Loading...
ENC2006-00101CITY OF CAMPBELL ROACHMENT PERMIT Per to c ti C Z-~-} C1C~ ' C'C~~G DEPT. OF PUBLIC WORKS (.,» working within the public X-Rt.. File 70 North First St. right-of-way) - Campbell, CA 95008 ~'._ / Application Date 7 ~~ C; ~~ (408) 866-2150 Issued tl ~ ~J :' ~~ L Application Expiration Date 1 ~ -- Fax (408) 376-0958 ~ ~ ~ - ,,~~[ Permit Expiration Date : G - APN 7 ~~ - b ~ ~ ~2 j 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. ApplicationeFee is non-refundable.) 4 A. Work address or tract # ~ ~ _ `-' (J ~~ ~ l/ S ~• ~ e / / yQ- Utility trench locati B. Nature of work C. Attach four (4) copies of an engineered plan showing the location and extent of the work, and four (4) copies of [he preliminary Engineer's Estitnate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved by the City Engineer, said plan becomes a part of this permit. D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result in job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2.) E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before starting work. Notice must be given to Public Works at least 24 hours before restarting any work. yvp ~1G ~7~~ Name of Applicant R/~ ~~/ ~ ~»I / e Telephone 7 ~ (print name)~~ ~ t!~~ ~~~ ~/ ~ ~ ~~~ Addresso( ~r~ ~ S • ~~~/nS Cy-n /~`'~-~ S~ / 24-HOUR EMERGENCY TELEPHONE NO. E-Mail Address ~ rC~'' ` ~ ~ ~ y~ L/ ~ ~- ~ ( o U '"~~ 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 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 i~~public right-of-way. ~ 7/x/0 ~ _ (Applicant Permittee) (sign) ,~.. !! ~ Date Contractor (Print Name) Date 7 S ~ 6 SPECIAL PROVISIONS _l . Street shall not be open cut for underground installations. Minimum cuts m~ be allowed for connections or exploration holes. Such cuts be s t~ecifically aporoved by the Inspector arior 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 owncr shall cxccutc an Agrccment far Private Improvements in the Public Righi-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 n APPROVED FOR ISSU ~ ~ T .T ~ - ___. ~~ i ~..~ ~ T AMOUNT ~ Z~1( S 7/~~~G For City Engi eT Date Permit Expires 12 Months After Date of Issuance RECEIPT N0. ~! --fi F u ,, ,r b U~Q O ~, a ro w x 0 T7 ~ ~ '~ z N pN O S ~r O O d J J ~ O O ~~ ~~ 00 00 [~~ ~~~ o ~. ~° ~~ ~~ ~~ ~~ ~~ y O m o ~ p' P~ ~' ~ '=J A b9 J ~-- N C ~ ~ O pO ~- ~ O ~ O ~ a ..+ N A 0 ~ ~ O O O O. 0 v, v~ ~ N N ~ O O ~' Q~ O~ p; ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ y ~ ~ ~ o o vT' z z d .. z ~o 0 0 ~ a a C c c 0 o x O rn O ~ O ~1 n' n m r ~ ~ .. ~ z ~. ~ x N ~' 0 ~ ~ 0 O ~ O ~ ~ O O ~T ~ N U PUBLIC Wt ~ DEPARTMENT RECEIPT BffecOve JWy 5, 2005 ~~; ( ZvG~ ~~71UU City Clerk PUDLIC WORKS FILE NO. PROPERTY ADDRESS ~ V'N~tY~IJ Please collect & receipt for the folbvrine mmdre: ~~' 'HMENI PERMIT iAMOI)NT,- - u Applicetbn Fee Noo-Utllity Eceroachment Permit (S275.00) n `~ ~ ~..!'~ L. Minor Errcroschmeot Permit <55.000 (561.00) R-I Firt Permit (No Fee) Subse cent (5135.011) Utlll[y Encroachment Permit ArtedaVCntlecmr Street (5530.00) ResWentlal StteeVgher Areas (5291.110) D3 Plan Cheek De l 2% of Deer's Estimate (5500 Mn) D3 Faithful Perfomuutce Security(FPS) (100%of ENCR.FSTJ D3 Labor and Materials Security (100% of ENGR. EST.) DJ MonumeMatbn Securil {I00%of ENGR.ESf.) _ 03 Cash De Il (4% of EnSr. Es0(5500 mirJ510,000 max) 22 Flan Check & Inspection Fee (Nat-Utility) EnFr.Est.