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ENC2011-00040CITY OF CAMPBELL DEPT. OF PUBLIC WORKS 70 North First St. Campbell, CA 95008 (408)866-2150 Fax (408)376-0958 F, :OACHMENT PERMIT (for working within the public right-of-way) Issued ~'2 ~ -2G l I Permit Expiration Date ~ ~~ 1 "Z G~ L Perr. p ~ ~ ~ '- ~~% X-Ref. File Application Date ~ ' ~ Application Expiration Date i0 `-f {~ ~ (( APN Z~9 -'4~ -~ 3`~ 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 ,~ A. Work address or tract # ~ ~ ~ ~ ~ 1.~Y1~117~J~ 1 ~ ~P . Utility trench 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 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 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 (east 24 hours before restarting any work. n ~ D J"r~~G `Tevc~ ~. 7 ~.~ 7 Name of Applicant / ~~~ J~ ~ ~ P. Telephone T~ i (Pr~ t amc)c,. - (~Ov^dl. ~ °t5.:5G ~~_ "( Address ~~C:~ ~ ~ d,~r f ~~ ~W`~Z4-HOUR EMERGENCY TELEPHONE NO. S~d~ • J /~ ' Z~I ~ / E-Mail Address J j6,~~.c !-'. l r._» ~ ht ~~-Yl~ 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 ApplicanUPermittee here a nowledges 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 dvis 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 conditi of y private i prove n the public right-of-way. Accepted ~GC h ~ f I (Applicant Permittee) (sign) ate Contractor (Print Name) llate SPECIAL PROVISIONS _l . Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts mati, be specifically anproved by the Inspector prior to cutting. _2. Pavement may be cut for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method "A", unless otherwise approved by Inspector. 3. Work to be staked by a licensed Land Surveyor or Civil Engineer and two (2) copies of the cut sheets sent to the Public Works Department before starting work. 4. Per Section 4215 of the Government Code this permit is not valid for excavations until Underground Service Alert (USA) has been notified and the inquiry identification number has been entered hereon. USA Phone 1-800-227-2600. USA TICKET NO. 5. Prior to any work, the property owner shall execute an Agreement for Private Improvements in the Public Right-of-Way, which shall be recorded. 6. Public Notification Requirements: 7 SEE P[IBLIC WORKS FEE SCHEDULE FOR CURRENT FEES AMOUNT RECEIPT NO. PERMIT APPLICATION FEE S~ 23 4~F2~ PLAN CHECK DEPOSIT S SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $ CONSTRUCTION CASH DEPOSIT 8 PLAN CHECK & INSPECTION FEE G as APPROVED FOR ISSUANCE - ~-ZI '-Zt~i ( For City Engineer Date Permit Expires 12 Months After Date of Issuance s~CU .TENERAL PERMIT CONDITIONS l . 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. G. 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 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 he to nearest scoremark and shall be doweled to existing improvements. 10. Prior approval of inspector is required for any work done after normal working how's, 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 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. l4. 