ENC2009-00083Print Form
CITY OF CAMPBELL ENCROACHMENT PERMIT Permit No EN ~- ~G cl - GGG ~ 3
DEPT. OF PUBLIC WORKS (for working within the public X-Ref. File
70 North First Street right-of-way) Application Date 7~ I G
Campbell, CA 95008 Issued ~ ~~ y ~G ~ Application Expiration Date
Ph. (408) 866-2150 APN 20 $ ~3..'~ ~,
Fx. (408) 376-0958 `7~ -~
Permit Expiration Date / ~ ~~
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 TractNo.: 10 I ~~~p~S I w.AY ~'I~Ip/~jELL7 C~ gSDp$
Utility Trench Location: 1 !-
B. Nature of Work: ~X'('}r-~10/~ W ~ N ~
O W iitt A S H ~o u~.r ~i_. W K1 S H
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 to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions
listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result
in job shutdown and/or forfeiture of Faithful Performance 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 Applicant: Su sT ~ (Now Telephone: ~D~_C0~8~ w-,..
Address: eZGSD i~~4G£!~ L.IJ SA u__ 3OSE~ CA 45 1..11
E-Mail Address: ~ 24-HOUR EMERGENCY PHONE NUMBER:
r9gru a Cg rFwrn- ~ C.orn 4 pg- Sql - DI69
Is this work being done by the property owners at their own residence? ~ YES ~s/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 da rmages arising out of the condition of any private improvements in the public right-of-way. oo~~
Accepted: J~ ~~ l~l/Q'~-0 ~ ~-I d/
(Applicant Permittee) (sign) Date
SMtAro6~4 MAt~fA6F~Vt~ d~ pICK rJo-cnna~J y ~a.~-~
(Contractor) (Print Name) Date
SPECIAL PROVISIONS:
1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may be
saecifically approved by the Inspector 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 the Engineer.
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. USATICKET 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
PERMIT APPLICATION FEE $ ~ ~"FS
PLAN CHECK DEPOSIT $
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $
CONSTRUCTION CASH DEPOSIT $
PLAN CHECK & INSPECTION FEE $ 2 7Q
APPROVED FOR ISSUANCE - -"- ~ `.. ~l
RECEIPT NO _
G ~~~
For City Engineer
Permit Expires 12 Months After Date of Issuance
GENERAL PERMIT CONDITIONS
I. 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 or 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. A 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 II 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 the nearest scoremark and shall be doweled to existing improvements.
10. 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 the 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.
16. 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 emeregencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per
occurrence.
19. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the municipal storm drain
system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff
Pollution Prevention Program.
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. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior
to distribution and include dates of work and a cnntact name and phone number.
Applicant shall be responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions.
~~~ ~~ ~T ~n~~ ~ 1 ~ ~ /o ~
Applicant Date:
Contractor (Print Name) Date:
J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf
Rev. 3/08
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PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT & TRAFFIC RECEIPT
Effective July 1, 2009 ~
TO: City Clerk PUBLIC WORKS FILE NO. ~~~ 2~(f ~ ' GUS-
PROPERTY ADDRESS ~ `J~ ~ ~ ~S ~c
Please collect & recei t for the followin monies:
ACCT. ITEM AMOUNT
LAND DEVELOPMENT
ncroac men erml p Ica ion ee
Non-Utilit Encroachment Permit $320.00
Minor Encroachment Permit <$to,ooo $145.00
Initial R-1 Permit $50.00
Subse uent R-1 Permits within Five Year Period $145.00
* 2203 Plan Check De osit 2% of En ineer's Estimate $500.00 min
4722 Gradin & Draina a Plan Review
Sin le Famil Lot $215.00
Site < 10,000 s.f. $640.00
Site ? 10,000 s.f. < Acre $860.00
Site >_ 1 Acre $1,280.00
Plan Check & Ins ection Fee Non-Utilit ~ v
**2203 En r. Est. >$250,000 Actual Cost + 20% min. $30,000 De osit
4722 En r. Est. <$250 000 13% of ENGR. EST.
2203 Emer enc Construction Cash De osit 4% of En r. Est $500 min/$10,000 max
2203 Faithful Performance Securit FPS 100% of ENGR. EST.
2203 Labor and Materials Securit 100% of ENGR. EST.
4721 Storm Drainage Area Fee Per Acre (R-1 $2,120.00)
(Multi-Res $2,385.00)
All Other $2,650.00
4722 Parcel Ma 4 Lots or Less $3 600.00 + $80/lot
4722 Final Tract Ma 5 or More Lots $4 400.00 + 108/lot
* 2203 Monumentation Securit 100% of ENGR. EST.