<S250000 (l3%of ENGR.FST.1 r. Est. >5250,000 (De t S% of FnSr. EsUS30,000 min)•* 22 Ut01ty <S100,000 at ~ "~ Mlntmmn ClutFe Per I.ocalbn CandWtslPicellnes up to 500 Feet (5150.00) (52.25/R) Above 5011 Llcear Feet (S1.JS/R) ManlakalVaWWFdc. (SI25.00/ea) Pole Set/Removal (5125.OOlea) Street Tree NaMittg/Removal (5135.00) Unlit > 5100,000 Actwi Cost +211% •• '60 SLOruSC Container Permit (5125.00) i60 PmJect Plans & SpeclReatkms ProjeM No. i60 Standard S elOcatbos & UetafLc (SI/PR S15_SO/Hk) 160 Cowes of Faeineerine Maos & Ram Aerial Print S t2" x Il" (522.00) Maps and Plxm 24"x36" (58.25) r 4722 PerWtks: Failure to restart public impmvemenas (SI00/CMerdar Uay) (M.N cd. se<.u_vama) d722 Pensltkx: FWlurc b eorrcct utassfc conditiom (S1001Cakndar Day) d722 Int tine Adl,Mmeer 15900.00) d722 Parcel Ma f4 Lots or less) (S3A110.00+S75Ibt) 4722 Firul Troct Ma (5 or Morc Lots) (54,200.00+ SIOOAOq 4722 Certificate of C lance 5650.00) 4722 CeRl0ule of Correction (5400.014 4722 Notsry Fee ( raf turc) (510.00) 4722 Vacation of PubOc StreeLS & Fncemetttc (52,2011.On) 4722 Assaxartenl SeSreptkm or Reapportionment First Spilt (5725.00) loch Addllbmri Lot (fZOD.00) 4721 Storm UninaBe Ares Fee Per Aerc (R-I S2,120.00) (M Wti-Res 52J85.00) (Ail ghat 52.650.00) 4920 Parkland Dcdicatbn Fare (75 %RS % Uce U Cert. of Occu cey) 511.7424 PoeuRe TRAFFIC d725 Intereeclfon Turn Counts (Two-flour Count) (576.50) 4728 Interseclfon Tum Couma (a.rn ar .m. aka) (5150.00) 6728 Traffic Fbw Ma (Dail Trartic VMumes) (532.00) 1728 Cs 11 Traftk Model (FWI Sco Assessment) (Actua4 6728 C II Tnrtk Model (Reduced Scope AsstameM) (Aelm4 4728 Siptal Tlmlrt5lntommtbn (562Mr) 1271 Truck Permits (S1t:00/ rMp) 4725 No Parlclnp Si (Slleach or 525/100) lTl'HER J~/~J Imo, TOTAL S ! 1 NAME OFAPPLICANT //~ 1 /~ lit S •' ` ~W t , NAME, OF PAYOR / ~"1 S /~~~ Vl l r/1 PHONE. ~ ~ ~~> J / "') '~/ ~ ~ / ADDRESS ~ ~ ~K ~ (3G~,S CG.i~. ZIP ~ ~ 2e~ •~~ •*Actual Cost Plus 20th Overhead TNominterest bcarinp deposit) COTY CLERK 11LGL1 ~~~~~1 15 ~ ~.;' ~ ~ ~~~~ ,~ ~ -I ONLY ~ ~, ~rPt.ne:~k,M+1.m~nrprn;,,,xm.eiw.,e.pytel~nw~e ,.. .w rft~y 'nl Fff~'k i"'ICCI ~' ,_ ,IDatellWVaLs <TFTi-GC ~:uemso-~apt brm os-ov re.-.6rz1ro5 „ENERAL PERMIT CONDITIONS 1. A Construction Cash Deposit is required. Charges will be made against this deposit if there is an emergency call-out, overtime inspection or when City ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee. 2. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. 3. Refund of the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work by the City. 4. The Permittee must request in writing a final inspection and acceptance of the work upon completion. Acceptance by the City will be made in writing to the Permittee. 5. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants and water valves. 6. A Construction Traffic Control Plan and a Construction Schedule are required for all lane closures, detours and street closures. This plan must be reviewed and approved prior to any lane closures. 