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ENCROACHMENT PERMIT ISSUANCE CHECK LIST
f4
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City of Campbell Encroachment Permit No. (, .
Department of Public Works
~PPliCant aection complete
~APPlicant .ignature and date
~Permit Application fee $50.00 ($35.00 for R-l Homeowner),
paid. Receipt number /77S -I- ::Ft) 7 y
f
--......',...-
Plan check deposit, $500.00 (waived for R-l Homeowner),
paid. Receipt number /P 7&'+ .5U /~-
~ive .eta of improve.ent plana aub.itted
--.--................-..........-.........-----------------.--------
Bond for faithful performance, lOOt of City Engineer's
estimate, ~aived for R-~ H~me~~er), supplied. ~1='! P~,!d~ !
Amount $ .3.,0 Form I' /.~, . / ';'1' I.D. tt ( ,)-"c>J.
/ :'
I,~,)
. (
Cash Deposit: 4t of FP bond, $500 min. ($200 for R-l
:::;n;r)C;' (p'a~d. Receipt No. S-o 7(~77>r
r...
o
Plan Check & Inspection fee of 7t of FP bond, $35.00 min.,
(waived for R.I Homeowner) paid. d.' ..~~
Amount $ 30Y/,ro Receipt No. y',? /,j
~Worker's compensation information received for Applicant
(see Information Sheet for Encroachment Permits)
g
All other Public Works requirements listed in the
Conditions of Approval of the development.
-.----.-....-.--.-...-.......-..--.-.-----.-----...--------....------.-----
;..
-t
~
.:I
:lo
V Worker'. comp and Contractor's Information received for
Contractor (see Information Sheet for Encroachment Permits)
~. Certificate of Insurance with Additional Insured's
Endorsment received from Contractor (see General Summary of
Insurance Requirements for Encroachment Permits)
~
:>
~
J
of
~
~
)
..
,.-,
Three aets of off-site plans, stamped APPROVED (Tract or
Development and Public Work. Permit number and property
address on plans)
Permit 8igned for City Engineer
VHEN AU. OF THE ABOVE ITEMS ARE COMPLETE, PERMIT HAY BE ISSUED
I.suer: Initial and date and file with permit
UPON ISSUANCE, INITIATE CHECK REQUEST FOR PLAN CHECK DEPOSIT REFUND
8/88
permchklst
( - '"
WI.\f8ERL Y HANDLING T
CITY OF CAMPBEll HElMS a. ~
.~ TURN TO
7 0 NORTH FIR S T STREET JOC$O/t DISCARD
C AMP BEL L, CALIFORNIA 95008 KR08ER
(408) 866-2100 I J PENOYER
FAX # (408) 379-2572 j j J
Department: Public Works
June 14, 1990
John A. Giancola & Sons Inc.
760 LaPa10ma Way
Gilroy, CA 95020
SUBJECT: ONE YEAR MAINTENANCE ACCEPTANCE
PERMIT NO. : 88-269
LOCATION: 250 N. Central Avenue
We have made a one year maintenance inspection of subject public
works improvements and find that no maintenance is required.
By copy of this letter, we hereby release your maintenance bond.
~lY' CtITUL cf!ij)
Gregg ~~n
Pub li c Works Inspector
GE:sd
Encl. (Certificate of Deposit No. 6360527)
Certified Mail #P573 303 644
\. f:88-269 (permits) ~
DAte (s' i
~/CfO
, ~ c:;o
PUBLIC WURKS INSPECTION REPORT
Permit or Project No. .?[ -;)[0.9,
I{. &/YJ~7flJL
AddrC:iJi
~.
Type of work; Street )( Storm
Other CdW'ribe)
SAnitAry
Electrical
(JPRELIMINARY INSPECTION WITH DEFICIENCY LIST (attAched)
(JFINAL INSPECTION WITH DEFICIENCY LIST (attAched)
o FINAL INSPECTION - ACCEPTANCE
Signed plAna:i? Y N (If Idgned, COWlcil AcceptAnce.)
