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ENC2006-00133
CITY OF CAMPBELL DEPT. OF PUBLIC WORKS 70 North First St. Campbell, CA 95008 (408) 866-2150 ENS \CHMENT PERMIT (for"working within the public right-of-way) Issued ~- ~°'1 - ~~ Permit "LC~Zxv ~ QG1l ~ X-Ref. r ..., "~ Application Date 1- ~ - D(rr Application Expiration Date Fax (408) 376-0958 p ) ,.,~ Permit Expiration Date 0 • ~1,~ ~~1t,~ APN ~ ~ ~~ ' ~ ~ - ~~~ Za 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. Ap/~plJJication Fee is non-refundable.) A. Work address ortract# I -,TV ~ ~'1~~~~~S~ir ~)V(~ Utility trench location B. Nature of work ~1~ ~~~ ~ ~~~~ ~ ~~ 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 undero ound 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. ` ("~ h ~~ o /' / ?n%~ !" `' Telephone ~~ " ~ ~ ~\"\ - \ ~~ r Name of Applicant (J _ (print name) ! ~ (~ _ ,1 Address ~ 7~( `J S ~ ~/'~'~ ~° f'`''~' ~~ c ~ 24-HOUR EMERGENCY TELEPHONE NO. ~ ~~ - 5`~ ~ E-Mail Address is this work being done by the property owners at their own residence? ~'" Yes ~` No ``~_ \, L 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 ApplicandPermittee 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 4ny fx?ivate prov Yn the public right-of-way. / Arrenterl ~ __ (Applicant Permittee srgn) Date ~nn~ ~, Contractor (Print Name) Date _1. Street shall not be open cut for underground installations. Minimum cuts ~ be allowed for connections or exploration holes. Such cuts be specifically 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 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 ar, Agreement for Private Improvements in the Fublic 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 & MATERIALS CONSTRUCTION CASH DEPOSIT PLAN CHECK & INSPECTION FEE ~.~.~ APPROVED FOR ISSUAN AMOUNT RECEIPT NO. $ I, l~ - 1$9518 S~ 9 / $ lBD_ /$95/$ ~ 325 _ ~ $°~5/S g, z ~ - v ~, ~ ~ ~or City )~rgineer Date Permit Expires 12 Months After Date of Issuance 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 [he Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated 1990, available at Caltrans. Traffic control equipment shall include Type [I 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 reimhursement of inspection costs at the current overtime rate. 1 1. 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 he 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 he 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 no[ 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. 19. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to he 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. Permittee must provide advance notification to all parties that may be affected by the permit activities. Notification shall he reviewed by City prior to distribution and include dates of work and a contact name and phone number. Applicant shall be respornible for ensuring that all those proy~di~rvices under the applicant are aware of and understand all of the above conditions. ,_ = ~ .--`' .. J ~ ~. Applicant Contractor (Print Name) Date Date J\forms\pwperm Rev. 11 /9/05 ~~ ~~ "«~, t~ ,,,~~, CITY of CAMPBELL Public Works Department January 23, 2014 Carlo Ganjeh 1740 S. Winchester Blvd. Campbell CA 95008 Subject: Permit No. ENC2006-00133 Location: 1740 S. Winchester Blvd. Maintenance Inspection -Acceptance Dear Mr. Ganjeh, The City of Campbell has made the final maintenance inspection of subject Public Works improvements and finds that no remedial work is required. Your remaining security deposit of $1,750, plus any interest due, will be sent directly to you from our Finance Department. Sincerely, r' L'Z.. ~.. Alan Hom Senoir Public Works Inspector cc: Permit ENC2006-00133 H:\LANDDEV\1740 S Winchester Blvd Maintenance Acceptance Ltr.doc 70 North Firsr Sereec Campbell, CaliFornia 9 5 00 8-1 423 rai. 408.866.2] 50 rnx 408.37(.0958 ~~i~r~ 408.8(6.2790 CITY OF CAMPBELL VENDOR NO. 00007220 cxECx No. 245237 Acco~tint Purchase Order Invoice Number Amount Descri lion 101 2203 CR0112314 1,750.00 DEPOSIT REFT.TND _~ ~~`~I \'`~~. ~' V WOU7220 CARLO GANJ6H Ot ~C`~i~, CITY OF CAMPBELL wELns Faaco aaNK, N.a. CHECK DATE CHECK NO. 11=Z4 02/10/14 245237 .~~ ~ 420 MONTGOMERY STREET 1210 ' ~~r 70 NORTH FIRST STREET .sari. FRaxc1G~~ ^- -41oa CAMPBELL; CALIFORNIA 950(18 !o o ~,/ AMOUNT ~ * * * * * 1, 7 5 0 . 0 0 * ~' :~ , ~, ~' ~~ VOID AFTER 90 DAYS ~! ~RCIIAR~ '~~ ~ ~ ni \ D: ~. PAY THE SUM OF ONE THOU: Y DOLLARS & ZERO m. r CENT, r' E To TxE CARLO GANJEH ~ ~ oxpsR RESTAURANT NEVSKY /~"'" -~I'~ U/w.