Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
ENC2009-00082
CITY OF CAMPBELL DEPT. OF PUBLIC WORKS 70 North First St. Campbell, CA 95008 (408)866-2150 Fax (408)376-0958 .CROACHMENT PERMIT (for working within the public right-of-way) Issued 71 ~ 3~0 Permit Expiration Date 7 ~ `G X-Ref. File Application Date ~~~ 3 ~~~ Application Expiration Date ~ p APN ~) 2 ~~~~d~ ~7 APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six (6) months if the permit is not issued. Application Fee isnon-refundable.) A. Work address or tract # l "~vv ~ C, Utility trench locarrtion B. Nature of work I h~~l ~ S C `~~~~ ~e r rl S ~ ~ c+_ CL~>^ ~ )7 "! G'1~ 5 ~~ P C,-S~-~,,~. C. Attach four (4) copies of an engineered plan showing the location and extent of the work, and four (4) copies of the preliminary Engineer's Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer, said plan becomes a part of this permit. D. All work shall conform [o 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 Sureties and cash deposits. (See General Permit Conditions 1 and 2.) E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work. Name of Telephone~Ll l ~~ ~ ~ Z - 0 ~ ~L.Q -~J (print na ) ~ ~ 7 ~ Address ("~ ~J~"~~G~1~.~ ~Il~ f~~Qi~,U 24-HOUR EMERGENCY TELEPHONE NO. E-Mail Address ~`~ ~~ G a rim 1 C 1,1(~t~ ~ ~ ~C ~ d Lb2d/~ Is this work being done by the property owners at their own residence? Yes No 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 harmless from any claim or demand for damages resulting from the work covered by this permit. The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. 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 condition of any private improvements in the public right-of-way. , , (Applicant Permittee) (sign) Contractor (Print Name) ate SPECIAL PROV ISIONS _1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be specifically approved by the Insnector prior to cutting. _2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A", unless otherwise approved by Inspector. _3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public Works Department before starting work. _4. 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 has been entered hereon. USA Phone 1-800-227-2600. USA TICKET NO. 5. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be recorded. 6. Public Notification Requirements: 7. -- SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO. PERMIT APPLICATION FEE $ G GG 21 ~ ~t 4 3 PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK & INSPECTION FEE $ 2 70 2 j ~6' y 4 ~i APPROVED FOR ISSUANCE -~"-~ 7~( ~f ~ ~'f For City' ngineer Date Permit Expires 12 Months After Date of Issuance ti t ~~ .~/i ~'~ , ~v cro 0 -n w 0 x 0 b b `~ b -~ N N ~ O O fD O O C J J ~ ~ ~ I ~ ~ ~ ~ tr ~ A W W W ~ J O N 00 W O O [ 'rl Crf d ~• ~ n ~ l77 O ~ n ~ '~ "'~ o m = a ,~ n ~s u ~~ 0 o ~ ~ ~ m x ~ ', ~ ' ~ ' y 69 00 J O N ~ I O ~ O O O O ~ O O ~° ' O O N ' b P'+ a N O\ °O o o '9 o O O ~' o O O -- 0 ~ ~ C7 w w ~ N N b O O y O O O. ~ ~ ~ ~ n J J ~ W W n r. O ~' ~' ~ y ~ ~ _~ C~" w w ~ ~ l17 ~. z z d .. ~, ~o 0 0 ~< a a d A ~ O O O O %n' O O c n n m r. 'V ~ ~ .. ~ ^~ ~ l 1 W N ~• O „•r O C `p ..ti O ~C O~0 O N "'~ ~ ~ in ~ ~ O "C7 a ~ PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT & MISCELLANEOUS RECEIPT Effective July 1, 2009 TO: City Clerk r, , PUBLIC WORKS FILE NO. ~`~ ~ ZGC ~ CCXJ~2 PROPERTY ADDRESS ~pC ~ /~ iV1 gt2~ Please collect & recei t for the followin monies: ACCT. ITEM AMOUNT ENCROA CHMENT PERMIT 4722 Utility Encroachment Permit Application Fee Utilit Arterial/Collector Street $600.00 F>'O U Residential Street/Other Areas $335.00 4722 Plan Check & Inspection Fee Utilit < $100,000 * 2 7p Minimum Charge Per Location ($270.00) Conduits/Pipelines up to 500 Feet ($2.40/ft) Above 500 Linear Feet ($1.45/ft) Manholes/Vaults/Etc. ($135.00/ea) Pole Set/Removal ($135.00/ea) Street Tree Plantin /Removal $500 de osit $155.00 ** 2203 Utilit > $100 000 * Actual Cost + 20% "' 4760 Stora a Container Permit $135.00 4760 Pro'ect Plans & S ecifications Pro'ect No. 4760 Standard S ecifications & Details $1/P $15.50/Bk 4760 Co ies of En ineerin Ma s & Plans Aerial Plot 24" x 36" $57.00 Aerial Print 8 1/2" x 11" $26.00 Aerial Search Fee $26.00 Ma sand Plans 24" x 36" $13.00 4722 Penalties: Failure to restore ublic im rovements $100/Calendar Da Muni Code Sec. 11.34.010) 4722 Penalties: Failure to correct unsafe conditions $100/Calendar Da 4722 Work Without Permits 4 Times A licable Fee '.MISCELLANEOUS 511.7424 Posta e Other Please S ecif *Engineer's Estimate shall be as approved by the City Engineer. NAME OF APPLICANT ~ tj TOTAL $ ~ 7U NAME OF PAYOR ~-- ~ PHONE L d~ ~ - z ADDRESS o ~ ~ ~ ,- ~ ZIP j S G **Actual Cost Plus 20% Overhead Non-Interest bearin de osit FOR RECENED BY CITY CLERK ONLY Date Recei t # J:\FORMS\TemplalesWGmimslralive\Raceipl Form V~tlily EnvoaChmen~ 8 Mix 0&10 Rev O6/00 ~~ ~~: „~ S`}~ ~~~ q ~~~~ Cj'~ ~ `a~ ~x ^~ „yam „A .L !, '~ i u .:,, ~ '~', v nav i' :,~., ~2° r,~ C "~ '2~' i . ~ (ti '~~ %.