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CIT~ Of ChMPBBLL
DBPT. or PUBLIC WORKS
70 North rir.t It.
Ca.pbellt CA 'SOOI
(408) Ih-2UO
PUBLIC WORJ(S PIRMIT Perait 110. ~ - r.::so,
'tor .DrKln~ In ~n.
pubUc ri9ht-of-way~ X-Ref. fUe 'P?"7 -~2~
luued <.f~( &(;: c::Y AppUcation Date 4 - \~- e~
Perai~ .~ r.. l~ .os. expires in - ~..
I Public Work. Perait in Iccordance with CI.pbell-
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APPLICATION - Applicltion i. hereby ..de for
Municipal Code, .ection 11.04.
A. Work Idduu or trlct ..-:J4f ~ w 1)0'[ Nc
Utility trench locltion
B. Nature of work: 1,.01; rt. C:::,'I Mo...,k..) S~ v..:>\1't.l: U!\.I-.::lU;O!.k W\"fI.\10 'Q:r( ~'b-'
C. Attach five (5) copies of I drlwing .howing the location, extent and cSiaen.ion. of the work
The drawing .hall show the relation of the proposed work to exi.ting .urface and underground
improvement.. When approved by the City Engineer, .aid drawing becomes a part of this perait.
D. The General Condition. for all permits are listed on the reverse .ide. SpeCial Provisions for
this permit are listed below. Pailure to abide by these conditions Ind provisions aay result
in job shut-down and/or forfeiture of Paithful Performance Bonds and cash deposits. (See
General Conditions land 2).
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E. An application fee must accompany this application. This is non-refundable. ~
Name of Applicant lol,..(~i <;'-~\--ft>..'''\lo~ "'\)\!(\\Llc:( 00. A-- TelePhone:l~) '; 1"5 .,.;rz4-DL ~
Address~. 'U~t.JiD~~S .Av1:: I f..AJA'ffJtj...t.., fA ~6DO~
Is this work being done by the property owner at their own residence? ____yes ~o
Complete attached Workers' compensation and Contractor foras.
The Applicant/permittee hereby agrees by affixing their signature to this permit to hold the City of
Campbell, its officers, agents and employees free, safe and haraless from any claia or demand for
damages resulting from the work covered by this permit.
The Applicant/perm'ttee hereby acknowledges that they have read and understand both the front and
back of thi perm , and th t they will inform their contractor(s) of ~e~formationo
ACCEPTED d-.LJ3~1 .
f II
SANI
NOTES: ALL RK SHALL CONPORM WITH THE ATTACHED, APPROVED PLANS AND ALL APPLICABLE CAMPBELL
STANDARD DRAWINGS AND CONDITIONS.
THE CONTRACTOR MUST HAVE THIS PERMIT AND APPROVED PLANS AND MUST MEET WITH THE P.W. INSPECTOR ON
THE SITE AT LEAST TWO DAYS BEFORE STARTING WORK.
NOTICE MUST BE GIVEN TO PUBLIC WORKS AT LEAST 24 HOURS BEFORE RESTARTING ANY WORK.
SPECIAL PROVISIONS
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Street shall not be open cut for underground installations. Minimum cuts may be allowed
for connections or exploration holes. Such cuts must be specifically approved by the
Inspector.
rave.en~ aay be cut for underground installations and aust be restored in accordance with
the Utility Trench Restoration Standard Drawing.
Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the
cut sheets sent to the Public Work Depto before starting work.
The hours of work are limited to outside the hours of 7-9 a.m. and 3-6 p.a. for any work
affectin~ traffic lane.
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PERMIT APPLICATION PEE
PLAN CHECK DEPOSIT
(11-1 )
($35.00)
STANDARD
AMOUNT RECEIPT NO.
$ ~,C'C) \~~q'7
$ <;.~ ~.1- '", l- '"l.-
$ _ c;~ ~-r- '"'L-1.'"'L
$~ . eSJ(:;) ~~~G('7
$ ~~. C:> u \~4 \ t\-
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P. P. (CASH) DEPOSIT
PERMIT PEE
$50.00
$500.00
(100' OP ENG. EST.)