-; 1740 S WINCHESTER E CAMPBELL CA 95008 __. II'24523711' ~:L21000248~: 4L2L8554L511' F CITY OF CAMPBELL 70 NORTH FIRST STREET CAMPBELL, CALIFORNIA 95008 CARLO GANJEH RESTAURANT NEVSKY 1740 S WINCHESTER BLVD CAMPBELL CA 95008 Ref undnble Deposit Check Request To: Finance Director Check Payable To: Address -Line 1: Line 2: City: Description: Carlo Ganjeh Restaurant Devsky 1740 S. Winchester Blvd Campbell 1740 S Winchester Account Number: 101.2203 Amount: $1,750.00 Account Number: Amount: Account Number: 101.540.7448 Amount: (Finance Dept only) Interest Earned (Finance Dept only) Total Payable: cExaotAmount> Purpose: i Refund remaining Faithful Performance De posit $1750 Voucher #: Permit #: ENC2006-00133 Receipt #: Date: 8/17/2006 Requested by: Title: Sr. Inspector Date: Approved by: Title: City Engineer Date: ~ ~~J ~~ Finance Dept Only: Verified by: Approved by: Special Instructions Mail AS IS: Mail in Attached Envelope: Return To: Joy Francois (Name) Other: Title: Accounting Clerk II Date: Title: Accountant Date: or Handling Check State: CA Zip: 95008 Interim Check: Needed By: Public Works (Department) f/n: Fortes/excel/chkreq - Revised OS/00 0 N M M ~ N O .~-~ ^ O M ~I rl ~ O it ~ O ~; U ~ W a U W .. 7 ~ >. ~+ m a .~ cc v C a P, r Gw7 i tl". ~I c 0 HI °o °o °o °o °o °o O 0 0 0 O O O D ~ ~ 0 ~ 0 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ oho o~0 0 0~0 0~0 0~0 0~0 ~ ~ rn rn rn rn rn M M M M M O O O O O O O N N N N N N ~ ~ ~ ~ t` ~ n r-' ^" \ ^. ~ .--~ N N o o 00 0 0 0 0 0o O~ O~ 0 0 O 0 O O O 0 0 ~ O N O ~ O ~ vl M N 0 000 0 0 0 O O O OM N O ~ .-r O ~--~ vl M ~ N t` ~ ~ ~ e a o .~ a~ Q ti ~ ~ ~ ~ ~ a U V' 4] . c~ i ~ ~ i ~ ~ a~ a~ a o .~ ~ ~ ~. ~ o ~ a, U w .~ a 3 ~~ ~ Q :~~ ~Ab~ c Saw U 0 v~ OZs wUa~n o ~ o o o ~ ~ ~O M O '--~ t~ ~ vl ~ O M N ~ 00 N M ~ ~ V't ~O l~ Q~ M M M M M V~ Vl ~~ ~ --~ O o ~~ ~ ~~ ~ °~ ~ 0 00 0 0 0 0 N N N N N N N 3 A x ~ x 3 w U Q a ~ w 0 0 0 614 W A V z z d w a Q H 0 H Y '. O ~ _) o vi O M r 69 1 a O O h O M 69 N 6> w 0 H e~ 0 c v A a y U .-. a pF ' ~~ ~~~ u ~ ARCH ARC _.. _.. CITY of CAMPBELL Public Works Deparnnent Date: October 2, 2006 TRANSMITTAL FROM THE PUBLIC WORKS DEPARTMENT TO: Carlo Ganjeh 1740 S. Winchester Blvd. Campbell, CA 95008 FROM: Joanne M. D'Ambrosia, Office Specialist SUBJECT: 1740 S. Winchester Blvd., Campbell, CA Encroachment Permit #ENC2006-00133 Enclosed is a check in the amount of $5,363.85, representing a refund of your Construction Cash Deposit and 75% of your Faithful Performance Surety Cash Deposit, plus accrued interest, `in connection with the above permit. ~j •-~------- Joanne M. D'Ambrosia Office Specialist Enclosure 70 North First Street Campbell, California 9500b-I43G TGL 408-866.2150 PAX 408-376.0958 TI>D 408.866.2790 ~,o,.,,~,.,..,,,,,, ti ___-___W..----~.._~r---__.._..___...__.__~.__.. ,; E _. O n H T n a D J P1 Ia ~ -P fJi 7? ,, ,~~ -~ r ~- ~ o ~ r ?.~Gl ti ~~~~ m _ ;, ti ~z-~c~ o ~ mm= o o r C O ~~U7 U 't ' ° ~ _ - oo c m z ~ ~ ~ ~ r ~ -{ ti ~ ~ '" m o m 0 O = y,~ C ~ to d W ~.-. m d o ~, H fL X ru ~ -i ~ ~<; , ~ ~ ~ ~ r C .n a ~ o *Nie C~~.r o p .' .A n a ~ ~ or} a ~1~4D y C1 ~o m0 ~~ ~ '" a ~' n O -~1 ~~ ~ ~~m ~ r r v \~ U7 iE m ~: m L1 ~ m a` ZZ t +` D m 9E t-~ $, ` ~ ~ ~~ ~ ~m a t•.J •.a ~ ~ m , o- r~J Y~ NO 0; ~ N •0 O P CO V F•] tvJ n D r 0 n z m 2 t~ F-~ t-~ I-~ tit -P ~ r•.J -P t••3 -P ~ i.a T ~J ~ r••J r•.J ~ ~ r••J r••) P• 0~ rn i :~ ~ rjz f:.j .., my ~~ ~m ~~ me ma -i ~ m -~ ~a ~~ ~~ m~ a 0 ~ A Z 0 O ~ ,n m ~ a (~ ~ n D ~ c ~ ~ m r r x 0 n °m 0 m z c 3 m O c m ~~ 0 z N ~ O N O Z ~ O ~'~, -,.~ r ,~~ ems. ~~~, i v ~~ ~~ ~`~.; ~~~ ~~ ~' . ,.w. 4 ~~~, ~ ,! /~/ M i) 'ii :s ~~~ '' ~.. ~ ~~ .f s .~.~. N f ~~ .. u ~ ~ ~ -~-. ~ I 4~ .r `~ G ~~ I i ~ i ,~~ ~~ _~ ~,~ ,~ _~ ~~ ~' _ s N A- ~ ~ ~~ -cf ~ ~~ ~~o ~~_ ~-~ >~ ~. ~_ '~~ ~~ -WEAKENED PLANE JOINT OR CUT JOINT 1 /8" WIDE, 2" DEEP WEAKENED PLANE JOINT- OR CUT JOINT 1 /8" WIDE, 2" DEEP +10%`MAX I CONFORM` ~ ~ SLOPE = 1 / 4" PER FT. - -6% MAX ... . . 6" CLASS A CONCRETE, TYP. • ..: 6 ..:';:,°, .: a. 6" CLASS 2 AGGREGATE BASE, TYP. DOWEL SECTION A-A NOTES 1. WHEN THE DRIVEWAY IS NOT POURED AT THE SAME TIME AS THE CURB AND GUTTER, 12" OF N0. 4 REBAR AT 4' INTERVALS SHALL BE INSTALLED AS SHOWN (REBARS TO 8E BENT DOWN AND COVERED UNTIL USED). 2. SCORE MARKS SHALL NOT EXCEED 4'-0" O.C., AND USE MECHANICAL SEPARATOR AT EVERY OTHER SCORE MARK. 3. DRIVEWAY APPROACHES (EXCEPT SINGLE FAMILY) SHALL HAVE A 6"X6"X10/10 WELDED WIRE FABRIC 3" ABOVE BOTTOM OF CONCRETE. 4. DOWEL ALL NEW CONCRETE IMPROVEMENTS TO EXISTING CONCRETE IMPROVEMENTS. 