~ V i c~ <~' ~J' ti~ ~v ;~ 4, Cs ~~ ~,Q~ INSURANCE REQUIREMENTS CHECKLIST Perini # ~ ~'~"~~1''vwd CIP Project # ""-' . ~' ~ ~~ GY" ~J The following msurai~c is required of all contractors working m 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 C mxnercial General Liability for bodily. personal injury and property damage: 1,000,000 per occurrence, and ^ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggre t ~i it~,o Policy expiration date Automotive Liability: ~( "Any Auto" checked on certificate $1,000,000 per accident for bodil injury and property damage Policy expiration date Workers' Compensation and Employer"s Liability Waiver of Subrogation clause $1,000,000 per accident for b dily in~ury or disease Policy expiration date Course of Construction (if required in Special Provision ^ Completed value of the project ^ Policy expiration date _~ ~ k '~ ~ ~~ C- Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement 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 to delete "endeavor to" and "but failure to mail such notice shall impose no obligation or liability of any kind upon the coi parry, its agents or representatives". (~ ~ ~ A. Workers' Compensation Insurance Sheet Submitted ~ ~~ w ~ ^ For General Contractor ~1~ ^ For Developer or Owner of ~~ P~~~r~~i~ ~~~~~ ~ ,,~~~ , ~ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact Vv~~ ~~ busiliess in the State of California. ~~~~ ~~~ In urance Certificate Reviewed ~~ , L ~ [_.~ _ nitials Date ^ Copy of Insurance Certificate placed in ticlaer file for month of expiration. j:Aforms\insclclst (rev 11/99) ACORDN CERTIFICATE OF LIABILITY INSURANCE ~ii2i2oo Y' PRODUCER (925)775-2000 FAX: (925)775-2001 CBI Insurance Agency 700 West First Street 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. Antioch CA 94509 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Llbert Sur lus Insurance The Scaffold Works Inc. INSURER B: The Travelers Indemnit 25658 1697 Rogers Avenue INSURER C: INSURER D: San Jose CA 95112 INSURER E: 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 . R A T AV N INSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DDIYY POLICY EXPIRATION DATE MM/DD/VY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 2, 000, 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 0 PREMISE Ea occurrence 5 ,000 $ A X CLAIMS MADE a DGL-SF-208831 028 4/1/2009 4/1 20 OCCUR - / 10 MEDEXP An one erson $ EXCluded PERSONA $ 2 000 000 L 8 ADV INJURY , r GENERAL AGGREGAT $ 2 000 000 E r , GEN'LAGGREGATELIMITAPPLIESPER: O PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY JEC T LOC AUT OMOBILE LIABILITY X COMBINED SINGLE LIMIT 000 000 $ 1 ANY AUTO (Ea accident) , , B ALLOWNED AUTOS BA-1690M94A-09-SEL 3/16/2009 3/16/2010 SCHEDULED AUTOS gODILY INJURY (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY ~ AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA A 5 AUTO ONLY: ~ ~ AGG S EXCESS/UMBRELLA LIABILITY '+ I ~/ ~ EA H RREN $ OCCUR ~ CLAIMS MADE PU LIC WOR AGGREGATE $ AD INISTRATI N $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? If yes, describe under E.L. DISEASE - EA EMPLOYEE $ SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS RE: Growers National Bank, Bid # 13193, 400 East Campbell Ave., Campbell CA. All work in public right-of-way. City of Campbell, City of Campbell Redevelopment Agency, its officers, employees and volunteers are named as an additional insured per the attached form in regards to general liability. *Except for 10 day notice of cancellation due to non-payment of premium. A - / ^ O ~ V f ~• (408)358-3411 City of Campbell Attn: Dept of Public 70 North First Street Campbell, CA 95008 ACORD 25 (2001/08) lucn~s ,n,na, „<.. ELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL .~D~~f~~ MAIL Works * 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, ~~ Yc~(i~CI~Cr~~S~4~~IXiYia~F,Yu~~4~ia~sX~oX-~I~'i~r~Xu1(c~i~foXU~~-iYc~C AUTHORIZED REPRESENTATIVE Stan Wristen/TWRIST ©ACORD CORPORATION 1988 P~no 1 M ~ ACORD,N CERTIFICATE OF LIABILITY INSURANCE ~ii2i2o 9Y' PRODUCER (925) 775-2000 FAX: (925) 775-2001 CBI Insurance Agency 700 West First Street 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. Antioch CA 94509 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA:Llbert Sur lus Insurance The Scaffold Works Inc. INSURERe:The Travelers Indemnit 25658 1697 Rogers Avenue INSURER C: INSURER D' $an Jose CA 95112 INSURER E: 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. R T N V R INSR ADD'L D Y E P N TYPE OF INSURANCE POLICY NUMBER ATE MM DD/YY DATE MMIDDIYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 2 r ~~~ r 000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence 5O r O~Q $ A X CLAIMS MADE a OCCUR DGL-SF-208831-028 4/1/2009 4/1/2010 MEDEXP An one erson $ Excluded PERSONAL & ADV INJURY $ 2 r 000 r OOD GENERAL AGGREGATE $ 2 r DOQ r OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 2 , 000 r 000 X POLICY JE ~ LOC AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1 r ~~~ r 00~ X ANY AUTO (Ea accident) B ALL OWNED AUTOS BA-1690M94A-09-SEL 3/16/2009 3/16/2010 gODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY D AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EAA $ AUTO ONLY: qGG $ I EXCESSIUMBRELLA LIABILITY ` EA H RR N E $ OCCUR ~ CLAIMS MADE PU LiC WOR AGGREGATE $ AD INISTRATI N $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND E ' WC STATU- OTH- MPLOYERS LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS RE: Growers National Bank, Bid # 13143, 400 East Campbell Ave., Campbell CA. All work in public right-of-way. City of Campbell, City of Campbell Redevelopment Agency, its officers, employees and volunteers are named as an additional insured per the attached form in regards to general liability. *Except for 10 day notice of cancellation due to non-payment of premium. O ~ V CERTIFICATE HOLDER CANCELLATION (408) 358-3411 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Clty of Campbell EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ~fraGX,~r~C~r3C MyAIYL Attn: Dept Of Pub11C Works *3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, aI/T 70 North First Street yF~GCr~~S~~~xXIiS~Sd4.?(rKT~6X2~G~~4~r~C~~4,~fDy,~~J~r~C Campbell CA 95008 Y.YY_YYY](.YYY1/KYYYYYYKVY ACORD 25 (2001/08) lucn~t ,n,na~ „o.. AUTHORIZED REPRESENTATIVE Stan Wristen/TWRIST ~ © ACORD CORPORATION 1988 Pine 1 of ~ IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. RECEIVED JUL 13 2009 ADM N~gTRAT ON AGUF2Dl5 (2009/OS) INS025 (0108).08a Page 2 of 2 Corporation ~ ?1cmUcr of L1DCfq' Sprtu:U Group Liberty Surplus Lisurance Cocpomtian ENDORSEMENT NO. THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFI~'~C E I VE D Endorsement Effective Date: 4 1 0 9 Policy No.: DGL - S F- 2 0 8 8 31- 0 2 8 JUL 1 3 2009 Insured: .The Scaffold Works, Inc. BLIC WORKS ADMINISTRATION ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS SCHEDULE Name of Person or Organization: As required by written contract. Location and Description of Completed Operations: Additional Premium: (if no enfry appears above, information required to complete this endorsement wilt be shown in the Declarations as applicable to this endorsement.) Section II -Who is An Insured 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" at the location designated and described in the Schedule of this endorsement performed for that insured and included in the "products-completed operations hazard". CGL 1038 1103 Page 1 of 1 Dui. !, 1UU~ 11:74H1~ No.O$25 P, 1 ~~=v,K~~, CERTIFICATE F LIABILITY INSUR ANC~ ~i~i o s""Y' . o PRODUCER (925) 775-2000 FAX: {925) 775-2001 THIS CERTiFtCAT6 iS ISSUED AS A MATTER OP INPpRM14TipN CHI InBUrance Agency ONLY AND CONFER8 NO RIOHTB UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DpE$ NOT AMEND, EXTEND OR 70d West First Street ALTER THE COVERAGE AFFORDED BY THE POLICIES t3Et.OW. Antioch CA 945b9 INSURERS AFFORDING COVERAGE NAtC sl INBURED INSURER A:Lilaert Su lus InBUrSnC@ The Saaf;Fold ~tTark~ Inc. IN&uRER s: The Travelers Indemnit 2565A 1697 Rogers Avenue INSURER C: INSURER D: sdn '?ase CA 95112 INSURfiRE; THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED Tp THE INSURED NAMt:{I ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING A Y . REQUIREMENT, TERM OR GONDITIQN OF ANY CONTRACT OR OTHER DOGUMENT WITH RESPECT TO WtifCH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN , THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE 7ERM5, EXCLUSIONS AND CONDiTiON5 OF SUCH POLICIES . B INSR ADD'L T PE OF IN8U NC POLICY NUMBER POLICY EFFECTIVE OAT M b POLICY EXPIRATION TE IdMlD LIMITS GENERAL LIABILITY S a, DOO, OOD X COMMERCIAL GENERAL LIABILITY DAMAO 70 RENTED 50 000 PR MIS a «en , S A X CLAIMS MADE ~ OCCUR D~GL-BF-208831-028 4/1/2009 4/1/201,0 $ ~ MEOEIiP on eon xa .uol®d t 2 000 000 , , S GENE A AG REGATE 5 2, OOO, OOO GEN'L AGGREGATE LIMIT APPLIES PER: PR _1 OOO OOO X uCY - c AUTOMOBILE LIABILITY X ANYAVTO COMBINED SINGLE LIMIT (Ea acddenll S 1, 000, 000 ALL OWNED AUTOS HA-1690M96A.