ChArges AgAinst deposit? y
Overtimc, hrJi. @ ~
DAte" reA&On;
N
/hr.
-
$
BArriCAde rentAl (AttAch invoice)?
DAte" reAson;
Y
N
$
Other?
~
~
TotAl chArges deducted from deposita
(CAsh DepoJiit $ lcas chArges $
$
- Refund $
[JONE YEAR MAINTENANCE WITH DEFICIENCY LIST (AttAched)
~NE YEAR MAINTENANCE - ACCEPTANCE
~ReleAae'mA1nten4nce bond. Check Request if CAsh.)
ck. r eq . )
In6pector
,~
Pacific Western Bank
CERTIFICATE OF DEPOSIT
NUMBER
6360527
Gil ' May 9,1989 $ **4,350.00******
~'CE ISSUE DATE AMOUNT
This certifies that the sum o~*Four 'Ihousarxl 'Ihree Hundred Fifty Arxi 00/100**** (Dollars)
Payable to ***City of C~l****************************** .
Has been deposited for a term of ~ ~s/Months. For; John A. Giancola
Interest Rate 5.00 % 5.126 % Annual Yield Tax 10# 545-80-4287
At maturity, this deposit will automatically renew for same period at the then current applicable interest rate.
Payable upon maturity, presentation, and surrender of this certif ate, r~perIY~nd .
Not Negotiable. Not Transferable.
Member: Federal Deposit Insurance Corp.
Member: Federal Reserve System BANK AUTHORIZED SIGNATURE
FORM 61 (3/88) MAS
UNIT OF ISSUE PKG (25)
.s~A1 - U!T'I -n .4~ g6~
':h t!'.---/~
~~
CITY OF CAMI)UELl
70 NORTH FIRST STREET
C AMP 8 ELL, C A L I FOR N I A 9 5 0 0 8
(408) 866-2100
FAX # (408) 379-2572
Department:
Public Works
July 25, 1989
John A. Giancola & Sons Inc.
10215 Whiskey Hill Lane
Gilroy, CA 95020
RE: Final Inspection and Acceptance
Permit No.: 88-269
Location: 250 N. Central
Maintenance Bond Amount: $1,087.50
We have made a Final Inspection of subject public works construction and
find it acceptable and in conformance with City standards. Accordingly,
the work is hereby accepted subject to the one-year maintenance
requirement indicated below.
You are responsible for the maintenance, repair and/or replacement of all
work done should any failures occur within one (1) year of this date. To
guarantee this, you must either post a maintenance bond in the amount
indicated above, or maintain your existing faithful performance bond. If
you post a separate maintenance bond, your current bond will be released
by a separate action.
We will inspect the work in one year and advise you whether or not
maintenance is needed.
Please feel free to call the undersigned if you have any questions.
Sincerely,
~
~ M. Jocson
Associate Civil Enginneer
CMJ : sd
cc: G. Eaton, P.W. Inspector
Suspense - 1 year
DAte
m~z
PUBLIC WORKS INSPECTION REPORT
- . '--~ -_.- -
Permit or Project No.
'BE'~ 21,;9 ~
Address
2:20 No _~ C-SVTlZ/iC
~pe of work: Stref!=t Storm
Other (describe)
SAnitary
Pee.
Electrical
o PRELIMINARY INSPECTION WITH DEFICIENCY LIST (Attached)
o FINAL ~NSPECTION WITH DEFICIENCY LIST (attached)
~ INSPECTION - ACCEPTANCE
Signed plAns? Y ~ (If signed, Council Acceptance.)
Charges Against deposit? Y
Overtime I hrs. @ $
DAte, reason:
. =
~
-
$
Barricade rental (Attach invoice)? Y
Date , reason:
o
$
Other?
[JONE YEAR MAINTENANCE WITH DEFICIENCY LIST (attached)
o ONE YEAR MAINTENANCE - ACCEPTANCE
(Release'maintenance bond. Check Request if cash.)
