95-260
crrv OF CAMPBEU.
DEPT. OF PUBUC WOJUCS
'70 North PirIt St.
CampbeJl, CA 9SO(Il
. a) 866-2150
~
ENCROAaINENT PERMIT
(for WOItiq wilbiD tbe
pIbIk ript44ay)
IIIued /-/?-:J~
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propoICd wort to cxiltiJlllUrfacc aDd 1IDdcrpoUDd impto...-lL Wbea appro.ed by tile Cty ~, IIid dmwiDc becameI. put ol tbiI pcnaiL
D. AD wort Iha1I coaform to tbe Cty'1 GeDcnl CaaditioaI, Studard CoaItruI:Iba ~ ad SGDdard a..tructioa DaaiII far ..... Worb
CoDItructioD; &be Geaenl Permit CaDditioal lilted OIl tbe maa Iidc; ad &be SpecW ~ far ddI pamit. lilted below. PaiIure to abide by
thae CODditioaa aDd proviIioaIlDI)' I'IIIUlt iD job aut.... ad/or forfeiture ol PaitbfuI Pafonuace SuretieI ad CMII depaliu. (See GeDcnI
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The AppiicaDtfPermittee hereby qrca by aftixiq their lipature to tbiI permit to bold tile Cty ol ~ ill aftk:ers, ...... ad ~ flee, afe
aDd humIea holD ...y daim or delllaDd for damapll'IIIUltiq from &be wort CCMred by tbiI pcnait.
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NOTFS: ALL WORK SHAU. CONFORM wrm 1lIE ATrAOIED, APPROVED PlANS AND ALL APPUCABLE CAMPBELL SI'ANDARD
DRAWINGS AND CONDmONs.
1lIE CONTRACI'OR MUST HA VB lHIS PERMIT AND APPROVED PLANS AT 1lIE SI'I1! AND MUSI' N011PY 1lIE PUBUC WORKS
DEPARThIENI' AT l.E.AST lWO DAYS BEFORE SI'AR.11NQ WOK
NOTICE MUSI' BE GIVEN TO PUBUC WOJUCS AT l.E.AST 24 HOURS BEFORE R.FSI'AR.11NG ANY WORK.
SPEOAL PROVISIONS
_1. StJeet Iha1I DOt be opell cut for 1IIIderpouad illltaUatioaL Miaimum cuD may be .uo..s far CIDIIIICCtioaI or apIoratioa bola. Suc:II cuD JIU!!l
be IDedficalJv atJDrOYed bv die Iasoector Drior to cuttia2
_2. Pavemellt IDly be cut for 1IIIde1pOUlld iDl&aUatioas ad must be ratored iD IICICOIdaDce 1ritIt tbe Utility TIadI ReItoratioa Studard DnnriJt&.
_3. Wort to be staked by . IiccIllCd Laad ~ or CviI &,iaeer aDd two (2) CDpieI ol the cut IbeetIlCDt to die Public Worb ~t
_4. ~e~~r ~~~A~~~~~~~~r/.h~~
PERMIT APPUCAnON PEE
PlAN OIECX DEPOSIT
SURETY POI. FAlI'HPUl. PERFORMANCE
CASH DEPOSIT
PLAN OIECX cl INSPECIlON PEE
Next S30,~S80,OOO 10%; Amouat pate
Sl'ANDAR.D
AMOUNI'
APPROVED POI. ISSUAN
RPrPJPT NO.
Il
* *
h:PW PERMIT /Rev.4/94
USA phone (800) 642-2444
(lee other side)
SPECIAL PROVISIONS #4
Permit #95-260
EXHIBIT "A"
Install 2 - 24" box street trees per City of Campbell Standard Detail 12 and Standard Drawing
No. L-13. The City Inspector shall mark the concrete cut-outs to be removed by saw-cut. The
applicant/permittee is required to locate all utilities prior to commencing work as indicated on
Page 1 of this Encroachment Permit.
h:95-260sp(mp)
To: Accounts Receivable
Please Issue Check
Payable to:
Address - Line I:
Line 2:
City:
Description:
Amount Payable:
Account Number:
ate and Receipt No:
Permit No:
Purpose:
Requested by:
Approved by:
FINANCE ONLY:
Verified by:
Approved by:
Mail As Is:
Return To:
(NAME)
Other:
rev: 3/25/95
Ci(, of Campbell - Cbel.~ Req.uest
LViark Jones
2422 Adonis Way
San Jose
State: CA Zip: 9 512 4
REFUNDABLE DEPOSIT
$350.00
Finance Only:
INTEREST EARNED
101.2203
11/21/95 #88873
95-260
101.540.7448
Refund remaining portion of faithful performance
surety cash deposit.