-09-8EL 3/16/2009 3/1 d/2010 SCMEOULEOAUTOS BODILY INJURY {Perperaonj >I MIRED AUTOS 80D1LY INJURY NDN-owNED Auras {Per acdRenQ s PaoPERTY ontuoE s (PeraoddenU GARAGGLIABILITY AU700NLY-EAACCIDEhtT E ANV AU70 07HEft THAN EA ACC J 1 AU70 ONLY: b E%CESSNMBRELLA LIABILITY PUBLIC ORKS occuR ~ CLAIMSMADE gDMINIS ATION a DEDUCTIBLE S WORKERSCOMPFNSATK)NAND A - OT EMPLOYERB' LUte1LTY ANY PROPRIGTOR/PARTNER/E%ECUTIVE fi, . EACIIgC pE T i OFFICERlMEMBER EXCLUDED? It yea, tleecnoe Under E.L. D ASE • A N{PL YE L PR YI 1 NS h low - OLICY IMR i OTHER DESCRIPTION QP OPERATIONB/LOCATfONSNEHlCL6E/EXCLU610NS AOD>;D 9Y ENDORSEMENTISPFCIAL PROYi810NS dt~ Conatruationr Inc. and Gsox®ss national Hank ase named as an additional insured par the attached form in regards eo general liability, +Exaept for ZO day notice oP aancellatian due to nos-p4Ym9nt O£ premium. EIS: Growers National Bank, Sid N 13143, 400 Sttst Caa~bell Ave., Campbell CA JME Canstruation, Ina. FO >3ax 1.363 Cupezi:ino, CA 9501.5 Z6 (2001108) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEPOAE THE EXPIRATION DATE THGREOF, THE ISSUING IN$URER WILL ENDEAVOR TO MAIL * 3O DAVS WRITTRN N4T(tE TO THE CERTIFlCATE HOLDER NAMED TO THE LEFT, BU7 FAILURE TO OD 80 SHALL 1MP08G NO OSLIGAT1gN OR LU181LITY OP ANY KING UPON THE AUTHORG'ED REPIIEBENTATIVE Stan Cdrist®n/TWRIST ®ACORD CORPORATION 9998 INSOZS (otoet,aea Pape t of Z ~ u i. t. ~vuy ~ ~ : ~4~~ No. a$25 P, 2 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the polscy(ies) must be endorsed. A statement on this Certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION 15 WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in Ileu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not consiifute a contract between the issuing Insurer(s), authorized representative or producer, and the certificate holder, nor does it affrrmatively pr negatively amend, extend or altar the coverage afforded by the policies listed tharoon, ACORD Zb {Z001t08) I NSC25 ro,oe,.nea Peed z cr s Jill, 1. LUUy I1:77HIVI ~. Carporidot,~ ?lcmber o(140cy tf` atawal Grove L~bcrt}~ Surplus Irrounwce f;nrForndon ENYIORSEIIIENT NO. No. 0825 P, 3 THL'~ EI~IDORSEMENT C„HA-NGES T~ POLICY. PLEASE READ IT CA`~REFULLY. Entjoi~sement &ffective Ante: 4 / 1 / 0 9 ppllCp loo,: DGL , S F ~ 2 p g S 31- 01$ Ilrsured: Th caffold Works, Inc. ~DDYTIONAL INSURED O'l~lV~RS, T~IaSSEES OR CONTRA,C~`OYtS ~- Xl'L~D PTRSON Off. ORGAIVIZATI, yN scyf=ouL~ or As required by written contract` (if no entry appears alcove, Information required to complete this endorsement will be spawn In the Declarations as appllcabie to this endorsement.) A. Section 11-Who is An insured Is amended to include ae an insured the parson or organization shown in the Schedule, but only with respect to liability arising out of your ongoing secretions performed for that insured. t3. With respect to the insurance afforded to these additional Insureds, the following exclusion is added: ~. ExCiuSions This insurance does net apply to "bodily injury" or "property damage" occurr9ng alter; (7) All work, irtoludin9 materials, parts or equlpmen# furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insureds) at the site of the covered operations has bean completed; ar (2) That pariion of "your work" out of which the Injury or damage arises has been put to its Intended use by any person or organizupon other than another contractor or subcontractor engaged In performing secretions far a prinelpel as a part of the same project. This endorsement does not change any other provlslan of the policy. GaL 10371 l03 page 1 of 1 C!ii'l0i"009 lE:'~3 Fki; CERTFi~LDER COPY STATE p,0. BOX 420$07, SAN FRANCISCO,CA 94142-p807 f„-OMPFNSATION INSURANC:! CERTIFICATE 4F WORKERS' COMPENSA710N INSURANCE ISSUe Dare: 07-io-20osa GROUP: 000671 PQLICY NUMBER: 0009425-~0o8 CERTIFICATE 10: 664 CERTIFICATE EXPIFiE$: 10-01-2009 1001-2008/10-01-2009 CITY OF CAMPBELL ATTN: SYED YAHIDI 723 UNIdN AVE CAMPBELL CA saB008-3108 NG JOB:GROYERS NATIONAL BANK 400 E. CAMPBELL AVE. CAMPBELL CA This is iv certify that we have issued a valid Workers' Compensation insurance policy in a form apprvvad by the California Insurance Commissioner to the employer named tSelow }ar the policy period Indicated. Th{s policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 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 altar the coverage afforded by the policy ligled herein Notwithstandln~ any requirement, term or condition of env contract or other document with respect to which this CeriiFiGate