92-160
CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
OWNER OCCUPIED R-l
ENCROACHMENT PERMrr
(for workinq in the
public riqht-of-way)
. . ($2,500 KAXIKDH VAWE OF WORK)
Permit No. qz -/6' G
.. .
X-Ref. file
Application Date..::)- - / - <9 Z
Application expires in 3 mos.
APPLICATION - Application is hereby made for a Public Works Permit in accordance with campbell
Municipal Coae, Section 11.04. (Application expires in 6 months if permit not pulled)
A. Work address '54~ \4AC"-. Ave., CAV\'ft>'6ELL. ~~
B. Nature ot work: AS"A-tAL.T c.~-p eN ~"RKlN6 ST7< It> IN C/7lj ST12ee-r E:A'SEMtE.WI,
J
J
I
I
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o
to
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C. Attach three (3) copies of a drawinq showinq the location, extent and diDensions of the work. The
drawinq shall show the relation of the proposed work to existinq improvements. When approved by
the city Enqineer, saia drawinq becomes a part of this permit.
D. The General conaitions for all permits are listed on the reverse .ide. Special Provi.ions tor
this permit are listed below. Failure to abide by these conditions and provisions aay result in
job ahut-down an~~or forfeiture ,of Faithful Performance Surety.
Nue of Applicant H'~RO~D \.-.\:::I\\O~I)C Telephone: .378-3eIO
Aaaress 15 4-~ rtAc..K Pwe. I CA N\ 'P~~u.... I 9.sooe
Complete ana attach Workers' compensation and contractor Information forma.
The Applicant/Permittee hereby aqrees by affixinq their siqnature to this permit to hold the City of
campbell, its officers, aqents and employees tree, safe and harmle.e from any claim or demand for
damaqes resultinq from the work covered by this permit.
The Applicant/Permittee hereby acknowledqes that they are the ownere and occupants of the address
listea above, or are providinq services for the owner occupant.
reby acknowledqes that they have read and understand both the tront and back
ey w'll inform their contractor(s) of the information.
, 5- J - 9'2..
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ACCEPTED
Date
NOTES: ALL WORK SHALL CONFORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL STANDARD
DETAILS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AND MUST ARRANGE TO MEET WITH THE P.W. INSPECTOR
ON THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK.
NOTICE MUST BE GIVEN TO THE P.W. INSPECTOR AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
SPECIAL PROVISIONS
3URETY FOR FAITHFUL PERFORMANCE
(loot OF ENG. EST.)
-AMOUN'J'
$ /17,,) ....0 6
RECEIPT 11
ql 6 b'6
\PPROVED FOR ISSUANCE
~
~/ "
k0~ ~.
forCit;?;nqineer
Permit expires 6 months after date of issuance.
r5'-G~ ~ ~Z-
Date
" PH PERMIT
tevisea 10/91
(SEE OTHER SIDE)
(
CITY OF CAMPBELL
70 NORTH FIRST STREET
C AMP BEL L, C A L I FOR N I A 9 5 0 0 8
(408) 866-2100
FAX # (408) 379-2572
Department:
Public Works
05/14/92
Mr. Harold Hendrix
1543 Hack Avenue
Campbell, CA 95008
SUBJECT: FINAL INSPECTION AND ACCEPTANCE
PERMIT NO.: 92-160 R-1
LOCATION: 1543 Hack Avenue
Dear Mr. Hendrix:
We have made a final inspection of subject Public Works
construction and find it acceptable and in conformance with city
standards. Accordingly, we will recommend the acceptance of the
work to the City Engineer.
Enclosed is your faithful performance deposit of $1175.00.
Please feel free to call me if you have any questions.
Sincerely,
A~
Sal Duckworth-Lanzo
Senior civil Engineer
f: 92-160.LTR(WP/JD)
,-- MAY-08-' 92 FRI 10: 07 ID:
C.P.O.