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. I ~. 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. I6. 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 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. [f 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 respons~for ensuring that all those providing services under the applicant are aware of and understand all of the above conditions. Contractor (Print Name) 1 L, Kfae~ ~~ ~ Da Date J\forms\pwperm Rev. 11 /9/05 t'UtiLIG VVVKY~J Uth'HKI IVICIV I LHIVU UCVCLVYIVICIV E & I KHI't'll. KCI.CIt' I Effective July 1, 2010 ~ ~ ~ i ~ ~ TO: City Clerk PUBLIC WORKS FILE NO. --- -- ~ l ------------ --- -- -- ---- ~ PROPERTY ADDRESS 2~.0~___~ ~ ii d C$r1r~j~~QJ~ I ~lY_-~____ ____ Please collect & recei t for the foliowin monies ~~ ~ ACCT. ITEM AMOUNT I LAND DEVELOP MENT 4 22 ~ ncroachment ermit A p icatlon Fee _ __ Non-Utility Encroachment Permit $350.00 ' Minor Encroachment Permit <~~o 000 _ $200.00 _- _ Initial R-1 Permit N/C _ Subsequent R-1 Permits within Two Year Period $200.00 203 ' 2 Ptan Check Deposit 2% of Engineer's Estimate $500.00 mm Utility and R-1 Permits no deposit required 4722 Grading & Drainage Plan Review Single Family Lot $250.00 Site < 10.000 s f $750.00 _ ----- --- - ~ ---- -- - -~ Site ? 10.000 s.f < Acre r $1,000_00 __ ___ Site >_ 1 Acre $1 .500.00 - -- (Pla n Check & Inspection Fee Non-Utility) ___ -__-__ _ _ _ - --_ _ _ I "22031 Engr. Est. up to $250.000 ______ _ 14°~ of Engneer's Estimate _ __ __ _ _ ___ 4722! _ _ _ _ Engr. Est. ?$250.000 Actual cost +20% Admin Overhead _ _ _ 1 _ _ _ I _~03 ? Emergency ~asn De osit _ _ Oro of ~n r Est ' ($500 min-/$10.000 Maxl _ PeE ? - 1 ~ 203 Faithful PerformancSecurit (FPS 100°io of ENG ' 2203 Labor and Materials Security 100°~° of ENGR. EST I -- 4721 ~1 Storm Drainage Area Fee Per Acre R-1 $2 120.00 li 1Multi-Res $n.385 00~ - -- - -- - --- 1 (All Other $2.650.OOi ----- -22 47 ____ _____ _ __ Parcel Map ~4 Lots or Lessj ____ -- - _ - $3.600 00 + 58011ot -- - - --- -- - ---- - 4722 Final Tract Map (5 or More Lots $4.400 00 + $108/iot -- -- ~' 2203' Monumentation Security 100% of ENGR. EST. 1 1 49201 Parkland Dedication Feed°ib/25°ro Due~on Cert__of Occupancy) _ I 4722 Lot Line Adjustment 51.400.00 4722.: Vacation of Pubiic Streets & Easements $2250.00 _ ~ 4722'. Certificate of Compliance- $1.700.00 4722. Certificate of Correction $500.00 -- _ 4722 A eal Filin Fee $200.00 1 7 n o - s $10.00 - - ----_ --- - _ - __ ----_ _- - _ -- -- I 4 21 Rea~portionmenf A sessment Segregatio -__ ~ First Split - - - -- $800.00 -- - --- _--- -__ --_ j __ _ ~ Each Additional Lot 5250.00 1 _ ~11.74~4 Postage -___ ___ _- _ _. ___ TRAFFIC 4.28 V Traffio Flow Map (Daily Traffic oiumes) _ $34.00 _ i 4728 _ _ ___ _ Signal Tlmina Information _ _ _ ____ ___ $72.00/Hr ~ _-- -- 4271 Truck Permits 516.00/ ear trip - - -- 1~ 4728 ____ _______ No Parking Signs $1/each or $25/100 1 MISCELLANEOUS l Other (Please Specifyl - ----- i "Engineer's Estimate shall be as approved by the City Engineer and sh all include all items of work. II "Actual Cost P lus 20 ~~ Overhead (Non-Interest bearing deposit) TOTAL $ .y~~ '"- ~ NAME OF APP LICANT ~'~~('(~_ ~Pl~VI t ` ~J,~ ~(L 11_~-~ _t`'TO ~y~- - - ~s--"`' -- --- -- -- ---- - - ----- - --- --- NAME OF PAY OR ~ PNONE ____ __ j ADDRESS __ _ ~Gj(~r'J' 1~ ~ ~-C{c SST, ~-/~~A_~~ia~ ZIP ~~j~~ __ FOR ry IRECEIVEDI` CITY CLERK e ~ J ONLY Dat i t# i *i=or Plan Gheck and Cash Deposits, end yellow copy to Fina e. ~ Datel Initials ~ i.l i i Li ~. iil n •- i~;L=~ ii;.