Rand;: W~Stfall /dJ
IYJJJ'e-l1e QulllLH='y
Title: PW Inspector
Date: 2/20/97 I
'-I/i)
Title: City Engineer
Dat
Title:
Date:
Title: Date: I
Special Instructions For Handling Cbec~
xx Mail in Attached Envelope:
(Department)
To: Accounts Receivable
Please Issue Check
Payable to:
Address - Line 1:
Line 2:
City:
Description:
Amount Payable:
Account Number:
ate and Receipt No:
Penn it No:
Purpose:
City of Campbell - Check Request
Mark Jones
2422 Adonis Way
San LTo!=le
State: ~n. Zip: 95124
REFUNDABLE DEPOSIT
$1,050.00
Finance Only:
INTEREST EARNED
101.2203
11/21/95 #88873
101.540.7448
95-260
Refund 75% of faithful performance surety cash
deposit ($1,400.00)
Requested by: Title: PW Inspector Date: 2
Approved by: Title: City Engineer Date: 2 8 96
FINANCE ONLY:
Verified by: Title: Date:
Approved by: Title: Date:
Mail As Is:
Return To:
Other:
rev: 3/25/95
Special Instructions For Handling Check
xx
Mail in Attached Envelope:
(NAME)
(Department)
PROPERTY ADDRESS
r::~3~:;~~~~;:~~~~2~~M~~~~{:"jji7~Srm~0:}::::)::::::~::::
ENCROACHMENT PERMIT
4722 Application Fee
Non-Utility Encroachment Permit 1$2251
R-1 F'nt Permit INo Feel, Subseauent PermitlYr 1.100
Utilitv Encroachment Permit
Arterial/Collector Street
Residential Street/Other Areas
Plan Check Deooait
Faithful PerformMCe Surety (FPSI
Monumentation Surety
Cash DeDO.it
Labor and Material Surety
Plan~k &. Inspection Fee INon-Util1tY1
2 Enor.Eat. < $250,000 IUK af [NeR. [ST.t-
t Enar.EIIt.>'250,ooo IDeDosit 15% of ENGR. EST.I"
UtilitY < '100,000
Conduits/PIpelines up to 500 Feet I'L60/ft.1
Above 500 Feet (.L10/ft.1
ManholesNaults/Etc. 1.,05/eal
Pole 5et/Removal 1'105/eal
Minimum atarue Per Location (.1201
Street Tree Plantinn'Removal 1"05/treel
Utilitv > .100 000 IDeoosit 15% of ENGR. EST.'"
Proiect Plans &. Soecifications Proiect No.
Standard Saecifications &. Details I"/Pa .,2/Bookl
CoDies of Enaineerina Maps &. Plans 1'.50/sa.ft.1
Penalties: Failure to restore nubUc imnrovements 1.,00/Calendar Davl
lMunl Code Section 11.34.0101
472 Penalties: Feilure to correct unsafe conditions I$tOO/Calendar Davl
LAND DEVELOPMENT
4722 Lot line Adiulltment
472 Parcel Man 14Loh or Lessl
472 Anal Tract MID 15 or More Lotsl
472 Certificate of Cl>InnIiMCe
472 Certificate of ComIction
472 Vacation of PubHc Streets &. Easements
472 Assessment Seal'1l1lation or Reapportionment
FIrst Split
7 Each Additional Lot
472 Stomrl rainall. A~a Fee Per Acre
OTHER
#~/6f/:~P'/'?pW ,'t:-ce/1/<<.
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NA. OF APPliCANT
NAME OF PAYOR ':22.....- /.f ~,./ ""/~"'r
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TO: City Clerk
4961
TRAFFIC
472
472
472
472
472
427
472
ADDRESS
PUBLIC WORKS DEPARTMENT RECEIPT
Effective July 1. 1995
PUBLIC WORKS FILE NO. <;?' ~ ~L,..-:;J
9A~~7L
-
220
220
220
220
220
1.3251
1$2251
(.5001
(100% of ENGR.EST.I
1100% of ENGR.EST.I
(4% of FPSIl.500 mln.1
1100% of ENGR. EST. I
472.
220
472
~~~
220
4~
4~
476
472
1.5001
.1 060 + $25/Lotl
.1 380 + $25/Lotl
.4001
.3001
(.5501
Polltaae
1.5501
1.1701
IR-1 U.oool
IMulti-Res. U.2501
IAR Other $2 500
Intersection Turn Counts ITwo-Hour Countl 1.601
Intersection Turn Counts la.m. or O.m. oesksl 1$1251
Traffic Flow Man IDaily Traffic Volumes' 1$271
Campbe" TnIfflc ModellFull Scooe Allellmentl 1$2 2501
CampbeR Traffic Model (Reduced Scone Assellrn$7401
TRICk Permits 1$35/triol
No ParkiNI Slnns 1$1Ieach or U5/100
TOTAL
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PHONE
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ZIP
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RECEIVED
JAN 0 91996
t.; ,~L[R!~'S OFFICE
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CITY OF CAMPBELL~ CA
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RECVD BY: LISAB
PAYOR: MARK JONES
TOD~Y~S DATE: Oli09!96
REG:2~ZR DATE: 01/09/96 TIME: 14:31:23
01000090079
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DESCRIPTION AMOUNT
ENGR & SUBDIV FILING F
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$32.00
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TOTAL DUE:
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$32.00
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CHEC}~ NO:
TnmERED:
CHANGE :
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PUSUCWORKSDEPARTM~RF"'9PT ./ . /~J#Y'" /?v
Eff8CtiveJuly1,1984 /0. ?~r/""ncI /7V'~
TO: City Clerk PUS~C WORKS FILE NO. 95:;1 be?
N:cr' >>W~~~~':~W'!:'~~~:i:~:::>:~?f~~~iiillWP<.;ntit!i.".
35-3396 Project Rev.nu'~'(~p~itv'P~OI~t)H $
ENCROACHMENT PERMIT
3372 Application Fe.
Regular or Utility ($218)
R-I rll'at Permit (No Fe.). SubseQuent PermitlYr ($60)
2203 Plan Check O.poait $500)
2203 Faithful Performance Surety (FPS) 100% of ENGR. EST)
2203 Cash Deposit 4'10 of FPS)($500 min.)
2203 Labor and Material SuretY 100'10 of ENGR. EST.)
Plan Ch.ck & Insp.ction Fe.
3372 Engr. Est < $100.000
2203 Enar. Est> $100.000
3372 Utility < S100.000
Conduits/Plp.lln..
Abov. 500 Fe.t
ManholesNaultslEtc.