TEL NO:
408-279-8537
1:*824 P01
May 8, 1992
Rhoncla K. Lazar
Vice President
First Interstate Bank
142~1 Winchester Blvd.
Los Gatos, CA 95008
, .
Dear Rhonda:
Thank you for help in this situation. As discussed in this morning's
telephone conversation, please set aside the amount of $1175.00 in an account
as required by the City of Campbell Public Works Department as surety for the
completion of some minor paving at my home. in Campbell.
After the work is completed and approved by the Public Works Department,
they will advise me in writing so the funds can be released back to me. Please
send a note regarding this arrangement to:
Donald King
City of Campbell
Public Works
FAX 379-2572
. I
0:: Don King, City of Campbell
John Sweeney, Cushman Construction
CITY OF CAMPBELL
Perm..._ No.
J'L- \ loO
INFORMAnON SHEET FOR ENCROACHMENT PERMITS
YORKERS' COMPENSATION INSURANCE INFORMATION
Name of Contractor/Applicant t(J~/rIIHA IJ tOn si1lve.77iJ1I'J I!~
One of the following must be on file with the Public Works Department:
A Ceftificate of Consent to Self-insure issued by the Director of
Industrial Relations; OR
,q' 'J'$ 5
Expiration Date 7-/.. 9'Z; OR
This Certificate of Exemption from the Workers' Compensation
laws printed below (certificate must be signed).
CERTIFICATE OF EXEMPTION
I certify that in the performance of the work for this permit,
I shall not employ any person in any manner so as to become
subject to the Workers' Compensation Laws of California.
Signed
Date
NOTICE TO CONTRACTOR/APPLICANT: 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 this permit shall be
deemed revoked.
CONTRACTORS INFORMATION
Note that all contractors and sub-contractors must have current City of
Campbell Business License, State Contractor's License and Workers'
Compensation Insurance.
Name of Contractor tluSJJlJ:JIIN' tc~1 L'4) Telephone ~() f"- ! 7J.- 'itJ ~3
Address .:z 20 0 P1L.rJ~..s 0#[ tlUrS lArA V SA-V .Jos~, C 1/ 9~-' ~
, ,
State Contractor License No. '/ '<I b 3 Cf
1383
City Business License No.
Expiration Date
l7/go/QZ
/ '
Will do the following types of work:
Underground
Other (specify)
P.C. Concrete ~A.C.Paving
Electrical
f:perminfo
10/91
..
CITY OF CAMPBELL
BANK OF AMERICA
CAMPBELL OFFICE
125 E. CAMPBELL AVE.
CAMPBELL CA. 95008
11-35
1210
No.
.......r~..,-r-
juf {O
70 NORTH FIRST STREET
CAMPBELL, CALIFORNIA 95008
DATE
06/02/1992
CHECK NU.
30775
AMOUNT
$1,175.00
ONE THOUSAND ONE HUNDRED SEVENTY FIVE AND 00/100 DOLLARS
SIGNATURE
PAY TO
THE
ORDER
OF
MR. HAROLD HENDRIX
1543 HACK AVENUE
CAMPBELL eA 95008
( ! I' ,,' ,:'; \ \ ' ---._~_._--_..,----_._~
:~'~::~7~~='-:-~~~:~~\,
: / ,', .. " ./ ." 1" / ",/ / " /' " I \ . \ \ \ . \ \
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////'.~ "//J :/ 1\1
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III 0 ~ 0 ? ? 5 III I: ~ 2 ~ 0 0 0 ~ 5 a I: 0 Ii ~ Ii ~ III a 0 2 0 0 III
VENDOR .010 MR. HAROLD HENDRIX
DETAIL PURCHASE ORDER '"
06/02/1992 Check D
INVOICE # DESCRIPTION
30ns
AMOUNT
001.00.905.0000.4662
REFUNDABLE DEPOSIT
1 .175.
