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ENC1999-00201 C:'FY OF C/~IPBELL i t ENCROACHMENT PERMIT Permit No. ~.~c:~ D -PT. OF PUBLIC WO~S (for wor~ng wi~n ~e X-Ref. file 70 No~ F~st St. public ~ght~f-way) Camp~ll, CA 95~8 (408) 866-2150 Issued ~Z/, l ~ ~ Applica,ion Da~ F~ (408) 376~958 Pe~t e~ires in 12 mon~ ApplicafioF e~ires ~ 6 mon~ C. A~h f~ (4) ~i~ of ~ mgin~ pl~ show~ ~e I~n ~ ex~ of ~e wo&. ~ f~ (4) ~i~ of ~ pm~ ~,s E. T~ CO~OR MUST ~V~ T~S PE~ ~ APPRO~D P~S AT T~ S~ ~ MU~ NO~ ~ P~LIC WO~ DEP~ AT ~T ~O DAYS BEF~ ~T~G WO~ ~ wo~ ~ng ~ by me pr~e~ ow~r ~ reek own ~ide~? / Y~ No ~y ~m or 8e~d for ~ ~ul~ from ~e work ~ve~ by ~ ~. 5PEC~L P~ APP~ICA~ON ~E ...... GENERAL PERMIT CONDITIONS I. A CONSTRUCTION CASH DEPOSIT is required. Charges will be made against this deposit if there is an emergency call-out, overtime ins~ction 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 MAIN~NANCE PERIOD AND SURETY are required. Such period will begin on date of written accep~nce by the City. 3. REFUND of 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. The Permir~ee 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. 3. MAINTAIN safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants and water valves. 6. A CONSTRUCTION TRAFFIC CONTROL PLAN and a CONSTRUCTION SCHEDULE is required for all lane closures, detours and street closures. This plan must be REVIEWED and APPROVED prior to any lane closures. 7. The CONSTRUCTION TRAFFIC CONTROL PLAN shall conform with the Calwans 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. 8. REPLACE IN ICIND any damaged or removed existing impwvements, including planting. 9. Sawcut for all PCC or AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements. I0. OVERTIME INSPECTION PREMIUM will be charged against the cash deposit for inspection required outside the hours of g:00 a.m. to 4:00 p.m. at the current overtime rate, ~um one hour charge. I 1. SATURDAY INSPECTIONS must be arranged in advance. Saturday inspection time is charged at the current overtime rate with a three hour minimum. Advance payment for the estimated time is required. 12. Adequate signing and lighted BARRICADING is required on the job site. Failure to pwvide such signing and barricading may result in the City's renting such signing and barricades and charging the cost (including all labor and mater/als) against the cash deposit. I3. Compaction testing of subgrade, base wck, and asphalt concrete by Permittee is REQUIRF_.D unless otherwise stated by the City Engineer. I4. The Contractor or Permit~ee will have a SUPERVISORY REPRESENTATIVE available for contact on the pwject at all times during construction. Conuactor 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 waveled way, or within the shouldefline 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. ~ permit is NOT TRANSFERRABLE. Work must be performed by the Pcrmiuee or his designated agent or conwactor as specified thereon. 19. CALL BACK (call out) due to emergencies regarding this permit, shall be at the current overtime rate with a three (3) hour minimum charge per oe,,~urrence. 20. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material inw the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the S, anta Clara Valley Nonpoint Source pollution Control Program. Applicant shall be responsible for ensuring that all those providing se~ices under the applicant are aware of and understand all of th~ above conditions. CITY OF CAMPBELL DEPT. OF PUBLIC WORKS 70 North First St. Campbell, CA 95008 (408) 866-2150 Fax (408) 376-0958 ENCROACHMENT PERMIT (for worldng within the public right-of-way) Issued Permit expires in 12 months X-Ref. file~:-:~,cSt~ - ..< c'-i Application Date-'~"-:~ '--{--C.:? Application expires in 6 months APPLICATION - A~lication is hereby made for a Public Wor~s Permit in a~cordance with Campbell Municipal Code, Section 11.04. (Application expires in 6 months if the permit is not issued. ApplicatiOn Fee is non-refundable.) / c. ^tt,~ four (4) copi~, of an ,'n[i~e~ prom s~owi.n[, t~e ~oc,~iou ar~ ext~m of t~,, ~ork, ~ four (4) co~i~ of thc ~m~imimn, EnCn~r'~ ~timat~ of ~o~. Tbe ptam ~lmll mow the relatao~ of the proposed ~ork to ex,sung ~urf~ ~ underground improvements. When ~pproved by the City Engineer. sal~ plan I~om~ a pm of this permit. D. All wo~ shall no,form to the Cit~ of C~bell Stant~'d Sl~:ification~ ~ l)ctail[ for Public Worl~ Constr~ion; the General Permit Conditio~ listed o~ the r~vcr~e side; and the Special Provisions for ~i~ permit, listed below. Failure to ~ide by thes," con~itiom and provisions my muir i~ job shut-~o~ anti/or forfeiture of F~ithful Pefformanc~ S-r~i~ and cmh deposit. (See General Permit Conditiom ! and 2.) E. THE CONTRACTOR MUST HA CE THIS PERMIT AND APPROVED PLANS AT TIlE SITE AND MUST NOTIFY I.~F. AfiT TWO DAYS BEFORE STAR FING WORK. NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RF-~TARTING ANY WORK. (print name) h this work being done by the proper~ owner at tbeb own residence? .Y~ ~ No / The Applicant/P,'rmittee beroby agreesI by ~ffixim~ their fignature to ,.his permit to hokl the City of Campbell, it~ officers, agents anti employees free, safe and l~rmless from any claim or demand £or dmm~es r~t~lting from the work covered by this permit. ! The Applicant/P~-mittee bereb¥ acknclwled~ that tbey have rend and under~tand both the front and back of this permit, and they will inform their contractor(s) of the information. SPECIAL PROVISIONS ~1(.=~. Street shall not be open ~ m for underground installations. Minimum cats may be allowed for cOnnections or exploration holes. ~ch cms may be specifgall¥ approved by the Inspectc r prior to cutting. ~2. Pavement may be cut roi underground installations and must be restored in ac¢ordanc~ with the Utility Trench Restorat. ion Standa~ Details, Me,hod 'A' gta~fiIl, unless otherwise approv{ d by Inspector. ~ Work to be staked by a I ieensed Land Surveyor or Civil Engineer and two (2) copies of the cut sbeets sent to thc Public Works l~artn~nt before starting work. ~ Per S'etion 4215 of tbe ~ ~overnment Cede this permit is not valid for excavations until Underground Service Alert (USA) ires been notified and the inquiry kl~ntifr, ation number ha~ been em-'red hereon. USA Phone 1-800-227-2600. USA TICKET NO. SEE PUBLIC WORKS FEE SCHEE ULE FOR CURRENT FEES TYPE * AMOUNT RECEIPT NO__ PERMIT APPLICATION FEE PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERI: ORMANCE/LABOR & MATERIALS $ CONSTRUCTION CASH DEPOSIT $ ~~.. PLAN CHECK & INSPECTION FE / ' for City Engineer ..- / ~ Date :\forms\pwp GENERAL PERMIT CONDITIONS 1. A CONSTRUCTION CASH DEPOSIT is required. Charges will be made against this deposit if there is an emergency call-out, overtin~ 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 wriuen acceptance by the City. 3. REFUND of 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. The Permittee MUST REQUEST IN WRITING a f'mal inspection and acceptance of the work upon completion. Accepumce by the City will be made in writing to the PermiRee. 5. MAINTAIN safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fh'e hydrants and water valves. 6. A CONSTRUCTION TRAFFIC CONTROL PLAN and a CONSTRUCTION SCHEDULE is required for ali lane closures, detours and street closures. This plan must be REVIEWED and APPROVED prior to any lane closures. 7. The CONSTRUCTION TRAFFIC CONTROL PLAN shall conform with 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. 8. REPLACE IIq KIND any damaged or removed existing improvements, including planting. 9. Sawcut for all PCC or AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improYements. I0. OVERTIME INSPECTION PREMIUM will be charged against the cash deposit for inspection required outside the hours of g:00 a.m. to 4:00 p.m. at the current overtime rate, minimum one hour charge. I 1. SATURDAY INSPECTIONS must be arranged in advance. Saturday inspection time is charged at the current overtime rate with a three hour minimum. Advance payment for the estimated time is required. 12. Adequate signing and lighted BARRICADING is required on the job site. Failure to provide such signing and barricading may result in the City's renting such signing and barricades and charging the cost (including all labor and materials) against the cash deposit. I3. 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 consmiction. Contractor or Perminee 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 propert3, 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. Ig. This permit is NOT TRANSFERRABLE. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 19. CALL BACK (call out) due to emergencies 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 S, anta Clara Valley Nonpoint Source Pollution Control Program. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above conditions. Applicant ate j:\fonns\pwperm2 6/96 INCORPORATED No. 354355 80 Casey Street · Gilroy, CA 95020 · E-mail: farotte@garlic.com Bus. (408) 847-3200 GORDON E. FAROTTE. JR. FAX (408) 847-1015 Res. (408) 842-2432 PUBLIC WORKB ADMINIBTRATION_ Rick Babcock Superintendent genconcal@aol.com 800 Cristich Lane Campbell, CA 95008-5406 (408) 879-1680 FAX (408) 879-1686 Pager: (408) 697-1916 Scott MacDonell 800 Cristich Lane Superintendent (- ( ~_1_ Campbell, CA 95008-5406 (408) 879-1680 t~f:j% ,.;~-ct\- ~.~\ FAX(408)879-1686 genconcal@aol.com Pager: (408) 989-8088 DIOCESE OF SAN JOSE VICAR GENERAL February 8, 2(,01 City of Camp~ ell Attn: Mr. Gon tez 70 North l~t S feet Campbell CA I5008 Dear Mr. Gorrlez, RECEIVED PUBLIC WORKS ADMINIB?RATION The enclosed "afficial" check dated February 07, 2001 and drawn on the Wells Fargo Bank to the order of the Cji y of Campbell is to be held by the City of Campbell in lieu of the required Performance mtd Labor and Material Bonds for the offsite work at St. Lucy church. 2350 Winchester Bo' ~levard, Campbell, CA (permit #99-201). After the comp etlon and final acceptance of the offsite work the check should be returned to the Diocese of San Jose, 900 Lafayette Street, Suite 301 Santa Clara CA 95050-4966 to the attention of Charles Tul ~. ' Sincerely your in Christ, Rev. Msgr. Mic~a~et~J. Mitchell Vicar General , Encl. Cc; Mr. Ch4_rles Tully Farotte ~onstruction 900 Lafayette Street, Suite 301, Santa Clara, CA 950504966 (408) 983-0237 FAX (408) 983-0296 Reglaces Official C~ $¢0499072542 dtd 1/11/01 0499 11-24 Office AU # 1210(8) OFFICIAL CHECK Purchaser: ROMAN CATHOLIC DIOSESE Purchaser Account: 4460060635 Operator LD.: cu004235 PAY TO THE ORDER OF ***CIIT~Y OF CAMPBELL*** ***P ERM IT #99-201 ********************************* ***Seven thousand four hundred dollars and no cents*** WELLS FARGO & COMPANY ISSUER 420 MONTGOMERY STREET SAN FRANCISCO, CA 94163 PAYABLE AT WELLS FARGO BANK CALIFORNIA, NA FOR INQUIRIES CALL (480) 394-3122 NOTICE TO PURCHASER-IF THIS INSTRUMENT IS LOST, STOLEN OR DESTROYED. YOU MAY REQUEST CANCELLATION AND REISSUANCE. AS A CONDITION TO CANCELLATION AND REISSUANCE, WELLS FARGO & COMPANY MAY IMPOSE A FEE AND REQUIRE AN INDEMNITY AGREEMENT AND BOND. Purchaser Copy RECEIVED FEF~ ~ 0 PUBLIC WORKS ADMINISTRATION SERIAL #: 0499072610 ACCOUNT#: 4861-504900 February 07, 2001 **$7,400.00** VOID IF OVER US $ 7,40000 NON-NEGOTIABLE o,~o.^u# 12~o(8) ! OFFICIAL CHECK 0499072610 Operator I.D.: cu004235 PAY TO THE ORDER OF ***CIITY OF CAMPBELL*** ***PERMIT #99-201'******************************** ***Seven thousand four hL WELLS FARGO & COMPANY ISSUER 420 MONTGOMERY STREET SAN FRANCISCO. CA 94163 PAYABLE AT WELLS FARGO BANK CALIFORNIA, N.A FC~ INQUIRIES CALL (480) 394-3122 ,ndred doflars and no cents*** February 07, 2001 **$7,400.00'* VOID IF OVER US $ 7,400.00 CONTROLLER To: Finance Director Check Payable To: Address - Line 1: Line 2: City: Description: Account Number: Account Number: Account Number: (Finance Dept only) Total Payable: Purpose: Voucher #: Receipt #: Requested by: Approved by: Finance Dept Only: Verified by: Approved by: Special Mail As Is: X Return To: Other: R, fundable Deposit Check Request DIOCESE OF SAN JOSE 900 LAFAYE'I-rE STREET, SUITE 30 SANTA CLARA Refundable Deposit 101.2203 101.540.7448 Interest Earned State: CA Zip: 95050-4966 Amount: $1,900.00 Amount: Amount: (Finance Dept only) (Exact Amount) Maintenance period expired. Refund balance of maintenance surety. Permit #: 1999-201 137609 Date: 2/20/01 Alan Horn ~ Title: Sr. PW Inspector Date: 7/14/03 Michelle Quinney ~ Title: City Engineer Date: 7/14/03 Title: Accounting Clerk II Date: Title: Accountant Date: Instr'uctions For' Handlin Check Mail in Attached Envelope: Interim Check: Needed By: (Name) (Department) h:~permits~99-201 2350 winchster refund. Xcl(mp) To: Finance Director Check Payable To: Address - Line 1: Line 2: City: Description: Account Number: Account Number: Account Number: (Finance Dept only) Total Payable: Purpose: Voucher #: Receipt #: Requested by: Approved by: Finance Dept Only: Verified by: Approved by: Refundable Deposit Check Request DIOCESE OF SAN JOSE ATTN: CHARLES TULLY 900 LAFAYETTE ST., SUITE 301 SANTA CLARA Refund Deposit 101.2203 101.540.7448 Interest Earned State: CA Zip: 95050-4866 Amount: $5,500.00 Amount: Amount: (Finance Dept only) (Exact Amount) Refund 75% Surety Deposit ($7,400.00) Permit 0: 99-201 137609 ! Date: 02/20/2001 /, Alan Hom ~ Title: Sr. PW Inspector Date: Michelle Quinney ~',~j ~' Title: City Engineer Date: Title: Accounting Clerk II Date: Title: Accountant Date: 08/14/2001 08/14/2001 Specioi ]:nstructions For Hondling Check Mail As Is: Return To: Mail in Attached Envelope: Interim Check: Needed By: Other: (Name) (Department) h:\perrmts 99-201ckreq(mp) PUb -.C WORKS DEPARTMENT RECEIPT TO: City Clerk PUBLIC WORKS FILE NO. · '-"'~ ' -'-5~ ,%'~"c~ -'=-':_--~- -' PROPERTY ADDRESS Please collec& receipt tbr the following mollies: 435.535.4921 .... P'~{;i~i P/i,;i: ,He (specify proiect) ENCROACHMENT PERMIT 4722 Applicatiou ee No i-Utility Encroachmem Permit ($245.00) Mi ~or Encroachment Permit < $5,000 ($50.00) R- First Permit (No Fee) Subsequent Permit/Yr ($110) Uti ity Encroachment Permit Arterial/Collector Street ($355.00) Residential Street/Other Areas ($245.00) 2203 Plan Check £ eposit - 2 % of ENGR. EST. ($500 mtn) 2203 Faithful Peril rmance Security (FPS) (100% of ENGR.EST.) 2203 Labor and M terials Security (100% of ENGR. EST.) 2203 Monumentati ~n Security (100% of ENGR.EST.) 2203 Cash Deposit (4% of ENGR.EST.)($500 min/$10,O00 max) 2203 Labor and M: terial Security (100% of ENGR. EST.) Plan Check 8 Inspection Fee (Non-Utility) 4722 Er r. Est.< $250,000 02% of ENGR. EST.) ** 2203 Er LEst. > $250,000 (Deposit 8% of ENGR. EST./S30,000 min.)** 4722 Utility < $1(D,O00 (8%) Mil imum Charge Per Location ($130) Col dulls/Pipelines up to 500 Feet ($Z00) AN ve 500 Linear Feet ($1.25) Ma flmles/Vaults/Etc. ($115.00/ea) Poi Set/Removal ($115.00/ea) Sm et Tree Planting/Removal ($115.00/tree) ** 2203 Utility > $1£ ),000 Actual Cost + 20% ** 4722 Street Tree PI rating/Removal Permit ($115.00) 4760 Proiect Plans }. Specifications Proiect No. 4760 Standard Spec ifications & Details ($1/Pg $12.50/Bk) 4760 Copies of En ineering Maps & Plans Aerial Plot 24' x 36" ($45) Aerial Print 8 1/2~ x 11" ($15) Maps and Pla ~s 24" x 36' ($5) 4722 Penalties: Fat ~re to restore public improvements ($100/Calendar Day) (Muni C~le See. il 34.UlU) 4722 Penalties: Fa lure to correct unsafe conditions ($100/Calendar Day) LAND DEVELOPMENT 4722 Lot Line Adju ;tment ($600.00) 4722 Parcel Map (4 Lots or Less) ($1,170 + $25/LOt) 4722 Final Tract M tp (5 or More Lots) ($1510 + $25/Lot) 4722~ Certificate of ;ompliance ($545.00) 4722 Certificate of 7orrectmn ($330.00) 4722 Notary Fee (p :r signature) ($10.00) 4722 Vacation oI P~ blic Streets & Easements ($600.00) 4722 Assessment Se qregation or Reapportionment Firs Split ($600.00) Eacl Additional t.ot ($185.00) 4721 Storm Draina Area Fee Per Acre (R-I. $2,000) (Multi-Res, $2~250) (All Other, $2,500) 4920 Parkland Dedi :ation Fee (75 %/25 % Due Upon Cert. of Occupancy) 4965 Postage TRAFFIC 4728 Intersection TI rn Counts (Two-Hour Count/ ($65.50) 4728 httersection Tt rn Counts (a. m. or p.m. peaks) ($136.50) 4728 Traffic Flow lap (Daily Traffic Volumes) ($29.50) 4728 Campbell Trat 'lc Model (Full Scope Assessment) ($2,460.00) 4728 Campbell Trat 'lc Model (Reduced Scope Assessment) ($810.00) 4271 Truck Permit~ ($32.00/rnd trip) 4728 No Parking Si, iIls (SI/each or $25/100) OTHER I NAME OF APPLICANT **Actual Cost Plus 20% Overhead (14q/'i-lnt~rest bearingldeposit) - ~ ~ ,~. ~ · F t.........,l.o~:l .... ~ ,. ONIY~:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~ ~i~ i~::~: '::::': '54 ~~::::::::::::::::::::: ::::::::::::::::::::::::::::::::::::::::::: :':':~:~::::' :':'; ~: :':':'~:':': ~ ':" h:\lbrms\receiptfbrm00-01.xls rev 7~17-00 (rap) To: Finance Director Check Payable To: Address - Line 1: Line 2: City: Description: Account Number: Account Number: Account Number: (Finance Dept only) Total Payable: Purpose: Refundable I eposit Check Request GEN CON, INC. 800 CRISTICH LANE CAMPBELL Refund Deposit 101.2203 101.540.7448 Interest Earned State: CA Zip: 95008 Amount: $296.00 Amount: Amount: (Finance Dept only) (Exact Amount) Project complete. Refund cash deposit. Voucher #: Receipt 0: Requested by: Approved by: Finance Dept Only: Verified by: Approved by: Specia Mail As Is: Return To: Other: Permit 0: 99-201 126076 Date: 11/30/1999 Alan Hom Title: Sr. PW Inspector Date: 08/14/2001 Michelle Quinney . Title: City Engineer Date: 08/14/2001 Title: Accounting Clerk II Date: Title: Accountant Date: Instructions For HandlingCheck Mail in Attached Envelope: Marlene Pomeroy Interim Check: Needed By: Public Works (Name) (Department) Please return to Marlene in Public Works so a transmittal can be sent along with the check. h:\permits\99-201 ckreq gencon(rnp) TO: City Clerk PL .2 WORKS DEPARTMENT RECEIPT Effective August 1, 1999 PUBLIC WORKS FILE NO. PROPERTY ADDRESS & receipt for the following monies: ENCROAC}~IENT PERMIT 22031 2203 2203 2203 I 2203I 2203I 4722 I " 2203 En! 4722 Utility < $1( Mi: Co: Ab, Ma Poi " 22031 Utihtv > 4760! Project Plans 47601 Standard Spe~ 4760! Copies of En I Aerial P~ot I Maps and Pla 4722! Penalties: Fai 47221 Penahies: LAND DEVELOPMENT 4722 Lot L ne Adj~ Encroachment Permit Encroachment Permit < $5.000 :nt Permit/Yr Encroachmem Permit Arterial/Collector Street Residential StreetYOther Areas Hah Check ~eposit - 2% of ENGR. EST. Faithful Peri'~rmance Security IFPS) Labor and M~terials Security Monumentan~n Security Cash DeposoI Labor and M~terial Security Plan Check & htspection Fee tNon-Utility) En1 r. Est.