$
$
$
- Refund $
~otAl charge. deducted from depositl
(Cash Deposit $ less charges $
ek. req.)
. /
~~gk;;r --
~
Inspector
REFUNDABLE DEPOSIT
CHECK REQUEST
TO: FINANCE DIRECTOR
CITY OF CAMPBELL
Please issue check payable to:
Address:
John A. Giancola & Sons
760 LaPaloma Way
(30 spaces)
(30 spaces)
Line 1:
Line 2:
City:
Gilroy
(20 spaces)
(30 spaces)
State: CA Zip: 95020
(2) (l0 spaces)
Description:
Cash Deposit Refund
(24 spaces)
Exact Amount Payable:
$500.00
Account Number:
905.4662
PURPOSE:
Release of cash deposit for excavation permit 88-269.
See receipt #5075 dated 4/13/89 ($300.00) and receipt
#1776 dated 12/8/88 ($200.00).
Requested by:
Gregg Eaton
TU~: P.W. Inspector
Approved by:
Verified by:
Date:
7/26/89
Donald C. Wimberly
Ti tle : P. W. D ire c tor
Date:
Accounts Receivable
Date:
SPECIAL INSTRUCTIONS FOR HANDLING CHECK:
Mail as is
xx
Mail in attached envelope
Return to:
(Department)
(Name)
Other:
08/24/88
TO : C i t Y C I e rk
"
PUBLIC WORKS FILE NO. XI? -,~ 6- j
Please collect & receipt
for the following monies:
ACCT.
--'-
35-3396
6J];/
3521
;)21
pro j e c t )
PeJu~.{;t Fe.M:
R-7 :
($.35)
:t VI.:
($ 50)
'( 500)
( % of FPB) rl
($500 mi n.) liJ-tyr
(7'7., of FPB).'1f.71!P
($ 35 min.)
Depos i t
3372
Plan Check & Inspection Fee
3521 Other Cash Deposit (specify)
3373
3373
Project
General
&
3372 Tentative Parcel Map Fil ing Fee ($350)
3372 Final Parcel Map Fil in Fee ($300)
3372 Tentative Tract Map Fil ing Fee $ 00
3372 Final Tract Map 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:
Categor i ca I Exempt ion
Ne ative Declaration
3370 Storm Drainage Area Fee per Acre Multi-Res.,
$2,060; all other, $2,250)
3395 Park Dedication In-I ieu Fee per Unit
3380 Pub] ic Works Special Projects
3510 Postage
'tAME
'\ ,
// 1,- iL
,
TOTAL
c j
. ~/C I( '-'
PHONE
c! 71/ --. J. 5-;: ~~-
/ (j .
(.(~ ~/ (. a Il (?rl.- ( 1'1
,
~/./tt(
,
./
AMOUln
$
as, {' (\
~tJo . (1 ('
$
~<',:..;~~ . c' C
U)DRESS / {' <) / .::::,-~
7/ ~-!t. L ...L ~' ( ')
-1J./
. L (.( /"'\ /1 .
ZIP
f/.~? ,;:1.(.
L
,. VL (. "- tL . I
,)
FOR
C I TV CLERK
ClliLY
July, 1987
RECEIPT NO.
AMOIAn' PAID
RECE 'VED BY
DATE'
TG: .Cifiy Clerk
PUBLIC WORKS FILE NO. 3S>-2.6' '1
I
Please collect & receipt
for the following monies:
35-3396
ACCT. ITEM AMOUNT RECEIPT NO.
3372
3521
3521
Project Revenues (specify project)
Public Works Excavation Permit Fees:
Application Fee
Plan Check Deposit
Faithful Performance (Cash) Deposit
$
R-1:
($ 35)
Other:
($ 50)
($500)
(100% of)
(ENGR. EST)
(4% of FPB)
($500 min.)
(7% of FPB)
($ 35 min.)
