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ENC2011-00014CITY OF CAMPBELL DEPT. OF PUBLIC WORKS 70 North First St. Campbell, CA 95008 (408)866-2150 Fax (408) 376-0958 ,NCROACHMENT PERMIT (for working within the public right-of-way) Issued 2 ~~~ Permit Expiration Date 2' ~~ Z ,tit No ~~ ~ !~- ~ ~ - G GG X-Ref. File Application Date 7' ( I Application Expiration ate ~ l~ APN ~~.2,~~7~~ 7 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.) n _ nn _ ,Q~~ 7 A. Work address or tract # ~ ~ ~ ~~ -[ ~ ~ C~~~ /"~L. L ~ ~ ( ~-/~ Utility trench B. Nature of work ~ ~~""t ~-'l~ r L ~~~ 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 [o 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 ]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 a/t~least 24 hours befo1re re~st/a~rting any work. G Name ofAp titan[ t~~(,~~J ~~%~~`~''`-' Telephonc((v~~./ /~~ ~~ ~~ ~b : 6~~ ~ ~v "~ '~t, j~int name) ~,~. , / /~CC _~~ y~ ' Address ~s~~ f~,~[nvs / f,.J y~4-HOUR EMERGENCY TELEPHONE NCCT~O/' ~- ` ~ ~' E-Mail Address /'t-~ ~~'~-~ ~N~ f ("' (~~ S , ~ t~syj Is this work being done by the property owners at their own residence? Yes ~!~No 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 the ve read and understand both the front and back of this permit, and they will inform their contractor(s) of the information. licant is adv' ed that upon issuan oft s permit, property owner, or property owner's successors, shall be responsible for any and all damages arising out o [he ndition o any j~rivate improve nts in th public right-of-way. -~J ''^ Accepted ~ ~ V '7 pplicant Permit[ee) (sign) Date %M- t%'C Z~~/ C~.~ S TIZuL. ~ .~~,..~ .~ r~ (r 'Z~ Z c~ C 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 be specifically approved by the InsQector 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 Sec[ion 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: SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AM2OL7NT RECEIPT NO. PERMIT APPLICATION FEE $ J~ 2 3 Z ~`j PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK & INSPECTION FEE $~ -~~~~ <_::~,: , APPROVED FOR ISSUANCE ~ ~ ~ 2/c For City Engineer Date Permit Expires 12 Months After Date of Issuance r;; ~, , S ;1;~ ;~ ; ~ S ~ . 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 he reviewed and approved prior to any lane closures. 7. The Construction Traffic Control Plan shall conform to the Caltrans Manual of Traffic Controls for Construction and Maintenance Work Zones, dated 1990, available at Caltrans. Traffic control equipment shall include Type 11 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. Sawcu[ for all PCC or AC removals. All PCC removals shall be to nearest scoremark and shall be doweled to existing improvements. 10. Prior approval of inspector is required for any work done after normal working hours, on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 11. Adequate signing and barricading is required on the job site. Failure to provide such signing and 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 a[ 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 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 far 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. l9. Pursuant to Chapter 14.02 of the Campbell Municipal Code, applicant shall not cause to be discharged any material into the municipal storm drain system other than storm water. Applicant shall adhere to the BEST MANAGEMENT PRACTICES established by the Santa Clara Valley Urban Runoff Pollution Prevention Program. 