< $250,000 ($236.25) iss0.0o) ($~05) (S341.25) ($236.25) ($500 rain) (100% of ENGR. EST.t (100% of ENGR. EST.) (I00% of ENGR.EST.) (4% hi ENGR.EST.)($500 min/$10,0OO max} (100% of ENGR. EST.) (12% of ENGR. EST.) 47221 Parcel Map (, 47221 Final Tract 47221 Certificate of 47221 Certificate of 47221 Notary Fee ( 4.722! Vacation of F 4722 i Assessment S I Ea¢ 4721 j Storm Drama 4920 Parkland Ded 4965 Postage TRAFFIC 4728[ Intersecuon 'I 4728! [mersecUon ] 47281 Traffic Flow 47281 Campbell Tr[ 47281 Campbell Tr[ 42711 Truck Perma 47281 No Parking OTHER I .lAME OF APPLICANT NAME OF PAYOR "Actual Cost Plus 20% Overhead CITY CLERKFOR ~C~ ONLY r. Est.>$250~000 (Deposit 8% of ENGR. EST./S30.000 rain,)" o,ooo (s%) imum Charge Per Location [$126) ,duits/Pipelines up to 500 Feet /SI.75/ft) ~ve 500 Linear Feet (Sl.15/ft) dloles/Vaults/Etc. I$1 IO.25/ea) Set/Removal ($I 10.25/eal et Tree Plauting/Removal (Sl 10.25/tree) 0.000 Actual Cost + 20% '* anung/Removal Permit (Sl 10.25) Specifications Project No. itications & Details (5 /Pg $12.50/Bk) meermg Maps & Plaits x 36' ($42) 2" x 11" ($15) 24" x 36' ($5) ute to restore public improvements ($100/Caiendar Day} lure to correct unsafe conditions ($100/Calendar Day) stment t$577.50) (Mulu Code Sec. I 1.34.nih) Lots or Less} ($1,125 + S25/Lot) ap (5 or More Lots) ($1.450 -r $25/Lot) Compliance ($5257 Correction t$315) er signature) ($I0) ablic Streets & Easements t$577.50} :gregation or Reapportionment t Split (S577,50) h Additional Lot ($178.50) ,,",rea Fee Per Acre ~R-i $2 1300) (Muhi-Res. 52,250) (All Other. $2.5(X)) cation Fee (75 %/25 % Due Upon Cert. of Occupancy) urn Counts (Two-Hour Count) ($63) uru Counts fa. re. or p.m. peaks) ($131.25) 'dap (Daily Traffic VolumesI ($28.35) ffic Model (Full Scope Assessment} (S2.362.50} t'fic Model (Reduced Scope Assessmem) ($777) iS36.75/tript gns (Si/each or 525/100) h:\forms\ecfrm4.xls rev, 7/13/99 (rap) City To: Finance Director Check Payable To: Address - Line 1: Line 2: City: Description: Total Payable: Account Number: Account Number: Account Number: (Finance Dept only) Purpose: Voucher #: Receipt #: 3mpbell - Refundable Deposit Check Request Diocese of San Jose 900 Lafayette Street, Suite 301 Santa Clara Refund Deposit $500.00 101.2203 101.540.7448 Interest Earned Refund Plan Check Deposit 121121 Req ue sted by:~ ~'~_~,,,~ ~~ C :ru,~ Approved by: Finance Dept Only: .ill..,,~,s Verified by: Approved by: State: CA Zip: 95050-4966 (Exact Amount) Amount: $500.00 Amount: Amount: (Finance Dept only) Title: Title: Title: Title: Permit #: 99-201 Date: 05/1811999 Assistant Engineer Date: Date: Land Dev. Mgr. Accounting Clerk II Date: Accountant Date: Speciql ]:nstructions heck Interim Check: Needed By: Public Works/City Hall (Department) Other: Mail As Is: Return To: Mail in Attached Envelope: Joanne D'Ambrosia (Name) 07~26~2000 07~26~2000 f/n: Forms/excel/chkreq Revised 02/00 ~JBLIC WORKS DEPARTMENT RECEIPT TO: City Cled~ PUBLIC WORJ~ fiLE NO. PROPERTY ADDRESS Plc~s~ collect & 1 =c~ipt for li~ foll~I ma: ACCT. ITEM :::: :: :::::::: :::::: ::: ::::: :::-:: :::: ': ::::: :::~:: ':::: ::: ::::::::::::::::::::::::::::::::::::::::: 435.5354921 I Project Revenue speci~.v i~o~ct ) ENCROACHMENT PERMIT 4722 Application Fee -I llnt Peri. it (No Fee). Sub~-nt Petmib'Yr tility Encmadunent Permit Anerial/Colleclm' Sleet R~idenfial Sm~t~3tbor .a~eas ($225) 2203 Plan C~eck Dope ~it - 2% of ENGIL EST. {S$00 mia) 2203 1 Faiint'ul P~,'om~l ace Secu~ty (FPS) 2203 Labor and Maten ils Security (100% of E~qGR. EST.) 2203 ,Monumenmtion .~ ~unty ( 10iP/. o1' ENGR. EST.) 2203 Cash Deposit (4% of ENGR-EST. X$500 min/$ I 0,000 max) Plan Chcck& Ins ~ection Fee (Non-Utility) 4722 rlgt. Es~ < ~2~0,0~O (12%of ENGR. EST.) oo 2203 r~.EsL>S250.000 (Deposit g*/. of ENG1L EST./S30.000 min.)** 4722 Utility < $10o.0o llnimu, m CIm~o Pet Lo~ation {$1201 onduiu/Pipelines up to 500 Feet bore 500 Feet ($1. lOAN.) [anholes~aults/Et~. ($105/ea) )lo Set/Removal ($105lea) ~ Tree Ptantln~ff. emoval 476~1 Copies or' Engine :rin$ Maps & Plans 4722 F~n&l Tract Map ( ~ or Mom Lots'~ (SI.380 + 477.2 Assessment Se~n ~nfion or R~al~t'oonment rs~ Split ($550) (Multi-Res, $2.2~0) (All Other, TRAFFIC 472! C~mpk-!! Trnl~¢ Model (Roduc~ Scope Assessment) 4271 Track permiu ($35/trip) ADDRESS ZIP J . · REc_IVED /_ _/ 1 g 1999 h:~ftm4(exc~mp(mv I/'~9/) Da~e/' Initiab : :J CiTY OF CA~P~.r., L, C~ ~',CC Ki,.TD~O?T~, CITY OF ......... ........ .' ;..ii FmL"(:'i'~D T DT T i'i~ AYi'IiiUT TilTAi TdIC, 4~".1-'~ AA · i':"9~. AA August 17, 2001 Gen-Con, Inc. 800 Cristich Lan Campbell, CA Re: Permit Locatior Gentlemen: The City of Car and finds the wI Enclosed is you If you have que Sincerely,,-, Alan Hom Sr. Public Wort Enclosure HSpemfits\99-201 fina CITY OF CAMPBELL Public Works Department le ~5008 [o. 99-201 2350 S. Winchester pbell has made a final inspection of subject Public Works improvements ~rk to be acceptable and in conformance with City standards. Bond for Faithful Performance and Bond for Labor and Material. tions, please contact me at (408) 866-2168. :s Inspector gencon(mp) 70 North First Street . Campbell, California 95008-1423 . TEL 408.866.2150 . F.z,X 408.376.0958 - TDO 408.866.279O BOND NO. 11133463122 -~EMIUM INCLUDED IN PERFORMANCE BOI~, 'OR LABOR AND MATE.RIAL ~ND We tl~ ~xl~r$igI~d GEN-CON, INC. , THE AMER1G.A~ i~u~ .. for ~ ~ent of w~ch ~ ~ obh~ o~elves ~ o~ s~:~ ~, J a ~e ~ co~ c~y of w~h is p~y on ~ ~ ~ ~by re~ed m [ md ~ a ~ ~f, ~ - co--ct ~ ~: ST. LUCY S CHURCH ~CTIVITY CENTER ~ ~DITI0N .. subcon=~cmrs s~l f~I :o pa~ for =y ~s, o~ o~er s~phes, or ~r will pay for ~e ~bt, ~ ~ ~ ~ ex~ing ~ s~ ~[e auomey's f~ m ~d by ~ ~. THE ~ERIC~ .... ~EN CON, INC ~OW, me~to~e, we, - , : - --, ~ ' ********************* obligated to ~e C]W of C~p~l, in ~c sum of S SgVEN ~OUSAND FOUR HUNDRED & ..NQ/_ _ __ · lawful mopey of thc United Sm'~s, fm the paymm~ of which mm~ will ~ n'uly m be made, we ~hc said Principal and Sm~ety bind ourselves, successors and assi~ :s, jointly a~ severally, by these provisions. Thc condition of this ,Ibligafion is g~at if Prir~ipal, im successors or ~sig~. or im subcon~acmr, or subcontractors, shall fail to pay for any labor, rn,~el ials, or other supplies, used in r.~ performance of r.~ work contractual to be done, or for amotm~ due trader r. be uaemploymem i~ mrance icl with respect m this work or labor, then r. he Surety on this bond will pay for ~hem, in an amoun~ ~ot cxceediag th~ sum ~ecified in this bond, and in care suit is brought upon ~ bond will also pay a reasol~able av~n~'s f~'e. to be f~,ed by r. be courL No prepayment or del y in payment a~l no chaag~s, extensiora, addition or alu:raion of any provision of said Coawact or in any plans ~md specifi~dons ~ efcrred I~ herein, and no fo~ on the part of the City sh~ll opcrat~ r~ release thc Sur~t~ from liability on this bond, and cons :nt to make such almrations without furor n~dcc m or consent by thc Surcty is hereby given, ~ the Surety hereb~ waives ~h~ pr ~visions of Seer. ion 2819 of the Civil Code of tl~ S~ate of California. have execul~ithis agreemenI asof NOVEMBER 22 ,19 99 In ~,imess, r~e l~v~ies (A~ac_h_ Aclmowledgemea~) (Both Principal's and Sure~'s Anomey in Fact) (j :\word\forms\l&mbond) By.._ _...~ A1 Inz'o~ateg/~, President . BYF~ Add~OfS~:l ~ET ~ ST., TOWER 10TH SAN F~CISCO, CA 94105 S~cV'~ ~nd N~r 11133463122 (Accomp~ ~ ~ wire Auo~-in-facfs c~fied [o ~lu~ ~ ~e of ~e bond.) State of California County of Santa CI ara before me, On ll/22/99 DATE personally appeare¢ [] personally kno to be the person(s) to me that he/she/th her/their signature(." person(s) acted, exE WITNESS my hand Signature of Notary Though the data belo~ could prevent fraudul( CAPACITY CL [] INDIVIDUAL [] CORPORATE Paula Mohr, Notflr¥ NAME, TITLE OF OFFICER - E.G., "JANE DOE, NOTARY PUBLIC" TITL [] PARTNER(S) E E [] ATTORNEY-IN-FAC [] TRUSTEE(S) E] GUARDIAN/CONSE [] OTHER: A1 Anzoategui NAME(S) OF SIGNER(S) vn to me - OR - [] proved to me on the basis of satisfactory evidence vhose name(s) is/are sUbscribed to the within instrument and acknowledged ;y executed the same in his/her/their authorized capacity(les), and that by his/ on the instrument the person(s), or the entity upon behalf of which the :uted the instrument. tnd official seal. OPTIONAL ' is not required by law, it may prove valuable to persons relying on the document and ~nt reattachment of this form. ~,IMED BY SIGNER LIMITED GENERAL CER --(s) DESCRIPTION OF ATTACHED DOCUMENT TITLE OR TYPE OF DOCUMENT NUMBER OF PAGES DATE OF DOCUMENT :RVATOR SIGNER IS REPRESENTING: NAME OF PERSON(S) OR ENTITY(IES) SIGNER(S) OTHER THAN NAMED ALL-PURPOSE ACKNOW..,EDGMENT before me, Danij ela L . Mosunic ' On NOVEMBER 22, 1999 -- ~ ~ ~ (NOTARY) personally appeared Francis_~E~' Cook SIGN~ER(5) ~ personally krown to me - OR- [] proved to me on the basis ofsatisfactc,-- evidence to be the person(x,.) whose name · is~R~ subscribed to the within instrument anu acknowledged to me that he/~}'~I:~ executed the same in his/'t:t:ex/Xl~tq- authorized capacity(}t~, and that by his/~x/Xl, l~il- ........... signature(~) on the instrument the person(~, ~/..e'~"_ "~m{k~Nk/l~[/l I., ~0SlJt~C .t or the entity upon behalf of which the ~ .... '. ~'2a'~5~?~ fi. person~) acted, executed the instrument. WITNESS my hand and official seal. OPTIONAL INFORMATION The information below is not required by law. However, it could prevent fraudulent attachment of this acknowl- edgment to an unauthorized document. CAPACITY CLAIMED BY SIGNER (PRINCIPAL) DESCRIPTION OF ATTACHED DOCUMENT ~ INDIVIDUAL ~ CORPORATE OFFR:ER LABOR i MATERIAL BOND ~~ ___ TITLE OR TYPE OF DOCUMENT [] PARTNER(S) ~, A~FORNEY-IN-FA£ T ~ TRUSTEE(S) ~ ~ ~ GUARDIAN/CONSE ~VATOR [] OTHER: __ ___ ~ .... NOVEMBER 22, 1999 SI(;NER IS REI RESE~TING: OTIIER ,______. __.__.__.__. __.__._t 4 VALLEY-SIERRA, 800-362-3369 BOND NO. 11133463122 PREMIUM: $100.00 "Contractor ') anti __THE of the State of NEW California. as Surety, are of thc S~.ate of Calitbrnia Dollars ($ 7,400. jointly and .severally by Tim cot~ition of Because the obli Contra~t with the City construction of Project BOND FOR FAITHlzUL PERFORMANCE GEN-CON, INC. , (hemhmRcr AMERICAN INSURANCE COMPANY ,. , a corporation organized muter the law~ JERSEY , ~d ~rmed to tr~t b~iness in tim Sram of obligated ~ ~e CiW nf C~pbcll, (hcrei~ec "Ci~") a municip~ cu~orafion u~r ~e laws , in ~ sum of SEVEN THOUSAND FOUR HUNDRED DOLLARS & ~*~) tbr ~e ~yment of w~ch s~ we oOliga~ o~selves ~d ~r succ~rs ~d msigm, tbllowing provisiom: Now, thcrek~r:. and contca~t documents d~ wi~ or wight notice ~o I ~lly i~et~ and ~ve k and s~ll reimb~c ~ ce obIigation s~l ~ void; o ~rtbn~anee of fll of Corn If any legal actio uxx~r the Contract excludi of Santa Clara. State of C; time. alteration or acrmmpanying it shall in change, extension of time. tl'~reby wmves the pmvisi~ In witness, the pa (Attach Acknowledgements (Bo~ Principal's and Sumty's Attorney in Fact) 0: ~forms\fpbond) (rev his obligation is: ar ~e ~oj<t. a copy of which con,act is a~hed ~d m~ a pm or' this ~nd. tbr ST LUCY'S CHURCH ACTIVITY CENTER & ~DITION if the Contractor shall faithfully pertbrm the work in accordanca with the plans, specifications tring the original tern. and any gxrcnsiom of the contrac: which may he granted by the City. he surety, and if it shall satisfy all claims 'and demands incurred under thc contract, and shall u-mless the City from all costs and damages wlfich it may suffer by reason of failure to do my the City all outlay and ex. nsc which the City may incur in making any dePault, then mis herwi~ to remain in full forvaa and effect, with surety obligated to secure the full and faithfial factor's obligations under the attached contract. a be filed upon tiffs bond. it shall be filed within one year after final payment has been mar~ ag the warranty ~ri~, if any. provided tbr in tim Contract. and venue shall lic in ~ County difurnia, and that surety, tbr value received stipulates and agre~ mat no clmnge, extension of I to thc terms of the Contract or to the work m be performed under it or thc specifications my way affect its obligation on this boner, and it cloes by this means waive notice of any alteration or addition to tl~ terms of the Contract or to the work or to the specifications, and ,ns of Section 2819 of the Civil Code of the Stat~ of Calitbrnia. tries have executed this agn:emem as of NOVEMBER 22 , 19 99 ~9) (Pnnmpal) G~N-~ INC. _ ~ A1 Anzoa~te~{~, President (Surety) / A / By . FRANCIS E.~RNEY-IN-FACT ^ddz~a,~o~Sur~l MARKET S~ ST., TOWER SAN FRANCISCO, CA 94105__~-.<... Surety's Bond Number 11133463122 (Accompany this bond with Attomey-in-t'act's authority from Suzety to execute the bond, certified to ir~lude the dam of ~¢ bond.) 10TH FLOOR BOND NO. 11133463122 FIREMAN'S FUND INSURANCE COMP/ ': NATIONAL SURETY CORPORATION ASSOCLATED INDEMNITY CORPORATION THE AMERICAN INSUILa. NCE COMPANY AMERICAN AUTOMOBILE INSURANCE COMPANY GENERAL POWER OF A~I'WO RN EY KNOW ALL MEN BY THESE PllESENTS: Thal FIREMAN'S FUND iNSURANCE COMPANY, a California corporation. NATIONAL SURETY CORPORATION. an {liinois corporation, THE Ai'4ERICAN INSURANCE COMPANY. a New Jersey corporation rcdomcsticalcd in Nebraska. ASSOCIATED INDEMNITY CORPORATION, a California co'poralion, and AMERICAN AUTOMOBILE INSURANCE COMPANY, a Missouri corporalu, m. (herein collect;vel} called "thc Companies") docs each hereby app,,iht Ronald G. Speno and Francis E. Cook, Cupertino, CA Iheir true anti lawful Attc, rney(s)-in- ::acl. with full power of authori!y hereby conferred in their name. place and stead, to execulc, seal, acknowledge and rich', cr any and all bonds, undcrlakings, recognizances 3r other wrutcn obligations in thc nature thcrcol .................................................................. and to hind the Companies thereby:; fully and lo the same extent as it' such bonds were signed bv the Prcsidcnl, scaled with Iht corporate seals ol Iht: Companies and dui.,, a'.tcsted by thc Companies' Secret~r' hcr~b.',' ralil5"ing and confirming all that thc said Attorney(sS-in-Fact may do in the premises. This ~ower of attorney is granted ~der and by t~e aulhoritv of Article VII of the By-laws of FIREMAN'S FUND INSURANCE COMPANY. NATIONAL SURETY CORPORATION, TH'E AMERIC~ N INSUR.3, NCE COMISANY, ASSOCIATED INDEMNITY CORPORATION and AMERICAN AUTOMOBILE INSURANCE COMPANY which provisions are n(w in full force and effect. This power of attorney is signed a~ d sealed under the aulhoritv of the following. Resolution adopted by the Board of Directors of FIREMAN'S FUND INSURANCE COMPANY, NATIONAL SURETY CORPORATION, THE AI~'IER[CAN INSUIS, j~,NCE COMPANY, A~SOCIATED INDEMNITY CORPORATION and AMERICAN AUTOMOBILE INSURANCE COI'IPANY at a meeting duly called and held. or bv written consent, on the 19th day of March, 1995, and said Resolution has not been amended or repeaied: "RESOLVED, that the s cma utc o- an,,' Vice-President Assistant Secretary. and Resident Assistant Secretary of thc Companies, and thc seal of Companies may. be affix~ :d or printed on any power of attorney., on any_ revocation of any power of atlomev, or on any. cert ficate relatm,z~ thereto, y facsimile, and any powe~ of attorney, any revocation of any power of attorney, or certificate bearing such facsimile signature or facsimile seal shall be valid and binding upo the Companies." raisin WITNESS__,.)oWHEREOF,day of the C eptember'npanies have caused thes~9~r~scnts, to be signed by their Vice-President, and their corporate seals lo be hereunto affixed ...,'."