($200) (4' OP 8OND,$500 MIN)
~._D
$35.00 MIN)
/"
80ND POR PAITHFUL PERPORMANCE
APPROVED FOR ISSUANCE
f: PWPERMIT
aevised 7/87
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Permit No.
Applicant
INFORMATION SHEET FOR PUBLIC WORKS PERMITS
A separate form must be completed for the applicant and each contractor
that will work under this permit.
CONTRACTORS INFORMATION
Note that all contractors must have current City of Campbell Business
License, State Contractor's License and Workers' Compensation Insurance.
Name of
Contracto);.. ~~ ~L.p..;S~
\?CJ ~~ 9(g\ CA"--P~\l
Telephone 3')~ ~t C)
Address
State Contractor License No.S~lol..9 8
City Business Lice~se No.' CB17o'i5S"-L
Expiration Date la'""",,)l -tits
Will do the following types of work:
~ound P.C. concrete
_____A.C. paving _____electrical
other (specify)
WORKERS' COMPENSATION INSURANCE INFORMATION
Name of Contractor/Applicant _\C')\r-~
bL~~R_
One of the following must be on file with the Public Works Department:
A Certificate of Consent to Self-insure
" D~tor of Industrial Relations; OR
~ Certificate 0 ensation
Insurance Co. ' \
Expiration date
issued by the
Insurance ~
Policy No.1 ()4 C{bS 4 -()?
OR
o ~'- \: \.- -e.
The Certificate of Exemption from the Workers'
Compensation laws printed below (certificate must be
signed) .
CERTIFICATE OF EXEMPTION
I shall not
Workers'
NOTICE TO CONTRACT 1APPLICANT: If, of
Exemption, you shou d 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.
f:PERMINFO
REV. 11/87
r
CITY OF CAMPBEll
70 NORTH FIRST STREET
CAMPBELL, CALIFORNIA 95008
(408) 866-2100
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Department:
· Public Works
July 5, 1988
J:: {-;.3 9'
. C-".:=:CC'::=-'-'--- r'---
West Valley Sanitation District
of Santa Clara County
100 East Sunnyoaks Avenue
Campbell, CA 95008
RE: FINAL INSPECTION AND ACCEPTANCE
PERMIT NO. 88-139
LOCATION: 79 AND 80 DOT AVENUE
We have made a final. inspection of subject Public Works construction
and find it acceptable and in conformance with City standards.. Ac-
cordingly, the work is hereby accepted.
You are responsible for the maintenance, repair and/or replacement
of all work done should any failures occur. .
We will inspect the work periodically and advise you whether or
not maintenance is needed.
Please feel free to call if you have any quest ions.
Sincerely,
~dL.----
David N. Valkenaar
Associate Civil Engineer
DNV!1 e
cc: G. Eaton, Public Works Inspector
CR
Glage Construction, P. o. . Box 961, Campbell, CA 95009
-
. ~
C H E C K R E QUE S T
TO: ' FINANCE DIRECTOR'
,City of Campbell..
Please issue check payable. to:.
, 4 '
Street :'
Ci ty: '
State: ,,~(2 spaces) .
.
.Zip:',. '~(5spaces)
(20 spaces)
(20 spaces)
(15 spaces)
Address:
(20 spaces)'
Exact Amount Payable:
500.00
Account Number:
'01446290500
Purpose:
Release of cash deposit for Excavation Permit #88-139. See
, '
Receip:t #18397.
Requested b
. . . Approved by:
'. SPECIAL' INSTRUCTIONS FOR HANDLIN
,"
Title: Assoc. Civ. Engr
Title: P.W. Director
. Date: ,7/nr;;/RR
~ ..
Da te: ---17/Y\r;;/RR
. .
Mail as is
Return to:
x,
Ma.il in attached envelope
Department'
Name
Ot~er:
" .
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REV 4/22/83
PUBLIC WORKS INSPECTION REPORT
.Jate
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1 -, - - .-
77 -8/
Permit or Project No. '88 -/31
--- ODi
Address
Sani tary X. Electrical
Type of work: Street Storm
Other (describe)
[JPRELIMINARY INSPECTION WITH DEFICIENCY LIST (attached)
[JFINAL INSPECTION WITH DEFICIENCY LIST (attached)
Q!j FINAL INSPEC.TION - ACCEPT~
Signed plans? Y ~ (If
Charges against deposit? Y
Overtime; hrs. @ $
Date" reason:
signed,
cP
Ihr.
