ENC2013-00156Print Form
Permit No ~_ Iy ~ ~~ ~~ t ~ L:+G (5
CITY OF CAMPBELL ENCROACHMENT PERMIT
DEPT. OF PUBLIC WORKS (for working within the public X-Ref. File
70 North First Street right-of-way) Application Date ~ . ~~
Campbell, CA 95008 / ~j Application Expiration Date ~~ ~ +-'(
Ph. (408) 866-2150 Issued ~~ [ ~~ ~ ~ -+ APN ~~-1 G1 ~,l L ~
Fx. (408) 376-0958
Permit Expiration Date
APPLICATION -Application is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six
(6) months if the permit is not issued. Application Fee is non-refundable.)
A. Work Address or Tract No.: ~° I ~ ~ ~ v' ~ ~ ~' __
Utility Trench Location: I ' ~ ~ n , A { ~~i p l
B. Nature of Work: f ~ ~ r/ I~ ~ 4 V Ir{.,V v "~'" _ ~ C- r~~ P __ ~ Y~ Y ~ ~ _/
C. Attach four (4) copies of an engineered plan showing the location and extent of the work, and four (4 copies of the preliminary Engineer's
Estimate of work. The plans shall show the relation of the proposed work to existing surface and underground improvements. When approved
by the City Engineer, said plan becomes a part of this permit.
D. All work shall conform to the City of Campbell Standard Specifications and Details for Public Works Construction; the General Permit Conditions
listed on the reverse side; and the Special Provisions for this permit, listed below. Failure to abide by these conditions and provisions may result
injob shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. (See General Permit Conditions 1 and 2.)
E. The Contractor must have this permit and approved plans at the site and must notify the Public Works Department at least two days before
starting work. Notice must be given to Public Works at least 24 hours before restarting any work.
Name of Applicant: ~i ~/)/ C~~ ~('j~ ~1 Telephone: ~~ ~~~
Address: ,'/ ~~. ~ V ~'~.~ I' V U't ~"
E-Mail Address: I i ~ /t 1A Q,~ 1~)C, I ~~~{~~~GENCY PHONE NUMBER: ~~,}(/~. ~,~j ~ 7 I ~~j
Is this work being don~y the., ropey owners at their own residence. •'~ r', YES r NO ' I " ` -/
The Applicant/Permittee hereby agrees by affixing their signature to this permit to hold the City of Campbell, its officers, agents, and employees free, safe
and harmless from any claim or demand for damages resulting from the work covered by this permit.
The Applicant/Permittee hereby acknowledges that they have read and understand both the front and back of this permit, and they will inform their
contractor(s) of the information. Applicant is advised that upon issuance of this permit, property owner, or property owner's successors, shall be
responsible for anv and all damal~es arising outpEthe conditipn of any private improvements in the public right-of-way.
Accepted:
Permittee) (sign)
~l ~~ r 3
Date
(Contractor) (Print Name)
Date
SPECIAL PROVISIONS:
1. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts may babe
cnarifi~ y~pnroved by the Ins e~or prior to cutting.
2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method
"A",unless otherwise approved by the Engineer.
3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public Works Department
before starting work.
4. Per Section 4215 of the Government Code this permit is not valid for excavations until Underground Service Alert (USA) has been notified and
the inquiry identification number has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO.
5. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be recorded.
6. Public Notification Requirements:
7
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
PERMIT APPLICATION FEE
PLAN CHECK DEPOSIT
SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS
CONSTRUCTION CASH DEPOSIT
PLAN CHECK & INSPECTION FEE
5
$ ~ ~
EMERGENCY PERMIT FEE `' $
~. -_. /°
APPROVED FOR ISSUANCE <---' ~ Vv' ~ F~ ` f~~
ForCit En ineer Date
AMOUNT RECEIPT 0.
s 2 i5 2~+ ~'~G$
Y 9
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 or the cash deposit balance and refund or cancellation of the Faithful Performance Surety wil I be initiated by the written acceptance of the work
by the City.
4. Submit project schedule 10 (ten) days prior to proposed start of work. Special provisions maybe required for work within City facilities and
downtown Campbell.
5. 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.
6. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants, and water valves.
7. 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.
8. A Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated
1990, available at Caltrans. Traffic control equipment shall include Type II flashing arrow signs if required.
9. 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.
10. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements.
11. 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.
12. Adequate signing and barricading is required on thejob 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.
13. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer.
14. 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.
15. 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.
16. 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 maybe required, nor does it relieve the Permittee of any obligation to obtain any other permit required by law.
17. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency
18. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon.
19. Call back (call out) due to emeregencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per
occurrence.
20. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the municipal storm drain
system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff
Pollution Prevention Program.
21. 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.
22. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notification shall be reviewed by the City prior
to distribution and include dates of work and a contact name and phone number.
Applicant shall be responsible for ensuring that all those providing services under the applicant are aware and understand all of the above conditions.
~-~
Contractor (Print Name)
~ ~ I~
Date:
Date:
J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf
Rev. 03/13
CITY OF CAMPBELL
PUBLIC WORKS DEPARTMENT
CLEARANCE FOR FINAL INSPECTION
AND ACCEPTANCE LETTER
Encroachment Permit#: ENC 2013-00156
Name: Ginger Powell
Property Address: 399 N. Third St.
Date of Final Inspection:
On File: ;~ Bonds ~ CD ~ Cash
=1 Faithful Performance: $
Labor and Material: $
Construction Cash Deposit to be released: $500.00
J Other overdue deposits to be released (Description):
Processed by:~,,4
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`'~~~ Adminisi
Reviewed by: ~~_~ ~__._~
Insti~ctar
Reviewed by:
nd Development Engineer
or
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J:'JoAnnaT\Deposit refunds\CHECKLISTS\1 Chu klist -Use this.doc (Rev. 10/I I )
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CITY of CAIVII~I~EI.L
Public Worl<s Department
October 17, 2013
Ms. Ginger Powell
399 N. Third St.
Campbell, CA 95008
SUBJECT: PERMIT NO. ENC 2013-00156
399 N. Third St.
FINAL INSPECTION AND ACCEPTANCE
Dear Ginger:
The City of Campbell has made a final inspection of subject Public Works improvements
and finds the work to be acceptable and in conformance with City standards.
Accordingly, the City Engineer accepts the improvements.
The one year maintenance period stated in the permit begins as of the date of this
acceptance letter. The permittee is responsible for the repair and/or replacement of any
defective work or failures that occur within one year. The City will inspect the
improvements within one year and notify you, in writing, whether or not any repairs are
required.
Your Construction Cash Deposit of $500.00, plus any interest due, is now being
processed and will be sent to you under separate cover.
If you have any questions, please call me at (408) 866-2165.
Sincerely,
_--- _ _ .
Syed Wahidl
Public works Inspector
Cc: Inspector file
Permit #ENC 2013-00092
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PLN2013-00175
Fee Payment Report
Application Applicant
Pentamation Account Code Date Amount Due
RDE Refundable Deposit
Site Address
399 N 3RD ST
101.550.2203
8/6/2013 MH $ 500.00
Total Fees: $ 500.00
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Receipt No Rcpt Dake Reg ~Jo Batch No Payar ReceiptAmount
7 n-~atch(esJ found.
PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT
Effective July 1, 2013 -, ~
TO: City Clerk PUBLIC WORKS FILE NO. ~l~ ~ '-~ I ~ ~'~- E;~
PROPERTY ADDRESS 7 C ~ ~ ~ ~~ ~~ ~~ ! J
Please collect & recei t for the followin monies:
:ACCT.... ITEM AMOUNT
LAND DEVELOPMENT
ncroac men ermi ication ee
Non-Utilit Encroachment Permit Ma'or >_$10 000 $377.00
Minor Encroachment Permit <$fo,ooo $215.00
Initial R-1 Permit N/C
Subse uent R-1 Permits within Two Year Period $209.00
Street Tree Plantin /Removal N/C
2203 $500 er Tree Plantin De osit Re uired $500.00/tree
2203 Plan Check De osit 2% of En ineer's Estimate $500.00 min
Utility and R-1 Permits no deposit required
4722 Gradin & Draina a Plan Review
Sin le Famil Lot $265.00
Site < 10 000 s.f. $795.00
Site >_ 10 000 s.f. < 0.5 Acre $1 060.00
Site z 0.5 Acre $1 590.00
4722 NPDES Review C3 Re uirements
_For projects not required to submit numeric sizing $153.00
For projects required to submit numeric sizing
Im envious Area 10 000 S . Ft to 1 Acre $663.00
Im envious Area 1 Acre or more $867.00
Plan Check & Ins ection Fee Non-Utilit
4722 En r. Est. u to $250 000 14% of En ineer's Estimate
'`*2203 En r. Est. >_$250 000 Actual cost +20% Admin Overhead
Min $35 000 De osit
2203 Emer enc Cash De osit 4% of En r. Est.* $500 min/$10 000 Max
2203 Faithful Performance Securi FPS 100% of ENGR. EST.*
2203 Labor and Materials Securi 100% of ENGR. EST.*
4721 Storm Drainage Area Fee Per Acre R-1 $2,120.00
(Multi-Res $2,385.00)