~,?t.tl!..~o',~".5 NATIONAL SURETY CORPORATION ...- x..?-;.--;":-,., c -~ _,- ,,.: .... ;~ ~ THE AMERICAN INSURANCE COMPANY f<' ~ ~] ,: ~,.... __ .... ~,.~: AMERICAN AUTOMOBILE INSURANCE COMPANY By STATE OF CALIFORNIA l is. COUNTY OF MARIN On this 22 da5,' of ;eptember 1998 , before me personally came M.A. Mallonee to me known, who, being by me duly sworn, did aepose and say: that he is a Vice-?resident o{~ach company, described in and which executed the above instrument; that he knows the seals of the said Companies; that the seals affixed to ~e said instrument are such company seais: that they were so affixed by order of the Board of Directors of said companies and that be signed his name thereto by like orde~ IN '_.,VI~TN E__SS~WH~ERE__OF~, I L G~.,g~P©"have k ereunto set my handl, and affixed my official seal, thc day and ),ear herein first above v,,ritteni.~..~ ~ ! ~'?"'"'TiKS, Commissior~ # 116.3726 ~ ~'~ Notary Pubik:- Ca!ifomia ~. ]] ..... ~/WY_C'~_m~.FD~ mN°v2S'2001t_ _ -- -- CERTIFICATE ~, 7h~':~rl~: ~;;dent Assi~tlSecrctaD' of each company, DO HEREBY CERTIFY that the foregoing and attached POWER OF AT'I?.R,N. EY, re.mares in full force and has not been revoked; and fi~r~her~nore that Article VII of the By-laws of eacl'~ company, and the Resolution of the Board of Directors; set £orm tn me rower of Attorney, are now in force. ! Signed and s~aled at the County of Mnrin. Dated the 2 2ND day of 'NOVF, M'P,I~,R , 19 9 9 . ............... ~,,"~,, ...... 7.,, " ........ --:.Xi :.'....= =-~'- ~...,%,?/01/Is.,x~,,,e. Rmttenlt A.s~istant Secn:taty 360789-11-98 State of California County of Santa Clara OR 11/22/99 DATE personally appeare~ [] personally knc to be the person(s) to me that he/she/th her/their signature(~ person(s) acted, ex, WITNESS my hand Signature of Notary Though the data belov could prevent frauduh CAPACITY CL I-'} INDIVIDUAL [] CORPORATE OFF CER TiTLE(S) [] PARTNER(S) E] LIMITED E'] GENERAL [] ATTORNEY-IN-FA(:T [] TRUSTEE(S) [] GUARDIAN/CONS E ;RVATOR F'] OTHER: SIGNER IS REPRESENTIi4G: NAME OF PERSON(S) OR. ENTITY(lES) before me, A1 Anzoategui wn to me OR - [] Paula Mohr, Notarv Public NAME, TITLE OF OFFICER- E.G., "JANE DOE, NOTARY PUBLIC" NAME(S) OF SIGNER(S) proved to me on the basis of satisfactory evidence ~vhose name(s) is/are sUbscribed to the within instrument and acknowledged executed the same in his/her/their authorized capacity(les), and that by his/ on the instrument the person(s), or the entity upon behalf of which the .~cuted the instrument. OPTIONAL PAUL,'A. I~?!'!R ~ Comm. ,,10... ' '} I,"} and official seal. not required by law, it may prove valuable to persons relying on the document and reattachment of this form. DESCRIPTION OF ATTACHED DOCUMENT TITLE OR TYPE OF DOCUMENT NUMBER OF PAGES DATE OF DOCUMENT AIMED BY SIGNER SiGNER(S) OTHER THAN NAMED ABOVE ALL-PURPOSE Ai~KNOW~.dDGMENT ~-, NOVEMBER 212, 1999 on ................. _ before me, Danij ela L . Mosunic (DA[[ 12) (NOTARY) ~ personally k~own to me -OR- [] proved to me on the basis ofsatisfactc / evidence to be the person(70 whose name / is~l~X subscribed to the within instrument anu ] ac~owledged to me that h~~ ex~uted / the same in his~~ authorized ~---~', ....................... ~ capacity(~, and that by his~~ -~ ~ DANIJELAcomm. IL'I239569M0SUNIC ~ signature~), on the instrument the person(D, ~~ NOTARYPUaUC.CALIFO,NIA ~ or the ennty upon behalf of which the Sama Cla~a County ' erson ' ) K~/ .... ~ p IT~SS my hand and officml seal. / edgment to ~ :~:;i:e:d d~ument. ~e information ~low is not required by law However, it could prevent fraudulent attachment of ~s ac~owl VA rS) I ~ GUARDm~CONSERVATOR ~ ~OTHER: ~ NAME THE ~RICAN INS~CE CO.ANY .............. ~ER ~,..\ ! ,.4 V,\Li.EY-SIERRA. 800-362-3369 City of Campbell Public Works Dept-Eng 70 N 1 st Street Campbell, CA 95008 l~he American Insm Bond No. 11133 neering Date: November 9, 2000 PUBLIC WORK~ mce Company , Surety upon a certain Permit Bond t63122 , dated on or about NoYember 22, 1999 in your favor, in the amount of covering hereby notifies you that it has ele cancellation/termination to becor This notice is given to yo Seven thousand four hundred and no/100 .............................. Dollars ($ GEN-CON, INC. :ted to cancel/terminate said bond in its entirety ae effective Thirty (30) days after receipt of this notice. in accordance with the cancellation/termination provision in said bond contained. 7,400.00 ), Reply To: Fireman's Fur P.O. Bc San FranciSco Ad~ The American Insurance Com.p~ny Surety Clarette McDonald Attorney-in-Fact Insurance Company CC: Principal 193136 h-ess CA 94119'3136 City State ZiP CC: R. G. Speno, Inc. 18900 Stevens Creek Blvd., Suite 200 Cupertino, CA 95014 360034-8-71 (Rev.) A CORD,,, PRODUCER C±±ent~: 42264 FAROTCONS CERTIFIC,' ?E OF LIABILITY INS RANCE Construction Unit ABD Insurance & Fin~ 305 Walnut Street Redwood City, CA 9, INSURED Farotte Construction 80 CaGey Street Gilroy, CA 95020 COVERAGES THE POLICIES OF INSURANCE LISTED ANY REQUIREMENT, TERM OR CONE MAY PERTAIN, THE INSURANCE AFFO POLICIES. AGGREGATE LIMITS SHOWN 2NSR LTR TYPE OF INSURANCE A GENERAl. LIABILITY X COMMERCIAL GENERAL LIAB ILFFY CLAIMS MADE X OCCUR GEN'L AGGREGATE LIMITAPPLIES PER: DATE (MM/DD/YY) 02/26/02 POLICY X PRO- JECT LOC B AUTOMOBILE LIABILITY X ANY AUTO ALE OWNED AUTOS SCHEDI!LED AUTOS X HIRED AU'FOS X NON-OWNED AUTOS GARAGE LIABILITY ANY AUTO EXCESS LIABILITY X OCCUR ncial 063 2o., Inc. C THIS CERIllqCATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 'CUS225451 CLAIMS MADE Services INSU~RS AFFORDING COVERAGE ~NSURERA:Greenwich InSurance Company INSURERB: Employers Insurance of Wausau INSURERC: Westchester Fire Insurance Company INSURERD: State Compensation Insurance Fund INSURER E: EELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIN( ITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED O[ ~.DED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OFSUCI~ DEDUCTIBLE RETENTION HAVE BEEN REDUCED BY PAID CLAIMS. POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE IMM/DD/Yy) DATE (MM/DD/yy) EC000130202 03/01/02 03/01/03 LIMITS EACH OCC/JRRENCE FIRE DAMAGE (Any one fire) MED EXP (Any one person) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS -COMP/OP AGG 03/01/02 03/01/03 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 $100,000 $5,000 $1,000,000 $2,000,000 $2,000,000 SCZ91543224032 BODILY INJURY (Per person) R E C EIVED:,,OD,LY iNJURY (Per accident) $1,000,000 FEB 2 ? 2,1~.~ ADMINISTRATION~ 03/01/02 03/01/03 PROPERTY DAMAGE (Per accident) AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EACH OCCURRENCE AGGREGATE ,$ D WOR[ERS COMPENSATION AND 0461014002 01/0i/02 0i/01/03 XWC STATU OTH- ITORY LIMITS . EMPLOYERS'LIABILITY WAIVER OF SUBROGATION: AS RESPECTS WORKERS' COMPENSATION AND EMPLOYER'S LIABILITY, THE RIGHT OF SUBROGATION IS HEREBY WAIVED. OTIIER ER E.L EACH ACCII)ENT '~1, 0 0 0, 0 0 0 E.L.DISEASE -EAEMPLOYEE[$1t 000 t 000 E.L. DISEASE POLICYLIMITi$I, 000, 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES~XCLUSIONS ADDED BY ENDORSEMENT/SPECIAl. PROVISIONS Re: 2350 S. Winches:er, EP 99-201. The City, the City of Campbell Redevelopment Agency additional insureds , per endorsements att, (See Attached Descri' CERTIFICATE HOLDER aDDrr its officers, employees and volunteers are named as ts respects general liability and automobile liability tched. )tions) )NAL ~NS URED; ffqS URER LETIER: City of Campbell Attn: Public Works Department 70 North First Street ~ Campbell, CA 95008 ACORD25-S(7/97) l of 3 #S371957/M371921 CANCELLATION Ten Day Notice for Non-Paymen{. S IIOUED ANYOF ~HE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE TIlE EXPR'IATION DATE THEREOF, TIlE ISSUING INSURER WILL~i~JC-~i[~II~3~i~3 0 DAYS WRIT1EN NOTICE TOTHE CERTIFICA1E ItOLDER NAMED TOTtlE LEFT, FAROTCONS JTH 0 ACORD CORPORATION 1988 If the certificate h( on this certificate If SUBROGATIOIX require an endors holder ill lieu of IMPORTANT ,lder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. A statement Ioes not confer rights to the certificate holder in lieu of such endorsement(s). IS WAIVED, subject to the terms aud conditions of the policy, certain policies may :ment. A statement on this certificate does not COlffer rights to the certificate ~ch endorse~nent(s). DISCLAIMER Tile Certificate of l the issuing insurer( affirmatively or ne lsurance on the reverse side of this form does not constitute a contract between ;), authorized representative or producer, and the certificate holder, nor does it atively amend, extend or alter the coverage atlbrded by the policies listed thereon. ACORD25-S(7/97) 2 of 3 #S371957/M371921 DES ~,IPTIONS (Continued from Pz 1) PRIMARY INSURANCE: IT IS UNDERSTOOD AND INSURANCE MAINTAINED NOT CONTRIBUTING WIT AGREED THAT THIS INSURANCE IS PRIMARY AND ANY OTHER BY THE ADDITIONAL INSUREDS SHALL BE EXCESS ONLY AIND H THIS INSURANCE. AMS25.3(07/97) 3 of 3 #S371957/M371921 ~Y: Greenwich Z~u~ THIS' ENDORSEMENT ENDOESEMENT # -- . :.' : _? . ]':;-: . ' .. ThiS:enCJOr~amel!~ effeu-'tive 1Z;01 a.m.,'-March 1, 20.02, fha'ns a. part.of N°'' G 'COOO 302 ssU.d', ' '"' -' 'I '::"' '. .-:.; ......... --,'.:. ' .a~ce Company :HAN.GES'THE.P'oLIcY:' PLEASE' READ IT CAREFULLY. -AUTOMATIC ADDITIONAL INSUREDS' This endorsement modifies insurance provided under the following:: ' COMMERCIAL G'ENEP,~'~'L'~IABILI~ COvERAGE'FAR'r;:!::.,:.:".",.'., ..,:; ::'.'.. : .."".- P RODUCTStCOMPLET The fC~llowing provision '5. Any ant · '.. (the "Ac · work" fc corlnec' 'b. F_.D OPEP. ATI'ONS. LIABILITY COVEP,.AGE PART .. . ~.i.i,,,..-'.':.-.. ': ~ ".!": ~"..~.: ..,:..~ . . ' ..... -' ' ,.." -. "added to (SeCtion II);:ii:W~J:l~'~. In~U:~d; ;i': i.:...:........~: ;........' . i".":"::.'].i .?::..-. · .... .... :...:,. fy'you are i%~ired in a written contract (~the Contact") to name as an.insured' ditiona. Insured") is an insured but.' only.w!~h respect to liability arising out of you, r ~ the ·Additional Insured; or'acts 0fi3mi-~:~i°ns of the. Additional Insured in 7.. '"':-L': :- ion With the.general supervision' of "yaur.~ork".to the extent'set forth ~)elow: '" The.'~imltS o~.lnsurance provided fo~ the. Add.iti~nal insured.shall not be gPeatar; ,;..':.:-... than those· required' b~ the contraCtarid, in:no event;."'shall the. Limits'of'Insurance .... ~:.? be increased, by the contract.' ::.' ......:" .... " ' ..... :' '!ii' ':.." ~ ' '..:.: :../ · "'.- ' :"~' "~ .":':,?:. !',',:i ::: ..... : ':~ '" ' ' All insuring.agreemen~s,.'exclusions,'terms arld"con-ditions of. the Po cY'.sh.a I',.i';!:'/i?:;:.. · ~" .' apply to the coverage(s) provided, to: the, Addition al .insured, and such coverage:: :., shall not be enlargec~ or expanded by,: reason of'tee contract, In'u "'or"PropertyDamage" occurring after' ':," "Bodily j ry.... ......... . . -.......{! ...:'.' ::' . ' ~'~].~ d.':.c' .-'".'" .!:. '.'?.:..: (1).' Ail"Wo~;k on the Project.:(other. th~-'~ se~jca; 'main[enance or repairS)to be. performed, by, or'ori behalf.'to'.the.'Additional Insured(s)at the.site:of.the., ..: ~ coVe~ed 'ol3efations has:been completed; or ~i::...':~:., "'"'i-!.:: '" (2).- Tha't'~brtion of '!you~.wOrk~ out'Of Whi~h' ('h~qnjury or damage arises has been put to its' intended U~e: by any. p~rsan, or Organization. other than.f;..J" '. another con~ractor or subcontractor engaged in .performing operations for a principal as. a'partofthe;same project .... ".:. .~ .: With respect to.AdditiOnal Insureds who are architects, engineers or'surveyors, this insurance does not apply to "Bodily Injury" "Property'Damage", "Personal InjUry, or "Ad~/ertising injury" arJsing'outof the' rendering of or the.failure to render any professional serviCes, by or for you, 'including: (1)' The preparing, approving, or failing to .pre~3are or approve maps, drawings, opinions, repo~, surveys, change orders, designs, or specifications; 'and (2) Supervisory, inspection or engineering services. GENL115 (7/99) Page1 All other terms and con~ Any coverage providecl hereun~ler shall be excess over an>, other valid and collectible insurance available to the Additional Insured(s) whether primary, excess, contingent 'or on any other basis unless a contract specifically requires that this insurance be primary or you request that it apply on a primary basis. titions remain the same. (Authorized Representative) GENL1 15 (7/9g) Page 2 POLICY NUMB] THIS This endorsemen iR: ~SCZ91543224032 ;NDORSEMENT CHANGES THE POLICY. CAREFULLY. ADDITIONAL INSURED modifies Insurance provided trader the following: BUSINESS AUTO COVERAGE FORM BUSINESS AUTO PLEASE READ it is agreed that the '"¢Fno Is An Insured" provision is amended to include as an insured the person or orgam ;ation designated below as an additional insured, subject to the following provisions: (1). This into trance applies only with respect to any Liability arising out of the operation of covered autos on the additional insureds premises described below: (2). The Nar ~ed insured is authorized to act for such additional insured in all matters pertainir g to this insurance, including receipt of notice of cancellation: (3). Return l:remium, if any, shall be paid to the Named Insured: (4). Nothing contained herein shall affect any right of recovery as a claimant ;vhich the addition: tl insured would have if not designated as such. City of Campl)ell Attn: Publi.; Works Department 70 North First Street Campbell, CA 95008 Re: 2350 S.!Winchester, EP 99-201. The City, the City of Campbell Redevelopment Agency, its officers, employees and volunteers are named as additional insureds as respects automobile liability. C4ient~: 42264 FAROTCONS CDAD CERTIFICA..= OF LIABILITY INSUI-... NCE I DATE (MM/DDIYY) 03/Oi/Oi PRODUC.';R Construction Unit ABD Insurance & Fina 305 Walnut Street Redwood City, CA THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ncial Services ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 0 63 INSURERS AFFORDING COVERAGE INSURERA:Greenwich Insurance Company Co. , Inc. ~RERB Employers Insurance of Wausau l~NSURERc:Fireman' s Fund Insurance i,NSURERD:State Compensation Insurance Fund I i INSURERE: THE POLICIES OF INSURANCE LISTED B--LOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR COND ]-ION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFOR ::)ED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN tv AY HAVE BEEN REDUCED BY PAID CLAIMS. INSURED Farotte Constructior 80 Casey Street Gilroy, CA 95020 COVERAGES ILN~RR[ TYPE OF INSURANCE ' POLICY NUMBER A ~,.G, ENERAL LIABILITY GEC 000130201 ' X' COMMERCIAL GENERAL LIABILITY CLA'MSMAOEi_X OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: / 1 POLIOY[~ JP~)'i: ~ LOC AUTOMOBILE LIABILITY ~-i ANY AUTO IALLOWNEDAUTOS I SCHEDULED AUTOS i~ HIREDAUTOS C GARAGE LIABILITY i-- ANY AUTO ID EXCESS LIABILITY occur I CLAIMS MADE DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AN D EMPLOYERS' LIABILITY OTHER 33200065606 ~EK84493063 [610140 POLICY EFFECTIVE IPOLICY EXPIRATION DATEIMMIDDIYY3/ DATEIMM/DD/YY} 03/01/01 103/01/02 03/01/01 03/01/02 03/01/01 i03/01/01 LIMITS EACH OCCURRENCE $1_~,. 0 0 0 I 0 0 0 FIRE DAMAGE (Any one fire:_$100 , 000_ MEDEXP(Anyoneperson) $5t 000 PERSONAL &ADVINJURY $1 , 000 , 000 GENERAL AGGREGATE "$2 000 000 PRODUCTS-COMP,OPAG~ $2, 000, ~0_0__0_ ~ COMBINED SINGLE LIMIT $1, 000 , 000 (Fa accident) BODILY INJURY ~ $ (Plsr person) BODILY INJURY (Per accident) $ PROPERTY DAMAGE (P~r accident) $ AUTO ONLY- EAACClDEN'[ $ OTHER THAN FAA_CC $ AUTO ONLY: AGG $ 03/01/02 EACH OCCURRENCE $~0, 000,, 00C A®GREGATE $1 O_~_000, 00 ( $ ,$ $ 01/01/02 Iv IWCSTATU- I lOTH-' ~[~Y UM,TS ~ tE.L. EACHACClDENT $1, 000, 000 E.L.DISEASE-EAEMPLOYEE $1,0 0 0 1 0 0 0 ~M~T~ $1, 0 0 0 ~ DESCRIPTION OF OPERATIONS/LOCATIONS, VEHiCLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Re: 2350 S. Winche~ter, EP 99-201. Tl3e City-, the City' of Redevelopment A~enc~, its officers, employees and volunteers are additional insureds/as respects general liability and automobile per endorsements att~ached. (See Attached Descriptions) CERTIFICATE HOLDER i i ADI~mONALINSURED;INSURERLE'I-rER: CANCELLATION Ten Da_v ~ot i ce Campbell named as liability for Non-Payment City of Campbell i Attn: Public Works ~epartment 70 North First Street Campbell, CA 95008~ ACORD25-S(7/97)1 of 3 #M280362 SHOULD ANYOFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE IDO=IRAT1ON DATE THEREOF,THE ISSUING INSURER WlL~AIL'~ 0 DAYS WRrrTEN NOTICE TO THE CERTIFICATE HO LDER NAME D TO THE LEFT,.