Council acceptance.)
$
$
$
- Refund $
-
Barricade rental (attach invoice)? Y
Date" reason:
@
-
Other?
Total charges deducted from deposita
(Cash Deposit $ less charges $
[JONE YEAR MAINTENANCE WITH DEFICIENCY LIST (attached)
o ONE YEAR MAINTENANCE - ACCEPTANCE
(Release'maintenance bond. Check Request if cash.)
Engineer
$
$
$
ck. req.)
@
;fwn/r4~~~/39
JOHN GLAGE UNDERGROUND
P.O. BOX 961
CAMPBELL, CA 95008
June 6, 1988
'"
City of Campbell
70 N. First Street
Campbell, CA 95008
Attn: Mr. Greg Eaton
RECEIVED
JUN 71988
PUBLIC WORKS
ENGINEERING
Re: Bond for Dot Ave, 77-81
Dear Greg:
As you are aware, we have recently installed a sanitary sewer
lateral at Dot Avenue 77-81 and I am requesting that you release the
Bond in the amount of $500.00.
If there is any problem, please let me know so I can rectify the
problem as soon as possible.
Owner
~ ~~i~~1~~~;~
RE'-t.:.IVZi)
APR 15 1988
HOME OFFICE ONE NATIONWIDE PLAZA. COLUMBUS, OHIO 43216
CERTIFICATE OF IllSUP.ANCE
/ia't~:Oll/J'7::i{;' InSUr'CL,'zcn
COlnpa,ny incl i(;({. teet bc' lorJ cer~/; -Lft-ts'r; t/'u~rt
be? ZOiJ ~'.,B -Zn :jf] t/~e cf'f'(;etl~ vc
o~p t:-!'~iD C;,?7-!;--t
CITY OF CAMPBELL
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T]~3r:.-lpe(:~ ' B //7JI1C o::r"d AdcZrJ(J8B:
J olL" G[age UndcPo]1?Ouni
7116' Dol. 7 Aocmue
C:wTpbcU, CA 95009
Co,wi; r'uct ton
Add'Z Insd.: City of C(~belZ & its
pespeetive Officeps, Agents, & Employees
70 N. Fipst StT'eet
Campbell, CA 9fi008
InDY,lY)(lnce '~'n fo'p(~e onLy ,for') hCX2(Cr~U:B "'~Yl(i~ir;"tted by ff):"
1; POL. # MID '/ POLICY
ISSUING </ EFFECTIVE
COMPANY '"j DATE
DESCRIPTIVE SCHEDULE
POLICY ~i
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DATE ~,
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DeD(n'{ption oJ' Opel"~ti.mw/LOC7..Di Oi'w/
AU opel'ations of the named insuped as eove}'ed by
the policy .of? endopsements attached thepeto.
INSURANCE COllPAllY
IJ..'.Li;c C)e)''}t.--l...:.....IC{~:'A-Lc j-DDU:3d: ..1pp'Ll 1 , 1 DP8
NATIONWIDE PROPERTY AND CASUALTY IllSURANCE COMPANY
Cotzonbus, Ohio
I
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
POLICY CHANGES
Policy Change
Number _
POLICY NUMBER
POLICY CHANGES
EFFECTIVE
COMPANY
505 975
NAMED INSURED
PR
Nationwide Mutual Insurance
0001
12-1-87
AUTHORIZED REPRESENTATIVE
JOHN GLAGE UNDERGROUND CONSTRUCTION
1116 Dell Avenue
Campbell, CA 95009
Gail H. Murrell #04-2318
P. O. Box 254648
Sacramento, CA 95865
COVERAGE PARTS AFFECTED
GENERAL LIABILITY
CHANGES
IT IS AGREED TO ADD ADDITIONAL INSURED -
OWNERS, LESSEES, OR CONTRACTORS (FORM B) PER ATTACHED FROM CG 2010 (11-85).