20. If the public interest requires a modification of, or a departure from, the plans and specifications, the City shall have the authority to require or approve any modification or departure and to specify the manner in which the same is to be made for City-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 resp9nsible for ensuring tl~ all t(iose providing services under the applicant are aware of and understand all of the above conditions. Z -~~2yr Applicant Date Date Contractor (Print Name) J\forms\pwperm Rev. 11/9/05 TO: City Clerk PUBLIC WORKS DEPARTMENT LAND DEVELOPMENT & TRAFFIC RECEIPT Effective July 1, 2010 ,~ t PUBLIC WORKS FILE NO. `~}~ 2c G - U Gc ~ 4 PROPERTY ADDRESS ~~ -T ~ ~~~~.L __ Please collect & recei t for the followin monies: ACCT. ITEM LAND DEVELOPMENT" AMOUNT 4 2 Encroac ment ermit A ication Fee _ Non-Utilit Encroachment Permit _ ___ $350.00 SCE Minor Encroachment Permit <~io,ooo $200.00 _ ' ___ I Initial R-1 Permit N/C Subse uent R-1 Permits within Two Year Period $200.00 _________+ 2203' Plan Check De osit 2% of En ineer's Estimate $500.00 min __~_ ______ ____ _ Utility and R-1 Permits no deposit required _ __ _______ 47221 Grading & Drainage Plan Review Single Family Lot ___ ~` $250.00 _ ' Site < 10.000 s.f. $750.00 ___ _____________ _ Site >_ 10,000 s.f < Acre $1.000.00 Site >_ 1 Acre __ $1 500.00 _ Plan Check & Ins ection Fee Non-UtilitV~ _ __ `3~ _ "2203 ~ En r. Est. u to $250.000 14% of Engineer's Estimate 4722' En r. Est. >_$250 000 Actual cost +20% Admin Overhead _ ___ _ ___ _ (Min $35 000 Deposit) 2203 Emer enc Cash De osit 4% of Engr. Est.` ($500 min/$10 000 Max) ' _ 22031 Faithful Performance Security (FPS) __ 100% of ENGR. EST.` _ 22031 Labor and Materials Security ___ _____ _ 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 Map (4 Lots or Less) _ $3.600.00 + $80/lot _ __ I 4722 Ffnal Tract Map (5 or More Lots) __ $4,400.00 + $108/lot ' 2203. Monumentation Security __ 100% of ENGR. EST. _ _ ~ 4920 __ ___ Parkland Dedication Fee X75%/25% Due Upon Cert. of Occupancy) ____ i ___ 4722, Lot Line Ad ustment $1,400.00 _ i4 4722 Vacation of Public Streets & Easements_ ___ $2,250.00 _________ 47221 Certificate of Com liance $1,700.00 _ ,___ 47221 Certificate of Correction __ $500.00 __ ____ 4722 ~, A eal Filin Fee _______ $200.00 47221 Notary Fee (per signature) __ $10.00 j_ _ _ 4722 ~ Assessment Segregation or Reapportionment __ First Split ___ _ _$800.00___ !, Each Additional Lot $250.00 __ ____ 511.7424'1 TRAFFIC 4728' Postage Traffic Flow Ma Dail Traffic Volumes __ $34.00 __ __ 4728'.. Si nal Timin Information $72.00/Hr i 4271 • Truck Permits $16.00/per trip 4728, No Parking Signs M15CELLANEOUS>' ___ $1/each or $25/100 ', I Other (Please Specify) 'Engineer's Estimate shall be as approved by the City Engineer and shall include all items of work. ~ 70 G "Actual Cost Plus 20% Ov/~e~r,^,head (Non-Interest bearing deposit) TOTAL $ NS t~-z-t LZ~-j~~~ ~/'l.~ NAME OF APPLICANT Ivl ~' I ~ ~ ~ / , C~g~ _ PHON ~~ Z ~ L'i` ~y~ (..