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ENC2000-00178
CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No.~=~ DEPT. OF P~C WO~S (for wor~g ~in ~e X-~f. file (408) 866-2150 ~ued Application APP~CA~ON - AppliCon h h~y ~ for a ~lic W~ ~ ~ ~ w~ C~l ff ~ ~ ~ ~ ~u~. Applicon F~ ~ mm~le.) A. Wo~s or~f ~- ~ ~ ~I~F~L~ C. ~ f~r (4) ~i= of ~ ~ p~ sh~ ~ I~on ~ ~ d ~ w~, p~ s~l show ~e ~on of ~ p~ wo~ m ~ ~ ~ ~ ~~. ~ ~mv~ by ~ C~ ~, ~ p~ ~m a p~ of D. ~1 wo~ s~l w~o~ m ~ Ci~ of C~II ~d S~if~m ~ ~ for ~bl~ Wo~ Co~n; s~e; ~ ~e Sp~ ~vhiom for ~ ~, Ih~ ~low. F~lu~ m ~i~ by ~ w~om ~ p~h~m ~ ~ult ~j~ ~ut~ ~ f~ of F~I P~o~ Su~ ~ ~h d~i~. (~ G~ ~t Co~go~ I ~ 2.) ' ~. ~ CO~OR MU~ ~ ~S PE~ ~ ~PRO~ P~S AT ~ S~ ~ MU~ NO~ ~ P~UC WO~ DEP~ AT ~ ~O DAYS BEFO~ ~NG. WO~. NO~CE MU~ BE G~ TO P~C WO~ AT ~T ~ HO~ B~O~ ~~O ~ WO~. Is ~ work being done by the property owner at their own residence? Yes 24 HOUR EJ~ERGE. NCY TELEPHONE NO. ~'~ The ApplicandPermiuee hereby agre~ by affixing their signature to this peri, it to hold the City of Can~bell, ~ offsets, agents and employees free, tafe a~d harmless from any claim or demand for damages resulting from the work covered by this permit. The Applica~/Permittee hereby acknowledges th~ they have read and ~ndm~cl bo~ the from and bark of ~ permit, and they will inform ~ conuactot(s) of the information. (Appiicant/Pennittee) (sign) ' SPECIAL PROVISIONS __1. Su'oet s .I.I.~! not. ~.. open cut for undcr~'ound ms~aila~iom. Mmmmm =;s ~ be allowed rot connex::~ms or cxptor'a~on holes; SOch ~: may be nppraveo ov t~elnspector prior toeu~ing. ' ' .. ..:' .:. :'!::... ' · .'. '..: :: :- :'.::?-.:' :'::.: .:i)'i'. ..... .. Pa.veme~ may. be cut £or und=ground installafio~ and must be' restored m a~c~rdance with the UtiliuZ Tre~:~ Restomti0n Standard Deta~, Method 'A' l~kfilt, unJ~s ome~v~s~provedby Inspector. · . · · · :..' : . i. :....:....'.:' · ": .:.i : :: Work Io be staked by a hc~:nsed Land Surveyor or C'P, ql ~ ~1 :wo ('2) Copies of ~ cut shee~ ser~ to thc ~ubr~" Work~ Delpatt~ before ~ work. Per Section 4215 of the Governmem r'_ _~_e this l~'mi~ is ax valid for e~a~iom u~! Uadergrouad Service Alert (USA) h~ beea aolifed aad the iaquity identif'~..ation number has beea er~red hereon. USA Prime I.,800-227-2600. ' USATICIC_ET NO. ' ' · · .... SEE PUBLIC WORKS FEE SCH'E2)ULE FOR CURRENT PERMIT APPLICATION FEE PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMAN~OR ,t, MA~ CONSTRUCTION CASH DEPOSIT' PLAN CHECK & INSPECTION FEE for c~ sn~tn~ :\forms~pwperm2Yr~v.6/96 GENERAL PERMIT CONDITIt,._~ 1. A CONSTRUCTION CASH DEPOSIT is requital. Charges will be made against this deposit if there is an emergency call-out, overthne inspection or when City o~lered barricading is required. Any such costs in excess of the deposit will be billed m the Permiuec. 2. A ONE-YEAR MAinTENANCE PERIOD AND SURETY m-~ requirod. Such period will begin on date of writ~n ac. ceptaa~ by thc City. 3. REFUND of the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the wril~n a~-pmnce of the work by the City. 4. The Permittee MUST REQUEST IN WR1T~G a final inspection and acceptance of the work upon completion. Acceptance by the City w~l be made in wri~ng to the Permittee. 5. MAINTAIN safe pedesn~an and vehicular crossings and f~e access to private driveways, bus stops, fu~ hydrators and water valves. 6. A CONSTRUCTION TRAFFIC CONTROL PLAN and a CONSTRUCTION SCHEDULE is required for all lane closu~s, detours and sueet closures. This plan must be REVIEWED and APPROVED prior to any lane closures. 7. The CONSTRUCTION TRAFFIC CONTROL PLAN ,hnll conform with the Calu-ans Manual of Traffic Controls for Construction and ]V{alntel~c~ Work Zones, dated 1990, available at Cain-ans. Traffic consol equipment shall include Type H flashing an'ow signs if requital. 8. R.E~LACE IN KIND any damaged or removed existing improvements, including planting. 9. Sawcut for ail PCC or AC removals. All PCC removals ~hnll be tO nea~ .~oremark a~d shall be doweled to existing improvern,-nts. 10. OVERTIME INSPECTION PREIViPo'M will be charged against the cash deposit for inspection required outside the hours of 8:00 a.m. to 4:00 p.m. at the current overtime rate, rmmmum one hour charge. ! 1. SATURDAY INSPECTIONS must be arranged in advance. Saturday inspection time is charged at the cur~nt overtime ram with a thee hour minimum. Advance payment for the estimated time is requital. 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. 13. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is REQUIRED unless otherwise stated by the City Engineer. 14. The Connmctor or Permittee will have a SUPERVISORY REPRESENTATIVE available for contact on the project at all times during consn'uction. Contractor or Permirtee 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 petit shall not be construed as authorization for excavation and grading on private property ADJACENT to the work. or any other work for which a separate permit may be required, nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 17. This permit does NOT RELEASE the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 18. This permit is NOT TRANSFERRABLE. Work must be performed by the Permity~e or his designated agent or contractor ~ specified thereon. 19. CALL BACK {call out) due to emergencies regarding this permit, shall be at the current overtime rate with a thee (3) hour minlm~L~ charge per occurrence. 20. Pursuant to Chapter 1~,.02 of thc Campbell Mumcipal Code, applicant sh~ not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Nonpoint Source Pollution Control Program. Applicant shall be r~sponsible for ensuring that ail those providing services under the applicant ~re aware of a~l understand all of the above conditions. j:\forms\pwperm2 6/96 WELLS FARGO BANK Received from ~ i ~¢C 0/~ R ~ ~ q~' ~ '] ~ ~' ~ ~ ~ Renewalterm / q~~ Maturity date 7/: ¢ ~*~ ,nterestrato ~' 0 Annualpo¢centagoyiolO &'~¢% or ~ paid by check. / f - This certificate is non-transferable. Presentation of the original cedificate, signed by the payee, is required to withdraw funds. If the deposit is withdrawn before maturi~, there may be an early withdrawal fee. At maturi~, this deposit will automatically renew. The terms of the ce~ificate, including the intere~te~annual percenta~ yield, are ~ . subject to change on the maturity date. Please refer to the Disclosure Statement for additional information about your account.~ ~ ~, ~ . ~ ~. ~ ~ _ Bank Representative's Signature ~~¢ ~~ ~ ~ [~ ~ PAYEE COPY / ~ ~ Mombor F~IG ASSIGNMENT AND RECEIPT OF INVE.~IENT CERTIFICATE TO CITY OF CAMPBELL, 70 N. FIR STREET CAMPBELL, CALIFORNIA 95008 (408) 866-2150 TR or DE, Loc. I am/We are the owner(s) of a savings account at ~UtS' (-~?_(~r¢, ~.~_ at its branch office at i~0 ~0~ ~.~.~ ~ ~ , California, inves~ent certificate No. IO~ ~ 000 in ~e n~es of ~ 0~ ~o~ and having a present ~lance of I hereby grant, transfer and assign said account, said investment certificate, said balance (including interest which accrues thereon), and all other rights in connection therewith to the CITY OF CAMPBELL, assignee, for a good and valuable consideration, receipt of which is hereby acknowledged, for the purpose of insuring construction described as follows: ! have physically delivered verification of said investment certificate and duplicate of this Assignment and Receipt to said assignee. I understand that assignee can withdraw from said account any ti~e on his signature alone upon presentation of a written order to the issuer. I also understand that I may not withdraw from said account unless I present a signed release from the assignee. The issuer of the certificate assumes no responsibility for the conduct of the assignee and may act on the signature of the assignee without further inquiry~ Executed on ~Ev~e~ ~ , ~9 "a~ said office of the issuer. sign /// ~ Assignor print r~ ~ ~ ~, c~._~r~ .