of rnsurance may 6e igaued or to which it may pertain, the insuranoa afforded by the policy desuibed herein is subject to all the terms, exclusions, and conditions, of such policy. THORIZEIJ REPRESENTA71 PRESIbENT EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: 51,000.000 PER OCCURRENCE. ENDORSEMENT #1800 - KENNETH C. NDLL PRES -EXCLUDED. ENDORSEMENT N1800 - DOYLE aRIMMETT VP - EXCLUDED. ENDORSEMENT #1600 - CINDI TUPOU SEC,TRES - EXCLUDED. ENDORSEMENT #2086 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-01-1882 IS ATTACHED TO AND FORMS A PART OF THIS. POLICY. ~~~ ENDORSEMENT #2670 ENTITLED YAIVER OF SUBROGATION EFFECTIVE 2008-07-10 I5 ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF CAMPBELL (~j ~ U 1 i (~ O 1 NG E+~~IVE® EMPLOYER d'UBLIC WORKS >DMINISTRATION THE SCAFlOLD YORKS. INC. NG ~ ~" ~~~ ~~~( A,/~ r' 1897 ROGERS AVE ti/ L/ - SAN .105E CA 96112 ~` (JFtJ,CS] i iREV.2-061 PRINTED 07-10-2008 Check a License or Home Improvemer` Calesperson (HIS) Registration -Contra*ors State License Board Page 1 of 1 ~c~rltr~~tt~rs c~~ ~~~ert~e ~0~ C,/~ontractor's License Detail - License # 267596 f DISCLAIMER: A license status check provides information taken from the CSLB license database. Before relying on this information, you should be aware of the following limitations. ~`~ CSLB complaint disclosure is restricted by law (B&P_7124.6). If this entity is subject to public complaint disclosure, a link for complaint disclosure will appear below. Click on the link or button to obtain complaint and/or legal action information. ~` Per t3fi~P 7J71.1 ; ,only construction related civil judgments reported to the CSLB are disclosed. >~ Arbitrations are not listed unless the contractor fails to comply with the terms of the arbitration. -%~ Due to workload, there may be relevant information that has not yet been entered onto the Board's license database. License Number: 267596 Extract Date: 07/10/2009 THE SCAFFOLD WORKS INC Business Information: 1697 ROGERS AVENUE SAN JOSE, CA 95112 Business Phone Number: (408) 436-8265 Entity: Corporation Issue Date: 02/16/1971 Expire Date: 08/31/2009 License Status: This license is current and active. All information below should be reviewed. CLASS DESCRIPTION Classifications: D39 SCAFFOLDING CONTRACTOR'S BOND This license filed Contractor's Bond number SCR6330712 in the amount of $12,500 with the bonding company AMERlCAN_CONTRACTORS INDEMNITY COMPANY. Effective Date: 03/02/2009 Bonding: Contra_ctor's_.BandIng History BOND OF QUALIFYING INI`lVIDUAL 1. The Responsible Managing Officer (RMO) KENNETH CALVIN NOLL certified that he/she owns 10 percent or more of the voting stock/equity of the corporation. A bond of qualifying individual is not required. Effective Date: 05/23/2001 This license has workers compensation insurance with the STftTE COMI~ENSAlION INSURANCE FUNt7 Policy Number: 571-0009425 Workers' Compensation: Effective Date: 10/01/1992 Expire Date: 10/01/2009 Workers'_ Com~sensation Hist_t~ry Conditions of_Use ~ Priva y Policy Copyright ©2009 State of California https://www2.cslb.ca.gov/OnlineServices/CheckLicense/LicenseDetail.asp 7/10/2009 Page 1 of 1 Joanne D' Ambrosia From: Edward Arango Sent: Thursday, January 27, 2011 10:27 AM To: Joanne D' Ambrosia Subject: RE: JME Construction Insurance -for Gaslighter No need. Just file the insurance received and we'll wait to receive input from the owner on the status of the project. From: Joanne D' Ambrosia Sent: Thursday, January 27, 2011 9:23 AM To: Edward Arango Subject: RE: JME Construction Insurance -for Gaslighter Ed -The insurance in the fiile is not for JME it is for Scaffold Works and if is all expired (in early 2010). Permit number it ENC2009-00082..Shall I get JME's insurance agent to supply missing itms and make corrections? Joanne From: Edward Arango Sent: Wednesday, January 26, 2011 2:09 PM To: Joanne D' Ambrosia Subject: RE: JME Construction Insurance -for Gaslighter Did the permit you found have insurance? Is so, was it expired? From: Joanne D' Ambrosia Sent: Wednesday, January 26, 2011 12:05 PM To: Edward Arango Subject: JME Construction Insurance -for Gaslighter The permit file I found was for scaffolding and canopy on sidewalk for 400 E. Campbell. The insurance was already reviewed by me in mid-July, 2009. This new insurance us written by another company and is not the same. Please advise. Joanne 1 /27/2011 Page 1 of 1 Joanne D' Ambrosia From: Joanne D' Ambrosia Sent: Wednesday, January 26, 2011 12:05 PM To: Edward Arango Subject: JME Construction Insurance -for Gaslighter The permit file I found was for scaffolding and canopy on sidewalk for 