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ENC2009-00085
Joy Francois Executive Assistant Department of Public Works City of Campbell 70 North First Street Campbell, CA 95008 Phone: (408) 866-2776 Fax: (408) 376-0958 E-Mail: joyf@cityofcampbell.com Fax To: Jorge Firm: West Valley Sanitation District Date: 7/20/09 Fax: 364 1821 Re: Encroachment Permit for 1930 S. Bascom From: Joy Francois Pages (including cover sheet): 3 If you do not receive all pages, please call. ^ Urgent ^ For Review ^ Please Comment ^ Please Reply ^ Please Recycle Comments: Attached is the permit for 1930 S Bascom Ave. Joy ~ ~ t, J:\FORMS\TemplatesWdministrative\Fax Form -Engineering -Joy PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT & MISCELLANEOUS RECEIPT Effective July 1, 2009 TO: City Clerk q ~~QC, PUBLIC WORKS FILE NO. ?~/ -(JG!/U PROPERTY ADDRESS D S . Please collect & recei t for the followin monies: ".ACCT. ITEM AMOUNT ENCROA CHMENT PERMlT 4722 Utility Encroachment Permit Application Fee Utilit Arterial/Collector Street $600.00 Residential Street/Other Areas $335.00 4722 Plan Check & Inspection Fee Utilit < $100,000 * Minimum Charge Per Location ($270.00) 2~~. Conduits/Pipelines up to 500 Feet ($2.40/ft) Above 500 Linear Feet ($1.45/ft) ManholesNaults/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. I~;~L~~ M ~/ ,/~ NAME OF APPLICANT Ir ~J'~'1~" \ 1' `I ~ 1- ~ ~ 1 TOTAL prU $ S ~~ NAME OF PAYOR ~// Mir ~-i PHONE ~- 2Z ADDRESS 'L e ~~ ! 'f't V ZIP **Actual Cost Plus 20% Overhead Non-Interest bearin de osit FOR RECEIVED BY CITY CLERK ONLY Date ~ Recei t # J'.\FORMS\Templalesl4tlminislralivelReceipl Form Utility Envoachmenl 8 Mix 09-10 Rev 08/09 CITY OF CAMPBELL DEPT. OF PUBL:` WORKS 70 North First St. Campbell, CA 95008 (408)866-2150 Fax (408) 376-0958 F' -'OACHMENT PERMIT (f~ orking within the public right-of-way) ~q Issued ~' ~~~" ~ Permit Expiration Date ~ ' ~ 0 Perm;.. ^'o ~~~ ' ~~ X-Rt le Application Date l ~~~ --~/ Application Expiration Date APN 2~ '17-0°)5 APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six (G) months if the permit is not issuegd. Application Feeds noCn-refundable.) A. Work address or tract # ' / ~ ~ k~/~~'~~ ~'~ Utility trench locatioCns Gn~_,~ er.~~C • _ 1~ 'A ~ B. Nature of work J~~ 1.0~\hwl 1~ ~ ~fl~ ""' C. Attach four (4) copies of an engineered plan showing the location and extent of [he work, and four (4j 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 Ciry 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 forieiturc 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 muss notify the Public Works Department at least two days before starting work. Notice must be given [o Public Works at least 24 hours before restarting any work. (~; a /~ Name of Applicant ~ ~~ ~ Telephone ~ UZ" ~ Z J V (print name) Address I'1S~ S 24-HOUR EMERGENCY TELEPHONE NO. ~ 2"'~-9U E-Mail Address v Is this work being done by the property owners at their own residence? Yes _~No The ApplicanUPermittee 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 ApplicanUPermittee 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. Accepted ~ . ~'~'L~- T!~'~ ~i2~"'!^ 7 ~ ~7 - ~ S (Applicant Permittee) (sign) Date //e ~~ ~dO~ rQ Ca+~ ~"~ Contractor (Print Name) ~~ Date SPECIAL PROVISIONS _1. Street shall not be open cut for underground installations. Minimum cuts >~ be allowed for connections or exploration holes. Such cuts >~ be specifically aayroved by the Inspector prior to cutting. 2. Pavement maybe 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 T[CKET 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 PERMIT APPLICATION FEE PLAN CHECK DEPOSIT SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MA CONSTRUCTION CASH DEPOSIT PLAN CHECK & INSPECTION FEE APPROVED FOR ISSUAN AMOUNT RECEIPT N0. ~~ 21 417 ,S,,o~ '-,~'V l Permit Expires 12 Months After Date of Issuance Date i ~, ~ { ~~W~`~ tti'l \\\\\\ ~~ L 1----- 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 [o the Permittee. 