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ENC2006-00090CITY OF CAMPBELL DEPT. OF PUBLIC WORKS 70 North First St. Campbell, CA 95008 (408) 866-2150 Fax (408) 376-0958 E "'ROACHMENT PERMIT (1 orking within the public right-of-way) Issued Permit Expiration Date Perm' ~ b ~~lC. c' Lam:%tc - ~;! t~(, (~ ~` X-Rt. 1e Application Date ~~~ ~ ~ l,) Application Expiration Date I ` ~, APN ~~~ `" L'~ (.~~~ APPLICATION -Application is hereby made for aPublic-Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six (6) months if the permit is not issued. Application`F~ee is/non-refunda/ble.) A. Work address or tract # ;/~ ~, ( ~ V I I `" ~~ ~ ~` Utility trench location( J~ B. Nature of work S~ ~ ~ ~ ~ ~ ~ ~~~ ~ ~ r-"~°U 1r ~ g ~~r0` (~ ~ PQ°~ Z 30 51' ~ F S I ~~L/h~-k) 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 [his 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 24chours before restart,~in~g~ any work. // ,, ~i Name of Applicant ~~"VG~ r~X`~~G~T ~ ~IY+`iv~l ~Cn'1tNT P Y~~" ~~o,e~~or~ y~~~7 ,1 t~ ~j Tele hone y ~ S ~ ~ U LVi ~c ~ ~` (Pnn~ > !~i 1 jY~ ~ ~ .`3~ y`'7 ~'' ~~~ E - f ~0 2 Address ~,/~~ e ~~ ~ 24-HOUR EMERGENCY TELEPHONE NO. E-Mail Address / 'v r ~ ~ v ~~ `--- ~ ~ ~ ' Is this work being done by the property owners at their own residence? Yes ^ No The ApplicandPermittee 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/Petmittee 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 res onsible for any and all damages arising out of the condition of any private improvements i ~e publi ght-o \~ay/~^~' II~/1~.~"~~.-,.~. ~/~ l /1 // (Applicant Pertfiittee) (§ign) ~ ~~\ Date- ~~ ~~~- CJ~C~~T~ q~(v--n75(P 6~j~Iv~ ~~ n~~ ~ M ~~ Contractor (Print Name) Date _1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts >~ be specifically approved by the Inspector prior to cuttins. _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 cxccutc 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 RECEIPGT N0. PERMIT APPLICATION FEE $ ~~ I ~ v PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS ~ /~~' ~ - ~_~~ CONSTRUCTION CASH DEPOSIT 17~jix.;c.~ $-~-~ PLAN CHECK & INSPECTION FEE $~/ APPROVED FOR ISSUANCE ~l 1~~~~ For City Engineer Date Permit Expires 12 Months After Date of Lssuance q~~t ~ +~ ,~ ~.. ,~ .a m ao i--~ b d x ~O n ~ ~ '~ N N O O ~ ~ ~ ~ ~ ~ ~ W N .~ W J ~„ 00 ~m~z ~ ~~o~ `y o x ~ ~. ~ n7 ~ c~ ~; Y CJ ~o ~ ~' b ~] p* r» ~ ~ w ~ 'S7 y 69 ~ N ~-' O ~ ~ ~p~i O O b w a s~ ~ ~ .- o ~-d o S °' o O a 0 ~ ~ d N N rc N 'y ~., ~ ~ O. ONO 00 ~ O O~F' ~ J J ~ " ~ ~ ~ C" ~ ~ ~ -~ '~ Z z d z ~. ~ by o ~ ~ ~-e a d C C O O O p p "^ O O /" 1 n m r. ~ ~ .. ~ z ~. ~ x N ~' ~ O 0 o ~ 0 c ~ ~ 0 rn ~ ~"' W ~ ~ O b 7 ~ PUBLIC dS DEPARTMENT RECEIPT Effective JWy 5, 2005 City Clerk PUBLIC WORKS FILE NO. PROPERTY AUURESS Rease collect & receipt for the f IlowinR monies: r- TTEM KOACDMEMP PERMIT '..,AMOUNT 4722 Applicat{on Fee Non-Utlllty Encroachment Permit (5275.00) Minor Encroachment Permit < 55,000 (561.00) R-1 First PerMt (No Fee) Suhse cent (5135.00) Utility Encroachment Permit ArteriaVCollector Street (5530.00) Residential StreeVOlher Areas (5291.00) 2203 Ran Check De t 2 % of 5npiceer's Estimate (5500 min) 2203 FWthfW Performance Securil (FPS) (100%o(ENGN.ESI'J 2203 Labor and Materials Security (100% of ENCR. FST.) 2203 Monumentation Security (100%of ENGR.FSI'J 2203 Cash Deposit (4% of Engr. FFU(S.sao miNSl0,000 max) 4722 Ran Check & Inspection Fee (Nun-Utility) Engr.ESl.<5250,000 (13%of F.NGR.N'_SI'.) 