TOTAL
1 , 17::; . '
~--'r ~
REFUNDABLE DEPOSIT
CHECK REQUEST
TO: SANDY TERPKO
ACCOUNTS RECEIVABLE
Please issue check payable to: Mr. Harold Hendrix
Address:
Line 1: 1543 Hack Avenue
Line 2:
City: Campbell
State: ~ Zip: 95008
Description: Ref Deposit/Permit No: 92-160
Exact Amount Payable: $1175.00
Account Number: 001.00.905.4662
INTEREST EARNED
001.05.540.4448
LOCATION:
1543 Hack Avenue
DATE AND NO. OF RECEIPT:
05/11/92
#41686
PURPOSE:
Return of Faithful Performance (cash) Deoosit
Approved by:
Verified by:
H. Imokawa .t.J J.)~i tl e: P. W. Inspector
~::2' 6.~ Title: City En\T~Il~er
/Jloan B 11ier
Title:
Date: os /14/<)2
Date: _"'/;51) 1.-
/ /
Requested by:
Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as is
Mail in attached envelope
Return to: Public Works
(Department)
Sal DUCkWOfN~%;).~n7.0
Other:
Rev 11/21/91
TO:
City Clerk
PUBLIC WORKS FILE NO. 9 L-->" ~ / b C.
35-3396
3372
3521
3521
Project Revenue (specify project)
Public Works Encroachment Permit Fees:
Application Fee
Plan Check Deposit
Faithful Performance (Cash) Deposit
$
3521
Other Cash Deposit (specify)
($105)
($500)
(100% of)
(ENGR. EST)
(4%of FPB)
($500 min.)
//7S~9-
3372 Plan Check & Inspection Fee ($0 - $100,00010%;
$100,000 - $500,0009%; $500,000 and above 7%; $100 min.)
3373 Project Plans & Specifications
3373 General Conditions, Standard Provisions & Details ($10 or $1/page)
3373 "No Parking" signs ($1/ea. or $25/100)
3373 Copies of Engineering Maps & Plans ($.50/sq.ft.)
3372 Final Parcel Map Filing Fee ($475 + $21/ per lot)
3372 Final Tract Map Filing Fee ($525 + $21/ per lot)
3372 Lot Line Adjustment Fee/Certificate of Compliance ($420)
3372 Vacation of Public Streets and Easements ($500)
3372 Assessment Segregation or Reapportionment
First Split ($500)
Each Additional Lot ($150)
3370 Storm Drainage Area Fee per Acre (R-1, $1,875;
Multi-Res., $2,060; all other, $2,250)
3380 Public Works Special Projects
3395 Park Dedication In-lieu Fee
3510 Postage
TOTAL
co
$ 1/7:r..:.-
NAME OF APPLICANT /J1C-6 L/)
ADDRESS / _.j-7=-~ /l.4-C/<-
h'E/l//)/'2/Y
A (/(~ . ?r4',;;?~ 0/<)"&[ L
PHONE
FOR
CITY CLERK
ONLY
RECEIVED BY V-~
DATE '23- \\-~2
~ ~ e
ZIP , 5' 00 I
CITY Cl' CAK'IlEl.L, CITY ENGINEER'S CIWSTRlI:TICJ. .IMATE PERMIT N).
Actress by elate
Slrface Ccn;tn.r:t i m
Clearirg & GrU:birg Lurp ~ EstinBte =$
Scw:ut: Calcrete LF lil *$4.50 =$
Calcrete REfID\I8l SF lil *$3.50 =$
D.rb & QJtter REfID\I8l LF lil *$5.50 =$
Inlot Drain with Pipe EAlil $600.00 =$
Qri) & QJtter LF lil $16.00 =$
Sidewalk SF lil $4.50 =$
Dri\llHl)' Woach SF lil $6.00 =$
Hlrdi~ Ra1p EAlil $475.00 =$
Extru:led Qri) EAlil 10.00 =$
Barricade LF lil $60.00 =$
Street Excavatim SF x (SO.12) x ( ") =$ '-.