Pole S.t/R.moval (No Permit Required)
Minimum Chllra. Per Location
2203 Utility> $100.000
3373 Proiect Plans & Specification.
3373 Standard SPecifications & Details
3373 Copi.s of Enaineering Map. & Plans
LAND DEVELOPMENT
3372 Parcel Map (4 Lo1a or Le..)
3372 Final Tract Map (5 or Mor. Lo1a)
3372 Certificate of Compliance
3372 Vacation of Public Slre.ts & Eas.m.nts
3372 As....m.nt Segregation or Reapportionm.nt
FIrat Split
Each Additional Lot
3370 Storm Orainag. Area Fe. Per Acre
**
(12% of ENGR. EST.)
(Deposit 15'10 of ENGR. EST.)"
**
$1.60/ft)
$1.101ft.)
S105/EA.l
$100/EAl
$1 1 5)
lDeDOSil15'1o of ENGR. EST.)"
Proiect No.
($12)
($.50/.q.fl)
rl1.04O + S221Lot)
$1.352 + S221Lofl
$520)
S548)
($548)
rl188)
(R-t. $1.950)
(Multl- R... S2.1 42)
(All Other. $2.340)
3510 Postaae
TRAFFIC
3368 Intersection Turn Counts (Two-Hour Count) (S80l
3368 Intersection Turn Counts (a.m. or p.m. peale.) 1$120)
3368 Traffic Flow Map (Dally Traffic Volum..) ($28)
3368 Campbell Traffic Mod.1 (Full Scop. A...ssment)(S2.200)
3368 Campbell Traffic Mod.1 (R.duced Scope A...aamentlCS725)
3368 Truck Permits ($35/lrlp)
3368 No Parking Signs 1$1/each or $25/100)
OTHER
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8BB79-.
B'bB73
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NAMI; OJ:,APPUCANT ~A' L ""T_
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ADDRESS d,l;5~,/7 '/r~'" ,
S~~~ c?# ~~d
TOTAL $ /71'::
PHONE~{;f!{tJ!iff
ZIP 9~~--4
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CITY CLl!RI:
ONLY
UCEIVErJ.yLff~Uj
DATE
*For Plan Check and Cash Deposits. send y.llow copy to Finance.
** Actual Cost Plus 20'10 Overhead (Non -inter.st bearing d.poslt)
h:recptfrm. wk3(mp)
~
RECEIVED
NOV 2 11995
CITY CLERK'S OFFICE
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RECVD BY: JANH 01000088873
PAYOR: HARK JONES
TODAY~S DATE: 11/21/95
REGISTER DATE: 11/21/95 TIME: 09:07:13
DESCRIPTION AMOUNT
REF DEPOSITS FUND 101 $1.400.00
---------
TOTAL DUE: $1.400.00
CHECK PAID:
CHECK NO: 7011
TENDERED:
CHANGE I
$1 ,400.00
$1.400.00
$.00
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CITY OF CAMPBElL. CA
RECIJD BY: JANH 01000088872
PAYOR: 95-260/MARK JONES
TODAY'S DATE: 11/21/95
REGISTER DATE: 11/21/95 TIME: 09:06:38
DESCRIPTION AMOUNT
ENGR & SUBDIV FILING F $225.00
ENGR & SUBDIV FILING F $168.00
roT~ N(: $3%.00
CHECK PAID: $393.00
CHECK NO: 7011
TENDERED: t393.00
CHANGE: $.00
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RECVD BY: JANH 01000089189
Si:r;~:;mr; i~;~~;~~R:IME: 13:32: 30
DESCHlf'TION
1"lf'r"'T:l.,,..,,,,,, I T""
!!LI.Jiht.~J t..,iL-ENSt: NEW/S
AMQUNT
$35.00
---------------
TOTAL DUE:
$35:00
CHEC~: PAID:
CHECt( NO: 8388
TENDEF~ ED:
CHAr~SE ~
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Allied Pacific Insurance
P.O. Box 24566
San Jose, Ca 95l~
CCMPI\I\'iES,
f. Pit" ~.'ERA,GE
:'4
Calvert Insurance
.0;;. i\ ':
i <.~~~,
Manuel Medeiras
DBA: MGM Concrete Company
1630 Chris Lane
San Martin, CA 95046
California Indemnity
'N:.,_iPfD
c
., .
COVERAGES .
E "Revises Certificate Issued 12/1/95"
vP;;.. IN:::,:.IHl>.!-','C":;'
k;",tRI-
~:~<:LFi/\L :. /\~~,. 'T-;
x
A
GL 040033
6/20/95
6/20/96
300,000.
300,000.
i1,.' ~UijiC)\:.:!.',_E ~iA8]L iT\
[!.c~.-::::'~ ~.iAB!L:-~\
IB
ANL"
N2034572E
6/2/95
6/2/96
1,000,000.
1,000,000.
_____m~_._"...,___ _ J ,000, 000.
:.:MPL L'{Er:~~ : ~ABit
'~)lHH1
: DECITIoNOF oCAMPBELL~AT:fTsvoFcFIseERS,L 'EMPLOYEES AND VOLUNTEERS
INSURED. RE: ALL WORK IN PUBLIC RIGHT OF WAY.
City of Campbe 11
Attn: Dept. of Public Works
70 N. First Street
Campbell, CA 95008
Attn: Harold Housley
Fax # 376-0958
~
. . - .
A.D..III.~
PRODUCER
DATE (MM/DD/YY)
12/1/95
Allied Pacific Insurance
P.O. Box 24566
I San Jose, CA 95154
1
I +OR.~~q.tjLA-6 ~x..3bq",q2Af
[iNsuRED-- ------~---------~-------
,
I' MGM Concrete Company ~
1630 Chris Lane ~
I San Martin, CA 95046(1t(~~ 3 -~~)&
I M~ ~r~~
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
____ ___ <:()~PA~I~~~~!()_R~G_~~\f~Fl~~_~___,_
i COM~ANY Calvert Insurance f~ I
.. ------i- ------------------- --- ----..---~ -~-~- -------, -I
! COMPANY fJ. {(., , I
ic~~:;~~- - ___n_" --n-------~-'Y.J--~i--"---l.-&-- ---1
I C California Ind~0~~ ~9$ i
r ----________n'_____________ _____ _'_~-------,--n-,----- ___ ___.. _,
' COMPANY *Revises & Superce~rtificate
D .A,.. '.