~I~~ A~TIVE SOG ® ACORD CORPORATION 1988 If the certificate I" on this certificate If SUBROGATION require an endo holder in lieu of I M PORTANT older is an ADDITIONAL INSURED, the policy(ies)must be endorsed. A statement does not confer rights to the certificate holder in lieu of such endorsement(s). IS WAIVED, subject to the terms and conditions of the policy, certain policies may 'sement. A statement on this certificate does not confer rights to the certificate such endorsement(s). DISCLAIMER The Certificate of the issuing insure affirmatively or nE Insurance on the reverse side of this form does not constitute a contract between r(s), authorized representative or producer, and the certificate holder, nor does it gatively amend, extend or alter the coverage afforded by the policies listed thereon. '~0RD25-S(7/97):2. of 3 #~280362 DES .{IPTIONS (Continued from, ~ge 1) PRIMARY INSURANCE: IT IS LrNDERSTOOD ANI INSUR3tNCE MAINTAINEI NOT CONTRIBUTING WII AGREED TH_AT THIS INSURANCE IS PRIMARY Ai~D AllY OTHER BY THE ADDITIONAL INSUREDS SI-IALL BE EXCESS ONLY ~kND H THIS INSURANCE. AMS25.3(07197) 3 of 3 #~280362 ENDORSEMENT # This enclorsem~ mt, effective 12:01 a.m., 03/01/01 , forms a part of PolicyNo. GECO001302 by Greenwich Insu THIS ENDORSEMENT 01 issued to FAROTTE CONSTRUCTION CO., INC. ca, nce Company CHANGES THE POLICY. PLEASE READ iT CAREFULLY. AUTOMATIC ADDITIONAL INSUREDS This endorsement modifies insurance provided under the following: COMMERCIAL GENEF~ PRODUCTS/COMPLE~ The fnilowing provision 5. Any en (the "A~ work" CO1'1 nec AL LIABILITY COVERAGE PART 'ED OPERATIONS LIABILITY COVERAGE PART is added to (Section II). Who Is An Insured. :ity you are required in a written contract ("the contact") to name as an insured Jditional Insured") is an insured but only with respect to liabiliby arising out of"your the Additional Insured, or acts or omissions of the Additional insured in tion with the general supervision of "your work" to the extent set forth below. The Limits of Insurance provided for the Additional insured shall not be greater than those required by the contract and, in no event, shall the Limits of insurance be increased by the contract. All insuring agreements, exclusions, Terms and conditions of the Policy shall apply tO the coverage(s) provided to the Additional Insured and such coverage shall not be enlarged or expanded by reason o1 the contract. Except when expressly required by the contract, this insurance does not apply to "Bodily Injury" or "Property Damage" occurring after: (4) All work on the project (other than service maintenance or repairs) to be performed by or on behalf to the Additional Insured(s) at the site of the covered operations has been completed; or (2) That portion of "your work;' out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or suocontractor engaged in performing operations for a principal as a part of the same project. With respect to Additional Insureds who are architects, engineers or surveyors, this insurance does not apply to "Bodily Injury", "ProperS7 Damage", "Personal Injury" or "Advertising Injury" arising out of the rendering of or the failure to render any professional services by or for you, including: (2) The ;~reparing, approving, or failing to prepare or approve maps, drawings, opinions, reports, surveys, change orders, designs, or specifications; and Supervisory, inspection or engineering services. GENL115 (7/99) Page All other terms and con, Any coverage providecl hereunder shall be excess over any other valid and collectible insurance availal:)le to the Additional Insured(s) whether primary, excess, contingent or on any other baSiS unless a contract specifically requires that this insurance be primary or you request that it apply on a Pdmary basis. Jitions remain the same. (Autl~odzed Representative) GENL115 (7/99) Page 2 POLICY NUMBEt THIS El This endorsement ,. 233200065606 BUSINESS AUTO NDORSEMENT CHANGES THE POLICY. PLEASE READ CAREFULLY. ADDITIONAL INSURED lodifies Insurance provided under the following: BUSINESS AUTO COVERAGE FORM It is agreed that t~e "Who Is An Insured' provision is amended to include as an insured the person or organization designated below as an additional insured, subject to the following provisions: ! (1). This insu~'ance applies only with respect to any Liability arising out oft}he operation of covered aatos on the additional insureds premises described below: (2). The Nam.,~d insured is authorized to act for such additional insured in ail matters pertainin :to this insurance, including receipt of notice of cancellation: (3). Return p ,~mium, if any, shall be paid to the Named Insured: (4). Nothing contained herein shall affect any right of recovery as a claiman~t which the additional insured would have if not designated as such. City of Campkell Attn: Public Works Department 70 North First Street Campbell, CA! 95008 Re: 2350 S. ~inchester, EP 99-201. The City, the City of Campbell Redevelopmen~ Agency, its officers, employees and volunteers are named as additional iqsureds as respects general liability and automobile liability per endorsemdnts attached. POL' "NUMBER: 4610140 J JN&~.,ED: Farotte Construction Co., 1 .... WORKERS COMPENSATION AND EMPLOYERS LIABIL]TY POLICY WAIVER OF OUR RIGhT.TO RECOVER FROM OTHERS ENDORSEMENT- CALIFORNIA / We have the righ: to recover Our paymenl:s fram anyone liable for mn inju~ covered by this policy'. We will n=t enforced out right against the person or organization nameci in the Schedule. (this agreamen! applies only to the' extent thst you perfnrm work ruder a wri~en conba~'that r~-quires you to obtain this agreeman[ from us.) You must mainLaJn payrolt the Work described in the Sch Thc additi¢'nal )~r~mium for Ih premium otherwise due on su C±ty o~ 70 Nor Campbe =rd~ ~c=ur~tety segregating the remuner~[ion oF your ernploy~t2 while enga!2ed in ~dule, ch remuneCation. % of the C, alifarnin workers'! compensstian Campbell ~b~±c ~orks Schedule' Department h First Street 1, CA 95008 .... 'Job ~es cr'i~:ti~rl 2350 S. Winchester, EP 99-201. WC 04 0~ 06 ACORD,,, ODUCER onstruction Unit BD Ins. and Financial 01 Island Parkway, Sui elmont, CA 94002-4110 SURED 'arotte Construction Cc ;0 Casey Street ;ilroy, CA 95020 I DATE (MM/DD/YY) CERTIFICATE QF LIABILITY INSURANCE z2/2 /oo THIS CERTIFICATE IS IS5 AS A MATTER OF INFORMATION l ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ,ervices ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. · e 3 0 0 ' INSURERS AFFORDING COVERAGE ii ,NSURER A: Greenwich [~surance Company i,NSURERB: ACE Fire underW~_i_te[s insurance c( i INSURERC: Fireman Fund Insurance _ :' INSURER D: Fremont C°mpens~,iOn In Co ti INSURER E: ~ HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POL1CY PERIOD INDICATED. NOTWITHSTANDIN( OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH T~IlS CERTIFICATE MAY BE ISSUED OI BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, t~XCLUSIONS AND CONDITIONS OF SUCF AVE BEEN REDUCED BY PAID CLAIMS. : ~LiCY EFFECTivE /pOLicY EXP~TiON~ LIMITS POLICY NUMBER DAT~~ $1 , 0 0 0 0 0 0 03/0i/00 03/0i/01 ~c~oc~o~c~ , FIRE DAMAGE (Ally one fire) $ 5 0 , 0 0 0 ~ M~D~X~., .... ,~o,~> .~ ~5, 000 mpany :OVERAGES 1.-..--.------- THE POLICIES OF: INSURANCE L1STED BELOW: ANY REQUIREMENT, TERM OR CONDITIOt MAY PERTAIN, THE INSURANCE AFFORDED POLICIES, AGGREGATE LIMITS SHOWN MAY TYPE OF INSURANCE GENERAL LIABILITY i GE C COM M ERCIAL G E NERAL L[AB[LITY CLAIMS MADE [ X L, CCUR GEN'L AGGREGATE LIM[TAPPLIES PER: POLICY I ViPRo- I !Loc ; ~ i JEC.___T_T AUTOMOBILE LIABILITY ANY AUTO At.L OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS GARAGE LIABILITY ANY AUTO EXCESS LIABILITY Xi, occur 'i DEDUCTIBLE 'i RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY iH0: 0001302 OTIIER pERSONAL & ADV INJURY GENERP[L AGGREGATE 03/01/00 03/01/0i COM~EDS,NG~-EUM~T :r pervo.) i '[ BODIL$ iNJURY DEC 2 7 000 ~U~CIC a~a .... --vnflQ ] ?er acdident) EA ACCIDENT OTH~ THAN ~A ACC 'k AUTO ~ONLY: AGG ~ j ' '[ AGGREGATE ~ ~ WC STAT~ 520039 iXEK'/4960659 CLAIMS MADE ') ~079947502 DESCRI~ION OF OPERATIONS/LOCATIONS/VEHI Re: 2350 S. Winches~ Redevelopment Agency additional insureds ~ per endorsements att; ELES~XCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS ~er, EP 99-201. The City, the City of Campbell its officers, employees and volunteers are named as ~s respects general liability and automobile liability ~ched. CERTIFICATE HOLDER ~ ,NALINSURED;INSURERLETIER: City of Campbell At,n: Public Works D 70 North First Stree Campbell, CA 95008 epartment t CANCELLATION ' - ; HOULD ANYOF THE ABOVE DES CRIBED p(~LIC~S B E CANCELLED BEFORE THE EXPIATION )ATE THEREOF, THE ISSUING INSURER ~/ILL~7~]~LEJ~[~AIL3 0 DA~S WRITTEN qOTICETOTHE CERTIFICATE HOLDERNAMED TOTHE LEFT,~[]~ICa~Ii[~]~rF~:Q~I~X TYM O ACORD CORPORATION 1988 ~ 8 ,CORD25-S(7/97) 1 of 2 ~S267943/M20 469 If the certificate holder on this certificate does If SUBROGATION IS require an endorseme holder in lieu of such IMPORTANT is an ADDITIONAL INSURED, the policy(les)must be endorsed. 5 statement not confer rights to the certificate holder in lieu of such endorsement(sd. WAIVED, subject to the terms and conditions of the policy, certain pplicies may :~t. A statement on this certificate does not confer rights to the c~ertificate endorsement(s). The Certificate of Insr the issuing insurer(s), affirmatively or negati DISCLAIMER rance on the reverse side of this form does not constitute a contrac~ between authorized representative or producer, and the certificate holder, nor does it rely amend, extend or alter the coverage afforded by the policies lisled thereon. ACORD 25-S (7/97) 2 of 2--~267 943/M208469 POLICY NUMBER: GEC00 THIS ENDORSEMI ADDITIONAL C( )1302 COMMER~,,AL GENERAL LIABILITY =_NT CHANGES THE POLICY. PLEASE READ IT CAREFUELY. INSURED -OWNERS, LESSEES or NTRACTORS (FORM B) This endorsement modifies COMMERCIAL GENE Name of Person or Organi;, ation: City of Campbell Attn: Public Wor] 70 North First SI Campbell, CA 95, (If no entry appears abov~ as applicable to this endor WHO IS AN INSURED (S Schedule, but only with re Re: 2350 S. Wix Redevelopment A, additional insu per endorsement~ ~surance provided under the following: ~,L LIABILITY COVERAGE PART SCHEDULE :s Department :reet )O8 , information required to complete this endorsement will be shown in the Declarations sement) action II) is amended to include as an insured the person or organization shown in the spect to liability arising out of "your work" for that insured by dr for you. chester, EP 99-201. The City, the City of Campbell ency, its officers, employees and volunteers are named 'eds as respects general liability and~aut°m°bile attached. PRIMARY INSURAN( E: IT IS UNDERSTO0 AND AGREED THAT THIS INSURANCE__I~¢._~PRi~NMssu~ED AND ANY OTHER I~SURANCE MAINTAINED BY THE ADDIT±O~Am z'~ SHALL BE EXCESS/ONLY AND NOT CONTRIBUTING WITH THIS INSURANCE. / as liability CG 20 10 11 85 POLICY NUMBER: lq THIS END This endorsement moc It is agreed that the person or organizat provisions: (1). This insura: covered attl (2). The Namec pertaining (3). Return pre (4). Nothing cc additional City of Campk Attn: Public 70 North Fir~ Campbell, CA Re: 2350 A. Redevelopmen' additional i: per endorsem WAIVER OF SU AS RESPECTS WAIVED UNDER IDENTIFIED I PRIMARY INSE IT IS UNDER~ MAINTAINED WITH THIS 11520039 BUSINESS AUTO ~RSEMENT CHANGES THE POLICY. PLEASE READ CAREFULLY. ADDITIONAL INSURED ifies Insurance provided under the following: BUSINESS AUTO COVERAGE FORM 'Who Is An Insured" provision is amended to include as an insured the >n designated below as an additional insured, subject to the fc~llowing ice applies only with respect to any Liability arising out of thO operation of os on the additional insureds premises described below: insured is authorized to act for such additional insured in all matters o this insurance, including receipt of notice of cancellation: nium, if any, shall be paid to the Named Insured: ntained herein shall affect any right of recovery as a claimant twhich the :nsured would have if not designated as such. i ell Works Department t Street 95008 Winchester, EP 99-201. The City, the City of Campbell Agency, its officers, employees and volunteers are named as sureds as respects general liability and automobile liability nts attached. ~ROGATION: LIABILITY, IT IS AGREED THAT ALL RIGHT OF SUBROGATION IS HEREBY SUCH INSURANCE POLICY AS RESPECTS THE ADDITIONAL INSUREDS AS N THIS ENDORSEMENT. ~ANCE: ~OOD AND AGREED THAT THIS INSURANCE IS PRIMAR~ AND ANY OTHER INSURANCE y THE ADDITIONAL INSUREDS SHALL BE EXCESS ONL~ AND NOT CONTRIBUTING 3URANCE. WORKERS WA1VF..R Of= (:;:)UP-, RIG) We h~¥e t.he r~gh~; to recover e~nt ~h~t you ~erfcrm work You must maintain payroll r~ ~e work described in the Sch Tho a~ditio'nal premium for Ih prern{um otherwise due an su City of First S City of officer WC 04 O3 O6 POLICY NUmBeR: WN0079947502 IN~e 'ED:Farotte Construction Compan5 ;OMPF.,,,~ATION AND EMPLOYERS LIABIL,, ~' POLICY ~T TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA ~ur payments fr~m. anyone liable for an inju~.y,, covered by this p~olicy. We wfIl not pers~'n or arganizatt~n named n ~e Schedule. (this 8greemen~ applies ~n~y to the ruder a wr ~en conba~'~t r~quires you to o~tain ~his agrpemeht from us.) :rd~ ~ccu~tety ssgreoadn¢ the remunera[ion of your em~l~ye~ wh~le en~aged in ~dule, ch rernunerailcn. % of the Oalif~rnia workers' comF:ensstion '. 'Schedule : ©r~&n!2~'~n Campbell~ 70 ~orth treet, Campbell CA, The Campbell Redevelopment Agency, , employees and volunteers. J~b QgsCEi~ti~n 2350'S. Winchester, EP its 99-201. Permit# (~)F",~ 2550 Cod< The following inst right-of-way. Insl These insurance re~ work being perforn Limits Commercia '~ $1,000j ~ $1,000,t ~ $2,ooo,~ ~6 Policy Automotiv "Any A $1,000,( Policy e Workers' C Waiver $1,000,( Policy e Course of C [] Comple~ ,n Policy e Required Endor Additional ~)~ The Cil volunte~ The inst: Cancell, such no agents c Worken rn For [] For INSURANCE REQUIREMENTS CHECKLIST CIP Project # : trance is required of all contractors working in the City of Campbell public ~rance certificates must be accepted by City staff before work can begin. tuirements apply to work being performed under an Encroachment Permit and led under contract for Capital Improvement Projects. ' General Liability fbr bodily, personal injury and proper/y damage: 00 per occurrence, and )00 general aggregate limit applying separately to the project, or )00 general aggregate limit. xpiration date [ ]1 ~::~.D~-4. {'~4)q_r.~x_,:~ { ,--~o,~, .c,': '/-~ (-~ Liability: ~to" checked on certificate ~00 per accident fbr bodily injury and property damage xpiration date I IJ[o~c'~ tT~t,r~e_~.~'c~ )mpensation ~d Employer's Liability )f Subrogation clause ~00 per accident for ~o4ily injury or disease <piration date '1~ ~ I Z]tl onstruction (if required in Special Provisions) ed value of the project i (piration date sements to General Liabilitv and Automobile Liabilitv P~olicies nsured Endorsement ', the City of Campbell Redevelopment Agency, its officers, employees and rs are named as additional insured. rance coverage afforded to the Additional Insured is primary insurance. tion area of certificate edited to delete "endeavor to" an¢--'" but failure to mail ice shall impose no obligation or liability of any kind upon the company, its representatives". Compensation Insurance Sheet Submitted ieneral Contractor Initials Copy of Insurance Uertificate placed in tickler file for month of expiration j:\forms\inscklst (rev 11/99) )eveloper or Owner Acceptability o Insurer(s) t/' O~ 'f~ '~ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of Califor~a. Date' ACORD. CERTI ICA 2 OF LIABILITY INSUR ' NC ,D .s OAHEIMM,DD , · ' ~ ~ENCO- 5 01/24/01 PRODUCER THIS CERTIFICATE IS I~SUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE R. G. Speno, Inc. HOLDER. THIS CERTIFICATE D ~ES NOT AMEND, EXTEND OR 18900 Stevens Creek Blvd. #200 ALTER THE COVERAGE AFFOF:DED BY THE POLICIES BELOW. Cupertino, CA 95014-3674 COMPANIES AF =ORDING COVERAGE Francis w.. Cook, C.P.C.U. COMPANY Phc.eNo. 408-973-9500 FaxNc A St Paul Fire & Marine Ins B State Compensation Insurance Gen-Con Inc. COMPANY MS. Paula Mohr JAN 2 9 2001 c 800 Ct/st/ch Lane Campbell CA 95008 PUBLIC WO~K~ COMPANY COVERAGES ..... ~: 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; 0 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PER' 'AIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALI. THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH P('LICIE$. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR POMCY EFFECTIVE POLICY EXPIRATION LIMITS CO TYPE OF INSURANCE POLICY__ NUMBER DATE (MM/DD/YY) DATE (MMIDD/YY) GENERAL LIABILITY GENERAL AGGREGATE $ 2, 000, 000. A X ! COMMERClAL GENERAL LIABILITY ~08301482 01/01/01 01/01/02 PR(~DUCTS-COMPIOPAGG $ 2, 000, 000. I CLAIMSMADE ~ OCCUR PErpONAL&ADVINJURY! S 1,000,000. OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $ 1 ~ 000,000. X~ Per Project A99. FIRE DAMAGE (Any one fire) $ 100 , 000 . ME~ EXP (Any one person) $ 10f000. AUTOMOBILE LIABILITY A X ANYAUTO ~08301482 01/01/01 01/01/02 COMBINED SINGLE LIMIT $ 1 , 000 , 000 . ALL OWNED AUTOS -- BODILY INJURY SCHEDULED AUTOS (Pe! person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Pe~accident) $ PROPERTY DAMAGE $ GARAGE LIABILITY AUtO ONLY- EA ACCIDENT $ ANY AUTO OTHiER THAN AUTO ONLY: i EACH ACCIDENT $ I AGGREGATE $ EXCESS LIABILITY EACH OCCURRENCE $ i, 000,000 ~ X UMBRELLA FORM I~08301482 01/01/01 01/01/02 AG(~REGATE $ 1,000,000 OTHER THAN UMBRELLA FORM $ WORKERS COMPENSA~ON AND X I WC STATU- EMPLOYERS' LIABILITY TORY LIMITS I OTH-ER EL EACH ACCIDENT $ 1000000 B THE PROPRIETORJ ~ INCL .611420 12/11/00 12/11/01 EL DISEASE - POLICY LIMIT$ 1000000 PARTNERS/EXECUTIVE OFFICERS ARE: EXCL EL ~ISEASE - EA EMPLOYEE $ 1000000 OTHER DESCRIP~ON OF OPERATIONS/LOCA~ONSA/EHI~ :LES/SPECIAL ITEMS * 10 day notice of canceLlation for non-payment of premium. E CERTIFICATE HOLDER CANCELLATION C- CAM- 3 SHOULD ANY OF THE ABOVE DESCRIBEI ) POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. THE ISSUI~ G COMPANY WILL ~AIL 30* DAYS WRITTEN NO~CE TO THE ~ER~FICATE HOLDER NAMED TO THE LEFT. City of Campbell Building Departm~.nt 70 North 1st Str,.et Campbell CA 95001 AUTHORIZED REPRESENTATIVE 'SI'ATE COMPENSATION INSURANCE I=UND cEF FEBRUARY 23,2001 CITY OF CAMPBELL BUILDING DEPARTME~ 70 NORTH 1ST STREE CAMPBELL CA 9300i' L This is to certify that we have Insurance Commissioner to ti' This policy is not subject to cz We will also give you ~N day~ XX This certificate of insurance policies listed herein. Notwil respect to which this certifi¢ described herein is SUbject to P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 AUTHORIZED REPRESENTATIVE ENDORSEMENT #2065 E 02/23/01 IS ATTACHE r- EMPLOYER GEN-CON INC 800 CRISTICH LANE CAMPBELL CA 93008 RECEIVED TIFICATE OF WORKERS!cOMPENSATION INSI POLICY NI CERTiFicATE EXPiF i '1 ~1].420 - 00 T issued a valid Workers' Compensation insurance policy in a form approved by the California e employer named below for the policy period indicated. ncellation by the Fund except upon t~ days' advance written notice to the employer. XX advance notice should this policy be cancelled prior to its normal ;xpiration. not an insurance policy and does not amend, extend or alter the ;overage afforded by the hstanding any requirement, term, or condition of any contract ~r other document with ate of insurance may be issued or may pertain, the insurance afforded by the policies all the terms excluSiOns and C°~d tons of such P0 c es ~ PRESIDENT INCLUDING DE;tENSE ' COS TS: $!'000,000 PiR OCCURRENCE. qTITLED CERTIFICATE HOLDERS' NDTICE EFFECTIVE TD AND FDRMS A PART DF THIS PDLICY. _~U8LIC WORK8 STATE UND HOM~ SAN ~RANCI$CO ALL ~FFECTIV~ 0ATE$ ARE AT I~ 01 AM PACIFIC STANOARO TiME OR TI~ IN01CAT~0 AT mACtFiC STANOAR0 TI~ .-LN'A ~'TH I N O IS AGREED CERTIFICATE HOLDERS' NOTICE ENDORSEMENT AGREEMENT :N T-t-{IS POLIO' TO THE CONT1L~:~.Y NO%V'ITHST.-%NDINO. IT ~__-kT ~-IIS POLICY SI'"LKL, L NOT BE C.-LN'CEI.f.F:D L.'.'%TIL .%3'T z. R '~tlI' THE .%L~L B WORk.q~RS' 3O "TEN NOTICE OF SUCH C.-VN'CEI.I.ATION HAS BEEN PLACED IN T STATE FL,L-NT) TO CURRENT HOLDERS OF'CERTIFICATE OF :O*fPENSATION I NS Lth~'q C E. SPEGIMEN NOTHING OR EX'TEN POLICY O'f HELD TO TATIONS COUNTERSIGNED AND SSUED AT SAN FRANCISCO: AUTHORIZED RE?qESENTATiVE N THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VkRY. ALTER, WAIVE O ANY OF THE TERMS. CONDITIONS, AGREEMENTS, OR LI~t~J_TATIONS OF THIS HER THAN AS ABOVE STATED. NOTHING ELSEWHERE IN THIIS POLICY SHALL 8E ARY. ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGiREEMENTS OR LIMI. F THIS ENDORSEMENT. 2065 P~ESIOENT STATE COMPENSATION INSURANCE I=U N D CER DECEMBER 28, 2000 CITY OF CAMPBELL BUILD lNG DEPARTMENi 70 NORTH 1ST sTREEi CAMPBELL CA 9500 b This is to certify that we have Insurance Commissioner to th, This policy is not subject to car 30 We will also give you :~N days This certificate of insurance is policies listed herein. Notwit~ respect to which this Certificl described herein is subject to AUTHORIZED REPRESENTATI~ EMPLOYER' S LIABILiT ENDORSEMENT #2065 E~ 12/11/00 IS ATTACHE[ EMPLOYER I- GEN-CON INC 800 CRISTICH LANE CAMPBELL CA 950~ P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807 'IFICATE OF WORKERS' COMPENSATION INSURAN¢ POLICY NuMBr CERTIFICATE EXPIR1 iRi 16114c0 - 00 is: 12~11~01 RECEIVED JAN 0 8 2001 WORK8 ADMINISTRATION ;sued a valid Workers' Compensation insurance policy in a form al~proved by the California employer named below for the policy period indicated, i 30 . ~cellation by the Fund except upon tie~ days' advance written notice io the employer. advance notice should this policy be cancelled prior to its normal expiration. not an insurance policy and does not amend, extend or alter the toverage afforded by the ~standing any requirement, term, or condition of any contract Ir other document with Ite of insUrance may be issued or may pertain the insuranCe ~ffOrded by the policies ~11 the terms, exclusi°ns and COnditi°ns of such POliCies. pREsIDENT ~E ~ ' LIM!T INCLUDING DEFENSE COSTS: $1,000,000 F, ER OCcURRENcE' ITITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE TO AND FORMS A PART OF THIS POLICY. A.M. Best's Rating for St. Paul rSre & Marine Ins Co Page 1 of 1 St. Paul Fire & Marine Ins Co Member of St. Paul Companies View a list of group members or view the group profile A.M. Best #: 02452 NAIC #: 24767 385 Washington Street · St. Paul, MN 55102 Phone: (651)310-7911 http://www.stpaul.com *Ratine of 11/30/1999 10:49:30 AM E.S.T. Best's Rating A+ (Superior)* Financial Size Category XV ($2 billion or more) Best's Insurer Pro available for appro: companies that are Rating. These repoJ and provide a cond, overview, financial licensing informati~ well as the financia assigned by A.M. E file reports are :imately 6,000 assigned a Best's ~ts are regularly updated ~nsed business statements, and ~n for each insurer, as strength rating est. Best's Company Reports, which are regularly updated for 6,000}insurers, provide the same comprehepsive information found in the annual Property/Casualty, Life/He~tlth, and International Editions of Bdst's Insurance Reports. These reports are regularly updated and provide a detailed business overview, extensive financial data and; analytical commentary, product and g~ographic information, company histo~:y, as well as the rationale supporting the[financial strength rating assigned by A.M. Best. Please note: Information in this directory is Updated nightlY. Fo late-breaking events, please refer to our Press Release section. he Best s Rating ~epresents an op~mon based on a comprehensive quantitative and oualitative evaluation of a co~npany's financial strength, operating performance and market pro~le. A Financial Size Cat~gory is assigned to all companies and reflects their size based on their capital, surplus and conditional reserve funds in millions of U.S. dollars. The rating symboB "A++", "A+", "A", "A-", "B++", and "B+ are registered certification marks of the A.M. Best Company, Inc. (Best's Ratings are propietary and may not be reproduced without permissiof~ from A.M. Best.) A.M. Best's Rating for Republic Indemnity of America Page 1 of 1 Republic Indemnity of America Member of Great American P&C Ins Group View a fist of group members or view the group profile A.M. Best #: 00800 NAIC #: 22179 15821 Ventura Boulevard, Suite 370 · Encino, CA 91436 Phone: (818)990-9860 *Ratings Read thi Best's Best's Insurer Prot available for approx companies that are ~ Rating. These repor and provide a cond{ overview, financial licensing informatic well as the financial assigned by A.M. B B~st's Rating A (Excellent)* Financial Size Category VIII ($100 million {o $250 milliqn) company's ~surer Profile ile reports are imately 6,000 .ssigned a Best's :s are regularly updated nsed business ~tatements, and n for each insurer, as strength rating ~st. Purchase this company's Best's Companyt Report Best's Company Reports, which are regularly updated for 6,000 insurers, provide the same compreher~sive information found in the anr~ual Property/Casualty, Life/Hea~th, and International Editions of Begt's Insurance Reports. These reports are regularly updated and provide a detailed business overview, extensive financial data and analytical commentary, product and geographic information, company histo~'y, as well as the rationale supporting the ~financial strength rating assigned by A.M. Best. ?leas~hot~::Infor~ation in this directorY is Updated nightly. late-breaking events, please refer to our Press Release section. The Best's Rating epresents an opinion based on a comprehensive quantitative and qualitative evaluation of a co] npany's financial strength, operating performance and market profile. A Financial Size Cat ~gory is assigned to all companies and reflects their size based on their capital, surplus and conditional reserve funds in millions of U.S. dollars. The rating' symbols "A ++" , "A +" , "A "," A- "," B++ ",and "B+ are registered' cert]ficatmn' ' marks o the A.M. Best Company, Inc. (Best s Ratings are prop]etary and may not be reproduced without permission from A.M. Best.) For more information on A.M. Best's Financial Strength Ratings, please refer to our Cun'ent CERTiFiCAT ACORD. OF LIABILITY INSUR cc DATE,MM,DDt, "~ ~ENCO-5 12/22/99 P~ODUCER THIS CERTIFICATE IS ISSUED AS A MA~TER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE R. O. SpenD, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 18900 Stevens Creek Bi~ d. #200 ALTER THE COVERAGE AFF¢)RDED BY THE POLICIES BELOW. Cupertino, CA 95014-367 4 COMPANIES ~ FFORDING COVERAGE Francis E. Cook · C.P. C. U. COMPANY INSUREDPh°neN°' 408--973--9500 Fax o.~"~/*~ i\i ~--~ A St Paul Fire & Marine Ins B REPUBLIC INDi CO OF AMERICA Gen-Con Inc. , Ms. Paula Mohr DIe 2 ? i99~ COMPANY C 800 Cristich Lane PUBLIC WORKS Campbell CA 95008 ADMINIStRAtION COMPANY D COVERAGES THIS IS TO CERTIFY THAT THE POLICIES ( F INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR 1~ -' POMCY PERIOD INDICATED, NOTWITHSTANDING ANY RE( JIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT V~TH RESPEC~ TO WHICH THIS CER~FICATE MAY BE ISSUED OR MAY PE tTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO A .L THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH I 'OMCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. co LTR ' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATE (MM/DDPfY DATE (MM/DDPfY i LIMITS GENERAL LIABILITY ' Gl [NERAL AGGREGATE $ 2000000 A X COMMERCIAL GENERAL MABILITY K/~08301117 01/01/00 01/01/01 P;:ODUCTS-COMPIOPAGG $2000000 t CLAIMS MADE ~ OCCUR PERSONAL&ADVINJURY $ 1000000 Z OWNER'S & CONTRACTOR'S PROT F_/CH OCCURRENCE $ 1000000 _~X Per Project Agg. FIIIEDAMAGE(Anyoneflre) $ 50000 MI D EXP (Any one person) $ 5000 AUTOMOBILE LIABILITY K~08301117 01/01/00 01/01/01 CdMBINEDSlNGLE LIMITI $ 1000000 A X ANY AUTO ALL OWNED AUTOS BI~DILY INJURY SCHEDULED AUTOS (p~r pemon) $ X HIRED AUTOS DILY INJURY X NON-OWNED AUTOS (%~ r accident) $ PR, )PERTY DAMAGE $ GARAGE LIABILITY AU r'o ONLY. EA ACCIDENT ANY AUTO OTI IER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY X EACH OCCURRENCE S 1000000 A UMBRELLA FORM CK08301117 01/01/00 01/01/01 AGGREGATE $ 1000000 OTHER THAN UMBRELLA FORM $ WORKERS COMPENSATION AND v IIWC STATU-I OTH- EMPLOYERS' LIABILITY ~ I; TORY LIMITS r ER EL IACH ACCIDENT $ 10 0 0 0 0 0 B PARTNER~EXECU~vETHE PROPRIETOPJ INCL 12564608 12/11/99 12/11/00 EL ['ISEASE-POMCY LIMIT $ 1000000 OFFICERS ARE: EXCL OTHER EL ISEASE - EA EMPLOYEE $ 1000000 A Leased/Rntd Equip ~/{08301117 01/01/00 01/01/01 i $20,000 DESCRIP~ON OF OPERA~ONSILOCATIONS~EHI( :LE~SPEClAL ITEMS *10 day notice of cancel .ation for non-p, ayment of Premium. RE:St. Luc 's Church Acti~,itv Center & A~d~tion-235D Winchester Blvd., _Campbell,~.All work in l)ub.l.ic ri~.ht-of-way~City of Campbell,City of PE+ uamDbell Redvlopmnt A~en¢.-~,[~s o=z~cers.emD-oyees&volun%eers are nmed as addl insds as rs~cts Iial)laty per CG2010 a%tached. CERTIFICATE HOLDER CANCELLATION C T T¥- 03 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRA~ON DATE THEREOF, THE ISSUING COMPANY V~LL~ MAIL City of Campbell ,,30' DAYSWRITFEN NO.CE TO THE CER~FICATE HOLDER NAMED TO THE LEFT, Attn:Dept.of Public Works I [ II I I I I 70 North Firsts S~reet Campbell CA 95008 ACORD 25~ (1/95) AI NUMBER: YR00-141 DATE ISSUED: Dece~nber POLICY NUMBER: INSURED: GEN-COI THIS ENE ADDi 22, 1999 ~K08301117 COMMERCIAL ORSEMENT CHANGES THE POLICY. PLEASE READ IT CA [TIONAL INSURED - OWNERS, LESSE[ ;ENERAL LIABILITY REFULLY. ',S OR CONTRACTORS (Form B) ! This endorsement mod~es insurance provided under the following: 1 COMMERCIAL GENERAL LIABILITY COVERAGE PART Name of Person or Org The City of Campbell The City of Campbell With respects to: St. Lucy's Church Ac right-of-way. City of volunteers. SCHEDULE anization: and Redevelopment Agency,its officers, employees and volunteers. :ivity Center & Addition - 2350 Winchester Blvd., Campbell,4_A. All work in public Campbell, City of Campbell Redevelopment Agency, its officers, employees and bt (If no entry appears a ve, information required to complete this endorsement will be shown in the Declarations as applicable t° this enl°rsement') WHO IS AN INSURE~D (Section II) is amended to include as an insured the person or o ganlzation shown in the Schedule, but only wiG respect to liability arising out of "your work" for that insured by or for you. PRIMARY INSURAN£ ~E / It is further agreed that such insurance as is afforded by this policy for the benefit of thea~ove additional insured(s) shall be primary insurax ce as respects any claim, loss or liability arising out of the named ~nsured's operations, and any other insurance mai ntained by the additional insured(s) shall be excess and non-contribUtory with the insurance provided hereunder. CG 20 10 11 85 Copyright, Insurance Service Office, Inc. 1984 ACO, D. CERTIFICA ' OF - ' DATE,MM,DD Y, LIABILITY INSUR5 1 /09 99 ' 7' - / PRODUCER THIS CERTIFICATE IS ~=UED AS A MATTER OF INFORMATION ,,/)") ~ ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE R. G. Speno, Tnc. t, ,q"~ HOLDER. THIS CERTIFICATE I)OES NOT AMEND, EXTEND OR 18900 Stevens Creek Blvd. #200 ALTER THE COVERAGE AFF( RDED BY THE POLICIES BELOW. Cupertino, CA 95014-367 ~ COMPANIES A=FORDING COVERAGE Francis E. Cook i C.P. C .*.,T. COMPANY PhoneNo. 408-973-9500 Fax! ~. A St Paul Fire & Marine Ins INSURED COMPANY B REPUBLIC IND CO OF AMERICA Gen-Con, Inc. COMPANY Ms. Paula Mohr C~-(e--I 'L 800 Cristich Lane Campbell CA 95008 COMPANY ! I Itl..... N,n~J.,~.l V D ~l~r . COVERAGES U~ ~ I 3 1999 THIS IS TO CERllFY THAT THE POLICIES 0 = INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THI[ POL CY PE~,iC INDICATED, NOTWITHSTANDING ANY REQI IIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH ~j W O~ K CERTIFICATE MAY BE ISSUED OR MAY PE! ~.TAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH ~ OUCIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO POLICY EFFECTIVE POLICY EXPIRATION LTR TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YY) DATE (MMIDD/YY) LIMITS GE__NEPAL LIABILITY GENERAL AGGREGATE $ 2,000,000. A X COMMERCIALi MADEGENERAL~v]LIABILITY [KK08300574 01/01/99 01/01/00 PRODUCTS-COMPIOPAGG $ 2,000,000. occu. P SO,AL.ADV,,JU.y ,1.ooo.0oo. Z OWNER'S & CONTPACTOR'S PROT E~ CH OCCURRENCE $ I ~ 000 ~ 000. X Per Project Agg. FI~ E DAMAGE (Any one fire) $ 50 , 000 . ME D EXP (Any one per~on) $ 5 ~ 000 . AUTOMOBILE LIABILITY ' A X ANYAUTO KK08300574 01/01/99 01/01/00 COMBINED SINGLE LIMIT $ 1,000,000. ALL OWNED AUTOS B-EILYO~ INJURY -- SCHEDULED AUTOS (Pe~person) $ X HIRED AUTOS -- BODILY INJURY X NON-OWNED AUTOS (Pe.accident) $ PR~ )PERTY DAMAGE $ GARAGE L/ABILITY AU..O ONLY. EA ACCIDENT $ ANY AUTO OTI IER THAN AUTO ONLY: EACH ACCIDENT $ AGGREGATE $ EXCESS LIABILITY LA( H OCCURRENCE $1,000,000 A UMBRELLA FORM ~(08300574 01/01/99 01/01/00 AGGREGATE $1,000,000 OTHER THAN UMBRELLA FORM $ WORKERS COMPENSATION AND %- JlWC STATU- I OTH- EMPLOYERS' LIABILITY ~% rTORY LIMITSI ER EL EACH ACCIDENT $ 1000000 B THE PROPRIETOR/ ~ INCL ~2564608 12/11/99 12/11/00 EL~ISEASE-POMCYUMIT $ 1000000 PARTNERS/EXECUTIVE , OFFICERS ARE:I I EXCL EL DISEASE - EA EMPLOYEE $ 1000000 OTHER A Leased/Rntd Equip ~/{08300574 01/01/99 01/01/00 ' $20,000 DESCRIPllON OF OPERATIONSILOCA]]ONSNEHI{ :LES/SPECIAL ITEMS *10 day notice of cancel't' f.or non-p, ayment of premium. ~RE: St. Lucv's Church Acti~;'a~°-n l=v uen=er & /~d~tion-235D Winchester Blvd., ~ampbell,~A.All work in ]~ub.l.ic ri~.ht-of-way~City of Campbell,City of PE+ uampbell Redvlopmnt A~en~;y,~=s oz=~cers,emp£oyees.