/<)~ .5D'71f-
~oo~ SCJ 7~
3521
Other Cash Deposit (specify)
($200)
3372
Plan Check & Inspection Fee
3373 Project Plans & Specifications ($10)
3373 General Conditions, Standard Provisions &
Details ($10 or $1/page)
3373 "No Parking" signs ($1/ea. or $25/100)
3373 Work Area Traffic Control Handbook ($5)
3373 Traffic Flow Map ($10)
3380 Traffic Data Services ($40/hr. + material costs)
3373 Map Revisions to Map Companies ($10)
3373 Copies of Engineering Maps & Plans ($.50/sq. ft.)
3520 Fire Hydrant Maintenance ($195/ea.)
3372 Tentative Parcel map Filing Fee ($350)
3372 Final Parcel Map Filing Fee ($300)
3372 Tentative Tract Map Filing Fee ($400)
3372 Final Tract Map Filing Fee ($350)
3372 Lot Line Adjustment Fee/Certificate of Compliance ($350)
3372 Vacation of Public Streets and Easements ($500)
3372 Assessment Segregation or Reapportionment
First Split ($500)
Each Additional Lot ($150)
3372 Environmental Assessment:
Categorical Exemption ($500 plus actual cost
Negative Declaration above $5(0)
3370 Storm Drainage Area Fee per Acre (R-1, $1,875; Multi-Res.,
$2,060; all other, $2,250)
3395 Park Dedication In-lieu Fee per Unit ($1,132)
3380 Public Works Special Projects
3510 Postage
TOTAL
$ c:=5/S~
PERMITTEE JolIl'\" 19
,
C:;, 4,,-, c.~ I~
l' SON' l/ov'-,
NAME OF APPLICANT
S "1M ,~
PHONE
<lyf- 3SCr.>
ADDRESS ?Co
~"d. ~/J,Lo~
y
""",,I'J-
G.. 'L.l8ov
I
~-::r7
,
(,11-
ZIP
9s-o 2 (}
FOR
CITY CLERK
ONLY
RECEIVED BY
DATE
@M
: 1\i ~< r~
>:::,!::
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Complete onty ""'er. tnis endorsement Is not prepared with the pOlicy
or whan the:. eHective date diHelS from Ihe polley.
Pol. No.:
EH.:
GENERAL CHANGE ENDORSEMENT
Insured:
TEN DAYS CANCELLATION NOTICE ENDORSEMENT
Y.
IT IS AGREED THAT SUCH INSURANCE. AS IS AFFORDED BY THE BODILY INJURY
LIABILITY AND PROPERTY DAMAGE LIABILITY COVERAGES OF THIS POLICY SHALL
NOT BE CANCELLED UNLESS TEN DAYS PRIOR WRITtEN NOTICE OF SUCH CANCELLA-
TION BE GIVEN
COUNTY OF SANTA CLARA
CITY OF MORGAN HILL
CITY OF SAN JOSE
CITY OF GILROY'
City of Campbell
All other terms of this policy remain unchanged.
~
American States Insurance Company
American Economy Insurance Company
INDIANAPOLIS, INDIANA
,,~v CL-.-
President
AUTHORIZED AGENT
L~~
Countersigned by
Secretary
Fonn ~2(4) (lHill)
(Short Form)
STATE
COMPENSATION
INSURANCE
FUND
P.O. BOX 807, SAN FRANCISCO, CA 94101-0807
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
December 7, 1988
POLICY NUMBER: 622767-88
CERTIFICATE EXPIRES: 8-29-89
r-
City of Campbell
Bldg. Dept.
75 N. Central
Campbell, Ca. 95008
L
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California
Insllrance Commissi~ner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon ten days' advance wrinen notice to the employer.
We will also give you TEN days' advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the
policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with
respect to which this certificate of insurance 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.
,N:~
PRESIDENT
EMPLOYER
r
John A Giancola & Sons, Inc.