NO CHANGE IN PREMIUM.
IL 12 0111 85
Copyright, Insurance Services Office, .nc" 1983
Copyright, ISO Commercial Risk Services, Inc., 1983
I
POLICY NUMBER: PR 505 975 0101
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 and i ts respective Officers, Agents
& Employees
70 N. 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 rnsured by or for you.
"It is hereby agreed that the City of Campbell & its respective Officers, Agents,
and Employees are named as Additional Insured from and against any claims loss
liability cost or expense arising out of or in any way connected wtih the construction
of the project.
This coverage shall be primary and any coverage carried by additional insured shall
be excess insurance only."
JOHN GLAGE UNDERGROUND CONSTRUCTION
1116 Dell Avenue
Campbell, CA 95009
CG 20 10 11 85
Copyright. Insurance Services Office, Inc. 1984
o
STATE
COMPENSATION
INSURANCE
FUND
REP
1049054-87
NEW
NG
EMPLOYER'S LIABILITY INSURANCE
AMENDED
ENDORSEMENT AGREEMENT
HOME OFFICE
SAN FRANCISCO EFFECTIVE DECEMBER 2, 1987 AT 12.01 A.M.
ALL EFFECTIVE DATES ARE
AT 12:01 AM PACIFIC
STANDARD TIME OR THE
TIME INDICATED AT
PACIFIC STANDARD TIME
PAGE IL
JOHN GLAGE UNDERGROUND
CONSTRUCTION
PO BOX 961
CAMPBELL, CALIFORNIA 95009
ANY CONTRADICTION BETWEEN THE POLICY AND THIS ENDORSEMENT WILL BE CONTROLLED BY THIS ENDORSEMENT.
IT IS AGREED THAT THE INSURANCE AFFORDED BY PART TWO - EMPLOYER'S LIABILITY INSURANCE OF THIS
POLICY IS SUBJECT TO THE FOLLOWING PROVISIONS,
A. "HOW THIS INSURANCE APPLIES", IS AMENDED TO READ AS FOLLOWS,
A. HOW THIS INSURANCE APPLIES
THIS EMPLOYER'S LIABILITY INSURANCE APPLIES TO BODILY INJURY BY ACCIDENT OR BODILY
INJURY BY DISEASE. BODILY IN~URY MEANS A PHYSICAL OR MENTAL IN~URY, INCLUDING RESULTING
DEATH. BODILY INJURY DOES NOT INCLUDE EMOTIONAL DISTRESS, ANXIETY, DISCOMFORT, INCON-
VENIENCE, DEPRESSION, DISSATISFACTION OR SHOCK TO THE NERVOUS SYSTEM, UNLESS CAUSED BY
EITHER A MANIFEST PHYSICAL IN~URY OR A DISEASE WITH A PHYSICAL DYSFUNCTION OR CONDITION
RESULTING IN TREATMENT BY A LICENSED PHYSICIAN OR SURGEON.
1, THE BODILY INJURY MUST ARISe OUT OF AND IN THE COURSE OF THE INJURED EMPLOYEE'S
EMPLOYMENT BY YOU.
2. THE EMPLOYMENT MUST BE NECESSARY OR INCIDENTAL TO YOUR WORK IN CALIFORNIA.
3, BODILY IN~URY BY ACCIDENT MUST OCCUR DURING THE POLICY PERIOD.
4. BODILY IN~URY BY DISEASE MUST BE CAUSED OR AGGRAVATED BY THE CONDITIONS OF YOUR EM-
PLOYMENT. THE EMPLOYEE'S LAST DAY OF LAST EXPOSURE TO THE CONDITIONS CAUSING OR
AGGRAVATING SUCH BODILY INJURY BY DISEASE MUST OCCUR DURING THE POLICY PERIOD.
S, IF YOU ARE SUED, THE ORIGINAL SUIT AND ANY RELATED LEGAL ACTIONS FOR DAMAGES FOR
BODILY INJURY BY ACCIDENT OR BY DISEASE MUST BE BROUGHT UNDER THE LAWS OF THE STATE
OF CALIFORNIA.