5. Maintain safe pedestrian and vehiculaz 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 al] 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 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 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 barticading 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 constmction. 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 no[ 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. 1 G. 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 a[ 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-awned 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. Applicant ,/ /~ Date ~j Contractor (Print Name) Date J\forms\pwperm Rev. 11 /9/05 '-v m w 0 '-n ro w 3 m 0 x 0 ^. m 0 O O 'b a J O O O y r Cyy~'7 r~ a z z n v sri 0 Q ~ b ~ ~. 'b N N ~ O O ~_ O O d ~ ~ ~ O O ~-. O~ O~ ~W o ~o W ~, ~~ ~W ~~ N~ 00 Nz~ m v .~ o~~~ x ~ w ~o' ~ ~; b n '~ ~. ~ ~, 0 0~ N O~ O O .~ A O O O O y N a~ ~1 O O O 'p _d O O ~ J J d y J J A N N "0 O O v ~ ~ a C'~ C') c~ ~ ~ r. G1 G7 ~ ti7 ti7 N_ N_ ~ ~ ~ n ~ _~ ~ J J M z 0 0 ,~ a A a d C 0 0 ,,., O O y 0 V n' n m r 'V ~ ~ .. ~ z n x N ^'• O ~ O .~ O ~ ~ "' o 7~ 1--~1 -~.. DEPARTMENT UTILITY ENCROACHMENT & MISCELLANEOUS RECEIPT PUBLIC WORKS Effective July 1, 2009 TO: City Clerk ~,~y~q /'~ ' PUBLIC WORKS FILE NO. G~ PROPERTY ADDRESS ~ S ~ ~^~'~H ~- Please collect & recei t for the followin monies: AMC?UNT - ACCT ITEi41 NT"~EF~CVLIT M - E >~NwRARCH 4722 Utility Encroachment Permit Application Fee ~ Utili Arterial/Collector Street $600.00 ---- ----- ~' Residential Street/Other Areas $335.00 ----- -- Plan Check & Ins ection Fee 4722 Uttlit < $100 000 * ~~ Mmimum Charge Per Location ($270.00) -- ConduitslPipelines up to 500 Feet ($2 40/ft) ----- ------ Above 500 Linear Feet ($1.45/ft) -------- -- ManholesNaults/Etc ($135.OOlea) -------- ----- Pole Set/Removal ($135.OO/ea) - - - Street Tree Plantin !Removal $500 de osit $155.00 --- -- --- ** 2203 Utili > $100 000 * Actual Cost + 20% ** --.--___.___--. _-_ 4760 Stora a Container Permit $135.00 ------ - ------- 4760 Pro'ect Plans & S ecifications Pro'ect No. ---- -------- 4760 Standard Specifications & Details ($1/Pq $15 5016k ----------------- 4760 Co ies of En ineerin Ma s & ans Aerial Plot 24" x 36" $57.00 --------- Aerial Print 8 112" 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 $loolcalendar oa ------ - 4722 Work Without Permits 4 Times A licable Fee _. _T~_ MISCELLANEOUS 511.7424 Posta e Other Please S eci *Engineer's Estimate shall be as approved by the City Engineer. Q~'} TOTAL $ " `~' ~ --- ~~r"~" " ` M1~ ~ ~ ~ - -------- f NAME OF APPLICANT NE ~~ Z Z ~1~ ~" 1 PHO ----- NAME OF PAYOR ,Z , J . ~ t/ ZIP -------------- c.i~ ADDRESS **Actual Cost Plus 20% Overhead Non-Interest bearin de osi ----- FOR RECEIVED BY - - CITYCLERK '~ ~ Reset t # Date ONLY --- J'.(FORMS\TempialeeWdminielretrvetROCeipt Form Uldlly E~cr°achmenl B MVeC °8-t° ReV °8!°° CITY OF LAN°RELL kECb'I+ Ar': ANNER FAYDk: BAkkY ~ilkr;IN DID002fS51i TOI,AY'S LATE: Oi:17i'0'~' kEGISTEk i+ATE: D7,~f?;G9 TIME; fi:~~ I,ESCkIFTION AhfDUN7 ENGk ~4 SI1I+I+I4' FILING F CUS7 II,: UTILITY AkTEkIALiCDLLEQ~6O0.DO ENGk R SURDI4' FILING F ~2rD.00 CUST IU: UTILITY ~fININUt~ CHAkGE TOTAL I+IJE: --------~OiU.OQ TENI+EFtEI+; X870.00 CFlANGE: ~ . OO ~ ~:~tiR~® DATE (MM/DDIYYYY) f. ~ CERTIFICATE OF LIABILITY INSURANCE OP ID CE ~ ~ BLACK03 05 05 10 PRODUCER THIS CER I ICA EIS ISSUED AS A MATTER O IN RMATIO ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Leavitt Pacific Ins . Brokers HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 695 Campbell Technology Pkwy ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Campbell CA 95008 Phone: 408-626-6100 Fax: 408-558-1600 