ENC2005-00018
CITY OF CAMPBELL
DEPT. OF PUBLIC WORKS
70 North First St.
Campbell, CA 95008
(408) 866-2150
Fax (408) 376-0958
R-l NO FEE ENCROACHMENT PERMIT
Permit No &u::: .20::::F:5 -COO I&'
X-Ref. File
Application Date .z.,. , , a '0 ~
Application Expiration Date~' (0 .o~
APN 3~-2.3-v8o
(Non-engineered work within the public right-of-way)
($5,000 maximum value of work)
ISSUED
~"Z-' I()~
Permit Expiration Date 2. . to. of,
APPLICATION - Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section
(Application expires in 6 months if the permit is not issued.)
MIL 7b to
AfrDAch
J?6
B. N""" ofWo,k elf!
c. Attach three (3) copies of a drawing showing the location, extent and dimensions of the work. The drawing shall show the relation of the
proposed work to existing improvements. When approved by the City Engineer, said drawing becomes a part of this permit.
D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit
Conditions listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and
provisions may result in job shutdown and/or forfeiture of Faithful Performance securities.
NAME OF APPLICANT~ 0 L J) ~ .e..tl .
6 if . (print name)1
ADDRESS \ ? ~ l ro 0\.,) I f\v C
da '-'e. k' ~ Q R::.r#, kA t, Y) ~ --I
The Applicant hereby confirms that this work is being done by the property owner/applicant at their own residence.
A. Work address
E-MAIL ADDRESS
11.04.
C~MDbell
UJ{i-fk C(JU~ 1- (~U,
AuC
+ Sf c&.
TELEPHONE
C~fV1 pbell.
The Applicant hereby agrees by affixing their signature to this permit to hold the City of Campbell, City of Campbell Redevelopment Agency,
its officers, agents and employees free, safe and harmless from any claim or demand for damages resulting from the work covered by this
permit.
contractor( s)
JACCEPTED
.-
..2 /0 D~
Date
(Apll!icant/fermittee) (Sign)
r3llt PJt tAJ 0' v..J Gl (,( 0 I"t. C; , r l.A-'t l.. (J""" .
NOTES: All work shall conform with the attached approved plans and all applicable Campbell Standard Details and Conditions and
applicable insurance requirements.
The Contractor must have this permit and approved plans and must arrange to meet with the Public Works Inspector at the site at least two
days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work.
Per Section 4215 of the Government Code this permit is not valid for excavations until Underground Service Alert (USA) has been notified
and the inquiry identification number (Ticket No.) has been entered hereon. USA PHONE: 1-800-227-2600. TICKET NO.:
Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be responsible for any and all
damages arising out of the design, installation or condition of private improvements in the public right-of-way.
SPECIAL PROVISIONS
_I. ~r to any work, the
---L..2.
_3.
Improvements in the Public Right-of-Way, which shall be recorded.
P<- .
SECURITY FOR FAITHFUL PERFOR
APPROVED FOR ISSUANCE
J:\forms\rl permit
Revised 1.20.04
AMOUNT ~
$ A' .{ c..
RECEIPT NO.
'Z' 10 .
Date
Permit Ex ires 6 Months After Date of Issuance.
f __'
r 5'.().J ,-
..-- 11'-8"
'I.::d'
C~
- .
...........
,
........ -ft7
~:
~I
ct..
,
- t - - - - - - - -f:~- - - - - - - - -:;- - - --
13'.0" '
_.. 'L .... ...
. _ I _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ .; Water Shut Off
-t.--.'1I"a::____.____ I,
~.-: :4: ....,;~ ::O'<C .......... *"= "4 . !
y
Location
I
New ConCrete
Driveway
I:
9
It)
N
I f
L ~'-O"i
1-0"----;
I
i
.
I
~
I
I.
~
,
; _ ~r"',:: ..:...-:..:"'::' -=.:; ':;'-'
.._.! "'_ . .._ ...J
141-0" 15'.9 1/2"
-------
.,
201-6"
SOl -0"
.~.
Js
-----------
201-0"
12<.3"
Q
.
i'r)
-'
o
t
Ln
-'
~
~?~b
\i ~r6 ACI(<
Contractor must have these plans
on the job. site during construction.
q ~ PlACE
~ Side. ~0tK .: -
o()"L~ib'+- G-'~\-te{L~
9?z'.iJ _.w
C of Campbell
Publ c Works F;'ennit No. 5Vc.. ~3 --CCX)I&'
..,..,....', '.-- ,"
17 6 N orthMi~iii:i:i;'j~~ Aver:
New Site p~t;flf(~t;!~'l" ='-,
. ". .......;f.;:./..:~J 2l'~~ .