ACPavaTEnt SF x (0.35) x ( ") =$
Adju;;t Ma-hole to Grade EAlil S425 .00 =$
Adju;;t IIcrdlole to Grade EAlil S325 .00 =$
McnI1e1t Box W/MaUrEnt EAlil $700.00 =$
Street Tree (15-gallm) EAlil S350.oo =$
PavaTEnt Stripirg ($100nin) LF lil $ .75 =$
Pavala1t Legenjs ($100nin) EAlil $50.00 =$
Step, Street Nale other Si!1l EAlil $140.00 =$
Pavala1t Marker EAlil $17.00 =$
PavEIIB1t Key CUt LF lil $10.00 =$
=$
=$
Slrface ~otal "S" =$
Adju;;t for size: "S" > $1oo,lXXl,Slbtract 1ax =$
Street U!iltirg
Electrolier EAlil $Z2OO.oo =$
Cal:iJi t LF lil $10.00 =$
ClnU:tor, r;mir LF lil $2.00 =$
Pull Box EAlil S2OO.oo =$
=$
Storm Drainaqe
12- or 15" Ref> LF lil $70.00 =$
18" or 21" Ref> LF lil SOO.OO =$
Street Inlet EAlil $1750.00 =$
Ma-hole EAlil S25OO.oo =$
Break & Enter Ma-hole EAlil $750.00 =$
=$
TOTAL ESTIMATE $
revised 3m. USE R:R 0CN:l $
F:cxrcost
MAY-0B-1992 10:55 FROM
All West Ins Brokers
TO
3792572
P.01
:' .: ,':,"; ',:-r.4-<.; 'RAti...,y~<..,. ';'1)0" h'$':"'~','~~~"'.':":.,'t~\.''''.'.'..'..'.(
N....S..:U.'. . '(." .,.,.,:'...:.~I'.;;:'.
':. ~",.' :\';', ,"'::/':'..."
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",.:' ~'.;;'.:"'f: "~r.~ ( '...:.. :.\~c)'lo'M\'!':l,' .1;rP..'<<~~:.;..!'::{..,I'.:.',:':~"if":':'.
.' :.., ISSUI!. DATE (MMIDDf'fY)
5-8-92
THIS OERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND. EXTEND OR Al. TER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
Ace"...
;""":,..~A.:- ...-..
PAOOuCEI't
ALL WEST INSURANCE BROKERS
P .0. BOX 17 37
CAMPBELL, CA. 95009
(408) 379-6590
r~~~NY A AMERICAN STATES INSURANCE CO
'NSUREO
., ,......" ,......, ...."... ",,,.,..... '..............,. ........, ,''',' ......__._..___...,...w '. ..........."..........." "''''.' ,...,.............--........,'..............
..! r~~~~NY BNATIONAL AMERICAN INSURANCE COMPANY
i'" .
CUSHMAN CONSTRUCTION COMPANY
2200 BLOSSOM CREST WAY
SAN JOSE, CA. 95124
COMPANY C
LETTER
COMPANY D
LETTEA
COMPANY E
LETTER
I.........., ,~'.
~ '~~ht~'~i~EI ~ ~~ .(;'~~\~~~.}~~f.f:':1~: ,':t.{{,~\, ;~< "
:.~.'~~').::~.'~... '.':.\~\:.~':::\,:".~~:({~.'.::.,~.:I.. ,>.!t t{~" '\~i~~~, .t:::h~~.;'
.~~~' ..1)1' {~,~~:~;;~~. ".\~, I.~t"
THIS IS TO CERTIFY THAT Tl-lE POLICIES OF lNSUFllANCE lISTEO BELOW HAve BEEN IssueO TO THE INSUREO NAMED ABOVE FOR THE POLICY peFlIOO
INDICATEO, NOl'WITt4STANDING ANY REQUIREMENT, TERM OR CONOITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICo\TE MAY BE ISSUEO OR MAY PEF'.lTAIN, THE INSURANCE AFFORDEO BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO Al.L THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIes, LIMITS SHOWN MAY HAve seEN REDUCED BY PAID CLAIMS.
co ,
TR'
; F'01.ICY Ef'FECT1VE POLICY eXPIRATION;
: DATE (MMlDD/YV) , DATE (MMlOO/VY)
TYPE OF IIlSURANOI!