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Interstate Fire & Casualt 22829 INSURER e: Allied Insurance Blackwell Genl Engr Inc INSURER C 1759 Junction Ave. S J CA 95112 INSURER D: an ose INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER OL EF ECTI DATE rMMlDDlVVVV LI V E PIRA I DATE rMPAlOD/YYYY LI!AITS GENERAL LIABILITY EACH OCCURRENCE $ 1 , 000 , 000 A X X COMMERCIAL GENERAL LIABILITY LIC1000619 05/04/10 05/04/11 PREMISES (Ea occurence) $ 100,000 CLAIMS MADE X~ OCCUR MED EXP (Any one person) $ X Owner/font Prot . PERSONAL & ADV INJURY $ 1 , 000 , 000 X Per Project Aggre GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 2 , 000 , O OO POLICY X JECT LOC Ben. 1,000,000 AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1 000 B X __ ANY AUTO ACP7803447084 06/01/10 06/01/11 (Ea accident) , , ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS - (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) r y D C t PROPERTY DAMAGE G (Per accident) $ GAR AGE LIABILITY ~ ~ ~ AUTO ONLY - EA ACCIDENT $ ANY AUTO ~~~ ~ OTHER THAN EA ACC $ W FtKS AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY ~,Nt~ EACH OCCURRENCE $ OCCUR ~ CLAIMS MADE ~ AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION - AND EMPLDYERS' LIAi31LITY ~ I T ORY LIMITS 1_ER YIN ANY PROPRIETOR/PARTNER/EXECUTIV~ E.L. EACH ACCIDENT $ OFFIGERIMEMBER EXCLUDED? (Mandatory In NH) E.L. DISEASE - EA EMPLOYE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $ OTHER B Rented/Leased 06/01/10 06/01/11 $10,000 E i ment DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE:09-10 Bascom Dental A11 work in public right of way ` ~ ~(~(~,. *10 day notice of cancellation for non payment of premium or non reporting N - 1 ~ ~~/ of payroll (City of Campbell, City of Campbell Redevelopment Agency it's ~ ~ officers, officials, employees and volunteers are named as additional insureds per CG2033 10/O1;CG2037 10/O1; ICB8001 04/05 attached) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITYO-4 DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL City of Campbell IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR Department o£ Public Works t St t 70 th Fi REPRESENTATIVES. rs ree Nor Campbell CA 95008 AUTHORIZED RE SENTATIVE ACORD 25 (2009/01) ~ +Fp988~009 ACQRD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ISO I Commercial General Liability Forms 110/01/01 POLICY NUMBER: LIC1000619 COMMERCIAL GENERAL LIABILITY CG 20 37 10 01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: See Section II Below Location And Description of Completed Operations: RE: 09-10 Bascom Dental dditional Premium: N/A (If no entry appears above, information required to complete this endorsement will 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". CG 20 37 10 01 © ISO Properties, Inc., 2000 ©ISO Prnnerties, Inc. Blackwell General Engineering, Inc. LIC1000619 AMENDMENT OF OTHER INSURANCE CONDITION -PRIMARY INSURANCE FOR AUTOMATIC STATUS ADDITIONAL INSURED THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART If required under a written "insured contract" with you, paragraph a. Primary Insurance in Section IV- COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance is amended by adding the following paragraph: Not withstanding the foregoing, the insurance afforded to any person or organization who has been added to this policy by an Automatic Status Additional Insured Endorsement is primary and non- contributory insurance, but only as respects "bodily injury" or "property damage" liability arising out of "your work" performed after the effective date of this policy under a written contract between you and such person or organization that requires you to maintain primary and non-contributory insurance and to include such person or organization as additional insured thereunder. All other terms and conditions of this policy remain