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ENC2017-00105a� CITY OF CAMPBELL ENCROACHMENT PERMIT DEPT. OFPUBLICWORKS (forworking within the public 70 North First Street right-of-way) Campbell, CA 95008 •� Ph. (408) 866-2150 Issued Fx (408)376-0958 Print Form Permit No E—NC 2—ak7-00tc)E X-Ref. File Application Date �� 17 Application Expiration Date APN Permit Expiration Date I Z-/ (r) U 1 U' APPLICATION -Application is hereby made fora 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.: 108 and 114 John Kirk Court, Campbell, CA 95008 Utility Trench Location: B. Natureofwork: Soil Vapor Probe Installations C. Attach four (4) copies ofan engineered plan showingthe location and extent ofthe work, and four (4) copies ofthe 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 ofCampbell 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. 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 startingwork. Notice must be given toPub] icWorks atleast 24hours before restarting anywork. Name of Applicant: (John Kirkorian / Kirkorian Plaza Partners, LLC ,,Telephone: (408) 379- -547 Address: 1290 Los Gatos -Saratoga Road, Los Gatos, CA 95030 E-MailAddress: �hn@klrkorlan.Com 24-HOUR EMERGENCY PHONE NUMBER: (408) 379-454.7 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 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 clam,, arising out of improvements completed in the public right-of-way. Accepted: Kirkorian Plaza Partners, LLC —/3—/7 (Applicant Permittee) (sign) Date Environmental Control Associates, Inc., C-57 #695970 (Contractor) (Print Name) Date SPECIAL PROVISIONS: ❑ 1. Street shall not be open cutfor underground installations. Minimum cuts maybe allowed for connections or exploration holes. Suchcutsmaybe specifically approved 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 the Engineer. El3. 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 4216 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. ❑ S. 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 AMOUNT /j� RECEIPT NO. PERMIT APPLICATION FEE $ `'Y h 25 ((e191 PLAN CHECK DEPOSIT $ SECURITY FOR FAITHFUL PERFORMANCE/LABOR & MATERIALS $ CONSTRUCTION CASH DEPOSIT $ PLAN CHECK & INSPECTION FEE $ MCDE ZC9 (8u EMERGENCY PERMIT FEE $ APPROVED FOR ISSUANCE For City Engineer Date Permit Expires 12 Months After Date of Issuance IN ,P GENERAL PERMIT CONDITIONS 1. The Permittee must provide evidence of insurance and Additional Insured Endorsements as required by the City. Insurance shall be maintained forth e duration of the permit work. 2. A Construction Cash Deposit is required. Changes 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. 3. Refund of the construction 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. A one-year maintenance period and surety are required. Such period will begin on date of written acceptance by the City. Surety posted shall be equal to 25% of the original Faithful Performance Security. 5. Submit project schedule 10 (ten) days prior to proposed start of work. Additional lead time may be required for work within City facilities and downtown Campbell. 6. 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. 7. Maintain safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants, and water valves. 8. 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. 9. A Construction Traffic Control Plan shall conform to the 2006 California Manual on Uniform Traffic Control Devices (MUTCD). 10. 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 as expeditiously as possible. 11. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and new PCC shall be doweled to existing improvements. 12. Prior approval of inspector is required for any work proposed after normal working hours, on weekends or holidays and may require reimbursement of inspection costs at the current overtime rate. 13. Work on arterials and collectors may require the use of changeable message boards. 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 construction cash deposit. 14. Compaction testing of subgrade, base rock, and asphalt concrete by Permittee is required unless otherwise stated by the City Engineer. 15. 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. and on weekends. 16. No storage of materials or equipment will be allowed near the edge of the pavement, the traveled way, or within the shoulderline which would create a hazardous condition to the public. 17. 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. 18. This permit does not release the Permittee from any liabilities contained in other agreements or contracts with the City and any other public agency. 19. This permit is not transferable. Work must be performed by the Permittee or his designated agent or contractor as specified thereon. 20. 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. 21. 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. 22. If the public interest requires a modification of, or a departure from the permit, plans, special provisions and/or 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. 23. Permittee 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 a phone number. 