P01.IC'I" NUMBER
: GENERAL L1A.ILlTT .
A:'.x COMMERCIAL GENERAL LIA81LIl't" >
j..';' .. ,OI.A1MSMADE:-iC.!occuR. :01-CC-335485
!' '. 'OWNEI'l'S & OONTR~CTOA'S PAOT.
["."'-')
i...... ......... ....-...-......-......... .
'10-1-91 : 10-92
~~~~~"'0811.E LIASILITY
Ai.l.iAN'I" AUTO 01-CC-335485
l.x-.. .;ALL OWNEO AUTOS
'X jSCHEDlJlEO AUTOS
tx-~)HIRED AUTOS
L~...!NON'()WNEO AUTOS
::GARAGE LIABility
\. ,.'....
i
10-1-91 !10-1-92
BI
WORICE"'S COMPENSATION
AND
EMPi.O'l"l!RS' LIABILITY
7-1-92
SFWC-I0004085A
7-1-91
iO~R
I
I
LIMITS
. GENERAL AGGReGATE $' · .
."".' -"......-.-..--.....,.,. ,". .................).. '''1-' '000'..-000.'" -.,...
I PRODUCTS.CQMP10P AGG, . $ .. ·
!PERSONAL i-i:ov: INJU~y....i..st.;"OOO;~OO.;.......
EAe-H.'occ~iRREN'Ce'" ....,... ";'$'1-;-000',-0'00';-
!....-..-...----..".". ........-.-.-...._..1..... . ..........so-.,;-ooO.;--.-
, Flf:lE OAMAG" (A...y ".... IIr.) : $
: Mer;EiPENse'~''';; ';;;;:;($ .... .,....-,Ji)O'O~."...,
COMBINED SINGLE
. 1.1"'IT : s 600,000
1....'..."....____...___....... ..... .,.....-.......... .........".....-...-.
. BODILY INJURY ! $
, (1'9' p.rson) I
1-.__...._,.,_..................___.._... .....' ,i. .........-....-.--...... ..... "...".....-
: BODilY lliJUFlY 'I' $
: (Per accldenll ,
~...___.____..._.........". ," .. \.._..,_..._..._...~....., .... .' ."\"......_..,,.___........~. ."1
'.
· PFlOPEI'lTY DAMAGE i $
i_~:~.~~.~.~R.~~c.~._......... ..' ".........__.._............,.__
AGGREGATe i $
r' ;:,<',;:-~(; ,~;?:: ,:(. :,:j(:~~,~\'~''''7~~;t: J'~.7.-:;~"~~..~''"''.--:7.~~~::~i~,1,.\
: : $TATtlTORY LIMITS ill'......... .~r
:..EAC;;-A.CC.iDENT..........-...: $t;.OOO';OOO'~"'.'
:.o.isEASe::PO~'cY'L~MIT......_..J..sl:-;.OOO.;.OOO:--..
L.DiiEASE_E~cM..EMPLOyE"E".....sl.~.OOO';OOO.:-........
oqelUPTION OF OPERATIONSIlOCATIONS/VEHICI.ESISP!CIAL ITEMS
INSURED OPERATIONS ADDITIONAL INSURED TO READ CITY
OF CAMPBELL AND ITS RESPECTIVE OFFICERS, AGENT AND
EMPLOYEES
''''''C'' ',""/"'" il' ~'."''110~'~' ','.'. 'v'j'>,;;4"Mi' ,..,!:):... 'JI."m#< ',fiI'i9lS""",,' . <$.~lPiw' .,~\~ '~I";.!Illl'1
':~t<~):,x:' )>,>"";:~\r'~':,; :~...~~~.~~~~~~.. 'r~', ~":" '~:I'J~'J~~.i. .,lr:,~?, :~~ '~~,:AV~'::'!~.,~.~'i.;'~~.:+i:j,,~'"r,'(:'~f~}~;.7~/;q,;~.)~
Ii: SHOULD ANY OF THE Asove DESCRIBED POLICIES BE CANCELl.EO BEFORE THe:
!~ EXPIRA"r6N DATE THEREOF, THE ISSUING OOMPANY WILL ENOEAVOR TO
it MAIL _ DAYS WRITTEN NOTICE TO TliE CERTIFICATE HOLDER NAMED TO THE
I.