unchanged. I CB-8001 04-05 ISO ~ Commercial General Liability Forms ~ 10/01/01 Policy No. LIC1000619 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CG 20 33 10 01 ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II -Who Is An Insured is amended to include as an insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability arising out of your ongoing operations performed for that insured. A person's or organization's status as an insured under this endorsement ends when your operations for that insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: 2. Exclusions This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and (2) Supervisory, inspection; architectural or engineering activities. b. "Bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment 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 been completed; or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20331001 © ISO Properties, Inc., 2000 COMMERCIAL GENERAL LIABILITY ©ISO Properties, Inc. 0x,''17!2009 11:32 4083641'" WVSD PAGE 01101 ... _ ~~Y..r.::' ni'c' .r' 1 ~,';,i Y ~'~1~~' ~r .., „~ .Y .. ~atgdl;k7P~ I wi~1: ~, 'i` ,x L" _ ' /~ iv.`•.ti .,•,~. .. xh~,'-..' ,r v` .may - • . sEVUeRCON~rynoN ~~~~ DISTRICI` WEST WALLEY SANtTATiON ~RMrr NutSns~r- ~, SANTA CLARA COUNTY.... e ~ Q~3 8Y ~~ - 1 QO,E_ Sunnyoaks Ave.. Campbell, CA 95008 -- - Issue pat ~ (4081378-2407 ~f.~noNy ~- ~r'~.,.~etC ~ Connection $Z3.F~~~,7~ ~')~n~nrr. c~4VER COIIIN~ Oly Feet of. vPropert A.P.N. ' Sewer Location: Bk. P9•-- SENioe Advance ~ ~2 ~`~~-`~~ lime feet from Main Sealer Tract Lot processing ~' ~a~ o `cc' and feet deep: - Proj. -- Assm# { ~ ~ Capacity ~ 1 3' ~~~~ Connection to Main Sewe - - '~~~~ ~ • t cam from M W F t ~~ " A,~ddress: " ' _, -- . ee ups "~ ' b P T ~ ' t l~.f t.~G.. C'~>; ,~. . ipe Ype U/S M. . . Jurisdiction ~- ~'~ M ~~" ' ~'~'~ -- ... BACKFLOW pR01~f;T10N: BUILDITI 1~ypE: ~Z.c~.~ss~ ~i~i'Z. ,,..Field Check Required ~, Single Family ~ TOTAL - Call District for fowndation survey . Disposition: <~ - _____^Condominium/Tovvn Houses GO Zone RL SJ •~ ;'`,~::-~ evice:Requ.ired; Yes ~ ~' ~ ` D Multiple Dwelling . •~ ~~~-~- ~.JA~L~~~ r~ `! ' Number of Unit4 - Ty.pe Commercial ~STRUCTlONS: ' r ~, "' _.,.~Industrial ~- ~"`'~~~~~~ Street encroachment permit required Nom ~ ,; Other lnformation•~`"' ~'~ `~ Permit invalid .if not oonnectod within 1.2 months,of issue. ~ - ' ~,'r tea:' ~~r~t>~ y' ~~-'~'' "'~'`' ` pa not connect until main sewer is accepted by. District. Change in Status:~'~'f'~ (Z." ~4"`' ~ Ohtain a building.ar plumbing permitfrorn the jurisdiction listed above. ^~ ., ~~ ,, ~ c, ~ ~$ ~ L1 1 it u~~' r~ ~. - UVlil7'E -PERMIT. (' PINK - DISTfiIGT . 7 YELLOW. ` ...~, IS>71CTlON:BUlLDING [N$PECTOR'S COPY .% CARD -._DI.STRI.C7 .Y.W.ri~awmr.,wi~~.. ~ _ .._-..,r;,,,v.,,.w.w.~L-rtill.ywir...ar:~~.xrr:+t'.~M .ur6-'...._~.. ` ~~.e'sri ~-2 'TA . REMARKS: BAGK~LUW DA 1) Previous determination made:-... ~_ 2) Field check required;.-.,, inches 3) Main sewer size: ft from 4) Building Sewer is.^~. upstream MH(riser. ft 5) Elevation upstream MH/riser: _.. 6) Ground elevation at edge of casement qr property ft line' ~~ 7} Difference in elevation between na, 6 above and elevation o~ lowest floor with plumbing:, $) Elevation of lowest floor with plumbing: ft 9) Difference in elevation between {owest floor with plumbing and upstream MH(riser: f't 10) if MH(Riser is higherthan flaorelevation a backflow protective device is required. 17) Minimum IH) from table required for overflow device 12) Available location for overflow device: 18) Minimum !-i av2ifabie @ device locations -t 14j "Cype ofi backflaw protective device required: 15) betermined by ~~ Uate.