10215 Wh~skey Hill Ln
Gilroy, Ca. 95020
L
selF 10262 (REV. 10-86)
OLD 262A
STATE
COMPENSATION
INSURANCE
F=UNO
P.O. BOX 807, SAN FRANCISCO, CA 94101~0807
RECEIVED
MAY 8 1989
PUBLIC WORKS
ENGINEERING
1
!"1A Y 3, 1 989
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
POLICY NUMBERL 0 2 8 4 0 8 - 88
CERTIFICATE EXPIRES: ~-1-89
r-
C r'rY OF CAMPB~iJc..
.l\l'TN :)i<; :J'C m' J:J1] 8LJ I C wOR.KS
70 N'OR.L1f{ ~'IRs'r s'r
C.I\MPBSfJL
CA 95008
L
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the California
Insurance Commissioner to the employer named below for the policy period indicated.
30
This policy is not subject to cancellation by the Fund except upoKYen days' advance written notice to the employer.
30
We will also give you>T.fN days' advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the
policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with
respect to which this certificate of insurance 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.
/f~
PRESIDENT
C';NI)OR':)';;'yL~'\I,[, #2065 b~N',[,II'LEi) CER'rIFICATE HOLDERS' NO'rICE EFFECTIVE
OS/Ol/89 IS .l\T'['ACr{8D TO AND FORl'1S .1\ 1?.I\R.'r Of 'rf{ IS POLICY.
EMPLOYER
I
GIANCOLA CONCRETE CONS'['RUC'rION
375 ROL'i/AN AVE
GILROY
CA 95020
selF 10262 (REV. 10~86)
L
RECEIVED
APR 1 0 1989
PACIFIC GAS AND ELECTRIC CO~lil:
+ 10900 NO. BLANEY AVENUE . CUPERTINO, CALIFORNIA 95014 . (408) 973~8930
~ f~
--...~.__....._- _. .. .. ~
1 WIM8ERLY i~;~![!.,.;~G--'I. -I..'
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i_~__;.~:~,,' _.o.~ .", J "~ J< J~ ~ ,~
>. - ~.-..".... ..-.----.-.._.~..' _,.r... .",."
L6~
~
April 6, 1989
Mr. John Mosstaghimi
Artman Construction Co.
123 Stockton Avenue
San Jose, CA 95126
Re: Third and Latimer, Ltd.
Campbell
S.D. #0541E/G071~4
Dear Mr. Mosstaghimi:
This is to advise you that tile .;chedule for construction to begin
during the week of March 10, 1 Y::l), has been cancelled and will be held
in abeyance until such time DS \(JU have complied with the City of
Campbell's off-site requirements and all proposals have been accepted
by them.
PG&E will re-schedule for construction after we have been notified by
the City that their requirements have been satisfied and corrective
actions stipulated in our letter dated March 9, 1989, have been
effected.
If I can be of further asshlill. ", please call me at (408) 725-2011.
Sincerely,
I
, I .I
/j'-4 -~
)
--/
,?
\
.~-
Reuben T. Tsujimura
New Business Representative
cc: Mr. Gregg T. Eaton, Inspector
City of Campbell
70 N. First Street
Campbell, CA 95008
GC: 6lA)C3, Dc2fl.
CITY OF CAMPBELL
Permit No.
Applicant
INFORMATION SHEET FOR ENCROACHMENT PERMITS
A separate form must be completed for the applicant and each contractor
that will work under this permit.
WORKERS' COMPENSATION INSURANCE INFORMATION
Name of Contractor/Applicant JoN"", .4 <:;;;'""c.., IA tj. ~ O-S .;1&..0 ,
One of the following must be on file with the Public Works Department:
A Certificate of Consent to Self-insure issued by
the Director of Industrial Relations; QR
~ A Certificate of Workers' Compensation Insurance
Insurance Co. ~7 <'97/1 FClIVLJ
Policy No. 0' :J.. 7, '7 ... ~ Expiration datei' _~9:!!j 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 must have current City of Campbell Business
License, State Contractor's License and Workers' Compensation Insurance.