~ sign Assignor print ACKNOWLEDGEMENT BY ISSUER Issuer affirms that there are no o~her holds on subject account, that subject monies are available, and that the above described assignment has been noted on the Records of said issuer. Title -- ACKNOWLEDGEMENT .t Please sign below for signature identification and as acknowledgement of your notice of Assignment. Return this Assignment and Receipt to the issuer at its address above. Retain one copy of this Assignment and Receipt for your files. RELEASE BY ASSIGNEE Said assignee hereby releases and relinquishes all his right, title and interest in and to said account, said investment certificate, said balance and all other rights in connection therewith. CALIFORNIA ALL-PURPO. . ACKNOWLEDGMENT State of ~-~ County of ~'l~_.l:)k CiO~r C~ On q/'"~-"61~'OOD before me, Date lejo~Off personally appeared ~,_T ~ ~._ C ~'7'~[~ndC; icer (e.g.. "Jane~ Notary Public") Name(s) of Signer(s) .~ /~,..personally known to me - OR - [] proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/a~e~ subscribed to the within instrument and acknowledged to me that he/she/the3r executed the same in h~s/her/tbeir authorized capacity(ies), and that by -his/her/~he~signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. WITNESS my hand a~icial seal. ~ / ~-~'"~gnature of OPTIONAL Though the information be/ow is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document. Description of Attached Document Title or Type of Document: Document Date: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: [] Individual Number of P.~s:'~/' [] Corporate Officer / [] Corporate Officer Tit~e(s): ./ Title(s): ___ : [] Partner- [] Limited [] General / [] Partner--[] Limited [] General [] Attorney-in-Fact ~ [] Attorney-in-Fact ii [] Trustee ..,~rr~-,.,,:,,,,,,,: ,,[] Trustee '~:'i [] Guardian or Conservator ~ [] Guardian or Conservator ~i!.~ [] Other:' / ~ [] Other: __ 1994 National Notary Association · 8238 Remmet Ave., P.O. Box 7184 · Canoga Park, CA 91309-7184 Prod. No. 5907 Reorder: Call Toll-Free 09~29~2000 9:49:49 AM P,' "MENT HISTORY FOR CASE ENC2000-00178 Fee Type: Fee Type: Fee Type: Fee Type: APP Description: Encroachment Application Fee Date Paid Receip~ Check# Recorded By 09/29/2000 134208 1061 JD Total Paid: CASH Description: Construction Cash Deposit Date Paid Receipt~ Check~ Recorded By 09/29/2000 134210 1061 JD Total Paid: PCDP Description: Plan Check Deposit Date Paid Receipt-# Check# Recorded By 09/29/2000 134209 1061 JD Total Paid: PCI1 Description: Non-Util Plan Ck/Insp to $250K Date Paid Receipt~ Check# Recorded By 09/29/2000 134208 1061 JD Total Paid: Totals for ENC2000-00178: $4,287.00 Paid: Fees: Total Fee: Amount Paid $245.00 $245.00 Due: Total Fee: Amount Paid $885.50 $885.50 Due: Total Fee: Amount Paid $500.00 $500.00 Due: Total Fee: Amount Paid $2,656.50 $2,656.50 Due: $4,287.00 Due: $0.00 $245.00 $0.00 $885.50 $0.00 $500.00 $0.00 $2,656.50 $0.00 Page 1 of 1 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: ReCundable Deposit Check Request KIRKORIAN ENTERPRISES 1600 W. CAMPBELL AVE. CAMPBELL Refundable Deposit 101.2203 101.2203 101.540.7448 Interest Earned State: CA Zip: 95008 Amount: $500.00 Amount: $885.50 Amount: (Finance Dept only) $1,385.85 (Exact Amount) Refund construction cash deposit ($885.50) and plan check deposit ($500.00) Voucher #: 134210 Receipt #: ,-, 134209 Requested by:~~-'- Syed Wahidi Approved by: ~ Michelle Quinney Finance Dept Only: Verified by: Approved by: Permit #: ENC 2000-00178 9/28/00 Date: 9/28/00 Title: PW Inspector Date: Title: City Engineer Date: Title: Accounting Clerk II Date: Title: Accountant Date: 7/15/O3 7/15/03 Special ]:nstructions For' Handling Check Mail As Is: X Mail in Attached Envelope: Interim Check: Needed By: Return To; (Name) (Department) Other: h:permits~000-O0178 refund 1550 campbell ave(mp) P lC WORKS DEPARTMENT RECEIPT Effective August 1, 2000 TO: City Clerk PUBLIC WORKS FILE NO. ~" ~ ~.C__~-- (,.~(..~ lirq~' PROPERTY ADDRESS Please collect & receipt for the fo[ ow ng mon es: ENCROACIIMENT PERMIT 4722 Application Fee 2203 2203 2203 2203 2203 2203 4722 2203 4722 Non-Utility Encroachment Permit Minor Encroachment Permit < $5,000 R-I First Permit {No Fee) Subsequent PermiffYr utility Encroachment Permit Arterial/Col lector Street Residential StreeffOther Areas Plan Check Deposit - 2% of ENGR. EST. Faithful Performance Security (FPS} Labor and Materials Security Monumentation Security Cash Deposit Labor and Material Security Plan Check & Inspection Fee (Non-Utility) Engr. Est.< $250~000 Engr. Est. >$250,000 (Deposit 8% of ENGR. EST./$30~O00 Utility < $1001000 Minimum Charge Per Location Conduits/Pipelines up to 500 Feet Above 500 Linear Feet Manholes/Vaults/Etc. Pole Set/Removal ($245.00) /$50.00} (5 ~ lo) (5355.0o) /$245.00} ($500 minT 000% of ENGR.EST./ 000% of ENGR. EST.} 000% of ENGR.EST.7 14% of ENGR,EST.)($500 min/$10~ooO max) 000% of ENGR. EST./ (12% of ENGR. EST.) Street Tree Planting/Removal 000 Street Tree Planting/Removal Permit Standard Specifications & Details & Plans Aerial Plot 24' x 36' Aerial Print 8 1/2' x 11' Plans24' x 36' Penalties: Failure to restore public improvements Penalties: Failure to correct unsafe conditions LAND DEVELOPMENT 4722 Lot Line Ad ustment 4722{ Parcel Map f4 Lots or Less) 4722[ Final Tract Map (5 or More Lots} 4722 Certificate of Compliance 4722 Cert ficate of Correction (8%7 ($13o) ($2.00} ($1.25) fSI 15.oo/na} (51 IS.00/ea) ($115.00/tree) Actual Cost + 20% ** ($1 Proiect No. ($1/Pg $12.50/Bk) ($457 (5157 ($57 ($100/CalendarDay) ($ loo/Calendax Day) (Mum Code Sec. 11.34.01n) 4722] Notary Fee (per signature) 47221 Vacation of Public Streets & Easements 4722 AssessmentFirst Segregation Split or Reapportionment I Each Additional LOt 47211 Storm Drainage Area Fee Per Acre 4920 4965 TRAFFIC 472-8I 4728 [ 4728[ 4728I 4728[ 427I t 4728 OTHER ($6o0.oo) ($1,170 + $25/LoQ ($1,510 + $25/LoQ ($330.O0) ($~o.oo) (56oo.oo) Parkland Dedication Fee (75 %/25 % Due Upon Cert. of Occupancy) Postage Intersection Turn Counts (Two-Hour Count) ($600.00) t5185.00) (R-I, 521000) (Multi-Res, $2,250} (All Other, $2,5OO) Intersection Turn Counts (a.m. or p.m. peaks) Traffic Flow Map (Daily Traffic Volumes) Campbell Traffic Model (Full Scope Assessment) Campbell Traffic Model/Reducod Scope Assessment) Truck Permits No Parking Signs ($65.5O) ($136.50) ($29.50) ($2,46o.oo) ($810.00) ($32.00/rnd trip7 ($ l/each or $25/100) TOTAL $ 4=-2-<~"'y. r2,'O NAME OF APPLICANT "Actual Cost Plus 20 % Overhead (il~ ~l~/¥,~,.arA ~n~a~s_ i~ K O $885.50 D£SCRZPT?~ AMOUNT CHEC!; N'J.: !(:6! TENiiERED: ~500, O0 INSURANCE REQUIREMENTS CHECKLIST Permit # -~t'~_~O O "OC.D} '"7 ~ CIP Project # The followin= insurance is required of all contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City. staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract tbr Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury, and property damage: 7~ $1.000.000 per occurrence, and a $1.000.000 general aggregate limit applying separately to the project, or '~ $2.000,000 general aggregate limit. ~. Policy expiration date Automotive Liability: ~i "Anv Auto" checked on certificate ~ $1.000.000 per accident forbodilv injury, and property, damage ~ Policy expiration date Workers' Compensation and Employer's Liability 5.~ Waiver of Subrogation clause ~ $1,000,000 per accident tbrobodilv injury or disease Policv expiration date/j l/L- Course of Construction (if required in Special Provisions) -n Completed value of the project a Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional insured Endorsement ~ The City, the City of Campbell Redevelopment Agency, its officers, employees and volunteers are named as additional insured. ~ The insurance coverage afforded to the Additional Insured is primary insurance. ~ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". n Workers' Compensation Insurance Sheet Submitted = For General Contractor n For Developer or Owner C.~c~e,,h ~,0qk~ b'x2>, iC~4'."~(V' ----' O_~ o~--. is authorized to transact Acceptability of Insurer(s) Oanmecc ' I Uhoq I,q insurer{s) has current A.M. Best Rating of A:V[I and business in the State of California. t Insurance Certificate Reviewed ~ ~/t.~'~~Initials Date Copy of Insurance Certificate placed in tickler file for month of expiration. j:\forms\inscklst (rev 11/99) IACORD. CERTIFICAI_ OF LI, JLITY INSURA,,CE I PROGUCER ~" I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ......... ."',~ . I ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE wl±±ow ~±en ins. Agency ~'.~-- .~ I HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 3225 F".'