C. "EXCLUSIONS", IS AMENDED TO READ AS FOLLOWS,
C. EXCLUSIONS
THIS INSURANCE DOES NOT COVER,
1, LIABILITY ASSUMED UNDER A CONTRACT,
2. PUNITIVE OR EXEMPLARY DAMAGES WHERE INSURANCE FOR SUCH LIABILITY IS PROHIBITED BY
LAW OR CONTRARY TO PUBLIC POLICY,
3. BODILY INJURY TO AN EMPLOYEE WHILE EMPLOYED IN VIOLATION OF LAW WITH YOUR ACTUAL
KNOWLEDGE OR THE ACTUAL KNOWLEDGE OF ANY OF YOUR EXECUTIVE OFFICERS,
4, ANY OBLIGATION IMPOSED BY A WORKERS' COMPENSATION, OCCUPATIONAL DISEASE, UNEMPLOY-
MENT COMPENSATION, OR DISABILITY BENEFITS LAW, OR ANY SIMILAR LAW,
S, BODILY IN~URY INTENTIONALLY CAUSED OR AGGRAVATED BY YOU,
8. BODILY IN~URY ARISING OUT OF TERMINATION OF EMPLOYMENT, OR
7. BODILY IN~URY ARISING OUT OF THE COERCION, DEMOTION, REASSIGNMENT, DISCIPLINE,
DEFAMATION, HARASSMENT OR HUMILIATION OF, OR DISCRIMINATION AGAINST ANY EMPLOYEE,
NOTHING IN THIS ENDORSEMENT CONTAINED SHALL BE HELD TO VARY, ALTER, WAIVE
OR EXTEND ANY OF THE TERMS, CONDITIONS, AGREEMENTS, OR LIMITATIONS OF THIS
POLICY OTHER THAN AS STATED. NOTHING ELSEWHERE IN THIS POLICY SHALL BE
HELD TO VARY, ALTER, WAIVE OR LIMIT THE TERMS, CONDITIONS, AGREEMENTS OR
LIMITATIONS OF THIS ENDORSEMENT,
COUNTERSIGNE~D AT SAN FRANCISC~
. 4 #._.~
AUTHORIZED REPRESENTATIVE
DECEMBER 9, 1987
~--- A ~
C7-;:SIDENT
2086
selF FORM 10217 (REV.7-841
OLD DP 217
PUBLIC WORKS FILE NO. Q~"'" /? 7'
TO: City Clerk
CT.
35-3396
3372
3521
3521
3372
3521
Please collect & receipt
for the following monies:
ITEM
Project Revenues (specify project)
Pu.bUc. (:JO:tlUl Exc.ava..:tion peJLm..{;t fe.M:
A 1 i ca t i on Fee
Plan Check Deposit
Faithful Performance (Cash) Deposit
AMOUIH
$
O:thVL:
($ 50)
'( 500
(4% of FPB)
($500 min.)
(7% of FPB)
($ 35 min.)
R-1 :
($35)
so
~cc>
($200)
~oc?
Plan Check & Inspection Fee
Other Cash Deposit (specify)
1373 Project
3373 General
3372 Tentative Parcel Map Fil ing Fee ($350)
3372 Final Parcel Map Fil ing Fee ($300)
~~72 Tentative Tract Map Fil ing Fee ($400)
_ 72 Final Tract Ma Fil in Fee ($350)
3372 Lot Line Ad'ustment Fee/Certificate of Compl iance
3372 Vacation of Publ ic Streets and Easements
3372 Assessment Segregation or Reapportionment
First Spl it ($500)
Each Additional Lot ($150)
3372 Environmental Assessment:
Categorical Exemption
Ne ative Declaration
3370 Storm Drainage Area Fee per Acre Multi-Res.,
$2,060; all other, $2,250)
1395 Park Dedication In-l ieu Fee per Unit ($1,132)
3380 Public Works Special Projects
3510 Postage
NAME
ADDRESS
TOTAL
$ 0-5- ()
3 79- 30/ (j
C; "0 0 9
PHONE
ZIP
FOR
C I TV CLERK
OII1..Y
RECE IPT NO.