~. :+MiaL~'l': t;~;, , -lJ~i; 77t,~, a,e~U u~i i~ ' ~ i ., ~/ INSUItEiN~E REQUIREMENTS CHE~h:LIST Permit # ~~C~%~~l - OGO ~~ CIP Project 2 (c ~7 E, C can ~,oh e /l ~ ~~ . The following insurance is required of all contractors working in the Cit}~ of Campbell public right-of--way. lnsurance certificates must be accepted b}~ Cite staff before work can be~,in. These insurance requirements apply to wort: 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 propert~~ damage: ~ l .000.000 per occun-ence, and ^ X1,000.000 general aggregate limit applying separately to the projec. or 1 "?.000,000 general aggregate unlit. ~ Policy expiration date (~ - 1 ~3 =1,x,11 Automotive Liability: ,~ "Any Auto' checked on certificate ~ n1,000.000 per accident for bodily injury and property damage ~ Policy expiration date C, - I ~ -2C~ l! --(rucit lrtsur~v~c~ ~~~orl:crs' Compensation and Employer-s Liabilit~~ ~=xc~~2n c~- ^ Waiver of Subrogation clause r~~ p>~~,-t- ~ p, : X v' ~ $1.000,000 per accident for bodily injury or disease C1~ i~ xt j~q9~-9 ^ Policy expiration date ~ - ~ -,1~ ~ ~ Cour ~ onstr~~ ~f required in Special Provisi ns) Completed value of the - ~ect ~^ Policy expiration date P.eQUired Endorsements to General Liability and Automobile Liabilin~ Policies Additional hisured Endorsement ~r The City. the City of Campbell Redevelopment Agency. its officers. employees and volunteers are named as additional insured. ~ The insurance covera~~e 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 obli~~ation or liability of any kind upon the compan}~, its agents or representatives~~. tip; ~cs~<<~?5 ~nL ^ Workers' Compensation Insurance S11eet Submitted ^ For General Contractor ^ For Developer or Owner Aece~ability of Insurer(s) Insurer(s) has current A.M. Best Rahn;.; of A:VII business in the State of California. ~ Campbell Business License ~ (~ ~ ~~ 9'S Co b~Li, Insurance Certificate Reviewed and is authorized to transact ~~3 i/~~ ~ Dare Copy of Insurance Certificate placed in tickler file one month prior to expiration. .I:ArORh15,Temnlates`,Liswance Requirements\hisurance Ru{uiremcnts Claist.doc (Ilcv 0~. 10 i e ~~°~-` CERTIFICATE OF LIABILITY INSURANCE DATE(MMJDOJYYYY) I 4/20/2011 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), AVTHORl2ED ! REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. ' IMPORTANT: IFthe certificate holder is an ADDITIONAL INSURED, the. policy(ies) must be endorsetl. J€ SUBROGATION IS WANED, subject to ' the terms and conditions of the policy, certain policies may require an endorsement A siatemertt on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER ! ! NAME: LEMMON INSURANCE AGENCY PHONE arc No ~,. (908.) 