4920 Parkland Dedication Fee 75%/25% Due U on Cert. of Occu anc
4722 Lot Line Ad'ustment $960.00
4722 Vacation of Public Streets & Easements $2,250.00
4722 Certificate of Com liance $695.00
4722 Certificate of Correction $425.00
4722 A eal Filin Fee $110.00
4722 Nota Fee er si nature $11.00
4722 Assessment Segregation or Reapportionment
First Split ($770.00)
Each Additional Lot $205.00
511.7424
TRAFFIC
4728 Postage
Intersection Turn Counts Two-Hour Count $82.00
4728 Intersection Turn Counts a.m. or .m. eaks $160.00
4728 Traffic Flow Ma Dail Traffic Volumes $34.00
4728 Si nal Timin Information $72.00/Hr
4271 Truck Permits 16.00/ er tri
4728 No Parking Signs ($1/each or $25/100)
MISCELLANEOUS
Other (Please S eci
4722 Street Tree Plantin /Removal Permit $155.00 + $500 de osit
*Engineer's Estimate shall be as approved by the City Engineer.
TOTAL $
NAME OF APPLICANT , 1
S ^ ' PHONE ~ ~ 7 >"t
NAME OF PAYOR
,,rr~~ ~n
ADDRESS I''t Cu ~ L, - r ~ ZIP
**Actual Cost Plus 20% Overhead Non-Interest bearin de osit
FOR RECEIVED BY
CITY CLERK
ONLY 2 `~~~ / JUL 1 4 2009
Date Recei t # /
"For Plan Check and Cash Deposits, send yellow copy to Ft;
Date/ Initials
J'.\FORMS\TemplabaUtlminlevetWe\Recsipl Fwm Laid Devebpmml T,eH 09-10 (RSV. 08/09)
GITY OF GAMPRELL
kECVD RY: ANNEB 01000~18ii7
PAYdk: ENC d9-OOd83
TODAY'5 DATE: 07/14!09
kEGISTEk DATE: d7l14ld~ TIME: 16:41
DESGRIFTION AMGUNT
ENGk R 5URDIV FILING F $145.00
CUST II:: ENC 09-00083
ENGk ~ SURI~FV FILING F 'b~7G.GG
CUST ID:
TGTAL DUE: ~415.dd
TENDERED: ~4i5.00
GiiANGE: B.OG
~~
' C~ P wl~~`, /±, L~ ~ • ~ ~~ ~ ~ +_ Page 1 of 1
e
.~.-~~:~~~~,~.P nr,, l
Robby/Jose: ~~ w~C~~ ~ ~~
Recently some vegetation was removed from the wall of the building of the subject property and was illegally dumped
over the fence between the creek and the trail.
The City will not issue the window washing permit until the debris is removed by the property owner.
Syed ~ ~ ~~ ~~
Public Works Inspector
From: Robby Garcia [mailto:rgarcia@crystalcleancompanies.com]
Sent: Wednesday, June 24, 2009 3:01 PM
To: Syed Wahid i
Cc: Jose Arevalo; Gabriel Bermudez; Emilie Gonzalo
Subject: 901 CAMPISI WAY CAMPBELL
Hi Syed.
I am re-sending the insurance and drawing requirements to get our permit.
We would really appreciate if you can expedite the process as our client is anxious to start the work. Thank you.
I will be out of the office tomorrow June 25 and will be back on June 30. Please call Jose Arevalo at 408-591-0711
and let him know if the insurance and everything else is ok so he can go to your office to submit the application.
Thank you.