24. Applicant shall remove water from utility vaults in accordance with the requirements of State Water Resources Control Board Water Quality Order WQ 2014-0174- DWQ. Said vault water shall not be discharged into the City of Campbell's storm drain system. See http://www.waterboards.ca.gov/water issues/programs/nodes/utilityvaults.shtml for more information. Applicant is hereby responsible for ensuring that all those providing services under the applicant are aware of and abide by all of the above conditions. Applicant Kirkorian Plaza Partners, LLC 11-13_/ 7 Environmental Control Associates, Inc., C-57 #695970 Date: Contractor (Print Name) Date: J:\FORMS\Templates\Encroachment Permits\Encroachment Permit STATIC form2.pdf Rev.03/17 CITY OF CAMPBELL PUBLIC WORKS DEPARTMENT CLEARANCE FOR FINAL INSPECTION AND ACCEPTANCE LETTER Encroachment Permit#: ENC Name: Property Address: Date of Final Inspection: On File: Bonds CD Labor and Material: Construction Ca " Deposit to be released: $ Other ov due deposits to be released (Description): Processed by: Reviewed by: Reviewed by: ministrator Insnect6r Land Development Engineer J:JoAnnaT\Deposit refunds\CHECKLISTS\Blank.doc (Rev. 10/11) CERTIFICATE OF LIABILITY INSURANCE - DATE(MtMDNYM 4/20/2017 THIS CERTIFICATEIS ISSUED AS A MATTER OF INFORMATIONONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATEHOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELYOR 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 REPRESENTATIVEDR PRODUCER, AND THE CERTIFICATEHOLDER. IMPORTANT: If the certificateholderis an ADDITIONALINSURED,the policy(ies)must beendomed. If SUBROGATIOMS WAIVED,subjectto the termsandconditionsofthe policyFertainpolicies aymquimnendorsement.A statementon thiscertificatedoesnot eonferrights tothe certificateholder in lieu of such endomement(s). CONTACT DINA ATHEY NAME: PRODUCER ISU INS SERV - BC ENV BROKERAGE PHONE FAX ac Np E Q: (916) 939-1080 AD. No: (916) 939-1085 E-MAIL ADDRESS: 1037 Suncast Ln Ste 103 INSURER(S) AFFORDING COVERAGE NAICA El Dorado H111s, CA 95762 INSURERA: ADMIRAL INSURANCE COMPANY 24856 INSURED ENVIRONMENTAL CONTROL ASSOCIATES, INC. INSURERB: STATE COMP. INS. FUND 35076 INSURERC: 3011 TWIN PALMS DRIVE APTOS, CA 95003 INSURERD: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: THIS IS TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWATHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMEM WIITH 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, D(CLUSIONSANDCONDITIONS OF SUCH POLICIESAMITSSHOWNMAY HAVEBEEN REDUCED BYPAID CLAIMS. POLICY EFF POLICY EXP UMITS TYPEOFINSURANCE POLICY NUMBER IMM/DDrYYYY) (MMIOD/Y1'M A X COMMERCIALGENERAL UABIUTY CLAIMS -MADE MROCCUR CONT.POLLUTION Y FEI-ECC-22900-00 8/01/16 8/0 EACH OCCURRENCE b 1 OOO OOO PREMISES Eaocwnence) S SO O.00 MEDEXP(Anyenepo-n) s 5 000 X PERSONAL I. INJURY s 1,000,000 GENERAL AGGREGATE b 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRO- X POLICY IJ JECT LOC PRODUCTS '-COMPIOPAGG s 2,000 OOO b OTHER 'COMBINED SINGLE LIMIT Ea accident b AUTOMOBILE LIABILITY BODILYINJURY(Perpereon) $ - BODILY INJURY (Per accident)' s ANYAUTO ALL OWNED PROPERTY DAMAGE .(Per aced-t) 5 AUTOS' AUTOS NON -OWNED LISCHEDULED b HIRED AUTOS AUTOS UMBRELLA LIAR OCCUR EACH OCCURRENCE s AGGREGATE 's EXCESS UAS - CLAIMS -MADE DED RETENTION S WERS COMPENSATION ORK AND EMPLOYERS'LIABILITY YIN 1972096-16 5/01/16 5/01/17 X PEROTH- STATUTE' ER b E.L EACH ACCIDENT 1 O.O.O 000 E / E.L DISEASE;EA EMPLOYEE b 1,000,000.. B "eEp, "ram cw N)A Y (Mandatoryn NH) If yes, de ffi. under E.L. DISEASE -POLICY LIMIT' s 1,000,000 A DESCRIPTION OFOPERATIONS below E&0 LIAB. CLAIMS MADE FE2-ECC-22900-00 RETRO: 08/11/93 8/01/16 8/01/17 $1,000,000 OCCURRENCE $2,000,000 AGGREGATE C DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (ACORD ID1. Addifional Remafl<`+_Sch d may be a..he I if mole space m required) F;0111 ORK IN WCAMPBELL,ITS CITY OF OFEIERSEMPLOYEES AND VOLUNTEERS ARE NAMED. AS ADDIAL 2 SURErIiE INSURANCE COVERAGE AFFORDED TO'THE ADDITIONAL INSURED. PRIMARY, AND NON-CONTRIBUTORY COVERAGE - APPLIES. WAIVER OF SUBROGATION APPLIES. WAIVER OF SUBROGATION APPLIES TO THE WORKERS COMPENSATION. 30 DAY WRITTEN NOTICE OF CANCELLATION APPLIES. (BLANKET ENDORSEMENTS ATTACHED)jC WA7VER TO FOLLOW FROM CARRIER TE HO CITY OF CAMPBELL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WALL BE DELIVERED IN 70 N 1ST STREET ACCORDANCEWTHTHE POLICY PROVISIONS. CAMPBELL, CA 95008 AUTHORIZED REPRESENTATIVE A. ACORD25 (2014/01) The ACORD name and logo are registered marks of ACORD PUBLIC WORKS DEPARTMENT UTILITY ENCROACHMENT, TRAFFIC & MISCELLANEOUS RECEIPT Effective July 1, 2016 TO: Finance Gc.) PUBLIC WORKS MILE NO. PROPERTY ADDRESS lop, xLt sr k" <+ r Please collect & receipt for the following monies ENCROAGFiMENT-PERMIT 1 r r ;I , ,;U5 "AOIBI i p 4722 Utility Encroachment Permit Application Fee $434.00 R-1 Encroachment Permit IV./C Emergency Permits $122.00 Plan Check & Inspection Fee Minimum Charge Per Location Conduits/Pipelines up to 500 Feet $2.81lift Above 500 Linear Feet $-1.68/ft Manholes/Vaults/Etc. $,179.00/ea Pole Set/Removal $179.00/ea 4760 Storage Container Permit (valid up to 60 days only) $163.00 4760 Project Plans & Specifications Project No. 4760 Standard Specifications & Details $1/Pg $'15.50/Bk 4760 Engineering Maps & Plans Aerial Plot 24" x 36" $63.00 Aerial Print 8 1/2" x 11" $31.00 Map Research (includes max of two 24"x36" copies) $31.00 _ Maps and Plans 24" x 36" $-15.00 4722 Penalties: Failure to restore public improvements $100/Calendar Day (Muni Code Sec. 11.34.010) 4722 Penalties: Failure to correct unsafe conditions $100/Calendar Day 4722 Work Without Permits 4 Times Applicable Fee TRAFFIC h i i 4728 Traffic Flow Map (Daily Traffic Volumes) $35.00 4728 Signal Timing Information $ 73 per hour 4271 Truck Permits $16.00 per trip 4728 No Parking Signs -$1 each or $25/100 MISCELLANEOUS " yy r wf a, t, `.; Iq�"r `•;q. ,; tl i�, a ''.