All Other $2 650.00
4722 Parcel Ma 4 Lots or Less $3 775.00 + $82/lot
4722 Final Tract Ma 5 or More Lots $4 590.00 + $112/lot
2203 Monumentation Securi 100% of ENGR. EST.
4920 Parkland Dedication Fee 75%/25% Due U on Cert. of Occu anc
4722 Lot Line Ad'ustment Includes Certficate of Com dance $1 785.00
4722 Vacation of Public Streets & Easements $2 386.00
4722 Certificate of Com liance $1 764.00
4722 Certificate of Correction $530.00
4722 A eal Filin Fee $200.00
4722 Nota Fee er si nature $10.00
4722 Assessment Segregation or Reapportionment
First-Split $846.00
Each Additional Lot $265.00
511.7424 Postage
MI L NE U
Other Please S eci
*Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. C(
**Actual Cost Plus 20% Overh//e~~``ad (Non-Interest bearing deposit) TOTAL $
NAME OF APPLICANT lJ1I-~ L ~ 4I
NAME OF PAYOR PHONE ~~~~ ~' • C1
ADDRESS ~ ~ ZIP t,~~~
FOR RECEIVED B ~ ' ~ ~`
CITY CLERK
ONLY ~
.Date ,, t
Recei t # ~ ~ ~~ ~,~;1;, E `, ~N ~r ~°~
_ #
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Datel Initiais~ ~ ,.^ } ~„~. ~;; ~ < ~ " ,~< ~ ._
J'~iORN.^.',T~nptage AtlmhriNratrvatR~rMFA Fam lyM °sv~Wpment 1151
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Ok CH ARO •
CITY of CAMPBELL
Public Works Department
November 12, 2014
Ms. Ginger Powell
399 N. Third St.
Campbell, CA 95008
SUBJECT: PERMIT NO. ENC 2013-00156
399 N. Third St.
ONE YEAR MAINTENNACE INSPECTION AND ACCEPTANCE
Dear Ginger:
The City of Campbell has made the final one year maintenance inspection of the subject
Public Works improvements and finds that no remedial work is required.
Your warranty requirements and any surety, therefore, are hereby released.
Sincerely,
Syed Wahidi
Public Works Inspector
Cc: Permit #ENC 2013-00156
70 North First Street • Campbell, California 95008-1436 • TEL 408.866.2150 • FAx 408.376.0958 • TDD 408.866.2790
U ,-
._
Public Worl<s Deparnnent
October 17, 2013
Ms. Ginger Powell
399 N. Third St.
Campbell, CA 95008
SUBJECT: PERMIT NO. ENC 2013-00156
399 N. Third St.
FINAL INSPECTION AND ACCEPTANCE
Dear Ginger:
f
,~, ~ ~ ._
~ . ..
The City of Campbell has made a final inspection of subject Public Works improvements
and finds the work to be acceptable and in conformance with City standards.
Accordingly, the City Engineer accepts the improvements.
The one year maintenance period stated in the pei-Init begins as of the date of this
acceptance letter. The pennittee is responsible for the repair and/or replacement of any
defective work or failures that occur within one year. The City will inspect the
improvements within one year and notify you, in writing, whether or not any repairs are
required.
Your Construction Cash Deposit of $500.00, plus any interest due, is now being
processed and will be sent to you under separate cover.
If you have any questions, please call me at (408) 866-2165. - ~~~
Sincerely,
Syed Wahidi
Public works h7spector
Cc: Inspector file
Permit #ENC 2013-00092
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U Ivorrh Firsr Srri_er CamnhPll, C'.aliYnrnia 9j(lUR-1423 rr~. 4(IR.86<21>0 pnx. 08.~?.>.09j8 Tnn ~C18.8G,.2'90
A~"ORO® CERTIFICATE OF LIABILITY INSURANCE
`../ DATE (MM/DD/YYYY)
11/25/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. 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).
PRODUCER CONTACT Linda Patenaude
NAME:
Moore & Miller Insurance ''" ~~~„~ ~
~ PHONE (g31j 462-6900 F C N0; (831)462-3884
)"''~ sa ~ ~±.
3333 Soquel Drive
:<;: IL . linda@mooremiller. com
D~ INSURE S AFFORDING COVERAGE NAIC #
y O 9
Socjtlel CA 95073 [ rv INSURERA:GeIR1I11 Insurance CO.