400 E. Campbell. The insurance was already reviewed by me in mid-July, 2009. This new insurance us written by another company and is not the same. Please advise. Joanne 1 /26/2011 INSURANCE REQUIREMENTS CHECKLIST Permit #~~IC2U~ ~? ~~~~~~ _ CIP Project # The following insurance is required of all contractors worming 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 ^ $1,000,000 general aggregate limit applying separately to the project, or $2,000,000 general aggr to limit. ^ Policy expiration date I '~ Automotive Liability: `f , "Any Auto" checked on certificate $1,000,000 per accident for bodily injury and property damage Policy expiration date ~~ / 1~- Workers' Compensation and Employer's Liability ~'\~~~-~ ^ Waiver of Subrogation clause $1,000,000 per accident for b dily injury or disease Policy expiration date L~~ ~ l l Course of Construction (if required in Special Provisions) ^ Completed value of the project ^ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement ,, ^ The City, the City of Campbell Redevelopment Agency, its officers, employees and d'~ ~ volunteers are named as additional insured. ^ The insurance coverage afforded to the Additional Insured is primary insurance. ^ Cancellation area of certificate edited to 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". ~ j l~ ^ Workers' Compensation Insurance Sheet Submitted ~ ~, ~~~~ L ^ For General Contractor - ~ ~~~ ^ For Developer or Owner ~ -~~ C'-~,~ ~ -~~~~~''~ \ ~~ Acceptabilit~of Insurer(s) ^ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. Insurance Certificate Reviewed Initials Date ^ Copy of Insurance Certificate placed in tickler file one month prior to expiration. .I:\FORMS\Tcmplates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev. 03/08) 5/2011 13:48 Remote ID Imprint ID ~ 2/3 ~~ ~' CERTIFICATE OF LIABILITY INSURANCE ~1T/19/2U1~Y' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATNELY OR NEGATNELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. TWIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATNE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les} must be endorsed. If SUBROGATION IS WANED, subJect to the terms and condklons of the policy, certain policies may require an endorsement. A statement on this certklcate does not confer rights to the certlilcate holder In lieu of such endorsement(s). PRODUCER 1-800-955-8700 NAME: Arthur J. Gallagher & Co. Arthur J. Gallagher & Co. Insurance Brokers WIONE (949) 349-9800 FAX (949) 349-9967 A1C No of California, Inc. 15 Enterprise, Ste 200 E-MAIL ADDRESS: PR D ER Aliso Viejo, CA 92656 Daniel Osornio INSURE S)AFFORDNGCOVERAGE NAICO INSURED INSURERA: FINANCIAL PACIFIC INS CO 31453 JME Construction Services, Inc. INSURERS: Box 1363 P O INSURERC: . . INSURER D Cupertino, CA 95015 INSURER E INSURERF: r+n~rctaer_ts CERTIFICATE Nt1MgER 19423216 REVISION NUMBER: vTHIS,15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY RECkU1REMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WffH 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUMBER MiDO F M C X LIMITS A GENERALLIABIUTY 180593K 12/01/1 12/01/11 EACH OCCURRENCE $ 1,000,000 X COMMERCULL GENERAL LIABILITY PRE ISES Ee ocwrranca $ 50 , 000 CLAIMS~IADE ~ OCCUR MED EXP (Any one person) $ 5, 000 PERSONAL & ADV INJURY $ 1, 000 , 000 OENERALAGGREGATE $ 2,000,000 GEN'LAGGREGATELIMITAPPLIESPER: PRDDUCTS-COMPIOPAGG $ 2,000,000 POLICY X PRO- LOC $ A AUT OMOBILEIJABIUTY 180593K 12/01/1 12 /O1/11 COMBINED SINGLELIMfT $ 1,000,000 (Ea actldeM) X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUT03 PROPERTY DAMAGE $ X HIRED AUTOS (Per accldeM) X NON-OWNED AUTOS $ A UMBRELIALJA6 X OCCUR 924021E 12/01/1 12/01/11 EACH OCCURRENCE $ 2,000,000 X EXCESSLIAB CLAIMS-MADE AGGREGATE $ 2,000,000 DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION WC STATU- OTH- TORY LIMITS R ANDEMPLOYERS'LIA&IJTY ANY PROPRIETORIPARTNERlEXECUTNE~ E.LEACHACCIDENT $ OFFICERMIEMBER EXCLUDED? (Mandatory In NH) N I A E.L. DISEASE - EA EMPLOYE $ If yes, descrbe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATION31 LOCATONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more apau is required) Re: 400 E. Campbell Ave., CA. f~C~TILIf+A TG LJnI neo CANCELLATION V Gr~iIrIVA1G 11vl.vvr~ --"'----'-'--- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Campbell THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Bill AUTHORIZED REPRESENTATIVE (`~ thanguy C~J 99SS-ZUV9 AGVKU I:VKYVKA1IVrv. All ngn[5 resarvea. ACORD 25 (2009109} The ACORD name and logo are registered marks of ACORD 19423216 1/19/2011 13:48 Rrgmote ID Imprint ID AGENCY CUSTOMER ID: LOC #: .d-c Ro'~ ADDITIONAL