Robby Garcia
Just Windows
408-229-6080
From: Syed Wahidi [mailto:syedw@cityofcampbell.com]
Sent: Wednesday, June 24, 2009 2:54 PM
To: Robby Garcia
Subject: test
*** eSafe 6 scanned this email for malicious content ***
*** IMPORTANT: Do not open attachments from unrecognized senders ***
6/26/2009
Page 1 of 2
Syed Wahidi
From: Bob Kass
Sent: Friday, June 19, 2009 4:17 PM
To: 'RLinquist@valleywater.org'
Cc: Alberto Oxonian; Larry laquinto; 'llee@valleywater.org'
Subject: Possible illegal dumping in Los Gatos creek
Follow Up Flag: Follow up
Flag Status: Red
Hi Rick--
Not sure if this is still your area of responsibility, but a Los Gatos creektrail user notified the City
today of what appears to be illegal dumping of vegetation into the Los Gatos Creek channel.
The location is at the rear of property located at 901 Campisi Ave, which backs up to the Los Gatos
Creek. As you can see in the attached photograph, vegetation was recently removed from the
building wall. It appears the vegetation was not disposed of properly, but was merely dumped
over the fence separating the creektrail from the Los Gatos Creek. The decaying vegetation is
more extensive than shown in the pictures and runs for a number of feet behind the fence.
AI Oxonian from my office will also be following up on this issue as necessary.
Bob Kass
Public Works Director
408.866.2150
6/26/2009
Page 2 of 2
6/26/2009
Syed Wahidi
From: Bob Kass
Sent: Friday, June 26, 2009 2:13 PM
To: Larry laquinto
Cc: Syed Wahidi
Subject: FW: New notes have been added to case #14764
Larry
note reference to City Worker
-----Original Message-----
From: gmalekos@valleywater.org [mailto:gmalekosC~valleywater.org]
Sent: Fri 6/26/2009 2:03 PM
To: dhonda@valleywater.org; rlinquistc~valleywater.org; duriarteC~valleywater.org;
gmalekosc~valleywater.org; mpilkington@valleywater.org; Bob Kass
Subject: New notes have been added to case #14764
On 6/23/09 the Santa Clara Valley Water District's Code Enforcement Officer George Malekos
inspected the site behind 901 Campisi Way, Campbell. Malekos took photos confirming that
someone removed vegetation from the back building wall of 901 Campisi Way & dumped the
vegetation debris over the Los Gatos Creek Trail fence onto the District's property. On
6/26/09 Malekos called the Saratoga Management Co. Property Manager Dick Norman
(408-249-8105). Mr. Norman told Malekos that he was aware of the debris & that while his
crew was cutting the debris from their wall a unknown City Worker (driving a pick-up) told
them that they could just leave it over the fence. Malekos informed Mr. Norman that the
debris is on District property and to please remove the debris within 30 days or a
violation letter will be sent. Mr. Norman agreed to remove the debris, but didn't give
any dates for completion. Malekos will give a follow-up call within a week.
Page 1 of 2
Joanne D' Ambrosia
From: Joy Francois
Sent: Thursday, June 25, 2009 2:36 PM
To: Joanne D' Ambrosia
Subject: FW: Trail Closure
Attachments: Possible illegal dumping in Los Gatos creek
From: Bob Kass
Sent: Thursday, June 25, 2009 2:33 PM
To: Syed Wahidi; Matthew Jue
Cc: Larry Iaquinto; Alan Hom; Joy Francois
Subject: RE: Trail Closure
DO NOT ISSUE THIS PERMIT.
Please see attached email (with photos) documenting illegal disposal of vegetation removed from this building.
The property owners should be required to remove all debris before being allowed to close the trail for window
cleaning. They should also be required to comply with all Non-point source BMPs with the window cleaning.
From: Syed Wahidi
Sent: Thursday, June 25, 2009 8:40 AM
To: Matthew Jue
Cc: Bob Kass; Larry Iaquinto; Alan Hom
Subject: RE: Trail Closure
Thanks Mathew,
I will make sure that they put additional signs.
Bob/Larry,
FYI--Once the insurance is OK, I will issue the permit for this one day job of window washing along creek trail where they will
close one lane.
Syed
From: Matthew Jue
Sent: Thursday, June 25, 2009 8:29 AM
To: Syed Wahidi
Subject: RE: Trail Closure
Syed,
With the speed of bikes on the trail, I don't think it will be safe for two directions of pedestrians and bikes to share just six feet (?)
of trail. There should be signs with messages like "Road Word Ahead", "Lane Closed Ahead", and "Walk Bikes" in both
directions.