INSURED {, Ifl
~ INSURERS Nat10nW1de Mutual Insurance CO 3787
r~
Mello Pipelines , Inc .
uU~3C WUrks Ac'n)frPistr SURER C :State Com ensation Ins . Fund
260 McGlincey Lane INSURERD:
INSURER E
Cam bell CA 95008 INSURERF:
COVERAGES CERTIFICATE NUMBER:CL13112503663 REVISION NUMBER:
THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR
TYPE OF INSURANCE
D
POLICY NUMBER POLICY EFF
MM/DD/Yl'YY POLICY EXP
MM/DD/YYYY
LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1 , 000 , 000
COMMERCIAL GENERAL LIABILITY DAMA E TO RENTED
PREMISES Ea occurrence
$ 50 r 000
A CLAIMS-MADE ~ OCCUR X CGP020959 12/1/2013 2/1/2014 MED EXP (Any one person) $ 5, 000
X Contractual Liability PERSONALBADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2 , 000, 000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 2 , 000 , 000
X POLICY PRO LOC $
AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT
Ea accident
1 000 000
B ANY AUTO BODILY INJURY (Per person) $
ALL OWNED
AUTOS X SCHEDULED
AUTOS CP7834805179 2/1/2013 2/1/2014 BODILY INJURY (Per accident) $
X
HIRED AUTOS
X NON-OWNED
AUTOS PROPERTY DAMAGE
Per accident
$
Ex erience Mod Factor ~ $
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION $ $
C WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY X WC STATU- OTH-
Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE
^
N / A
E.L. EACH ACCIDENT -
$ 1 000 000
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) 06729513 /1/2013 /1/2014 E.L. DISEASE - EA EMPLOYE $ 1 000 000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE -POLICY LIMIT
$ 1 000 000
DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Re: 1504 Ridgeley Ave., Campbell.
All Work in public right of way, City of Campbell, City of Campbell Redevelopment Agency, Its Officers,
employees and Volunteers are named as additional insureds as respects liability
Thirty (30) days notice of cancellation.
Compensation policy. ~ 1 ~-~
I+CK I IrwA I t
City of Campbell
Attn: Dept. of Public Works
70 North First Street
Campbell, CA 95008
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Patenaude/LMP C ~.n..~r~~~U> '~yc`~c-.-rv,_„a~ti~J
AGUKU Z5 (Z010/U5) U 1988-2010 ACORD CORPORATION. All rights reserved.
INS025 (2oloos>.o1 The ACORD name and logo are registered marks of ACORD
Policy: VCGP020959 CG 20 33 04 l3
insured Name: MELLO PIPELINES INC
Number: 2l Effective Date: l2/Ol/2013
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED -OWNERS, LESSEES OR
CONTRACTORS -AUTOMATIC STATUS WHEN
REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU
This endorsement modifies insurance provided under the following:
Commercial General Liability Coverage Part
A. Section II - Who Is An Insured is amended to include as an additional insured any person or organization for whom
you are performing operations when you and such person or organization have agreed in writing in a contract or
agreement that such person or organization be added as an additional insured on your policy. Such person or organization
is an additional insured only with respect to liability for "bodily injury", "property damage" or "personal and advertising
injury" caused, in whole or in part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on your behalf;
in the performance of your ongoing operations for the additional insured.
However, the insurance afforded to such additional insured:
1. Only applies to the extent permitted by law; and
2. Will not be broader than that which you are required by the contract or agreement to provide for such additional
insured.
A person's or organization's status as an additional insured under this endorsement ends when your operations for that
additional insured are completed.
B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply:
This insurance does not apply to:
1. "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure
to render, any professional architectural, engineering or surveying services, including:
a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field
orders, change orders or drawings and specifications; or
b. Supervisory, inspection, architectural or engineering activities.
This exclusion applies even if the claims against any insured allege negligence or other wrongdoing in the supervision,
hiring, employment, training or monitoring of others by that insured, if the "occurrence" which caused the "bodily injury"
or "property damage", or the offense which caused the "personal and advertising injury", involved the rendering of or the
failure to render any professional architectural, engineering or surveying services.
2. "Bodily injury" or "property damage" occurring after:
a. All work, including materials, parts or equipment furnished in connection with such work, on the project (other
than service, maintenance or repairs) to be performed by or on behalf of the additional insureds) at the location of
the covered operations 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 subcontractor engaged in performing operations for a
principal as a part of the same project.
CG 20 33 04 13 l of 2