7. The Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Constmction 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. 1 l . 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 [he cost (including al] 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. ] 5. 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 Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 17. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 18. Call back (call out) due to emergencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per occurrence. 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 reyuire 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 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) ? ~ o ~,_ Date Date J\forms\pwperm Rev. 11 /9/05 INSURANCE REQUIREMENTS CHECKLIST Permit # ~L 2~~~- ~ ~ 1 ~ ~ CIP Project # ~, ~~~, y~1S L(~C-~-- r--~~~ l)-~"1, ~ ~ d-~ ~?vb ~ The fol owing tnsurance is required of all contractors working in the ity 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: j~ $1,000,000 per occurrence, and ^ $1,000,000 general aggregate limit applying separately to the project, or ~6 $2,000,000 general aggrega li it. ~, Policy expiration date ',~~~,~"~ Automotive Liability: l -~~' '~ =-' ^ "Any Auto" checked on certificate ~( $1,000,000 per accident for b dily injury and property damage ~ ~ Policy expiration date ~ "~ C~ ,~ (;~ ~~~ I -~-~ ~ v e ,~ h' ~~WWorkers' Compensation and Employer's Liability ~ ,, ~~ ~~ ^ Waiver of Subrogation clause ~ ~ `~ ~ -- ~5 L_1 ~,C ~". ^ $1,000,000 per accident for bodily injury or disease ~~ ..}~ ~ ^ Policy expiration date ~"~~ 1'' Course of Construction (if required in Special Provisions) ^ Completed value of the project ^ Policy expiration date Required Endorsements to General Liability and Automobile Liability Policies Additional Insured Endorsement The City, the City of Campbell Redevelopment Agency, its officers, employees and 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 t t'' ~ ~ ~ such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". ~~' ~,l ^ Workers' Compensation Insurance Sheet Submitted ~- ~~ ~ t~ L• ^ For General Contractor 'S-.i~~- l~s C~' ~ Sri C~~' ~~5 ~,, t~- ^ For Developer or Owner ~~(~ ~C~C1~~ ~~ (~~ A _ ~ ~ ~ ~~CP 913 ~~~ ~c,~'~'1', I..,~. L ~'i~ ~~~3i ~0~"1 Acceptability of Insurer(s) Insurer(s) has current A.M. Best Rating of A:VII and is authorized to transact business in the State of California. ~ Insurance Certificate Initials Copy of Insurance Certificate placed in tickler file for month of expiration. j:Aforms\inscklst (rev 1 1/99) ACORD CERTIFICATE OF LIABILITY INSURANCE OP IDMC DATE (MM/oomvr) ,M AZZAR-1 08/02/06 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bozzuto & Associates Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 3425 S Bascom Avenue #100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Campbell CA 95008 Phone: 408-377-8712 Fax: 406-377-5741 INSURERS AFFORDING COVERAGE NAIC # INSURED NIC Insurance Company INSURER 8: OlazanGOn National Ins. <o. Azzarello's Truck-N- Hoe Chuck Azzarello INSURER C. 38 Nicholas Ave ill 5037 INSURER D: Morgan H CA 9 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED AROVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WMICM