6/25/2009
Page 2 of 2
From: Syed Wahidi
Sent: Thursday, June 25, 2009 7:40 AM
To: Matthew Jue
Subject: Trail Closure
Mathew,
Window washing company has submitted the attached sketch for the trail lane closure behind 901 Campisi. It's a one day job.
One lane will be closed and the open lane will be used as two way lane.
Please let me know if they need to add more signs in addition to advance warning signs.
Syed
__ __ _ __
From: Robby Garcia [mailto:rgarcia@crystalcleancompanies.com]
Sent: Wednesday, June 24, 2009 3:01 PM
To: Syed Wahidi
Cc: Jose Arevalo; Gabriel Bermudez; Emilie Gonzalo
Subject: 901 CAMPISI WAY CAMPBELL
Hi Syed.
I am re-sending the insurance and drawing requirements to get our permit.
We would really appreciate if you can expedite the process as our client is anxious to start the work. Thank you.
I will be out of the office tomorrow June 25 and will be back on June 30. Please call Jose Arevalo at 408-591-0711 and let him
know if the insurance and everything else is ok so he can go to your office to submit the application.
Thank you.
Robby Garcia
Just Windows
408-229-6080
From: Syed Wahidi [mailto:syedw@cityofcampbell.com]
Sent: Wednesday, June 24, 2009 2:54 PM
To: Robby Garcia
Subject: test
*** eSafe 6 scanned this email for malicious content ***
*** IMPORTANT: Do not open attachments from unrecognized senders ***
6/25/2009
Page 1 of 1
Syed Wahidi
From: Robby Garcia [rgarcia@crystalcleancompanies.com]
Sent: Wednesday, June 24, 2009 3:01 PM
To: Syed Wahidi
Cc: Jose Arevalo; Gabriel Bermudez; Emilie Gonzalo
Subject: 901 CAMPISI WAY CAMPBELL
Attachments: SKMBT_C35109062217470.pdf; 96b417447444.pdf
Hi Syed.
I am re-sending the insurance and drawing requirements to get our permit.
We would really appreciate if you can expedite the process as our client is anxious to start the work. Thank you.
I will be out of the office tomorrow June 25 and will be back on June 30. Please call Jose Arevalo at 408-591-
0711 and let him know if the insurance and everything else is ok so he can go to your office to submit the
application.
Thank you.
Robby Garcia
Just Windows
408-229-6080
From: Syed Wahidi [mailto:syedw@cityofcampbell.com]
Sent: Wednesday, June 24, 2009 2:54 PM
To: Robby Garcia
Subject: test
*** eSafe 6 scanned this email for malicious content ***
*** IMPORTANT: Do not open attachments from unrecognized senders ***
6/25/2009
CITY OF CAMPBELL
PU .IC WORKS DEPARTME T
70 NORTH FIRST STREET
CAMPBELL, CA 95008
FACSIMILE/EMAIL TRANSMITTAL SHEET
TO: FROM:
Archway/Valley General Insurance Joanne D'Ambrosia, Office Specialist
EMAIL DATE:
6/25/09
FAX NUMBER: TOTAL PAGES INCLUDING COVER:
1-408441-1982 10
PHONE NUMBER: SENDER'S EMAIL:
1-408-441-2000 j oanned@cityofcampbell.com
RE: YOUR REFERENCE NUMBER:
Certificate of Insurance
^URGENT(]FOR REVIEWI]PLEASE COMMENT X PLEASE REPLY ^ PLEASE RECYCLE
NOTES/COMMENTS:
Re: Insured: Crystal Clean (Just Windows)
Permit/Project #: Permit # Not Yet Assigned
Worksite: Los Gatos Creek Trail
We have received the Certificate of Insurance for the work your insured will be doing in the City of
Campbell right-of--way. In order to meet our minimum insurance requirements, we must ask that the
following changes or additions be made to the certificate or information provided to the City.
1. Proof of Workers Compensation coverage. A waiver of subrogation clause is required in connection
with the Workers' Compensation
2. The required endorsements to General Liability and Automobile Liability policies are to show:
- Additional Insured Endorsement that states The City, the City of Campbell Redevelopment
Agency, its officers, employees and volunteers are to be named as additional insured.
- The insurance coverage afforded to the Additional Insured is primary insurance.
- The cancellation area of the certificate is to be 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".