A . '..P;"N 3.rl. '. :~lr~~...r~jh.>3 08. O.
.." .~~,~c~-_,-:<., 4
, -.. '" . . .. .. , ,',- '.. .. ..._~..'.." .
.' ~h., . -':<:;-_>j-,;;::-"::.:','
-tii~.tt.\;~.M;~}~ ___"_ ....;;:;':
rnr~
fY\ L/.) 7< ~
I
INSURANCE REQUIREMENTS CHECKLIST
Permit # 8.J C ;2..0D5- 000 I g CIP Project #
The following insurance is required of all contractors working in the City of Campbell public
right-of-way, Insurance certificates must be accepted by City staff before work can begin.
These insurance requirements apply to work being performed under an Encroachment Permit and
work being performed under contract for Capital Improvement Projects.
Limits
Commercial General Liability for bodily, personal injury and property damage:
~ $1,000,000 per occurrence, and
o $1,000,000 general aggregate limit applying separately to the project or
~ $2,000,000 general aggrerte li~it.
~ Policy expiration date :3 28 4fS0
[jutomotive Liability: {24..t-'4 "'Z-(IO(fYi ~
o "Any Auto" checked on certificate
o $1,000,000 per accident for bo i1y'nju and property damage
Policy expiration date 0.0
Workers' Compensation and Employer's Liability el!ctJ UA~ue((l.:>(~
o Waiver of Subrogation clause
o $1,000,000 per accident for bodily injury or disease
o Policy expiration date
Course of Construction (if required in Special Provisions)
o Completed value of the project
o Policy expiration date
Required Endorsements to General Liability and Automobile Liabilitv Policies
Additional Insured Endorsement
l . .z,:~ \t(
~ ,"('O'J ,.J\ pi'
'-"
)'
-=;0
o
~n~
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 10 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",
Workers' Compensation Insurance Sheet Submitted
o For General Contractor
o For Developer or Owner
A- : V II
oY- LA
CBAlf>
Acceptabilitv of Insurer( s)
o Insurer(s) has current A.M. Best
business in the State of California.
Llneu\", ~ ln~, Co.
Rating of A: VII and is authorized to transact
Insurance Certificate Reviewed
c~
Initials
o Copy of Insurance Certificate placed in tickler file for month of expiration,
j:\fonns\inscklst (rev 11/99)
z./t%s
Date I
ACORDN CERTIFICA' . OF LIABILITY INSURAt E OP 10 N~ DATE (MMlDDIYYYY)
ONEILL1 04/22/05
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
James E. McGovern, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
1625 E1 Camino Real ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Belmont CA 94002
Phone: 650-593-8216 Fax:650-594-9130 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Lincoln General Insurance Camp
INSURER B:
Brian O'Neill Construction INSURER C:
Brian O'Neill
706 San Tomas Street INSURER D:
Sunnyvale, CA 94086
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,
I~~~ ~~~~ TYPE OF INSURANCE POLICY NUMBER PD~~~l,i~J~tW;E Pgk~CEY(~~h'1f'~~N LIMITS
GENERAL LIABILITY EACH OCCURRENCE $1,000,000
r-- UAMAGI: I U KI:N I t:u
A X X COMMERCIAL GENERAL LIABILITY 632002442700 03/28/05 03/28/06 PREMISES (Ea occurence) $100,000
1--- .=J CLAIMS MADE W OCCUR
f-- MED EXP (Anyone person) $5,000
PERSONAL & ADV INJURY $1,000,000
r--
GENERAL AGGREGATE $2,000,000
r--
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ INCLUDED
!xl n PRO- n
X POLICY JECT LOC
AUTOMOBILE LIABILITY R ECE'V~ ~~NED SINGLE LIMIT
f-- $
ANY AUTO ( cident)
f--
ALL OWNED AUTOS BODILY INJURY
- } ~R 2 5 ZOO~ (Per person) $
SCHEDULED AUTOS
-
HIRED AUTOS ..J~I..IC WOAK ~ODIL Y INJURY
- A.t Per accident) $
NON-OWNED AUTOS
- MfNfSTRATlc ')IROPERTY DAMAGE
- (Per accident) $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
=j ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
:=J OCCUR D CLAIMS MADE AGGREGATE $
$
R DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND TTORY LIMITS I IUJ~-
EMPLOYERS' LIABILITY E.L. G'\Cll ACC:DE::~Ji $
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L. DISEASE. EA EMPLOYEE $
If yes. describe under E,L. DISEASE - POLICY LIMIT $
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Verification of Insurance.