2203 Engr. Est. >5250,000 (De 't 8 % of Fn r. EriJS30,000 min)«• 4nz uubtr<Slao,ooo MiNmum Charlie Pcr Location CondWtslPipellnes up to S00 Feet (5180.00) (52.25M) Above 500 Linear Feet (51.3_SIR) ManholesNaWtslElc. (5125.UOlea) Pole Set/Removal (5125.gVea) Strtet Tree RantinP/Removal (5135.00) 2203 Utility>SIOO,OW Actual Cost+20%•« 4760 Ston Container PertNt (5125.00) 4760 14ojecl Ram & S ificatfom Project No. 4760 Smrdard Speciticatbre & UetaiL~ (SI/PR SI5.50/Bk) 47140 Copies of Faginrtrin8 Ma 8 Ram Aerial Rot 74"x36" (554.00) Aerial Print B 1/2" x ll" (f22.00) Maps and Ram 24" z 36" (5835) 4722 Perwltiec: Failure to restore public I rovements (SI00/Calerdar Uay) (Meal Cade xra~.ll_4.al U) 4722 Penalties: Failure to correct unsafe conditbro (5100/Calerdar Day) 4722 Work Without Permits (d Times Applicable Fte) LAND UEVELOPM ENT d722 Lo[ Lice Adjustmrnt (5900.(80 4722 Parcel Ma (41.ots or Leti~s) (S3,d00.0U+S75/lot) 4722 Final TmM Ma (5 or Mom I,oLS) (54,2110.00 + 51181/loU 4722 CertlMate of Compliance 5650.00) 4722 CertlRcate of Correction (5400.00) 0722 Notary Fee ( r slpnaturc) (510.00) 4722 Vacation of Public Streets & FxsemenLS (51,200.010 4722 Assesvrlent SeprtRation or Reapporllonment First Split (5725.W) Each Additbnal Int (52011.00) 4721 Storm Drairu8c Area Fee Per Acrc (K-1 52,120.00) (MWtI-Res SZ.iS5.IM1) (All Other S2,KSO.W) 4920 Parkland Ikdlcalbn Fet (75 %/25% Dce Uoon Cert. of Occuoacevl Tropic Flow Map (Dolly Ti Campbell Trolllc Makl (F Campbell Tragic Model (k Siplal Timirl6 Informatbn Truck Permits No Parkins SI¢ns OF APPLICANT ~~J 1 ~ ~ /t 1 OF PAYOR~ " ~'~ 7' ` " "1 ~~~ (r TOTAL L) S ~.-~=~4 2 3 ~_ Q E zlr ~~~~.> ««Actual Cast Rus 20% FOR CITY CLERK ~>Faawl w-a~ata i~ ~ itit~ _.._. RECEIVED AV ONLY - ~~'., ~, llate - Rece Pt 4 ' «Far Plan Check and Cash De t~ ye w y. M .Date/ TNthls j1furms4eceipt ibrm OS-lX rev.62IN5 -__ ~a t: ..... ....:. .L.._~. _ o- ._. _....._. __.: _,..sa; ,.~, _ ~.. _4~? ._ i i _..... - -j ~. _. ,. _ -a y,.-_ -. ~.. . ............. 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 Ciry will be made in writing to the Pernrittee. 5. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants and water valves. 6. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures, detours and street closures. This plan must be reviewed and approved prior to any lane closures. 7. The Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated 1990, available at Cal[rans. 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 and bamcadesrand hargintg the cost (in lud ng all labor and materials) againstdthe cash deposit nd barricading may result in the City's providing signing 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. Conuactor 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. 1 G. This permit does not release the Pennittee 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 Pennittee 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 otheu than storm[ wate02 Appl antnshalll adhetettolthe BESTIrMANAGEMENTSPRACTICESrestablishedtbyathetSanta 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 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 Contractor (Print Name) Date Date .l~forms~pwperm Rev. 11(9/05 INSURANCE REQUIREMENTS CHECKLIST Permit # L~i'~,,IC Z- ~_~(~; CLt L~l C~ CIP Project # 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 1'mit. ^ Policy expiration date h ' G~,c. Automotive Liability: ~ ` ~~~ ~ ~; ~' ^ "Any Auto" checked on certificate ~ $1,000,000 per accident for bodil injury and property damage ~ Policy expiration date 1 I I ~ l~ k: / - ("i~., Workers' Compensation and Employer's Liability S ~ ~ /r~ (Yl'sy ~ `> ~ ^ Waiver of Subrogation clause ~ ,~~ $1,000,000 per accident for b dily injury or disease Policy expiration date ~ i ~'"~ ~~ CL t. (, h ~ Course of Construction (if required in Special Provisions) ~~ ' ^ Completed value of the project ~ 1 ~ ~, ^ Policy expiration date ~,) Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement '~ The City, the City of Campbell Redevelopment Agency, its officers, employees and volunteers are named as additional insured. The insurance coverage afforded to the Additional Insured is primary insurance. ~n ~"~ `" ' --`-~ ^ 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 ~, I •~ ~ i ^ For General Contractor <L f~ ~~~ rZ~+ ~ ~~'~~~'~~ r~S ~ r. ~-~`~ ~ ~ ^ For Developer or Owner ~._,_ ,- ---- ----... ~ ~; ~ ~~ ;__._~ __ Acceptability of Insurer(s) j~~>, b , c +~(ls=,-r>rl.. ~~ ~ I X ~ C=ti-- ,,; ~ rt~I ^ Insurer(s) has current A.M. Best Rating of A:VII and is au rized to transact business in the State of California. Insurance Certificate Reviewe ~~'~ti~,~~~ ; J ~ ~-~.~'t-~i~ L`"~~~.~ ~ ~ J~/~ ~j Initials Date T- ~] Copy of Insurance Certificate placed in tickler file for month of expiration. j:Aforms\inscklst (rev 11/99) CITY OF CAMPBELL Public Works Department 70 North First Street Campbell, CA 95008 Date: ~' ~ `"fi ' L~ FACSIMILE COVER SHEET TO: ~~ti~ h~~ ~ l' Fax Telephone No. ~ ~ ~j ~~ ,~ 3 cf FROM: ~~~ ~ Llk.~,-L~-t,~J Number of Pages Transmitted (including this page) MESSAGE: ~1, ~1~'~.~L~ttt. b~C~--~ ~c,1.t.~4~,!?ZC't~~~ cL-E~~ C.,~'~--z~.C~' / r ~ ., C ;~-+~i' `~.1~'~~..iLZ-LJtit .~C!.E:.~ ~e~71.CC ~ ~ .~4 ~ Cl (' Cr c j~,.Zc'~~: L.t 9-~' -k~-- '~ 1 (/.~~~..~_> /1..) ~,L.,(.-~;1 ~ /_l .C~-~.1 Cr ~-~1'l~C-L~-C~~- Ct"~ (I fi ~ .Q~, ~J n _ ~ ~' 7 T ansmitted from Fax Phone # (408) 376-0958 If there are any problems with this transmission, please call !~ L' ~- ~ w ~~ .~ /~~ i Dept. Phone No. J: \FORMS\FAXFORM(W ORD) ACORD,~ CERTIFICATE JF LIABILITY INSURAN~t 06/09/2006 PRODUCER (650) 592-7333 FAX (650) 594-4936 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Professional Ins. Assoc. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Lic. #0467457 P. 0. Box 1266 San Carlos, CA 94070 NSURED Mario and Manuel Concrete, Inc. DBA: Pioneer Concrete Company 139 South White Rd. San Jose, CA 95127 INSURERS AFFORDING COVERAGE NAIC # INSURER A: Contractors Bonding Ins. Co. 37206 INSURER B: Lincoln General Ins . 33855 INSURER c: Republic Indemnity Co of CA INSURER D: INSURER E: ':AVFROf;FS 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. JSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMBS GENERAL LIABILITY CN302 C059 10/01/2005 10/01/2006 EACH OCCURRENCE $ 1 ~ 000 ~ p0 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 300 ~ 00 CLAIMS MADE ~ OCCUR MED EXP (Any one person) $ 5 ~ 00 A X PERSONAL & ADV INJURY $ 1 ~ 000 ~ ~~ GENERAL AGGREGATE $ 2 ~ 000 ~ ~~ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPlOP AGG $ 2 ~ QQQ ~ QQ X POLICY PRO LOC JECT AUTOMOBILE LIABILITY ANY AUTO 6310001692-01 11/17/2005 11/17/20D6 COMBINED SINGLE LIMIT (Ea accident) $ 1 ~ 000' DO ALL OWNED AUTOS BODILY INJURY $ X SCHEDULED AUTOS (Per person) B X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS - -~ ---- (Per accident) $ o ,, PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY V AUTO ONLY - EA ACCIDENT S ANY AUTO €.,;....., v :l.1F;~.`; OTHER THAN ACC 3 :`11Ii`+IIS ATICz~` AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ~ CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND 026984-13 01/01/2006 01/01/2007 X WC sTATU- oTH- EMPLOYERS' LUIBILITY RTNER/EXECUTIVE P E.L. EACH ACCIDENT S 1, OOO, OO ANY PROPRIETOR/ A OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYE $ 1, OOO, OO If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMfr $ 1, 000, 00 OTHER 7ESGRIPTION OF OPERATIUNI / WGAI IVIVS / VCnIGLW i en~,~uawna rwcu a. cnuvrwcmcrv, , arca.wa. rnvr,an.n..