REMARKS SCHEDULE ~ 3/3 Page 1 of 1 AGENCY Arthur J. Gallagher & Co. Insurance Brokers of California, Inc. NAMED INSURED JM8 Construction Services, Inc. POLICY NUMBER p, 0. BOX 1363 A 95015 i CARRIER NAICCODE Cupert no, C EFFECTNE DATE: ADDITIONAL REMARK, THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: FORM TITLE: Additional Remarks ACORD 101 ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 1/19/2011 13:48 Remote ID Imprint ID Fax d 1I3 EBBX BPO City of Campbell TO Fax: 1-408-866-8361 Attn: Attn: Bill JMB Construction Services, Inc. FROM Phone: -- - Arthur J. Gallagher & Co. Insurance Brokers Agency: of California, Inc. Phone: 1-800-955-8700 S ub ~ ct:Delivery by CertificateaNow To whom this may concern: This insurance document was brought to you by CertificateaNow and Arthur J. Gallagher ~ Co. Insurance Brokers of California, Inc. in Aliso Viejo, CA. If you have guestione regarding the content of this document, please contact the Producer/Agent listed on the certificate of insurance. The data included 1n this notice and in the attached document is confidential to ConfirmNet and Arthur J. Gallagher & Co. Insurance Brokers of California, Inc. cc The data included in this notice and in the attached document is confidential to Ebix BPO and the party responsible for bringing you this information. Certificate Delivery by CertificatesNow - www.ConfirmNet.com - 877.869.8600 Legt's Credit Rating Center -Company Information for Financial Pacific Insurance Company Page 1 of 2 I~.atin~s c ~~1alysis ~c~nt~r Regional Centers: Asia Pacific ~ Canada J Europe, Middle East and Africa Nor7te ~ Abouf Us Contact Us (Sitentap Ratings & Analysis u Home » Best's Credit Ratinys + » Financial Strength Ratings » Issuer Credit Ratings » Uebt Ratings » Advanced Search „About Best's Credit Ratings n Get a Credit Rating + >, Best's Special Reports » Add Best's Credit Ratings Search To Your Site » BestMark for Secure-Rated Insurers » Contact an Analyst » Awards and Recognitions News & Research Products & Services Industry Information Corporate Support & Resources Conferences and Events ~ Financial Pacific Insurance Company ~ ennt this page "' '', - (a member of Mercer insurance_Grqup) For ratings and product access A.M. Best #: 000143 NAIC #: 31453 FEIN #: 680111081 Assigned to Rneneiai Sbwrplri Rating t.ogin I Sign-up companies Sgg7 y that have, in A o•Ifant our opinion, Find n Best's C'redrl Baling Address: P.O. Box 292220 an excellent ability to meet their --- Sacramento, CA 95829-2220 ongoing insurance obligations. Enter a Company Name ~ UNI I h O STl~TL:-S » Advanced Search Phone:916-630-5000 Fax. 916-630-3700 ~n9~.. Web: www.rinanciaipacific.com ,~~~~ Best's Ratincls Financial Strength Ratings vlcw f.>efinaions Issuer Credit Ratings view Uefinitiom L'iew Raring DeJinilions Rating: A " (Excellent) Long-Term: a " Select one,.. Affiliation Code: g (Group) Implication: Negative Financial Size Category: VIII ($100 Million to Action: Under Review 5250 Million) Date: December 02, 2010 Implication: Negative Action: Under Review Effective Date: December 02, 2010 ` Denotes Under Review Best's K~trngs Office: A M Best Company Senior Financial Analyst: Marc Liebowitz Assistant Vice President: Gerard J Altonji Reports and News Visit our NewsRoom for the latest news and .press releases for this company and its A.M. Best Group. AMB Credit Report-Insurance Professynal -includes Best's Financial Strength "`~~; Rating and rationale along with comprehensive analytical commentary, detailed business overview and key financial data Report Revision Ddte: 12!02/2010 (represents the latest significant change). Historical Reports are available in AMF3 Credit Repgrt -.Insurance Professional Archive. - Best's Executive Summary Reports (Financial Overview) -available in three ~~~ versions, these presentation style reports feature balance sheet, income statement.. key financial performance tests including profitability, liquidity and reserve analysis. Data Status: 2010 Best's Statement File - P/C, US Contains data compiled as of 1 /2412 0 1 1 (Quality Cross Checked). • Sngle_C.o.mpany -five years of financial data specifically on this company. • Comparison -side-by-side financial analysis of this company with a peer group of up to five other companies you select. • Composite -evaluate this company's financials against a peer group composite. Report displays both the average and total composite of your selected peer group. AMB Credit_Report -_ESUSiness_Professiot>al -provides three years of key I~'~ financial data presented with colorful charts and tables. Each report also features the latest Best's Ratings, Rating Rationale and an excerpt from our Business Review commentary. Data Status: Contains data compiled as of 1124/2011 (Quality cross Checked). Best's Key Rating Guide Presentation_Report -includes Best's Financial Strength ~:, ~ gating and financial data as provided m Best's Key Rating Guide products. Data Status: 2009 Financial Data (Quality cross Checked). Financial and Analytical Products Best s Key. Rating Guide - P?C, US ~ l.anada Best s Statement File - P!C US Best's Statement File -Global Rests Insurance Reports P/C,_US $ Canaria http://www3.ambest.com/ratings/FullProfile.asp?B1=0&AMBNum=143&A1tSrc=1 &A1tNum=&URATIN... 