~F '~% ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Monterey CA 93947/_~.) . %% ~+.- / .................... ~ --- ~'~k~' '% _,0 ~L~%y INSURERS AFFORDING COVERAGE ,.au.ER ~ %~' .~q.~x". I,NSUR~A:Navigators Insurance Co. ~ Kirkorian Enterprises, LLC ~G~ ,NSURERB:COmmercial Union Insurnace Co. {1630 W. Campbell Avenue ~ [~ Insurance Co. ~ Campbell, CA 95008 '/ /INSURERD: / I / INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFFECTIVE POUCY EXPIRATION LTR TYPE OF iNSURANCE POUCY NUMBER DATE (MltNDD~fY) DATE (MltNDD/YY) LIMITS GENERAL UABIM'rY EACH OCCURRENCE $1, 000, 000 A ~ COMMERCIAk GENERAL LIABILITY GL 106313 06 / 01 / 01 06 / 01 / 02 F,RE O~ASE (~y o.e f,~.) s 50, 000 I CLAIMS MADE I V J OCCUR MED EXP (Any one person) $5, 000 PERSONAL&ADVINJURY $1, 000 , 000 GENERAL AGGREGATE $ 2,0 0 0,0 0 0 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2 , 0 0 0 , 0 0 0 VIPOLICY ~PRO-JECT ~LOC AUTOMOBILE,. LIABIMTY COMBINED SINGLE LIMIT V/ ANY AUTO (Ea accident) $1, 0 0 0, 0 0 0 B ALL OWNED AUTOS CAAX62146 01/13/01 01/13/02 BODILY INJURY SCHEDULED AUTOS (Per person) $ V HIRED AUTOS BODILY iNJURY NON-OWNED AUTOS (Per accident) $ -- PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS LIABILJI'Y EACH OCCURRENCE $1 5 ! 0 0 0 , 0 0 C C ~OOCUR ~CLA,MSMAOE PI-IA204263 01/13/01 01/13/02 AGGREGATE S15,000,00¢ $ DEDUCTIBLE $ RETENTION $ $ WC STATU- WORKERS COMPENSATION AND TORY LIMITS J J%TRH' EMPLOYERS' LIABILfl'Y E.L EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDER BY ENDORSEMENT/SPECIAL PROVISIONS Re: Permit #ENC2000-00178 @ 1550 - 1600 W. Campbell Avenue, Campbell, CA- Ail work in public right-of-way. City of Campbell, City of Campbell Redevelopment A~ency, its officers, employees & volunteers are named as Additional Insured per Form #CG 20 10 11 85 attached. *10 Day Notice for Non-Payment of Premium CERTIFICATE HOLDER I ~/ J AoDmONAL INSURED; IN,URER LEI'rF.R: A CANCELLATION ~HOULD ANY OF THE ABOVE DESCRIBER POLICIES BE CANCFLL;n BEFORE THE EXPIRATION City of Campbell DATE THEREOF, THE ISSUING IN~JRER~TO MAIl 30* DAYS WRITTEN Attn:Dept. of Public Works NOTICE TO THE CENTIFICATE HOLDER NAMED TO THE LEFT, -- - 70 North First Street -- - - - _ _L Ill ........ J_JL. . II AU'rHORIZED REPRESENTATIV ACORD 25-S (7/97) ORATION 1988 Policy Number: GL106313 Commercial General Liability THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED- OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: ANY PERSON OR ORGANIZATION TO WHOM OR TO WHICH YOU ARE OBLIGATED BY VIRTUE OF A WRITTEN CONTRACT OR BY THE ISSUANCE OR EXISTENCE OF A PERMIT, TO PROVIDE INSURANCE SUCH AS IS AFFORDED BY THIS POLICY. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you. IF YOU ARE REQUIRED BY A WRITTEN CONTRACT TO PROVIDE PRIMARY INSURANCE, THIS POLICY SHALL BE PRIMARY AS RESPECTS YOUR NEGLIGENCE AND CONDITION 4. OTHER INSURANCE DOES NOT APPLY, BUT ONLY WITH RESPECT TO COVERAGE PROVIDED BY THIS POLICY. CG 20 10 11 85 Copyright, Insuranc. e .Services Office, Inc, 1.984. 06/13/2001 13:41 831-655-1800 STRU WILLOW GLEN INS PAGE 02 ACORD_~ Willow Glen Ins. Agency P.O- Box 3225 Monterey CA 93942 CERTIFICATL. OF LIABILITY INSURANL I o6/ 3/o Kirkorian Enterprises, LLC 1630 W. Campbell Avenue Campbell, CA 95008 ONLY AND CONFERS NO RIQHTS UPON THE CERllFICATE HOLDER. THI~, CERllRCATE DOES NO'T AMEND, EXTEND OR ALTER 1HE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDANG COVERAGE .~$~^:Naviqator$ I~s~rance Co. m~,,Commercial Union Insurnace Co. .~su~, cRoyal Insurance Co. IN~URE~ D: INSURER E: COVERAGES THI': POLICIES OF IN~URANC~ USTEO BELOW HAVE §~£N I~UED TO THE ~NSUI~D NAUED ABOVE FOR THF POLICY PERIOD ]NDICATEO NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY coNTRACT OR OTHER DOCUMENT WITH RFSPECT TO WHICH 'I'HI~ CER'TIFIC&TE MAY BE I$~UEO OR ~AY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I$ SUBJECT TO ALL THE TFRM$. EXCLUSIONS AND CONDITIONS OF SUCH POUC]ES AGGR~-GATE LIMITS SHOWN ,lAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPt OF .?.I-L'-RAWCB GL106313 06/01/0~ 06/03./02 C~%X62146 tpFu~204263 01/13/01 o1/13/oz 01/13/02 ~c, occ~."-..'~..c~ s 1,0 0 O, 0 0 0 FiRE DAN~0E (any o.. fife) $ 5 0 , 0 0 0 ,5,000 one per,o.) ADV tHJUR~ P~OOUC~ - ~lliOp AGG i COM~I~ED SINGLE LIMIT , {Ee ecc~d~n~ AUTO O~ILY - F..A ^CCiDt!'NT EA ACC OTHER 'mAN AU~ ONLY AGG EACH OCCb~;.'CE AOOREOAI~ $1~000,000 s2,000,000 s2,000,000 $1 o00 000 $ $ ,15,000,000 si5,000,000 l L' OEDUCTIBLE RIECEIVED $ $ S WC STATU- OTH. TORy LIMIT~ I i F~ E.L EACH ACG~DE44T [ L DISEASE - EA EMPLO*'/~E[ $ City of Campbell A~tn:DepE. of Public Works 70 North First Street campbell, CA 95008 I ACORD 25-S (7197) I I IJl&l ,I ~ ,,~,;Jl,I Et. OISEA~E-POUCYLIM~T Lu-,,, ! o uu, PUBLIC WORK8 rluiMi--- ~n_ ...... ~ i KATIOM D£~CRL~ON OF 0B~RAg~N~nff~cku~k~iA& Au-m, my~_j,C~j~;~N~3~im~.~L ~'.%~::-2-'~-- ....... 1 1 Re: Permit flENC2000-00178 ~ 1550 - 1600 W. Campbell Avenue, campbell, ~'~- ~ I work in public right-of-way. City of Campbell, City of Campbell Redevelopment ~ Agency, its officers, employees & volunteers are named a~ Additional Ensured per Form ~CG 20 10 11 85 attached. Notice for Non-Pa~ent of Premium Day 86/13/2881 13:41 831-655-1888 STRU WILLOW GLEN INS PAGE 83 Policy Number: Gt106313 Commercial General Liability THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED- OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: ANY PERSON OR ORGANIZATION TO WHOM OR TO WHICH YOU ARE OBLIGATED BY VIRTUE OF A WRITTEN CONTRACT OR BY THE ISSUANCE OR EXISTENCE OF A PERMIT, TO PROVIDE INSURANCE SUCH AS IS AFFORDED BY THIS POLICY. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you. IF YOU ARE REQUIRED BY A WRITTEN CONTRACT TO PROVIDE PRIMARY INSURANCE, THIS POLICY SHALL BE PRIMARY AS RESPECTS YOUR NEGLIGENCE AND CONDITION 4. OTHER INSURANCE DOES NOT APPLY, BUT ONLY WITH RESPECT TO COVERAGE PROVIDED BY THIS POLICY. CG 20 10 11 85 Copyright, Insuranc. e, .Se. rvices Qffice, Inc, !9.8,4. 0G/13/2001 13:41 831-G55-1800 STRU WILLOW GLEN INS PAGE Philip Strutner P.O. Box 3225, Monterey, CA 93942 Direct Phone: (831) 655-1200 Direct FAX: (831) 655-t800 Willow Glen Insurance Agency License No. 0702299 To: Joanne - City of Campbell Date: 6/13/01 Fax: 408-376-0958 ~ Pages 3 Including this page From-' Joyce Fleming Re: Kirkorian Enterprises LLC Policy # GL106313 [] Urgent r~ For Review [] Pleaue Comment O Please Reply · Comments: Attached is the certificate of insurance for the above mentioned insured, Please call me if you have any questions. Thank you ACORD.. CERTIFICAT,. OF LIABILITY INSURA,..;E D~TE (MWDD/YY) Ol/26/Ol PRODUCER Willow Glen Ins. Agency P.O. Box 3225 Monterey CA 93942 INSUR~ Kirkorian Enterprises, LLC 1630 W. Campbell Avenue Campbell, CA 95008 THIS CERTIFICATE IS ISSUED AS A MA'FI'ER 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. INSURERS AFFORDING COVERAGE .NSURERA:Clarendon American Ins. Co. INSURER B:Commercial Union Ins. Co. INSURER C: INSURER D: INSURER E: :OVE.^GES JAN ' THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTI~LI~Y MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. '~"~mlr~I~TFI&TION IN~R FOLICY i:J-P.-CT1VE POUCY EXPIRATION LTR TYPE OF INSURANCE POUCY NUMBER DATE [MM/DDP/'Y~ DATE (MWDD/YY) UMITS Ga~ERALLm",L.