o, $2,000,000 general aggregate limit. ❑ Policy expiration date 4(\\lLS Automotive Liability: "Any Auto" checked on certificate 4 $1,000,000 per accident for bodily injury and property damage ❑ Policy expiration date x el\\\ -1 Workers' Compensation and Employer's Liability Ler-Waiver of Subrogation clause a>�1,000,000 per accident for bodily injury or disease ❑ Policy expiration date Cf I I I� Course of C struction required in Special Provisions) ❑ Completed I of the project ❑ Policy exp. ti n date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement ov The City, its officers, employees and volunteers are named as additional insured. ❑ The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: u Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". OR should say: Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. LJ Workers' Compensation Insurance Sheet Submitted u For General Contractor ❑ For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc(Rev 07/11) Page 1 Acceptability of Insurer(s, ❑ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Name: Q.A-cam NAIC# D3SIA Rating: 6- XV Authorized in CA: Name: ?AA:A NAIC# VW-Rating: ifi >CV Authorized in CA: Name: S-1,..e4L-Su1 -�,-e..M NAIC# 1' Rating: A -v Authorized in CA: Name: NAIC# Rating: Authorized in CA: ❑ Campbell Business License # � } 1 X %,31k(1 Insurance Certificate Reviewed 3I-) \13 Initia Date u Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc(Rev 07/11) Page 2 Print Form CITY OF CAMPBELL ENCROACHMENT PERMIT Permit N 7u, c) 0-)At� DEPT.OF PUBLIC WORKS (for working within the public X-Ref.File 70 North First Street right-of-way) Application Date —1\3O�\�j Campbell,CA 95008 Application Expiration Date Ph. (408)866-2150 Issued APN LAC) U\ Fx. (408)376-0958 Permit Expiration Date 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.: C\ _ \"\— 4 r J Utility Trench Location: B. Nature of Work: ` C. Attach four(4)copies of an engineered plan showing the location and extent of the work, (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: Telephone: COT g —Nu() Address: V\-C—P\C\ *O_C E-Mail Address: 24-HOUR EMERGENCY PHONE NUMBER: Is this work being done by the property owners at their own residence? YES r` NO The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell,its officers,agents,and employees free,safe and harmless from any claim or demand for damages resulting from the work covered by this permit. The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all damages arising out of the condition of any private improvements in the public right-of-way. Accepted: (Applicant Permittee) (sign) Date (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 $ PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR&MATERIALS $ CONSTRUCTION CASH DEPOSIT $ __ PLAN CHECK&INSPECTION FEE $ EMERGENCY PERMIT FEE $ \p �O 00 APPROVED FOR ISSUANCE For City Engineer Date Permit Expires 12 Months After Date of Issuance GENERAL PERMIT CONDITIONS 1. A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency call-out,overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. 3. Refund or the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. Submit project schedule 10(ten)days prior to proposed start of work.Special provisions may be required for work within City facilities and downtown Campbell. 5. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. 6. Maintain safe pedestrian and vehicular crossings and free access to private driveways,bus stops,fire hydrants,and water valves. 7. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures,detours,and street closures.This plan must be reviewed and approved prior to any lane closures. 8. A Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones,dated 1990,available at Caltrans.Traffic control equipment shall include Type II flashing arrow signs if required. 9. Replace as directed by the City Engineer any damaged or removed improvements in accordance with City Standards and Specifications at the sole expense of the Permittee. 10. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements. 11. Prior approval of inspector is required for any work done after normal working hours,on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 12. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost(including all labor and materials)against the cash deposit. 13. Compaction testing of subgrade,base rock,and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 14. The Contractor or Permittee will have a supervisory representative available for contact on the project at all times during construction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m.to 4:00 p.m. 15. No storage of materials or equipment will be allowed near the edge of pavement,the traveled way,or within the shoulderline which would create a hazardous condition to the public. 16. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a separate permit may be required,nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 17. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 18. This permit is not transferable.Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 19. Call back(call out)due to emeregencies regarding this permit shall be at the current overtime rate with a three(3)hour minimum charge per occurrence. 