779-7665 , (Arc.Nb}•{.408) 779-1856 ~ 17680 Monterey Rd - IL ADORESS:bob@rclemmon.com Morgan Hill, CA 95037 -~ CUSTOMER ID#: ___ INSURER(S) AFFORDING COVERAGE NAICF INSURED pELICAN SIGN SERVICE INC . wsuRER A: TRUCK INSURANCE EXCHANGE 1565 LAFAYETTE ST INSURER B : ! `~ I SANTA CLARA, CA 95050 INSURER C : 246-3833 INSURER D: - -t--+ INSURER E :. ~ INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: TN151S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERiOp ; i INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS i I 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 $Y PAID CLAIMS. IN9R I - ADDL LTR TYPE OF INSURANCE INSR SUOR WVD POLICY NUMBER MMlOD/YYYY MM/DDJYYYY i LIMITS GENERAL LIABILnY _ I ~ EACH OCCURRENCE ~. I $ 1 , OOO , OOO j , X ;COMMERCIAL GENERAL LIABILITY I I ' ~ !PREMISES E ~ I $ 100 000 ~ I I ! a occurrence r ~_~ CLAIMS-MAD£ OCCUR ~ 1 i ! ~ MED EXP (Any one person) i $ 5 , 0 0 0 A ; I Y ~..,~ ! i ~ 60482 91 29 6-18-2010 ~6-18-2011 ~ -~ ; i PERSONAL&ADV INJURY ], OOO 0 00 I S r r I ___..__ ~ r ! j GENERAL AGGREGATE _ ! $ 2 r 000 r 000 I GEN'L AGGREGATE LIMIT APPLIES PER: ~ I ! !PRODUCTS - COMPlOP AGG j $ 2 r 000 r 000 ! li f POLICY ~ ' PRO• ~I L } { JECT LUC ! I ~ ; $ ! 'AUT i j X OMOBILE LIABIUTV i ANYAUTO ' , ~ ~ ~ ~ i COMBINED SINGLE LIMIT ( (Ea accident} - ~ $ 1 , 000 , 000 j i - ! ~ I BODILY INJURY (Per person) + S I ! I f A ~ ALL OWNED AUTOS SCHEDULED AUTOS ~ Y 604829129 i----------._....___j 6-18-2010 `6-18-2011 j BODILYINJURY(Peraccident) I _....__-..__._~ I $ L- ;PROPERTY DAMAG i ~ ~+ HIRED AUTOS i I E $ I I (Per accident} j X_ ~ i NON-OWNED AUTUS r I ~ ~ ~ $ t i ~ $ I I ; UMBRELLA LIAB X OCCUR I I ( I TEACH OCCURRENCE ( $ ! ! }{ i EXCESS LIAB CLAIMS-MADE ( Y ~ ~ ~ AGGREGATE i $ - ~ I ~ I DEDUCTIBLE ; ( ~ II ~~~ $ ~ i X i R[TENTION $ ~ I I _~~~- ' i E ~ WORKERS COMPENSATION ! ( ( ~ ;AND EMPLOYERS`LIABILITY YIN { ( ~ ~ C TATU- OTN- ~ X TORYLIMITS ER , I A ANV PROPRIGTOR!PARTNER/EXECUTIVE 1 ~ OFFICER/MEMOER EXCLUDED? NIA I ~ A1911 O V 10 ( Y I _ 8 - 7 -10 I8' 7 -11 ___ E.L. EACH.ACCiDENT ' 1 00 000 ': 0 $ / , tMantlatory m NNI . If Bb debClll)e Under ! I ! El. DISEASE - EA EMPLOYEE $ 1 ! 00 0 [ 0 Q Q I , .DESCRIPTION OF OPERATIONS below ' ~ E.L. DISEASE -POLICY LIMIT ... $ 1 , 000 , 000 i ' I ~ I ~ I + !! ... i ! wtscrclrl IuN ut- urtltAUDNS/ LOCATIONS I VEHICLES (Atfach ACORD t07, Adtlitional Remarks Schedule, ii mwe space is required) j267 E CAMPBELL AVE PERMIT # BLD2011-0031 FILE # ENC2011-0:0040 TALL WORK IN PUBLIC RIGHT OF WAY, CITY OF CAMPBELL, CITY OF CAMPBELL REDEVELOPMENT AGENCY ITS OFFICERS EMPLOYEES AND VOLUNTEERS TO BE NAMED AS ADDITIONALLY INSUREDS AS RESPECTS LIAIBLITY CANCELLATION CITY OF CAMPBELL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ATTN: DEPT OF PUBLIC WORKS THE EXPIRATION DATE THEREOF, NOTICE WILL 8E DELIVERED IN 70, NORTH FIRST STREET ACCORDANCE WITH THE POLICY PROVISIONS. CAMPBELL CA 95008 AUTHORIZED REPRESENTATIVE ~ ~ /~ ~ ~ O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD25(2009/09) The ACORD