THIS CERTIFICATE MAV BE ISSUED OR MAV PERTAIN, THE INSURANCE AFFORDED BV THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEPMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAV HAVE BEEN REDUCED BV PAID CLAIMS. INER LTR DD'L NSRO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE ATE (MM/ODIYYI POLICY EXPIRATION OATS (MMIOOIYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE 3 1000000 A X X COMMERCIAL GENERAL LIABILITY GS514503 08/01/06 8/01/07 DAMAGE TO RENTED PREMISES (Ea accuranca) 5 SOOOO CLA'~MS MADE ~ OCCUR ll~~~ll MED EXP (Any one person) 3 5000 PERSONALBADV INJURY 3 lOOOOOO GENERAL AGGREGATE 3 2000000 GEN'L AGGREGATE LIMIT APPLIES PER'. PRODUCTS-COMPIOP AGG 3 lOOOOOO PRO- X POLICY JELT LOC AUTO MOBILE LIABILITY COMBINED SINGLE LIMIT 3 1000000 B ANV AUro CPP2036189 08/01/06 08/01/07 (Ea accitlanD ALL OWNED AUTOS BODILY INJURY 3 X SCHEDULED AUTOS (Par parson) X HIR ED AUTOS BODILY INJURY 3 X NON~OWNEO AUTOS (Per accitlant) PROPERTY DAMAGE (Per accitlenl) 3 OARAOE LIABILITY AUTO ONLY-EA ACCIDENT 3 ANYAUTO AUG O /~ 1J 2006 EAACC OTHER THAN 3 AUTO ONLY: AGG 3 EXC ESSNMBRELLA LIABILITY ~3 1~1 , - V ~ y ~% OR~ EACH OCCURRENCE 3 ^ a~J /~~/ ~~y ~ N ' ~ ~I /1~ OCCUR CLAIMS MADE ~•~• • ~ Ya AGGREGATE E E DEDUCTIBLE 3 DETENTION 3 3 WC STATU- OTH- ORNERSCOMPENSATION AND TORY LIMITS ER EMPLOYERS' LIABILITY AVV PROPRIETORIPARTNER E%ELUTIVE E.L. EACH ACCIDENT 3 : OFF1LERiM[rri>ER E :LLUCiD? E.. OIGE~.SE~EA EMPLOY''.e 3 If yes, tlescriba un0ar SPECIAL PROVISIONS below E.L. DISEASE-POLICY LIMIT E C Property 2606519 08/01/06 08/01/07 BPP 2500 DED 500 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXLLUEIONE RODEO BY ENDORSEMENT /SPECIAL PROVISIONS Excavation/Install PG6E Power @ 68 Sunnyside Campbell, CA 95008 City of Campbell, City of Campbell Redevelopment Agency its officers, employees and volunteers are named as additional insured with repects to liability per endorsement. *10 days for non payment of premium CERTIFICATE HOLDER CANCELLATION CITYCAM SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE E%PIRATON GATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O* DAYS WRITTEN City of Campbell NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, DUT FAILURE TO 00 SO SHALL Public Works 70 N. 1st St. IMPOSE NO OBLIGATION OR LIp BILITV OF ANV KING UPON THE INSURER, ITS AGENTS OR Campbell CA 95008 REPRESENTATIVES. AUT RI OREPREEENTATIVE ACORD 25 (2001/08) ~ " ©ACORD CORPORATION 1988 THIS ENCtC)RSEMENT CHANGES TH€ POLIGY. PLEASE REAQ IT CAREFULLY_1 BLANKET ADDITIaNA~L 1ht~l1RED EryC1dR5EMENT ~EXCLUbIMG FtES{pENT1AL) This end~sement modifias insurance provided underthe i~allcwing; C~MMER~44!_ GEh1ERAL LIABILITY COVERAGE PART ADDITIONAL 1NSUREQ - iCIVyMERS, LESSEES flR CONTRACTORS:{FORM Bj CCs~diQ11$S SCHE©ULE :Name of Persr~n or organezatianc Aitty person or ~arganiaatiipn #hpt the Warned insured is vlalgated ~ virtue of a written cvntraat ar agreement t4 pravlde insurance such as is s~f41'd@G1 by this policy. WH91S AN IN;~l1REd (Sectic~ri li) is amended tv include as an insured the person yr o~aniZation shouvn in the Schedule,.. but only with rospact to Liability arising out 4f "your work° far that insured