&volun%eers are nmed as addl insds as rs~cts Iia])l~t~ ~er CG2010 a~tacb~ CERTIFICATE HOLDER CANCELLATION CITY- 0 3 SHOULD ANY OF THE ABOVE DESCRIBEr POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUIN ~ COMPANY WILL ............ MAIL City of Campbell 30* DAYS WRITTEN NOTICE TO THE ~ERTIFICATE HOLDER NAMED TO THE LEFT, Attn: Dept. of Public Works~~9 70 North Firsts Street Campbell CA 95008 ACORD 25-S (1/95) 88 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE R. G. S~eno, Inc. HOLDER. THIS CERTIFICATE DOES NOTAMEND. EXTEND OR 18900 Stevens Creek Blvc[. #200 ALTER THE COVERAGE AFFORDED. BYTHE POLICIES BELOW. Cupertino, CA 95014-3674 COMPANIES AFFORDING COVERAGE Francis E. Cook, C.P C.U, COMPANY St-Pal~ Fire i&~ [vX~rine Tns Phone No, 408-973-9500 Fax No. INSURED COMPANY B REPUBLIC IND ¢0 OF ~CA n-Con nc. COMPANY ,,ttn: Pau a .o .r c 800 Cristi '.ane COMPANY NOV Canqabell CA 95008 D ................................ · '""'"'"""""""""' ""'"' ~'"' ............ I!~b~ W 3RK$ ......... ..... ~Hi$ iS fO SERT'iF~'"i:'H~'i: :i'VE ~0Li~iE $' 0~= i'NSUF~ANCE~ L;$TED BELOW Hja[VE ~EEN issuED TO T~E i~~l ~)R'THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY F EQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMEN] ' WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY :'ERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS ~UBJECT TO ALL THE TERNS, EXCLUSIONS AND CONDITIONS OF SUe :H POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM~. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR DATE (MM/DD/YY) DATE (MM/DD/YY) GENERAL LIABILITY GENERAL AGGREGATE $ 2 , 000 , 000 A X COMMERCIALGENERALLIABILITY ,~08300574 01/01/99 01/01/00 PRO~UCTS-COMP/OPAGG $ 2,000,000 i:i:i:i I CLA~MSMAOE ~ ~CUR PER~ONAL&ADV~NJURY $ 1,000,000 X! OWNER'S&CO.reACTOR'S.ROT EAC. ~CURRE.CE $ 1,000,000 X Per Proj. Aggreg FIRE DAMASE (Any o,e fire) $ 50,000 MED EXP (Any one ~mon) $ 5,000 AUTOMOBILE LIABILITY A X ANYAUTO 08300574 01/01/99 01/01/00 COMBINEOSINGLE LIMIT $ 1,000,000 ALL OWNED AUTOS ~ BODILY INJURY $ SCHEDULED AUTOS (Per IPemon) X HIRED AUTOS BCE ILY INJURY $ X NON-OWNED AUTOS (Per accident) PR£ PERTY DAMAGE $ GARAGE LIABILITY AUT ~ ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN AUTO ONLY: ::::::::::::::::::::::::::::::::::::::::: EACH ACCIDENT $ i AGGREGATE $ EXCESS LIABILITY EA£~ OCCURRENCE $ i, 000,000 A X UMBRELLA FORM ]~K08300574 01/01/99 01/01/00 AG~REGATEt $ 1,000,000 OTHER THAN UMBRELLA FORM , $ WORKERS COMPENSATION AND TORY LIMITS EMPLOYER~ LIABILFFY EL EACH ACCIDENT $ i, 000,000 1~ THEPROPRIETOPJ ~ ~NCL ;1554607 12/11/98 12/11/99 EL DISEASE- POLICY LIMIT $ 1,000,000 PARTNERS/EXECUTIVE OFFICERS ARE: EXCL EL ~ISEASE- EA EMPLOYEE $ I, 000 ~ 000 OTHER ~ ~easec~/~td ~.qai~ ]~08300574 01/01/99 01/01/00 $25,000 DESCRIP~ON OF OPERATIONS/LOCAT~DNS~/EHIC LE.~SPECIAL ITEMS '10 day notice of cancellation for non-pa .lr~e. nt of premium.. . -. RE:St. Lucv's Church Activity Center & Ac~d~=ion-235D Winches=er ~v~., Camp.bell,~A.All work in public ri.~h.t-of-way=Cit¥ o_f .Campbell,City of. PE+ C .am~. 11 .Redvlopmn.t Ag.en ~, ~s o==ic__e_r.sz .e~q~.~o~ee.s__~_~..u~_=e_ers_a_re_ __n~meg. 9~s .... a~CLL lnsc~s as rs c=s~ao~y ~er c~zu~ua~one=.~u-~u =~'.'a~'a~'~'-~ c T ~- 0 3 SHOULD ANY OF THE A~OVE DESCR~BE~ POL,C,ES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUIN~ COMPANY V~L~~MAIL 30_~_~ DAYS 9VRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, City oE Cam~3ell ~ttn: De~t. oE Da~;.ic ~orks : _ - -- 70 North Firsts ~treet ' -~ II ; Campbell CA 950011 AUTHORITEDREPRESENTATIVE Francis E. Cook, C~~. A1 NUMBER: YR99-0, DATE ISSUED: Nove~ POLICY NUMBER: K INSURED: GEN-COI~ THIS ENI ADD This endorsement modi COMME Name of Person or Org The City of Campbell The City of Campbell With respects to: St. Lucy's Church Ac~ right-of-way. City of volunteers. (If no entry appears al~ applicable to this endor, WHO IS AN INSUREI Schedule, but only with PRIMARY INSURANC It is further agreed that be ~ instumace a~ insurance maintained b hereunder. CG20101185 Copy [1 ~bcr 22, 1999 K08300574 INC. COMMERCIAL ~ENERAL LIABILITY DRSEMENT CHANGES THE POLICY. PLEASE READ IT CA[ EFULLY. ITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (Form B) 5cs insurance provided under thc following: RCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE afization: md Redevelopment Agency,its officers, employees and volunteers. 3, All work in public ricers, employees and ivity Center & Addition - 2350 Winchester Blvd., Campbell,C Campbell, City of Campbell Redevelopment Agency, its ot ye, information required to complete this endorsement will bc shown in thc Declarations as ;cment.) } (Section II) is amended to include as an insured the person or organization shown in the respect to liability arising out of "your work" for that insured by or for you. ch instmmce as is afforded by this policy for the benefit of the above ~xlditional insured(s) shall restx~ any claim, loss or liability arising out of the named insureffs Io~erations, and any other the additional insured(s) shall be excess and non-contributory wi~ the insurance provided ght, Insurance Service Office, Inc. 1984 DEC O~ 'gg (18:55 FROM:RI SPENO R. G. SPENO, INC. 40g-gT3-9500 Insurance Brokerage T-?gZ P O1/OZ F-HZ DATE: Dec TO:. ]otto COI~A.~: City FAX#: (-40~ FROM: Cm TRANSMITTAL SHEET -. ~ber S, 1999 of Campbell 376-0958 line Hal'ton **"TBIS-DO~Ubl EI~.C~.OF_ 2. PA~I~S) INELId'DI~G COVE] IF YOU DO NOT RECEIVE PLEASE CAt,L TEE TE~ Attached is the Wm orr ~1-.3099. I trust you will fred Thank- you DOC~T k~'s' Compensation Waiver of Subrogation endorsement tha =he attached in order. LLEGI~LE, we spoke about DEC 08 '99 08:55 FROM:~G SPENO WORKE 408-97~-9500 T-792 P 02/02 We have the right to our ri~t against the perform work under You must n~ntain t work described in the The additional pr, mil othet~vluc alu= on Person or Or~ani CItY OF CJ~P~ BY PUBLIC 70 NOi~ This endorsement cl~n~es fl Republic Inde Compsay No. 19739 Iasured: GEN-CON, Policy Number:. 02.~646-$ Endorsement Number:. Endorsement Effective: Form No. WC306 ~' COMPENSATION AND EMPLOYERS' LIABILITY POLICY ver of Our Rieht to Recover From Others Endorsement ? California WC040306 (Ed. 4.84) ecover our psymcnts from anyone liable for an injury coveredby tim poti~y. W.e ~vffi not.enforce .crson or organization named in the Schedule. This agreement applies on~y to tAe extent ~ you writtencontractthat requffes you to obtnm thia agreement ffomus. ayroll records accurately segregating the remuneration of your employes while enF, aged m the Schedule. tm for this endorsement shall be 5.0 0 % of the CsUforni~ workers' ~ompenntion Schedule ration IBLL KBDBVBLOPM]SNT Job Deseriptlon RE: B?. T.UCY' B CHU~ C~R & AD~ZT/ON, BLVD ~&MPB~LL, CA LC policy to which it is attached and is effective on the daSe issued unless =mnity Company of America® ? 13 qovembor 18, 1009 Prm~l on: O~g3 ,CK ACT1%'ITY 3350 otherwise stated. DecembeF 03, 1900 I glllllmllllllllllllifllllflllllillllllllfll .........................................;.:.:.:.:.:.:.:.:.;.:.:.:.:.:.:.+:.:.:.:.;.:.:.:.:.:.. ..:.:.;.;.:.:.:.:.:.;.;.:.:.:.;.:.:.;.:.;.:.:.:.: .... .... ::::.:i;.:.....:.;...;.;.;:;...;..:. .... :...; .....GENCO~-.-.-.-% .... :.i. 11/18/99 PRODUCER ' T~I'S CERfJFI~ATE'I~ issuED A~;'/~,'M~'~i-'ER'b'F: iN~:'ORMATION R,' G, S~eno, In=, ~ ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 18900 Stevens Creek Blwi. ~200 ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. Cu~rtino, ~ 95014-367,~ COMPANIES A~FORDING COVERAGE Fran~s E. Cook ~ C. P. C ~. COMPANY PhoneNo. 408-973-9500 F~N~ A St. Paul FAre & ~rine Ins. INSURED COMPA~ B ~P~LIC I~ ~CO OF Attn: ~. Paula Mc,~r C ~ '" 800 Cristich Lane ~ C~~ ~ 95008 D THIS IS TO CERTI~ THAT THE POLIO lES OF INSU~NCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED ~ED ~0~ ~ ~ a INDICATED, ~TW~HSTANDING ~Y REQUIREMENT, TERM OR COND~ION OF ANY CO~ OR OTHER ~UME~ W~H RESPE~ TO WHICH TH $ CE~IFICATE ~Y BE ISSUED OR ~' PB~N, THE INSU~CE AFFORDED BY THE ~LICIE$ DESCRIBED HEREIN I~ $UBJE~ TO ALL THE TER~, EXCLUSIONS AND COND~IONS OF $1 JCH POLICIES. LIMITS SHOWN ~Y ~VE BEEN REDUCED BY P~D C~IM$. ' CO ~LICY EFFEC~VE POLICY ~PIRA~ON L~ ~PE OF INSURANCE POLICY NUMBER DATE (MM/DD~ DATE (M~DD~ LIMITS GENERAL LIABIL~ GENERAL AGGREGA~ $ 2 ~ 000 ~ 000 ~ X COMMERCIAL GENERAL LIABILIW ~0830057~ 0~/0~/~ 0~/0~/00 PRODUCTS-COMPIOPAGG $2,000,000 :':' ~ CLAIMS MADE ~CUR ]']']' P~RSONAL & ADV INJURY $1,000,000 ~ OWNER'S & CONTRACTOR'S PROT E~H ~CURRENCE $ ~, 000,000 X Per Proj. Aggreg Fl~E DAMAGE (Any one fim) $ 50 , 000 MBD ~P (Any one pemon) $ 5 ~ 000 A~OMOBILE LIABILI~ A X ANYAUTO ~08300574 01/01/99 01/01/00 CQMBINED SINGLE LIMIT $ 1,000,000 ALL OWNED A~OS B~ILY INJURY SCHEDULED AUTOS (Pdr pemon) X i HIRED AUTOS B~ILY INJURY X NON-O~ED AUTOS (P~racciden0 $ PR 3PER~ DAMAGE $ GARAGE LIABILI~ __ ,.~,u~o OT~E.~.*.*~OO.LV~ ::::::::::::::::::::::::::::::::::::::::: ~CH ACCIDENT $ ~ AGGREGATE $ ~CESS LIABILI~ ~H ~CURRENCE $ i t 000,000 A X UMBRELLA FORM ~08300574 01/01/99 01/01/00 AGGREGATE $ i, 000 , 000 OTHER THAN UMBRELLA FORM $ WORKERS COMPENSATION AND ~ WC ~A~ EL EACH ACCIDENT $ 1,000 , 000 ~ THE PROPRI~O~pAR~ERS~ECU~VE ~ INCL ~56~607 12/11/98 12/11/99 EL ~ISEASE- POLICY LIMIT $ OFFICERS ARE:~ ~ ~CL EL~ DISEASE-EA EMPLOYEE $ 1 t 000 ~ 000 OTHER A ~e~e~/~ ~ip ~08300574 01/01/99 01/01/00 $25,000 DESCRIPTION OF OPERATION~L~A~ON~EHI( :LE~SPEClAL ~EMS ~: ~. ~'s C~u~h ~a~i~i~y Cea~ez [ ~ioa - 2350 ~iaa~es~ez ~ C~ll, ~+~ · , C~-O 3 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ~PIRA~ON DATE THEREOF, THE ISSUI~ COMPANY WILL ENDEAVOR TO MAIL C~ o~ C~~ 30 * DAYS ~N NOTICE TO ~E ~ER~FICA~ HOLDER NAMED TO THE ~ ~0~ ~ep~ L~ BUT FAILURE TO MAIL SUCH NO~CE SH~LL IMPOSE NO OBLIGATION OR LIABILI~ ~ 0 ~0~ ~ ~ ~a~ OF ANY KIND UPON THE COMPANY, ITS ~ENTS OR RE~ESENTATIVES~ C~~ ~ ~500: AUTHORIZED REPRESENTA~VE / / / AI NUMBER: YR99-0 DATE ISSUED: Novel POLICY NUMBER: INSURED: GEN-CO~ THIS EN] ADD This endorsement modi COMME Name of Person or Org City of Campbell - Pul With respects to: St. Lucy's Church Acl (If no entry appears abc applicable to this endor WHO IS AN INSUREI Schedule, but only with CG 20 10 11 85 Copyl 39 nber 18, 1999 K08300574 INC. COMMERCIAL GENERAL LIABILITY ORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (Form B) ties insurance provided under the following: RCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE mization: fiic Works Department ivity Center & Addition - 2350 Winchester Blvd., Campbell,CA ye, information required to complete this endorsement will be shov,n in the Declarations as ;ement.) } (Section II) is amended to include as an insured the person or organization shown in the respect to liability arising out of "your work" for that insured by orfor you. ight, Insurance Service Office, Inc. 1984 PR~UCER THIS CERTIFICATE IS ,~SUED AS A MA/ 1 ER OF INFOR~TION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ~. G. ~no, Znc. HOLDER. THIS CERTIFICATE ~OES NOT AMEND, ~END OR 18900 Ste~ns Cr~k Bi~ . ~200. ALTER THE COVERAGE AFFO}~DED BYTHE POLICIES BELOW. Cu~rtino, ~ 95014-3674 J COMPANIES AF FORDING COVERAGE F=~CiS ~. Cook , C · P. C · U ~ COMPANY PhoneNo 408-973-9500 ~=N0. ~ A St. Paul Fir~ & ~rine Ins. ~NSURED [ COMPA~ ~ B ~P~LIC At~: ~. Paula Mo]~r ~ C r 800 Cristi~ L~e ~ C~ll ~ 95008 O THIS I$ TO CERTI~ T~T THE ~CI~ S OF IN~U~CE M~ED BELOW ~VE BEEN ISSUED TO THE INSURED N~E~ iNDICATED, ~H~DING A~ ~ EQUIREME~, TERM OR COND~ION OF ANY ~~ OR OTHER DOCUME~ · W~H RESPE~ TO WHICH THIS CE~IFtCATE ~Y BE ISSUED OR ~Y ~E~NN, THE INSU~CE AFFORDED BY THE ~CIES DESCRIBED HEREIN IS ~U~E~ TO ~ THE TER~, ~CLUSIONS AND COND~IONS OF SU( :H ~OLI~IES. LIM~ SHOWN ~Y ~VE BEEN REDUCED BY ~ND C~I~. CO J ~LICY EFFE~VE ~LJCY ~PfRA~ON LIM~S L~ ~PE OF INSU~NCE .~" ~LICY NUMBER . DA~ (M~D~ OA~ (M~DD~ A X COMMERCIALGENE~L LIABILI~ ~ ~K08300574 ; 01/01/99 01/01/00 PR~DUCTS-COMP/OPAGG : $ 2,000 , 000 "' C~IMSMAOE , X~ ~CUR PEJ[SONAL&ADVINJURY $ ~,000~000 X OWNER'S&CO~ACTOR'SPROT , ~ ~ :H OCCURRENCE , $ 1,000 , 000 ' ~ FtR[OAMAGE(Anyo~fim) ; $ 50~000 ~UTOMOBILE LIABILJ~ ~ ~ I r A [ X ANYA~O ~ KK08300574 [ 01/01/99 01/01/00 CO148(NEDSINGLELJM~ ~$ 1,000 ,000 __ ALL OWNED AUTOS · BO[ ~ILY INJURY ' SCHEDULED A~OS ~ X HIRED AUTOS ~ , GARAGE LIABILJ~ ~ ; AUT 3 ONLY- ~ ACCIDE~ ~ $ ' J ~ ~CHACCIDE~ S ' [ ~ ' AGGREGA~ , $ ~CESS LIABIU~ ~ ~ ~ ~C fl OCCURRENCE $ [ f 000 t 000 A ~ U~eREL~FOR~ ~ ~:08300574 ~ 0[/0[/99~ 0[/0[/00 AO~EGAm ~S [,000,000 ' O~ER ~AN UMBREL~ FORM ·,~ m c~ ~CC:OENT S I, 000 0 OFFICERS ARE: ~CL ~ I ~ D~SEASE- EA EMPLOYEE $ 1,000, 0 ~ ' Leased/~td m~B [ ~.08300574 J 01/01/99 01/01/00 r $25,000 DESCRI~ON CF OPERA~ON~ON~ICLE ~SP~CIAL ~S '10 ~y notice of c~cell~[tion for non-Da~nt of pr~ ~: ~%~.L~'s Chur~ Ac~:i~ty Center ~ ~tion - 2350 ~inchester Bi~.., 30* DAYS ~N NO~CE TO ~E CER~FICA~ HOLDER NAMED TQ ~E LE~ 70 Nor~ Firsts Street : ~~o- -~s- /~ ' Fr~cis E. Cook, C.P~ Ad NUMBER: DATE ISSUED POLICY NUME INSURED: GE This endorsement COM~ YR99-039 November 18, 1999 ER: KK08300574 ~-CON, INC. ENDORSEMENT CHANGES TFIE POLICY. PLEASE READ T CAREFULLY. )nmOS^L L sktts oa CONTRACTORS (Form B) ~od/fies insurance provided under the following: ~RCIAL GENERAL LIABiLITY COVERAGE PART SCHEDULE COMM! RCIAL GENERAL LIABILITY (If no entry appears abo applicable to this endors WHO IS AN INSURED Schedule. but only with 1 CG 20 10 11 85 Copyrigh information required to complete this endorsement will be sho~ :merit.) espect to -: s out ot your work" for that insured by t, Insurance Service Office,/nc. 1984 m in the Declarations as banization shown in the you. Name of Person or O~ ganization: c~y~, ~.,,. ~l,~~~._,7.Z_~_./_Z,~ ~ ,~., ,~. /; .' St Lucy s Church A~ Center & Addition. 2350 Winch~er Bivfl, C~pbell, C~ NOV ZZ '99 14:ZZ FROM:tG. SPENO 408-973-9500 T-503 P.OZ/03 F-440 PROO~¢ER THIS CERTIFICATE IS ISSUED AS A MA r~hR OF INFORMATION , ONLY AND CONFERS NO RIGHTS UPON THE CER~FICATE R. g. SpenD, ~a~. HOLDER. THIS CERTIFICATE D()ES NOTAMEND, ~END OR 18900 Ste~aa C~eA Sl~[. t200 ALTER THE COVERAGEAFFOR3ED BYTHE POLICIES BELOW. ~=~ino, ~ 95014-367~ ..... COMPANIESAFI?~_~.COVE~GE ~N= ~0.~:973-9500 F~N~ A St. Paul Fi~ i ~=rlne Zne. B ~P~LIC BO0 Cri~t~ L~ COMPLY C~ll ~ 9500e D T~S I$ TO ~1~ T~T THE ~UC ES OF ~U~ U~ ~L~ ~ BEEN ISSUED TO THE IN~RED ~CATED. N~H~DING ~Y ~IR~. T~ OR ~Dff~N OF ~ ~ OR OTHER ~EN F WffH RESP~ TO ~ICH THIS ~RTIF~TE ~Y ~ IES~D ~ ~ PE~NN, ~E ~SU~ ~F~ED BY THE ~LI~ES ~CL~IONS ~ ~N~S ~ SL CH ~LI~E$. ~S SHOWN ~Y ~ BEEN REDUC~ BY PND C~. ~ POU~ EFFE~VE u~ ~l~Oh O~ bl~ GEF E~ AG6]R~A~ $ 2 r O0 Oz~ 0 A X COMM~O~XLL~ ~08300574 01/01/99 01/01/00 ~CDU~S-CO~,~,~OO S2.000.O00 X ~&CO~mO~SP~T ~C~R~E~E~.._ $ 1,000,000 ~EC ~P (A.y ~. ~) S S ~ 0 0 0 A X ~YA~ ~08300574 01/01/99 01/01/00 ~L ~ A~OS ~D~LY INJURY G~GE U~ A~ ~ ONLY - EA ~O~ $ __ ~CH ACCID~ LIABI~ ~c~ ~c~ s 1 ~ 000 t 000 EL E~CH ACCmE~ S 1,000 ~ 000 A ~as~/~ E~ip ]K0830057~ 01/01/99 01/01/00 $25,000 C~--O3 ' ~LD ANY OF ~ ~ D~R{B~ F OUCI~ ~ CANCE~ B~ORE ~E ~ 0 ~ DAYS ~ ~E TO NOV ZZ '99 14:22 FROM:I Az NUMB£R: YR99~ DATE ISSUF-D: Nov~ POLICY NUMBER~ l INS~: GEN-CO 'IRIS EN ADI This endorsement mo~ CO~ Name of Person or Org The City of Campbell The City of Campbell With respects m: SI. Lucy's Church A~ right-of-way, City of volunt~.rs. (If no entry appca~ abo applicable to this ending. WHO IS AN 1NSUREE 8cttedule~ but onJy with PRIMARY INS~RANC~ It is further agreed that be pdma~ imur~ as t i~smancc maimam~ ~ CG 20 10 I1 85 Copyri G SPEN0 408-973-9H00 T-B03 P.03/03 F-440 )41 tuber 22, 1999 COMMERCIAI DORSEMENT CHANTS THE POLICY. PLEASE READ IT CA ~ITIONAL INSURED - OWNERS, LESSEI CONTRACTORS (Form B) ties insurance provided under thc following: RCIA!, GENERAL LIAB!I,ITY COVERA SCHEDULE mization: and Rcdcvciopment Aieucy,its officers, employees and volunteers. OENERAL LIABILITY REFULLY. ',S OR GE PART ivily Center & Addition - 2350 Winchester Blvd., Campbell,C~L All work in public ~ cmpioyces and Campbell, City of Cnmpl~il Redevelopment Agency, its o~ccra, ~c, iz~'ormafio~ requircd to complete this endor~.mcnt will be shoran in thc Declarations as emeat.) (Section 11) is amended to include as an insured the person or oq,,aniz, ation shown in the ~ to llabtllty arising out or"your work" for that insured by or ."or you. ch insuran~ as is nffordcd by this policy for thc lx~fit of thc above a~idifional insured(s) shall ~ any claim, loss or linl~lity arising out afthe named ~mred's~fim=, and any other tl~ additional in.