5. AT LOCATIONS WHERE THE NEW SIDEWALK ENDS AND MEETS AN EXISTING SIDEWALK, THE NEW SIDEWALK SHALL TRANSITION TO MEET THE EXISTING SIDEWALK AS DETERMINED BY THE ENGINEER. CITY OF CAMPBELL REV. DATE BY SCALE: OF CAyp ~ ~~ PUBLIC WORKS DEPARTMENT T1.T.S. ~•~s;~:, r DRAIIN HY: EA DATE 02/04 C o rrmm e r c i a l DETAIL :e.o •.z. ..~:°•Od°% cB~CKED BY: DATE 1V0. Driveway Detail ~ ,~'~` APPROVED BY: ~F~BCgAR9 `~ ![C~HE1.E GINEU ERA ]:/Drawings/Std_Details/D16 ~ - 8" I 10" R=6" i i I ~ ~ 1" _ ° Instal! -~--- PCC ~ ' 6" a Weakened a Class A I 6 CL 2 AB, Plane Joints ~ %~ 95% R.C. at 20' O.C. ~~o~ ,Y , o ~~' Rolled Curb and Gutter 6„ 2'_0,. Slope ~- _--- - ---- -_ __ _ ~- 1/4" per -_ .- -- ~ (2" Max.) __ 1 6" R=2„ ; R=1" --_ - - ------- -- - a 6„ ~ ~ R 2 6" CL 2 AB, `r ~ " ---~- 95% R.C. ~_ __ ~,~, ~ `, ~,~ Vertical Curb and Gutter NTS ° i! CITY OF CAMPBELL ~'' DATE BY DETAIL .~ °F xjD~~, PUBLIC 1PORK5 DEPARTMENT N ~ . -;•~,o~` r DR,,~ri BY; DA'r~ Curb & G u tt e r .:_`~.,o ~" Details ...e.~c3"' CBECI~D BY: DATE ~s~ G~~. APPROVED BY: D - 19 ~RC$A1~ ~~ J:IDrawlrgs/std DetaIlsID19 BGULEVARD WALK ~' - o I ~ * c~ z a~ ;~ UO a oz W o a _ 4 ~ W 1~/1 m W L fY ~ J fY ] WW OQZQ mJ UCJ ~ stn O a ~ ~ " 3 1D'-D !~ U s'-o" 0 4 - 6" ~ * r UO O ZQQ Q~ _ ¢ m `'' ww ~_ ~~ O w UCH I ~ ;~ o U N ~' O7 4'-6" 4'-6" w O ~ w ¢~ U N ~Q~ z~ ~w F- va >_ ~J~ w W ~ ~ /1 ~I O /1 ( Q _I r a 4'-6" 5'-0" W 0 z w ~Q~ Jln v"i z ¢~' p ~ w w UO ~ ~ m ~G W ~ ~ O ~~ U C7 Q DUI U I * g ~ `~ 1 zo 4 a3W ~ O m p I w\ O W ^ N 1' ~" 3~ r~ ~•? S=1/4" PER FOOT ~ ~'2 II-II T II * c~c8 c~ c ~ no_ n W_ Q~ mZ W d ~z w- ~°w a'~ U - W -a ~ N ~Q U ~o 3" CLASS III 3 1/2" P.C.C. AGG. BASE SECTION A-A * = INSTALL STREET TREES AT 40' O.C. CURB, GUTTER, AND SIDEWALK REVISED CONFIGURATIONS DATE: JULY 1994 -- DRAWN BY: NECKED BY: CITY OF CAMPBELL DETAIL ~ APPROVED: R ~ ~'-D.. ~'-o" ~ D'-o.. w 3 2 5=7/4" PER F00T - a w =O ~•. ~w I n II I-111-1 I I-III-III-III-111- - \~ p f0 1 Xn~n~nnn ~n( * n f(1 O O IrN ~ 3 1/2" P.C.C. 'z 10 s cuss ul AGG. BASE SECTION D-D . = BOULEVARD LANDSCAPING AS APPROVED BY THE ENGINEER. COMMERCIAL WALK W <~ mg Wa R Q 10'-0^ w Z W Wi Z p U c~ °, C7 ~ a3a ~'? S=1/4" PER FOOT - au W\~ ~~ Y E N ~ Z o o _ l J.oC7 0_ on on_o~, t n0 O n ~ a ~ U O 3~ 3 1/2" P.C_C. ~,o 3" CLASS III AGG. BASE ~~~III SECTION C-C r =INSTALL 4'6"X5' TREE WELLS WITH STREET TREES AT 4D' O.C. BACK OF CURB W/IRRIGATION. RESIDENTIAL. SEPARATED WALK R 10'-0" w / zo m 4'-6" of a3w 7. a oj~w ~ ~ ? 5=1 /4" PER F00T w IW\° 0 1:2 1- ~K z!= W N ~K U C9 4 ? ~ ) U (_ J 3 ° ~ 3" GLASS III 3 1/2" P.C.C. AGG. BASE SECTION B-B » = INSTALL STREET TREES AT 40' O.C RESIDENTIAL MARGINAL WALK R 10'-D" - z W W a~ a ~UW ~O~ ~x° W a F" ~`~~ ~wv~i w H O z H W ~z a. O w ~¢ Q a~ Q Wo aao vi c7 H ~ H z w w Q a ~~ F' ~° N d F ~ ' ~] o ~ ., Fy Q ~ O~~ ~ U w0 ate. ~'"' O ~ W ~ W ~ ~ ~ U ~ F ze~ QN~ w~ z, U > ~,wp Saco H~ ~~H ~~~ zw .W U a~eA." Amy QQ N [.. U ra ~~~ ~~ o~V ~V. ~~~~~~ ~~~_ ~iII ~~ a ~ ~~ ~~ea~o _ °~ illl o Via- °.- ~= ~z..x ~ _I ~¢~~ a!~aloQ W O ~ WHN W ~ ."'a ~ V O W ....Q ~ ° ~ ~ ~~~wW 'a .'a '+a ~adWrx °~ ~ ° )`~~`' z 3 `n° )~~i~ w ~ ~ n. >'~ ~~ Q ~R;y~~" ,"'a o-W p~ ~~U-a ° pa " ' c UC7Q~ °~' H ~ ~ ~ U e~na~ ~~1/ zU¢¢ a~~~ (~(\ Q °~c ~~ i ~ ~ Z [-' W o .n ~ ~ ~ >G W °' ° W7W W ;~ Oaa W ~ ~ x ° U Q aU. 3 c~ ~a Qa O~ H~ ~O O ~a FQ-~UU ~" w d ¢~z w F O z ~z ~o wv H y Q ~ C7 O ~; d F N Q' Q Q: U, ~~ ~--i M ^w I--I s a w Q~ A C7 Z 3 0 g ., O V1 w °,~ (~ O~ [~~ W F-+ r~ V W ~ QnW.. ~ax~ L1UQ O~rL ~ ~~i 4 `~ ? ~yi~ ~N~ ~ p:p . c;°~«~ ~ o ;.. o a~~J'. ~` O r ro w rv x 0 0 A y b9 W J O O O b A7 G. Efi W 0 O 0 O r 3 a .. z z n d c O O 0 b ~ b y dy b 0 0 0 0 0 0 ~ 0 ti 0 0 0 0 0 0 0 0 0 0 0 0 0 o C ~D N ~D N o0 r-~ 00 00 00 ~ ~ .-~ 00. ~ _ ~ ~ ~ ~ ~ ~ O O r+ l~ ~O Vi lh Vl C.h lJl l/i t1~ W W W W W ~ W i ~ V i ~ N A N W O N Oo 1--~ ~-+ N ~ t n A J O W O\ O O O 0 0 0 O ~r~~ ~ ~zo ~ ~ ~b ~ ~ ~ N ~ ~ Q ~ O 0 ~ ~ ~ N ~s ~' ~ ~ ~ ~ ,.~ b h ~ ~ ~ k M ~ M y y~~ ~ ~ ~ ~ ~ ~ . a o N ~p iM 'Zf i ~ ~ J ~--~ N r+ W lJi ~ O r-. O O to O O O O yy O O O O O O O ~ v i N ~ J N ~ w In ~--~ O Cn O N W O O O O O c.n 0 0 0 O ^J O O O 0 0 0 O O O O O O O O r < ~ ~O ~o 00 00 00 00 0o p N N ~ ~ ~ ~ ~ ~ `--' J J J J J ~ ~ ~ ~ ~ ~ ~ O O O O O O O -c O O O ~ O O O ~ O i i O O i O i O i O i W W W W W r..~ ~ ~ ~ ~ ~ W W W W W ~ Vt ll~ Ch C1~ Vt r. 3t 0 0 0 0 0 0 0 Z 0 0 0 0 0 0 o ~ ~ ~ ~ ~ ~ ~ u ~ ~ ~ ~ . . ~ ry - 00 00 00 , . 00 00 00 00 ~. 