July, 1987
~ PAID
RECE I VED BY
DATE'
TO: City Clerk
PUBLIC \oIORKS FILE NO. ~~-V~~
Please collect & receipt
for the following monies:
CT.
35-3 96
3372
3521
3521
project)
VLP.l'u F e.u :
R-l :
(S'35)
($200)
t1eA:
($ 50)
( 500)
(4% of FPB)
($500 min.)
(7% of FPB)
($ 35 min.)
( Cash) Depos i t
Plan Check & Inspection Fee
Other Cash Deposit (specify)
3373
3373
Proj ect
General
&
3372 Tentative Parcel Map Fil ing Fee ($350)
3372 Final Parcel Map Fil in Fee ($300)
~~72 Tentative Tract Map Fil ing Fee $400
_ 72 Final Tract Ma Fil in Fee ($350)
3372 Lot Line Ad'ustment Fee/Certificate of Compl iance
3372 Vacation of Publ ic Streets and Easements
3372 Assessment Segregation or Reapportionment
First Spl it ($500)
Each Additional Lot ($150)
3372 Environmental Assessment:
Categorical Exemption
Ne ative Declaration
3370 Storm Drainage Area Fee per Acre Multi-Res.,
$2,060; all other, $2,250)
3395 Park Dedication In-lieu Fee per Unit ($1,132)
3380 Publ ic Works Special Projects
3510 Postage
TOTAL
NAME
PHONE
AMOUtH
$
<it. ~<S:, ~C>
$ '=3"'S". C::> 0
ADDRESS
ZIP
FOR
C I TV CLERK
a-ll.Y
'-11
~ PAID ~S- frO
RECE J VED BY t-P
i-f- II L/ / g e
, f-
RECEIPT NO.
DATE'
July, 1987
PRODUCER
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.
G"m!
Gail H. Murrell
Nationwide Insurance Company
P. o. Box 254648
Sacramento, CA 958;5
COMPANIES AFFORDING COVERAGE
f~-f4~~NY A NATIONWIDE INSURANCE COMPANY
INSURED
COMPANY B
LETTER
COMPANY C
LETTER
JOHN GLAGE UNDERGROUND CONS'l'RUCTION
1116 Dell Avenue
Campbell, CA 95009
COMPANY D
LETTER
COMPANY E
LETTER
,.'i
THIS IS TO CERTIFY THAT 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 CONDI-
TIONS OF SUCH POLICIES.
,~:
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFfECT,VE POLICY EXPIRATION
LTR DATE (MM/ODiYY) OA TE (MM/DDIYY).
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE GOCCURRENCE
A OWNERS & CONTRACTORS PROTECTIVE PR 505 975 0001 12-1-87 12-1-88
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNEO AUTOS
SCHEDULED AUTOS
* HIRED AUTOS
NON-OWNED AUTOS BA 505 975 0002 12-1-87 12-1-88
GARAGE LIABILITY
CO 505 975 0003 12-1-87 12-1-88
OTHER THAN UMBRELLA FORM
-WORKERS' COMPENSATION
AND
EMPLOYERS' LIABILITY
OTHER
ALL LIMITS IN THOUSANDS
GENERAL AGGREGA 1 E
PRODUCTS-COMP/OPS AGGREGATE
PERSONAL & ADVERTISING INJURY
EACH OCCURRENCE
FIRE DAMAGE (ANY ONE EIRE)
MEDICAL EXPENSE (ANY ONE PE RSON)
CSL
$ 500,
BOOIL Y
INJURY
(PER PERSON) $
BOOIL Y
INJURY
tJC~OENTl $
$
EACH
aCCIIRAENCE
1,000,
$
$
$
lEACH ACCIDENT)
(DISEASE-POLICY LIMIT)
(DISEASE-EACH EMPLOYEE)
DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES I RESTRICTIONS I SPECIAL ITEMS
1 operations of the named insured as covered by the policy or endorsements attached thereto.
~
CI'n of CAMPBELL
70 North First Street
Campbell, CA 95008
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX.
PIRATlON DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL 30 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 COMP NY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZE EPRESENTATIVE
'/1u~
Isabel Lord
. - .