~ UCLWlO00562 06/01/00 06/01/01 EACH OCCURRENCE $1, 000, OOO a ,/' COMMERCIAL GENERAL LIABIUTY FIRE DAMAGE (Any one fire) $ 5 0 , 0 0 0 I CLAIMS MADE IV'] OCCUR MED EXP (Any one person) ,5, 0 0 0 PERSONAL & ADV INJURY $1 , 0 0 0 , 0 0 0 GENERAL AGGREGATE $2 , 0 0 0, 0 0 0 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2 , 0 0 0 , 0 0 0 V/' I POLICY ~]®JECT [~LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ B ,/ ANYAUTO CAAX62146 01/13/00 01/13/01 (Eaaccident) 1, 000, 000 ALL OW.ED ADTOS 01 / 13 / 01 01 / 13 / 02 BOD,LY ..JURY SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY NON-OW.ED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE lIABIlITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXC~S U~-,UW EACH OCCURRENCE $15, 000, 00 C c BO°CDR [~C~.MSMADE P~204263 06/16/00 01/13/01 ^GOREOATE i$15,000,00¢ $ __~ DEDUCTIBLE $ RETENT,ON $ None 01/13/01 01/13/02 $ wc STATU- WORKERS COMPENSATION AND TORY LIMITS EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIFTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Re: Permit #ENC2000-00178 @ 1550 - 1600 W. Campbell Avenue, Campbell, CA - All work in public right-of-way. City of Campbell, City of Campbell Redevelopment Agency, its officers, employees & volunteers are named as Additional Insured per Form #CC 20 10 11 85 & Primary Wording Endorsement #19 attached. *10 Day notice for non-payment of premium CERTIFICATE HOLDER I 'V/IAODI'IIONAL INSURED; INSURER LETTER: A CANCELLATION City of Campbell Attn: Dept of Public Works 70 North First Street Campbell, CA 95008 ACORD 25-S (7/97) SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCFI I ten BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ~ MAIL 3 0 * DAYS WRn'rEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, --" ...... . ..... AUTHOR[ZED REPRESENTATIVE A~C~ORD CO~TO~P RATION 1988 81/26/2881 16:29 1-22-2~1 A: ~gPM 831-655-1888 5TF~U %4ILLO~J GLEN F'~3M C '~BELL PUBLIC WK$ &~8 37~958 PAGE Ol Joyce Fleming Willow Glen Insurance PO Box 3223 Monterey, CA 93942 Phone (831) 055-1200 Fax Pkot~ (83D 6f~.1800 CC: 1/2/2001 I Nsrnlnr ofgage~ inclmflng covvr sheet~ .... 2 Joanne D'~mbrosia City of Campbell 70 JVorth First Street Campbell, CA ~5008 Pltone (408)866-2701 Fa~ Phone (408) 376-0958 RI;MAR~: [] Urgent ~] For yo~r reWew R~: Insured: Ki~korian Ent~a-in'ises Work Location: 1550-1600 W. Campbell Avenu~ Permit No. ENC2000-00178 [] P~piy A~P [] Please Comm, nt Thanks for your quick response to our request for changes to thc insurance certificate for Kirkofian Enterprises. There remains just one small change that we ne~d made to the certificate and thcn it will mevt our ~ce requirements. W~ mu,t a~k that the cmacellation a~a of tl~ certificate be edited to delete the words "cadmrvor to" and "but failure to mail ~uc, h notic~ shall impose no obligation or liabil/ty of any kind upon the comtnmy, its a~cnts or represeatatives". Again, thanks for your help. Please call mc if you have any questions. 01/26/2001 15:29 831-555-1800 STRU WILLOW GLEN INS PAGE 02 ACORD. CERTIFICATE OF LIABILITY INSURANCE m~uc~ willow Glen Ins. Agency P.O. Box 3225 Monterey CA 93942 THIS CERTIFICAI~ Ig ISSUED AS A MAI~E~ 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. Kirkorian EnterDrises, LLC 1630 w. Campbell Avenue Campbell, CA 95008 INSURERS AFFORDING COVERAGE ,,suG, A~Clarendon American Ins. Co. m~m~eCommerciai Union Ins. Co.__ ~NSURE~ 0 ---- COVERAGES Ck,~M$ UAO~ OGCV~ THE POLICIES OF INSUF~ANCE LISTED BELOW HAVE I~EEN ISSUEO TO THE INSURED NAME0 ABOVE FOR THE POUGY PER~OO INDICATED NOTWITHSTANDING ANY I:IEQbIREMENT, TERM OR CONDITION OF ANY coNTI]IACT OR oTHER DOCUMENT WITH RESPECT TO WHICH TIAIS CERTIFICATE MAY' BE ISSUED OR MAY PERTAIN, THE INSURANCE AFI::ORDEO BY THE POLICIES 0[$CRIBEO HEREIN IS SUBJECT TO ALL THE TERMS, F...XCLUSlONS AN0 CONDITIONS OF SUCH POLICIES AGGREGATE UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM8. ~TWr.. OF IN~RANC[ FOUC¥ NU-~'~-~"~ oa~ ,uunv'~r~_. I DAT~ [MMt~)DPt'~ : ! GDIF,~AL uAmR.,'I'Y UCLW1000562 06/01/00 06/01/01 [~r. ACH OCCUI~I~IENCG )$ , 000, 000 I~ ~,I[N% A3GI;;GATE ,%.IM)T AP;:'UES ~'~q: JECT : DARAGE LMIIff3TY $ None ' WO#KI~$ COIIP~NI&IION &NO ' ~ll%.OY-r~' I.I&BIUTT O~4~1 CAAX6214 6 P~EA204263 oi/i3/oo 0i/i3/0i 06/i6/00 oi/i3/,oi oi/i3/oi oi/i3/o2 oi/i3/oi 0i/13/02 ~ ~O~o~ : s 2, 00 0, 00 Q~ ~c~.c~p~o ~,2, 000, 000 I C~INEO SINOL~ L~IT S 1 0 O 0 t 0 0 O ~J ICC~ , GOO~Y ~ S (Pec ~ ~LY - EA ~CCLDENT J O~[~ ~ Ea ACC ~ $ uc. occuuae.ce J s i 5,0 0 0,0 0 C ~O~G*~ J,15,000, OOC E.c. D~E ~v U~T J S D~RIIVT~# OF Ot~JqA'T10N~OCATIONS/V~'I~M~ ~u~ IY ~w Re: ?erm~t #E~C2000-00178 ~ 1550 - 1600 ~. Campbell Avenue, CAmpbell, CA All work in public right-of-way- City of Campbell, c~ty of Campbell Redevelopment Agency, its officers, employees & volunteers are named as Additional Insured per Form #CG 20 I0 1! 85 & Primary Wording Endorsement #19 attached. *10 Day notice for non-p~¥ment of premium City of Campbell Attn~ Dept of Public Works 70 North First Street Campbell, CA 95008 ACORD 2~-S CANCELLATION FAX TO: Phone Fax Phone Joyce Fleming Willow Glen Insurance PO Box 3225 Monterey, CA 93942 (831) 655-1200 (830 655-1800 CC: Date 1/2/2001 I Number of pages including cover sheet FR OM: Joanne D'Ambrosia City of Campbell 70 North First Street Campbell, CA 95008 Phone Fax Phone (408)866-2701 (408)376-0958 REMARKS: [] Urgent [] For your review Re: Insured: KirkorianEnterprises Work Location: 1550-1600 W. Campbell Avenue Permit No. ENC2000-00178 [] Reply ASAP [] Please Comment Thanks for your quick response to our request for changes to the insurance certificate for Kirkorian Enterprises. There remains just one small change that we need made to the certificate and then it will meet our insurance requirements. We must ask that the cancellation area of the certificate be edited to delete the words "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". Again, thanks for your help. Please call me if you have any questions. 81/22/2881 12:42 831-655-1888 STRU WILLOW GLEN INS PaGE 82 ACORD. CERTIFICATE OF-LIABILITY INSURANCE Willow Glen Ins. Agency P.O. Box 3225 Monterey CA 93R42 Kirkcrian Enterprises, LLC i~30 w. Campbell Avenue Campkel!, CA 95008 oi/i~/oi THIS G,-.~ir~CAT~ IE I~SUED AS & M&TIbR OF INFOS~ON HOLDE~. THIS CE~A~ ~ES N~ AMEND, ~NO OR ALTER ~E COVERA~ ~FORDED BY ~E ~U~ES EELOW. INSURER8 AFFORDINQ COVERAGE ,NSU~n~Clarendon American Ins. Co. '~Commerclal Union Ins, Co. [ r~E ~OL!C;E$ OF !NSURANCE USTED BELOW wAVE BEEN ISSUED TO THE INSUREQ NAMED ALCOVE CDR THE POUCY PERIOD ANY mEOdIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO ~ICH T~tS CER~FICJ~ MAY BE [SSU~ O~ MAY PERTAIN, THE INSURANCE ~;O~DED BY THE ~LiCI~ DESCRIS~ HE.TN t$ SU~ECT TO A~ TH~ TE~S. EXCLUSIONS ~0 CONOITIONS OF SuC~ $ Nor~e ~ ~e~q~DYF..qq' U~MJ"tY ,~:v ~_____._ UCLW1000562 CAAX62146 pFLA204263 CO~:~:~D g~LE L~~T 01/13/00 01/13/0i 01/13/01 01/13/02 ~ (P~' ~) [ S AU~ ~Y 06/16/00 01/13/01 13/02, } , , .$1,000,000 :sS,000 ;,l,O00,O00 'I 000 000 [$ . .siS, ooO,,ooc 'siS, 000, ..... " .... 2000 00178 ~ 1550 - 1600 W, campDe~ - blic ri hi-C-way. City of Campbell, City of Campbell Re~evezopmen~ work zn pu -~. g ........... ~,~rs are named as Additional Insured Aztr.: Dep: of Public works ...... 70 North First Street Campbell, CA 95008 ACORO 25,.S (?/~?) ,4CORD. CERTIFICAT,_ OF LIABILITY INSURA,,.~E DATE (MM/DD/YY) 0i/ig/0i PRODUCER Willow Glen Ins. Agency P.O. Box 3225 Monterey CA 93942 INSURED Kirkorian Enterprises, LLC 1630 W. Campbell Avenue Campbell, CA 95008 THIS CERTIFICATE IS ISSUED AS A MAI'FER 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. INSURERS AFFORDING COVERAGE ~NSURERA:Clarendon American Ins. Co. INSURER B:Commercial Union Ins. Co. INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NO~/WITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFFECTIVE POUCY EXPIRATION LTR TYPE OF INSURANCE POUCY NUMBER DATE (MVJI~Ip~fY) DATE (MM~D~I"f) UMITS GENERALLIABILITYi ~ UCLWlOOO~EoEI o6/ol/oo o~/ol/Ol ~C. OCCURRE.CE ,1, ooo, ooo A V" I COMMERC'~ GENER~ L'"m'L'TY ~ED F'RE DAMAGE (.~y one 'me) $50, 000 I C~IMS MADE I"l OCCUR MED ~ (.~y one person) $ 5, 000 Ja~ 2 ~ ;~00! PE,~SONAL~,~.DV,.JU.Y ,i, 000, ooo GENERAL AGGREGATE $2 , 000, 000 GEN'L AGGREGATE LIMIT APPLIES PER: ~)US~,,IC WI 3RK~ PRODUCTS- COMP/OP AGG $ 2,0 0 O, 0 0 0 AUTOMOBILE LIABIMTY COMBINED SINGLE LIMIT B v/ ANYAUTO CizLAX62146 oi/i3/00 01/13/Ol (Eaaccidon,) $1, 000, 000 ALL OW.ED AUTOS 0 i / i 3 / 0 i 0 1 / i 3 / 0 2 BODILY INJURY SCHEDULED AUTOS (Per person) $ BODILY INJURY HIRED AUTOS NON-OW.ED AUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE UABIUTY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY; AGG $ EXCESS u*muw EACH OCCU..ENCE $1 5, 0 0 0, 0 0 0 c '/IOCCUR ~]C~MSM^DE PHA204263 06/16/00 0i/13/0i A*G~EGATE $i5, 000, 000 $ DEDUCTIBLE $ RETENTION $ None 01/13/01 01/13/02 s WC SIAIU- E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ ! E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Re: Permit #ENC2000-00178 @ 1550 - 1600 W. Campbell Avenue, Campbell, CA - Ail work in public right-ot-way. City of Campbell, City of Campbell Redevelopment A~ency, its officers, employees & volunteers are named as Additional Insured per Form #CG 20 10 11 85 & Primary Wordin~ Endorsement #19 attached. .. *10 Day notice for non-payment of premium CERTIFICATE HOLDER I v' I Ar'omoNAL INSURED; INSURER LETTER: A CANCELLATION City of Campbell Attn: Dept of Public Works 70 North First Street Campbell, CA 95008 ACORD 25-S (7/97) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANC":~ ~ ~;n BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3 0 ~' DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBUGATION OR UABIUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORr~n REPRESENTA'rlVE ;'~'~/--'~ ©ACORD COI:~,J~RATION 1988 ENDORSEMENT E0349 (E.D. 03101100) (rev. 4/20~00) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR / CONTRACTORS - (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Any person or organization you have agreed in an insured contract to name as an additional insured but the coverage provided to such additional insured, unless otherwise agreed or separately scheduled, is limited to liability arising from your negligence in performing your work during the term of this policy. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. Policy Number Insured Effective UCLW 1000562 KIRKORIAN PROPERTIES, A CALIFORNIA LIMITED PARTNERSHIP 06/01/2000 Countersignature of Authorized Representatjve C LA R E N ~~ _R ..A..__N ~.E_ COMPANY CG 20 10 11 85 Copyright, Insurance Services Office, Inc., 1984 ENDORSEMENT E0348 ~t ~ ~9/~:'/~9) (te-~ 01,'17/OO) IENDT. NO. ler AMENDMENT OF OTHER INSURANCE CONDITIONS / PRIMARY AND NONCONTRIBUTORY COVERAGE FOR AN ADDITIONAL INSURED IN CONSIDERATION OF THE PREMIUM CHARGED, IT IS AGREED THAT OCC1-17 (ED. 09/01/91) (REV. 06/15/96), SECTION IV, COMMERCIAL GENERAL LIABILITY CONDITIONS, PARAGRAPH 8.A. IS DELETED AND REPLACED BY THE FOLLOWING: OTHERINSURANCE A. PRIMARYINSURANCE THIS INSURANCE IS PRIMARY FOR ANY PERSON OR ORGANIZATION WHICH YOU HAVE AGREED IN AN INSURED CONTRACT TO PROVIDE PRIMARY ADDITIONAL INSURED COVERAGE AND WHICH WE HAVE ADDED AS AN ADDITIONAL INSURED BUT ONLY WITH RESPECT TO YOUR PREMISES OR OPERATIONS FOR THAT PERSON OR ORGANIZATION. ALL OTHER TERMS AND CONDITIONS OFTHIS POLICY REMAIN UNCHANGED Policy Number UCLW 1000562 Insured KIRKORIAN PROPERTIES, A CALIFORNIA LIMITED PARTNERSHIP CLARENDON AMERICAINSURANCE COMPANY Effective 06/01/2000 Countersignature of Authorized Representative 81/22/2881 12:~2 831-G55-1800 STRU WILLOW GLEN INS PAGE 82 .A_..C__.ORD. willcw Glen Ins. Agency P.O. Box 3225 Monterey CA 93942 CERTIFICATE OF LIABILITY INSURANCE 0 / ...... THIS C~'~FICATE 18 ISSUED AS A MATTER OF INFORMATION Kirkcrian Enterprises, LLC 1630 w. Campbell Avenue Campkell, CA 95008 ONLY AND CONFERB NO RIGHTS HOLDER. THIS CERllFICATE DOES ALTER THE COYERAQE AFFORDED UPON THE CER'I]FiCATE NOT AMEND, Ex'rENO OR BY THE POLICIES BELOW. INSURERS AFFORDINQ COVERAGE .N~Ciarendon American Ins. Co. I~;.Commercial Union Ins. Co. IN~4.IRER C: INSU.E~ O~ _ *~, ..... m~u~ ~, COVERAGES Ti4E POLICIES OF fNSURANCE USTED 8~LOW HAVE BEEN ISSUED TO THE INBURED NAMED ABOVE ;OR THE POUCY pERIOD INDICATED NOTWITHSTANDING ANY ~aEO.JIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WiTH RESPECT TO WHICH THiS CERTIFICATE MAY BE iSSUED OR MAY PERTAIN, THE INSURANCE AFcOROED BY THE POLtCIF.$ DESCRIBED HEREIN IS SUBJECT TO ALL THE. TERMS. EXCLUSIONS ~,.ND CONOITION$ O; SUCH PQLIC~ES AGGREGATE LIMITS SNOWN MAY HAVE BEEN REDUCED BY PA~O CLAIMS. UCLW10005~2 l C~62146 I ~ ~,N'~ AU*TO None i WORI{ER$ COf,#~4~T~ON AND i FJm)t~)qrER~' uABE.Y~W tPH3~204263 EOEIVED JAP. 9_.2 2001 PUBI,.IG WORKS. oi/i3/oo oi/i3/oi oi/13/oi 0i/i3/02 o~/i~/oo I ol/~3/oi oi/i3/oi oi/i%/o2 ~c. ~C~NC~ ~ S I Z 0 O 0, 000 , ~.~ ~ (~ o~ ,~,,~ '. s 5 0. 0 0 0 .~ ~ ~ ,~.~ ;. l, 000.0 O ~ ~ow:~s- c~,~ ~ ~ ,2.0~ 0.0 0 0 SINGLE ' EACH OCCu~'~"~-~,,;CE f,:., ooo, o. oo AG6 [ s .,i s, o.__.o_o ,__2._o_d ':~15. 000,000 E.L. D~E - E~ EMPLOYEE · EL. D¢3EA,..~E - POliCY Lr~IT Re: ~ermit ~ENC2000-00178 ~ 1550 - 1600 w, Campbell Avenue, Campbell, CA - All w~rk in pubtic right-~-way. City of Campbell, City of Campbell Redevelopment A~ency, i~s officers, employees & volunteers are named as Additional Insured per Form ~CG 20 10 11 85 & Primary Wordin~ Endorsement ~19 attached. *%0 Day ,notice for non-p~ent of premium City of Campbeil' Attn: Dept of Public works 70 North First Street Camubell, CA 95008 ACORD 2~-$ (?,I71 81/22/2881 12:42 831-655-1800 5TRU WILLOW 6LEN INS P46E 83 ENDORSEMENT ENDT NO THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY, ADDITIONAL INSU,R. ED - OWNERS, LESSEES OR / CONTRACTORS - {FORM B~ This endorsement modifies insurance provided under the following; COMMERCIAL GENERAL LIABILITY COVERAGE[ PART SCHEDULE Name of Person or Organization: Any person or organization you have agreed in an insured contract to name as an additional insured but the coverage provided to such additional insured, unless otherwise agreed or separately scheduled, is limited to liebility arising from your negligence in performing your work during the term of this Doticy. (If no entry al~13ears above, information required to complete this endorsement will be Showr~ ~n the Declarations as aoplicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect I0 liability arising out of "your work" for that insured by or for you. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. ~olicy Number 'i Insured [ E. ffective UC, LW 100056~. KIRKORIAN PROPERTIES. A CALIFORNIA LIMITED PARTNERSHIP 0~/01/2000 CLAREN~URANCE COMPANY Countersignature of Authorized RepresenLat~ve CG 20 10 11 85 Copyright, Insurance Sen/ices Office. inc., 1984 01/22/2001 12:42 831-655-1800 STRU WILLOW GLEN IH PAGE 04 ENDORSEMENT ,t ~ ,~,-~ '~7} I,m, ENDT. NO, AMENDMENT ,O,F ,OTHER INSURANCE. CONDITIONS /' _PRIMARY AND NONCONTRIBUT,,ORY CO,VERAGE FOR AN ADDITIONAL INSURED IN CONSIDERATION OF THE PREMIUM CHARGED, IT IS AGREED THAT OCC1-17 (ED 09/01/91) (REV. 06/15/96), SECTION IV, COMMERCIAL GENERAL LIABILITY CONDITION5 PARAGRAPH 8.A. IS DELETED AND REPLACED BY THE FOLLOWING: OTHER INSURANCE A PRIMARY INSURANCE THIS INSURANCE IS PRIMARY FOR ANY PERSON OR ORGANIZATION WHICH YOU HAVE AGREED IN AN INSURED CONTRACT TO PROVIDE PRIMARY ADDITIONAL INSURED COVERAGE AND WHICH WE HAVE ADDED AS AN ADDITIONAL INSURED BUT ONLY WITH RESPECT TO YOUR PREMISES OR OPERATIONS FOR THAT PERSON OR ORGANIZATION. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED Pohcy Number UCLW IO005BZ CLARENDON AMERICA INSURANCE COMPANY Insured KIRKORIAN PROPERTIES. A CALIFORNIA LIMITED PARTNERSHIP t 06/01/2000 Countersigneture of Authorized Rel3resentative 81/22/2881 12:42 831-655-1888 5TK~3 WILLOW GLEN INS PaGE 81 Philip Strutner P.O. Box 3225, Monterey, CA 93942 Direct Phone: (831) 655-1200 Direct FAX: (831) 655-1800 Willow Glen Insurance Agency Lic~se No. 0702299 To= Joanne D'Ambrosia Date:, 1/22/01 Fax: 408-376-0958 # ~ 4 Including this page Fl~m: Joyce Fleming Re: Kirkodan Enterprises, LLC Policy # UCLW1000562 Urgent L~ For Review I-1 Plesie Comment [] Flu Reply ® Comment~ Enclosed is the certificate of insurance for the above mentioned insured. Please review it carefully. If you have any questions, please call me. Sincerely, FAX TO: Phone Fax Phone Joyce Fleming Willow Glen Insurance PO Box 3225 Monterey, CA 93942 (831) 655-1200 (830 655-1800 CC: I Date i/16/2001 Number of pages including cover sheet FROM: Joanne D'Ambrosia City of Campbell 70 North First Street Campbell, CA 95008 Phone Fax Phone (408)866-2701 (408)376-0958 REMARKS: [] Urgent [] For your review Re: Insured: KirkorianEnterprises Work Location: 1550-1600 W. Campbell Avenue Permit No. ENC2000-00178 [] Reply ASAP [] Please Comment Thank you for providing our office with a Certificate of Insurance for Kirkorian Enterprises in connection with the work they will be doing in the City right-of-way. We must, however, request that the following edits be made to the certificate so that it meets our minimum insurance requirements: 1. We require proof of Automobile Liability coverage in the amount of $1,000,000. 2. An endorsement or wording needs to be added to the certificate showing that the coverage afforded to the Additional Insured is primary insurance. 