20. Pursuant to Chapter 14.02 of the Campbell Municipal Code,applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. 21. If the public interest requires a modification of,or a departure from the plans and specifications,the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made for City-owned or maintained facilities. 22. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior to distribution and include dates of work and a contact name and phone number. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions. Applicant Date: Contractor (Print Name) Date: 1:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.03/13 l PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT TO: City Clerk EffectivPUBLIC WORKS FILE NO.�--\1L (" U\-> - ��1y PROPERTY ADDRESS ; \'' I fl b\0 Please collect&receipt for the following monies: ACCT. ) ITEM AMOUNT LAND DEVELOPMENT 4722 Encroachment Permit Application Fee Non-Utility Encroachment Permit Major≥$10,000 $377.00 Minor Encroachment Permit<sio,000 $215.00 Initial R-1 Permit N/C Subsequent R-1 Permits within Two Year Period $209.00 Street Tree Planting/Removal N/C 2203 ($500 per Tree Planting Deposit Required) $500.00/tree 2203 Plan Check Deposit 2% of Engineer's Estimate $500.00 min Utility and R-1 Permits no deposit required 4722 Grading&Drainage Plan Review Single Family Lot $265.00 Site< 10,000 s.f. $795.00 Site≥ 10,000 s.f. <0.5 Acre $1,060.00 Site≥0.5 Acre $1,590.00 4722 NPDES Review(C3 Requirements) For projects not required to submit numeric sizing $153.00 For projects required to submit numeric sizing Impervious Area 10,000 Sq. Ft to 1 Acre $663.00 Impervious Area 1 Acre or more $867.00 Plan Check& Inspection Fee(Non-Utility) 4722 Engr. Est. up to$250,000 14%of Engineer's Estimate "'2203 Engr. Est. ≥$250,000 Actual cost+20%Admin Overhead (Min$35,000 Deposit) 2203 Emergency Cash Deposit 4%of Engr. Est.*($500 min/$10,000 Max) 2203 Faithful Performance Security(FPS) 100%of ENGR. EST.* 2203 Labor and Materials Security 100%of ENGR. EST.* 4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00 (Multi-Res$2,385.00) (All Other$2,650.00) 4722 Parcel Map(4 Lots or Less) $3,775.00+$82/lot 4722 Final Tract Map(5 or More Lots) $4,590.00+$112/lot 2203 Monumentation Security 100%of ENGR. EST. 4920 Parkland Dedication Fee (75%/25% Due Upon Cert. of Occupancy) 4722 Lot Line Adjustment(Includes Certificate of Compliance) $1,785.00 4722 Vacation of Public Streets& Easements $2,386.00 4722 Certificate of Compliance $1,764.00 4722 Certificate of Correction $530.00 4722 Appeal Filing Fee $200.00 4722 Notary Fee(per signature) $10.00 4722 Assessment Segregation or Reapportionment First Split $846.00 Each Additional Lot $265.00 511.7424 Postage MISCELLANEOUS.: v ' ,R .,_O-3 I Other(Please Specify) C Fly -)-01-)O5.11— �- ,,,�--, .C-O.C s\_,,,,,5 C1f(1: 4 _to v000 "Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. **Actual Cost Plus 20%Overhead(Non-Interest bearing deposit) TOTAL $ I,C.) L' i I 0O NAME OF APPLICANT \ `t�` Q NAME OF PAYOR C)P_\-\\c\G ,c-\&\\-e C) -, \ PHONE A:\tx --5D- - ---)Lt O,. ADDRESS --2C)\ �,�� ,.� �`� C4 ��. 31� ��.� ,� , ZIP lv1G �. FOR RECEIVED BY, **) - CITY CLERK ONLY Date 0 I Receipt# Z i i,51 Date! Initials CITY OF CAMPBELL RECVD BY: JAZ 01000249315 PAYOR: D R HORTON INC TODAY'S DATE: 07/30/13 REGISTER DATE: 07/30/13 TIME: 14:43 DESCRIPTION AMOUNT REF DEPOSIT - 101 $10.000.00 CUST ID: CFD DEPOSIT - 2013-00147 TOTAL DUE: $10,000.00 CHECK PAID: $10.000.00 CHECK NO: 426487 TENDERED: $10,000.00 CHANGE: $.00 (cM a D R RDRIUN' File Copy-Do Not Mail f t.,rrordu+'si��Nlwar Check Number 0426487 CITY OF CAMPBELL Date 07/23/13 70 NORTH FIRST STREET DRII Inc Controlled Disb. Stub 1 of 1 1665341 PO Numb Invoice Number Subdv Lot# Lot Address Coat Cde Legal Desc Gross Deductions Amount Paid CITY1 60263 Duc, Campbell 10,000.00 10,000.00 10,000.00 10,000.00 Check Number 0426487 CITY OF CAMPBELL Date 07/23/13 70 NORTH FIRST STREET DRH Inc Controlled Disb. Stub 1 of 1 1665341 PO Numb Invoice Number Subdv Lot# Lot Address Cost Cde Legal Desc Gross Deductions Amount Paid CITY1 60263 Duc, Campbell 10,000.00 10,000.00 10,000.00 10,000.00 D'Rll0RlON • 011-1111 Amer iCta?5 O144111/49 JUL 2 6 2013 Public Works Admsnistrauu,, uu JUL 6 2013 a Fed Ex ��°n July 23, 2013 City of Campbell 70 North First Street Campbell, CA 95008 Attn: Lisa Petersen Re: Tentative Vesting Subdivision Map(PLN20112-132) 1181 Abbott Avenue Dear Lisa: D.R. Horton BAY, Inc. purchased the above referenced property from DUC Development and closed on July 11, 2013. We are in the process of preparing the final map and improvement plans for submittal to the City, and various agencies, for plan check which we anticipate within the next four weeks. Per the condition of approval number 32, we are hereby submitting a check in the amount of$10,000 representing the deposit for staff to establish the CFD. If you have any questions, please do not hesitate to give me a call at(925)413-9072. Sincerely, D.R. on Ba , Donald Babbitt Project Manger 5050 HOPYARD ROAD,STE. 180 PLEASANTON,CA 94588 TEL(925)225-7400 FAX:(925)225-7402