0 0 0 000 0 O O O O O O O O O O 0 0 0 O Q ~, c 2 v. 4 j c A7 b ~ ~ ^~ ~••r l1 N ~• O ,~ O C o `C O W -.r O N O N a~ ~° Ref undnble Deposit Check Request To: Finance Director Check Payable To: Carlo Ganjeh Address -Line 1: Restaurant Nevsky Line 2: 1740 S. Winchester Blvd. City: Campbell State: CA Zip: 95008 Description: Refund Deposit Account Number: 101.2203 Amount: $5,350.00 li Account Number: Amount: Account Number: 101.540.7448 Amount: (Finance Dept only) Interest Earned (Finance Dept only) Total Payable: $5,350.00 (ExactAmount> Purpose: Refund Faithful Performance Surety ($5,250.00) and Construction Cash Deposit ($100.00) on 1740 S. Winchester Blvd. Voucher #: Permit #: ENC2006-00133 Receipt #: 189518 Date: 08/17/06 Requested by: ___-- _ Title: PW Inspector Date: 9/21/2006 ~,ehidi ; (~ ~r Approved by: ~~I^'(_.~'~- ``` ~ Title: City Engineer Date: 9/21/2006 Michelle Quinney Finance Dept Only: Verified by: Title: Accounting Clerk II Date: Approved by: Title: Accountant Date: Special Instructions For Handl inc~ Check Mail As Is: Mail in Attached Envelope: Interim Check: Needed By: Return To: Joanne D`Ambrosia Public Works/City Hall (Name) (Department) Other: f/n: Forms/excel/chkreq - Revised 05!00 r vvr.rv rrvn YNn MCI:CIYI Ef/eetiw July 16, 2006 •~~f /~ TO: City Cork PUBLIC WORKS FILE NO. D (r DD~ - (J -- I ~ ~ c , t I PROPERTY ADDRESS 1 ~~ .? . V Pk lb ' {/1.,L' ~1 ~.{ (I'~ ,~ (,J( vd. +ese oo ct 8 receipt for the following monlsa: ACCT. REM ENCROACHMENT PERMR AMOUNT 4722 Application Fes Non•Utility Encroachment Psrmtt (5275 00) X Minor Encroachment Permit c S6 000 (3126 00) R 1 Fi t P i F • rs erm t Ne ee Suba usnt 5125.00 Utlltt E ncroachment Permit AnerleVColleetor Stroet 5660.00 R id k 2209 es ant l StrsaVOther Arses 3900.00 Pl Ch k D h ' an ec e t 2%of En inaer e Estimate 5600 min 2203 Faithful PeAormenee Securit FPS 100%of ENOR.EST. 2203 2203 Labor and Materiels Sscu ' 100%of ENOR. EST. Mon m t tb S i 2203 u en a n acur t 100%of ENOR.EST. Cesh D it s a 4%of En r. Est 5600 miN510,000 max Plan Ch k 8 I ti F 4722 2209 ee nspec on es (Non-Uliltty) Engr.Est. c3260,000 (19%of ENOR EST) E E 32 '__ a722 n r. st. >5260,000 Ds ait fl%of En r. EstJ530,000 min •' utttn <51oo oog , Mi i Ch P n mum arge sr Location (3260 00) Conduka/Plpshnsa up to 300 Faet (5226/11) Above 600 Lmsar Fest (St 96/h) M h l N l /E en o ea au ts te. (5726 00/ee) Pole SeURemovel (3126 00/ea) St t T pl h 2203 ree roa en n amoval 3146.00 Utili >5100 000 4780 , Actual Coal+20%'• Ston C t i P i 1780 on a ner erm t 5126.00 Pro'ect Pl 8 S ifi f 4780 ena e cat ons Pro set No. Standard S Ifi ti 8 D ce ona ste{la 51/P 31b.60/Bk 4780 Co Ns of En Inaerin Me s 8 Plana Asriel Pbt 24" x 96` 564.00 Aerial Pri t 8 12' 11" n x 526.00 Aerial S h F earo se 526.00 Ma sand Pl 24" 9 ` 4722 ans x 6 312.00 Penski s: F il t 4722 a e uro o rostoro ublic im rovemems 5100/Calendar De Muni Cods Sec.11.34.010 Peneltiaa: Feil t f 4722 uro o corroct unea s conditions 31o0/Cek+nder De Work Wtth t P it ou erm s 4 Timea A linable Fsa LAND DEVELOPMENT 4722 Lot Line Ad uatnwnt 3800.00 4722 4722 Perosl Ma 4 Lob or Lsaa 59,400.00 + 575AOt Fi l T t M 6 M 4722 na rac e or oro Lots 54,200.00+S100Ao1 Certilicel f C li 4722 a o om enoe 5860.00 Cerlilie t f C ti e s o orrec on ,Sgpg 00 /722 Ondin 8 Draine a Plan Review Sin le Femil Lot 5200.00 Sits c 10,000 s.f. 5800.00 Site> 10,000 s.f. <Aera 5800.00 Sits> i Acro 57,200.00 4722 Nota Fee rsl nature 570.00 4722 Vacation of Public Strseta 8 Eesemsnta 52,200.00 4722 Aaaasament SsgroBSibn or Reapportionment First SPIit (5726.00) Each Additi l L t 1721 ona a 5200.00 Storm D i A F P ra nage rea w sr Aero (R-1 S2 120 00) (Multi•Ras 52,386.00) 1920 All Other 52,860.00 Perkle M D di ti F 7 l e ca on es 3%26% Due U n Cerl. of Oocu enc 611.7424 Poste e TRAFFIC 4728 Intensclion Turn Counts Two•Hour Ccunt 578.60 47211 4728 Intsraection Turn Ceunta e.m. or .m. ks 3160.00 T ffi Fl M 4728 re e ow a Deil Tretfic Volumes S,j2,Og C b ll T ffi M 1728 em e n c odel Full Sco Assessment Aetuel C b ll T tti M em a n e odel Reduosd Sco A»aasmant Aelual 4728 Si net Timin Information 582Air 4271 Truck Pvm(ta 516.00/ rtd 4728 Na Parkin Sin S7/each or 526/100 OTHER TOTAL 5 9 ~' NAME OF APPLICANT (~ 1 ~ C,ar, ~ h e /L ~ NAME OF PAYOR ~ / ~l PHONE 7 q y~ ADDRESS i O S. ~f f h ~~ ZIP J~ // I"Actual Cost plus 20%Ovsrhssd Non•Intsroa~ beerin de sit FOR CRY CLERK RECENE BV ONLY - Date 'Recsi t 4 t Plan Check and Cash Deposits, sand ysllaw copy to Finance. j:\farms4eceipt form 06-07.x1s ~..iT~' flE ;,,kr~{'fiELE.4 ,~ GEC.tiI~ yY: A;didE~ fllflflflla951fl 1~'attlE: EESFr'+l«AtdT tdE4'~o}~.~, REGiSiER Itt;TE: fl3;'i"r,`fl5 iii~E: it.:i8:49 iaESCRiFTIflt~ "Mfll4~fT ~i,ilfl.flfl E;dflN ~4 SL'RIfi+~ EiLiNCt E iiEF IFEPflSiTS -it11.22fl3 ~i,flGG.flfl ~1flfl.flfl REE i~EE'flBiTW; -1fli.~~fl3 ~~32`t.flfl E~iGF; 8 3L~Ri~i4' Fitl~kG F ~53fl.flJ '4TflC?c~ i+RAii1 ~EE`a rte' ~ ---------------- TfliHZ IiI~E: ~9,fl~..LC CHEC'r: GhiI}: ~R,i3Jfl,flfl CHEC•P; t~Q: 393 4 iE~llfEr:EI~: '~~,Ci~:.t1fl ~ fl.