~
."-~~
. .......\
I
I
I
I
I
RECEIPT
CITY OF CAMPBELL
CAMPBELL. CALIFORNIA
~o
~:Ol
n5f')-~
REVENUE ACCOUNT NOo..3 :3 7 '2 , (~~I
/ .
FUND NUMBER
~CK
o MONEY ORDER
o CASH
DATE
APR 13-
AMOUNT
2014 -li***
THIS RECEIPT
MUST BE MACHINE
VALlI)ATED AND
SIGNED BELOW.
c1201l,JA *** 500.00
U20,qA ****5Q.00
BY
18397
.'
Thank You
CITY OF CAMPBELL
o No CITIZEN COPY
....
9..9-87..,tt
FROOUCEA
I
O Aa.x.nder' A!.uoq.r 0' California Inc.
1530 Morldilfl
, p.o. eo. 5700 ' ',01 .,~I,i ,fl... .
.. San Joa4. J;a1If(>rolf &Sl~ . '. . 'j
Telephone 408 264-67QO "," "':'
1WX 91().338.0239
T'lI" ~,~'I+.'~~~ ~' .. ;. .
THIS CERTIfiCATE IS ISSUED AS A "ATTEA OF INfOfl..ATION ONLY AHD CONFERS
NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOeS NOT AMEND.
EXTEND OR ALTER THE CO\lERAGE AFFORDED 8Y THE POUCIES BELOW.
, : f" ~',i '. .',
COMPANIES AFFORDING COVERAGE ,', r"; \..1
:". '.fI".~ ',",
INSURED
WATTI~. C~~S'f~CTION C9.. I , INC.
964', Stock.~on 4v~l\l,le ..., ,
sa~':J,c)~~,;~:,; C:A ',: 9,590, :':::J
COMPANY A
LEITER ARGONAUT INSURANCE COMPANY
COMPANY B
LEITER
f. :
J ',:..1'.
" .
.:" COMPANY C , J " i ., ;
, " LETrER .' :; ..' .
GOMPANY 0 \.... :.:) : \!,'. J, .., i
,. LEnIOR, ,., . " ., ,.
.
CO TYPE OF INSURANCE POLICY NUMjjER KllI(;V WlCI:vl I'ULlCV I ~l'lkA , lOt;
LTR llAll IMMiOOlYYj llA I f IMM/OOlYYI . '
GENERAL LIA81LrTY OOOIL Y $
X COMPRtHfNSIVE fOHM IN.JURY
r x PHiM1SES/OPERA TIONS PROPI:RJ"t $ $
X UNDERGROuND CL76461002932 12-31-86 12-31-8 DAMAGE
EXPLOSION 0\ COLLAPSE tlAZARO
! x PHOOUCTSlCOMI'LElfO OPERATIONS
A CONTRACTUAL BI /I. PO
X COMIlINEO
X INDEPENDENT CONTRACTORS
X BROAD fORt,t PROPERTY DAMAGE
'x PERSONAl. INJURY PERSONAL INJURY
AUTO"08ILE UA8'LITY lIOOIll
IlIJUHI $
X ANY AUTO II'(R I'lllSOHl
ALL OWNED AUTOS (PAN. PASS) CA76461002933 12-31-86 12-31-871lOOw.1
AU OWNED AUTOS (OlHER THAN) lIWUIll $
PAN PASS lI'tR ACOOlHn
ItIHt:Q AUTOS I.' \ ~.I : ~ . .' PROPERTY $
A . I '. ~ . . '. ", "- DAMAGE
NON.OWNED AUTOS
GARAGE LIABILITY B. & PO
COMBINEO $ 1 000
EXCESS UA81LITY
UMllAfLLA fORt,t BI & PO $ $
COMBINED
OTHER THAN UMBRELLA fDIiM
STATUTORY {' :~r~~};J:: ;,::< ': .'
WORKfAS' COMPfNSA TION
AND WC76-463-002939 2-1-87 12-31..~
A E....LOYERS' UA81LITY
OTHER
DESCRIPTION OF OPEAATIONSlLOCATlONSI\IEHICLESlSPEClAL ITEMS
P~oject 83-9 UQioQ Avenue Street ImprovementQ
. . .