~s) shall be excess and non-contributot~ wi~ tl~ in:mrancc i:aovidcd hr, Insurance Se~ice Olticc, Inc. 1984 PRODUCER THIS CERTIFICATE IS ISSUED AS A MA~FER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE R. G. SpenD, ThC. HOLDER. THIS CERTIFICATE DOES NOTAMEND, EXTEND OR 18900 Stevens Creek Blvct #200 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Cupertino, CA 95014-3674 COMPANIES AFFORDING COVERAGE ! Francis E. Cook, C.P.C. U COMPANY Pho,eNo. 408-973-9500 F=No. . A St. Paul Firel & Marine Ins. INSURED COMPANY B REPUBLIC IND CO OF AMERICA Gan-Con Inc. COMPANY gM~OM Att~: Ms Paula Mo] Lr C · Boo cristi '.ane OOMPANY 1 Cam[nbell CA 95008 D THIS IS TO CERTIFY THAT THE POLICI! S OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDIABo~ ~IL~ ~ll~Q~ ~ INDICATED. NOTWfTHSTANDING ANY ~ rEQUIREMENT. TERM OR CONDrrlON OF ANY CONTRACT OR OTHER DOCUMENT WrrH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY ~ERTAJN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS ~UBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SU~ :H POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAiD CLAIMS. ?TO POLICY EFFECTIVE POLICY EXPIRA~ON I TYPE OF INSURANCE POLICY NUMBER J I DATE (MM/DD/YY) DATE (MM/DD/YY) ! LIMITS GENERAL LIABILITY I GENERAL AGGREGATE I S 2,000,000 A i. Xl CO,~MERC,ALGENERALL,AB,UTY , ~08300574 Ol/O~/99 ol/ol/oo PR~DUCTS-COMP/OPAGG $ 2,000,000 i:i~i:~! I O~"MS~ADE i x Jocc~Rl I PE~SONA''^DV'NJURY * z,ooo,ooo ix! OWNER'S & CONTRACTOR'S PROT ] II EA(~H/OCCURRENCE $ 1,000,000 X ~: Per Proj · Aggreg i i FIR~ DAMAGE (Anyone fire) $ 50t 000 ' 5 000 ! , i AUTOMOBILE LIABILITY ~ I i COmBiNED S~NGLE UMIT $ 1,000,000 ~ ~ ANYA~O ~K08300574 0~/01/99 0[/01/00 ~, ~ ALL OWNED AUTOS BO~,LY ~NJURY SCHEDULED AUTOS I 1 HIRED AUTOS BOdiLY INJURY (pe~ accident) No~ovv. Eo AUTOS j pRgPERTY DAMAGE ! GARAGE LIABILITY { [ AUT~ ONLY - EA ACCIDENT i ANY AUTO II , OTHER THAN AUTO ONLY: ' I ] ! AGGREGATE $ I EA¢ H OCCURRENCE $ I, 000 , 000 ~i EXCESS LIABILFP¢ i A i ~', UMBRELLA FORM I{K0830057~ 01/01/99 01/01/00 i AG(REGATE $ 1,000,000 OTHER THAN UMBRELLA FORM i i $ WORKERS EMPLOYERS' COMPENSATION L ABILrT'¢ ANDf ~ ~J~ _...~1~.~/~. ! [ITM IIWC STATU- i J :TH- ER --¢ ~ EL ~ACH ACCIDENT $ 1 ~ 000 ~ 000 TH~PROPR~O~ it ~NCL 2564607 12/11/98 12/11/99 EL~ISEASE-POUCYLIM~ $ 1~000 ~000 B i PART~ERS/EXECUTIVE OFFICERS ARE:~ EXCL!, ~ EL/~iSEASE. EA EMPLOYEE S 1,0OO, 000 i OT'ER ~ i ~ [~ T.easect/Rntc[ ~.qui~ 1~E08300574 01/01/99 01/0[/00 ; $25,000 I DESCRIPTION OF OPERATIONS/LOCATIONSA/EHIC[ ES/SPECIAL ITEMS '10 day notice o~ cancel]..at£o.n ~o_r .noa-pa~nt o~ pr~m{~um... RE: S~. T.u_cy's Church ~¢ C~-mbell,cA ~~;~Y ~ea~e= · Actdit~on - 2350 ~achester B~.., ~~~ CITY- 03 SHOULD ANY OF THE ABOVE DESCRIBE[] POLICIES BE CANCELLED BEFORE THE ~. ~ ~ ~ EXP1RA~ON DATE THEREOF. THE ISSUIN~COMPANYW]LL~MAIL City of Ca~ll 3 0 * DAYS vvRn~EN NOTICE TO THE CER~FICATE HOLDER NAMED TO THE LEFT. ~lic Works Oema=~n~ ~ c 70 North ~£r~t~ S~reet ~~o frs .~ ES~, Carol:bell CA 95008. AUTHOf~[ZED REPRESENTATIVE - -- / / / AI NUMBER: YR994~ DATE ISSUED: Nove~ POLICY NUMBER: INSURED: GEN-COP TI-IlS EN] This endorsement modi COMME Name of Person or Org; City,,; Caaq, b~:ll - gui With respects to: St. Lucy's Church Act (If no entry appears aba applicable to this endor: WHO IS AN INSURE[ Schedule, but only with CG20101185 Copyr 39 nber 18, 1999 K08300574 [, INC. COMMERCIAL GENERAL LIABILITY )ORSEMENT CHANGES THE POLICY. PLEASE READ IT C~REFULLY. ITIONAL INSURED - OWNERS, LESSE~S OR CONTRACTORS (Form B) ties insurance provided under the following: RCIAL GENERAL LIABILITY COVERA GE PART SCHEDULE ivity Center & Addition - 2350 Winchester Blvd., Campbell,C3 ye, information required to complete this endorsement will be sho~ m in the Declarations as ;ement.) ~ (Section Il) is amended to include as an insured the person or o~ ganization shown m the respect to liability arising out of "your work" for that insured by or for you. ight, Insurance Service Office, Inc. 1984 WORKEI~'s COMPENSATION INSURANCE INF( The following wor~e~r's compensation insurance information is required Contractors. One l>f the following items for each Applicant and Contrac prior to working m~der a Public Works permit or contract. WORKERS' COM Name of Contracto A Certificat, A Certificat Insurance C Policy No. A signed C below. I certify that in th, person in a manne California. Signed Title NOTICE TO AP1= Exemption, you st Labor Code, you will be cancelled ?ENSATION INFORMATION: '/Applicant Gen-Con, Inc. of Consent to Self-Insure issued by the Director of In of Workers' Compensation Insurance Republic Indemnity Co. of America 256/4607 Expiration Date 12/11/' :rtificate of Exemption from the Workers' Compem CERTIFICATE OF EXEMPTION )RMATION for all Applicants and tor must be submitted :lustrial Relations; OR ; OR ation laws as printed performance of the work for this contract, I shall m>t employ.any so as to become subject to the Workers' Compensal ion Laws of Date LICANT/CONTRACTOR: If after signing this Certlficate of tould become subject to the Workers' Compensation i~>fovision of the nust forthwith comply with such provisions or the Pe.C'mit or Contract ,r revoked. j:\forms\workcomp(rev6 '96) APPRC-V~_ Public '-- D3s Gatos; CA~9~O ........... _L_:, .............. :_:Z July 14, 2003 Diocese of San Jose 900 Lafayette Street, Santa Clara, CA 95i SUBJECT: PER~ LOC, MAIl Gentlemen: The City of Campl improvements and fi Your warranty requi Your warranty depo Finance Department Sincerely Alan Hom Senior Public Work,, MQ p,~ cc: Permit 99-201 Public WorksfM .o~ CITY OF CAMPBELL Public Works Department Suite 301 )50-4966 41T NO. 99-201 kTION: 2350 S. Winchester Blvd. (St. Lucy's Church) ;ITENANCE INSPECTION - ACCEPTANCE CAMPBELL ~ell has made the final maintenance inspection of subject Public Works nd that no remedial work is required. :ements and any surety, therefore, are hereby released. ~it of $1,900.00, plus any interest due, will be sent dire( tly to you from our Inspector fintenance Division H:\permits\99-201 2340 ,inchester mtceacc(mp) 70 North First Street · dampbell, / California 95OO8-1436 - TEL 408.866.2 150 · FAX 408.376.0958 · TDD 408.866.2790 September 13, 2 Gen Con, Inc. 800 Cristich Lat Campbell, CA Re: EncroaC 2350 S. Gentlemen: Enclosed please your $296.00 ca Encroachment P Sincerely, Marlene Pomerc Department Sec~ Enclosure O~ · CAdg.~' :~ r~ CITY oF CAMPBELL Public ~O(/orks Department 001 [e )5008 wnent Permit 99-201 Yinchester Blvd. (St. Lucy's Parish) find the City's check in the amount of $323.89 representing a refund of Dh deposit, plus interest, that was deposited at the time y~u applied for ermit 99-201. 'etary 70 North First Street · campbell, California 95008-I 423 · TEL 408.866.2150 · F^X 408.376.0958 · TOD 408.866.2790 C~TY OF CAMPBELL CAMPBELL, CA. 1(')1.54(.') 7448 ! C) 1 (])(')(:)(])2626 GEN CON I NC REFUND DEF' REFUND DEF' REMITTANCE ADVICE - PLEASE DETACH BEF{ ~ CITY OF o o 70 NORTH ," a CAMPBELL, C RE BANKING PAY VOID AFTER 90 DAYS 11-35 BAN CAMPBELL ~2~o c^b` 125 --IRST STREET CAb' %IFORNIA 95008 DA 27.89 DEPOSIT INTEREST #99-201 296.0C) REFUND DEPOSIT #99-2C)1 THREE HUN GEN CON INC 800 CRISTICH L CAMPBELL CA 95 DRED TWENTY THREE DOLLARS & 89 CENTS SIGNATURE - --j...¢.~r · . ~ ~ ~ .... - | / .,.-...~,--/ :; . . ANE -' · ~'"'-->' --',7--' ' /"""~;'~'"'----'--. ', :)08 , ., .... ~ . ( OF AMERICA WARRANT NO. PBELL OFFICE caM,.,,E,,_,VE. 89219 DBELL. CA_ 95008 rE 08/27/01 89219 *******323.89** WARRANT NO. 89219 AMOUNT August 15, 2001 Diocese of San Jose 900 Lafayette Street, Santa Clara, CA 95~ ATTN: C. Tully SUBJECT: PERi LOC FINt Dear Mr. Tully: The City of Campbe work to be acceptabl the improvements· The one year mainte The permittee is resl occur within one ye: writing, whether or The City will requir the maintenance perit Gen Con's Construc will be sent to them 75% of your Faithfi now being processe( your FPS cash deposi If you have any quest Sincerely, Alan I-tom Senior Public Works MQ ¢&_, Suite 301 )50-4966 VlIT NO. 99~201 .0f · C44q/~ CITY OF CAMPBELL Public Works Department ATION: 2350 S. Winchester tL INSPECTION AND ACCEPTANCE has made a final inspection of subject Public Works impr(~vements and finds the and in conformance with City standards. Accordingly, the City Engineer accepts tance period stated in the permit begins as of the date of ~onsible for the repair and/or replacement of any defective tr. The City will inspect the improvements within one y~ ot any repairs are required. you to post a Maintenance Bond in the amount of $1,850. }d. ion Cash Deposit of $296.00, plus any interest due, is nov nder separate cover. Performance Surety (FPS) cash deposit of $5,500.00, plt and will be sent to you under separate cover. We will co: as a maintenance surety. 2ns, please call me at (408) 866-2168. [nspector this acceptance letter. work or failures that ~.ar and notify you, in 00 for the duration of being processed and ts any interest due, is ~tinue to hold 25 % of cc: Suspense - 1 Il months Permit #99-2q) 1 Inspector Fil~ H:\permits\99-291 maint acce!t(mp) 70 North First Street · CUmpbell, I California 95008- I 423 · TEL 408.866.2150 · F.5X 408.376.0958 . TOD 408.866.2790 "~ ENVIROSCAPE Irrigation · Installation · Maintenance · Design Complete Landscaping Sen/ice Lic. # 451332 P.O. Box 1867 (831) 722-2242 Watsonville, CA 95077 Fax: (831) 722-2242 August 21, 2001 Diocese of San 900 Lafayette S Santa Clara, C) Re: 2350 S. Encroac Plan Ch, Gentlemen: Enclosed is a~ representing a r permit. Please contact this refund. Sincerely, ~/Joanne M. D'A~ Principal Clerk J:\LD\DIOSJ .0¥' c44qa CITY OF CAMPBELL Public Works Department ose reet, Suite 301 ~5050-4966 Winchester Boulevard - St. Lucy Parish arnent Permit No. 99-201 ~ck Deposit Refund :heck in the amount of $500.00, payable to the Dioc ~fund of your plan check deposit in connection with the :he undersigned at (408) 866-2158 if you have any qu nbrosia ese of San Jose, above-referenced estions regarding 70 North First Street · Campbell, California 95008-1423 · TEL 408.866.2150 · FAX 408.376.0958 · mD 408.866.2790 0 0 ,.-, 0 0 0 C [11 Z City of Campbell Department of Public Work ITEMS RI~QLrIRED FOR _~.A..pplicant sec!ion c f~&pplicant signature _/' J~ermit Application Engineer's Estimate _E?"'ROACHMENT PERMIT ISSUANCE cl:rv~K LIST Encroachment Permit No. Tract No. Address: PERMIT APPLICATION: )replete and date (front and back) Fee $225.00 paid - Receipt Number Submitted Paid (2% of Engineer's Estimate, $500 rain) Receipt Number YHan Check Deposi~ e Sets of Impro~ ement Plans Submitted ri'EMS REQUIRED PRIOR TO PUBLIC WORK CLEARANCE FOR BUILDING PER~v[grs ~/'~FP-Is~imCa~:C>k ~2~s0.~(~io~h:;74cmlfalEn~Te.~'s~ Es~otimate < $250,000, thereto.., f_Enflineer's~ Estimate;, If Engineer's · , , r~off,,.) .0 %. (Deposit of 8 % of Engineer s t:sti mate required; $,0,000 minimum deposit). A~aount $ f/Jr Receipt No. /.,~ ~b~Secu_fi~ for Faith? Performance and Labor and Materials, 100% each of ~ngineer'i' Estimate,' supplied or paid Amoun S 7~"f'~ Form "'~ I.D. #/'~,,' _~',~fd.:~j~,.~ ' ~ Security for Monun~nmtion Amount S_ ~ Receipt No. b/' Construction Emer_g~,ncy Cash Deposit: 4% of Engineer s Estimate. ($500 minimum4 $10,000 maximum) ' Amount $ ~, r_/~ Receipt No..~_~_~_~.,~ ,~"//~ Storm Drainage Are: .f/)'//~ Worker's Compensa f"/' All other Public Wo: Other Fees, Paymem t Fee Amount $ Receipt No. [ :ion Insurance Information Sheet Received for Applicant. ks requirements listed in the Conditiom of Approval of the devel~pment./tv, fcc s, Deposits Amount $ Receipt No. TO ISSU.4a'qCE OF ENCROACHMENT PERMIT: added to the permit application (front and back) m Insurance Information Sheet received from Contractor. :e with Additional Insured's Endorsement received from Applica tr blueline sets of off-site plans signed by licensed engineer, sm Engineer. at or Contracto~o~, ,.L ~ped APPROVED FOR Issuer: Initial f' [ ;f2yVON ISSUANCE, j:\word\forms\pmmklst rev. 4/97 ALI. OF THE ABO5 Permit signed by Cit ITEMS REQUIRED PRIOI~ ~/CC0ntractor's signatur // Worker's Compensat Certificate of Insurar t.-""~OnOne mylar set and fo CONSTRUCTION. ITEMS ARE COMPLETE, PEI~.MIT MAY BE ISSUED. and date and f'fle with permit. NITIATE CHECK REQUEST FOR PLAN CHECK DEPOSIT REFUND CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT ENGINEER'S ESTIMATE Address: 2350 S. Winchester Date: I I / 17/1999 ENCROACHMENT PERMIT NO. ~9-201 APPLICATION NO. M98-12 ITEM UNIT PRICES FG R PROJECT AMOUNT NO. )ESCRIPTION UNIT QTY < $30 K $30 K [o $150 K > $150 K $ AMOUNT I. SURFACE CONSTR JCTION MOBILIZATION I LS $ 250.00 i $ 250.(.X) CONSTRUCTION TI~ AFFIC -~ONTROL/PHASIN( I LS $ 250.00 $ 250.0{) , CONSTRUCTION Sq- &KING LS CONSTRUCTION TE STING I LS $ 250.00 ~ $ 250.00 1I. DEMOLITION/CLE kRING I. CLEARING & GRUB [lING LS $500.00 2, SAWCUT P.C.C./A.IL(UP TO 6") 54 LF $4.50 i $3.00 $2.00 $ 243,/)0 3. P.C.C. REMOVAL 2 SY $30~00 ! $23.00 $10.00 $ 60.00 4. CURB AND GUTTEI~ REMOVAL 43 LF $6.00 $300 $200 $ 25800 5. MEDIAN REMOVAl SF $4,50 I $2.25 $1.25 6. DEMOLISH EXISTII' [G INLET/PLUG RCP'S EA , IlL STORM DRAINAGI 1. 12" R.CP. (CLASS ') LF $60.00 [ $4000 $20110 2. 15" R.C.P (CLASS [I) LF $65.00 $48.00 $38.(I0 3. 18" R.C.P. (CLASS II) LF $70.00 $60.00 $52.00 4. 24" R.C.P. (CLASS I1) LF $80.00 ~[ $68.00 $59.00 5. 30" R.C~P. (CLASS Ill) LF $90.00 [ $75.00 $65.00 6. T.V. INSPECTION , 2") LF $1.20 I $0.75 $0,60 7. STD. DRAINAGE lb LET EA $1,600.(X) I1.300.00 $1,000 00 C.C. DETAIL 5) 8. FLAT GRATE INLE EA $ 1,400.00 ~ 1,10000 $91X).00 C.C. DETAIL 6) 9. STANDARD MANH )LE EA $2,000.00 11,600.00 $1,300.00 INCLUDES FRAM[ & LID) 10. BREAK AND ENTE M.tt./D,I. EA $700.00 i $550.00 $450.(X) ITEM UNIT PRICES FO R PROJECT AMOUNT NO. )ESCRIPTION UNIT QTY < $30 K $30 K to $150 K > $150 K $ AMOUNT IV. CONCRETE IMPR(] VEMENTS 1. SIDEWALK 115 SF $6.50 I $4.50 $2.75 $ 747.50 2. DRIVEWAYAPPRO~CH 209 SF $7.50 I $5.50 $375 $ 1,567.50 3. UURB AND GUTTEI~ 43 LF $22.00 I $18.00 $15.00 $ 946.0{) 4. VALLEY GUTTER SF $12.50 ~ $10D0 $8.25 5. !CURB RAMP EA $1,20000 $800.00 $700.00 6, TYPEB-I CURB LF $12.(X) [ $9.50 $7~50 7. TYPE Al-B3 CURB LF $15.00 $12.00 $10.(X) 8. COBBLESTONE MEI~IAN SURFACE SF $12.00 '~ $8.00 $5.00 9. P.C.C. DRIVEWAY :ONFORM SF $7.00 [ $5.50 $4.50 10 A.C. DRIVEWAY C(~ NFORM SF $450 $3 75 $3.00 ¥. PAVEMENT I 1. ASPHALT DIGOUT ,ND REPLACE 43 CF $5.00 I $3.50 $2.5(I $ 215.0{) [ 2. PAVEMENT WEDGE CUT (6') LF $5~00 [ $2.50 $150 3. PAVEMENT GRINDIX!G 43 SF $0.80 ! $0.50 $0.35 $ 34.40 4. PAVEMENT FABRIC (PETRO-MAT) 5 SY $2.00 I $1.85 $1.50 $ 10.(X~ [ 5. ASPlfALT CONCRE'I E (TYPE A) T $80.00 , i $50.00 $3500 $ 800{) 6. AGGREGATE BASE CLASS 2) T $40.0{) i $20.00 $12.00 7. SLURRY SEAL (TYP ~2 Il) SF $0.07 ' $0.06 $0.05 8. SLURRY SEAL (TYP ~ Ill) SF $0.11 $0.09 $0.07 VI. TRAFFIC SIGNALS~ LIGHTS 1. DETECTOR LOOP (6' ROUND) EA $450.00 $30{L00 $25000 2. DETECTOR LOOP (6' x 30') EA $650,00 15540.00 $440.00 3. DETECTOR LOOP (fi' x 50') EA $900.00 15750 00 $64000 4. ELECTROLIER EA $2,600.00 $~,200.{X) $ 1,80{I.(X1 5. 1/2" RIGID COND[ IT LF $9.00 I $7.00 $5,00 ITEM UNIT PRICES FO~, PROJECT AMOUNT NO. DESCRIPTION UNIT QTY < $30 K $30 K Io;150 K > $150 K $ AMOUNT 6 2" RIGID TRAFFIC SIGNAL CONDUIT LF $ 17.00 $ 1300 $ I(LI)0 7 CONDUCTOR LF $ 0~7(}$ i 0.55 $ 0.45 8 PULL BOX (NO. 3 1/ [) EA $300.00 1240.00 $185.00 9 TRAFFIC SIGNAL PIILL BOX (NO. 5) EA $400.00 ~350.00 $30000 VII.STRIPING AND SIG qS 1. REMOVE PVMT. M/ RKINGS (PAINT) SF $2.50 I $1.50 $1 00 2. REMOVE PVMT. M/ RKINGS (THERMO) SF $3.00 I $2.00 $1.40 3 REMOVE PVMT STI~ IPING LF $1.40 [ $0.80 $0.4{} 4 STRIPING DETAIL 9 LF $1.35 $0.85 $0.35 5. STRIPING DETAIL 2 ~ (THERMO) SF [ $3.80 6 STRIPING DETAIL3!