-~ NAME OF PAYOR / ~ S ~ k -- ADDRESS / , p ~ " ,, `D ,BOA 2-~~Z Cy~~Z~~cM ZIP ~~ Z_~_ FOR RECEIVED Y _ ~ W ~~ . CITY CLERK ONLY ~'~} ~~~ Date ~ ~ Recei t # Q'' *For Pian Check and Cash Deposits, send yellow copy to Finance. Date/Initials t-t~ u y LU11 J \FORMS\TamplatasWOminisitaUVelReceipl Form ~antl Devalopmenl Trailic 10-1 I (Rav C5/1C. INSURANCE REQUIREMENTS CHECKLIST ~0-i Permit # -- C`~i~~r> ~~ 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: ,per $1,000,000 per occurrence, and ^ $1,000,000 general aggregate limit applying separately to the project, or sv $2,000,000 general aggregate limit. ^ Policy expiration date < ~ 7_ ,~=a:'~, ; Automotive Liability: tg.~'"Any Auto" checked on certificate ~''~$1,000,000 per accident for bodily injury and property damage ^ Policy expiration date ~ ~ ~ ~~ ~~j/~2. Workers' Compensation and Employer's Liability ~Y'°"~Vaiver of Subrogation clause ~' $1,000,000 per accident for bodily injury or disease ^ Policy expiration date ~ ~~'~, / ~, Course of Constructio if required in Special Provisions) ^ Completed va of the project ^ Policy exp' tion 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 such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives". ^ Workers' Compensation Insurance Sheet Submitted ^ For General Contractor ^ For Developer or Owner Acce abilit 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. Campbell Business License #~Z,a;~. n~ j Insurance Certificate ~ (~ Initials v ~ Da ^ Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\hrsurance Requirements\lnsurance Requirements Cklist.doc (Rev 05.10) OP ID: VC '`~`~,.~°ROp CERTIFICATE OF LIABILITY INSURANCE I DAT07/25/11rrY) 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 endorsements . PRODUCER 408-979-8160 NAME: CT MISSION COUNTIES INS AGCY INC 408-978-6801 PHONE Fax License # 0544474 ac No Ext : _ IA/c, Not: __ P O BOX 6717 E-MAIL ADDRESS: _ _ _ _____ SAN JOSE, CA 95150 PRODUCER METHO-1 ____ Veronica Castro CUSTOMER ID #: INSURERISI AFFORDING COVERAGE NAIC # INSURED Method Construction, Inc. P O Box 2702 Gilroy, CA 95021 INSURERA:.SCOtt8dale Insurance CO. INSURER a :Property 8r Casualty Ins #34690 INSURER c :Granite State Insurance INSURER E f`AVFRA(_FS RFRTIFICATF NIIMRFR• RFVLSIAN NIIMRFR• 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. INSR LTR TYPE OF INSURANCE A L U POLICY NUMBER MM/DD/YYYY MMIDDY/YYYY LIMITS GENERAL LU181LITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY BCSOO23760 12/30N0 12130N1 DAMA E TO RENTED PREMISES Ea occurrence 50,00 $ CLAIMS-MADE ~ OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ 1,000,00 i GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: i PRODUCTS -COMP/OP AGG $ 2,000,00 POLICY PRO LOC $ AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT id E t $ 1,000,00 08/0 /11 08/05/12 en ( a acc ) B X ANY AUTO 57UECPC6425 5 BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE -- X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION X WC STATU- OTH- ' T RY LIMIT R LIABILITY AND EMPLOYERS Y/N C ANY PROPRIETOR/PARTNER/EXECUTIVE 00310088 08/01/11 OB/O1/12 E.L. EACH ACCIDENT $ 1,000,00 OFFICER/MEMBER EXCLUDED? ~ N / A 1 00 000 (Mandatory In NH) E.L. DISEASE - EA EMPLOYEE , , $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATKNS /LOCATIONS /VEHICLES (Akaeh ACORD 101, AddlUOnal Remarks Schsduls, H more spaea Is roqulred) Project: 384 E.Campbell Ave, Campbell CA All work in public right-of-way. City of G~ampbell, Cittyy of Campbell d d l unteers are name as vo Redevelopment Agency, Its officers, employees