[ tn.. I: t r ?,'.'41 ,",d 14 �';`35 ,n 511.74241 Postage Other (Please Specify) TOTAL 3 NAME OF APPLICANT ��� i^ l rl, CkIn NAME OF PAYOR ���'^ ICv'� �>'1 `'—� PHONE ff�� II q ADDRESS 2-9 S—v- .: I—e1 L 67 ZIP I SG 36 �f G36 FOR f < RECI k D BY a lw �� s I tt ` ,(�y E� r wh..d.kl 1x*. CITY CLERK ONLY t a rq Date 5t t -t- I i1r t 1 r 11i i ( t J:%FORMS1TemplatesWAdministrativelReceipt Form Utility Encroachment & Misc 16-17.xls AllWest April 12, 2017 Mr. John Birchfield City of Campbell Department of Public Works 70 North First Street Campbell, CA 95008 AllWest Environmental, Inc. Specialists in Physical Due Diligence and Remedial Services 2141 Mission Street, Suite 100 San Francisco, CA 94110 415.391.2510 AHWestl.com RE: Encroachment Permit Application and Soil Vapor Probe Nested Cluster Diagram 108 and 114 John Kirk Court, Campbell, California 95008 SCCDEH Case # 2016-28s AllWest Project Number 16195.23 Dear Mr. Birchfield, AllWest Environmental, Inc. (AllWest) is submitting the attached encroachment permit application for the soil vapor probes to be installed within the City of Campbell right-of-way at 108 and 114 John Kirk Court, Campbell, California. We are submitting this permit application on behalf of our client Mr. John Kirkorian of Kirkorian Plaza Partners LLC, who signed the attached application (see Attachment A). Our State of California C-57 licensed drilling contractor, Environmental Control Associates, Inc. (ECA) of Aptos, California also signed a copy of the permit application (Attachment A). This work is being performed as part of the ongoing subsurface investigation at the adjacent Kirkwood Plaza Shopping Center site at 1570-1630 West Campbell Avenue and 75 South San Tomas Aquino Road, Campbell, California (Figure 1). The work is being required by the Santa Clara County Environmental Health Department (SCCDEH) in their letter dated March 17, 2017 (see Attachment B). We are planning on drilling and installing two nested soil vapor probe clusters (SVP-38A/B and SVP-39 A/B) at a depth of 5 and 14.5 feet below ground surface (bgs) within the John Kirk Court street right-of-way (see attached Figure 2 Site Plan with Proposed Soil Boring and Vapor Probe Locations). It is our understanding that Santa Clara Valley Water District (SCVWD) well construction permits are not required for soil vapor probes with a depth less than excess of 15 feet bgs; therefore no SCVWD well construction permits applications are being submitted for these probes. A brief description of our proposed nested soil vapor probe construction procedures follows: Mr. John Birchfield April 12, 2017 Page 2 of 3 Two soil borings will be advanced to 15 feet bgs with truck -mounted Geoprobe direct push technology (DPT) methods by a State of California C-57 licensed drilling contractor, ECA of Aptos, California. In order to keep the boreholes open for vapor probe installations, the borings will be advanced using a Geoprobe® DPT dual -casing system with continuous core sampling methods. A 2 1/4-inch diameter outer drive casing will seal the borehole while samples are recovered using a 1 1/2-inch diameter inner driven core barrel. Following Geoprobe° DPT soil boring advancement to the designed depth, the two borings will be completed as permanent nested soil vapor probes at 5 and 14.5 feet bgs. A total of four individual vapor probes will be installed (two in each boring). The nested soil vapor probe construction schematic diagrams are included as Figures 3. Stainless steel soil vapor probes, %2-inch diameter by 2-inches long and tipped with porous plastic membranes, will be inserted within the outer Geoprobe® DPT drive casing to the bottom of the 2 1/4-inch diameter boreholes at the designed depths of approximately 5 and 14.5 feet bgs. The probe tips will be attached to lengths of 0.25-inch OD Nylaflow tubing, extending to approximately 2 feet above the ground surface. An approximately 1-foot thick layer of fine #3 Monterey sand filter pack will be placed in the 2 1/4-inch diameter borehole annulus around each individual nested probe and tubing, starting with the 14.5 feet bgs probe. Dry granular bentonite will then be used to fill the annular space to 1 foot above the filter pack, than a hydrated Portland cement with 5% bentonite grout slurry will be emplaced with a tremie pipe to approximately 0.5 feet below the next nested probe. A similar layer of sand pack, non -hydrated granular bentonite and cement/5% bentonite grout slurry will be emplaced as described above within the annular space