Except for non-pay which is 10 days.
./ZA./.. c.. 2.co5 ..> Debl '6
CERTIFICATE HOLDER
CANCELLATION
CAMPBEL
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ 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
City of Campbell
70 North First Street
Campbell CA 95008
@ACORDCORPORATION 1988
ACORD 25 (2001/08)
IlC_08[)~
CERTIFICA"
~ OF LIABILITY INSURAf 'E
OP 10 N,.J DATE (MMlDDIYYYY)
ONEILL1'j 02/08/05
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
James E. McGovern, Inc.
1625 E1 Camino Real
Belmont CA 94002
Phone: 650-593-8216 Fax:650-594-9130
INSURED
INSURERS AFFORDING COVERAGE
NAlC#
INSURER A:
Lincoln General Insurance Camp
--
INsURm B:
Brian O'Neill Construction
Brian O'Neill
706 San Tomas Street
Sunnyvale, CA 94086
INSURER c:
INSURER D:
~.
INSURER E:
f---.--.------- ..
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"--~~;:;-CY NUMBER POLl%EFF'EtTlXE- POLlCYtFXPIRATIRN .--- ..-------
L TR NSR TYPE OF INSURANCE DATE MMlDDIYY DATE MMlDDIYY LIMITS
GENERAL LIABILITY I EACH OCCURRENCE $ 1 ~.Cl..Q.()~O_Q_.
-,
A X X I COMMERCIAL GENERAL LIABILITY 25370098141 03/28/04 03/28/05 PREMISES (Ea occurence) $100,000
I CLAIMS MADE [!J OCCUR MED EXP (Anyone person) $5,000
PERSONAL & ADV INJURY $ 1,000, O..QQ.__
-
I GENERAL AGGREGATE $ 2 , Q..Cl..Q..,_Q.O_O___
GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS - COMP/OP AGG $ INCLUDED
Xl n PRO- il -~-----_.
X POLICY JECT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
- $
ANY AUTO RE :CEIVE 0 (Ea accident)
- _u_
ALL OWNED AUTOS
- BODILY INJURY $
SCHEDULED AUTOS F ~B 9 Z005 (Per person)
- -----
HIRED AUTOS BODILY INJURY
- Ai;JBUO W~ (Per accident) $
NON.OWNED AUTOS ! --. m."__ ._ .....
- MINI~ N
PROPERTY DAMAGE $
- (Per accident)
GARAGE LIABILITY AUTO ONLY. EA ACCIDENT $
l ANY AUTO ___n_..n
OTHER THAN EA ACC $
--- ~----_.- --_.- .
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
~ OCCUR D CLAIMS MADE .--
~ . AGGREGATE $
..
$
-------------
~ DEDUCTIBLE $
___________________..u___
RETENTION $ $
WORKERS COMPENSATION AND I I I TORY LIMITS I IUJ~- ."
EMPLOYERS' LIABILITY I E.L. EACH ACCIDENT $
ANY PROPRIETOR/PARTNER/EXECUTIVE --.. ..~--_._- ----
OFFICER/MEMBER EXCLUDED? E.L. DISEASE. EA EMPLOYEE $
------- -----
~PEM.ls~~'Ov':s1o~s below E.L. DISEASE. POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
RE: 176 Milton Ave., Campbell, CA EAJC;;uJOS - OOf) i~
Additional Insured & Primary Phrase: See Attached
Except for non-pay which is 10 days.
CAMPBEL
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAlL ~ 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
CERTIFICATE HOLDER
City of Campbell
70 North First Street
Campbell CA 95008
@ACORD CORPORATION 1988
ACORD 25 (2001/08)
POLICY NUMBER: 2'5370098141
COMMERCIAL GENERAL LIABILITY
CG 20100397
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, it's officers. directors. and
employees
(If no entry appears above, information req,uired to complete this endorsement will be shown in the
Declarations as applicable to this endorsem-ent.)
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 "ongoing operations" performed for
that insured,
Primary Phrase:
Such Insurance as provided by this policy shall be deemed primary but only with
respect to work performed by or for the named insured in connection with this
project.
CG 20 10 03 97
Copyright, Insurance Service Office, Inc" 1992
~
<@>
'V
ijnw[n generaL
Jnsurance..l Compat!Y
Renewal Declarations
General Liability ar. .,Iand Marine Declaration
Specialty Contractors Program
POliCY NUMBER:
2537009814 - 1
POLICY PERIOD Effective from 03/28/04 to 03/28/05 at 12:01 AM
Standard Time at the address of the insured stated herein
1\ Producer 91063
James McGovern Inc
\ pO Box 186
BELMONT CA-94002
I
\
I Telephone Number: 650 593 - 8216
I
I
IN RETURN FOR THE PAYMENT OF PREMIUM AND SUBJECT TO ALL THE TERMS OF THIS POLlCY, WE AGREE WITH YOU
TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE DECLARATIONS AS WELL AS
COVERAGE FORMS AND ENDORSEMENTS LISTED ON THE SCHEDULE OF FORMS AND ENDORSEMENT.