~;' LEFT. BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY ANY KIND UPON THE COMP Y. ITS AGENTS OF! REPRESENTATIVES.
ALL CALIFORNIA OPERATIONS
: "I: ~'. ..1". \ "~1~>f.i~1~~.:J;:>'7P'<,>:':~~'~;.'~.'~1€{~'
CITY OF CAMPBELL
75 N. CENTRAL AVE.
CAMPBELL,CA 95008
ATT: DON KING
MAY-08-1992 10:56 FROM All West Ins Brokers
TO
3792572
P.02
/'
THIS ENDORSr'- U CHAN.l3ES TH~ POLICY. PLEASE REAO( ';AREFULlY:
p
~
ADDITIONAL INSURED PRIMARY COVERAGE
CG 76 34 01 89
COMMERCIAL GENERAL LIABILITY
ThiS endorsement modifies insurance provided under the following:
COMM::RCIAl GENERA!.. lIABILllY COVERAGE PART
SCHEDULE
Name of Person or Organization:
CI TY OF CAMPBELL AND Its RESPECTIVE OFFICERS, AGENTS AND EMPLOYEES.
(If no entry appears above. information reQuired to complete this endorsement will be shown in ttle Declarations as applicable
to this endorsement.)
WHO IS AN INSURED (Sectior. II) is amended to include as an inS\Jred tne person or organization shown in the Scnedul~,
subject to the following provisions.
1. Th!s l:"lsurance aooiies only with resoeCl to li2bility:
z. ArisinC out .~l nYOiJ~ work" to~ tha~ insurec by o~ for yoe: O'
t. A:!sing frOG i:r!S penerai suoervision Of "YOt,;~ work" Cy tM oe;-sor: O. organizatioi! SMwr: h the Schec1uie,
2. Th:~ :~surance oce~. no: 2DOly to "bodilY injur..... C~ "nrooe1y c;ama;~" arisinc out Of the soie nepilger.r;e o~ willIu!
m:s~cncuc: c;, ~~ 70" detects 1TI oesipr' ~urnisne~l 0;.', tne osrSOi: c~ (;rgar.izatic;: snown ir, me $::r.edll;~.
Wittl resoec! t~ ,;'ie insuranc: aftordeo the additional insured, Daragraoh 4 (17 COMMERCIAL GENERAL LIABILITY CONDITIONS
(Section IV., :~ aeleted anr: ieo:acecl by the tollovJlng:
4. Othe:- insurance
a. Tnl::; :nsurancc I~ :>r:mary. and aUi oOligations are no! affected oy a:Jy other insuranc.e carrieCl c:: sue:; additiona:
insure:: whethe; c:-rmarr. excess, contingent. or or; an~' other baSIS
b. Th!~ aOditional CroVlSIOr. appiies onl~' ,0 tne persof, O' organizatior~ shown in me Scneduie,
A.~..III.~
CERTIFICA", .: OF INSURANCE
ISSUE DATE (MMIDDIYY)
ALL WEST INSURANCE
P.O. BOX 1737
CAMPBELL, CA 95009
(408) 379-6590
BROKERS
10/2/90
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.
PRODUCER
~~T~~~NY A
COMPANIES AFFORDING COVERAGE
AMERICAN STATES INSURANCE CO.
INSURED
~~T~~~NY B
NATIONAL AMERICAN INSURANCE CO.