~ E Job: Pruneyard Apts, Campbell, CA. The City, the City of Campbell Redevelopment Agency, is officers, employees and volunteers are to be covered as insureds with respect to liability arising gut of work or operations performed by or on behalf of the Contractor, as respects the above referenced job, and per form CBGL00410104 attached. Primary Wording Included, per referenced form. 0-day notice of cancellation applies to non-payment of premium only. City of Campbell- Department of Public Works 70 North First Street Campbell, CA 95008 ACORD 25 (2001108) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ,~ Sterling Hammack S/KMG ~ ~ ~ _. ©ACORD 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. 4CORD 25 (2001/08) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ___ BLANKET ADDITIONAL INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART A. Section li -Who Is An Insured is amended to include as an additional insured any per- son or organization for whom you are per- forming operations when you and such per- son or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional in- sured on your policy. Such person or organi- zation is an additional insured only with re- spect to liability for "bodily injur~J', "property damage" or "personal injury" and "advertis- ing injury" caused by your negligence in the performance of your ongoing operations per- formed for that additional insured. A per- son's or organization's status as an addi- tional insured under this endorsement ends when y our operations for that a dditional i n- sured are completed. B. With respect to the insurance afforded to these additional insureds, the following addi- tional exclusions apply: This insurance does not apply to: "Bodily i njury", "property damage", "per- sonal injury' or "advertising injury' aris- ing out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, in- cluding but not limited to: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or draw- ings and specifications; or b. Supervisory, inspection, architectural or engineering activities. 2. "Bodily injury" or "property damage" oc- curring after: a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or re- pairs) to be performed by or on be- half of the additional insureds) at the location of the covered opera- tions has been completed; or b. 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 subcon- tractor engaged in performing opera- tions for a principal as a part of the same project. 3. "Bodily injury" or "property damage" oc- curring or commencing before: a. Execution of the written contract or agreement that such person or or- ganization be added as an additional insured on your policy. CBGL 00 41 01 04 Contains Copyrighted Material of Page 1 of 1 ISO Properties, Inc., with permission "~. ~~ti *~°" . ~ -c '"""k"°~'} i~ ~.3 ~~ „~,: 1 ~, ~:i ~~ .~ 1.%M A~• ~N a ~~^~ ~ t ~'~~.,_ ~ ~. ~~ 06 ® "~~~ z g~~o m D ~ ~ i7 --1 ~ ~ -i 17 ^v ~~ ~ o o = a m I7 tT! '~ D ;Ti ~ Z mo o- a C (~ • o x ~ 7? Z ~ ~ ~ ri 7! ' . ~°~~ f~ d !~ is V 3 ~ v ~ o' rf ~ ~i ~ H^ ' ~ o ~ n ~ } ~ 1 4 1 y O C~ y 2 ~ ~ _ ~ ^ W~=~ ^~=may ;.Tl Tr o n ~ T~.~~ ~ -~ ' m J a i mo _ ~-, ~q ~.d n ~ o - o ~ ~~ ~ o = _~~- moo ~ a~= ~ ,~~ ~ ~ o _ ~ /p9 ,~,' G o= = o ~~ ~J ~ ~h ~ y y ~ 2 -- 0 ~ O~ ~ ~ n yvin< HN O o ~ t-i ~ Z m ~ _ ~ a am r ~~ p N S ~ (~ ~- ~ _~ a _~ o r _ y ~ S C , D "', a o °' w °-- r Z w y ' n .~ i~ n~' D ~~1 ~ o v• ~ d v' ~ ~l n m a F''' ~ o o m o ~ \ ~ u 1 „~ N. O ~ i-~. ,L•t t•.1 Z r ~ -.~ ~ ~ ~ D .p '< P^J t~J , , , ~ ~ m o fn ~. ^ ~ ° o w D ~ ~~ !Ti ~ ~ ~ ~~ ~ X D V v ~ n m ~