* .., f /, ,
THIS IS TO CERTIFY THAT THE OF BELOW HAVE TO INSURED NAMED FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
I CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
~ EXCLUSIONSAND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS,
;~ -'----;Y:E -::SUR:NCE-----~---------~:::-:iJMB~~------Tp~L;;~ ;;;~;TIVE-1 P~~I~~ ;X-;I~~~I~~ [ -
LTR I DATE (MM/DD/YY) I DATE (MM/DD/YV)
Xi STATUTORY LIMITS
i-EACH ACCIDENT [$-r;rrno-;-rrn-
IOISEASE - POLICY LlMIT--T$I; 0 ocr; 000-
iDISEASE - EACHEMPLOYE-E- i $T, 000 ,00"01
-I- ' I
I
I
I
-l
IA
I
BI & PD COMBINED OCC
BI & PD COMBINED AGG
I PERSONAL INJURY AGG
1-...----..---- '-----..~-~--...._-- ------
6/20/95
I
6/20/96
I BODILY INJURY OCC
'SODIL Y INJURY AGG
PROPERTY DAMAGE OCC
COMPREHENSIVE FORM
PREMISES/OPERATIONS
UNDERGROUND
EXPLOSION & COLLAPSE HAZARD :
PRODUCTS/COMPLETED OPER
CONTRACTUAL
INDEPENDENT CONTRACTORS
I i BROAD FORM PROPERTY DAMAGE
1-1 PERSONAL INJURY
i AU~OMOBILE LIABILITY
,-J ANY AUTO
, ALL OWNED AUTOS (Private Pass)
ALL OWNED AUTOS
(Other than Private Passenger)
, HIRED AUTOS
I NON-OWNED AUTOS
1---1
I __ _J GARAGE LIABILITY
GL 40033
PROPERTY DAMAGE AGG
i
I BODILY INJURY
(Per person)
BODILY INJURY
(Per accident)
PROPERTY DAMAGE
'-i30DILVINJORY &---
i PROPERTY DAMAGE
I COMBINED
EACH OCCURRENCE
AGGREGATE
I
, EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
, WORKERS COMPENSATION AND
, EMPLOYERS' LIABILITY
I THE PROPRIETOR/
C 'PARTNERS/EXECUTIVE
, OFFICERS ARE:
I OTHER
I
iN 2034572E
6/2/95
I 6/2/96
i INCL
i EXCL :
I
,
LIMITS
$
$
i
I
uj
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1
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$
$
i $
$
$
$
1$
, $
$
Re: All California Operations
DESCRIPTION OF OPERA TIONS/LOCA TIONSIVEHICLES/SPECIAL ITEMS
CERTIFICATE HOLDER
CANCE...LATIO"'10 Days NOe for Nonpayment
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
Mr. Harold Housley
City of Campbell
70 N. First Street
Campbell, CA 95008
(408) 866-2158
Acditi)i~~rJ9~f2 5 72
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. I
AUTHORIZED REPRESENTATIVE --I
I
I
@lACORD CORPORATION 1993 I
JAH-12-96 FRI 06:36 PM DIRTY.WORK.
.......... ...... ...... . .....,.... .
i:1
:~ Ar.~..IU...
~:::~>>)l>n~,:.)W:-:~,-:':-~;':<.':':-':t'J':':':":\I:t.:~
PRODUCER
MICHAEL L. WARREN INS. AGENCY
112A CRYSTAL SPRING CENTER
SAN MATEO, CA 94402
41:'5 347 3914
P.02
COMPANIES AFFORDING COVERAGE
;........ "..... ..................................... .,,,....... .."....... .......... .. ............,'
: ~~NY A WESTERN UNIT:ED INSURANCE COMPANY
(415)349-4246 ;.... ............' . ........,..... .......... ....
,. . ....... ..".. .............~..,.................... ",....... ........... ................................."...., COMPANY B
INSURED , LETTER
DIRTY WORK LANDSCAPING :.... .... ......... . ..... .... ..,... .... .,... ..... . ..... .... . .." .. ..... . .... .
KEVIN HOLLAND ! ~~r" C
1704 EASTON DRIVE .... .. .,.... .........,. .. .. . .. .... .. . .. ........ . .. . ..
BURLINGAXE, CA 94010 : rm~~NY 0
.... ........ .... ,,'..... . .... .. . ...... '. ......,,, .",... .....'1..... . .....".. .,
COMPANY E
LETT'ER
THIS IS TO CERTIFY THAT THE POLICIES Of' INSURANCE lISTEO BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED NOTWITHSTANDING ANY REOUIREMEI'fT, TERM oR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICAtE MAY BE ISSUED OR MAY PER1AIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBeD HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITiONS OF SUCH POlICIES.
CO
LTR,
: QENl!RAL LIABILITY
T'fPE OF lNSUFlANCE
POLICY NUMBER
.. ,. .... .'" . ... .. .. ~..,..... ...... .. ."'" . .....' . "
POLICY EFFECTIVe : POLICY EXPIRATION:
OATE (MM/DD/YY) ! DATE (MM/DD/YY) i
l/IIo1IT5
iCOMPFlEJ.fENSlVE FORM
. ;PREI,lISESIOPEFlATIONS
: .... "~UNDERI3ROUNO
, ;El'J'L05ION &. COLLAPSE HAZAFlD
!PROOUCTSICOMf'LETED OPER.