(THERMO) SF [ $3.80 7. STRIPING DETAIL 3~ (THERMO) LF $1.85 $1.50 $ 1.00 8. STRIPING DETAIL 3 I (THERMO) SF $3.80 9. STRIPING DETAIL 3 LF $1.50 [ $0.85 ${}45 10. STRIPING DETAIL 41 LF $2.20 [ $1.70 $1.00 11. LIMITLINE LF $1 35 ! $1.05 $0.90 I 12. CROSSWALK, 12" WHITE LF $1.35 $1A)5 $0.90 12.5 NEW CURB, RED p,6INT LF $1.35 13. PAVEMENT MARKIIlGS (PAINT) SF $2.50 i $3.80 $1.60 14. PAVEMENT MARKIltGS (THERMO) SF $5.50 I $3.80 $2.60 15. PAVEMENT MARKE ~ (NON-REFL.) EA $4.50 $3.00 $2.20 16 PAVEMENT MARKE ~. (REFLECTIVE) EA $6.00 [ $4.15 $3.15 17. TYPE K MARKER EA $9500 [ $80.00 $70.00 18. TYPE N MARKER EA $95.00 $80.00 $7{}3.)0 19. SALVAGE ROAD Sb N EA $85.00 $75.00 $651)0 20. RELOCATE ROAD Si GN EA $100.00 $85.00 ITEM NO. 21. INST. RD. SIGN Ob 22. ROAD SIGN WITH P~ VIII. LANDSCAPING I. IRRIGATION, PLANq 2 PRUNE TREE ROOT 3 TREE REMOVAL 4 ROOT BARRIER (12' 5 ROOT BARRIER ( 18' 6. STREET TREE (24" 7. STREET TREE (36" TOP SOIL BACKFIL IX. MISCELLANEOUS 1. PEDESTRIAN BARRII 2. CHAIN LINK FENCE 3. RAISE MISC. BOX T~ 4 RAISE MANHOLE T( 5, INSTALL MONUMEN 6. MEDIAN BACKFILL PREPARED BY: CRIJZS. GOMEZ REVIEWED BY: [. HAROLD HOUr APPROVED BY: *See Section 66499.4 of the Map Act. ~ESCRIPTION :-XIST. POLE )ST 'lNG WORK 3X) iR 163 GRADE GRADE BOX .EY UNIT QTY EA $200.00 EA $3(X).00 SF EA $125.(X) EA $650,00 LF $20,00 I.F $250O EA $450.00 EA $700.00 CY $15,00 LF $75.00 LF $15.(X) EA $300.00 EA $400.00 EA $450.00 CY ] $19.OO UNIT PRICES FOf < $30 K $30 K to $150 K M45.00 t240.O0 $3.00 Il (X1.00 500.00 , $ lO(X) $15OO 325.00 550.00 $60. tX) $11.50 200.OO 275.00 $350.00 $17.OO 10% SECURITY ENFORCJEMENT FEE TOTAL ESTIMATE FOR :AFFIIFUL PERFORMANCli SECt/RI FY PROJECT AMOUNT > $150 K $11000 $195.00 $85,(X) $400 00 $6.00 SI(MX) $25OO0 $400.00 $5000 $9.25 $175 00 $20(}.00 $300.{}0 $15,50 SUBTOTAL $ AMOUN'F $ 1,8(X).(X) $ 6,711.40 $ 67114 $7,382.54 $7,400. h:\laIlddev\2350SWinchester.xls(ir p) BOND NO. 11133463122 PREMIUM: $100.00 We, the undcrsi ~Contracwr ') and _THE of ~e Sram of NEW California. as Surety, are of thc Stare of Californi: Dollars ($ 7,4.00.00'~ jointly and severally by ct Tim cot~ition o( BOND FOR F~ PERFORMANCE gned GEN-CON, INC. AMERICAN INSURANCE COMPANY , a corporation Because the obli Contract with the City constmcfiou of Project Now, theft:fore, and contract documcrll~ with or without notice ro tully indemnify and ~ve and shall reimburse and ohli§ation s~mlI be void; pertbrmance of all of Con~ If any legal acfic under the Con,tact cxcludi of Santo Clara, State of C time. alteration or addifio accompanying it shall in change, ex~nsioa of time, them:by waiv~ the pmvisi~ In witnr.~, thc p~ (Agach A~:lmowlcdgements (Both Principal's 'and Surcty's Attomcy in Fact) O:\forms\fpbond) (rev I0/ JERSEY , and auflmrizcd to transact I obligated m the City of Campb,-ll. (hereinaRer "City") a municipal ct ., in ~ sum of SEVEN THOUSAND FOUR HUNDR~ED DOLLAR ~*****) tbr the payment of wkich sum we ot~ligate ourselves and .e t~llowing provisions: , (hereinafter 2rgarazr. d under the laws ,usiness in tl~e Sram of rporauon unc. h~r the laws & NO / 100'***** successors and a~sign~, this obligation is: br the Project, a copy of which contract is attached and made al pag of this Ix)nd. tbr ST LUCY'S CHURCH ACTIVITY CENTER & ADDITION[ if the Contractor shall faithfully pertbrm the work in accordance with ~ring the original term, ami any extcnsion~ or' thc cotltracl which may 3e surety, ;ma if it sh~l satisfy all claims and demands incurred unde armless the City from all costs and damages wlfich it may suffer by re '.pay the City all outlay and expense which the City may incur in therwi~ to remain in full force and cffect, with surety obligated to ractor's obligatlans under thc attached contract. n be filed upon ti:is bond. it shall be flied within one year at~r final ag the warranty period, if ally, provided tbr in tim Contract, and venu flifurnia, and that surety, tbr value received stipulates and agrees that 1 to the terms of the Contract or to the work m be performed under my way affect its obligation on this bond, and it does by this mca alteration or addition to the terms of the Contract or ro the work or u }ns of Section 2819 of the Civil Code of the State of Calitbrnia. NOVEMBER 22 riles have executed tl~ agreement as of the plan~, specifications he granted by the City, r the uomracL and shall ason nf failure to do so, ag any dePault, then :ute the full and faithful 3ayment has been made : shall lie in rile County ao change, extension of it or thc specifications ls waive notice of any the specifications, and .19 99 (Pnnmpal) A1 Anzoa..~A.~e~ President (Surety) THE AM~ ~IJ.~I~URA]~CE BYF~NCIS E.~ A~ess ofS~l ~ET SAN F~NCISCO, CA 941~)5 S~e~'s ~nd Numar 11133~63122 (Accomp~ ~s bond wi~ A~ey-in-t~ct's au~ori~ ~m ~fied to i~l~e ~e ~ of ~ ~nd.) 70RNEY-IN-FACT ST. , TOWER )9) 10TH FLOOR We. the undersigned THE ,AMERIQ~N INSUi _ NEW 3ERSEY obligat~t to the City of Campt for me payment of wWch m pmv~io~: The condition of ~ City da~ed .-~/-/~.-~z~z' ~r~le and corr~cz copy of whi( hereby referred to ST. LUCY'S CHURCH Because Principal is r subcontracrnrs, shall fail rn pay or for amounm du~ under the m will pay for the debt, in a~ amc reasonable attorney's fee m be BOND NO. 11133463122 BO1¥ FOR LABOR AND MA~.~AL ~REMIUM INCLUDED IN PERFORMANCE 3NDI GEN-CON, INC. LA. NC E COMPANY · , ~ .,,tlamiz~ lo tmmact ~ in fl~ !mm [of California, as Suxtty, ¢11 ('am~im~r 'City'), a municipal c. orlx~aio~ _u~.,- the law~ of th¢[$~at~ of California, in the sum IR HIINDRED DOI,I,AR~ X. NO/10()*********** Dot~($i 7 AQD ~1 we 0blig~ ourselves ,nd mm' sm::~.sors mx[ mmigns, jointly ax[ ~ver~lly by the f~'llowing NOW, ~erefore. we, obligated to the City of Campbe lawful money of the United ourselves, succ~sors and assig~ The condition of this fail m pay for any labor, mamri due under the unemploymem ira amour~ ~ot cxce~din§ the sum fee. m be fixed by the court. No prepayment or dela, in any pl,va and specifications n liability on this bond, ami conse ~he Surety h~reby waives the pro' In ~imcss, the panics h (Arc,ch Acknowlcdgemenm) (Bo~h Principal's and Surety's Armrnay in Fact) (j :\word\forms\l&mbond) obh~gation is that the Principal =nm~d, ar is ~bout r~ enter, into a c~ 'h is pmsemly On file in zt~ office of r.~ Ciqr Clerk of the City of C~ and made a part hereof. TM · ~CTIVITY CENTER & ADDITION xaln wri~n Cona-act ~ the npbell, which said Coat, tot is comract is entitled: ~iuired m furnish a bo~ in conneerion with ~!~ contract, providiag for any mamrials, or other supplies, or for any work or labor on ~employmem insurance act with r~p~c~ m any work or labor on this p ua not exceeding tim sum specified in this bond, and also, in case su THE AMERICAN ~N-CON, INC. ., ~ Pria~ipal. AND INSURANCE COM]~ANY , ss Stu~y, are cs, far ~he paym~n£ of which s~ms will and n-uly m be made. we th~ ~aid Principal and Surety bind s, jointly and se~rally, by ~s~ provision. ~Iiga6on if Prir~ipal, im suc¢~ssor~ or ~.~ign.s, or ia snbcomr,tor, or snb¢omracmrs, shall ali, or o~er snppli~, ~ed in ~ l~rforma~e of rl~ wo~ ¢o~-a:m~i m be ursnce ~c~ with r~pe~ m rigs work or labor. ~hen the Sur~ on this ~ifi~t in ~ bond, ami in csse mi~ is brougl= upon ~ ~nd will al!b pay a r~aiomble awmey's fiat if Principal, or any of its ¢onwaet~d work of any · eject, the Surety on this bond. is brought upon thc bond, a , in payme~ a~d ao almages, extensiora. ~dirlon or altm'~tion of any provision of said Contract or ferred m h~rein, and no fofc~a~uc~ on the part of the City ~h~ll ~cr,,m m release the Surety from it to make such alt~ra~as without furfl~r notice m or conse~ by the Surety is hereby given, amd ,isions of S~'tion 2819 of thc Civil Code of th~ State of California. [ ~ve executed this agreeraent as of NOVEMBER 22 , I9. 99 Tide ~,-'~ T C ~-., ~ ($ur~Ai A_nzo~t~g~, l~r~$idont BYFRAN~I S~//~i/./L~ '"~ TI~.~RN'kY'-'~N-FAC T Addr,r~ofSu~,:l MARKE~7 SFB-A.Pq ST., TOWER SAN FRANCISCO, CA 9~105 ~ $urcty'$ Bond Nua~r 11133463122 (Accompany this bond wire Al~orney-in-fact's authority from Surety to ex, cute the bond, certified ~o/m:lude fl~ da~e or,he bond.) IOTH FLOOF NATeONAL SURETY C THE AMERICAN INSU KNOW ALl. MEN FIY TItESE P an liimtns corporation. 'DiE A, CORPORATION. a Califorma cc Cumpamcs') docs each hereby app the,r !me and lawful ,.\lh)rncsts)-in- and Io b/nd Ibc Companies Iherebv: aHestcd bv the Companies' Sccrcl~.p This power of attorney is granted CORPORATION. TH'E AMERICi COMPANY which provisions arc no This power of a!tornc;, is signed am COMPANY,: N,,\TIONiAL SURETY AUTOMOBILE INSURANCE CO~ amcmied or repeaJed: "RESOLVED, that lhe si Companies may be affixe facsimiie, and any power be valid and binding upor IN WITNESS \VHEREOF, the Co S Lns ~- day of BOND NO. 11133463122 FIREMAN':/ FUND INSURANCE COMF Y DRPORATION ASSOCUkTED INDEMNITY CORPORATION [lANCE COMPANY AMERICAN AUTOMOBILE INSURANCE COMIS\NY GENERAL POYVER OFA'I'I'ORNEY [ ~F~$ENTS: That FIREM/\N'S FUND INSURANCE COMPANY, a Calilbrnia corporation. NATIONAL SURETY CORPORATION. ,IERICAN INSURANC'E CO.".IPANY, a Nc',,,,' Jersey corporation rcdomcsLlcatcd tin Nchruska. ,,\S,'SO('IATITD !NDEMNIT'h rporation, and AMERICAN AUTOMOBILE INSURANCE COMPANY, a Missuuri/corporalmn, (hcrcm collcch,.ch called "thc ,nt Ronald G. Speno and Francis E. Cook, Cupertino CA Fact. whh full power of aulhori!v hereby con(erred in their name. place and stead, m exctutc, seal. acknowlo, lac and dclv, :: ,in,. and ail or other WflItCn obJl~iillons in lilt flaltlrC lhcrcol .............................. ~_ ................................... s fully and to the same extent as il such bonds were s~gned by thc PrcstdenL scaled v. ith ~h¢ corporate scats ol thc C,mmames and dui, hereby ratifying and confirming all that the said Attorney(s)-in-Fact may do in the prcliscs. ' ' [ Mcr and by he auh{rty of Articic VII of the Bv-taws o'FRL:MAN'S FUND NSUIRANCE COMPANY. NA"ON.\LSJREI'5 N INSURANCE COMPANY, ASSOCIATED I~DEMNITY CORPORATION and AMERICAN AUTOMOBILE INSURANCE in full force and effccI. ! scaled under the authority of thc !'o!lowinz Resolulion adopted bv the Board of Directors of FIREMAN'S FUND INSURANCE ]ORPORATION. THE A~IER[CAN INSUtS,.A, NCE COMPANY, A~iSOCIATED INDtiMNITY CORPORATION and AME:v. ICAN [?ANY al a meeting duly culled and held. or by written consent, on Ihe 19th day of M ~rch. 1995, and said Resolution has not been nature of any Vice-President, Assislant Secretary. and Resident Assistant Secretary of t! or primed on any pov.'er of attorney, on any revocation of an',,' power of attorney, br on )f attorney, an?,' r~'vocation of an) pbwcr o[attorney, or certificate bearing such 'facsimil the Companies." 'npanies have caused thc scms 198s'e9Er£ . to he signed by their Vice-President, and th :ptember S%kTE OF CALIFORNIA COL'NTY OF Ma, RIN On th:s -- day of duly sworn, did de.se and say: that Companies that the sealsa[Excd~o[h~ s~g:sd h~s name thereto by iike order. 1~ WITN'ESS WHEREOF. [ hay:, he .~ L OC~ STATE OF CALIFORNIA SS. ffOUNTY OF MARIN l, the undemigned, Resident ~istant S and h~ not ~en revoked; and are now in Signed and sealed at the County of Marl By FIR Companies, and the sca[ o[ mv certificate relatma thereto. signature or facsimde seal sha![ :ir corporate seals to bc hereunto affixed :cretan' of each company, DO HEREBY CERTIFY that the foregoing and attached PO\ re that'Article VII of the By-laws of each company, and the Resolution of the Board of I lritten. fER OF ATTORNEY remains in full fore,,: irectors; set forth in lhe Power of Altorne':', '~. Dated the 22N1) day of ISOVRM'P, ER 1999 360789- Dtember 1998 . me personally came lallope~ to me known, who, beret bv me e is a Vice-PresMent of eac~7,apanv, described in and ~hich executed the aeove ins{mment; that he knows the seals of ~'he'said said instrument are such corn?any sefiis; that they were so affixed by order of the Boated of Directors of said companies and that hs eunto set mv hand and affixcd m; o;'ficiai seal th,: day and )'ear herein first xbo',,e APO ~ I 163726 Ca!;focnra ' i ~.OV ~. ~] Notary Pubiic .... CERTIFICATE EMAN'S FUND INSURANCE COMPANY NATIONAL SURETY CORPORATION TIlE AMERICAN INSURANCE COMPANY AS SOCIATED INDEMNITY CORPORATION AMERICAN AUTOMOBILE INSURANCE COMPANY State of California County of Santa C On ].1/22/99 DATE personally appeare~ [] personally knc [ara before me, .. A1 Anzoategui Paula Mohr, Notary Pub[lie NAME, TITLE OF OFFICER - E.G., "JANE DOE, NOTARY PUBLIC- NAME(S) OF SIGNER(St proved to me on the balsis to be the person(s) to me that he/she/th her/their signature(., person(s) acted, ex~ WITNESS my hand Signature of Notary Though the data belo~ could prevent frauduh CAPACITY CL INDIVIDUAL CORPORATE OFFI( vn to me - OR - [] of satisfactory evidence tchose name(s) is/are subscribed to the within instrument and acknowledged .~y executed the same in his/her/their authorized c¢.pacity(ies), and that by his/ ;) on the instrument the person(s), or the entityI upon behalf of which the ~cuted the instrument. / and official seal. OPTIONAL, PAULA Comm. NOTARY PUBLIC · C SANTA CLARA ~) Exp. March 24, 2uuO is not required by law, it may prove valuable to persons 'elying on the document and nt reattachment of this form. ~ TITLE E] PARTNER(S) ["- [] [] A'I-FORNEY-IN-FAC- [] TRUSTEE(S) E]] GUARDIAN/CONSE~ [] OTHER: SIGNER IS REPRESENTIN dMED BY SIGNER ;ER (s) LIMITED GENERAL VATOR DESCRIPTION OF 4TTACHED DOCUMENT TITLE OR TYPE OF DOCUMENT NUMBER OF PAGES DATE OF )OCUMENT SiGNER(S) OTHER '~' ^" ,',,-,vl ~. ~ ABOVE State of California County of Santa Clara On 11/22/99 DATE personally appeare, [] personally knc before me, A1 Anzoategui Paula Mohr, Notary P~blic NAME, TITLE OF OFFICER - E. Gt, "JANE DOE, NOTARY PUBLIC" NAME(S) OF SIGNER(St proved to me on the basis to be the person(s) to me that he/she/th hedtheir signature(,' person(s) acted, ex~ WITNESS my hand Signature of Notary Though the data belov, could prevent frauduk vn to me - OR - [] of satisfactory evidence ,vhose name(s) is/are subscribed to the within inslrument and acknowledged ~:y executed the same in his/hedtheir authorized cCpacity(ies), and that by his/ ;) on the instrument the person(s), or the entity upon behalf of which the ;cuted the instrument. and official seal. OPTIONAL CAPACITY CL [] INDIVIDUAL r"] CORPORATE TITL[ [] PARTNER(S) E E [] A'FI'ORN ET-IN-FAC [] TRUSTEE(S) [] GUARDIAN/CONSE [] OTHER: is not required by law, it may prove valuable to persons !elying on the document and nt reattachment of this form. MMED BY SIGNER DESCRIPTION OF/~TTACHED DOCUMENT .~ER -.'(s) LIMITED GENERAL RVATOR SIGNER IS REPRESENTIN ,.i *~- OF ,,AM,_ PERSON(S) OR TITLE OR TY!E OF DOCUMENT NUMBER OF PAGES DATE OF ~OCUMENT OTHER '~ ^*, ALL-PURPOSE At ~KNOI,'~t, EDGMENT ,~ NOVEMBER '2, 1999 un ~r~7--'-~-~ before me, D anijela L. 7NOoT!RUy~iC personally appear(',d Francis E. Cook ~ ~ ~ SIGNER(S } X_ personally krtown to me OR ? .......... [ - - - ~ p~ove~ to me on me ~asis of satisfactc ,- evidence to be the p4rson(~ whose name is&m subscribed to th~ within instrument ac~owledged to me t~at h~~ ex~uted the same in his~~ authorized ' .......~ ........................ capacity(~, and ~hat by his~~ ~~ DANIJELA [. ~OSUNIC ~ signature(~) on the in tmment the erson(~ ~(~ N0~&It~J~Agt~N,A ~ or the entity upon?J2half of x x~-~/ sam c~,~ c0~,t~ . person~) acted execu ed th .~ M~ Comm. ExDire$ Nov. 12,200 ~ -- , ' e ins~ument. WIT~SS my hand ar d official ~ NOTARY'S: :IGNATU~ ~~ O~IONg INFOR~ON edgment%e informatiOnto ~ unau~or~l°w izediS notd~ument.required by law. However, it could prevent fraudulent altachment of ~is ac~ow1- CAPAC~ C~ED BY SIG~R (PR~CIPAL) DESCRI~ION OF A~,IC~D DOCUMENT ~ ~DIVIDUAL t ~ TRUSTEE(S> NUMBEROFPAGES ~ G UARDIAN/CONSEI tVATOR ~ OTHER: ~~~ NOVE~ER 22, 1999 THE ~ER~A~ !NSU~CE C0~ANY ........ ~, '~ ! ' 4 V,\LI.EY-.";II!RRA, 8tY0-362-3!(,9 ALL-PURPOSE AI~KNOV. £EDGMENT ? ' ) (NOTkR¥) ' ~ personally appe~,;d Francis E. Cook ~ personally kl~own to me OR ~ ......~, .... ~ _ . , - - ~ p~uvcu to me on evidence to be the p0son(~)whose name is~ subscribed to th~ within instrument anu ac~owledged to me t~at h~~ executed the same in his~~ authorized capacity(~, and ~hat by his~~ ~- sianature~) on the instrument the erson(~., .~~ or the entity upon [behalf of which the ~/~~ Comm. ~ 1239569 ~ person~) acted, execu ed the ins~um wITNeSS my hand a~d official seal ~e ~nt O~ION~ IN~OR~ON ' 'ormafion ~low is not required by law. However, it could prevent fraudulent a4tachment of this ac~owl- edgment to ~ unau~o~ized d~ument. ~ CAPAC~ C~ED BY SIG~R (PR~CIPAL) DESCRIPTION OF I~C~D DOCUMENT ~ ~DIV~UAL ~ PAR~ERfS) ' ~ TRUSTEE(S) ~~ ~ ~ :T~_i~;~N/CONSE aVATOR N~B~ OFf. ES ~--~ ~ NOVE~E~ 22, 199~~ SIGNER IS REPRESI ITING: ~ ~:4 VAIJ.EY-SIERRA, 8~-362-