~{~,i~GE: ~ . flC~ 't a INSURANCE REQUIREMENTS CHECKLIST Permit # ~(~1 C 2= ~y ~' Z~~~ 1 ~ ~ CIP Project # ~ "~~-E-~ ~S. 1,11 t t~-C-~,~ #~.f- The following insurance is required of all contractors working 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 aggregate li it. ~, Policy expiration date f ~~ ~ `7 Automotive Liability: 0 ~ I ~) ~ ~ ~S ~ ~.~ ~ L~ ^ "Any Auto" checked on certificate ~~~ ~~ ~ $1,000,000 per accident for od'ly injury and property damage ~Q Policy expiration date 12 ~~ X43 Workers' Compensation and Employer's Liability Waiver of Subrogation clause ~- $1,000,000 per accident for bodily injury or disease ~(j Policy expiration date S 1 ~`~ Course of Construction (if required in Special Provisions) ^ Completed value of the project ^ Policy expiration date R_ equired 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 company, its agents or representatives". ^ Workers' Compensation Insurance Sheet Submitted n -~- ;t~ ~~`~,~,L~1 ^ For General Contractor r~ t"~ l C~~r Lai - Vic' ~ ~~~,~ ~~ .3~ ~ ~`~~ ^ For Developer or Owner ~ ~, ~ ~S ~ 2,n~ Acceptability of Insurer(s) ~`~ ~~~, y 13U~ ~~~_ Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact r\ -;~-:,~ ~ ~ business in the State of California. , Insurance Certificate Reviewed + ~~ / / K ~~ L`~ ^ ~'`) ~~ l~ Initials "Date ^ Copy of Insurance Certificate placed in tickler file for month of expiration. j:\forms\inscklst (rev 11/99) ~~ ~ ~~2 I ,~~ ~ i ~ ~ f ~. k. FAX ~ Date 8/21/06 Number of pages including cover sheet ~~~ TO: Sheppard & Neilson Insurance FROM: Joanne D'Ambrosia 8035 Madison Ave., Suite E-1 City of Campbell Citrus Heights, CA 95610 70 North First Street Campbell, CA 95008 Phone (916)536-9292 Phone (408) 866-2701 Fax Phone (916)536-0202 Fax Phone (408) 376-0958 CC: REMARKS: ^ Urgent ^ For your review ® Reply ASAP ^ Please Comment Re: Insured: Aberle Concrete, Excavating & Grading. Permit #: ENC2006-00133 REVISED FAX Work Site: 1740 S. Winchester Blvd., Campbell, CA We have received the certificate of insurance for work the above 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 be made to the certificate. These endorsements/changes need to be added/done: - The Citv, the Citv of Campbell Redevelopment Agency, ,their agents, officers, attorne~ployees, officials and volunteers are named as additional insured shown on a separate endorsement rather than just on the face of the certificate. The insurance coverage afforded to the Additional Insured is to be shown as rip marX. 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 rights or representatives". 2. We require auto liability in the amount of $1,000,000 per accident for bodily injury and property damage. The "any auto" box needs to be checked on the certificate under the auto liability section. 3. We also require Workers' Compensation and Employer's Liability in the amount of $1,000,000 that includes a waiver of subrogation clause. Subsequently, we did receive a workers' compensation insurance certificate but it does not include a waiver of subrogation clause as we require in our insurance requirements. spy of the certificate, as well as our insurance requirements, follows for your reference. You may forward the requested items to us by fax. Please call me if you have any questions. Thanks for your help. . CEI .OLDER COPY STATE P 0 BOX 420807, SAN FRANCISCO,CA 94142.-0807 COMPENSATION 1 N SIJRANCE FUN D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 08-17-2006 GROUP: 000229 POLICY NUMBER: 0024654-2006 CERTIFICATE ID: 52 CERTIFICATE EXPIRES: 05-01-2007 05-01-2006/05-01-2007 CITY OF CAMPBELL 70 N 1ST ST CAMPBELL CA 95008-1458 NB This is to certify that we have issued a valid Workers' Compensation insurance oolicv in a form anprovad 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 upon30 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 UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPENSATION LAW. EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 05-01-2003 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER ABERLE, RICK DBA: ABERLE CONCRETE ENTERPRISE 42100 BOSCELL RD FREMONT CA 94538 [616,NF] PRINTED 08-17-2006 NB (!iEV.2-o51 08/2212006 13:58 1-510-7'"-0516 STATEXFARMXINSUR°'" PAGE 01102 Stag Farm Insurance 3936G Fre~mot~t Blvd Frerttont, CA 94535 Phol~e (51 Cl) 7'94-5555 Fay (510) 794-0516 I~~ gyp; ~y~: From: APRIL FI.ETCHER ~~: ~: Re: ~ ^ Urgeni# s Corirst:eMts: D ~'ok Rerrle~nr ^ Please Comment ^ Please Reply ^ Pleas® Recycle 08/22/2006 13:58 Hen .e~w ~~nur~we 1-510-7`"-0516 STATEXFARMXINSUR' "' CEFtTtFI~ATE C)F INSU~'i,AN~~ PAGE 