3. Please make reference to the related Encroachment Permit Number ENC2000-00178 on the insurance certificate. A copy of the certificate follows, as well as copies of the applicable section(s) of our insurance requirements, for your reference. You may submit a fax copy of the edited insurance certificate to us for approval before issuing a new hard copy. Thanks for your help in this matter. Please call me if you have any questions concerning my comments. ACORD., CERTIFICA%. OF LIABILITY INSURAi,,.;E PRODUCER Willow Glen Ins. Agency P.O. Box 3225 Monterev CA 93942. i'NSURED~- - . Kirkorian Enterprises, LLC 1630 W. Campbell Avenue Campbell, CA 95008 DATE (MM/DD/YY) 09/27/00 THIS CERTiFiCATE IS ISSUED AS A MA'I'FER 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. INSURERS AFFORDING COVERAGE ~NSURER A: Clarendon American Ins. Co. INSURER B: INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I TP~' OF INSURANCE POLICY NUMBER I POLICY ---'-7'-,.O~*vE POUCY Ex~,ATION LTR ] DA~ (MWo~"~ DATE (MW~D~ UM.~ G-'-'~=nAL LIABIUTY UCLW100056~ 06/01/00 06/01/01 EACH OCCURRENCE $1 000 000 A ¢ COMMERCIAL GENERAL LIABILITY ' ' ~j OCCUR FIRE DAMAGE (Any one fire) $ 50 , 000 r CLAIMS MED EXP (Any one person) $ 5 , 0 0 0 MADE PERSONAL &ADVINJURY $1, 000, 000 GENERAL AGGREGATE $2, 00 O, 000 GEN'L AGGREGATE LIMIT APPLIES PER: ¢l,'OL,CY FqJE~T"RO- I~ LOC ,'ROOUCTS- COM,',,:,,' A~G ,2, o o o, o o o ALL OWNED AUTOS -- BO~,LY,.JURY SE*° 2 0 2000 SCHEDULED AUTOS (Per person) HIRED AUTOS _r'u~LiC BODILY ~NJURY~h. .... NON-OWNED AUTOS (Per accident) ~MI~' PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ ,~, u...~., EAc. OCCURRENCE $ DEDUCTIBLE $ RETENTION $ $ WORKP.,~ COMI'tNSATION AND I WC STATU- TORYL.M.TS I 1°~'~' EMPLOYERS' UABIUTY I E.L EACH ACCIDENT E.L DISEASE. EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ OTHER ~E~i~'.uN OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDOR~.M~,r~T/SPEClAL PROVISIONS Re: 1600 W. Campbell Avenue, Campbell, CA - All work in publ±c r±ght-o£-way. City o15 CampBell, City o15 Campbell Redevelopment Acjency, its o1515icers, employees & volunteers are named as Additional Insured per attached form #CG 20 10 11 85. *10 Da',/- notice for non-payment of premium CATE HOLDER ADD~NAL IN~RED; IN~RER LETTER: A City of Campbell Attn: Dept of Public Works 70 North First Street Campbell, CA 95008 ACORD 25-S (7/97) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCFtl Fn BEFORE THE EXPIRA'nON DATE THEREOF, THE ISSUING INSURER WILL ~ MAIL 30 ''~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, .............. ---~ :.r... 2__ =~ ~_--.~ ..... '--:- --'-"~ ~' -%-%'¥ '- .... ~?J,~ T; ..... -J.~---~, ~ -'_::~-:._ L.. d v ~ACORD ~.~ORATION Policy Number: UCLW100056 Commercial General Liability THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED- OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: City of Campbell, City of Campbell Redevelopment Agency, its officers, employees & volunteers At-tn: Dept. of Public Works 70 North First Street Campbell, CA 95008 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you. RE: 1600 W. Campbell Avenue, Campbell, CA - All work in public right-of-way. CG 20 10 11 85 Copyright, Insurance Services Office, Inc, 1984 ACORD_ CERTIFICATE Willow Glen Ins. Agency P.O. Box 3225 Monterey CA 93942 Kirkorian Enterprises, LLC 1630 W. Campbell Avenue Campbell, CA 95008 COVERAGES OF LIABILITY INSURANCE 09/27/00 THIS CERi,-JCATE IS 18~UED AS A MATTER OF INFORMAT)ON ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICAT~ HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE ~u,ER,:Clarendon American Ins. Co. INSURER C; INSURER D: INSUREq E: THE POLICIES OF tNSURANCE USTED BELOW HAVE SEEN ISSUED TO THE INSUREO NAMED ABOVE FOR THE POUC¥ PERIOD INDICATED. NOTWITHSTANOING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUEO OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLusIONS AND CONDITIONS OF SUCH POECfES. AGGREGATE MM/TS SHOWN MAY HAVE BEEN REDUCEO 8Y PAID CLAIMS. LTR : TT~ OF INSURANCE POUCY NUMBER POUGY ~..~'~ ~l~l,~Y I . DATE {MM/DO/YY'J J DATE ~I/DD~"~'} UM/T~ ~ ,,,a~.n.~~ UCLW1000562 06/01/00106/01/01 ~^cH occu..ENc~ A I g ; COMM~RCLAL G~EN-/~RAL LJ.aJalkffY FIRE DAMAG[ {Ar~v one CL~.S ~ LvJ occu~ M~D EXP pet~) . P~,SONN. & AOV rN,,um' ~ GENERAL. AGGREGATE ~ GEN'L AGGR~GAT~ UMIT API:~.IF..S I'---~ POLICY ~ PRO- I } PI:IOOUCI'S- COMP,~P · .-- ' ' -$;:~T J I LOC i AUTOMOBILE LJaBIUT~ COMBINED S~NG~E L/MIT i'~1 AJaY AUTO (*Fa m~cid~nO ~' ' ~ OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per i}g'~) $ { HIR~0 AUTO~ BODILY INdURY NON-OWNED ALrI'O5 (lae~ acc~em) ; PRO~H{Y DAMAGE · . ~e~ a~cldeno ~_~AJ~GE AUTO ONLY - EA ACCIDENT OTHER '~-IAN EA ACC ALrrO ONLY: AGG $ e~eeee L~B,~P/ EACH OCCURRENCE $ $ ,I RETENTION WO~,m.~q.S COI6~'~-~.A"rloN AND I~'LO~. ~..,.~ {I I TORY LIMIT~ I J ! I ~.L. ~CH ACC~OENT i OTHER Re: 1600 W. Campbell Avenue, Campbell, CA All work in public ri~ht-of-way. CiEy of Campbell, City of Campbell Redevelopment Agency, its officers, employees & volunteers are named as Additional Insured per attached form #CG 20 10 11 85. '10 Day notice for non-payment of premium :ER'i'~FiCATE HOLDER J '/I A~NA~ ..*u.=; .~su,m~ ~'n~: A CANCEL ! ATION C i t y on ~f C ampbe 11 ~u,- m ~ ~ ABOV~ DESC~BBI) ~ BK CANe-- ,-n B~PORE Attn u~JF~ of PLlblic Works DATE ~HEREOF, I~E I~INQ ~ Wl~~ ~L 3 : 70 North FiUS~ Strs~t NO~a~E~A~H~B~E~,-- ..... ?--,~ ~ ~ ~~am~e~, CA 95008 ...... ~_ . ~. ..... ~.. ~. ........ ~CORD 25.-S (7/9?) sl, 000 is50, 000 /s5,000 [sl, 000, /12~ 000, ~$2,006, ooo 09/2@/2000 09:22 831-655-1800 STRU WILLOW GLEN INS PAGE 03 Policy Number: UCLW100056 Commercial General Liability THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED- OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the foJlowing.' COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: City of Campbell, City of Campbell Redevelopment Agency, its officers, employees & volunteers Attn: Dept. of Public Works 70 North First Street Campbell, CA 95008 (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you. RE: 1600 W, Campbell Avenue, Campbell, CA - All work in public right-of-way. CG 20 10 11 85 Copyright, Insurance Services Office, Inc, 1984 ACORD. PRODUCER CERTIFICA'''=. OF LIABILITY INSUF '[NCr= CSR DF I DATE(MM,DDt,, 'R/~O-2 11/26/01 Suhr Risk Services 1338 Bayshore Highway Burlingame CA 94010 Phone= 650-342-9535 Fax= 650-343-5941 INSURED Kirkorian Ente.rprises, L.L.C. 1630 West Campbell Avenue Campbell CA 95008 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 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSURERA: Everest National Insurance Co. INSURER B: INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFFECTIVE POLICY EXPIRATION LTR TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YY) DATE {MM/DD/YY} LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY FiRE DAMAGE (Any one fire) $ I CLAIMS MADE ~] OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ JEOT LOC ,ll/r" AUTOMOBILE LIABILITY -- · ~' ~J COMBINED SINGLE LIMIT -- ALLANYAUTOowNEDAUTOS DEC[ 2001 (Ea accident) $ BODILY INJURY -_UeI.,IC~ ---..:.:WORK8 (Perpersonl ~ SCHEDULED AUTOS !~g~81' $ HIRED AUTOS .~ ~iS,,~iI BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND X I WC STATU- OTH- TORY LIMITS ER EMPLOYERS' LIABILITY A 39000080880'11 01/01/0.I 0'1/01/02 E.L. EACHACCIDENT $ '1,000,000 F.L. DISEASE- EA EMPLOYEE $ '1 1000 ~. 000 E.LDISEASE POLCYLMIT $ 1~000~,000 OTHER I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS /'~i--DTII~'I/~A'I'~ Ud'~l I~'m I ~ I HOLDER I N I ADDITIONAL INSURED; INSURER LE'I'TER: CANCELLATION CITY042 City Of Campbell 70 North First Street Campbell CA 95008 ACORD 25..S (7197) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. ©ACORD CORPORATION 1988 ACORD. PRODUCER Suhr Risk Services P.O. Box 9098 San Jose CA 95157-9098 Phone= 408-246-7887 Fax.- 408-246-4919 INSURED CERTIFICA- ' OF LIABILITY INSUF - NO. ,D sc I DATE,M DD ) ~''KIRKO-202/26/01 THIS CERTIFICATE IS IS~[JED 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. Kirkorian Enterprises, L.L.C. 1630 West CamDbell Avenue Campbell CA 95008 COVERAGES INSURERS AFFORDING COVERAGE INSURERA: Everest National Insurance Co. INSURER B: INSURER C: INSURER D: NoIj. v¥., ..... e-Uo~ t, reWO~ INSURER E: ~ ~?~,~!