by yr for you. The fiollowii7g ~ttidiiional provisions- apply to eny entity that is stn insured by :the terms of this endorsement: 7. Primary lA/or~ina If required by writt8n +rantract cir agteem+or,t..Such: insurance as is afforded ay this- paficy shall. be primary insurance, and' any insurance orserf-insurance maintained by the above additional' insured(sj shall ~ excess af`the insurance afEordeti to the named insured and shall nat,contribute to it. ~, Waives of SubrcrQa#ion if r~uired by written contract ar agreement. We wahre arty right of re~coverar we may have. agains# +~n entitle #hat isi an additional insured per tFie terms of this endaraicment because. of payments we moke fnr injury of damage arfsiitg Out Of '"yqur work" dOr18 under .contract w#h that persorti yr organization. 3. Neither the coverages provided by this insurances policy mar the provisions of this endorsement shall apply to any claim arising. gut +~f the sole negligencae of any .additional insures! or any of their aaentslempbyaes. 4. This endorsement does not apply. tq any :world irlvoMirtg cr related to properties intended fcrr permanent resdertial or habitatir~nal occupancy (other than apartments). The words"you" and "your" refer to the Nsrned Insurad shoyvn In the Opcfarations_ ..Your work° means work or operations pertonx~ed by you o'r on yr~ur behalf;. and materials, parts ar equiprrtent furnished in cx7nnection with such work ar operations. ANF-ES 16C? (~zoasj ACORD CERTIFICATE OF LIABILITY INSURANCE OP IDMC GATEIMMIDOIVYVV) AzzAR 1 08/02/06 PRODUCE0. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE sozzuto 6 Associates Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 3425 S Bascom Avenue #100 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Campbell CA 95008 Phone: 408-377-8712 Fax: 408-377-5741 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA NIC Insurance Company INSURER 8: Azzarello's Truck-N- Hoe Chuck Azzarello INSURERL 38 Nicholas Ave M H ll CA 95037 INSURER O. organ i INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANV REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAV BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CON OITIONS OF SUCH POLICIES AGGREGATE LIMITS SHOWN MAV HAVE BEEN REDUCED BY PAID CLAIMS. INSR DO'L POLICY Ef FECTIVE POLICY E%PIRATON LTR NSRO ttPE OF INSURANCE POLICY NUMBER DATE (MMIDD/YY) GATE IMMIDO/YVI LIMITS GENERAL LIABILITY EACH OCCURRENCE S 1000000 A X X COMMERCIAL GENERALLIABILITV GS514503 08/01/06 06/01/07 DAMAGE TO RENTED PREMISES (E.p«ur.ppa) s 50000 CLAIMS MADE ~ OCCUR MED EXP (Any one parson) 5 SOOO PERSONAL&ADV INJURY 3 ZOOOOOO GENERAL AGGREGATE 5 2000000 GEN'L AGGREGATE LIMIT APPLIES PER'. PRODUCTS-COMPIOP AGG 5 1000000 PRO- ][ POLICY JECT LOC AUTO MOBILE LIABILITY COMBINED SINGLE LIMIT 3 1000000 ANV AUTO CPP2036169 08/01/06 08/01/07 IE""ida"° ALL OWNED AUTOS BODILY INJU RV 3 ][ SCHEDULED AUTOS (Per parson) ][ HIRED AUTOS BODILY INJURY 3 )[ NON~OWNED AUTOS (Per accident) PROPERTY DAMAGE (Per accident) 3 GARAGE LIABILITY AUTO ONLY-EA ACCIDENT 3 ANV AVTO EA ACC OTHER THAN E AUTO ONLY' AGG S E%CESSNMBRELLA LIABILItt EACH OCCURRENCE 3 OCCUR ^ CLAIMS MADE AGGREGATE E 3 OEOUCTIBLE 5 DETENTION S E