02102 SUCH INSURANCE AS RESI~ECTS THE INTEREST OF THE CERTIFICATE HOLDER NAAMEb r3ELOW WILL NQT BE CANCf`Lli=b OR QTH>;RW15S TERMINATED WfTHOUT GMNC ~a HAYS PRIOR WRITTEN NOTICE TO THE CERtIFICAtE HOLp1=R, BUT IN N~ EVENT SHALL '~FIIS CEIIiTtFICATE BE VALID AMOK THAN 30 DAYS FRQAA THE bAT'E WRITTEN. THIs CERTIFICATIE of= INSURANCE DOES NoT CHANGE THE COVERAGE PROVIDED BY ANY IoOLICY bESCR18ED BELOW. This certifies that ~ STATE FARM MUTUAL AUTOMQI3ILE INSURANC>r COMPANY of Bloomington, Illinois [] STATE FARM F!R>= ANd CASUALTY COMPANY of Bloomington, Illinois © SPATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS of Dallas, Texas , ar [] STATE I*ARM INpEMNITY COMPANY of Bloomington, Illinois has coverage in force for the following Named Insured as shown below: NAMEDINSUREb: ABERLE CONCRETE EXCAVATING 6 GRADING INC. ADDRESS OF NAMED INSURER: 42100 SOSCELL ROAD E'RL~MONT, CA 9453A POLICY NUMBER C039704A1705I EFFECTIVE DATE OF POLICY 06/30/06 7.2/30/06 DESCRIPTION dF VEhIICLE (Indudlrtg VIN) 04 FORD F550 1FDI1F56,F24EC50369 LiABILrTY COVERAGE ^YES [~ NO ^YES C~ NO ^YES C~ NO ©YES ^ NO LIMIXS OF LIABILITY a. Bodily Injury Each Person Each Acxldent b. Property Damage Earl Accident c. Bodily Injury & property Dafnage Single Umlt Each Accident tMM PHYSICAL bAMAGE COVERAGES ®YES ^ NO ©YES ^ NO ^YES ^ NO ^YES ^ NO a. Com hensiee $ 500 Deductible $ Deductible $ Deductwle $ Deduct~le ® YES ^ NO ^YES ^ NO ^YES ^ N© ^ YE=S ^ NO ts. Collision $ 500 Dedu~tibie $ Deductible $ Deductible $ Deductible EMPLOYERS NON~OWNED CAR LIAHILI7Y COVfRAt~ I~ YES ^ NO ^YES ^ Nb ^YES ©Nt] ^YES ^ NO ~> ~ CAR LIAI3ILI'rY ^YES ^ NO ^YES ^ NO ^YES C( NQ ^YES ^ N4 FLEET -COVERAGE FOR dLl.OUIiPEDAND UCb MOTOR VEHICt:ES I~ YES ^ NO ^YES ^ Nb ©YES ^ NO ^YES ^ NO tVICE REP 238p tiNe Name end Address of Certlfic2lte Molder Name and Address of A 'COM BARTLEY "ALL GQORK IN PUBLIC RTGFITTOk'-GPAY. C21'X OF 39366 FREMON;C BLVD CAMPBELL, CITY OF CAMPBELL DEVELOPMENO' FREMONT,CA 94538 AGENCY~IT5 OF.'BZCEltS, EMPLOYERS AND VOi~bNTEERS AS ADDTTIONAJ.~ TAISUREDS" JOS LOCRTT,ON: 1740 WINCHESTER I3LV1~. CAMPF3EI~T~, CA 95008 08/22/06 ___ D2te INTERNAL STATE FARM U9E ON4Y: [a Request permanent CertiNcato of Insurance for liablllry coverage. 12zaz9,2 Rev. og-taztloa ©Request Cerrficate Holderrto be added as an Additional Insured. Rug 21 2006 16:09 916--96-0202 p.l TM. i4~ CERTIFICATE QF LIABILITY INSURANCE DAT0811712006 ~ PRODUCER phone; (9161636-9292 Fay: 81Bfi36-D202 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION SHEPPARD 8 NEILSON INSURANCE SERVICES, INC. ONLY AND CONFERS NO RIOHTS UPON THE CERTIFICATE 80$5 MADISON AVE., SUITE E-1 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR CITRUS HEIGHTS CA 95810 ALTER THE rt-vERAri1= AFCnRnrn aV Tuc onl Ir!IRQ ocl nw INSURERS AFFORDING COVERAGE INSURED ABERLE CONCRETE, EXCAVATING 3 GRADING 5178 MOWRY AVE IR2122 FREMONT CA 94638 INSURER R: INSURER B: INSURER C: INSURER o: INSURER E: Insurance NAIC # Inc ryut=its ur INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIICYPERIOp INDICATEp, 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 fNSURANCE 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. INSR LTR ADD'1, INSR TYPE OF INSURANCE POLICY NUMBER PoL,ICV EFPECTiVE POUGYE%PIRATTON LNIAI7S DAT ~ IYY M cENERALLIAeILITY $761706 01/29/06 01!21!07 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DgMA0ET0 RENTED D00 ~ b0 PREMISES (EO Ceturenee , CLAIMS MADE OCCUR MED EXP (Any one person) $ 5,000 A PERSONAL 8 ADV INJURY S 7 000 000 , , GENERAL AGGREGATE 5 2 000 OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRCDUCTS~COMPIOP AGG , , $ 1 000 000 . , , POLICY ~ LOC AUT OM091LE UA6ILITY ANY AUTO COMBINED SINGLE LIMIT {Ea acca~nt) ~ ALL OWNED AU703 ~ BODILY INJURY SCHEDULED AUTOS E C E I E (Per person) $ HIRED AUTOS NON-OWNED AUTOS AU G ~ 1 2 06 BODIeLCYC IUNeJ 1 RY $ PUBLIC WO KS PROPERTY DAMAGE !6 Per accident) GARAGE LIA9IUTY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC 9 AUTO ONLY: AGG S EXCESS/UYBREILALIABILnY EACH OCCURRENCE S OCCUR a CLARASMADE AGGREGATE $ S DEDUCTIBLE 3 RETENTION S S WORKERS COMPENSATION AND ' we srwru- OTHER EIIIPLOYERS' LIABILITY TORY LIMITS ANY PROPRIETDRlPARTNERlEXECUTIVE E L. EACH ACCIDENT S OFFICERREMBER EIItLU060? Ilya dwcAOe antler E-L. DISEASE-EA EMPLOYEE S , ePECYiL PROVISN1Nelwow ~ E.L. DISEASE-POLICY LIMIT S OTHER DESCRIPTION OF OPERATIONSfLOCATIONSNEHICLESJEXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS CANCELLATION EXCEPTION: 10 DAYS NOTICE FOR NON-PAYMENT OF PREMIUM. CERTIFICATE HpLDER, CITY pF CAMPBELL REDEVELOPMENT AGENCY, ENE-06UrFT~X~-SAN.TA_G1,ARlk; THEIR OFFICERS, EMPLOYEES AND VOLUNTEERS ARE NAMED ADDITIONAL INSURED PER ATTACHEp ENDORSMENT. JOB LOCATION: 1740 WINCHESTER BLVD, CAMPBELL CA. 95008 CERTIFICATE HDLOER r+w urci I wTlnu CITY OF CAMPBELL SHOULD ANY OF 7HE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ATTN: DEPT. OF PUBLIC WORKS EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL MAIL 30 DAYS WRITTEN 70 NORTH FIRST STREET NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. CAMPBELL, CA. 95008 AUTHORIZED REPRE6ENTATNE Atbention: 61Q~B7-1954 & 40&376-D9b8 ~~''-~ ~...