~Lo~ L"%%~N?E ?ED ~ELOW .AVE ~EE. ~SSUED TO T.E ~.SURED RAMED A~OVE FOR T.E POLICY PER~OD ~.D,CATED. "O~N~THST^~'~d/I I ~'X '"'... giN,/H~ IN~UHANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLI I~l~ A~n r~ ~ ,~,e ,~ ~,,~u ~ ~ U POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. , ................. ~,~ INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY U.,%".~CTIVE POLICY EXPIRATION DATE (MM/DD/YY) DATE (MM/DD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ i COMMERCIAL GENERAL LIABILITY FiRE DAMAGE (Any one fire) $ I CLAIMS MADE ~ OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ -- GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: -~ POLICY ~JEcTPRO' ~-~ LOC PRODUCTS' COMP/OPAGG $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANYAUTO OTHERTHAN EAACC $ AUTO ONLY: AGG $ EXCESS LIABILITY EACH OCCURRENCE $ --~ OCCUR ~-] CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ I WC ,~ FATU- C)TH- WORKERS COMPENSATION AND X TORY L M TS ER EMPLOYERS' LIABILITY A 3900008088011 01/01/01 01/01/02 E.L. EACH ACCIDENT $1,000,000 : E.L. DISEASE- EA EMPLOYEE S 1,000,000 OTHER E.L. DISEASE - POL CY LIMIT $ 1, 0 0 0, 0 0 0 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Re: Encroachment Permit Number ENC2000-00178. Work Location: 1550-1600 W. Campbell Avenue, Campbell, CA 95008. Workers' Compensation waiver of subrogation has been requested and will follow under separate cover. *10 days notice of cancellation for non-payment of premium* HOLDER I N I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION City Of Campbell Joanne D'Abrosia 70 North First Street Campbell CA 95008 CITYO42 ACORD 25-S (7/97) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3 0 * DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. ©ACORD CORPORATION 1988 FEB-25-200! SUN 10:36 tim SUHR RISK SERVICES Ffi× NO, 14082464919 ?. 01/02 Suhr Risk Services 1190 Saratoga Avenue, Suite 100, San $ose, CA 95129 P.O. Box 9098, San Jose, CA 95157 Phone: 408-246-7887 FAX: 408-246-4919 E-Mail: solutions~insuhr.com Website: www. insuhr, com License 0610521 DATE: TO: ATI'ENTION: FROM: February 25, 2001 City o f Campbell J'oannc D'Ambrosia Sarah Holcomb FAX: 408-376-0958 TOTAL NUMBER OF PAGES WlTfI COVER SHEET: 2 Igc: Kirkorian Enterprises Prcmit No. ENC2000-00178 Following is an updated certificate of insurance for the City ofCm'npbelt. 1 will also send the originals by mail. Should you have any questions or need additional infomlation, please feel free to contact me dir~tly at 408457-2657. FEB-25-2001 SUN 10:37 AIl SUHR RISK SERVICES FAX NO. ]4082464919 Acog . CERTIFICA _ OF LIABILITY INSURA 2 ,o ~-o~uc~ ' - '-- 'RIRKO Suhr Risk Services P,O. Box 9098 :gan Joes CA 95157-9099 Phone ~ 408-2,16-7887 Fax; 408-246-4919 JN~URED Kirkorian Ente.rpri.ee, L.L.C. 1630 Wes~ CamPbell Avenue Campbell CA ~$008 COVERAGES P. 02/02 DATE IMIWDDP(Y) 02/26/01 THI~ CERTIFICATE IS ISSUED AS A MATrER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVE~eZ;~= ArrORpE~ aY THE POUCmS INSURERSAFFORDING COVEFUt~GE T~ E POLIGIE$ OF N~URANGC Ll,~¥[rd [;LOW ~VE ~ I~U~ TO ~ ~D ~D ~O~ r~ THE ~LICY PERIOD INDICTED. NO~I~$T~D~G ANY RE~,~N'r. 1'[~ OR ~flUn ;~ ~ A~ ~R~T OR O'~ER ~U~T Wi~ ~ ~S~CT TO W~CH MAY PEN~AIN, THE INS~E AFFORDED ~Y THE POLICES DE~R~D HE~ ~ ~U~ECT ~ ALE THE ~RMS. ~CLU~IONS ~D C~Dff~NS OF ~L~G, AG~F~TE LtMil ~ ~WN ~Y FIA~ BE~ ~CEO BY P~ C~l~. LT~ TYPE OF IN~U~C[ ~U~ NUMgER , DATE (~D~) ~TE I~) U~TS C~IMS ~OE OCC~ '-- ~IN~ SINGLE LIMIT ANY ~tO , ' ALL OWNFO AUTOS .... ~LY INJ~Y __ ~DULED AUTO3 (p~ HI~D -- ~LY INJURY ....................... ~Oe ~ AUTO ONLY, A~O ONLY: '" AGO EXCESS] L~ILITY[_~ ~H ~CURR~C~ '1 ~RKER~ COM~ENSA~ON AND m~oYemS'~Lny 39000080880[~ 0[/0~/01 0[/0[/02 ~-~ ~C~ E.L m~.~[~; ~R~P I ~N OF OPE~fI~ATI~H~E~CL~S ~ED BY END0~EM~/~C~ PR~$10N~ C~pbe11 Avenue, C~pbell, CA 95008. Workers' C~enaa~ion waiver a~roga~ion ham been rejected and will ~ollow ~der separate cover. *10 day~ notice DE cancellation for ~n-pa~ent of CITYO~2 C~t¥ Of Campbell Joanne D~Abroe~a 70 North F£rak Stree~ Campbell CA 95008 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLiCiES BE CANCELLED BEFORE THE E~IalR~TIOh DATE THEREOF, THE IS~;UING INSURER. WiLL ENDEAVOR TO MAIL .3 0 * DAYS WRITT6N NOTICE TO THE CERTIRCATE HOL~...R NAMED TO THE LEI:T, tlUT FAILURE TO OD e,-O SHALL IMPOSE NO OELK;ATION OR LIAelt,rrY OF ANY WND UPON THE INSURER. ITS AGEHT~ OR REPRESENTATIVE. S. ACORD 25-5 J7/97) ~)ACORD CORPORATION 1988 FAX TO: Suhr Risk Services PO Box 9098 San ,lose, CA 95157-9098 Phone Fax Phone (408) 246-7887 (408) 246-4919 CC: I Date 1/29/2001 I Number ofpages including cover sheet FROM: Joanne D'Ambrosia City of Campbell 70 North First Street Campbell, CA 95008 Phone Fax Phone (408)866-2701 (408)376-0958 REMARKS: [] Urgent [] For your review Re: Insured: Kirkorian Enterprises Work Location: 1550-1600 W. Campbell Avenue Permit No. ENC2000-00178 [] Reply ASAP [] Please Comment Kirkorian Enterprises is getting ready to start work in the City right-of-way and we need to have all their insurance in order before they may begin work. We still need to receive an updated workers' compensation insurance certificate for Kirkorian Enterprises that includes the following items: 1. The certificate we have on file shows an expiration date of 1/1/01. Please provide us with an updated certificate. 2. We require Workers' Compensation coverage to include a Waiver of Subrogation clause. 3. Please make reference to the related Encroachment Permit Number ENC2000-00178 on the insurance certificate. A copy of the certificate follows for your reference. You may submit a fax copy of the edited insurance certificate to us for approval before issuing a new hard copy. Again, thanks for your help. Please call me if you have any questions. ACORD. PRODUCER Suhr Risk Services P.O. Box 9098 San Jose CA 95157-9098 Phone: 408-246-7887 Fax: 408-246-4919 INSURED CERTIFICA- OF LIABILITY INSUF ' NO. ,D sc DATE,MM,DDt, .... 'K'/RKO-2 09/26/00 THIS CERTIFICATE IS I~SUED 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. Kirkorian Ente.rprises, L.L.C. 1630 West Campbell Avenue Campbell CA 95008 COVERAGES INSURERS AFFORDING COVERAGE INSURERA: Golden Eaqle Insurance INSURER B: INSURER C: INSURER D: INSURER E: THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLICY EFFECTIVE POLICY EXPIRATION LTR TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YYI DATE IMM/DD/YYI LIMITS GE~NERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY I ~ FIRE DAMAGE (Any one fire) $ _I CLAIMS MADEI I OCCUR MED EXP (Any one person) $ ~ PERSONAL & ADV INJURY $ - GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS. COMP/Dp AGG $ POL,CY JEcTPRO' LOC SI!p 2 9 AUTOMOBILE LIABILITY -- ~U~ rLJC WORK COMBINED SINGLE LIMIT -- ALLA"VoWNEDAUTO AUTOS 4D~ INIsTFi&i.lO8~ (E .... ident) $ BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHERTHAN EAACC $ AUTO ONLY: AGG $ EXCESS LIABILITY MAC. OCCURRENCE $ :_~ oCCUR ~ CLAIMS MADE AGGREGATE DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND $ X I WC STATU- OTH- EMPLOYERS' LIABILITY TORY LIM TS ER A NWC64051900 01/01/00 01/01/01 E.L. EACH ACCIDENT~ ] $ lr000,000 E.L. DISEASE- EA EMPLOYEI~r $ i ~ 000,000 OTHER E.L. DISEASE. POLICY LIMIT / $ i , 0 0 0 , 0 0 0 DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES/EXCLUSiONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS *10 days notice of cancellation for non-payment of premium* CERTIFICATE r N I ADDITIONAL INSURED; INSURER L~-I It:R: CANCELLATION HOLDER CI TYO42 SHOULD ANY OF THE ABOVE DESCRIBED POUCHES BE CANCELLED BEFORE T.E EXP~"nT~ON DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3 0 * DAYS WRITTEN City Of Campbell NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL 70 North Firs t Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Campbell CA 95008 REPRESENTATIVES. ACORD 2§-S (7/97) (DACORD CORPORATION 1988 FAX TO: Suhr Risk Services PO Box 9098 San Jose, CA 95157-9098 Phone Fax Phone (408) 246-7887 (408) 246-4919 CC: Date 1/16/2001 Number of pages including cover sheet FROM: doanne D'Ambrosia City of Campbell 70 North First Street Campbell, CA 95008 Phone Fax Phone (408)866-2701 (408)376-0958 REMARKS: [] Urgent [] For your review Re: Insured: KirkorianEnterprises Work Location: 1550-1600 W. Campbell Avenue Permit No. ENC2000-00178 [] Reply ASAP [] Please Comment Thank you for providing our office with a Certificate of Insurance for Kirkorian Enterprises in connection with the work they will be doing in the City right-of-way. We must, however, request that the following edits be made to the certificate so that it meets our minimum insurance requirements: 1. We require Workers' Compensation coverage to include a Waiver of Subrogation clause. 