Name of Contractor J#N A ~~;'I".c.A1 ji..sd^-,,,,,,,,, Telephone iivs:- .j:)_~,~
Address ,/(J J.I S' fA" liS /( FL & /1.1.. ~;v
I
State Contractor License NoJ2. 91111 City Business License No.
Expiration Date
Will do the following types of work:
underground ~P.C. concrete _____A.C. paving _____electrical
.
other (specify)
f:PERMINFO
REV. 8/88
<<-----
AMERICAN STATES INSURANCE COMPANY
INDIANAPOLIS, INDIANA
PAGE 01
***************************************
* POLICY CHANGE *
* EFFECTIVE. 12-07-88 *
***************************************
POLICY NUMBER: 01-CC-296624-1
NAMED JOHN A. GIANCOLA AND SONS,INC.
INSURED 10215 WHISKEY HILL LN.
MAILING GILROY, CA 95020
ADDRESS:
AGENT: LINK INSURANCE AGENCY
PO BOX 576
MORGAN HILL, CA 95037
04-48820 (497)
(408) 779-3211
POLICY PERIOD:
FROM 05-26-88 TO 05-26-89
***********************************************************************************
* *
* THANK YOU FOR YOUR PAYMENT. *
* YOUR POLICY CHANGE DOES NOT AFFECT THE COST OF YOUR POLICY. *
* THERE IS NOTHING DUE AT THIS TIME. *
* *
***********************************************************************************
VB=3
ADDING ADDITIONAL INSURED, AS PER CG-2010.
-----------------------------------------------------------------------------------
POLICY CHANGES
-----------------------------------------------------------------------------------
THE FOLLOWING HAS BEEN ADDED
----------------------------
OTHER
INTERESTS:
II
1 CITY OF CAMPBELL, ITS OFFICERS #
AGENTS AND EMPLOYEES
ATTN: PUBLIC WORKS
CAMPBELL, CA
CERTIFICATE HOLDER
(ADD'L INSURED, PER CG-2010)
PREMISES 11001
2 SOUTH VALLEY NATIONAL BANK
7597 MONTEREY ROAD
GILROY, CA 95020
CERTIFICATE HOLDER
(ADD'L INSURED,PER CG-2010)
PREMISES 11001
~
, I
j
\
'~
?eem/ r-d 88- Zb 9
?':J-O - Cr=.~TlZ-A L ~,
9-CM(01-86) SAN FRANCISCO
(D)
PREPARED 12-12-88
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
t~J
ADDITIONAL INSURED - OWNERS, LESSEES
OR CONTRACTORS (FORM B)
CG 20 10 11 85
COMMERCIAL GENERAL LIABILITY
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
CITY OF CAMPBELL,ITS OFFICERS,AGENTS
ATTN: PUBLIC WORKS
CAMPBELL, CA
(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.
Copyright, Insurance Services Office, Inc., 1984
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFUllY.
t~J
ADDITIONAL INSURED - OWNERS, LESSEES
OR CONTRACTORS (FORM B)
CG 20 10 11 85
COMMERCIAL GENERAL LIABILITY
This endorsement modifies insurance provided under tha following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
, ,
f .,.
Name of Person or Organization:,.
"t.
SOUTH VALLEY NATIONAL BANK
7597 MONTEREY ROAD
GILROY, CA 95020
SCHEDULE
f
,
f
~.
~
(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.