name and logo are registered marks of ACORD Attach to your policy with the same policy number shown on this endorsement. PRIMARY PROVISION ENDORSEMENT Effective Date: APRIL 19, 2011 b0482 91 29 Policy Number of the company designated in the Declarations This endo~•sement rnodi:Eies Insurance provided under the following: Businessowners Policy SCHEDULE Name of Person Or Organization: CITY OF CAMPBELL, SEE L+'0002 if the additional insured designated herein has an Other Insurance provision making its policy excess, and You agreed in a written contract or «mitten agreement to provide the Additional Insured coverage on a Primary basis under the provision of the Additional Insured endorsement BP 04 48 Ol 97 attached hereto, then this po]cy shall be Primary to any insurance issued directly to the Additional Insured, provided such written contract or written agreement were executed prior to the issuance of the Additional Insured endorsement. This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is otherwise subject to all other teams of the policy. COUNTERSIGNED (Date) 91-0002 (E 0002) t'~ EDITION 3-88 ~ Printed in U.S.0. "~" TRUCK INSURANCE J FARMERS INSURANCE .r MID-CENTURY n p EXCHANGE EXCHANGE INSURANCE COMPANY S ~V~~D NCCI CO. NO.18244 NCCI CO. NO.17744 NCCI CO. NO, 12998 SALIFt)RXIA 2nd 6'dlt3on WC3RKERS` GOMf'EHSATi©N ANC f=MPf_OYERS' LIABIC,ITY fNSURANCE PQLtCY Named , PELICAN SIGN SERVICE INC insured 1565 fAFAYETTE ST Agent j SANTA CLAfiA, CA 95054 96-63-319 A191i86i0-00 2010 Policy Number Poiicy 4-20-2011 of the Company Year Effective Date . WAVER flF flUR RIGHT Tfl REGfl1tER f=RflM pTHERS ENDORSEMENT - CALERORNfA We have the right ~ recover-our payments trom anyone tiabte-for an injury coverd~by=~tris paticy. We ~rri}t not anfor~ ourright-ayai;-~st u'ie ---- person or organization reamed in the Sr~tedule. (This agreement applies onfy to the extent that you perform ~vortc under a ti~rritten contract that requires you to obtain this agreementfrom us.} You must maintain payrot! records accurately segregating the remuneration oz your employees while engaged in the vrork described in the Schedule. fie additional premium for this endorsement shalt be 3 °!o of the Cat'~;ornia Vdcrkers` Compensation premium olhenrise due on such remuneration. Minimum Charge: $750.110 Sahedute Person orOrganlzatlon Job Elescription CrTY of cAt~BEil: AT"I'N: DEPT OF PUBLIC WORKS, 70 NORTH FIRST STREET; CAMPBELL CA 95008 RE: Ii OR WORK PERFORMED AT 267 E C.A~'~ZPBEI,L AVE; FILE #EtiIC 2011-00070 PER~'v1iT # BLD 201 I-0031 IN PUBLIC RFGHT-OF-WAY, CITY OF CAtV1.PBELL, CITY OF CAii~iPBELL REI3E~lELOPiI~IENT AGFNCY, ITS OFFICERS, EMPLOYEES AND VULITitizTEERS. pis endorsement is Bart of r policy. tt sulrers;;des 2nd controls anythng trt the contrar,+. It is athanvise subject to a}l fire ferns c L;s Lucy, i//r.