;CONTAACrUAL
;INDEPENDENT CONTF\AC10A$
'BROAD !'OR'" PFlOP~RTY DAMAGlE
;P€R,SONAL INJURY
X: AUT~MOBILi lIABILt'rY
..~..:ANY AUTO
:ALL OWNED AUTOS (Pn.. Pass.)
: ;.' AlL OWNED AUTOS (Oth., Than )
........., PtN. f';;ee,
;HIR€O AUTOS
, ..... ,[NON.()WNEO AUTOS
; ;GAl\AGE LIAIlIUTY
WOC0023969-A
L~~~~:,~~~~~~.~.........,........~...,..,.... .... """"""
i BODILY INJURYAQIJ. : s
f.~~~~~~~.~~~~..~:..........:.~. ,""'" .. ...,...,
; PROPERTY DA!l.lAGE Aoo. S
...... ............ .,. ......." .'.
; BI & PD OO",BINEO OCC. , S
......,.,..,.........................................., "'J"" ,.,...... ..........
! 81 & PO COMBINED AGGI. ; S
[' PER'SONAL INJURVAG'G.':" .... .: S"
;:::::," ':' ': ': ~'.:":'" ...........:....... '," ".... .: .. ............,........... .."... ....
:....:..............:..... ,""".'..:... .:......:.. ........... . . .
:, . :
. ". ",.
11/30/95 : 11/30/96 1S00ILY1NJUFlY
; I.~~~.~,~~~.~,~).............. ...........:.~.... " ..
~ BODILY INJURY
i (Per aceiden!)
:..'''.............. ".........................".,"........ . ....
1 PROPeRTY DAMAIJE ' S
$
....................,.......,... ..,.'.."..,................
: EXCESS LIABIUTY
, ...,...iUMBRELLA FOFiIA
;OTl-lER tHAN UMBRELlA FORM
: BODILY INJURY &
; I'ROPERTY DAMAGE
! COMBINEO
i.~~~~~~~~N~
! AGlQREGlATE
'$
1pOOpOO
$
S
!;:'. L.~::,:.. :::~.'.::: '. <: ,.'....
WORKER'S COMPENSA110N
AND
EMPLOYER'S LIABILITY
; STATUTORY LIMITS
: oTHER
...........................,"'''.......... ........".."..... .' ",
: EACH ACCICENT . S " .
r O'I$E:,lSE :. POLiCy LIM IT '"'' ~ s
!'CiSEME:'EACH'EM'PLovEe"'"';'s''' . .....,.
DESCRIPTION OF OPEFlA110NS/LOCATION5NEH1CLES/SPECIAL ITEMS
JOB - PACIFIC TELESIS, 90 EAST LATIKER, CAMPBELL, CALIFORNIA
:~~R!<mJ~.i.?].:Jf!98!m~il~lj:j!@!!@~l~i~i!i)]~:!;i~.]~~M!~~i~~&;!MJii[;:~:!mr,{tt~1~~tl~I;:g~~~.:.:.,:,,;~.;: :!ii~fiJii~1~:!ijW~li!iji;!@i\Hi~Vmi:;i:1iim~~~~:~1!:W!IM&i@ii~lWj~m~\~;:t~(::::~::}:~::.:...::?:::.::::::::'.:"::~:.'
CITY OP CAMPBELL ill!l SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THe .
70 NORTH FIRST STREET ;lli
CAMPBELL, CA 95008 q
),:~::
ATTN - DEPT. OP PUBLIC WORKS ~
HAROLD ""
ft1
~~
M AUTHORIZED FlEPlliSENTATIVE
W GLENN F. DAVIS -
:~~~ill1,1>!~"(fWt*~i~~t~tWl~~f.tt.t.t:@~1~t.1.~1f:t:.~tJ~@~~]~Wj.}~n~~ml;HEil~~f;j~fJilii1~i~i~W~ll~j;ill~~~r~iJ':1~~j~~~~)~)*W!~~~i;~i~:,A~~;iiiii;~]~$tf~!!!S~!ii::;i~fi:....Jr~~1fjtJ?tNJtJ~
EXPI~u..qN DAlE THEREOF, THE ISSUING COMPANY WILL '5 _
MAIL 'JI'DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT.
.... ...... .... .... .................. ...........................................
...................
At~t.lil.B .,........~I:I:I.I..I.11;::........:::::I.I:I:f1I.I1.I:.1..1111111:.1.:.11::111.:11::.1.1.11111 :.:.:.:::::::::.::.::.....:.::.::..i:i::..:.!:...:::::.:.:.:.:.:.:::::.. . ",......:.;:.:....:::.:i:.::.:.:.:.;:..'..........:....:.:......:;...:..::..:......,.....:.......:.. ~~i(~~i~
THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM.