Copyright, Insurance Services Office, Inc., 1984
ACORD CERTIFICATE OF INSURANCE - PAGE 2
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
COMP TYPE
LETTER OF INSURANCE
EXCESS LIABILITY
POLICY NUMBER
EFFECTIVE/EXPIRATION DATE
LIMITS OF LIABILITY
IN THOUSANDS (000)
EA. OCCUR./AGGREGATE
TO
OTHER THAN
UMBRELLA FORM
WORKERS COMPENSATION
AND
EMPLOYERS' LIABILITY
*STATUTORY*
TO
EACH ACCIDENT:
DISEASE POLICY LIMIT:
DISEASE EACH EMPLOYEE:
OTHER
TO
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS:
The City of Campbell & its respective officers, agents & employees are named as Additional Insureds
from & against any claims, loss liability, cost or expense arising out of or in any way connected
withtthe construction of the project. This coverage shall be primary & any coverage carried by
Additional Insured shall be excess insurance only. 250 Central Avenue, Campbell
-----
-----
CANCELLATION
-------------------------------------------------------------
-------------------------------------------------------------
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY
WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
BELOW NAMED CERTIFICATE HOLDER, BUT FAILURE TO MAIL SUCH
NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY
KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
-----
-----
CERTIFICATE HOLDER
------------------------------------------------------
------------------------------------------------------
CITY OF CAMPBELL
70 N. FIRST STREET
CAMPBELL, CA
DATE ISSUED: 05/03/89
95008
I
ACORD CERTIFICATE OF INSURANCE (ACORD 255 - 03/88)
--------------------------------------------------------------------------------
--------------------------------------------------------------------------------
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.
NAME AND ADDRESS OF AGENCY:
Ron Mingus Ins Service Inc
P. O. Box 579
Gilroy, CA
COMPANIES AFFORDING COVERAGE:
COMPANY A: American States
95021
COMPANY B:
COMPANY C:
COMPANY D:
COMPANY E:
NAME AND ADDRESS OF INSURED:
Giancola Concrete
375 Ronan Avenue
Gilroy CA
95020
===== COVERAGES ================================================================
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED
TO THE INSURED NAMED ABOVE FOR THE 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 TERMS,
EXCLUSIONS, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN
REDUCED BY PAID CLAIMS.
COMP TYPE
LETTER OF INSURANCE
POLICY NUMBER
EFFECTIVE/EXPIRATION DATE
LIMITS OF LIABILITY
IN THOUSANDS (000)
A GENERAL LIABILITY 01-CC-296942-1
X COMMERCIAL GENERAL 05/04/88 TO 05/04/90
LIABILITY
CLAIMS MADE X OCCURRENCE
GENERAL AGGREGATE: $ 1,000
PRODUCTS COMP/OPS AGG: $ 1,000
OWNERS & CONTRACTORS PROTECTIVE
PERSONAL & ADVERTISING INJURY:
EACH OCCURRENCE:
FIRE DAMAGE (ANY 1 FIRE):
MEDICAL EXPENSE (ANY 1 PERSON):
$ 1,000
$ 1,000
$ 50
$ 5
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
GARAGE LIABILITY
TO
CSL:
BI:
(EACH PERSON)
BI:
(EACH ACCIDENT)
PROPERTY DAMAGE:
TO: City Clerk
PUBLIC WORKS FILE NO.
Please collect & receipt
for the following monies:
~J"-2C 9
I
35-3396
ACCl ITEM AMOUNT RECEIPT NO.
$
Project Revenues (specify project)
Public ~ks Excavation Permit Fees:
Application Fee
Plan Check Deposit
Faithful Performance (Cash) Deposit
R-1:
($ 35)
Other:
($ 50)
($500)
(100% of)
(ENGR. EST)
(4% of FPB)
($500 min.)
(7% of FPB)
($ 35 min.)