WC STATU- OTH- WORKERSCOMPENBATIONAND TORY LIMITS ER EMPLOYERS' LIABILItt ANV PROPR IETORIPARTNERIEXEC UTIVE E.L. EACH ACCIDENT 3 OFFIGER~MEMBER EXCLU0E0i E.L. DISEASE-E4 EMPLOYEE S u r•s, aeapdb. ~pda. SPECIAL PROVISIONS babes E.L. DISEASE-POLICY LIMIT 5 C OTHER Property 2606519 08/01/06 06/01/07 BPP 2500 DED 500 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BV ENDORSEMENT I SPECIAL PROVISIONS Project: Removal and replacement of sidewalk will be performed at 1601 Van Dusen Avenue, Campbell, CA. City of Campbell, City of Campbell Redevelopment Agency, its officers, employees and volunteers are listed as additional insured per endorsement. * Except 10 days notice for nonpayment of premium CERTIFICATE HOLDER CANCELLATION CIOFCAM SHOULD ANV OF THE AOOVE OESCRIBEO POLICIES OE CANOELLEO BEFORE THE E%PIRAPON DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O* OAVS WRITTEN City o£ Campbell NOTCE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAIW RE TO 00 SO SHALL Dept. of Public Works 70 N. First Street IMPOSE NO OBLIGATIO N OR LIABILItt OF ANV KIND UPON THE INSURER, ITS AGENTS OR Campbell CA 91008 REPRESENTATIVES. PUT RI DREPRESENTATIVE ACORD 25 (2001/08) ~ ©ACORD CORPORATION 1988 THIS ENDt'~RSEM~NT CHANGES THE. POLICY. PLEASE REAQ IT CAREFULLY.1 B[ANKET ADDIT(aNAL (NSt1REb ENDORSEMENT %E7CCLUDING RESIDENTIAL) This endorsement. modifiies insurance provided under the following: GUMMtERC44!__GENERAI.UABILITY £©VERA~E PART AQDtT1UNAL INSURED - DOWNERS, LE35EE3 ORC+©NTRACTC3RS (FARM Bj CG~O~Q11$6 SCHEDULE :Name df 1~erson or+Or~anaa#ian•. Any parson or cargsnizatian that the named insured is obligateri by vir#ue of a written cvntraGt 4r agreement to pravkie Insurance such as is ~rfforded by this policy. WNI:3 IS Ah11NSURED eSeckiorl If) is amended to include as an leisured the person yr organization shown in the Schetlule, but ottty with respect to liability arising ou# of "your work" for that. insured. by or for yQU. The following atitltgnal provisions apply #o any entity tllait is an insUr~d by :the terms of this ®ndarsement". 1. Primary Wording If required by written contract or agr~rrrent:.Such: insurance as is afforded lay this poli~.y shall. be primary insurance, and: any insurance or self-.insurance maintained by the above additional insured(sj shalt be excess crf #he' insurance aftor~ded to the named' insured snd shall not contrltrute to lt: 2, Waiver of ub titian If required by wn'tten contract ar agreement We wawa any right of recovery we may have against an entity #hat is an &ddltQnal insured per the terms of this endoraamtnt taecau$e of payments we make for injury or damage arising. dui of "your work" stone under a ccrntrac# with that person or oryanizatian. 3. Neither the coverages provided by this insurancse policy nor the provisions of this. endorsement shall apply to any claim aristnc~ out of the aerie negtigerlr,~ of any additional insured or any. of their agentslempbyaes. 