~~~.~ ..+ ~e.vv .rvv1 c,enmca>;e ~ 4(tif 4 ~ - ~ ACORD CORPORATION 1888 Rug 21 2006 16:09 67 f'170 6 9~fDtlRTT lltis 6tttiaranattgq 4~i0Q1104 'i~ri b 1 •,21 ~- 0 twagts a tans 4a pep~+ •ra., 87 6'17fl iss¢ed to aba~~+a ~~ox®~ &aeaavs#~r~g & Gsadi.rrg @mA LYEltt6TDN IiiStlRltt~ R;,4lRI}ANY . 916-~96-0202 p.2 AgDITIdlIbL Ih1S(lR6D~dkN~R6, sxs8ties aR rpprllkL~'oR9 ~F'4At1 Pl3 7F,i7 endnlsY'eattie taodlfl4a It~avrmnde ustdtr the Ibltptrlr~s r eoHr~otJli. d~F1aRAL LiriR1L1TY GQVeRAOB PART Ntbui of Persoh yr ds'gSnFaaltlona llao~k~ 1lAOr# rtqutrWd unttD:r wrl~an nnrrtMamti (if a+a .nery app+ars #~ve4 111farA~ttiort rtq~ired xo asmpl+lT,~ thi• caetaereansPd< 1"kiI t bo mi1CN~ !ro the OeclaXat'toru a5 appt icabl~ to tTtis endars~e~,) iiPiD f S i~ ! NSTIIlEII ~C'>: i oa I f) i a smeudad #A t netaded ae ars i r~s~red the+peraen or orBaRTxat]a~ sh+srn in too 9~ttula, bwt on9Y with rsspaCt; xa Iiei7it4try arising f,:rt wp pYrur wdrU~' 4er that' fastlred d~ ar for rv~~ t t Iz ~Ptt+sr sgcaed tfittt tttroh ! nstirar+ca ao lr a~fivrded bit t'#-s pal Ioy eqr Cite btr~I+i L aY tip a ari81 t9 ctla t I ns shall be prr ilntt r~r lnsyran~, EKrt only as reeprats any Glatma, 1095 4r lia~itliy arising vut e€ rhs t~md tnearad1a 4peq~ap1~11A eed tiny insupanee mairttalned by }~s atfdltlottal in=u?ed shalt >ie aon~sontrli~tlr~- ccl ~a9 yd l? ~g RECE~ V E~ AUG Z 1 2006 Pusuc woRlcs ADMINISTRATION ~topC~1 I~ smear wfrP.ce app11~~ r Rug 21 2006 16:09 916 '-36-0202 p.3 CERTHOL,OER COPY NB STATE P.O BOX 4208x7, SAN FRANCISCO,CA 94142-0807 COMPENSATION INSURANCE F U N ~ CERnFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE OATS: 08-21-2008 GROUP: 000229 POLICY Nt1f,ABER: 0024854-2006 CERTIFICATE ID'. 55 CERTIFICATE EXPIRES: 06-01-2007 06-01-2006/03-01-200? THIS CERTIFICATE SUPERSEDES ANO CORRECTS CERTIFICATE k 134 DATEO 08-21-2006 CITY OF CAMBELL NB 70 N f5T 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 upon30 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 wlth respect to which this certificate of msuronce 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. HORI2ED REPRESENTATI PRESIDENT UNLESS INDICATED pTHERWISE BY ENDORSEMENT, COVERAGE UNDER THI5 POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A CpMIPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFDRNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPENSATION LAW. EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE, ENDORSEMENT N2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 05-01-2003 IS ATTACHED TO AFl~D FORMS A PART OF THIS POLICY. ENDORSEMENT N2570 ENTITLED WAIVER OF SUBROGATION EFFECTIVE 3008-OB-21 IS ATTACHED TO AND FDRMS A PART OF THIS POLICY. THIRD PARTY NAME: -CITY OF CAMBELL RECEI~~F AUG 2 1 2006 !'UBUC WORKS ADMINIBTggTI©N EMPLOYER ABERLE, RICK DEtA: ABERLE CONCRETE ENTERPRISE 42100 BOSCELL RD FREMONT CA 94698 [916,NF} crtt:v.s-os1 ~ PRINTED OS-31-200lS C~1 C,~z ~;~: ~~~ - ~~ i ~ _ ACORD CERTIFIC~,, . c OF LIABILITY INSURANt~~ DAT08 17/2006 ' TM. PRODUCER Phone. (916) 536-9292 Fax: 916-536-0202 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION SHEPPARD & NEILSON INSURANCE SERVICES, INC. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 8035 MADISON AVE., SUITE E-1 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR CITRUS HEIGHTS CA 95610 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW- INSURERS AFFORDING COVERAGE Lic#: OD79656 INSURED ABERLE CONCRETE, EXCAVATING & GRADING 5178 MOWRY AVE #2122 FREMONT CA 94538 COVERAGES i INSURER A: Lexington Insurance 'INSURER B'. I --- -- -- - --- INSURER C' _____ I, INSURER D: ___ .INSURER E: ', NAIC # 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. INSRI D ~ ~T TYPE OF INSURANCE I POLICY NUMBER ~POUCV EFFECnvE i LTR INSR - ~- -_.- -_~ Poucv ExPIRAnoN I LIMITS DATE MM/DD/VY DATE MM/DD/YY .GENERAL LIABILITY $761706 i 01/21/06 01/21/07 BEACH OCCURRENCE I$ 1,000.00 X ~ COMMEFCIAL GENERAL Lb>BILITV I ' ~ cAr.tACE To REN ~eD li $ 50 000 ' PREMISES i I ,-~~ .