1 /26/201 1 best's Lredit Rating Center -Company Information for Financial Pacific Insurance Company Page 2 of 2 Best's State Line - PlC, US Best sJt~s~Uance Expense Exhibit qEE) - PrC, US Best's Scheciuie f= {F2einsurancc) - P%C, US Best s Schedule Q (Munlclpal Bonds) - US Best's Corporate Changes and. Rehrem_ents PG, US!GN F3est s Schedule P (loss Reserves) - P!C, US Best S Schedule U_(Corporate Bondsj - US Best's_Insurance Regorts Online P!C, US & Can<~da Best s Schedule [)A~Short 1 erm Investments) - I'1C & L/H, U$, Customer Service I f roducl Support I Member Center I Contact Info ~ Careers About A_M. Best Sde Map Pnvacy Policy Seourity Terrns of Use Legal & licensing Copyright O 20~ 1 A.M Best Company- Ina. A!1 R161-ITS RESERVED A M Best Worldwide Headquarters, Ambest Road. Uldwick, New Jersey. 08858, LLS.A http://www3.ambest.com/ratings/Fu1lProfile.asp?B1=0&AMBNum=143&A1tSrc=1 &A1tNum=&URATIN... 1 /26/2011 GENERAL PERMIT CONDITIONS 1. A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency call-out, overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. 3. Refund of the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. 5. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants and water valves. 6. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures, detours and street closures. This plan must be reviewed and approved prior to any lane closures. 7. The Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated 1990, available at Caltrans. Traffic control equipment shall include Type 11 flashing arrow signs if required. 8. Replace as directed by the City Engineer any damaged or removed improvements in accordance with City Standards and Specifications at the sole expense of the Permittee. 9. Sawcut for all PCC or AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements. ]0. Prior approval of inspector is required for any work done after normal working hours, on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 11. Adequate signing and barricading is required on the job site. Failure to provide such signing and barricading may result in the City's providing signing and barricades and charging the cost (including all labor and materials) against the cash deposit. 12. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 13. The Contractor or Permittee will have a supervisory representative available for contact on [he project at all times during construction. Contractor or Permittee shall provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4:00 p.m. 14. No storage of materials or equipment will be allowed near the edge of pavement, the traveled way, or within the shoulderline which would create a hazardous condition to the public. 15. This permit shall not be construed as authorization for excavation and grading on private property adjacent to the work or any other work for which a separate permit may be required, nor does it relieve the Permittee of any obligation to obtain any other permit required by law. 1G. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 17. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 18. Call back (call out) due to emergencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence. l9. Pursuant to Chapter 14.02 of the Camplbell Municipal Code, applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant s}~all adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. J 20. If the public interest requires a modification of, or a departure from, the plans and specifications, the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made for City-owned or maintained facilities. 21. Permittee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by City prior to distribution and include dates of work and a contact name and phone number. Applicant shall be responsible for ensuring that all those providing services under the applicant are aware of and understand all of the above conditions. Contractor ~Prin[ Name) D e D e ]\fotTtts\pwperm Rev. 11 /9/05