around the next successive individual nested probe at 5 feet bgs and tubing, extending to approximately 4-6 inches below the asphalt or concrete pavement. The outer Geoprobe DPT drive casing will be withdrawn from the borehole as the sand pack, bentonite and cement grout slurry is emplaced. A traffic -rated 8-inch diameter vault box will then placed flush with the pavement around the top of the borehole and the coiled probe tubing, and the annular space sealed with concrete slurry. The Nylaflow probe tubing will be sealed at the top ends with air- and watertight Swagelok fittings and caps. The bentonite and cement grout will be allowed to hydrate and borehole conditions to equalize for at least 2 hours prior to sampling activities. It is anticipated the vapor probes will remain in place for a period of two years or more, and will be monitored semiannually as part of the Kirkwood Plaza investigation and remediation activities until approval of case closure. Following the completion of Kirkwood Plaza site remediation activities and approval of case closure by the SCCDEH, the nested soil vapor probe clusters will be abandoned by removing the vault boxes, drilling out the tubing, vapor probes, and annulus seal and sand pack material to the total depth of the boring using a hollow -stem auger drill rig equipped with a minimum 6-inch OD auger. The borehole will be grouted through Mr. John Birchfield April 12, 2017 Page 3 of 3 the hollow -stem augers with a hydrated neat Portland cement slurry while withdrawing the augers. The asphalt or concrete pavement will be restored to its original appearance. We hope this cover letter adequately addresses our request for an encroachment permit. Please let us know as soon as possible what the permit fees will be and when we can expect approval. Please call me at (415) 3 91-25 10 if you have any questions or wish to discuss this further. Sincerely, AllWest Environmental, Inc. o�ZP. i 0F� �I Leonard P. Niles, P.G., C.H.G. Senior Project Manager cc: Mr. Aaron Costa, Santa Clara County Department of Environmental Health Mr. Tim Tyler, Environmental Control Associates, Inc. Mr. John Kirkorian, Kirkorian Plaza Partners, LLC FIGURES Figure 1 — Vicinity Map Figure 2 — Site Plan with Proposed Soil Boring and Vapor Probe Locations Figure 3 — Multiple Soil Vapor Probe Nested Cluster; 5 and 14.5 feet bgs ATTACHMENTS Attachment A — City of Campbell Department of Public Works Encroachment Permit Application Attachment B — SCCDEH Workplan Approval Letter, March 17, 2017 II OF 99R? Rma BY. Gmle @+£SITE TER+: ALLkg ENVIRONMENT TO £s DATE: 04Z20d9 RQaa DATE: 0 d7 TIME;D:S kkwGI+ AMOUNT CgI 2:aS017227 ykam£R FILING y#.m mG D: 1.000 qa & m2R FILING %28.00 ---���-- mGE me *e&m I7RRW $qam CHANGE: tm CHECK ; $82.00 REF qe !a2 FIGURES Topo USAF S U G Il ro o �--ls0 � PEP p 1W riMER.AVE3 z O O ppINE 0 1602 W. CAMPBELL AVE. T LA PRA Z ,-77� 7 Us. z II 9S p, p WHIT`WOOD LN QI4` NO,RWICH_WAY�.1 � z r rr �o n 0 z p v 0 z MADDC WAY z RIN rn p 2 LBURY-DR vo p I1 p L _..GRIMSBY DR ft 0 400 800 1200 1600 2000 M N (12.5- E) ' U1 m 74l z Cr CT '� S®® AI 1\10�sSt VICINITY MAP FIGURE 2 1602 WEST CAMPBELLAVENUE CAMPBELL, CALIFORNIA 008 SOURCE: DE ORME TOPO PROJECT NO. 16195.23 PREPARED BY: D. CAMACHO / L. NILES DATE: 9/22/16 & 1/25/17 D S—i G A BUILRE TA RUINING C2 O URANT, AND DENTAL 75 S?SAN TOMAS AOU NO ROADCES Op NOB HILL GROCERY STORE, 1602 W. CAMPBELL AVENUE SHELL 3 BUILDING B O FORMER DRY CLEANER LOCATION O STATION O 4: O WALGREENS PHARMACY, 1570 W. CAMPBELL AVENUE O ELEMENTS DAY SPA 1604 W. CAMPBELL AVENUE (HISTORICAL PRINT SHOP LOCATION) CO 0 O C� 3¢ - ❑ BUILDING CI OG o MARTINONG DRY CLEANERS, 1610 W. CAMPBELL AVENUE o. OC BIG 5 SPORTING GOODS, 1600 W. CAMPBELLAVENUE - J= (HISTORICAL HARDWAFiE/PAINT STORE) O De YOUNG FLOWERS, 1616 W. CAMPBELL AVENUE - - OI MEDICAL OFFICES, 1600 W. CAMPBELL AVENUE, SUITES 201-206 (HISTORICAL PRINT SHOP LOCATION) O REBEKAH CHILDREN'S SERVICES, 1600 W. CAMPBELL AVENUE, SUITE 201 --� O • BUILDING C2 BUILDING ERETAILJOFFICES/ ^ p ' - RESTAURANTS J BUILDING B A BUILDING F O BUILDING C1 Q RETAIIJRESTAURANTS -- O J _ BUILDING to ti BUILDING C3 SVP30,VBQ• A Q FORMER I I I i OI©I IO I OE II O ' SVP-29 ING D CLEAINNG BUI MAC RETAILLOFFICES MACHINE SEWERLOCATION I h I WH17WOOD LANE I I I I I MANHOLE r I I I i i qq 1 Q II AWB-1 AbLTS 'TORM D IN -STORM DRAIN_ STO sE- - - 9 _____________ __ - __ _SEWER----- - 7-------------1—_—_1 Y _1_---__ _.G _. S _ _ SVP3 C/D _ - SVP32A/B 2C/D 3 VP33 / 34 SVP35NB SVP35C/D TRANSFORMER � SVP 4 � SVP36W8 SVP-36 /D - - --- — JP36PAB MANHOLE SVP-31/VB SEWER HOLES WASTE PCE STORAGE AREA, CURRENT ENCLOSURE 'n' i, VP37A(B - 4) 4 39A/B wmrwow LANE 7 TORM DRAINS - — S _ _ E W LEGEND E SVP30AIB &• Proposed Permanent Nested Soil Vapor Probe at 5 and 14.5 feet bgs SVP-29 { Proposed Semi -Permanent Sub -Stab Vapor Probe i Awe-1+ Proposed SoilBoring toGroundwater SVP-32C/1) ® Proposed Permanent Nested Soo Vapor Probes at 30 and 60 feet bgs N FIGURE 2 -L—OJ-- Sanitary Sewer Line. and Laterals, and Manholes SITE PLAN WITH PROPOSED SOIL ---- Site Boundary BORING AND VAPOR PROBE LOCATIONS ---ppSt --- StomDrainLineandManholes Kirkwood Plaza,1570-1630WestCampbell Avenue and ---e--- Water Line and Vault Boxes ------- Electric Line !l1 �i 75 South San Tomas Aquino Road, Campbell, California ------- Teleconununioations Line B 901so PROJECTNO. SOURCE:AIIWest ------- Gas Line Nam: � � APPROXIMATE SCALE IN FEEL 16195.23 DRAWN BY: CM/ LN (03/30/2017REV 4120/17 E 2 L SWAGELOK FITTING AND CAP - 8-INCH DIAMETER TRAFFIC RATED VAULT BOX CONCRETE ANNULAR SURFACE SEAL: BOREHOLE DIAMETER - 9-10 INCHES CEMENT WITH 5% BENTONITE SLURRY -1/4" O.D. x 1/8" I.D.NYLAFLOW TUBING FEET BELOW % BORING DIAMETER = 2-1/4 INCHES GROUND SURFACE 3.5 FT / NON -HYDRATED GRANULAR BENTONITE / �\ FINE SAND FILTER PACK 4.5 FT 1/2" x 1/8" I.D. STAINLESS STEEL / PLASTIC POROUS VAPOR �j PROBE TIP 5 FT 5.5 FT NATURAL SOIL CEMENT WITH 5% BENTONITE GROUT SLURRY 1/4" O.D. x 1/8" I.D.NYLAFLOW TUBING 13 FT y 4wl\ NON -HYDRATED GRANULAR BENTONITE Y FINE SAND FILTER PACK 14 FT �\ 1/2" x 1/8" I.D. STAINLESS STEEL / PLASTIC POROUS VAPOR PROBE TIP 14.5 FT :.: 15 FT TOTAL BOREHOLE DEPTH � FIGURE 3 0 MULTIPLE SOIL VAPOR PROBE NESTED CLUSTER; 5 AND 14.5 FEET bgs ,` II�V—VSt Kirkwood Plaza, 1570-1630 West Campbell Avenue and /`� 75 South San Tomas Aquino Road, Campbell, California NOT TO SCALE PROJECT NO. SOURCE: AIIWest 16195.23 DRAWN BY: CM (03/31/2017) Attachment A Attachment B County ®i Santa Clara Department of Environmental Health hazardous Materials Compliance Division Site Mitigation Program 1555 Berger Drive, Suite 300 San Jose, CA 95112-2716 (408)918-3400 FAX (408)280-6479 March 15, 2017 SENT VIA ELECTRONIC MAIL ONLY Mr. John Kirlcorian Kirkorian Plaza Partners, LLC Oohn@kirkorian.com) Subject: Subsurface Investigation Report — Kirlcorian Plaza, 1570-1630 W Campbell Ave., San Jose, CA Case No. 2016-28s Dear Mr. Kirlcorian: The Department of Environmental Health (DEH) has reviewed the Remedial Investigation Work Plan (Work Plan) submitted by AllWest Environmental (AllWest) and dated January 30, 2017. The Work Plan proposes additional soil, soil vapo r, and groundwater activities both on and off - site to define the extent of volatile organic compounds (VOCs). The results of the investigation will be used to develop a plan for corrective action. The DEH approves the activities proposed in the Work Plan and asks that you proceed with implementation. TECHNICAL REPORT REQUEST Please submit the following document via GeoTr acker to the DEH according to th e following schedule: Remedial Investigation Report July 14, 2017 This technical report is required pursuant to our authority under Sections 25289 and 25296.10 of the California Health and Safe ty Code. E ach report shall include conclusions and recommendations for the next phases of work requi red to protect water resources, hum an health and safety, and the environm ent at the site. W e request that all required work be performed in a prompt and timely manner. Revisions to the schedule shall be requested inwriting with appropriate justification for the anticipated delays and a proposed revised schedule. The California Business and Professions Code(Sections 6735, 7835, and 7835.1) require that work plans and technical or implem entation reports containing geologi c or engineering evaluations and/or judgments must be performed under the direction of an appropriately registered or certified professional. Board of Supervisors: Cindy Chavez, Mile Wasserman, Dave Cortese, Ken Yeager, S. Joseph Simitian County Executive: Jeffrey V. Smith Kirkorian Plaza March 15, 2017 Page 2 of 2 ELECTRONIC SUBMITTAL REQUIREMENTS As outline in the Rem edial Action Agreement, this case is subject to California regulations for electronic submittal of information for all soil and groundwater cleanup cases in California (Title 23, Division 3, Chapter 30, Articles 1 and 2; Title 27, Division 3, S ubdivisions 1 and 2). To be considered complete, all required submittals must be up loaded to the Sta to of California GeoTracker database in compliance with State Water Resources Control Board requirements by specified submittal due dates. All reports a nd correspondence should be uploaded directly to GeoTracker and notification provided to the caseworker via email of the upload. To obtain on- line GeoTracker access to a fac ility for the e lectronic submittal of to chnical documents, an "Authorized RP Agent" form must be completed and submitted. The assigned caseworker will accept and review all documents in GeoTracker. Please note there is a two day delay between the document upload and caseworker's ability to view and accept the document. Do not submit paper copies of reports to this office. PERJURY STATEMENT All proposals and reports submitted to this office must be accompanied by a cover letter from the responsible party which states, at a minimum, the following: "I declare, under penalty of perjury, that the inform ation and/or recommendations contained in the attached pr oposal or report is true and correct to the best of my knowledge." This letter must be sig ned by an o fficer or legally authorized representative of your com pany. Future submittals made without the perjury statement may be returned as insufficient. If you have any questions, please feel free to contact me at (408) 918-1954 or via email. Sincerely, Aaron