CUSHMAN CONSTRUCTION COMPANY
2200 BLOSSOM CREST WAY
SAN JOSE, CA 95124
~~T~~~NY C
IEeEIVie'>
OCT 0,11990
COMPANY D
LETTER
~~T~~~NY E
Public Workt/Enginoering
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 TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLlCIE CRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDU D BY PA CLAIMS.
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
LIMITS
A G~ERAL LIABILITY
COMMERCIAL GENERAltlABILlTY
CLAIMS MADE OCCUR.
OWNER'S & CONTRACTOR'S PROTo
01-CC-335485
10/1/90
G NERAL AGGREGATE $
P ODUCTS-COMP/OP AGG. $ 1,000,000.
ERSONAL & ADV. INJURY $ 1,000,000.
$ 1,000,000.
$ 1,000,000.
MED. EXPENSE (Anyone person) $
A
AUTOMOBILE LIABILITY
X ANY AUTO
X ALL OWNED AUTOS
X SCHEDULED AUTOS
X HIRED AUTOS
X NON-OWNED AUTOS
X GARAGE LIABILITY
500,000.
01-CC-335485
10/1/90
PROPERTY DAMAGE
EXCESS LIABILITY
EACH OCCURRENCE
$
$
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
AGGREGATE
B
AND
SFWC-10004085A
7/1/90
7/1/91
STATUTORY LIMITS
EACH ACCIDENT $ 1,000,000.
DISEASE-POLICY LIMIT $ 1,000,000.
DISEASE-EACH EMPLOYEE $ 1.000.000.
WORKER'S COMPENSATION
EMPLOYERS' LIABILITY
OTHER
DESCRIPTION OF OPERA TIONS/LOCA TIONS/VEHICLES/SPECIAL ITEMS
ALL CALIFORNIA OPERATIONS
CERTIFICATE HOLDER
ADDITIONAL INSURED:
CITY OF CAMPBELL
PUBLIC WORKS
75 N. CENTRAL AVENUE
CAMPBELL, CA 95008
ATTENTION: DON KING
CANCELLATION
ACORD 25-$ (7/90)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHOR~R~.VE.~ -J
:;/. 0 ~f/~ ,~~
v' 'ACORD CORPORATION 1990
THIS ENDORSI,,-- r CHAN.GES.JJ:I~ POLICY. PLEASE READ
AREFULL Y.
~)
ADDITIONAL INSURED PRIMARY COVERAGE
CG 76 34 01 89
COMMERCIAL GENERAL LIABILITY
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
CI TY OF CAMPBELL AND ITS RESPECTIVE OFFICERS, AGENTS AND EMPLOYEES.
(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 I~SURED (Section 11) is amended to include as an insured the oerson or organization shown in the Schedule,
subject to the following provisions.
1. This msurance aooiies only with resoect to liability:
a. Arising out 0' "your work" for that insured by or for you: 0"
b, Ansing from ,ne general supervision of "you: work" by ths oerson or organizatIO;! sl10wn i~; me Scheoule
2. nus insurance coes no: apol\' to "bodily injur;" or "orooerty oamaOf" arising out of tns sOle ne~J11gence 0' VJilitu
mlsconouc: c; c.. TO" o8tecb Ir1 oesiQ: turntsneo O,,! tm: Ds,son Ci oraanizatioi' snowiI Ir, me Si.neCiLJi"
With resoect to me insurancs afforded the additiOnal insureo, paragraoh 4 o~ COMMERCIA~ GENERAL LIABILITY CONDITIONS
(Section IV'! IS oeleted anc reolaced by the tollowlng:
4. Other insurance
a. ThiS insuranCE; IS [mmary, and our ooligations are not affected tJy an)' oHler IrIS11raneE carrier] D.. slier arj(Jitiona
inslJreci whether Dnmary, excess. contingent, or on an\' other basis
b, ThiS additional orovislon applies only to the person or organization shown in tns ScneciuiE:.
Page 1 of 1
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