4. This andor58ment does rat apply. tQ any :want involving or related to properties. irrtended fc,r permanent residential or habitatii~nal occupancy (other than apartments}, The wards. "you:" and'yaur" refer to the Namsd lnsurad shown fn the Diaclarattons. ~~ ' Your wock° means work or operaticstrS performed by you or on your behalf;. arn~ materials, parts or egviprrtent furnished in corrnec6on with such work ar operations. ANF-E$ 1 Fi(~ (~I2E~aB~ WORKERS' COMPENSATION INSURANCE INFORMATION The following workers' compensation insurance information is required for all Applicants and Contractors. One of the following items for each Applicant and Contractor must be submitted prior to working under a Public Works permit of contract. WORKERS' COMPENSATION INFORMATION: r Name of Contractor/Applicant l ~~ ~ ~ ~~ ~ ~ _ /~~~ ~-/ ^ A Certificate of Consent to Self-Insure issued by the Director of Industrial Relations; OR ^ A Certificate of Workers' Compensation Insurance Insurance Co. Policy No. Expiration Date ; OR A signed Certificate of Exemption from the Workers' Compensation laws as printed below. CERTIFICATE OF EXEMPTION I certify that ~ e performance of the k for this contract, I shall ~ t employ any person in a ma s a o b o ~ubject~ Workers' Comp nsatio aws of California. Sig ~ ~ , %l ~ ~- Date Title / // NOTICE TO APPLICANT/CONTRACTOR: If after signing this Certificate of Exemption, you should become subject to the Workers' Compensation provision of the Labor Code, you must forthwith comply with such provisions or the Permit or Contract will be cancelled or revoked. j:\landdev\forms\street improvements\workcomp (rev. 6/96) _ ______ ~- ____ __ .- ~_ _ a v 0 I ~ I -~ r ~ J O~ --~ ~ N p ~ ~ ii i I~ ~; r__________ ~~_ N =~ - Z ,6 O Cn m N -n r-- ~_ -~ c~~ I~ N O v ~7 I 6961 ~ ~~ 11S ~H ~Z ~ ~ ~` x,05) end ~als~Nns ^^ .r N -+ ^ N ^ v N -~ -~ '~- '~- ~ C~. ~ N = N' co a W WNrnv.:.N`:. .x I i ~ s !-. -r~, ~ ~ 7C x N ~ .. ~ ~ t'~Z~O'o~Or~NOr~*~ ~ ~ n r Z~~ O I D~ Z~pC< ~-1 C Z ~ ~ ~ ~ ~ Z Z L '-~ ~~ I ~ J ~ T W ~.~ ~/ ~.;~ ._ I . ,_ _ _ . ~- ~ . ` ~, ~ 0 r, ~ o ~ ~ ~lb'M301S ~ _ ~~ fit .. Z r mu z ~ ~«. N w n C.7~ Q f'r7 ~~ C~ fTl o~ ~~ *~~~~ ^ _ ZC~~*1"DG~ Z r~Zr~ D rZ~Z sr N so ~~N~~v -+ r OHO D Vl ~ "'~ 1'*t O ~ -1~~ N • r''~~r*tZ~ s R'ZZ=(~!) r nfs°r-a G7 ~ n ~ ~ ~ ~ ~ m ~ <-a zn~n 111' ld ~Z/ l _____~_ c 1 Z ~~ S rn cn --~ rn I N s 'O .. ~~I.]Q~ ,£ 11S dH .Z ~~ ~~ ~ N Zxs -+ -+ N-~ J ~" v ~ Z ~~ ~~ 7 Y ~ T r~ ^Z !~ • O 0 v f- ~ G7 s ~. cr rn "r „. , • ~a;~• .. .. . • , , ~.. ..~ i .... „ •~ .....w..... .. ._ ...~uw s ..... ___. ,, .. , g ~ ~ ,. .. - >.. .:... • ... . • •. ..._.. !!! I • ~ ~ ~, ~ _... ~,•.. f t; if it i i ~ ..• A r ~~n i~auawwww«~ '> ~ Ji. , i~ +t:i• ',t fj'~ ~•~ el~• •~,F•~~'•' .~ R ri ~•~ •r` ~£`.. x.53 •.l.~ .t:~::., i •z "`:.::.~: "»i:~_:S..i y ,j~;~a ~~' .... • ~ .. :;~; ` , : 3 t } •3~ ~ mid ,<R~. ~„ ... ...... - h .. .. ~ ~. .. .. • .. ~{•• . ..... ,a . ~ .: €.. iOk~~ :!> •: r,• x~ ~,a:.a>. •.~ • . ~::,.„:, .i~A.uuw;,A t~.;y:~-',.~'Fw..i~''M~; • ..:"~ .. .:. ,,~{((ii • : rn rn II Z c ,• • :.. .eu m } ii ~` . -y ( is D • ~ ~• ~o C~ ~°' -- y~.~ ~' ~.' 1 t •• ... ~ . ~~ , .,. t F ~ ;w. ^' ~ ,,ram„ 'r~ ~ .. P ~. i O ~~ ~~ og ~~ o ~~ ~~ ~ ~~ ~~ o~ ~~~ C Z ~ ~ C c~ _ mD ~ D C~ I ~ ~ o n ~~ D .,.D T1 ~ O rrt cN~ -P c.r C~ C a ~. m F~1 d C~ .C 0 a C'1 :..l~~! ,OL l/,9L/,6~ -P c.r! c.,~ I N -'--? c'~ ~~~ '0 C ~ O Imo DAN Z ' -+ v c' o ~ cr 0 c r*, ~~~ J ~ W ~j'1 ~ ~ N C~ N n C.Ti c z y ~c b ~ o~