3372
3521
3521
3521
Other Cash Deposit (specify)
($200)
3372
Plan Check & Inspection Fee
3373 Project Plans & Specifications ($10)
3373 General Conditions, Standard Provisions &
Details ($10 or $1/page)
3373 "No Parking" signs ($1/ea. or $25/100)
3373 Work Area Traffic Control Handbook ($5)
3373 Traffic Flow Map ($10)
3380 Traffic Data Services ($40/hr. + material costs)
3373 Map Revisions to Map Companies ($10)
3373 Copies of Engineering Maps & Plans ($.50/sq. ft.)
3520 Fire Hydrant Maintenance ($195/ea.)
3372 Tentative Parcel map Filing Fee ($350)
3372 Final Parcel Map Filing Fee ($300)
3372 Tentative Tract Map Filing Fee ($400)
3372 Final Tract Map Filing Fee ($350)
3372 Lot Line Adjustment Fee/Certificate of Compliance ($350)
3372 Vacation of Public Streets and Easements ($500)
3372 Assessment Segregation or Reapportionment
First Split ($500)
Each Additional Lot ($150)
3372 Environmental Assessment:
Categorical Exemption ($500 plus actual cost
Negative Declaration above $500)
3370 Storm Drainage Area Fee per Acre (R-1, $1,875; Multi-Res.,
$2,060; all other, $2,250)
3395 Park Dedication In-lieu Fee per Unit ($1,132)
3380 Public Works Special Projects
3510 Postage
TOTAL
PERMITTEE
.:5.q-rrJ~
NAME OF APPLlcANTJDh'/V 4. r;//J~~L.4 ,fv0lUS" ;Z;}<!.
,
ADDRESS /() d / s:- ;:U// / r;~if #/L L. L4Ai e-
~-
. ---po- trO
.-
<--< ...
~
~{J t./- /-f 1 J~
$ 3~~~
?L/J -3 Sb",S
ZIP ,~<){)d 0
PHONE
FOR
CITY CLERK
ONLY
~
.:s-1{)-~9
RECEIVED BY
DATE
eM
Lump Sum Eatimate - $
LF @ $ 4.00 - $
SF @ 3.00 - $
LF @ 5.00 $
ItA @ 600.00 $
LF @ 14.00 - $
SF @ 4.00 - $
SF @ 5.50 - $
ItA @ 400.00 - $
LF @ 8.50 - $
U' @ 50.00 - $
SF)x($O.lO)x(____") - $
SF)x($0.30)x(____") - $
EA @ 375.00 - $
ItA @ 275.00 - $
ItA @ 600.00 - $
ItA @ 300.00 - $
LF @ 0.65 - $
ItA @ 40.00 - $
ItA @ 120.00 - $
EA@ 15.00 - $
LF @ 10.00 - $
- $
- $
Surface Subtotal "S" $
Adjuat for aiza: "S"<$30,OOO add 20\, "S">$lOO,OOO aubtract 10\ (+ or -) $.
CITY OF CAMPBELL, CITY ENGINEER'S CONSTRUCTION COST ESTIMATE
Addn..
Surface Con.tru~tion
\...../
Claaring & Grubbing
Sawcut Concrete
Concrata Removal
Curb & Gutter Re.oval
Inlot Drain with Pipa
Curb & Guttar
Sidawalk
Driveway Approach
Handicap lap
Extruded Curb
Barricada
Streat Excavation
AC rava.ent
"--.-/
Adjuat Kanhole to Grade
AdJuat Handbole to Grade
Monument Box w/Konument
Straat Trae (15-gallon)
Pava.ent Striping ($100 ain)
rava.nt lAgenda ($100 ain)
Stop, Streat Name or Other Sign
rave.ent Karkera
rava.nt Key Cut
Street Lil[htinlr
EIectrol1ar
Conduit
ItA @ 2,000.00
U' @ 10.00
LF @ 2.00
Ea @ 200.00
Conductor, pair
Pull Box
Storm Draina.e
12- or 15. RCr
18. or 21. Rcr
Stnat Inlet
Kanhola
Braak & Entar Kanhole
LF @ 60.00
U' @ 70.00
ItA @ 1,600.00
EA @ 2,400.00
ItA @ 650.00
"--
... r
,t.2
/://1
TOTAL ESTIMATE $
USE FOR BOND $
Permit No.
by_date
) ,
:
- $
- $
- $
- $
- $
- $
- $
- $
- $
- $
- $
nviaed 6/88
f/con-coat-eat