~~"" ~ ~ ~ r ountersignad _ _ ~-~`~ Authorized Representative zroo Eomora 7-sa (VVC C4 Q3 4& - Edi<tton 484} Page 1 of 1 Jeanine Grundman From: Jeanine Grundman Sent: Tuesday, April 19, 2011 2:53 PM To: 'bob@rclemmon.com' Subject: Ins. Regs. for Pelican Sign Service Attachments: 157341.pdf; Insurance Requirements.pdf Hi Bob, I am checking insurance for Pelican Sign Service Inc. as they intend to start work on a project at 267 E. Campbell Ave. under Encroachment Permit number ENC2011-00040 with the City of Campbell. There are a few additional items required for us to accept their insurance certificate for the project: 1. Please revise the certificate to indicate that the insurance coverage afforded to the Additional Insured is Primary insurance. 2. "Any Auto" is checked on the certificate. 3. We also need a copy of the Waiver of Subrogation clause for Workers' Comp. and Employer's Liability. I have attached the City's Insurance requirements as well as the Pelican Sign Service Inc. Insurance Certificate. Thank you so much for looking into this. Please reference the above permit number and address on the revised certificate. Have a very nice afternoon. Thank you very much, Jeanine Jeanine Grundman City of Campbell Department of Public Works 70 N. First St. Campbell, CA 95008 408-866-2150 phone 408-376-0958 fax 4/19/2011 APR-19-2011 11:09 From: To:37'=9958 P.2~3 .....~ -~`~~~- CERTIFICATE QF LIABILITY INSURANCE 4%isi2ox"i THIS CERTIF{CATE IS ISSUED AS A MATTER OF INFORMATION pNLY AND CONFERS NO RIGHTS UPpN THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE PCf LICaE3 BELOW. THIS CERTIFICA7F OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S). AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTiPICATE HOLDER. IMPORTANT: It the certificate holder is an ADDITIONAL INSURED, the pOI1Cy(los) ntuel ba endorsed. If SUEIROGATION I$ WAIVED, suhJccl to tpo term9 and condltlone of the policy, certain policies may require an endofsomont A statement on to{s rcrtitiwte does not confer Hghts to tim CertlflGate holder In Ileu of surh endorsement(s). RRODUCER NAME. LEMMON INSURANCE AGENCY (40$) 779-7665 a~ Noy(Q08) 779-1656 (ac niu Exu 17880 Mgnter~y Rd , . r:~mt"' AuDKESS.bob@rclemmon. cOm -- r7organ Hill , CA 95037 r uu (;I~ "` -' - - GU°TOMCR IU q I INSURER191 AWUItOINC rnyERAOE NAICa INSURED PELICAN SIGN SERVICE INC . INSIIRFR A TRUCK INSURANCE EXCHANGE 2( ~ ~ _ _ 1565 LAFAYETTE ST wauutrt u ~_ _ _ ^• SANTA CLARA, CA 95050 INSURER C _ 24 6-3J~33 INSURER D INSURCR [ I IN!iUKtK F . I;UVERAGE9 CERTIFICATE NUMBER REVISION NUMBER. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANOE LISTEp BELOW HAVE BEEN ISSUED TO IHt INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITtISTANDING ANY REOUIREML-NT, TERM OR CONDITION Or ANY CONTRACT OR OTHER DOCUMENT Wll'H RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, TkE INSURANCE APIT01'~UCD BY THE POLICIES DESCRIBED HEREIN t$ SUBJECT IU All THE TERMS, EXCLUSIONS AND CONDITIONS Or SUCH PpLICICS LIMITS 51 IOWN MAY HAVE BEEN REDUCED RY PAID r,LAIMS. IN6R POLL' 3LIG'Y 'f( LrR TYFF (7F INRIIAANC.F INSR wvp POLICY NIIMRFR MMlUU1vvYY ~ MM/DDIYYYY LIMITB ' GCNCRAL LIADILIfY' EACH OGGURRENLE $ I , DOD ~ QOQ i X f.pMMFRCIAI f;FNFRAI I IAAII ITY REMISg~(E=a occurrence) S 100 r 000 I ~ GLAfMS•MAUE I -- UCCUIi -._. MCD CXP(Ai~yone pmaun) 16 5 r OQO ''I A ~'' Y (,0482 91 29 8-18-2010 6-18-2011 pCRSONAL&ADVINJIIRV S. 1, Q1000 .