PRODUCER PHg~o Ex!: ( 415 ) 349 - 4246 COMPANY BINDER tit
MICHAEL L. WARRREN INS. AGENCY WESTERN UNITED
112A CRYSTAL SPRING CENTER DATE EFFE TIVE
SAN MATEO, CA 94402
11/30/95
TIME
12:01 AM
AM
12:01
PM
11/30/96
NOON
CODE: 3 087
AGENCY
CUSTOMER 10:
INSURED
SUB CODE:
THIS BINDER IS ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY
X PER EXPIRING POLICY # WUC0023 969-A
DESCRIPTION OF OPERATIONSNEHICLES/PROPERTY (Including Location)
KEVIN G. HOLLAND
1704 EASTON DRIVE
BURLINGAME, CA 94010
(DBA - IRTY WORK LANDSCAPE)
ALL SCHEDULED VEHICLES
TYPE OF INSURANCE
PROPERTY CAUSES OF LOSS
BASIC D BROAD D SPEC
COVERAGE/FORMS
AMOUNT
DEOUCTIBLE COINS %
GENERAL LIABILITY
AUTO PHYSICAL DAMAGE DEDUCTIBLE
COLUSION:
I OTHER THAN COL:
GARAGE LIABILITY
! ANY AUTO
ALL VEHICLES
SCHEDULED VEHICLES
GENERAL AGGREGATE $
PRODUCTS. COMP/OP AGG $
PERSONAL & ADV INJURY $
EACH OCCURRENCE $
ARE DAMAGE (Anyone fire) $
MED EXP (Anyone p&r.IOn) $
COMBINED SINGLE LIMIT $ 1000000
BODILY INJURY (Per person) $
BODILY INJURY (per accident) $
PROPERTY DAMAGE $
MEDICAL PAYMENTS $
PERSONAL INJURY PROT $
UNINSURED MOTORIST $
$
ACTUAL CASH VALUE
STATED AMOUNT $
OTHER
AUTO ONLY. EA ACCIDENT $
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EACH OCCURRENCE $
AGGREGATE $
SELF-INSURED RETENTION $
STATUTORY LIMITS
EACH ACCIDENT $
DISEASE. POLICY LIMIT $
DISEASE. EACH EMPLOYEE $
i COMMERCIAL GENERAL LIABILITY
CLAIMS MADE D OCCUR
OWNER'S & CONTRACTOR'S PROT
AUTOMOBILE LIABILITY
RETRO DATE FOR CLAIMS MADE:
LIABILITY (COMMERCIAL AUTO)
, ANY AUTO
ALL OWNED AUTOS
X SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
EXCESS liABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
RETRO DATE FOR CLAIMS MADE:
WORKER'S COMPENSATION
AND
EMPLOYER'S LIABILITY
e==-~.. ~
AUTHORIZED REPRESENTATIVE
GLENN F. DAVIS
~~,
J.., ---
(j~/ijj}m.:JimMM#(ijjfqt:$t4.tjjNfQijM4.tmij:QN:ijjW$tOOUijP.i[.:::~fA&~.#~#~ATt()N1~~"
PIA~BRANDI 4155983582
A 4' '^' r .." ' Go ~ .'t<\'J "NIIQ \..AI... A.."\,)IJ\,; 11\ I Q'"
P.01
14J~~Vf4~~;H L( 1
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Inclfc.tM. IlObfftJIilUMt.. ., ....1...... t... ... CHdltllln '" .... ..-\rtl(.t vr vU.c:r __, lI1ta ,,"",' _ .,d1 '\"'$ l
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~hl"'.a olld aMt~1Cl1la of -- 110"':'11$. UlI1tll ~ -, Iltlw Ileal red....... r,y ,.f4 ~l.'... I
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......... It. - t "'1 (10 J ..,. ,""n_ -U.. t. . tatttficd.. I&tltkr .......t. Uto I
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aDllWlE. CA. MOIO
ACORD 025-S CERTIFICATE OF INSURANCE I Issue Date I
1============.....--..-----..-----------............--..................--........--....................-1 12 - 15 - 95 1...----
Producer I This Certifcate is issued as a matter of information only and confers
I no rights upon the certificate holder. This certifcate does not amend,
I extend or alter the coverage afforded by the policies below.
I Companies Affording Coverage
1--------------------------------------------------------------------------
I Company
I Letter
I Company
I Letter
I Company
I Letter
I Company
I Letter
I Company
I Letter
PROFESSIONAL INS. ASSOCIATES
P. O. BOX 1266
SAN CARLOS, CA. 94070
.
A ACCEPTANCE INSURANCE COMPANY
I~sured
B
KEVIN HOLLAND
DBA: DIRTY WORK LANDSCAPING
1704 EASTON DRIVE
BURLINGAME, CA. 94010
C
D
E
Coverages ======-=---.-..-===------===-..--..----__.......__.___.....-........_____..____......___...__....____...___.__._._.___
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 terms,
exclusions and conditions of such policies. Limits shown may have been reduced by paid claims.
ICo I Type of Insurance I Policy Number IEffective Datel Expire Date I
ltrl---General Liability-----------------------------------------------------------------1
A I XICommercial General Liab. 1 CL314390 I 03 - 25 - 95 103 -25 - 96 1
I Claims made X Occur. I I I I
I Owners & Contractors I I I I
I I I I I
I I I I I I
---I-----Automobile Liability -----------------------------------------------------------1
I I Any auto I I I
I I A II owned autos I I I
I I Schedu led autos I I I
I I Hired autos 1 I I
I I Non-owned autos I I I
I I Garage Liability I I I
I I I I I Property Daege $
I---I-----Excess Liability--------------------------------------------------------------- I Each Occurrence $
I I I Umbre Ila Form I I I Aggregate $ I
I I I Other than Umbre Ila Form I I I I
1---1--- Workers Compensation ----------------------------------------------------------- I Statutory I
I I and I 1 I (Each Accident) $ I
I I Employers Liability I I I (Disease-Pol Limit) $ I
I I I I I (Disease-Ea Employee) $ I
I---I----Other----------------------------------------------------------------------------1 I
I I I I I I
I I I I I I
I I I I I I
I Description of Operations/Locations/Vehicles/Restrictions/Special Items ---------------------------------------------------------I
I **PRODUCTS/COMPLETED OPERATIONS ARE COVERED UNDER THE OCCURRENCE LIMIT ONLY I
I INSOFAR AS THOSE CONTEMPLATED BY THE CLASSIFICATION "LANDSCAPE GARDENING I
I 97047" I
I Certificate Holder =_c~__________c___==________=_____..1 CANCELLATION------------------........---.......--.......-----------.-. I
I --ADDITIONAL INSURED-- ! Should any of the above described policies be cancelled before the I
I CITY OF CAMPBELL, ITS OFFICERS, I expira date thereof, the issuing cOlApany will ~JY&1CMX1lElXXXX I
I EMPLOYEES & VOLUNTEERS I mail 30 days written notice to the Certificate Holder nailed to the I
I 70 NORTH FIRST STREET I left, lfJ(~r~CCoOCIJ(mtuek>t1)l\j(~)E!lnDQX.K*XKD<Xm~~lS~XX I
I CAMPBELL, CA. 95008 I Jt ~JtX~X~x~~~xtltI~~MJ"~,X~X*ICOe;XIOX;(_~1ClttX~X,q
: ATTN: DEPT. OF PUBLIC WORKS l---~-----------~----::--------------------------------------------- I
I CR/GI I 'IJtlJIilJt!It;.."';:JO:;IATES I
IACORD 25-S (7/90)
Limits
General Aggregate- $ 1,000,000.