A copy of our insurance requirements and your insurance certificate follow for your reference. You
may forward the requested items to us by fax or email.
cc: Syed Wahidi
ACORD CERTIFICATE OF LIABILITY INSURANCE OPID HC DATE (MM/DD/YYYY)
CRYST-2 06 22 09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Archway/Valley General Ins . HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
1731 Technology Drive #250 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
San Jose CA 95110
Phone: 408-441-2000 Fax:408-441-19.82 INSURERS AFFORDING COVERAGE NAIC #
INSURED ~ - -- -
INSURER A: Travelers eroparty Casualty
Crystal Clean InC. ; Cry Stal INSURER B:
Parent Inc.;DBA: Just FTindows
Crystal Clean Janitorial Inc. INSURER C:
2680 Pacer Lane INSURER D:
San Jose CA 95111
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 MAYBE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NSR TYPE OF INSURANCE POLICY NUMBER PO
DATE MM/DDlYY DATE MMIDDIYY
LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1 , 000 ~ Q Q 0
A X COMMERCIAL GENERAL LIABILITY 660696X2691 12/01/08 12/01/09 PREMISES (Eaoccurence $ 300 000
CLAIMS MADE ~ OCCUR M
ED EXP (Any one person) $ 5 , 0 0 0
-.-- _.- PERSONAL 8 ADV INJURY $ 1 , 000 , 000
GENERAL AGGREGATE $ 2
QQQ
000
GEN'LAGGREGATELIMITAPPLIESPER:
PRO PRODUCTS-COMP/OPAGG ~
,
S2,000,OOO
X POLICY
JECT LOC
AUT OMOBILE LIABILITY
A
X
ANY AUTO
810-2662A871
12/0],/0$
12/01/09 COMBINED SINGLE LIMIT
(Ea accident) $ 1 000 000
r r
ALL OWNED AUTOS --
SCHEDULED AUTOS BODILY INJURY
(Per parson) $
HIRED AUTOS
NON-OWNED AU705 BODILY INJURY
(Per accldaM) $
-
X Comp $1,000
X
COl1 ~` 1, 000 PROPERTY DAMAGE
(Per accidenq
$
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO
OTHER THAN EA ACC
$
AUTO ONLY: AGG $
EXCESS/UMBRELLALZABILITY EACH OCCURRENCE $ 1, O OO , OOO
A X OCCUR ~ CLAIMSMADE CUP4442Y149 12/01/0$ 12/01/09 AGGREGATE $ 1 000,000
_---
DEDUCTIBLE
X RETENTION $ l O OOO
$
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY TORY LIMITS ER _
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDE09
If yes, describe under E.L. DISEASE - EA EMPLOYEE S
SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $
OTHER
A Property 660696X2691 12/01/08 12/01/09 BPP $55,000
DESCRIPTION OFOPERATIONS /LOCATIONS /VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Limit $5 000
10 day NOC for non-payment of premium.
rFRTIGICeT•GUnI neo __-.___ _ ____ _
CITYCAM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3 O DAYS WRITTEN
City of Campbell NOTICE 70 THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO 50 SHALL
70 North First Street IMPOSE Na OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Campbell CA 95008 REPRESENTATIVES.
AUTHORIZ EPRESENTAT
ACnRr1 75 NADi/f1A1
~+ v ACURU CORPORATION 1988
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.
rsnnvne-
CERTHOLDER COPY
STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807
COMPENSATION
iNSIJRANCE
FUND CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: OB-22-2009 GROUP:
POLICY NUMBER: 1743518-2008
CERTIFICATE ID: 241
CERTIFICATE EXPIRES: 07-01-2009
07-01-2008/07-01-2009
CITY OF CAMPBELL DEPT OF PUBLIC WORKS NG
70 N 1ST ST
CAMPBELL CA 85008-1458
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 that will expire or did
expire as indicated above.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy 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 to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
THORIZED REPRESENTATI
~~
PRESIDENT
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT #1800 - RICHARD ROGERS CE0,5ECRETARY - EXCLUDED.
ENDORSEMENT #1600 - THOMAS PUA PRES,TRES - EXCLUDED.
.~~
ENDORSEMENT #2066 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 07-01-2005 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
CRYSTAL CLEAN JANITORIAL, INC
2680 PACER LN
SAN JOSE CA 96111
NG
[614,NG]
NG
(REV.2-06) PRINTED OB-22-2009