__ ._ .. GENERA[ AGt;RFL 1A I'E S z r 0 0 0, O d 0 II GCN'L AGGRECATC LIMIT APPLIES PER ~ PROD11f:T;- CUMPfUPAGG ~ = 2 i 00~ ~ QOQ . I'RO- r S ' AUTOMOBILE LIABILITY CDMRINEU SINGLC LIMIT S ' -- ' (Ea accidaRl} 1, 000 , 000 i ~ , ANV AtITD I NUUILY INJURY (per perean) $ ' A X ALL U4VNtU A! I I US I ~ Y 604629129 6-18-2010 6-1B-2R71 BOQ4Y INJURY (Per ecrldent) ___ :t -- SCHEDULED A11T05 ., I'KUYERTY OAMAC,F , X KIRFr7 AUTO& ~ (Pcr Rry,7tlenl) 6 X NON-OWNEG AUTOS 3 I S t1MBRELLA LIAB X Ut'.t;UK EACIa QCr.IIRgENCE I ){ `EXCESS LIAB CI n1MS~MnDF . Y ~ ACCRFf.gTE S. F UF,DUCTIrIIC I ', t S X RE1'EN'I'IUN $ . S y, WUHKt:kS CUMFtNSATION X WC JT ~ Fq I A AND FMPI OYFRS IIARILITY I AITS ', A i vtN ANT PROPRICTOR.'PARTNCRICX000TIVC I OFFICERIMEMBE - N A y y y A19118610 , p y $-7-10 8-7-11 EL CACIIACCIDtN'r $ /~ /~ 1,000,OOU i R ENCLUOEOT IMnndarny in NHj ~ t.L DISEASE FA EMPLOYE[ $ 1 OOO OOO I / r IIy9F d66Gflb?Untlar UL•SCllll' I It}N UI UI'tIL41 WNS he19W I E 1. 1718FA6E -POLICY LIMI I T /~r~ 1 OOO V4O r ~ I DE$CRIPTIQN QF QPFRATIQN$ / LOCATIONS! VCI IICLCS (Attxh ACORD 101 AddHional R4nlaths, S~I1tlJultl. if mule epacr: is rrgnlrnn) 267 E CAMPBELL AVE PERMIT # BI,D2011-0031 FILE # ENC2011-00090 ALL WORK iN YUBLIC RIGHT OF WAY, CITY OF' CAMF$ELL, CITY OF CAMPBELL REDEVZaLOPMENT AG OFFICERS EMPLOYEES AND VOLUNTEERS TO 8E bTAMED AS ADDITIONALLY INSUREDS AS RESFECT3 L ENCY ITS IAIBLITX CITY OP' CAMPBELL ATTN: DEFT QF PU$Z,IC WORKS 70 NORTH FIRST STREET CAMFBELL CA 9500$ SHOULD ANY 01 IIIE ABOVE DESCRIBED POLICIt;$ [1C CANCELLED BtF'pRE THE CXPIRATIDN DA'L'E rHEREOF. NOTICG WILL B£ DELIVERED IN ~ ACCbRDANCE WITH T'Ht POLICY PROVISION."i j AIITI IfIwkU KtF'KESENTATIVF. ~ 1 AA8-2009 ACUKD CORPORATION. All rights reserved. ACORD25(2009109} The ACQRp name and logo are registered marks of AC^RO APR-19-2011 11:09 From: To:3758958 P.3~3 POLICY NUMBER. 804829129 BUSINESSOWNERS THIS ENDORSEMENT CHANGES 7NE POLICY. PLEASE READ IT CAREFULLY ADDITIONAL INSURED-OWNERS, LESSEES OR CONTRACTORS This endorsement rrrodities insurance provided under the following: EiUSINESS OWNERS POLICY SCHEDULE" Name Of Person Or Organization: CITY OF CAMPBELL, CITY OF CAMPBELL REDEVELOPMENT AGENCY ITS OFFICEi4S EMPLOYEES AND VOLUNTEERS ~Infcrrmation required to romplete this Schedule, if not shown on this cndorsernent, will be shown in the Declarations The fotlowng is added to P2ragraph C. Who is An Insured in the Businessowners Liability Coverage Form: 4. Arry person or organization strown in the Sched- ule is also an insured, but only with respects to Lability arising out of your ongoing operations performed for that insured. BP 04 50 01 97 Copyright, Insurance Services Office, I~~c; , 1997 Page 1 of 1 f~PR-19-2011 11:89 From: Ta:37S8958 P.1~3 7 ,l'lt r f[18_t~~~~--38:3:3 ~._,... ~.~.~~•wR0(l-9~~i-:fir"l~N~ ~; ........_.._._._,_~__.__...rr--~ ~ ; ~,s--~__ 1 - ~'aLiFii [ ~ ~¢ IJ ~ ~ ~ 4 ~ r ~ ~~. N~JWIEC!<1..~ /~ 1 ! 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