Prod-ColAp/Ops Aggr. $ **AL2007
Pers/Advertising Inj $ 500,000.
Each Occurrence $ 500,000.
Fire Damage(One fire) $ 50,000.
Medical Expense $ 1,000.
(Anyone person)
$
CSL
Bodily Injury
(Per Person)
Bodily Injury
(Per Accident)
$
$
............_...__......_.._-~.~...... ..-....................................-..-.....-............-~I
CL 690
(10-93)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
CG 20 10 10 93
ADDITIONAL INSURED-OWNERS, LESSEES OR CONTRACTORS (FORM B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.
Endorsement effective Policy No.
12/15/95 12:01 A.M. standard time CL314390
Named Insurer! Countersigned by
DIRTY WORK LANDSCAPE TRANS CAL ASSOCIATES/SACTO.. CA.
..
(Authorized Representative)
SCHEDULE
RM0_f~.
Name of Person or Organization:
CITY OF CAMPBELL, ITS OFFICERS, EMPLOYEES
& VOLUNTEERS
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 Sched-
ule, but only with respect to liability arising out of your ongoing operations performed for that insured.
-
THIS INSURANCE COVERAGE SHALL BE PRIMARY FOR THE ADDITIONAL INSURED AND ANY
OTHER INSURANCE MAINTAINED BY OR AVAILABLE TO THE ADDITIONAL INSURED IS NON-
CONTRIBUTORY.
/'
12/15/95 GI
.,.~~\~.~o'"
OAUTHENTICO
..~ -.... .
--........,.GOWlo..~.~
Copyright, Insurance Services Office, Inc.. 1992
/ /'
Ct ,_ S ;i . 1. 00' ~ l:I ,"2, J L.\' .s
Professional Insurance Assoc
P.O.Box 1266
San CarlosL Ca. 94070-1266
(415) 592-,333
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AHHEND,
EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Producer
COMPANIES AFFORDING COVERAGES
Company
Letter A CALCOMP INSURANCE
Insured
DIRTYOI-RMS
Company
Letter B
Company C
Letter
Company
Letter D
Company
Letter E
E, C' ,!!", l1
. ..,.... ;.'~
'" '";~'" "
~~,'-
DIRTY WORK LANDSCAPING
KEVIN HOLLAND
1704 Easton Drive
Burlingame CA 94010
Jf~,\t11 '? 199h
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PER-
IOD INDICATED, NOTWITHSTANDING ANY REQUIREMENTS, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO walCH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSION AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFF DATE POLICY EXP DATE
(mm/dd/yy) (mm/dd/yy)
LIMITS
Any Auto
All OWned Autos
Scheduled Autos
Hired Autos
Non - OWned Autos
Garage Liability
General Aggregate $
Prod-Comp/Ops Agg $
Pers , Adv Injury $
Each Occurrence $
Fire Damage $
(Anyone fire)
Medical Payments $
(Anyone person)
combined $
single Limit
Bodily Injury $
(Per Person)
Bodily Injury $
(Per Accident)
Property Damage $
GENERAL LIABILITY
[ ] Commercial General Liab.
!~mm!l[ ]Claims Made [ ] Occur
[ ] OWner's' Contractors
Protective
AUTOMOBILE LIABILITY
EXCESS LIABILITY
[ ] Umbrella Form
[ ] Other Than Umbrella Form
Ea Occurrence $
Aggregate $
m~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~m~
A
WORKER'S COMPENSATION
AND
EMPLOYER'S LIABILITY
W955120059
OS/24/95
OS/24/96
st~tutory i!!!!~!!!!!l~m!l!!!!m!!1
Each Acc1.dent $ ~, UUU , UUU
Disease-Pol Limit $ 1,000,000
Disease-Each Empl $ 1, 000, 000
OTHER
rniPc1aI~ORN~AnsgpEItAT~vo~~es/special Items
/~ /2/r h- a1 t
,l!H_
C"d ti"
CITY OF CAMPBELL
70 NORTH FIRST STREET
CAMPBELL CA 95008
ATTN: DEPT. OF PUBLIC WORKS
HAROLD HOUSLEY
FAX 408 376 0958
immAWi1l.~~~~~~Ql~~l;~lfol;l~~m;:0~; . .