an Such insurance as is afforded b ' Li bili t dditi l i d y ~ ty. nsure s as respec s a ona a ~~~~ I ~ _ ~U I h n r l Li iii li i rim in r n n h r in urn f /~~ <r~~MPCIT ~1(/~ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of Campbell .q A~/e ~bt ., O ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Dept of Public Works ~'1i~~0 ~ ~0~~ AUTHORIZED REPRESENTATIVE 70 North First Street ~-' 0,4 Campbell, CA 95008-1039 ~TjQS ~ ti © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD From:MISSION COUNTIES INSUF - 4089786801 0210" ''1 15:52 #968 P.0011004 coir~~ CERTIFICATE OF L[AB[LlTY INSURANCE OP ID v~ _-.~-'- --- ~,/ METHO-1 02 09 11 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION MISSION COUNTIES INS AGCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE License # 0544474 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P 0 Box 6717 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. SAN JOSE CA 95150 Phone: 408-979-8160 Fax:408-978-6801 !INSURERS AFFORDING COVERAGE ~ NAIClk INSURED !~ INSURER A: SCOttad8le In811ran_C__e Co. i ~-'~ v_____ INSURER B: property s Casualty ice ><14690 _~ \,~, ~ ~'~ Method Construction, IIIC. ~ INSURERC:--__Granite State Insurance ~ ~~_,,,, '-- - - -- P O BOX 2702 INSURER D: Gilroy CA 95021 - -- --- INSURER E: COVERAGES -- _ THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO tHE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NO-f WITHSTANDING TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT W tTH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR ANY REQUIREMENT , MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDfT10NS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ ,~_ _~-T_.__._ LTR NSR TYPE OF INSURANCE '~ POLK:Y NUMBER pgTE~~ DATE MMIODM'YY LIMITS I GENERAL LIABILITY j EACH OCCURRENCE $ 1, O O O, 0 0 0 ti- ~ COMMERCIAL GENERAL LIABILITY ! A I X ' BCS0023760 12/30/10 12/30/11 PREMISESjEaoaurence) '~ $ 50, 000 __ -- - ~ - _ i CLAIMS MADE ~ OCCUR ~ ` MED EXP (Any one parson) $ -.-.------- - f 000 I ~ ~ ~ PERSONAL&ADV IWURY $ 1, 000, ', -.....___......._ ~~ I ~i , i _ GENERALAGGREGATE $ 2, 000, 000 '~ J ~ ~ .~-- -- ---.. - GEN'L AGGREGATE LIMIT APPLIES PER: I ~ ~ ' PRODUCTS -COMP/OP AGG $- 2 , O O O , O O O - ~- - POLICY --_~ PRO- -~--' LOC JECT -~- - AUTOMOBILE LABILITY I COMBINED SINGLE LIMIT $ 10 0 0 0 0 0 $ ~ ANY AUTO 57U8CPC6425 ' 08/05/10 i i 08/05/11 Ea accident) L( ALL OW NED AUTOS '_ __ X SCHEDULED AUTOS ~' ~ ~ ',- ': t ~ BODILY INJURY (Per person} S _._- i _ X .HIRED AUTOS l I BODILY INJURY P dd t $ ! NON-OWNED AUTOS i en er ac ) ( __. _-i ~---- i ~ ~I ' PROPERTY DAMAGE (Per accidani) $ , 1'+ GARAGE LIABILITY ~ AUTO ONLY - EA ACCIDENT $ __ _ _ ANY AUTO ~ p~ ~~ OTHER THAN ~ ACC $ ___-~- 4J o g } ~ z® ~ AUTO ONLY: -----. i AGG $ EXCESS! UMBRELLA LABILITY ~ ~: r'U~LIC: EACH OCCURRENCE , $ . '`°`~MIN ' ' J OCCUR ~ CLAIMS MADE ~ 1~11 j -~QN AGGREGATE ~ $ _ i ~ $ __.. __- ~ DEDUCTIBLE ~. I $ ~ RETENTION $ k -------___.._----- --- i $ WORKERS COMPENSATION X TORY LIMITS ER _ __ ------ C i AND EMPLOYERS' LIABILITY ~ ANYPRDPRIETOWPARTNERIEXECUTIV YIN 00310088 08/41/10 08/01/11 ._______ E.L. EACH ACCIDENT ~ 1000000 OFFICERlMEMBER EXCLUDED? MPLOYEE $ 10 0 0 0 0 0 (Marrclatory 1n NH) ErE.L. DISEASE - EA E If yes, describe under SPECIAL PROVISIONS below i ~ E.L `DISEASE-POLICY LIMIT $ 1000000 OTHER ~ DESCRIPTION OF