Costa Senior Hazardous Materials Specialist Department of Environmental Health Site Mitigation Program Aaron.costa@cep.seegov.org cc: Len Niles, AllWest Environmental, (leonard@allwestl.com) File — GeoTracker ,aco/a® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY► 4/21/2017 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 Hansen Insurance Agency License #0831440 CONTACT William Hansen NAME: PHONE No Ext: (831)722-9666 A/C No: (831)722-2932 E-MAIL bill@hanseninsurance.com ADDRESS: INSURERS AFFORDING COVERAGE NAIC# 800 East Lake Avenue INSURER A: UNITED FINANCIAL CASUALTY COMPANY 11770 Watsonville CA 95076 INSURED INSURER B : INSURERC: ENVIRONMENTAL, CONTROL ASSOCIATES INSURER D : 3011 Twin Palms INSURER E : INSURERF: Aptos CA 95003 COVERAGES CERTIFICATE NUMBER:2016-2017 AL & PD 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. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MM/DDYEFF /YYYY MMIDDIYYXYpY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMAGE TO RENTED PREM SES (E. occu nce $ MED EXP (Any one person) $ PERSONAL & ADV INJURY S GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PROCT ❑ LOC JE PRODUCTS - COMP/OP AGG $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ p' ANY AUTO ALL OWNED SCHEDULED AUTOS X AUTOS X 02075960-7 9/28/2016 9/28/2017 BODILY INJURY (Peraccident) $ PROPERTY DAMAGE Peraccident $ NON -OWNED HIRED AUTOS AUTOS STSO4 $ UMBRELLA LIAB EACH OCCURRENCE $ HOCCUR AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ $ WORKERS COMPENSATION EMPLOYERS' LIABILITY Y / N PER OR STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N / A E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Automobile Physical 02075960-7 9/28/2016 9/28/2017 Comprehensive Deduct/$1,000 Damage Collision Deduct/$1, 000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Limits at policy inception. *Except 10 days notice for non-payment of premium. The City of Campbell, its officers, employees and volunteers are named as an Additional Insured under the Automobile Liability policy as per the attached form 1198(01/04). Job Name/Description: Permit # ENC2017-00105 - 108 & 114 John Kirk Court, Campbell CA. (408)376-0958 joannat@cityofcampbell.com City of Campbell Public Works Department 70. N. 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 R Roberts/RACHEL �e�j LcLtl�-ems fJ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) INS025 r?mnnn The ACORD name and logo are registered marks of ACORD 2016/2017 Tim Tyler 02076960-7 Year I Make'. ... , , Model ' 'VIN ,. : . -,. Body Typ6 ,.. 2003 Ford F350 1FTSX31P83EC35688 Pickup truck 1997 Ford F250 1FTHX26F6VEB65793 Pickup truck 2005 Ford F350 Super Duty 1FDSX34P95EA17110 Pickup truck 2008 Ford F550 Super Duty 1FDAF57R18EB72326 Truck 2008 Ford F350 1FTWX33RX8EB00333 Pickup truck 2003 Chevrolet Silverado C2500 1GCHC29173E177847 Pickup truck 1994 Intl 490 1HTSHPCRlRH560924 Truck 1995 Dodge Ram 3500 lB7MC36C7SSC38470 Pickup truck 2007 Dodge Ram 2500 3D7KR28A87G791266 Pickup truck DATE(MM/DONYYY) _JC��R CERTIFICATE OF LIABILITY INSURANCE 4/20/2017 THIS,CERTIFICATEIS ISSUED AS A MATTER OF INFORMATIONONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATEHOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELYAMEND, 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 REPRESENTATIVEOR PRODUCER, AND THE CERTIFICATEHOLDER. IMPORTANT: If the certificateholderis an ADDITIONALINSURED,the policy(ies)nust be endorsed. If SUBROGATIONIS WAIVED, subject to the terms and conditionsof the policyFertain policiesnayrequireen endorsement. A statementon thiscertificatedoesnot conferrlghts to the certificateholder in lieu of such endomement(s). ' PRODUCER CONTACT NAME DINA ATHEY ISU INS SERV - BC ENV BROKERAGE PHONE FAX A/C. Nn. Ext: (916) 939-1080 PJC. No: (916) 939-1085 E-MAIL ADDRESS: 1037 Suncast In Ste 103 E1 Dorado Hills, CA 95762 rNSURER(S) AFFORDING COVE RAGE NAIC9 INSURERA: ADMIRAL INSURANCE COMPANY 24856 INSURED ENVIRONMENTAL CONTROL ASSOCIATES, INC. INSURER : STATE COMP. INS. FUND 35076 INSURERC: 3011 TWIN PALMS DRIVE INSURERD: APTOS, CA 95003 INSURER E INSURERF: 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, EXCLUSIONSANDCONDITIONSOF SUCH POUCIES.LIMITS SHOWNIMAY HAVEBEENREDUCED BYPAID CLAIMS. a POLICY EFF POLICY EXP TYPEOFINSURANCE POLICY NUMBER MMIDD M/DD LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE E 1 000 000 PREMISES Ea occurrence E 5 O CLAIMS -MADE �X OCCUR X MEDEXP(Anyoneperson) E 5 000 CONT.POLLUTION FEI-ECC-22900-00 8/01/16 8/01/17 PERSONALBADV NJURY E 1,000,000 A y GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE E 2,000,000 qP.Li.Y F-1 JECT [:] LOC PRODUCTS-COMP/OPAGG E 2,000,000 E �) OTHER: AUTOMOBILE LIABILITY COMBINED SINGLELIMIT E Ea accident BODILYINJURY(Per person) E ANYAUTO ALL OWNED SCHEDULED AUTOS AUTOS xi BODILY INJURY (Per edan) E PROPERTY DAMAGE E NONOWNED HIRED AUTOS AUTOS (Peraccident) 8 UMBRELLA LIAB OCCUR EACH OCCURRENCE E AGGREGATE E EXCESS LIAB �_J CLAIM DED I I RETENTION E E RKERS COMPENSATION X I PER OTH- B D EMPLOYERS'LIABILITV IIIr,^N NIA y 1972096-16 5/01/16 5/01/17E.L.1,000,000 STATUTE ER EACH ACCIDENT E E.L. DISEASE -EA EMPLOYEE E 1,000,000 omcewueuernsexcrao[mscurw 1 1 (Mandatoryn NH) `u 1•�, If yes, describe under DESCRIPTION OFOPERATIONS below E.L. DISEASE -POLICY LIMIT E 1,000,000 A E&O LIAB. FEI-ECC-22900-00 8/01/16 08101117 $1,000,000 OCCURRENCE CLAIMS MADE RETRO: 08/11/93 1$2,000,000 AGGREGATE DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (ACORD 101. Additional Remarks Schedule, maybe attached if more space is required) RE: ALL WORK IN THE PUBLIC RIGHT OF WAY - KIRKWOOD PLAZA CITY OF CAMPBELL, ITS OFFICERS EMPLOYEES AND VOLUNTEERS ARE NAMED AS ADDITIONAL INSURED. THE INSURANCE COVERAGE AFFORDED TO THE ADDITIONAL INSURED. PRIMARY AND NON-CONTRIBUTORY COVERAGE APPLIES. WAIVER OF SUBROGATION APPLIES. WAIVER OF SUBROGATION APPLIES TO THE WORKERS COMPENSATION. 