:::::::::::::_f:.~ffl&~:i::::~::::::::.~;:~::T(~l:~f:iI"~~W:iM:i'
Should any
expiration
mail 10
left
" ",. ~1F:~Nlimmmm~mmmmmmmm~mmmmmllMlllll~ll~l~~lll~llllmmmm~m~mm,l
.. ~'Wn::::::::::::>':::::::::::::::::;:;::l::;:;:;:;:;:;:;l::;:::::;:::;:;:;:;:;:;:;:;:;l::;:;:;:;:;:;:;:::;:;:;:;:;l::;:;;;:;:::;:;:;:;:;;;:;:;:;l::;:;:;:;:;:;l::;:;:;:;:;l::::;:;:;:;:;:;:::;:;:;'i:.~lt:c:: ~
of the above described policies be cancelled before the
date thereof, the issuing company will
days written notice to the certificate holder named to the
Authorized Representative
APPRO,VED Lr~ t""" 'C''''''RlJCTrO~~
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'O~CH"\lO
CITY OF CAMPBELL
Public Works Department
February 19, 1997
Ms. Angela Zambetti
13203 West Zalpico Road
Tracy, CA 95376
SUBJECT: PERMIT NO. 95-260
LOCATION: 90 E. Latimer
ONE YEAR MAINTENANCE INSPECTION - ACCEPTANCE
Dear Ms. Zambetti:
The City of Campbell has made the final one year maintenance inspection of subject Public
Works improvements and find that no maintenance is required.
Your warranty requirements and any surety, therefore, are hereby released. Your remaining
warranty deposit of $350.00, plus any interest due, will be sent to Mark Jones from our Finance
Department.
Sincerely,
f7i~.fIl
Public Works Inspector
MQ
~UJ
cc: Permit #95-260
Public Works/Maintenance Division
Doug Foley, FAX 297-1904
Mark Jones, 2422 Adonis Way, San Jose, CA 95124
H:\90ELAT.ACC(JD)(WP)
70 North First Street. Campbell, California 95008.1423 . TEL 408.866.2150 . FAX 408.379.2572 . TOO 408.866.2790
NEW PW FAX #
Ann ....~,r .....".,.__
Of'C"'A1
~. P.p
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'O~CHAY.l>'
CITY OF CAMPBELL
February 6. 1996
Public Works Department
Ms. Angela Zambetti
13203 West Zalpico Road
Tracy, CA 95376
SUBJECT: PERMIT NO. 95-260
LOCATION: 90 E. Latimer
FINAL INSPECTION AND ACCEPTANCE
Dear Ms. Zambetti:
The City of Campbell has made a fInal inspection of subject Public Works improvements and
fmds the work to be acceptable and in conformance with City standards. Accordingly, the City
Engineer accepts the improvements.
The one year maintenance period stated in the permit begins as of the date of this acceptance
letter. The permittee is responsible for the repair and/or replacement of any defective work or
failures that occur within one year. The City will inspect the improvements within one year and
notify you, in writing, whether or not any repairs are required.
75% of your Faithful Performance Surety (FPS) cash deposit of $1,400.00, plus any interest
due, is now being processed and will be sent to Mark Jones under separate cover. We will
continue to hold $350.00 of your FPS cash deposit as a maintenance surety.
If you have any questions, please call Randy Westfall, Public Works Inspector, at (408) 866-
2165.
Sincerely , ~
~(U
Michelle QUinney~.
City Engineer
RRW~
cc: Doug Foley, FAX 297-1904
Mark Jones, 2422 Adonis Way, San Jose, CA 95124
Suspense - 11 months
Permit #95-260
h:\95260FAC.LTR(JD)
70 North First Street, Campbell, California 95008.1423 . TEL 408.866.2150 . FAX 408.379.2572 . TDD 408.866.2790
NEW PW FAX #
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City of Ca; J.1 ~ Pemi.t No. 95~c7
Oepart:ment of Public War.ks
-J4lf-/ Applicant secticn cazpl.ete'
-J,IIAl; Awlicant signature and data~
j;JjI/ Pemi.t ~licati.an fee ~O paid
~ ~ ~ J p....,ipt.....,.... t.r~ hilI?
-A- Plan, d1ec::k deposit, . paid
fIltmner _ mll7
Five sets of 1mprcvemern: plans subnitbd
~SUrety fer faithtuJ. perfa:mance, lOOt of City ~'s
estimate, ~lied or paid , ~
Ancunt $~ Fom ~//0' I.D. I
~, Cash Ooposit: 4t of no sw:et:y, ~ IIIini= paid
Am::unt $ p,-:.1 pt No.
~ Plan C1ec:k & Inspecticn. fee of ~ of F.P. surety fer amcunt:s af
o - 0 000; 10% for-3(tiOOO--.... $80-,000; 7% for $80,000 and above;
#/hL- 0 m;n;1'III'lltl) 0.,1J
~ -Amalrit $ ~;pt No.d~?z,;
- 5.:'0 -~/7///:7.
~rker's c::anpenSaticn infcmaticn received for Applicant
jl/ i/. ~see Infonation Sheet for Enc:roadmIent Pemi.ti)
~ All ather Public Works requi.rement:s listed in the Con::titicns of
ARJrcval of the develcpDent.
/
- f;'s CUtponSatian and O:lnt.......-t:cr.s InfOllllatian received far
( Contractor (see Infoxmaticn Sheet for Encroachment Pemits)
. icate of Insurance with Additional Insured' s Endorsement
-- 'ved fran 0Jntractcr (see General. SUmlna%y of Insurance -
Requ:irement,s for &lc::road1ment pemi.ts)
sets of off-site plans, s+-~ APP9JVED (Tract or
Develcpnent and Public Works Pel:mi.t fIlDnha..r and prcperty address
an plans)
Pemit signed for City &1;Ji.neer
WHEN AIL OF '!HE ~/Jl>>5 ARE ~~ ~ MAY BE ISSt1EO
Issuer: Initial.-H- and date ~ and file with pemit
//# OR:N ISSUANCE, INI'I'IA!E aIECK ~ FOR PIAN O!ECK JJEmgIT
. REFUND
f:pmtck1st
Revised 8/92
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