~ CLAIMS MADE I X I OCCUR (Ea occurence) I MED. EXP (Any one person) ~' $ 5,000 A 't I ~ _ ______ ~ I PERSONAL & ADV INJURY 'i $ 1 ~DDO~DOD r ! IGENERALAGGREGATE I$ Q,000,000 i GEN'L AGGREGATE LIMIT APPLIES PER: - ~ PRODUCTS-COMP/OP AGG. $ 1 000 000 PRO- ~ ' POLICY ~ JECT ! LOC ~ i ~ ~ i, ~ AUTOMOBILE LIABILITY II I- ~ COMBINED SINGLE LIMIT ' I j ANY AUTO ~! ~--i~ ALL OWNED AUTOS ~i ~, i (Ea acci t) $ BODIL1~ , r- i I (Per person) LL........... Y' ~~ ~ SCHEDULED AUTOS '~ I ~ ~ '~, ! HIRED AUTOS i, I -- JURY ~+ (y y ~/'1nL* I BODILY IN i NON-OWNED AUTOS I~-~, ICI ~ ~ ----..._---------- ! ' LI A U~70 (Per accident) ---~~ql! .4~a "~+I 1' YI'YA- ~"w~+ 1 ~ ~ ~ ~ ~ ~p r '~ ~~ PROPEf (Per accident) •~~Y I ;GARAGE LIABILITY ~ ' ', i ' I AUTO ONLY - EA ACCIDENT ' ~' $ , i '~. ~~ ~ ANY AUTO ~~ _ ____ __ OTHER THAN _ EA ACC $ ~ i AUTO ONLY. AGG I $ ~~F_EXCESS /UMBRELLA LIABILITY I ~ ~ ~ EACH OCCURRENCE $ ~~ i - J OCCUR ~ CLAIMS MADE ~ I'i AGGREGATE _ ii $ _- - _ ~- f DEDUCTIBLE I I i ~ I RETENTION $ ~ I -- ---- ~---- ------- _--. - ~ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ? we sTATU- gTHER TORY LIMITS L ' r ' ANV PROPRIETOR/PARTNER/EXECUTIVE 'I ~ E.L. EACH ACCIDENT ~ $ OFFICERIMEMBER EXCLUDED? I i I E.L. DISEASE-EA EMPLOYEE -__---_ $ If yes, describe untler SPECIAL PROVISIONS below j E.L. DISEASE-POLICY LIMIT -- $ OTHER: II ~ I ~ I DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS CANCELLATION EXCEPTION: 10 DAYS NOTICE FOR NON-PAYMENT OF PREMIUM. CERTIFICATE HOLDER, CITY OF CAMPBELL DEVELOPMENT AGENCY, ITS OFFICERS, EMPLOYEES AND VOLUNTEERS ARE NAMED ADDITIONAL INSURED PER ATTACHED ENDORSMENT. JOB LOCATION: 1740 WINCHESTER BLVD, CAMPBELL CA. 95008 GtK I IFII:A I t MULUtK CANCEL 1 ATIUN CITY OF CAMPBELL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ATTN: DEPT OF PUBLIC WORKS EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS . WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE 70 NORTH FIRST STREET TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. CAMPBELL, CA. 95008 IT'S AGENTS OR REPRESENTATIVES. Attention: 510-687-1954 & 408-376-0958 AUTHORIZED REPRESENTATIVE ~/~ Jaso Na r AcOrzD z5 (zovv08) Gertrilcate # a28/4 ©ACC)RD CU(2PORATiON 1988 876 796 >=ND~RS~N'1' 'this eriaorsetn~t, ei'FeCS[Ya YID'! A1V 01.,21 ~ 0 Forpts a putt ~t peli'sy r~a.a 676170$ las~vol to Ab~F~rs C~a~aF~t:o, ~scaavatirig & Gzad3,ng IBy, LEXINt3TDN Ifi1SlfRaNGE C41~11}AiVY Ag1a1Y14NAE. IN'SIJREDrOWN~RS, L[5$EQS 4~ CgN'rRkC1'ORS ~F0~1 B) 76f~ endnradnem modifl~s lf+s^ursnCp pnd8r the pailowin~: r aoHrlERaiAt, D&FIfRAL LIAeILil'Y COVERAGE >"ART Name of Person or OrganPzatlon: 6lecnkct ~tltmre rCquirad +~ndt~r wrl'ttan ttsntPgeC (If no onCry oppeats at~ava, InParmasion re'gaired to acmplet6 this cedOfnenleRL still b'4 mi14WF1 lro ttte DeclaYgClons as ~ppiicably to this els8orsrment -) WHD IS ilil INSURED (Section i l) is ainended to included as an insured tha person or organizat;o~n ahssirn in the ~ct~edule- bpt on9y with raSpeC$ to 13ekri14xy ariatng avt a~P ~~yaur Wtlrk~' ~Fer 3:HaL Inslt~+ed by ar ~`ar rv~• f t is ~uPtiter egret that such l osararsse as is afforded by ~ha poi my tc~r >;ne betia~'iL trY t#+rr additFonal iltisureds shall ba prlinar~ , insvrani:e, but only as respeots any Claims, loss cr iiakiitity arising out al• the N~ymd tnsvr<:xlla OPm'cG1Cns gnd anY insurance m~airttained by the additional Insure+3 shall ba nvn~aantrilyutlns~ 4G ~0 lq l? ~f5 ~topc~l tXii~ ~ -~ A,utitorix~sd p re9~ v~ O!R to urr»etsl~r~aiure {ICi ~t~ wince applloabl~) CErtTHOLDER COPY Ng STATE P.0 BOX 420807, SAN FRANCISCO,CA 94142-0807 COMPENSATION INSURANCE FUN D CERTIFICATE OF WORKERS' COMPENSATION INSURANCE ISSUE DATE: 08-17-2006 GROUP: 000229 POLICY NUMBER: 0024654-2006 CERTIFICATE ID•. 52 CERTIFICATE EXPIRES: OS-01-2007 05-01-2006/05-01-2007 CITY OF CAMPBELL NB 70 N 1ST ST CAMPBELL CA 95008-1458 This is to certify that we have issued a valid Workers' Compensation insurance oolic, in a form anprovad 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 UNLESS INDICATED OTHERWISE BY ENDORSEMENT, COVERAGE UNDER THIS POLICY EXCLUDES THE FOLLOWING: THOSE NAMED IN THE POLICY DECLARATIONS AS AN INDIVIDUAL EMPLOYER OR A HUSBAND AND WIFE EMPLOYER; EMPLOYEES COVERED ON A COMPREHENSIVE PERSONAL LIABILITY INSURANCE POLICY ALSO AFFORDING CALIFORNIA WORKERS' COMPENSATION BENEFITS; EMPLOYEES EXCLUDED UNDER CALIFORNIA WORKERS' COMPENSATION LAW. EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE. ENDORSEMENT N2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 05-01-2003 IS ATTACHED TO AND FORMS A PART OF THIS POLICY. EMPLOYER ABERLE, RICK DBA: ABERLE CONCRETE ENTERPRISE 42100 BOSCELL RD FREMONT CA 94538 [616,NF] ;Rev.2-o5, PRINTED 08-17-2006