30 DAY WRITTEN NOTICE OF CANCELLATION APPLIES. (BLANKET ENDORSEMENTS ATTACHED) iC-f1'AZVER TO FOLLOW FROM CARRIER CITY OF CAMPBELL I SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE 70 N 1ST STREET I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACC, THE POLICY PROVISIONS. CAMPBELL, CA 95008 AUTHORIZED REPRESENTATIVE 01988-2014 ACORD CORPORATION. All rights reserved. ACORD25 (2014101) The ACORD name and logo are registered marks of ACORD AOM18A*a-MAff Environmental Control Associates, Inc. Endorsement Number: 5 Automatic Additional Insured — Owners, Lessees or Contractors ECC-319-0712 This endorsement, effective 8/1/2016 attaches to and forms a part of Policy Number FEI-ECC-22900-00. This endorsement changes the Policy. Please read it carefully. In consideration of an additional premium of $Applied, this endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Any person(s) or organization(s) whom the Nained Insured agrees, in a written contract, to name as an additional insured. However, this status exists only for the project specified in that contract. The person or organization shown in this Schedule is included as an insured, but only with respect to that person's or organization's vicarious liability arising out of your ongoing operations performed for that insured. Environmental Control Associates, Inc. Endorsement Number: 20 ADMIRAL Additional Insured — Owners, Lessees or Contractors — Completed Operations This endorsement, effective 8/l/2016 attaches to and forms a part of Policy Number f EI-ECC-22900-00. This endorsement changes the Policy. Please read it carefully. In consideration of an additional premium of $Applied, this endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) I Location And Description Of Completed Or Organization(s): Operations Any person(s) or organization(s) whom the Named Insured Those project locations where this agrees, in a written contract, to name as an additional insured. endorsement is required by contract. However, this status exists only for the project specified in that contract. Information required to complete this Schedule. if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "Your work" at the location designated and described in the schedule of this endorsement performed for that additional insured and included in the "products - completed operations hazard". CG 20 37 07 04 © ISO Properties, Inc., 2004 Environmental Control Associates, Inc. Endorsement Number: 15 ADMIRAL � ff Automatic Primary and iVon-Contributory Insurance Endorsement Designated Work Or Project(s) This endorsement, effective 8/1 /2016 attaches to and forms a part of Policy Number PEi-ECC-22900-00. This endorsement changes the Policy. Please read it carefully. SCHEDULE Name of Person or Organization: Any person(s) or organization(s) whom the Numed Insured agrees, in a written contract, to provide Primary and/or Non-contributory status of this insurance. However, this status exists only for the project specified in that contract. In consideration of an additional premium of $Applied and notwithstanding anything contained in this policy to the contrary, it is hereby agreed that this policy shall be considered primary to any similar insurance held by third parties in respect to work performed by you under any written contractual agreement with such third pally. It is further agreed that any other insurance which the person(s) or organization(s) named in the schedule may have is excess and non- contributory to this insurance. ECC-548-0712 Environmental Control Associates, Inc. Endorsement Number: 6 anMrent = k.-E Automatic Waiver of Subrogation Endorsement This endorsement, effective 8/1/2016 attaches to and forms a part of Policy Number FEI-ECC-22900-00. This endorsement changes the Policy. Please read it carefully. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART CONTRACTORS POLLUTION LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: Any person(s) or organization(s) to whom the .Named bzsured agrees, in a written contract, to provide a waiver of subrogation. However, this status exists only for the project specified in that contract. The Company waives any right of recovery it may have against the person or organization shown in the above Schedule because of payments the Company makes for injury or damage arising out of the insured', work done under a contract with that person or organization. The waiver applies only to the person or organization in the above Schedule. Under no circumstances shall this endorsement act to extend the policy period, change the scope of coverage or increase the Aggregate Limits of Insurance shown in the Declarations. ECC-320-0712 INSURANCE REQUIREMENTS CHECKLIST Permit # CIP Project # Consultant/Contractor: The following insurance is required of all consultants/contractors working in the City of Campbell public right-of-way. Insurance certificates must be accepted by City staff before work can begin. These insurance requirements apply to work being performed under an Encroachment Permit and work being performed under contract for Capital Improvement Projects. Limits Commercial General Liability for bodily, personal injury and property damage: �$1,000,000 per occurrence, and ° ❑ $1,000,000 general aggregate limit applying separately to the project, or ,mK—$2,000,000 general aggregate limit. ❑,-,�?olicy expiration date VJ- Automotive Liability: 7fT "Any Auto" checked on certificate $1,000,000 per accident for bodily injury and property damage So`��`���. Policy expiration date `'l �2'S I\'1 Workers' Compensation and Employer's Liability �6 Waiver of Subrogation clause 0- $1,000,000 per accident for bodily injury or disease Policy expiration date 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, its officers, employees and volunteers are named as additional insured. (Reference Project Location/Permit Number) d The insurance coverage afforded to the Additional Insured is primary insurance. Cancellation area: ❑ Cancellation area of certificate edited to delete "endeavor to" and "but failure to mail such notice shall impose no oblieation or liability of any kind upon the company, its agents or representatives". OR should say: Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions. ❑ Workers' Compensation Insurance Sheet Submitted ❑ For General Contractor ❑ For Developer or Owner J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 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. _ . �5 Name: d � Cc, ��Yl -NAIC # a 4 Rating: V XV Authorized in CA: Name: �rct�e CO-M_ NAIC # Rating: Authorized in CA: Name: c,\ NAIC # L=gating: Authorized in CA: Name: NAIC # Rating: Authorized in CA: Campbell Business License # Expiration: ❑ Contractors License # (DLl C,\1C) Class: -`51 Expiration: Insurance Certificate Reviewed Initials Date ❑ Copy of Insurance Certificate placed in tickler file one month prior to expiration. J:\FORMS\Templates\Insurance Requirements\Insurance Requirements Cklist.doc (Rev 08 14) Page 2 PR94;RFf1/YF' COMMERCIAL HANSEN INS 800 EAST LAKE AVE WATSONVILLE, CA 95076 ab/ o S CITY CAMPBELL/PUBLI 70 N FIRST ST CAMPBELL, CA 95008 Additional insured endorsement Policy number: 02075960-7 Underwritten by: United Financial Cas Co Insured: ENVIR CTRL ASSOC INC May 4, 2017 Policy Period: Sep 28, 2016 - Sep 28, 2017 Mailing Address United Financial Cas Co PO Box 94739 Cleveland, OH 44101 1-800-876-8270 Name of Person or Organization For customer service, 24 hours a day, CITY CAMPBELL/PLIBLI 7 days a week 70 N FIRST ST CAMPBELL, CA 95008 The person or organization named above is an insured with respect to such liability coverage as is afforded by the policy, but this insurance applies to said insured only as a person liable for the conduct of another insured and then only to the extent of that liability. We also agree with you that insurance provided by this endorsement will be primary for any power unit specifically described on the Declarations Page. Limit of Liability Bodily Injury Not applicable Property Damage Not applicable Combined Liability $1,000,000 each accident All other terms, limits and provisions of this policy remain unchanged. This endorsement applies to Policy Number: 02075960-7 Issued to (Name of Insured): ENVIR CTRL ASSOC INC Effective date of endorsement: 04/21/2017 Policy expiration date: 09/28/2017 Form 1198 (01104) OASIS INS AGENCY PO BOX 1028 SAN JOSE, CA 95108 THE CITY OF CAMPBEL 70 NORTH FIRST CAMPBELL, CA 95008 Additional insured endorsement Name of Person or Organization THE CITY OF CAMPBEL 70 NORTH FIRST CAMPBELL, CA 95008 PR99RE -11YE® COWW-RC/AL Policy number: 02565626-9 Underwritten by: United Financial Cas Co Insured: MARIA HERNANDEZ May 3, 2017 Policy Period: Mar 14, 2017 - Mar 14, 2018 Mailing Address United Financial Cas Co PO Box 94739 Cleveland, OH 44101 1-800-444-4487 For customer service, 24 hours a day, 7 days a week The person or organization named above is an insured with respect to such liability coverage as is afforded by the policy, but this insurance applies to said insured only as a person liable for the conduct of another insured and then only to the extent of that liability. We also agree with you that insurance provided by this endorsement will be primary for any power unit specifically described on the Declarations Page. Limit of liability Bodily Injury.Not applicable Property Damage Not applicable Combined Liability $750,000 each accident All other terms, limits and provisions of this policy remain unchanged. This endorsement applies to Policy Number: 02565626-9 Issued to (Name of Insured): MARIA HERNANDEZ HERNANDEZ CONCRETE Effective date of endorsement: 05/02/2017 Form i 198 (01/04) Policy expiration date: 03/14/2018