.
..., J.'Y OF ,CAHPBELL
70'N~Firat Street
Campbell, CA 95008
SHOULD ANY OF THE AUOIIE DESCRIBED ..OLICIES BE CANCELLED BEFORE THE
EXt>IRATlON DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL ] n DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMa;o TO
THE LEFT:&tiT FAILURE TO MAIL SUCH NOTICE SHALL I..POSE NO OULlGATION OR
LIABILITY OF ANY I<IND UPON THE COMPANY,ITS AGENTS OR REPRESEHTATIVES.
AUTtl~A/Z,EP AEPFlES,E!'HATlVE'
Rosalie E. Williams
. .. .
. ,#
.~.;. .
,.t.,...
. .. .. ...
.. -
:t ~
. '.
(. ; .
;, ... ~.....-~
Ila.
ENDORSEMENT
., ..'.~. . Thl. cndorun.cnt, cfl"II.,. 12; 01 a. Me 9-9-87
p"Jj'VN~:Clt.7t.l4.pio02932 ilWCdio Watt1s Construction Co., Inc.
. . ~~;, ." 0" , ...~ . .
. fOllN. Ptrt '"
,
, , '&1t, ~rgonaut Insurance Co.
. .
IT 'IS HEaE~Y AGREED THAT THE CITY OF CAMPBELL AND ITS RE~PECTIVE OFFICERS. AGENTS AND
.EMP~OYEES ARE 'NAMED AS ADDITIONAL INSURED FROM AND AGAINST ANY CL4IHS. LOSS LIABILITY,
COST OR EXPENSE ARISING OUT OF OR IN ANY WAY CONNECTED WITH THE CONSTRUCTION OF THE
PROJECT, 'THIS COVERAGE SIW..L BE PRIMARY AND ANY COVERAGE CARRIED .BY ADDITIONAL '
INSURED SHALL BE EXCESS INSURANCE ONLY.
,
E'
.'
.
P,roject ,83-9 Union Avenue Street Improvements
. .
) ':1. 10, ~ .
.... ~ ,,' :', .i'~ j' '1
.' ,".\ '" '1..:, I ,,:
: I
~~LJ" '
-.. . .
. "......... ..~......_._._.._--
, R 11 A.m'll"ull R.p...,,,......
OBa e E. W111iawa
.
.....---. .oo ." .. .,.~_.__.. -
I
...:;., '" ~
PROJECT
//
,/
, NOTE: THIS IS NOT A PART OF THE CONTRACT
This is a general summary of the insurance requirements for City of C~mpbell
projects, and specifically for this project.
Please refer to the project Special Provisions and the City of Campbell
General Conditions for specific contractual language covering insurance
requirements.
Prior to commencing work and until project is accepted by City, Contractor is
to provide insurance having the following minimum limits:
(a) Bodily injury liability - $500,000 each person; $1,000,000
each occurrence.
Property damage liability - $250,000 each occurrence; $500,000
aggregate.
or . (b) A single limit for bodily lnJury liability and property damage
liability combined of $500,000 each occurrence; $1,000,000
aggregate.
All insurance policies shall have an Additional Insured Endorsement, naming
r the City of Campbell, its officers, agents and employees as additional in-
sureds.
The certificate shall clearly state as follows:
The City of Campbell and its respective officers, agents and
employees are named as additional insureds from and against any
claims, loss liability, cost or expense arising out of or in any
way connected with the construction of the project. This cover-
age shall be primary and any coverage carried by additional
insured shall be excess insurance only.
Each carrier must give the City at least ten days' prior notice of the can-
cellation of any policy during the effective period of the contract.
Policies are not to contain the so-called "X" "C" "u" exclusions.
Insurance must be issued 'by a company or companies authorized to transact
business in the State of California.
Insurance coverage in the minimum amounts set forth herein shall not be
construed to relieve Contractor for liability in excess of such coverage,
nor shall it preclude the City from. taking such other actions as are avail-
able to it under any other provision of the contract or otherwise in law.
THIS SHEET MAY BE REMOVED FOR REFERENCE
Also to be named as Additional Insured's:
Apri 1, 1986