~ y 1B) Notice to Permittee CERTIFICATE OF LIABILITY INSURANCE OP ID CE ,acoRQ DATE (MM/DD/YYYY) . BLACK03 07/17/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIO ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Leavitt Pacific Ins. Brokers HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 695 Campbell Technology Pkwy ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Campbell CA 95008 II Phone: 408-626-6100 Fax: 408-558-1600 INSURERS AFFORDING COVERAGE ~ NAIC # INSURED INSURERA. Interstate Fire & Casualty ~ 22829 INSURER B Nationwide Insurance 25453 Blackwell General Engineering Inc INSURER c , . 1759 Junction Ave . INSURER D I San Jose CA 95112 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE 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 ~ 4NSRp TYPE OF INSURANCE POLICY NUMBER POL C CTIVE I DATE (MM/DDIVY OL C RA 10 DATE MM/DD/YY LIMITS I GENERAL LIABILITY EACH OCCURRENCE $ 1 , OOO , OOO p, f }( ~ COMMERCIAL GENERAL LIABILITY I LIC1000514 'I 05/04/09 05/04/10 I $ 100 , OOO PREMISES (Ea occurence) j i j CLAIMS MADE X OCCUR I MED EXP (Any one person) ~ $ X ~ OWner/COnt Prot . PERSONAL & ADV INJURY $ 1 , OOO , OOO X Blkt COntraCtual ~ ~ ~ GENERAL AGGREGATE $ 2 , OOO , OOO I GEN'L AGGREGATE LIMIT APPLIES PER. li PRODUCTS -COMP/OP AGG $ 2 , O O O , O OO POLICY X~ JECT '. LOC Ben. I 1 , OOO , OOO AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1 OOO O00 B ~ g _ __ ANY AUTO ' ACP7803447084 ~ 06/01/09 06/01/10 (Ea accident) , , _._ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) j }{ HIRED AUTOS ~ ' ~ BODILY INJURY $ }{ NON-OWNED AUTOS I ; (Per accident) ~' PROPERTY DAMAGE $ ~ (Per accident) GARAGE LIABILITY j I AUTO ONLY - EA ACCIDENT I $ ANY AUTO 'OTHER THAN EA ACC $ li AUTO ONLY. AGG $ '. EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ I OCCUR ~'I CLAIMS MADE AGGREGATE $ ~, S - - _.___ _.. _- -------------- _. DEDUCTIBLE 'j f I $ I RETENTION $ I $ WORKERS COMPENSATION AND I' I TORY LIMITS I ER I ! EMPLOYERS' LIABILITY ~ E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE ~, OFFICER/MEMBER EXCLUDED? ! E.L. DISEASE - EA EMPLOYE $ If yes, describe under POLICY LIMIT ~ $ DISEASE E L I SPECIAL PROVISIONS below - . . I OTHER B (Equipment Floater IACP7803447084 106/01/09( 06/01/10' Rented $100;000 I E i ment 1000 ded DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS RE:09-10 Bascom Dental A11 work in public right of way *10 day notice of cancellation for non payment of premium or non reporting of payroll (City of Campbell, City of Campbell Redevelopment Agency it's officers, officials, employees and volunteers are named as additional insureds per CG2033 10/O1;CG2037 10/O1; ICB8001 04/05 attached) CFRTIFICATF H(')I f1FR CANCtLLAl1UN CITYO-4 CANCELLED BEFORE THE EXPIRATION IC IE S B E SHOULD ANY OF THE A80VE DESCRIBED POL X x y y X X DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O DAYS WRITTEN C1 ty of Campbell NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILU~RE5T0 DO SO SHALL Department of Public Works ~~ ;W9WVRER, ITS AGENTS OR 70 North First Street bell CA 95008 Cam S' p AUTHOR( D R SENTAT . ACORD 25 (2001/08) © ACORD CORPORATION 1988 ISO ~ Commercial General Liability Forms ~ 10/01/01 COMMERCIAL GENERAL LIABILITY Policy No. LIC1000514 CG 20 33 10 01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section II -Who Is An Insured is amended to include as an insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability arising out of your ongoing operations performed for that insured. A person's or organization's status as an insured under this endorsement ends when your operations for that insured are completed. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: 2. Exclusions This insurance does not apply to: a. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: (1) The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and (2) Supervisory, inspection, architectural or engineering activities. b. "Bodily injury" or "property damage" occurring after: (1) All work, including materials, parts or equipment 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 been completed; or (2) That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 20 33 10 01 © ISO Properties, Inc., 2000 ©ISO Properties, Inc. Blackwell General E~,yineering, Inc. LIC1000514 AMENDMENT OF OTHER INSURANCE CONDITION -PRIMARY INSURANCE FOR AUTOMATIC STATUS ADDITIONAL INSURED THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART If required under a written 'insured contract" with you, paragraph a. Primary Insurance in Section IV - COMMERCIAL GENERAL LIABILITY CONDITIONS, 4. Other Insurance is amended by adding the following paragraph: Not v+~ithstanding the foregoing; the insurance afforded to any person or organization who has been added to this policy by an Automatic Status Additional Insured Endorsement is primary and non- contributory insurance, but only as respects '`bodily injury" or "property damage' liability arising out of "your work' performed after the effective date of this policy under a written contract bet~nieen you and such person or organization that requires you to maintain primary and non-contributory insurance and to include such person or organization as additional insured thereunder. All other terms and conditions of this policy remain unchanged. I CB-8001 04-05 ISO ~ Commercial General Liability Forms ~ 10!01!01 COMMERCIAL GENERAL POLICY NUMBER: LIC1000514 LIABILITY CG 20 37 10 01 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE ime of Person or Organization: City of Campbell Redevelopment Agency, it's officers, employees and volunteers City of Campbell And Description of Completed Operations: 09-10 Bascom Dental -All work in public right of way Premium: (If no entry appears above, information required to complete this endorsement will 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". CG 20 37 10 01 © ISO Properties, Inc., 2000 ©ISO PmnPrtleS, InC. PG~..;YHOLDER COPY STATE P.O. BOX 420807, SAN FRANCISCO,CA 94142-0807 COMPENSATION I N S U R A N C E U N ~ CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 07-17-2009 GROUP: 000571 POLICY NUMBER: 00 1 05 32-2 008 CERTIFICATE ID: 580 CERTIFICATE EXPIRES: 10-01-2009 10-01-2008/10-01-2009 CITY OF CAMPBELL NG ATTN: DEPT OF PUBLIC WORKS 70 N 1ST ST CAMPBELL CA 95008-1458 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 indicated. This 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 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 #1600 - MARK BLACKWELL PRES - EXCLUDED. ENDORSEMENT #1600 - CRAIG BLACKWELL SEC,TRES - EXCLUDED. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 10-01-2003 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. ENDORSEMENT #2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 2009-07-17 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. THIRD PARTY NAME: CITY OF CAMPBELL EMPLOYER BLACKWELL GENERAL ENGINEERING, INC 1759 JUNCTION AVE SAN JOSE CA 95112 NG [AW2,CN] NG PRINTED 07-17-2009 (RE V.2-05) WAIVER OF SUBROGATION NOTICE Enclosed is your copy of a certificate of insurance on which the certificate holder required a waiver of subrogation: 1. Please be advised that a waiver of subrogation requires that a 3% surcharge will be applied by State Fund ONLY to the premium assessed on the payroll of your employees earned while engaged in work for that certificate holder who requested the waiver. (Note: if you have no employee payroll on that job, then there is no charge.) 2. To apply the 3% surcharge, you must also agree to maintain accurately segregated payroll records for employees engaged in work on job/s for the certificate holder who has the waiver. The payroll records are subject to verification by an auditor. Example: Payroll for job: Sample Rate: Regular Premium equals: Surcharge: Additional Waiver charge: Total premium equals $5,000.00 13.300 $ 665.00 3.OOo $ 19.95 $ 684.95 (665.00 + 19.95)