OPERATIONS f LOCATIONS !VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT !SPECIAL PROVISIONS Project: 384 E. Campbell Ave, Campbell, CA All work in public right-of-way. City of Campbell, City of Campbell Redevelopment Agency, its officers, employees sad volunteers are named as additional insureds as reapecta Liability. Such insurance as is afforded by the General Liability policy is primary insurance and no other insurance of rconclr~eTC unl nca CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATK)N CAMPCIT DATE THEREOF, THE ISSUING INSURER YYILLiIiDMY9R TO MAIL 3 O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LE , I , City of Campbell Attn: Dept of Public Works AUTHORIZED REPRESENTATIVE 70 North First Street Cam bell CA 95008-1039 ACORD 25 (2008!01) ©1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD From:MISSION COUNTIES INSUI - 4089786801 02lC 11 15:53 #968 P.0041004 "' r ~. POLICY NUMBEF~ BCS 0 02 3 7 6 0 COiiAMItEf~C1AL GENEtiAL L1/481LJTY c~ uo~ os a WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO U S This endorsement modifies insurance provided under the following: COMMF..RCIAL GENERAL LIABILITY COVERAGE PART PFiDDUCT'S1 COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Narrw Of Person Or Organixatlon: ANY PERSON OR ORGANIZATION WITH WHOM THE INSURED HAS AGREEA TO WAIVE RIGHTS OF RECOVERY, PROVIDED SUCH AGREEMENT IS MADE IN WRITING AND PRIOR TO THE LOSS The tollowring is added to Paragraph 8. Trsnsier Of RigtMs Of t~soovary Apaint Olfws To Us of Secifon N-Condltlons: 1Me wanre any right of rooovery we have against the person or organization shown ~ if~e 3cheduie above t~ecause of payments we malts for injury or damage arising aut of your ongoing operations or your work' done under a contract wR~ that person or anizatbn and inckrded in the'products- com~eted operations hazard". This waiver applies any to the perBOn or organization shown in the Schedule above. CG 24 l14 05 09 ®Insurance Services Office, inc.. 2008 Pap 1 of 1 O www soar From:MISSION COUNTIES INSU', ,.,. { POLICY NUMBER BCS 0 0 2 3 7 6 0 4089786801 02/[ 11 15:53 #968 P.003/004 ,--. i trQNME,I~IAL GENERAL tJAf3lurY CG ~O 37 fJ7 OL 'THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ R CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -COMPLETED OPERATIONS This endorsement modifies insurance provided under the foibwing: COMMERCIAL GENERAL. LIABILITY COVERAGE PART SCHEDULE Nance O[Addibia~al Insured ParaaKs) Or O s : L~oe~tlort And Of ANY PERSON OR ORGANIZATION ALL LOCATIONS WHEN YOU AND SUCH PERSON OR ORGANIZATION HAVE AGREED IN WRITING IN A CONTRACT OR AGREEMENT, EXECUTED PRIOR TO THE "OCCURRENCE" TO WHICH THIS INSURANCE APPLIES, THAT SUCH PERSON OR ORGANIZATION BE ADDED AS AN ADDITIONAL INSURED ON YOUR POLICY Information wired to late th~ Scftedu if not shown abo will be shown ~ the Declarations. .cseliorr II -Who Is An Irraurod is amended to in- clude as an additional insured tt-e persons) or or- ganization(s) shown ~ the Schedule, but only witt- respect to liebilirty for 'body injury` a ~toperty damage' caused, in whole or in part, by 'your work" at the locadion designated and described ~ the schedule of this endorsement patfoRrted for that additional insured and inc~ded in the ~roducts- oompleted operations hazard". CG 20 3T 07 Qt ®iS0 Properties, Inc., 2004 Page 1 of 1 [] Inw~.e coot