Named Insured and Address
DBA: Brian ONeill construction
Brian O'Neill
706 San Tomas Street
sunnyvale CA 94086
Form of Business:
Individual DBA
LIMITS OF INSURANCE
LIMITS OF LIABILITY
COVERAGE
GENERAL AGGREGATE LIMIT
Products/Completed Operations
COVERAGE A: Bodily Injury and Property Damage
Fire Damage Legal
COVERAGE B: Personal and Advertising Injury
COVERAGE C: Medical Payments
$2,000,000
Applies to all coverages
Included
$1,000,000
anyone occurrence
$100,000
$1,000,000
$5,000
anyone fire
anyone person or organization
any one person
BUSINESS DESCRIPTION: Remodleing - Handyman
Rate per 1000
Premises/Products
40.120/2.911
2.756/1.324
Exposure
$25,000
$15,000
Class Code
91344
91583
Classification Description
Remodeling/Handyman
Subcontract-construct, Reconstruct Repair
$1,000 BI/PD Deductible Per Occurrence
Location of Business (if different from above):
THE LIABILITY PREMIUM BASIS OF THIS POLICY IS SUBJECT TO AUDIT. ADDtTtONAL OR RETURN PREMIUM MAY BE DUE.
Date: 03/24/2004
Processing Center
501 West Broadway, Suite 1400
San Diego, CA 92101-8509
...
/_, J
~~'. ..., , LoD-t UU' (~~ / <;...,-.,/-::1~--
~C~005-0bO\ 13
Allstate Property and Casualty Insurance Company
Policy Number: 9 04 20470810/18
P8HcJ fIecIin Date: Ott. 18, 2084
YOlIr A,ent: Arline L SIIv. (408) 842-5608
COVERAGE FOR VEHICLE # 1
2888 GMC Sierra 1500
COVERAGE
UMlfS
DEOOCTIBlf
PReMIUM
AutomobUe liability lnsurance
. Bodily Injury
. Property Damage
Uninsured Motorists tnsurance
for Bodily Injury
Not Applicable
$446.00
$30,000
$60,000
$25,000
$15.000
$30,000
each person
each occurrence
each occurrence
eath person
each accident
Not Applicabfe
$20.00
Auto Collision Insurance
Waiver of deductibJe applies
Actual Cash Value
$1.000
$456.00
Auto Comprellensive Insurance
Actual Cash Value
$500
$145,00
$1,861.10
Total Premium for I. GMC Sierra 1518
DISCOUNTS Your premium for this vehicle reflects the foflowing discounts:
Multiple Car Antilodc Brakes
Persist8nCy
d...._., "," .,~Jj,~,,,_I.'>
,".' "
...".~ .....L .It..... t_
'-~::_"'~
'WORKERS' COMPENSATION INSURANCE INFORMATION
The following workers' 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 of contract.
WORKERS' COMPENSATION INFORMATION:
Name of Contractor/Applicant g IL ( ;:t '^-.)
o Net C L
(0/7 S frulf 011\),
~/ A Certificate of Consent to Self-Insure issued by the Director of Industrial Relations; OR
o A Certificate of Workers' Compensation Insurance
Insurance Co.
Policy No.
Expiration Date
'OR
'-
o A signed Certificate of Exemption from the Workers' Compensation laws as printed
below.
CERTIFICA TE OF EXEMPTION
I certify that in the performance of the work for this contract, I shall not employ any person
::~~;;t to the w::::rs';o;:: u; of Clliifonlla.
/
Title O{AJ /'ve:/? ,
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:\landdev\forms\street improvernents\workcornp (rev, 6/96)
.....
.....
--
(,)
o
--
'"
o
o
01
co
I
o
D
~~~
-.u~~
r. ~ ZIt!
CD.03 ~ g
:8. ~
Z 0)0" ;a.
I"" 0
C Q) >bV?
G) 0 ~'.S'
:I :::!.II 1D'
o ~~Q
Z !:~()
mOm!!!.
r ~CQ
r Ul~ 2,
mzlll.
l/)
m
tll
o
;a.
~
o .0
<Il
,,~,.)J...
. '.' .;.~, f:l~'., ,....,'.~
~
~
~
z