2. The certificate we have on file shows an expiration date of 1/1/01 for the worker's compensation insurance. Please provide us with an updated certificate. 3. Please make reference to the related Encroachment Permit Number ENC2000-00178 on the insurance certificate. A copy of the certificate follows, as well as copies of the applicable section(s) of our insurance requirements, for your reference. You may submit a fax copy of the edited insurance certificate to us for approval before issuing a new hard copy. Thanks for your help in this matter. Please call me if you have any questions concerning my comments. cc: Chuck Gomez 11:58 ~EP 2~, 2000 . ¢oRo. C£RTIFICATE OF LIABILITV INSUI NCE $53543 PAGE: 2/2 I OP ID SC I OATE ~a,~O~ IC[1~O-2 J 09/26/00 PRODUCER Euhr Risk Services P.O. Box 9098 San Jose CA 95157-9098 Phone: 408-246-7887 Fax:408-246-4919 Kirkorian Ent _e~prises, L.L.C. 1630 West Campbell Avenue C~mp~bell CA 9~008 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 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE INSUREF~ B: INSURER C: INSURER D: INSURER E: Golden Eagle Insurance COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INER I POLICY EFFECTIVE POLICY EXPIRATION LTR TYPE OF INSURANCE POLICY NUMBER DATE (MM/OD/YY) DATE (MM/OD/YY) LIMITS GENERAL, LIAEilLITY EACH OCCURRENCE I CI'~JMS MADE ti OCCUR MED E~P (Any one p .... ) PERSONAL & ADV INJU~Y $ G~NERAL AGGREGATE $ $ $ A EMPLOYERS'L~ILITY NWC640§1900 01/01/00 01/01/01 E L. EACHACCIOENT $ i , 000, 000 EL. OS~SE-~EMP,O~e $ 1, 000, 000 ~ L OS~E-POUCYU~T $ 1, 000, 000 *10 days notice of cancellation for non-payment of pr,~m~um* CERTIFICATE HOLDER r N I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION City Of C~m?bell 70 North First Street Campbell CA 95008 aCORD 25-S (7/97) CITYO42 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MA]L 30~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FA]LURE TO DO SO SHALL iMPOSE NO OBLIGATION OR LIABILITY OF ANy KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. ~ ACORD CORPORATION 1988 WORKER'S COMPENSATION INSURANCE INFORMATION The following worker's compensation insurance information is required for all Applicants and Contractors. One of the following items for each Applicant and Contractor must be submitted prior to working under a Public Works permit or contract. WORKERS' COMPENSATION INFORMATION: Name of Contractor/Applicant A Certificate of Consent to Self-Insure issued by the Director of Industrial Relations; OR A Certificate of Workers' Compensation Insurance' Insurance Co. (~-o,~,,~,-, Policy No. N'v4Cb~os~-?Oo Expiration Date c~, ~ c, ~ o, ; OR A signed Certificate of Exemption from the Workers' Compensation laws as printed below. CERTIHCATE OF EXEM2FrION I certify that in the performance of the work for this contract, I shall not employ.any person in a manner so as to become subject to the Workers' Compensation Laws of California. Signed Title Date NOTICE TO APPLICANT/CONTRACTOR: If after signing this Certificate of Exemption, you should become subject to the Workers' Compensation provision of the Labor Code, you must forthwith comply with such provisions or the Permit or Contract will be cancelled or revoked. j:\forms\workcomp(rev6/96) CITY OF CAMPBELL Public ~Vorks Department CAMPBELL July 16, 2003 John Kirkorian Kirkorian Enterprises 1600 W. Campbell Avenue Campbell, CA 95008 SUBJECT: PERMIT NO. ENC2000-00178 LOCATION: 1550-1600 E. Campbell Avenue MAINTENANCE INSPECTION - ACCEPTANCE Dear Mr. Kirkorian: The City of Campbell has made the final maintenance inspection of subject Public Works improvements and find that no remedial work is required. Your construction cash deposit of $885.50, and plan check deposit of $500.00, plus any interest due, are now being processed and will be sent to you under separate cover. Please find attached your original Certificate of Deposit for faithful performance security which we are returning to you. Sincerely, Syed Wahidi Public Works Inspector CCl Permit 2000-00178 Public Works/Maintenance Division H:\permits~2000-00178 maint accept(mp) 7o North First Street . Campbell, California 95008-1436 · TEL 408.866.2150 · FaX 408.376.0958 . TI)I) 408.866.279(} i~tJ~LIC W(31~ i~PAITI~2~rr ENGINEER'S ESTIMATE P . t ~T GRATE ~L~ ~C.C. D~AIL e q 27-$un-96 Page 1 of 4 ~ uNrr I~ ICT~ I~.OJEC~ AMOUNT P.C.C. DR~AY ~W ~ ~ ; S. ~ALT CONCR~ ~ ~ T ~.~ ~ ~.~ , , 27-Jun-96 Page 2 of 4 fiT. MIl' UMTII.IC~' t'ttOJ~CTAMOUNT NO. I p F. SC'Rll'T~.,,~ ,~UANTrFIES I · 1, ~EMOVE ~STRINNG L~ 81.40 ~.8 10,40 ~. J~'RIPING DETAIL, 29 : 6. PING DETAIL 32 I.F ~2.4~ $1.~ $1.2~ '7. STRIPING DETAIL 37 (THERMO) I ', a. ~TIUPINO DERAIL JI ffHEiMO) L.e S2.~0 SI.IS SLU: I ] $1JoI SO.4~ [ si. L~rr LINE L.f:: SI .1.S Si.~ SO. go I 12. CROSSWAUC LF $ I..1.S SI.0S SO.~] I 13. ~PAVEMENT MARKINC~ (PAINT) SF ~2.~' Sl.ffi SI.m I 14. ~AYEMENT MARICING~ ffHERMO) SF SS.~ S3ol0 l~60 i 15. PAVEMENT kiaiUCER (NON-REPL.) EA $i.~, S3.00 S2.20 j16. PAVEMENTMARKER(RF.r"LSCTIVR)- EA ~6.00 ~4. L~ ~.U i 17. ~TYPE K MARKi~R 20. ItELOCATE ROAD SIGN EA $l~0.O0 U4.QO r/S.QC 11. INST. RD. SIGN ON EXLST. POLE ER $~0.00 $14S,00 1110. O~ 22. I~OAD SIGN WfrH P(~T EA 130~0 S240.re SlgS.~I L~ OU'~ 27-Jun-96 Page 3 of 4 / ~ ~~ ..:..< ...... ~. ~.~:- ....... >......:.... I H:\C~CO~FF. ST. WF,.2(M P)P~V6,"J~S 27-Jun-96 Page 4 of 4 CTI'Y OF CAMPBF, I~ I~'BLIC WOP, KS ENGINEER'S MOBILI~,ATION :'ONSTRUCT'ION TRAFFIC .'ONTROLCONTRO~ .'ONSTRUCT1ON STAliNG .'OI'GTRUCTION ~ =. DZ~oLrn~ 1. ~LEARING & GRUBBING ~AWCUT P,C.CJA.C.(UP TO 3. P.C.C. REMOVAL 4. CURB AND GUTTER REMOVAL 5. vIEDIAN REMOVAL 6. DEMOLISH EXISTING INLET/PLUG RCP'S 1. !2' R.C.P. (CLASS V) i ~$' R.C.P. (CLASS 3. ~8' R.C.P. (CLA.gS 111) 4. 24' R.C.P. (CLASS Ili) I.V. INSPECTION DETAIL 9) ,FLAT GRATE INLET [:c.c. DETAIL O) i 9. ~'TANDARD MANHOLE C.SJ. DETAIL D-I 1) [INCLUDES FRAME & UD) 10. ~BREAK AND ENTER M.H./DJ. I. !IDEWALK DRWEWAY APPROACH IV. ~ORK8 =.oo ,,o.oo F-/14:o $1,100.00 $1.~0.00 SF $7.,~) 27-Jun-96 Page 1 of 4 4. ~'AL~EY GUTTER ~HANDICAP RAMP ITYPE ~1 CURB I ?- ~ Ai~3 CURB ! & ~OBBLESTONE MEDIAN SURFACE ~. P.C.C. DRIVEWAY CONFORM Vo 10. L A.~- DRIVEWAY CONFORM ~'PHALT DIGOUT AND REPLACE PAVEMENT ~E ~ (~ PAVE~E~ GRINDING ~AVEME~ F~RIC ~A~ ASPHALT CONC~E ~ A) 6. ,;AGGREGATE BASE (CLASS 2) 7. ,~LURRY SEAL (TY~E Ir) & ~SLURRY SEAL ('rYPE lid I t. D~OR L~P (6' ROU~) · ~E~OR L~P (6' x ~') ~. ~OR L~P (6' x ~3 · ELE~OLIER 2' RIGID CO~U~ SF T ~O~CT AMOUNT SIt~ SI0.00 SilGO - $*~0 SS-q) Si.tq $1..~0 $20.C0 S12.00t SO.O~ ~0.05I $2~00.00 S1.~.~ ~'~ 27-.~un-96 Page 2 of 4 NO. D~CR~ ~ ?. ~ONDUCTOR & 9. ~L~ BOX (NO. 3 PULL BOX (NO. ~ ~OV£ ~T. MARrdN~ ~MOVE ~MT. MAR~N~ 3. R£MOVE~~ 5. ,STRIPING DETAIL 29 6. ~RIPING DETAIL 32 ?. ~'RIPING DETAR. ~7 (THERMO) STRIPING DETAIl. 3tq (THERMO) 9. STRIPING DETAIL 39 I0. STRIPING DETAIL 40 11. LIMIT LINE 12. CROSSWALK 13. ?AVEMENT MARKINGS (PAINT) 14. ~AVEMENT MARKINGS (THERMO) 15. PAVEMENT MARKER (NON-REFL.) 16. PAVEMENT MARKER (REFLECTIVE) 17. iTYPE K MARKER 18. ~TYPE N MARKER 19. .~LVAGE ROAD SIGN 10. ~£LO~AT~ RO^D ~IGN 11. INST. RD. SIGN ON Sl.t~: 27-Jun-96 Page 3 of 4 ffE~ NO. VIIL I. IRRIGATION, PI.ANTING WORK PRUNE TREE R°OTS ~FREE REMOVAl. tOOT BARRIER ~. ROOT BARRI~q (It') 6. ~.E'r TRP~ (24- BOX) 7. [ITRRETTREE 06' BOX) 8. FOP SOIL BAC~CFILI.. L I~DEXTRIAN BARRIER ., 2. I~HAIN LINK FENCE (6') 3. ~.AISE MISC. BOX TO GRADE 4. RAISE MANHOLE TO GRADE $. IN~TAL.L MONUMENT BOX 6. ~EDIAN BACJCF{LL APPROVED BY: I QUAmTI'IES s6SO.ooi t~oo.~o $~o. oo S20.00 S10.~ $2~.00 Si&G0 $~0 ~.00 $~00 $'R0.0 $~0.00, $4~0.0~ 115.(~ $11JG $19.001 S17.00 10% SECURITY ENFORCEMENT FEE TOTAL ESTIMATE FOR FAITHFUL PERFORMANCE SECURITY $ AMOUNT °See Section 66499.4 of the Ma~ Act. H:\CECOSTEST.WJOO~P)REV6/3/~ 27-Jun-96 Page 4 of 4 Kirkwood Plaza-20001059 Exhibit Condition at Handicapped Access Curb Ramps CAR WASH Curb Ramp A Curb Ramp B Curb Ramp C Curb Ramp D Curb Ramp E Curb Ramp F